LGBTQ Cultures: What Health Care Professionals
Need to Know About Sexual and Gender Diversity

Michele J. Eliason, PhD
Suzanne L. Dibble, DNSc, RN
Jeanne DeJoseph, CNM, PhD
Peggy Chinn, RN, PhD

Publisher: Jennifer E. Brogan, MA

Authors: Michele J. Eliason, PhD; Suzanne L. Dibble, DNSc, RN; Jeanne DeJoseph, CNM, PhD; and Peggy Chin, RN, PhD

Production Director: Leslie Caruso

Managing Editor, Production: Erika Fedell

Creative Director: Larry Pezzato

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Detailed Table of Contents

Preface

Part I: Introduction to LGBTQ Cultures

Introduction to Part I

Chapter 1: Overview and Theoretical Framework

Terminology

LGBTQ

Health care professional

Patient/client/consumer

Culturally appropriate care

Why a book on LGBTQ cultures?

Why should I learn so much about a small segment of the population?

Our philosophy and basic assumptions

Underlying assumptions of this book

Theoretical framework for the book

Conclusions

Reflection questions

Awareness

Sensitivity

Knowledge

Chapter 2: What’s in a Word? Concepts Related to Sex/Gender and Sexuality

Sex

Gender

Sexual orientation

Sexual expression

Gender identity

Transgender

Transsexual

Intersex

Gender expression

Sexuality, gender, and cultural diversity

Disclosure

“Coming out”

Disclosure to health care professionals

Conclusions

Reflection questions

Awareness

Sensitivity

Knowledge

Chapter 3: The Deadly Effects of Stigma

Terms/Concepts related to stigma

Homophobia

Biphobia

Transphobia

HIV/AIDS-related stigma

Heterosexism/heteronormativity

Gender normativity

Gwen araujo justice for victims act

Internalized oppression

Lifestyle

Other forms of stigma

Social effects of stigma

Lack of recognition of relationships and family

The right to adopt

Hate crimes and violence

Social rejection

Discrimination in employment and education

Discrimination in housing

Effects of living in the “closet”

Conclusions

Reflection questions

Awareness

Sensitivity

Knowledge

Chapter 4: Myths and Facts About Sexual Orientation and Gender Identity

Myths related to sexuality

Myth 1: People could change their sexual orientation if they wanted to.

Myth 2: Minority sexual orientation is caused by sexual trauma in childhood.

Myth 3: Gay men hate women, and lesbians hate men.

Myth 4: Gay men want to be women; lesbians want to be men.

Myth 5: Gay men want to look like women, and lesbians want to look like men.

Myth 6: LGB people have uncontrolled sexual urges and try to “hit on” anyone they can.

Myth 7: LGBTQ orientation may be “contagious.”

Myth 8: Children should not be exposed to LGBTQ people nor should adults even discuss LGBTQ issues, as children might be unduly influenced.

Myth 9: Gay men are child molesters.

Myth 10: Most LGBTQ people are white; there are practically no LGBTQ people among other ethnic groups.

Myth 11: LGBTQ people do not have long-term or stable or monogamous relationships.

Myth 12: Homophobia, biphobia, and transphobia exist only among heterosexual people.

Myth 13: A person is not lesbian or gay if he or she has ever had sex with the other sex.

Myth 14: LGBTQ people are blatant: they flaunt their sexuality.

Myth 15: LGBTQ people are not happy; many are mentally ill.

Myth 16: The Bible or other religious organizations/systems say that it is wrong to be LGBTQ.

Myth 17: An LGBTQ person cannot be religious.

Myth 18 LGBTQ people want special rights.

Myth 19: Bisexuals can choose heterosexual privilege.

Myth 20: Bisexuals are confused about whether they are gay or straight; they are really gay or lesbian, but just cannot commit.

Myth 21: Bisexuality is just a phase.

Myths related to gender identities

Myth 22: There are two and only two sexes: male and female.

Myth 23: Men and women are different mainly because of their biology, not their socialization.

Myth 24: Transgender identity is rare.

Myth 25: Transgender people are mentally ill.

Myth 26: Transgender people are actually lesbian and gay people who cannot accept their sexuality, so try to change their bodies to be heterosexual.

Myth 27: Transgender identity stems from a biological disorder of sex hormones, chromosome anomalies, or brain dysfunction.

Conclusions

Reflection questions

Awareness

Sensitivity

Knowledge

Chapter 5: LGBTQ Families

Disclosure to family

Coming out to parents

Coming out to children

Coming out to spouses

Significant other relationships

Becoming parents

Child outcomes

Health-related family issues

Conclusion

Reflection questions

Awareness

Sensitivity

Knowledge

Chapter 6: Cultures Within Cultures: Diversity and LGBTQ Communities

Age differences

LGBTQ children

LGBTQ adolescents

LGBTQ young adults

LGBTQ midlife

LGBTQ elders

Race/ethnicity

Religion/spirituality/moral beliefs

Ability/disability status

Gender expressions within sexual identities

Resiliency

Conclusions

Reflection questions

Awareness

Sensitivity

Knowledge

Part II: Health Care Applications

Introduction to Part II

Chapter 7: The Effects of Stigma on Health

Effects of stigma on health

Mental health problems

Substance abuse

Alcohol use and abuse

Drug abuse

Smoking

Summary: substance abuse

Axis I mental health disorders: depression and anxiety

Body image and eating disorders

Domestic violence/intimate partner violence

Physical health disorders

Chronic health disorders

Cancer

Sexually transmitted infections and HIV

The role of stress/distress on health

The impact of stigma on health care professionals’ knowledge, attitudes, and skills

Physicians and medical students

Nurses and nursing schools

Other health care professionals

GBTQ people’s experiences with health care

Disclosure decisions

Reactions/responses from health care providers

Treatment of partners and family

Use of health care services

Conclusions

Reflection questions

Awareness

Sensitivity

Knowledge

Chapter 8: Structural Barriers to Quality Care

Making health care settings inclusive

The waiting/reception area

Health care intake forms

Clinician-personal interaction with the client

Confidentiality

Making referrals

Health care setting policies

Health equality index

Health insurance

Legal issues

Living will/medical directive

Durable power of attorney for health care/health care proxy

Hospital visitation authorization

Authorization for consent to medical treatment of minor

Durable power of attorney for finances

Wills

Trusts

Nomination of a conservator or guardian for a minor

Elder guardian/conservator

Autopsy and disposition of remains

Conclusions

Reflection questions

Awareness

Sensitivity

Knowledge

Chapter 9: LGBTQ Health Care Professionals

Physicians and medical schools

Nurses and nursing schools

Other health care professions

General recommendations for health care training

Policies

Better training and education

Support and advocacy

Conclusions

Reflection questions

Awareness

Sensitivity

Knowledge

Chapter 10: Conclusions and a Call to Action

A levels approach to change

Individual level

Institutional and community level

Societal level

The 10 things health care professionals can do

Conclusions

Part III: References and Resources

References

Appendix: LGBTQ Links and Resources on the Web

Preface

The purpose of this book is to serve as an introduction to lesbian, gay, bisexual, transgender, and queer (LGBTQ) health issues and offer health care professionals tools for creating safer and more inclusive environments for the people they serve, and a more humane workplace for their LGBTQ coworkers. It provides a broad overview of the issues that are shared among those who identify as lesbian, gay, bisexual, transgendered, or queer, but does not provide detailed information on how to care for each specific population. We provide resources in the Appendix for that more detailed information. The six chapters of Part I provide the background information on sexuality and sex/gender identities, stigma, myths and stereotypes, diversity, and family structures in LGBTQ communities that form a foundation for understanding and designing health care applications, the topic of Part II.

We are four lesbian White women from the United States and have been actively involved in lesbian social, cultural, and political circles most of our adult lives. Mickey grew up in rural Iowa in a working class Dutch and Norwegian assimilated family and resided in Iowa until she was over 50. The word lesbian was never mentioned at any time in her childhood or adolescence. Sue comes from an English, Danish, and Norwegian background. Although born in California, she went to high school and college on the East coast before returning to California. She too grew up with no concept or understanding of lesbian lives. Jeanne’s roots are Swedish, Polish, and German. She was raised in Bridgeport, Connecticut, an only child in a large, noisy, happy, Catholic, working-class extended family. Peggy grew up “haole” in Hawaii (which simply means mixed breed of European descent) and spent her early adult years as a Yankee in Texas and a gentile in Utah, which basically adds up to a life-long history as “outsider”! We now are older adults with rich personal and professional histories. We have lived through and been deeply impacted by the civil rights, the women’s rights, and gay rights movements of the United States. We each experienced the social demands to be heterosexual in early adulthood and identified as such for varying amounts of time and in various ways. We have mixed working and middle-class backgrounds, but as White women with doctoral degrees and academic careers, most of our adult experience is middle class.

Our socialization as nurses has provided a valuable lens through which to view the depth and breadth of LGBTQ experience in health care. However, in contrast to the diversity of the cultures that we write about in this book, our personal experience is relatively limited, and so we have made conscious efforts to confirm that we have represented the many subsets of LGBTQ cultures accurately. We know the United States the best but have incorporated research from other countries throughout the book and recognize that whereas some issues are the same from one geographic location to another, other issues differ. The work of writing this book has indeed been an eye-opening experience, as we challenged one another and discovered ways in which our personal experience and assumptions did not “hold” for the diverse LGBTQ cultures we wish to represent.

We have written this book with the assumption that most readers will not identify as LGBTQ and will have little or no experience with our communities. We also anticipate that readers will come to this book with varying degrees of openness to learning and understanding our experience. We hope that our approach provides a bridge to greater understanding and appreciation. If you are an LGBTQ reader, we hope that the content will affirm your experience and also provide for you the same kinds of insights and appreciations of other LGBTQ people that we ourselves experienced in the writing.

Each chapter in this book contains case examples and reflection questions for those who wish to use these materials in existing health classes, in LGBTQ health classes or certificate programs, in continuing education offerings, or to understand your own opinions and belief systems. The final chapter draws conclusions about the state of the art of LGBTQ health and outlines the action steps needed to overcome barriers to health care for LGBTQ people. We have labeled these the “10 things health care providers need to do to create a welcoming and inclusive environment for LGBTQ patients/clients.” We also provide an appendix with other resources that might be useful to those who wish to deepen their knowledge of specific topics. Our hope is that the content of this book stimulates open discussion of the influences of sex/gender, sexuality, and other human differences on health care access and quality of care. For too long, there has been silence on these issues. In the spirit of healthy dialogue, we offer this book.

