Even though LGBTQ+ Americans have made social and legal gains in recent years, health disparities have persisted and continue to undermine LGBTQ+ well-being. Perhaps most prominent among health disparities is the ever-present shadow of HIV/AIDS across all LGBTQ+ communities, and especially in the lives of LGBTQ+ persons of color and young men. In addition to the risks posed by HIV/AIDS and other STIs, LGBTQ+ people are more likely to attempt or commit suicide; transgender women have the highest rates of suicidal ideation/attempts in the country at around 40%. (APA.org, 2013; James, et al., 2016) From the APA, additional health disparities include:
risk of injury via harassment, victimization, and violence
chronic stress and trauma due to persistent homophobia and transphobia
social determinants such as homelessness, poor family life, geographic location
substance abuse, smocking, alcohol abuse
higher rates of obesity among lesbian-identifying women
health and wellness exams that do not correlate with gender identity
chronic loneliness and fears of isolation
As stated by the NIH, "eliminating [these and other] LGBT health disparities and enhancing efforts to improve LGBT health are necessary to ensure that LGBT individuals can lead long, healthy lives." (Healthypeople.gov, 2018) This is particularly necessary, not only to make LGBTQ+ health more equitable, but also because reducing sex/gender stigmatization allows persons who identify as heterosexual and/or cisgenderto explore their own sexuality and gender identity without fear of discrimination.
GLAAD is a media-based organization that focuses on journalism, media advocacy, and outreach to push for cultural changes. While not focused primarily on healthcare, GLAAD does provide resources and work directly related to combating HIV/AIDS.
The HRC is one of the most vocal lobbying and advocacy groups for LGBTQ+ communities in America. Their Healthcare Equality Index has become an essential "benchmarking tool that evaluates healthcare facilities' policies and practices related to the equity and inclusion of their LGBTQ patients, visitors and employees."
HealthHIV is affiliated with the National Coalition for LGBT Health, and is one of the most prominent HIV/AIDS advocacy networks in the United States. Outreach efforts include: "health departments, AIDS directors, AIDS service organizations, municipal leadership, health centers, faith and community-based organizations, primary care, and allied health".
"In this study, we provide data and research documenting the prevalence of several forms of stigma and discrimination against LGBT adults and youth in Arizona, including discrimination and harassment in employment, housing, and public accommodations; bullying and harassment in schools; and family rejection of LGBT youth. We discuss the implications of such stigma and discrimination on LGBT individuals, in terms of health and economic security; on employers, in terms of employee productivity, recruitment, and retention; and on the economy, in terms of health care costs and reduced productivity."
An essential resource for LGBTQ+ communities, providers, and policy makers, "Lambda Legal, a 501(c)(3) nonprofit, is a national organization committed to achieving full recognition of the civil rights of lesbians, gay men, bisexuals, transgender people and everyone living with HIV through impact litigation, education and public policy work."
Part of an extended coalition that also promotes community health interventions for HIV/AIDS, the National Coalition for LGBT Health focuses on advocacy, education, and research as well as training in community-based activism.
"The Task Force" focuses on legislative action and activism to promote increases in equity for LGBTQ+ populations. It is particularly noteworthy as the organization which supports and reports on the US Trans Survey.
PFLAG is a grassroots, community-based organization with chapters in towns and municipalities across the country. It is often a front line service for LGBTQ+ people looking for to participate in a safe community.
Disparities in transgender / gender-expansive populations
As with LGBTQ+ populations as a whole, transgender people continue to experience extreme health and healthcare disparities, even as access and medical services have improved. Transgender people are more likely than any other social group to experience psychological distress leading to suicidal ideation, with 40% having attempted suicide at least once in their lifetime (James, et al., 2016). This is an astoundingly high figure that grows even higher when compounded along intersectional lines; for instance, 54% of transgender people with disabilities report attempting suicide at least once, and 42% report being mistreated by health care providers (James, et al., 2016). Unsurprisingly, transgender people report chronic anxiety and stress, mostly resulting from cultural discrimination and transphobia, but also from experiencing high rates of economic instability and poverty (James, et al., 2016). Transgender people also deal with HIV/AIDS at a higher rate than other LGBTQ+ people; 19% of black transgender women live with HIV, higher than any other social group in the United States (James, et al., 2016).