–Michele J. Eliason, PhD

–Suzanne L. Dibble, DNSc, RN

–Jeanne DeJoseph, CNM, PhD

–Peggy Chinn, RN, PhD

Part I Introduction to LGBTQ Cultures

Medical, nursing, and other health care professional schools have historically ignored the needs of lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients/ clients. In recent years, however, with growing recognition of health disparities based on race/ethnicity, class, gender, and sexual orientation, the health care professions have increasingly acknowledged the need for culturally appropriate care. We are coming to believe that providing generic care means that many people receive inadequate or culturally inappropriate care and that failing to address health disparities means that some patients/ clients do not enter health care institution doors until their illnesses are far advanced, because they fear poor treatment, because they do not have insurance, or on occasion, because a health care professional has refused to care for them.

Part I introduces basic definitions and concepts related to sexuality and gender that form the foundation for Part II, which focuses on basic health care applications of this knowledge. Chapter 1 provides a rationale and a theoretical overview and lays out the underlying philosophy and assumptions for the book. Every author has an agenda for her writing. We wish to make ours transparent and do so in chapter 1. Chapter 2 addresses some of the basic concepts related to sex/gender and sexuality, confusing terms that beg more precise definition. The third chapter raises awareness of the concept of stigma and its related terms, such as homophobia, biphobia, transphobia, heterosexism, and internalized oppression, and discusses the similarities between the stigma associated with sexuality and gender and other forms of stigma. Chapter 4 reviews the most common stereotypes related to sex/gender and sexuality and provides empirical data when possible to counteract the stereotypes. Chapter 5 discusses LGBTQ relationships and families, and Chapter 6, the diversity within LGBTQ communities. The first six chapters set the stage for Part II, the application of this knowledge to health care settings and situations.

Chapter 1: Overview and Theoretical Framework

I have come to believe over and over again that what is most important to me must be spoken, made verbal and shared, even at the risk of having it bruised or misunderstood…. My silences had not protected me. Your silence will not protect you…. What are the words you do not yet have? What do you need to say? What are the tyrannies you swallow day by day and attempt to make your own, until you will sicken and die of them, still in silence?

African American lesbian poet Audre Lorde (1980, pp. 19–20)

This first chapter is offered in the spirit of the opening quote—breaking the silence about LGBTQ health care. We believe that open dialogue about sex/gender and sexual diversity is healthy and will benefit all people. We will raise issues that are controversial and have no easy resolution, and, indeed, we struggle with many of the thorny issues raised in this book ourselves. We raise them in order to challenge health care professionals to begin conversations about these issues and start identifying the steps that are needed to change the health care climate to one that is open, welcoming, and inclusive to all the people it serves. In this chapter, we introduce our core terminology, philosophy, and assumptions and provide a rationale and theoretical framework for the content and format of this book.

Terminology

A lot of space is devoted in this book to the definition and critique of words and concepts used to describe people and behaviors. Language both reflects and creates deep-seated cultural biases and anxieties, and the terminology we use sets the climate for social interactions. Chapters 2 and 3 focus on the definitions related to the concepts of sex/gender, sexuality, and stigma, but some terms are used throughout the book and need to be defined before we proceed any further. We have chosen to be as inclusive as possible in our language, but any terms we select have some limitations. We provide a rationale for our choice of those core terms now.

LGBTQ

We have chosen to use the shorthand LGBTQ when talking about the shared influences of stigma among lesbian, gay, bisexual, transgender, and queer-identified people, and other terms if we are talking about a specific group or groups. The Q could also send for questioning. Some of the previous works have focused on gay men and lesbians, or on men who have sex with men, or on transgender individuals, or on lesbian, gay, and bisexual people. We wanted to be as broadly inclusive as possible in this book and chose to include “queer” in our list of identities because a growing number of youth, and a fair number of adults, use this term to refer to their identities. Some use it as a way to reclaim a term previously used as an insult. If you call yourself “queer,” it no longer has the power to intimidate or degrade. Others use queer as a more inclusive identity that encompasses a wide diversity of sexual and gender expression, and some people use it for political reasons to point out the unique experiences of many LGBT people, who are not just like everyone else. But we also recognize that the term offends some people, that it has been used in mostly White, gay men, and academic circles, and that there is no one satisfactory umbrella term for all the diversity contained within categories of sexuality, gender, class, race/ethnicity, age groups, transnationality, and geographic locations, to name just a few. Language is always a limitation, but it is a necessary evil when communicating with each other. On one hand, it lets us share information with others, but on the other hand, it is often the source of misunderstandings and confusion with our patients. In the various literature and in social service agencies, you may see different terms used, or a different order of the terms, such as GLBT, LGBTAIQQ (lesbian, gay, bisexual, allies, intersex, queer, and questioning), or LGBTQFF (the FF standing for friends and family), LGBTQ2S (the 2S standing for two spirit), and so on.

Health care professional

We wanted a book that could be used in all types of health care settings and situations, from professional schools (medicine, nursing, dentistry, pharmacy, physician assistant, health and clinical psychology, medical social work, physical therapy, occupational therapy, and so on) to clinical settings (hospitals, clinics, residential programs, and private practices) to health policy settings (departments of public health, elected officials). The individuals who might find this book useful include, but are not limited to, clinicians of every sort, student services personnel and educators in health training programs, human resource and continuing education specialists in health fields, community health workers, and policy makers. There is no one term that encompasses them all, so we chose what we thought was the broadest term health care professional.

Patient/client/consumer

Similarly, we wanted to discuss the needs of all LGBTQ people who access health care services. In various settings, they are called patients, clients, residents, or consumers. We have decided to alternate between the use of patients and clients, because these are the most commonly used terms. People who fall into these categories may be interested in the content of this book, but we have written it primarily to address a health care professional audience.

Culturally appropriate care

There are a multitude of terms in the literature to denote some level of knowledge, skills, and attitudes about people who are different from the health care professional. These terms include cultural diversity, multiculturalism, cultural competency, cultural sensitivity, cultural awareness, culturally specific care, cultural humility, cross-cultural care, and so on. We believe that no one can fully achieve cultural competency for all the types of people she or he will encounter in health care settings, and recognizing the limitations of all the terms, have chosen to use “culturally appropriate.”

Why a Book on LGBTQ Cultures?

Why do we need a book on LGBTQ people for health care professionals? Have we not come a long way toward acceptance and adequately addressed the negative stereotypes? Indeed, considerable progress has been made, but a substantial segment of the population continues to hold negative attitudes about LGBTQ people based on lack of information, misinformation, and/or deeply ingrained belief systems about the nature of gender and sexuality. Sometimes these belief systems are rooted in religious or moral value systems, and sometimes they stem from beliefs about the way things are or are supposed to be (what is “natural” or “normal”). A portion of those people with negative attitudes treat LGBTQ people differently. Some people ignore, some discriminate, some harass, and a small minority perpetrate violence on people they perceive to be LGBTQ. When those people are health care professionals, the results can be poor quality of care, inappropriate care, or even refusal of care, and whether the violence is subtle or blatant, LGBTQ people suffer. The author of the opening quote, Audre Lorde, died of breast cancer in 1992, and throughout her life, experienced health disparities related to the totality of her experience, including her race/ethnicity, gender, and sexuality. She was a champion for “breaking the silence,” and we owe her a great debt for paving the way.

The negative attitudes have receded somewhat in recent years. Smith and Mathews (2007) compared southern California physicians’ attitudes in 1982 and 1999. In 1982, 58% were labeled as “strongly homophobic” compared with 19% in 1999. That is progress, but it still means that one in five doctors is likely to treat LGBTQ patients differently. Even in 1999, one third of physicians were against same-sex marriage (Smith & Mathews, 2007). Another study reported that 11% of physicians in New Mexico would not refer a patient to an LGBT physician (Ramos, Tellez, Palley, Umland, & Skipper, 1998). Sheldon, Pfeffer, Jayaratne, Feldbaum, and Petty (2007) conducted phone interviews about the “causes” of homosexuality with randomly selected respondents from the United States, and the stereotypes elicited were staggering. Here are a few examples of respondent comments:

It’s a female brain inside of a male body, and vice versa with a lesbian. (p. 124)

It’s something wrong with them—a brain defect or something. (p. 124)

Part of their genitals are outside and they have to make a decision whether they’re gonna be a boy or a girl at birth, so they did surgery and sometimes they didn’t always make the right decision. (p. 125)

He wasn’t accepted by his father and that had a lot to do with him being a homosexual. (p. 126)

The reason they started going with each other—because of the bad experiences that they had had with men. (p. 127)

I think a lot of time when people revert over to the same sex it’s because they done been raped by a man or a woman. (p. 127)

It might be someone at a young age was approached by someone or introduced to it. (p. 127)

It’s Satan’s work. (p. 129)

These statements highlight the confusion that some people in the general population have regarding the overlapping concepts of gender and sexuality. The respondents do not know the difference between lesbian, gay, bisexual, transgender, and intersex identities. The comments also highlight lack of understanding of the research on the relative influences of nature and nurture on development. Surely, people in the health care professions are more knowledgeable about these issues? Historically, health care training programs have been notoriously poor at including accurate, research-based information about LGBTQ issues, or sexuality in general, for that matter. A recent survey of medical school curricula showed that more than half had no formalized information about LGBTQ issues at all (Tesar & Rovi, 1998) and other educational programs, such as nursing, physician assistant programs, and others, are no more likely to include these topics. For example, a recent survey of public health programs found that only 9% had a course that “covered LGBT health topics extending beyond HIV and AIDS” (Corliss, Shankle, & Moyer, 2007, p. 1024). These findings mean that health care professionals go into clinical settings with little or no more information than people in the general population. There are few or no sources of factual information to counteract the stereotypes learned in childhood and adolescence, so they persist among many health care providers today.

Why Should I Learn so Much About a Small Segment of the Population?

Health care professionals have so much to learn about health, disease states, treatment options, and technical skills and procedures. Why should they spend time learning about subsets of the clinical population? Is that not a bad use of limited time in health care training programs? We give you three reasons here why it is important to learn the content in this book—there may be several other reasons, but these will resonate with at least some readers.

First, LGBTQ people make up a larger portion of the population than many people think. Surveys of the LGBTQ population are flawed and unreliable for a number of reasons, including how one asks the questions (e.g., many more people have engaged in same-sex activities than will adopt an LGBQ identity; many transgender people consider themselves male or female, thus are not counted) and the role of stigma (LGBTQ populations are suspicious of people who ask for this information and may not reveal their identities or behaviors to researchers or health care providers they do not yet trust) leads to an underreporting of LGBTQ identities. No one knows what the actual number is, but it is likely to be close to the 1 in 10 figure that is so often quoted (i.e., about 10%). This means that there are more LGBTQ people than there are people of the Jewish faith (about 2%), people in the world with green eyes (about 2%), and about the same number as left-handers (10%). LGBTQ patients will be found in every type of health care setting, from dermatology clinics to birthing suites, from pediatrics to geriatrics, and from substance abuse residential programs to community-based free clinics. Professionals from every discipline and specialty will encounter some LGBTQ clients and coworkers. In addition, LGBTQ people contain every other form of diversity, including race/ethnicity, gender, social class, educational levels, and national origins.

Second, everyone has gender and sexual identities and expresses them in various ways. The information in this book will help health care professionals be more aware of and sensitive to the needs of all patients/clients and more comfortable asking them about these issues. Many patients/clients of any sex/gender or sexuality want their primary health care providers to be more knowledgeable and approachable about topics related to sexuality.

Finally, the information may be personally relevant. Everyone has LGBTQ friends, relatives, children, coworkers, neighbors, and so on. Being more comfortable talking about these issues will open the individual up to the possibility of deeper, richer relationships with others and allow some readers to explore how their own sex/gender and sexuality have impacted their lives as health care professionals.

Our Philosophy and Basic Assumptions

Most authors have agendas, often hidden. The messages they give in their writing may be obvious or subtle. We choose to state our agenda directly in the form of a philosophy statement and underlying assumptions that we have about LGBTQ identities and health care professionals. Our mission for this book can be expressed as follows: To positively change the culture of health care for LGBTQ individuals.

More specifically, we believe that

- when health care professionals know about many different populations they can provide better care, make better decisions, and make better referrals;

- health care professionals are responsible to learn about the populations for whom they provide care or develop policies;

- background knowledge about LBGTQ health issues can assist both health care recipients and their direct care providers to focus their questions for each other; and

- dialogue from a position of mutual understanding is necessary to bring about equitable health care.

Underlying assumptions of this book

1. Sexual orientation and gender identity are not risk factors for health problems: stigma associated with those identities creates the risk.

2. The world, including health care settings, can be unsafe for LGBTQ people.

3. There is a lack of knowledge among health care professionals about LGBTQ cultures and people.

4. There are many different communities and cultures within LGBTQ populations.

5. Even members of LGBTQ communities have misunderstandings about health needs of other members of their own communities and may have biases and prejudices about others.

6. Clarity about definitions can facilitate understandings.

7. Learning can facilitate awareness, which can improve sensitivity and build a knowledge base that facilitates social justice.

8. Many health care professionals lack knowledge about ways to communicate their acceptance of their LGBTQ clients.

9. All people are experts on their own health, body, and experiences. It is the responsibility of the health care provider to “tune in” to that expertise.

Theoretical Framework for the Book

The ASK model (Lipson & Dibble, 2005) serves as the theoretical framework for this book. The three components of the model are awareness (A), sensitivity (S), and knowledge (K), and they apply to learning about any new cultural group. We come to each patient encounter bringing along all of our beliefs, stereotypes, and morals/values. We do not practice in a vacuum away from the lifelong influences of our cultural socialization from the media, friends, family, and religious leaders. It is critical that each person identify and take the time to reflect on potential internal barriers to quality care that have been produced by our environment. This reflection will facilitate awareness of our biases about specific groups of people and the impact these biases might have on providing quality care (both overtly and covertly). This awareness allows us to avoid verbal and nonverbal social gaffes that potentially might offend our clients and their families. We hope that all of the chapters in this book will facilitate a greater awareness of LGBTQ cultures in health care settings.

The second part of the model teaches us to be sensitive in our approach to similarities as well as differences in cultures. For example, we can examine the art, magazines, questionnaires, and forms in various health care setting from multiple perspectives. Have we unconsciously created a space that conveys a message that everyone is heterosexual by our choice of language in the intake forms and brochures and the posters on the walls? Do the materials we use reflect the cultures we serve in terms of language and visual images? Are we aware of gender diversity and have we set a climate that will allow patients to discuss their real lives with us? We address the issue of a welcoming environment further in chapter 8.

Knowledge is the final component of the ASK model, and the purpose of this book is to provide the reader with some basic information about LGBTQ cultures to build the individual health care professionals’ knowledge base. Notice, we use the plural term; the cultures within and among each LGBTQ community vary by race/ethnicity, age, gender, socioeconomic status, educational preparation, social class, and disability status, among others. Sexual orientation and gender identity are other threads in the tapestry of being human. All “facts,” especially those that we use to make decisions about a patient’s needs, must be checked out with the individual, not just assumed to be true.

Conclusion

We have explained our use of basic terminology, laid out the rationale for this book, and made transparent our assumptions and philosophy about sex/gender, and sexuality in health care settings. Finally, we have introduced a theoretical framework, ASK that is useful for understanding a wide variety of cultural differences. In the next chapter, we deal with definitions of terms and concepts related to sex/gender and sexuality, concepts that are fascinating and complex manifestations of human diversity. We will end each chapter with a set of reflection questions based on the ASK model.

Reflection Questions

Awareness

1. Think about your health care setting from the perspective of a new LGBTQ patient or client…. Would the new client find welcoming signs? What are they? Are there potential barriers to creating a welcoming environment?

2. What did you learn about LGBTQ cultures in your youth? How about college? Your health care training program? What gaps in knowledge do you have, if any?

3. What LGBTQ issues make you uncomfortable?

Sensitivity

1. How could you alter the health care environment in which you work to convey a more welcoming message to LGBTQ clients?

2. Think of a time when you thought someone you took care of was LGBT or Q. Write a short description of what you recall about your interactions with this person. How might your interaction have changed if you knew more about LGBTQ issues and cultures?

3. Think of a joke that you have heard about LGBTQ people. What would be a sensitive and appropriate response if you heard this joke told in a group at work?

Knowledge

1. What have you learned in this chapter that you did not already know? How can you use the information in this chapter in your work setting?

2. What questions do you have about LGBTQ cultures that this chapter did not answer? Make a list of these questions, and if they are answered in later chapters, make a note of what you learn. If they are not answered in the book, check the resource links in the appendix to find the answers to the remaining questions.

Chapter 2: What’s in a Word? Concepts Related to Sex/Gender and Sexuality

Silence is a knife—it cuts both ways.

Essex Hemphill, Tongues Untied (1989)

This chapter contains an introduction to important concepts and terminology related to sex/gender and sexuality. These definitions are useful in ensuring that all readers are on the same page before focusing on health care settings. We caution readers that language/terminology, styles, and fashions change over time and are highly contextual and culturally bound. Slang terms in particular are often specific to a particular age group and/or geographical region, so we do not spend much time on slang terms. Instead, we focus on the core concepts that define sexuality and gender, relying on dominant U.S. cultural constructions of sex/gender and sexuality. Non-Western cultures and even some subsets of westernized regions of the world have very different understandings of the same concepts.

Part of the reason that many people are confused about issues related to sex/gender and sexuality is that usually we are not taught a language as children about these topics in school or in our homes. They are still considered “controversial” topics and families may not discuss them openly, peers may use slang terms or use words inappropriately or in derogatory ways, and most schools shy away from any substantial comprehensive sexuality education. Taboo topics are imbued with secrecy, guilt, and a titillating anxiety for many people. No wonder our language is imprecise and laden with emotionality. This chapter provides some discussion of the words sex, sexual orientation, gender identity, intersex, and gender expression or presentation and the diversity of the definitions for these terms. The chapter ends with a brief discussion on disclosure of gender and sexuality.

Sex

This term has two meanings. The first definition refers to the physical/biological characteristics thought to distinguish men and women, such as

- Chromosomes: women have an XX pattern and men have an XY pattern;

- Genitals: men have a penis and testicles and women have a clitoris, vulva, and vagina;

- Reproductive organs: men have a prostate and testes and women have a uterus and ovaries; and

- Hormones: women have estrogen and men have testosterone.

We will address the reality of these distinctions between women and men in a later section, but for now, we just point out that they are not as simple and straightforward as they appear. The second meaning of the word sex has to do with those behaviors or internal desires that are related to pleasure and/or reproduction. We discuss these issues in a section labeled “sexual expression.” Sometimes you will hear people refer to “gay sex.” This term has little meaning because any persons can engage in a wide variety of behaviors that result in arousal—these behaviors are not limited by one’s sexual orientation or identity. The only fairly consistent difference between same-sex encounters and other-sex encounters is the likelihood of pregnancy, and even this is not a reliable difference.

Reflection: Write a definition for the word sex. Was it an easy task? Is your definition clear and unambiguous? Does it reveal underlying assumptions about sex (there are only two sexes and they are “opposites,” sex is an activity between a man and a woman, sex is for reproduction, and so on). We have not been taught to talk about sexuality openly, which means that every individual learns about sexuality in quite different ways, and there is no one universally accepted definition of sex.

Neither of the two meanings of the word is universal, completely straightforward, or consistent, as we shall see as we proceed through this book.

Consider this scenario: You are meeting your new supervisor for the first time, a person named Chris Chinn. What do you assume about Chris? If you do not know Chris’ gender, does that cause any anxiety about the first meeting? How about Chris’ ethnicity? Why do those things matter?

Gender

Usually, one of the first things we notice about people is their gender, not their sex, because this would require asking the person to undress so that we could observe their genitals, or take a blood test so we could check their chromosomes. We rarely, if ever, use the biological sex markers to categorize people; we use the gender markers, such as hairstyle, clothing, amount or type of adornment, posture, voice, and communication styles. These are the characteristics that a particular culture determines are the appropriate appearance and behavior for someone who is male-bodied or female-bodied. This means that sex and gender are conflated (interdependent) and that the use of the term “sex/gender” is more accurate when we are talking about issues of maleness/femaleness or their cultural expressions as masculinity/femininity.

Sexual Orientation

Sexual orientation is the umbrella term used to refer all the factors related to object of sexual attraction and with whom we form sexual and romantic relationships. The American Psychological Association (APA) defines it this way:

Sexual orientation is an enduring emotional, romantic, sexual, or affectional attraction toward others. It is easily distinguished from other components of sexuality including biological sex, gender identity (the psychological sense of being male or female), and the social gender role (adherence to cultural norms for feminine and masculine behavior). Sexual orientation exists along a continuum that ranges from exclusive heterosexuality to exclusive homosexuality and includes various forms of bisexuality. Bisexual persons can experience sexual, emotional, and affectional attraction to both their own sex and the opposite sex. (APA, 2004)

There are three terms that are sometimes used interchangeably in the literature: sexual orientation, sexual preference, and sexual identity. Each has a distinct underlying assumption about sexuality, as expressed in the following list:

- Sexual orientation: The biological or early childhood experiences that determine sexuality. Some think of it as biologically “hardwired,” innate attractions that cannot be altered. This term is mostly used by scientists who believe sexuality to be biological, and LGBTQ rights activists who are fighting for civil rights on the basis of the idea that sexuality is immutable like sex or race (although the concepts of sex and race are equally contested and complex social terms, not as rooted in biology as most of us were raised to believe).