In many ways, disparities among transgender populations can be combated by dealing with the sociocultural pressures that cause emotional and mental trauma across the lifespan. Additionally, providers should become knowledgeable as to transgender-specific healthcare needs such as: hormone replacement therapy, puberty-blocking hormones, surgeries, and counselling services. Providers should also strive for increased cultural competence, for instance, by finding ways to create electronic healthcare records that allow people to select multiple gender options.
Resources for transgender / gender-expansive populations
A fairly new organization established in 2016, AZ TYPO provides support to families with transgender and gender-expansive children. They focus primarily on education, outreach, and community development.
The Center of Excellence for Transgender Health is an essential source for providers, with information as to cultural competencies, HIV prevention, routine care, mental health, and outreach to transgender communities.
From the abstract: This study finds that the passage of such laws is not related to the number or frequency of criminal incidents in [bathroom] spaces. Additionally, the study finds that reports of privacy and safety violations in public restrooms, locker rooms, and changing rooms are exceedingly rare. This study provides evidence that fears of increased safety and privacy violations as a result of nondiscrimination laws are not empirically grounded."
"Transgender Health is the first peer-reviewed, open access journal dedicated to addressing the healthcare needs of transgender individuals throughout the lifespan and identifying gaps in knowledge as well as priority areas where policy development and research are needed to achieve healthcare equity."
From the abstract: " Discrimination in health care settings creates a unique health risk for gender minority people. The passage and enforcement of transgender rights laws that include protections against discrimination in public accommodations-inclusive of health care-are a public health policy approach critically needed to address transgender health inequities."
From the abstract: "In this issue, Reisner and colleagues7 affirm an extraordinarily high prevalence of mental health diagnoses, including lifetime episode of major depressive disorder (35.4%), generalized anxiety disorder (7.9%), suicidality (20.2%), posttraumatic stress disorder (9.8%), and substance dependence. These findings are certainly not new; increased prevalence of mental health morbidities has been reported consistently among transgender youth seeking care at gender-specific clinical sites. Disproportionately high levels of depression, anxiety, substance use, social isolation, self-harm, and suicidality are consistent findings in these reports."
"Refuge Restrooms is a web application that seeks to provide safe restroom access for transgender, intersex, and gender nonconforming individuals. Users can search for restrooms by proximity to a search location, add new restroom listings, as well as comment and rate existing listings."
This report, published by the National LGBT Health Education Center and the National Center for Medical-Legal Partnership, explores the legal barriers that prevent transgender and gender-expansive populations from receiving proper access to health and healthcare services.
From the abstract: "We mitigated common barriers to developing and integrating new, diversity-related topics into a baccalaureate nursing curriculum. Added transgender health content was well received by students and faculty."
WPATH is most famous for its Standards of Care, which have improved immensely in recent years to provide information as to gender confirmation surgery for both adults and young persons, counselling and insurance services that do not resort to gatekeeping, and cultural competencies for providers.
Disparities in intersex populations
As a biopsychosocial term, Intersex* describes populations with sex characteristics that vary in comparison to binary conceptualizations of female and male bodies (InterACTadvocates.org). Statistically, there are more intersex persons in the global population than transgender people, with roughly 1.7% of persons having intersex characteristics and .33% identifying as transgender (Intersexequality.com, 2013). However, similar to transgender populations, the data is skewed such that we cannot reliably know how many people exhibit intersex characteristics. This is particularly true because intersex anatomies have historically been erased by medical professionals who operated under the assumption that healthy infants should be either female or male in all regards, even if invasive cosmetic surgeries were necessary (UNFE.org). It is still common practice for intersex children to be made subject to invasive, life-altering surgeries for which they can provide no consent, and often resulting in "permanent infertility, pain, incontinence, loss of sexual sensation, and lifelong mental suffering, including depression" (UNFE.org).