- Sexual preference: The choices we make regarding sexuality; a preference can be changed or another object can be substituted fairly easily for the “preferred” choice. This term is mostly used by opponents of LGBTQ rights, who claim that people could change if they wanted to and that sexual attraction is a learned behavior. This term is the most politicized of the three.

- Sexual identity: Our internal schemas about our sexuality; the way we think about or label our sexuality. Sexual identity is one of the many components of our self-concept, working in interactions with other social identities related to our sex/gender, race/ethnicity, social class, occupation, and family roles.

Because we do not really know the differential role of biology or environment in the development of sexualities, the term sexual identity is the most neutral choice. Orientation, identity, and preference all refer to our attractions to others—what characteristics of individuals we find sexually attractive. They do not provide any information about the specific sexual behaviors a person enjoys or practices. This topic is dealt with in the next section.

In the academic literature, four sexual orientations or identities are often presented:

1. Gay: Men whose primary sexual attractions are to men;

2. Lesbian: Women whose primary sexual attractions are to women;

3. Bisexual: Men or women who are sexually attracted to people on the basis of characteristics other than their sex/gender. Bisexuality can be threatening to heterosexuals and gays and lesbians who base their identities on the sex/gender of the people to whom they are attracted; and

4. Heterosexual: Men or women who are sexually attracted to people of the other sex/gender.

Both men and women are often referred to as gay or homosexual. Younger individuals may call themselves “queer”; however, some LGB individuals consider this word offensive. On the other hand, there is a growing academic literature about queer identity, and in the near future, this term may be used as often as LGB. Many LGB individuals may also consider the word “homosexual” to be an insult, because it was a term imposed upon the community by a largely negative medical establishment. Some people may consider “asexual” as a sexual identity as well. The sexual identity categories break down when talking about the sexuality of transgender individuals. How would one label a postoperative transgender woman (born biological male) who is attracted to women? How about a preoperative transgender man who likes athletic blonds regardless of their sex/gender?

The idea that people can be defined by their sexual orientation or identity is a relatively new one, stemming back to the rise of sexology a little over 100 years ago. Prior to that time, in all cultures and all studied time periods, some people engaged in same-sex behaviors and deviated from social norms related to sex/gender, however, they were not thought to be a different type of person because of it. The term “homosexual” was first coined in the 1860s, and the labeling of same-sex behavior in the medical literature allowed people to recognize that others shared their differences and were able to form communities based on the label. In some other cultures, less influenced by western medical ideas than the United States, same-sex behavior is something you do, not who you are.

Given the lack of clarity about the terminology of sexual orientations and identities, it is safest for health care professionals to use the words that patients use to describe themselves, or use the more neutral “sexual identity.” In general, avoid terms such as “sexual preference” and do not refer to individuals as “queer” or “homosexual” unless they expressly ask you to. Sexual identities are the public facts about who people are attracted to and say nothing about a person’s private sexual behaviors. Behaviors may not be congruent with sexual identity—that is, a woman who identifies as a lesbian may have recent or past sexual experiences with men, a self-identified heterosexual man may have considerable same-sex experience, and a bisexual woman may never have had a sexual relationship with a woman. Many people use the terms “men who have sex with men” (MSM) and “women who have sex with women” (WSW) or “women who partner with women” (WPW) to reflect the disconnect between sexual identities and sexual behaviors. If the purpose is to identify only those people who are engaging in same-sex sexual activities (keep in mind that sex/gender of the partner is not a risk factor—only actual behaviors are risky or not risky), then MSM and WSW are adequate terms, although bisexual health care advocates have pointed out that it would be more accurate to say “men who have sex with men and women” (MSMW) and “women who have sex with women and men” (WSWM) (Miller, Andre, Ebin, & Bessonova, 2007). However, some people feel that to use any of these behavioral terms too broadly is an erasure of LGBTQ culture, identity, and community (Young & Meyer, 2005). After all, knowing about communities is essential to developing environmental prevention strategies to improve the health of any subpopulation, and to reduce people merely to their behavior does not reflect their whole being. Health care professionals need to address both behavior and identities.

Reflection: When were you first aware of, or begin to question, your own sexual identity? What do you think “caused” your sexual attraction patterns? These are relatively easy questions for openly LGBTQ individuals, because the coming-out process requires thinking about these issues, but heterosexual people often must think long and hard about this. Heterosexuality is taken-for-granted, but if people take this question seriously, they will see that many expectations and pressures were put upon them from family, religion, popular culture, education, and peers to be heterosexual. (Eliason, 1995)

Sexual Expression

Sexual expression refers to how we act out our sexual desires, including what we like or do not like sexually and what arouses us or turns us off. Some of this comes from our biology, but probably most of it comes from our conditioning, societal taboos or norms, personal experiences, personality styles (thrill seekers vs. don’t rock the boat) and our partners’ characteristics and wishes. People engage in a wide variety of sexual behaviors for a wide variety of reasons, ranging from solitary activities (looking at sexually explicit materials on the computer, fantasizing, or masturbating) to behaviors with other people, and from motives of curiosity, seeking pleasure, wanting to get pregnant, or other motives such as revenge, boredom, wanting to please a partner, rebellion, or wanting to hurt someone. These motives are not attached to particular sexual identities. There are huge cultural variations in what is considered sexual (and sexy), and these cultural norms are often contradictory. What is pronounced as “normal” or “conventional” by some forms of popular culture varies considerably from what is “normal” by conservative religious standards. What one person labels as sex, another does not (think about the controversy over whether or not former U.S. President Bill Clinton had sex with Monica Lewinsky). In contemporary U.S. culture, behaviors that are portrayed in the media as “sex” might include kissing, fondling, masturbation, mutual masturbation, rubbing genitals against each other, oral sex, vaginal sex, and anal sex. Other things that may or may not be considered sex might be bondage, role-playing, wearing fetish clothing (e.g., leather), watching sexually explicit images, watching others have sex, etc. None of these behaviors are linked tightly with one’s sexual orientation or identity.

Table 2.1 contains a chart of how the different components of sexuality and gender might manifest in individuals. There are infinite combinations and possibilities, testimony to the diversity of the human experience and imagination.

Gender Identity

Gender identity refers to one’s self-concept as male or female, masculine or feminine. Gender identity is established quite early in life, with most children being able to identify their own gender by age 3, and they start to categorize others on the basis of gender stereotypes (called gender schema in the developmental psychology literature) soon after that. Most women and men, regardless of their sexual identities, have a gender concept that is fairly consistent with their physical bodies. People who do not have a consistent gender identity and physical body gender presentation are referred to as transgendered.

Transgender: The term transgender is used to describe people whose gender identity is not congruent with their sex as assigned at their birth and is an umbrella term that can contain people who are quite diverse, such as transsexuals, cross-dressers, drag queens, and drag kings (gay men and lesbians, respectively, who cross-dress on occasion), butch lesbians, and androgynous people (Stryker, 2008). Coined in the late 1980s, the term transgender caught on in a big way in the 1990s following the publication of a pamphlet by Leslie Feinberg titled “Transgender Liberation” (Stryker, 2006). But exactly who is included in the term?

Transsexual: The term transsexual is used by the medical profession to define those individuals who seek interventions to change their bodies to align with their psychological gender. Some activists use the term “transsexual” (one “s”) instead of transsexual (Wilchins, 1997). A male-to-female (also written as MTF, MtF, or M2F) transgender individual is a transgender woman (“trans woman”) and a female-to-male transgender (FTM, FtM, or F2M) individual is a transgender man (“trans man”). Some individuals in the transgender community do not identify as either male or female, but “gender queer” or gender crosser (McCloskey, 1999) or some other term. Transitioning is the process that some transgender people undergo to bring their outward gender expression into alignment with their gender identity. Transitioning can involve medical treatments such as hormonal therapy, cosmetic procedures, chest surgery (“top surgery”), and genital surgery (“bottom surgery”), as well as behavioral/psychological interventions such as speech coaching, electrolysis, counseling, and learning how to dress/present like the other sex (Israel & Tarver, 1997; Lawrence, 2007; Lombardi, 2007).

Table 2.1 Fictitious examples of various components of sex/gender and sexuality

Some gender nonconforming people do not identify as transgender and may express their individuality in dress, in behaviors, and/or in speech (e.g., Skidmore, Linsenmeier, & Bailey, 2006). Some of these individuals identify as “gender queer,” “butch,” or other terms. Cross-dressers, who are often called “transvestites” in the medical literature, are predominantly heterosexual men who like to dress in women’s clothing on occasion but do not wish to permanently become women. They may or may not identify with a community or call themselves transgendered. The organization Tri-Ess addresses common issues of heterosexual cross-dressers (see the Appendix for links to this and other organizations).

Intersex

Intersex is a term used for a number of biological conditions or physical variations in which a person has reproductive or sexual anatomy that does not fit the typical parameters of female or male bodies. Some people may refer to such individuals as “hermaphrodites,” but this term is both inaccurate and offensive. A person might be born appearing to be female on the outside but having mostly male-typical anatomy on the inside, or with genitals that seem to be in-between the usual male and female types—for example, a girl with a noticeably large clitoris or lacking a vaginal opening, or a boy with a notably small penis or with a scrotum that is divided like a labia. Some people who appear to have completely female bodies are found to have XY chromosome patterns. Some of these conditions are not noticed at birth, and they manifest only later in childhood or around puberty, yet others are not identified unless the person seeks assessment for infertility or on autopsy. Some of these conditions require medical or surgical interventions, but many others do not. Some authors suggest that as many as 1 in 100 individuals has some form of intersex variation (Blackless, Charuvastra, et al., 2000). See www.isna.org/faq/what_is_intersex for more information. People with intersex variations may have lesbian, gay, bisexual, or heterosexual orientations and identities, and they vary as much as any other group on gender identity and gender expression. Recently, some people with intersex conditions who were subjected to invasive procedures as children before they could be consulted about their wishes have formed social and political organizations to campaign for more humane treatment. Some people who identify as intersexed also align with the LGBTQ communities, because of the similarities of experiences of stigma, shame, and secrecy.

A well-publicized case that was reported in many news venues in 1997 told the story of one of twin brothers who was mutilated during circumcision at the age of 8 months. A decision was made to raise this biological boy as a girl, renamed as Brenda. Famous sexologist John Money followed the case and reported successful adaptation to a female role. However, later researcher Milton Diamond encountered this individual who wanted the story to go public. Diamond found that Brenda never felt comfortable in a female role, and when s/he found out what had happened in infancy, at the age of 14, he reverted to a male role and started living as David. David committed suicide at age 38. In this tragic case, nature seemed to trump nurture (see Colapinto, 2000, for the whole story).

Gender Expression

As noted above, sex/gender can include biological components such as genitalia, but mainly we recognize gender by the way people express themselves through choices in clothing, hairstyles, accessories, body postures, communication styles and voice, and other behaviors. A person with XX chromosomes, a vagina, and a uterus may be comfortable being a woman, regardless of sexual identity, but may choose more “masculine” attire (defined by the culture) and body postures and may self-identify or be called “butch.” Other biological women may choose more traditionally feminine gender expression and use a label or be recognized as “femme,” “girly,” or “feminine.” Yet, others are androgynous in their appearance and behaviors. The same is true of people with typically biological male bodies, although the terms may differ. For example, the term effeminate has sometimes been applied to boys or adult gay men who have feminine interests or behaviors rather than the term femme. Because “effeminate” is not a word of the LGBTQ communities’ choosing, it may be considered offensive by many. Some gay and bisexual men may call each other “girl” or “girlfriend” in a jesting play on gender, but it does not mean that they identify as transgendered or think of themselves as female in any way. Transgender individuals may express a disconnection between their physical bodies and the gender they perceive themselves to be, and they may strive to match their physical appearance with their internal gender concepts. Some individuals “play” with gender expression, such as cross-dressing for fun or political reasons on occasion, whereas others live more permanently within one part of the gender continuum. Gender expression is an ever-changing cultural construct, determined by fashion trends, religious beliefs, family socialization, developmental phase, and many other factors. Because sex and gender are so overlapping, some theorists use the terms together sex/gender to refer to gender expression. Take a look again at Table 2.1 for some examples of how any individual might vary across the many dimensions of sex/gender and sexuality.

Reflection: How did you express your gender today? Did you make a conscious choice to appear more masculine, feminine, or androgynous in your appearance? How much variation is there in your own gender expression from day to day? If you have access to childhood pictures, what clues are there in those pictures about your gender expression? Were these signs of gender of your own choosing?

Sexuality, Gender, and Cultural Diversity

Definitions of sex/gender and sexuality in the academic literature developed out of White European, middle-class values and belief systems, and people from other cultural groups may use different terms (e.g., mahu in French Polynesia; hijras in India and Pakistan; fa’afafin in Samoa; or tomboy in the Philippines) and have different understandings about sex/gender and sexuality (Herdt, 1994; Roscoe, 1998). As an example, the term two spirit is used by some people who are indigenous to the Americas to describe sexuality and gender. The term does not equate exactly to lesbian, gay, bisexual, transgender, or intersex but denotes a greater level of sexual and gender fluidity that is common to many American Indian groups (Fieland, Walters, & Simoni, 2007; Tafoya & Rowell, 1988). Similarly, the slang terms used to refer to gender expression vary by geographical region and community, and terms such as “bulldyke, “fairy,” “stud,” and “bulldagger” might be used to describe a person’s gender expression. Many researchers use the term sexual minority, rather than lesbian, gay, or bisexual, as an umbrella term that encompasses same-sex attraction, behavior, and identity, because there is considerable fluidity and flux among these different ways of viewing one’s sexuality, particularly in many adolescents (Diamond, 2006; Russell, 2006), regardless of whether or not the youth give a label to their sexualities. We will discuss diversity in sexual and gender expression and identities in more detail in chapter 6.

Youth often reject labels (and a growing number of adults do as well) as people recognize that sexual desire does not need to be attached to gender. As one respondent in a study said: “Labels don’t really matter because when I’m falling in love or whatever, I’m falling in love with the person’s soul and packaging is incidental.” (Diamond, 2006, p. 84)

Another issue related to “cultural diversity” is the criticism some people make about including LGBTQ issues in larger diversity training programs or curriculum. They often argue that sexual or gender identities do not constitute “culture.” It is certainly true that there are differences between ethnic minority cultures and LGBTQ cultures (see chapter 6 for a longer discussion of this issue). Most LGBTQ people are not born into a sexual/gender minority culture in which they are socialized for their role in the culture during childhood—instead, LGBTQ people consciously adopt the culture later in life. Reasons that LGBTQ may be considered a cultural community include the following:

1. LGBTQ people often organize around a common identity—most express that they are part of a community that has some shared beliefs (e.g., that homophobia, biphobia, and transphobia need to be eradicated; that LGBTQ people deserve full rights and benefits; that same-sex relationships are normal and healthy).

2. There is a long and extensive LGBTQ history. Same-sex behaviors and gender crossings have been noted throughout recorded history, although the trend to label these behaviors as identities only has a history of about 100 years. The contemporary LGBTQ movement often dates itself from two major events: January 1, 1965, when police raided a San Francisco drag ball, and June 27, 1969, the day that a police raid on a gay bar in New York City, called the Stonewall Inn, erupted into a riot that lasted several days and spawned gay liberation groups to emerge across the country. Of course, it was not as simple as one or two events creating a movement, rather the entire climate of the 1950s and 1960s civil rights and women’s liberation movements set the stage for a gay liberation movement as well.

3. LGBTQ communities have developed a unique language. Terms such as coming out, passing, the closet, transitioning, stealth, top/bottom, butch/femme, queen, MTF, and FTM are commonly understood by people in LGBTQ communities.

4. There are well-organized social and political organizations within LGBTQ communities, including restaurants, book stores, social service agencies, choirs and bands, clubs, informal online chats and message boards, bars, music festivals, cruises, and local, state, and national political organizations.

5. There are almost universal rituals and rites of passage in LGBTQ communities, including individual rites such as coming out to self, coming out to others, and the experience of rejection and discrimination; group rituals such as gay pride rallies and parades; and the experience of the first time attending a gay bar or social group.

6. There is clear evidence of cultural productions. LGBTQ people have created music, poetry, literature, and art that reflect their experiences as oppressed minorities and as part of a unique cultural group. For example, the AIDS quilt reflects grief over loss of so many LGBTQ people to AIDS but is also a form of artistic and social expression about community. Another example is the rainbow flag that represents the vast diversity of LGBTQ communities.

Just because LGBTQ communities might be considered a “culture” or community does not mean that all LGBTQ people agree on everything. On the contrary, there are vast differences in opinion about marriage, monogamy, sexual values, how to go about getting equality, politics, religion, gay pride parades, and everything else you can think of. This is true of any social identity: Put a group of people who call themselves “feminists” or “democrats” in a room and see if they agree on all the important issues!

Disclosure

Most of the time sexual and gender identities are not visible differences, and most LGBTQ people cannot be reliably identified by their appearance. The majority must proclaim their identities in some way if they want others to know. Research on disclosure of sexual/gender identity has taken two forms: most of the literature has focused on the processes that LGBTQ people undergo to adopt an LGBTQ identity, often referred to in the lay literature as coming out. A smaller body of research has examined the effects of revealing one’s sexual or gender identity to others, including health care professionals, a process called disclosure. Both sexuality and gender identities are important factors for health care professionals to know to provide the highest quality and most relevant care.

“Coming Out”

Older models of sexual identity formation described it as a linear process progressing from a same-sex attraction to same-sex behavior and culminating in adopting a stable and consistent gay or lesbian sexual identity (Cass, 1979, 1996; Eliason, 1996a, 1996b; Troiden, 1988). The studies that informed these early models were generally based on retrospective memories of adults (mostly men who identified as gay). Prospective studies, and those with more diverse samples, have indicated that the processes are much more complex than this and involve a great deal of fluidity, periodic reevaluations of the identity, and changes in the labels used for one’s sexuality or gender (Diamond, 2006; Eliason & Schope, 2007). Some people never adopt a label of lesbian, gay, or bisexual in spite of considerable same-sex experience, and some explore various forms of gender expression without adopting a transgender identity.

There has been little research on sexual identity formation processes for bisexual and transgender individuals (exceptions include Fox, 1995; Devor, 2004; Rust, 1996), but it does appear that identity formation is even more complex for people who fall between the binary positions of society, such as man/woman and gay/straight. Whether or not coming out is a linear process with identifiable steps or stages, or a more cyclical or free-flowing process, all people who have a sexual identity (whether LGBTQ or heterosexual) have experienced some sort of process that informs their self-identities (Eliason & Schope, 2007). Common experiences of this process include confusion and questioning, experimenting, feeling alienated, feeling different from others, fearing rejection from others if they reveal their identity but also feeling inauthentic or fraudulent for not disclosing, preferring to be around other people of the same identity (isolating oneself in LGBTQ communities), integrating the sexual or gender identity into the larger self-concept, or becoming an activist and celebrating the difference. For heterosexual people, the processes may be taken-for-granted and not involve alienation or fears of rejection, or they may include confusion, anxiety, and experimenting.

There is some evidence that the process of questioning one’s sexual or gender identity is the most stressful point of the process, because thoughts of having a nonnormative gender or sexuality raise fears of rejection by loved ones and by peers (Meyer, 2007). The stress of the questioning phase may be associated with increased frequency of depression/anxiety, suicide thoughts or attempts, and other health risk behaviors such as substance use and misuse, and unsafe sexual experiences. These will be explored in more detail in a later chapter.

George is a 32-year-old middle school teacher in a small city with only one hospital. Following a nasty cold, he develops pneumonia and goes to the emergency department (ED). He informs the doctor that he is gay but not out in the community. He is tested for HIV and is negative, and he is also treated for the pneumonia. The next week when he returns to school, there is a derogatory message written on the blackboard of his homeroom. He eventually discovers that the husband of one of his coworkers was employed as a nurse in the ED and told his wife the details of George’s ED visit, and the wife then told other teachers and students that he is gay. George’s faith in confidentiality has been destroyed, and he now faces harassment and potential discrimination in his workplace.

Disclosure to health care professionals

Because sexual and gender identities are usually not visible differences, they generally require disclosure to others, including health care professionals. The majority of health care professionals do not ask about sex/gender identities, instead making the assumption that all patients are heterosexual. This puts the onus on the client to disclose, creating undue burden on the one who is in the most vulnerable position. Therefore, deciding whether to disclose one’s identity to a health care professional can be a very stressful event. In a study of lesbians in Oregon, 90% had disclosed to a health care professional, and 92% of those had to raise the issue themselves (White & Dull, 1997). In another study, 61% of lesbians and gay men reported that a health care professional had never asked them about their sexuality (Stein & Bonuck, 2001), and a national survey of lesbians found that 37% had delayed health care in the past year because of fear of discrimination (van Dam, Koh, & Dibble, 2001). In one of the few studies to compare gay mens’ and lesbians’ experiences with disclosure (Eliason & Schope, 2001), lesbians were more likely to have disclosed their sexuality to a health care provider, and they were also more likely to report that they were hypervigilant in health care settings than were gay men. Whereas many gay men and lesbians had actively told their health care professionals about their sexual identities (37%), a subset had relied on “passive disclosure” (15%) and assumed that their providers knew, although they had not actually told them, and others reported that the health care professional did not ask, so they did not tell (38%).