The continuation of unnecessary (and dangerous) interventions adds to the number of health and healthcare disparities experienced by intersex persons. Additionally, lack of representation has resulted in poor data collection and a lack of information about psychosocial supports and social determinants. There are studies which suggest that surgery in infancy actually produces negative outcomes (Zhu, et al., 2012, Bennecke, et al., 2017). However, recent studies show that intersex people who receive preventative care relevant to physical or mental health rather than bodily anatomy report a higher QOL (Rapp, et al., 2018).
As such, medical practitioners should focus on combating the disparities and social determinants which result in low QOL. Primarily, these arise from binary conceptualizations about sex identity. However, they also include misconceptions about proper care during immediate neonatal care and care during early life. Researchers and practitioners should work to identify the many ways that sex and anatomy are expressed (not only in reference to internal and external genitalia, but also through brain chemistry, prenatal hormonal balances, postnatal hormone balances, genetics, and chromosomes).
*The MeSH heading for Intersex is Disorders of Sexual Development. Even though this term is widely accepted in biomedical research, it presents intersex characteristics as abormalities which need to be "fixed". In following with the guidelines set by intersex advocacy groups in the United States, this page uses Intersex when possible rather than DSD.
"Accord Alliance’s mission is to promote comprehensive and integrated approaches to care that enhance the health and well-being of people and families affected by DSD by fostering collaboration among all stakeholders."
"The purpose of these guidelines is to assist health care professionals in the provision of diagnosis, treatment, education, and support to children born with disorders of sex development (DSDs) and to their families."
This fact sheet provides a quick overview of the health disparities and barriers to health faced by intersex people globally.
Disparities in lesbian, gay, bisexual, and queer populations
We described various health and healthcare disparities for LGBTQ+ people as a whole in the first tab. However, many facets of LGBTQ+ health are intersectional, especially regarding sexuality and gender identity. However, just because sexual orientation and gender identity overlap, they do function as asingle phenomenon; rather, the two operate interdependently, and for that reason, LGBTQ+ people are likely to experience a wide range of health disparities that are different for cisgender gay men and transgender gay men (this is only of many possible examples).
Providers should be cognizant to the intersections of LGBTQ+ identity. In order to this, it's important to establish healthcare spaces and services which are recognize the many facets of gender/sexual orientation. Electronic health records should be redesigned to include multiple genders as well as sexual orientations (Grass & Makadon, 2016). Providers, policy makers, and community organizers should also increase awareness towards LGBTQ+ people who do not identify as gay or lesbian. For instance, 39% of bisexual men and 33% of bisexual women report not disclosing their sexual orientation to a provider, as opposed to 13% of gay-identifying men and 10% of gay-identifying women (HRC.org, 2016). For the most part, this discrepancy is due to negative experiences involving lack of understanding as to bisexual identity and deligitimizing stereotypes that erase bisexual people's experience (HRC.org, 2016). The result is a significant portion of LGBTQ+ people who experience chronic stress and anxiety, depression, higher rates of alcohol and tobacco abuse, and unsafe sexual practices. This is especially concerning considering the likelihood that LGBTQ+ people as a whole will experience these and other disparities.These inflated figures are just as likely to occur for people who identify as sexually queer (pansexual, asexual, demisexual, etc.).
Resources for lesbian, gay, bisexual, and queer populations
From the abstract: "This study provides important quantitative support for theories related to biphobia and double discrimination. Our findings provide strong evidence for understanding how stereotypes and stigma may lead to dramatic disparities in depression, anxiety, stress, and other health outcomes among bisexual individuals in comparison to their heterosexual and homosexual counterparts."
GMHC is a global network focused on preventing and testing for HIV/AIDS while practicing educational awareness and community health initiatives that increase literacy towards HIV contraction and risks.
A 2016 report that breaks down various disparities experienced by bisexual people. The report is helpful for explaining the intersections of bisexuality, since transgender people and people of color are more likely to identify as bisexual than other social groups.