There are many reasons that LGBTQ people may not disclose, including fear of homophobic reactions, being early in the coming-out process, being single, or holding a belief that one’s sexual orientation is private (Boehmer & Case, 2004; Eliason & Schope, 2001; Hitchcock & Wilson, 1992; Schatz & O’Hanlan, 1994; Stevens, 1994). LGBTQ people who disclose often do so because the environment seems safe and/or they had done preparatory work in researching the health care professional before scheduling an appointment.

A woman in treatment for breast cancer remarked about her decision whether or not to disclose to the surgeon that she worried that finding out she was a lesbian might cause the surgeon to “…take another snip out that she is not supposed to?” (Boehmer & Case, 2004, p. 1885)

LGBTQ people of color may be even less likely than White LGBTQ people to disclose their sexuality to a health care professional because of cultural norms about the privacy of sexuality (Chng, Wong, Park, Edberg, & Lai, 2003; Diaz, 1998; Dowd, 1994; Gomez & Marin, 1996), religious beliefs (Woodyard, Peterson, & Stokes, 2000), not relating to the White gay culture (Wolitski, Jones, Wasserman, & Smith, 2006), or family obligations related to marriage and family (Morales, 1990). There may be even greater mistrust of health care professionals and systems among LGBTQ people of color than White LGBTQ people because of historical abuses (Battle & Crum, 2007; Greene, 1997; Wilson & Yoshikawa, 2007).

Disclosure decisions may vary by generation, gender, ethnicity, couple status, and reason for seeking care. Several studies have indicated that many LGB patients would prefer that health care professionals ask them directly about their sexuality, either in written or oral assessments. Lucas (1992) reported that 64% of lesbians wanted health care professionals to ask directly about sexual identities, and in a study of LGBT youth, 64% also indicated that they wanted their health care professionals to ask about sexual identities (Meckler, Elliot, Kanouse, Beals, & Schuster, 2006).

On the questionnaire, optional information was “Were you heterosexual, lesbian, or gay or bisexual?” And that was wonderful. I could just tell him and they wouldn’t be asking if they weren’t open and aware. (Barbara, Quandt, & Anderson, 2001, p. 56)

Situations in which disclosure might be unlikely could include

- older LGBTQs who grew up in a more restrictive, homophobic environment than today;

- LGBTQs of color who have more to lose by disclosing, for example, losing the support of family within a racist society;

- LGBTQ people from working-class backgrounds who might not feel as empowered or privileged as middle- or upper-class LGBTQ people;

- LGBTQs in the military for whom “don’t tell” is a mandate;

- LGBTQ people who receive support and comfort from religious institutions that would potentially reject them if they came out;

- situations in which sexuality is not considered to be relevant, such as being treated in an ED for a minor injury;

- LGBTQ people who fear loss of custody of children if they disclose;

- others who are early in the coming-out process themselves and not ready to talk to anyone about it;

- LGBTQ health care professionals who fear gossip about them will spread, or fear that their confidentiality will be compromised;

- LGBTQ teachers and childcare workers for whom “don’t tell” is an understood but unspoken rule; and

- those who fear loss of insurance benefits.

Of course, some individuals in all of these situations may disclose their sexuality/gender identities to a health care professional because they feel they will receive more appropriate care that way or they have developed a level of trust in the health care professional, so they feel safe. Disclosure decisions are highly individual, and only the individual can determine if conditions are “safe” enough for disclosure.

Conclusions

Concepts related to sex/gender and sexuality are under constant transformation in our rapidly changing world. Our understandings of the role of biology, social environment, and societal norms and expectations influence the language we use. However, all language is ultimately limiting and too often becomes a barrier to communication. For health care professionals, the best way to work with LGBTQ clients is to put aside all assumptions and expectations, and treat each person as a unique individual.

Reflection Questions

Awareness

1. If you identify as heterosexual, what would you stand to lose if you came out as LGBTQ? How would your family of origin respond? How would it affect your religious or spiritual beliefs or their practice, your friends, employment situation, and community?

2. If you identify as LGBTQ, have you shared your identities with your primary health care provider? If yes, what was that experience like? If no, why not? Do you have any evidence that the provider would not be accepting? What evidence do you have?

3. What signs or symbols do you associate with gender and sexuality? In other words, do you rely on markers such as a ring on the left-hand ring finger, body piercings, whether a person’s gestures are “feminine” or “masculine,” hair length or hairstyle, or occupation to make guesses about a person’s gender or sexual identity?

4. Do you believe that sexuality is biological and fixed, or fluid and changeable?

Sensitivity

1. If you work in a clinical setting, how could you word questions when taking a history from a patient so that you are perceived as sensitive to the nuances of sexuality and gender?

Knowledge

1. Does anything in this chapter help you better understand the sexuality and/or gender of someone you know? If so, how?

2. Discuss some of the terms in this chapter with coworkers and ask them to share their definitions. Do those definitions reveal any of the confusions or misperceptions discussed in this chapter?

Chapter 3: The Deadly Effects of Stigma

The health care system is so imposing and it is so daunting. It is not me looking in someone’s eyes and having them understand that I have a problem that they have the expertise to help me, but it is in fact me out here off to the side terrified that the first person that I see is going to do something to shame me or embarrass me or cause me to be ridiculed in front of other people.

Hussey (2006, p. 137)

In chapter 2, we introduced terms related to sexuality and gender. Why have variations in the development of sex and gender been considered as forms of deviance? The process has been called stigmatization. This chapter defines and critiques the terminology used to describe the effects of stigma. From the Greek, stigma is derived from the term tattoo, referring to marks placed on the body of a person labeled as criminal or deviant. Stigma operates through a process of separating oneself from people who are “not like me,” a practice often called othering. This process of rendering some people as “others” can lead to dehumanizing of the other group. We choose to stigmatize some human differences such as skin color or minority sexual identifications, whereas other differences are not stigmatized, such as left-handedness or eye color. As you will see, there are many terms and concepts used to describe stigma, leading to some confusion. Language is constantly evolving, and terms used in psychology may differ from terms used in the health sciences. We will try to include as many of the terms used for each concept as possible, but recognize that we will miss some of them, and define other terms differently from some other authors in this field. That is an occupational hazard of being in a newly emerging field of study. The first section of this chapter examines the concepts and terms related to stigma, and the second section addresses the effects of stigma.

Goffman (1963) first applied the term stigma to sexuality, likening minority sexual identification to a “spoiled identity,” leading to a sense of inferiority and isolation from the mainstream. We will explore the far-reaching effects of gender and sexual stigma on health and well-being in chapter 7, but it is becoming abundantly clear that the stress of being LGBTQ arises from stigma, not from the sexual or gender identities in and of themselves. Stigma is the umbrella concept under which the other terms in this chapter fall. Stigma results in inordinate stress that increases the chance of physical and mental health problems in LGBTQ people. The rest of this chapter explores the terminology used to describe the effects of stigma on the basis of minority sexual or gender identifications, but the concept of stigma is also useful when exploring health disparities for women, racial/ethnic minority individuals, and many other vulnerable populations.

Stigma-related terms pertaining to LGBTQ people include homophobia, biphobia, transphobia, AIDS-related stigma, heterosexism and heteronormativity, gender normativity, “lifestyle,” and internalized oppression. Similar processes underlie racism, sexism, classism, and other systems of oppression that intersect with gender and sexual identities for many LGBTQ people. Near the end of this chapter, we discuss some of the similarities and differences among the various forms of oppression that are common today. All forms of oppression involve privilege. In our use of the word, privilege refers to the unearned rewards that are granted solely on the basis of belonging to a certain class of people and is based on a belief that one class of people is superior to others. Men, regardless of other identities, have male privilege; White people have White privilege; heterosexual people have heterosexual privilege. These privileges are largely invisible and taken-for-granted by those who have them, but painfully obvious to those people who do not. People with privilege are the ones who get to set the “norms” of society, and those norms often exclude or marginalize those without privilege. The terms described in the next section help demonstrate how privilege is maintained.

Terms/Concepts Related to Stigma

Homophobia

Coined by a psychologist in the 1970s (Weinberg, 1972), homophobia was originally defined as an irrational fear of lesbian and gay persons. The term has been widely criticized in the research literature, as often it is not irrational or based in fear and it is not similar to other phobias, but the term caught on despite its shortcomings. It is now understood to refer to any negative attitudes about LGBTQ persons. One good thing about the term is that it puts the blame for stigma on the person who holds the negative attitudes, not the gay or lesbian person. Some authors suggest that the term sexual prejudice (Herek, 2004) is more appropriate and more inclusive. Another term that is used in some of the literature is homonegativity.

Considerable research has examined the predictors or correlates of homophobia or sexual prejudice (Eliason, 1998; Eliason & Raheim, 2000; Herek, Chopp, & Strohl, 2007). In general, sexual prejudice is more common among

- men than women;

- youth and older adults than young and midlife adults;

- people from evangelical and fundamentalist religions than less conservative religions, or people without formal religious affiliations;

- people who are racist and sexist versus those who are not;

- people who have conservative views about sexuality, such as negative attitudes about masturbation and premarital sex;

- in the United States, people from the south and midwestern regions rather than other regions; and

- people with unacknowledged or unaccepted same-sex desires in themselves.

Homophobia or sexual prejudice is seldom an “all or none” phenomenon. It is best described as a continuum of attitudes that range from very mild discomfort to very negative reactions. The varieties of homophobia may also be qualitatively different from one another and require different interventions to address them. Table 3.1 shows one attempt to categorize some of the varieties of attitudes about LGBTQ people (Eliason & Raheim, 1996) and suggests what interventions might work best to move individuals with negative attitudes to more positive positions along the continuum.

Biphobia

The term biphobia has similar conceptual problems to homophobia but is commonly used to refer to negative attitudes about bisexual persons. There is sufficient evidence that homophobia and biphobia have considerable overlap and many of the same factors (such as conservative religious affiliation and sexist beliefs) predict both, but there are also unique differences (Eliason, 1997). Some gay men and lesbians are biphobic, sometimes for different reasons than heterosexual people may be biphobic. These reasons have been reported anecdotally to be related to a sense of betrayal. Some gays and lesbians have been heard to wonder, “If there is a revolution, whose side will you take?” In reality, many people have dual or multiple identities that are experienced as part of their whole. We often have situations in which one part of our identity is in conflict with another, and we must choose. For example, when a child is sick or in trouble, many people choose to express their parental role over the expectations of their work role. LGBTQ people of color may experience racism more acutely than sexual prejudice and choose to belong to political organizations that combat racism rather than LGBTQ organizations. That does not mean that they reject their sexual identities, but prioritize where to put their energies at any given time.

For heterosexual as well as gay and lesbian persons, sexual orientation is defined by the sex/gender of the partner or the potential partner. Bisexuality challenges the centrality of sex/gender to a person’s core identity by proposing that characteristics other than sex/gender are more critical in sexual desire and relationships. In general, there is more stigma attached to male bisexuality whereas female bisexuality is sometimes glorified, particularly in heterosexual male-oriented pornography (Eliason, 1997; Mohr & Rochlen, 1999). Male bisexuals have been accused of spreading HIV and other sexually transmitted infections to their heterosexual female partners and have been labeled as deceitful and deviant. There is a big difference between cheating on one’s partner or spouse with a person of a different gender and adopting a bisexual identity. People of any gender or sexual identity can be deceitful and unfaithful—bisexual people are no more likely to cheat on their partners than anyone else. Anyone who is having unsafe sex behind a partner’s back is putting the partner at risk. Later in the book, we will discuss the phenomenon called “the downlow.”

A woman who had identified as lesbian unexpectedly fell in love with a male friend and reported, “Overall, people have been supportive, but I’ve definitely seen some nastiness because of it. One lesbian I know, she said it was just a phase, that I was misguided, that she didn’t want him in her house. It made me angry, it made me cry, it made me question—I mean these were the same types of things I heard from straight people when I first came out about having relationships with women.” (Diamond, 2006, p. 82)

Biphobia arises from the stereotypes about bisexuality, such as

- it does not exist; people are either gay or straight;

- it is a phase;

- it is “trendy”;

- it means that monogamy is not possible;

- bisexuals are confused;

- bisexuals are fence-sitters (unable to commit to a gay or straight identity); and

- bisexuals are responsible for introducing HIV/AIDS to heterosexual communities.

Gay men and lesbians may hold these stereotypes about bisexual people, as well as believe that bisexuals can exercise heterosexual privilege. These stereotypes are addressed in chapter 4.

Table 3.1 Experiences of Discrimination in Midlife Adults in the United States

Transphobia

Negative attitudes about transgender people often stem from deeply ingrained cultural beliefs that there are two and only two sexes, therefore a person must be male or female, and that gender is derived from biological sex. For example, if you have a male body, you are a man (forever) and your gender expression must be stereotypically male and masculine. We are only recently beginning to comprehend that these are stereotypes, not as rooted in biology as we once thought. But gender stereotypes run deep and hate crimes against transgender individuals are often even more horrific and violent than those reported for other groups.

On the night of October 3, 2002, four young men found out that their friend, Gwen Araujo, was biologically male. They kneed her in the face, slapped, kicked, and choked her, beat her with a can and a metal skillet, wrestled her to the ground, tied her wrists and ankles, strangled her with a rope, and hit her over the head with a shovel. She begged for mercy, offered money in a desperate attempt to buy her freedom, and said her last words, “Please don’t. I have a family.” Her killers buried her in a shallow grave and went to McDonald’s for breakfast. (Steinberg, 2005, pp. 1–2)

Notably, although homosexuality was removed from the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1973, gender identity disorder, defined as a strong and persistent cross-gender identification combined with discomfort with anatomical sex, as well as transsexualism, was added to the DSM in 1980. In the next version of the DSM in 1994, transsexualism was collapsed into the gender identity disorder category (Stryker, 2006). At the time when sexual orientation was depathologized, gender identity disorder became a psychiatric diagnosis. Even people with fairly positive attitudes about lesbians and gay men may have more negative attitudes about transgender people. For example, in one of the few studies that examined attitudes toward LGB and T people separately, there were more reports of feeling uncomfortable and carrying negative attitudes about transgender clients among a large sample of substance-abuse counselors from urban and rural communities (Eliason, 2000; Eliason & Hughes, 2004). Figure 3.1 shows these data.

Figure 3.1 Percentage of substance abuse counselors with ambivalent or overtly negative attitudes about lesbians, gay men, bisexuals, and transgender individuals. From “Substance Abuse Counselors’ Attitudes About Lesbian, Gay, Bisexual, and Transgendered Clients,” by M. J. Eliason, 2000, Journal of Substance Abuse, 12, pp. 311–328.

HIV/AIDS-related stigma

HIV/AIDS is also a stigmatized condition, related to its “contagion,” the fact that it is often terminal, and the fact that it can be transmitted through sexual activities. HIV/AIDS-related stigma represents the intersections among homophobia/biphobia/transphobia, racism, and classism. Assigning a label of “diseased” or “contagious” has been one way that stigma has formed the boundaries between the acceptable and the unacceptable. HIV/AIDS is still considered by some people to be a “gay” disease and contributes to shunning LGBTQ people whether or not they are HIV positive (Padilla, Vasquez del Aguila, & Parker, 2007). The high prevalence of HIV/AIDS among intravenous drug users, poor people, people of color, as well as gay, bisexual, and MSMW, contributes to the idea of HIV-positive people as “throwaway” populations, who got what they deserved from engaging in deviant behavior. No one deserves death and disability, and HIV risk is associated with specific behaviors, not classes of people, yet the association of HIV with certain populations persists.

Heterosexism/heteronormativity

Homophobia, biphobia, and transphobia are generally used to refer to individual belief systems or attitudes (prejudice) and behaviors that stem from those attitudes. However, there are larger societal- and institutional-level influences that support and give power to the individual attitudes and behaviors. The terms heterosexism and heteronormativity are used more widely in the academic literature than in lay usage, and they refer to institutionalized belief systems found in most or all of the dominant discourses of a society, such as the media, education, medicine and health care literatures, legal systems, and religion (Morin, 1977). These are the systems that set laws and the unspoken “norms,” establish how people who deviate from the laws and customs will be dealt with, and often, how they will be punished. Heterosexist belief systems state that only heterosexual relationships between one man and one woman are “normal.” This belief system was solidified into federal law by the Defense of Marriage Act, passed in 1996, and is based on an assumption that all “normal” people are biologically heterosexual. In reality, no one knows what “causes” a person to be heterosexual—there is virtually no research on this. Freud was one of the first to challenge the belief that heterosexuality is biological, by proposing that family and environmental circumstances in early childhood determined sexual orientation. Most research takes for granted that people are born male or female and straight or gay, but as we have seen, there is considerable diversity within the categories of gender and sexuality.

Reflection: Think about your elementary school days. Did any of the storybooks that your teachers or parents read to you have children from households with two dads? Did the Dick and Jane readers or their equivalent have any transgender boys and girls? If your family went to church, synagogue, temple, or mosque, what did you hear about LGBTQ people there? In the media? From your family? Until fairly recently, LGBTQ people were absent from most discourses, or if present, were discussed in the most negative light. What effect does that have on adult attitudes about LGBTQ people?

One example of heteronormativity can be found in the forms that we are asked to fill out in health care settings. Most standardized forms are based on the assumption that everyone is heterosexual and there are no options for same-sex identities or relationships. Some people consider heteronormativity to be the source of heterosexual privilege. People who are heterosexual in the United States can, among other things, take a date to the prom without raising an eyebrow, get engaged and married with family and community support and be legally recognized as a couple/family, profit from the multiple financial benefits given to legally married couples, not feel afraid that they may be beaten because of their sexual identity, not worry that their children will be discriminated against or taken away from them, and not feel they were passed over for promotion because of their sexual orientation. The power of heteronormativity can be seen when some LGBTQ people mimic heterosexual relationship patterns, because that is all they have been exposed to. This concept is sometimes called “heterorelational,” and it refers to thinking that relationships need a male figure and a female figure to be viable.

Reflection: Imagine that tomorrow morning you wake up in the body of the other sex. How would your life change?

Gender normativity

Similar to the concept of heteronormativity, gender normativity refers to institutionalized belief systems about sex/gender: that there are only two sexes (and, therefore, genders), that the sexes are “opposite,” and that everyone must be one or the other. Gender normativity is more strictly enforced for boys than girls in childhood. Being a tomboy is often tolerated, but being a “sissy” is usually punished by parents, teachers, religious leaders, peers, and many others. Some authors think that this strict enforcing of gender and the linking of gender nonconformity in boys with same-sex orientation is what makes adolescents and adult men more likely to have negative attitudes about LGBTQ people than women generally have (Herek, 2000). Homophobia is often part of masculine identity formation in a way that is not found in feminine identity formation. Girls are not as severely or as consistently punished for deviations in gender as are boys, and they are allowed more freedom in clothing, interests, behaviors, and the ability to form emotional attachments and show physical affection for their same-sex friends. Boys, on the other hand, are socialized that masculinity equals heterosexuality and being gay means not being a man. As Pascoe (2007) noted, “boys lay claim to masculine identities by lobbing homophobic epithets at one another” (p. 5). Boys who deviate from masculine gender activities are punished by their peers by taunts and beatings on the playground, and sometimes they are taken to psychologists for “gender identity” therapy because of parents’ and teachers’ anxiety about boys who are not masculine enough. Girls may also be taken to therapists for gender identity therapy, but not as often as are boys. For a biological male to want to transition to a female gender identity in our society is considered “crazy.” Why would a man want to give up his male privilege for the inferior class status of a woman? And, how dare a woman try to deceive society and assume the power position of male? The documentary The Brandon Teena Story and the Hollywood version of that story, Boys Don’t Cry, illustrated how one community reacted to what they perceived as a monumental betrayal when Brandon attempted to pass as male. He was brutally raped and murdered when his biological sex was revealed.

Gwen Araujo Justice for Victims Act

The nation’s first bill to address use of panic strategies, the Gwen Araujo Justice for Victims Act (AB 1160), was signed into law September 28, 2006, by California Governor Arnold Schwarzenegger. The bill states that a defendant may not use societal bias against their victim to decrease their own culpability for a crime. "This is a victory for fairness in our criminal justice system and a tribute to the courage of Gwen Araujo,” said Assemblywoman Sally Lieber of her bill that also mandates the creation of practice materials for District Attorney’s offices. “Too many Californians live with the very real fear that they will be victimized simply because of who they are. Making sure that our court system treats every one fairly, regardless of individual differences, is essential.” (Transgender Law Center, October 2006)

Internalized oppression

When people are stigmatized by negative attitudes or institutionalized belief systems about sex/gender and sexuality, sometimes these negative attitudes are incorporated into their self-concepts, resulting in self-doubt, guilt, shame, depression, and/or self-hatred (Meyer, 2007). Internalized oppression appears to contribute to many of the health risk factors seen in LGBTQ people, such as suicide attempts, mental health disorders, unsafe sexual behaviors, and substance abuse. Other terms that appear in the literature to describe this concept include internalized homophobia (biphobia, transphobia), internalized homonegativity, and internalized heterosexism. Internalized oppression can result in a self-fulfilling prophecy. For example, if a young man is socialized to believe that bisexuals are “promiscuous,” and has internalized this view, when he comes out as bisexual, he may think that it is his destiny to engage in many casual sexual encounters. If a young woman who is attracted to women is raised within a conservative religion to believe that all LGBTQ people will go to hell, she may think that suicide is her only option. The internalization of the negative stereotypes begins very early in life and is rarely contradicted or counteracted by authority figures or role models in the child’s life. For example, children hear taunts of “fag,” and “lezzie” and “sissy,” in school every day and teachers rarely challenge this on the playground when it occurs. Teachers rarely address issues of sexual and gender minorities in the classroom, sending a message that it is okay to make derogatory remarks about LGBTQ people, or use those words to try to control or hurt people. Sex education programs in today’s climate of abstinence only until marriage programs either do not mention LGBTQ people at all or discuss them as “abnormal.”

Reflection: “Sticks and stones may break my bones but names can never hurt me.” Do you believe this? Can you think of a time when someone called you a derogatory term? What was it? Notice what feelings come up for you when you remember the incident. What does it feel like to think about it now?

Lifestyle

Many opponents of LGBTQ civil rights refer to “the gay lifestyle.” This term has virtually no meaning, because it can refer to so many different things, such as the pace of our lives, where we live, our diet and exercise patterns, the amount of stress in our lives, whether we are single or partnered, and so on. LGBTQ people have diverse lives, not one universal lifestyle. Using the term lifestyle to refer to only one’s choice of sexual partners is a form of stigmatization. A similar notion to this idea of a gay lifestyle is the idea that LGBTQ people are asking for “special rights.” Most LGBTQ people merely want what heterosexual people can take for granted—lives free of discrimination, harassment, and violence based on their sexuality or gender—and the ability to form relationships and families that are recognized and respected.

Reflection: In recent years, there have been bills introduced to at least three state legislatures proposing that health care workers can refuse to treat certain individuals if they feel those individuals violate their moral, ethical, or religious beliefs. Most of these bills were primarily focused on addressing health care professionals such as pharmacists who did not want to administer emergency contraception, but the wording of these bills paints a broad stroke. Health care professionals of all sorts could refuse to treat LGBTQ people (as well as women who are seeking abortions, illegal immigrants, and people with HIV/AIDS or other sexually transmitted infections) on the basis of beliefs that LGBTQ people are unnatural or immoral. Do you think that health care professionals have an obligation to provide quality care to all people, or can they choose not to care for some patients?

Other Forms of Stigma

Stigma stems from the stereotypes that pervade the institutional belief systems of a culture (the power structures) and affect individual attitudes (prejudice). Oppression results from the combination of power and prejudice. Look at the characteristics of the people with wealth and power in the United States and around the world—who are the senators, judges, CEOs of Fortune 500 companies, and presidents of the TV channels and newspapers? Who are the administrators at hospitals, the deans of medical schools, and the makers of health care policies? They are still overwhelmingly wealthy, White (presumably), heterosexual men. Maintaining the status quo means not letting any other groups gain power and recognition. If the group in control is in charge of the legal system, medicine and health care systems, the media, and education, it can consciously or unconsciously maintain the stereotypes and reinforce the barriers to true equality. That is why stigma is so hard to address. It is not in the best interests of the people in power to share or give up their power. People who do not have the power of the “movers and shakers” of society try to hang on to whatever power (or privilege) they do have and often oppress people who are perceived to be lower than they are in the hierarchy. Even well-intentioned White people may stand quietly and not challenge racism for fear of the repercussions on their own lives, and some moral and ethical men do not question sexist jokes or behaviors for fear of being shunned by their peer group. White LGBTQ people may ignore racism in their communities, maintaining their White privilege. Finally, heterosexuals may not challenge sexual and gender prejudices for fear of being labeled as LGBTQ or “too sensitive.” It takes great courage to be an ally to LGBTQ communities and other stigmatized groups.

Stigma operates through stereotypes, the topic of chapter 4. Eliason (1996) proposed a model for understanding how oppression works. Dominant discourses (controlled by those people in power) bestow privilege on people who are White, male, heterosexual, with some degree of wealth. These are the primary privileges in the U.S. society, as in most of the world, and those who do not have these privileges are marked by stigma. We call the various forms of stigma or oppression racism, sexism, heterosexism, and classism. The dominant discourses create and maintain stereotypes for each of these forms of stigma. This is where racism, sexism, and heterosexism diverge somewhat, because the stereotypes differ in many ways, although they do overlap as well. The common basis of stereotypes is that they render the “other” group as inferior to the dominant groups. Stereotypes lead to attitudes, ranging from positive to negative, and when they are negative, we call them homophobia/transphobia, biphobia, or sexual prejudice. These attitudes also influence behavior. It is possible to have a negative attitude about some group of people or some behaviors and not express it in one’s outward behavior, but in general, the more negative the attitude, the more likely that it will be expressed in behavior.

Figure 3.2 shows a simplified model of oppression, based on two common forms of oppression in contemporary society: race and sexuality. In the United States, society certainly privileges other statuses as well, such as male gender, upper and middle class, Christian, able-bodied, U.S.-born, and English-speaking. Stereotypes about most stigmatized groups involve some element of sexual deviance (such as myths that African American men are oversexed, Latina women are “hot,” Asian women are sexual slaves, working-class women are “sluts,” Asian men are “asexual,” and so on). Labeling someone as a “sexual deviant” is one of the major ways of stigmatizing or dehumanizing another person. For many people, these stereotypes are compounded because the person has multiple stigmatizing identities. How might an American Indian bisexual man be perceived? An Asian American transgender woman with disability? People often respond to others first on the basis of their visible cues—race/ethnicity signifiers such as skin color and facial characteristics or gender markers, not seeing the whole person.

Returning to the model, individual stereotypes and discriminatory and even violent behavior toward people in the oppressed minority classes are encouraged by those who create the dominant discourses that establish the laws, enforce laws, and police the unspoken norms. For example, if the state or country in which you live does not include gender identity in its human rights codes, transgender people could be fired for their gender expression and have no legal recourse. If a bisexual person of color is denied medical care, there are few legal organizations that will take on the case.

Table 3.2 Experiences of Discrimination in Midlife Adults in the United States

Figure 3.2 The processes of oppression based on race and sexuality.

The next section outlines the consequences of stigma on the lives and livelihoods of LGBTQ persons. The effects can be far-reaching, particularly for LGBTQ people with multiple stigmatized identities. Table 3.2 shows some examples of how LGBTQ people perceive the effects of stigma on their lives. Imagine how you would feel if you experienced these events just by being who you really are. The next section reviews some of the more common non–health-related effects of stigma on LGBTQ individuals, families, and communities, and chapter 7 deals with the health-related effects.

Social Effects of Stigma

The rest of this chapter deals with the effects of stigma on the lives of LGBTQ people, their families, and communities. These effects set the stage for a potentially stressful life, and that stress can affect one’s health and well-being.

Lack of recognition of relationships and family

The most apparent social and legal discrimination against same-sex couples is the fact that they are not afforded the same rights to marriage as those who are in heterosexual relationships. Although many countries, provinces, and states have recently passed legislation to allow either marriage equality or a form of civil union or domestic partnership, the issue remains deeply divisive with highly charged negative feelings toward same-sex couples who seek the right to marry. This lack of legal recognition of relationships can have significant impact on access to more than a thousand federal rights and benefits, and hundreds of state benefits, including health care coverage (National Center for Lesbian Rights, 2005). The lack of access to health care benefits can be especially devastating as the cost of health care soars in the United States. Transgender individuals have a more complicated relationship with marriage. If those in same-sex relationships legally change their sex, they are now allowed to marry. If they are in heterosexual marriages/relationships prior to a legal sex change, their relationships stand to lose any legal authority. Chapter 8 covers these issues in more detail.

Reflection: As soon as the California Supreme Court ruled that same-sex couples could marry (June of 2008), opponents organized a petition that put an initiative to ban same-sex marriage on the November ballot. Why do you think there is so much opposition to same-sex marriage?

The right to adopt

A related legal right that is denied LGBT people is that of the adoption of children. Adoption is sometimes the best option for LGBTQ people who wish to have children, and denial of this right can be a severe and painful form of discrimination. LGBTQ people are often denied the right to second-parent adoptions as well, which can significantly impair the ability of the nonlegal parent if a child becomes ill or injured in their presence. See chapter 8 for more detail on family law issues.

Hate crimes and violence

Another devastating consequence of stigma is expressed in hate crimes against LGBTQ people. Lombardi, Wilchins, Priesing, and Malouf (2001) found that 27% of transgender individuals in their survey had been victims of violence in their lifetimes; studies of gays and lesbians find similar rates (20%–25%; Herek, 2007). All too often, these crimes result in death, with inadequate law enforcement to apprehend or justly prosecute the perpetrators. Hate crime legislation is beginning to be enacted to protect LGBTQ people, but the fact remains that people of minority sexual and gender identities experience great danger and fear that is simply nonexistent for people who are not LGBTQ. Non-LGBTQ people also do not have to worry about being retraumatized by the people who are supposed to help them after a violent attack—police, hospital ED staff, social workers, ambulance attendants, etc. The Fenway Community Health Center (2001) suggests these common reactions to hate crimes based on sexual identity:

1. Even if the event was random, the victim may feel personally targeted.

2. Victims may question their own identity and self-worth.

3. Victims may feel shame, guilt, and self-blame.

4. They may lose trust in law enforcement and service providers.

5. They may have an increased perception that the world is a dangerous place.

6. They may experience an increase in mental health symptoms.

Historically, perpetrators of violence against LGBTQ people have received light sentences, or no legal punishments, for their crimes. Since the national publicity about the murder of gay college student Matthew Shepard, this has begun to change, as noted in the news release below.

September 27, 2007

Washington, September 27—The National Gay and Lesbian Task Force, Inc., hails today’s landmark passage of a gay and transgender-inclusive federal hate crimes measure, included as an amendment to the Department of Defense reauthorization bill. The amendment, introduced by Sens. Edward Kennedy (D-Mass.) and Gordon Smith (R-Ore.), passed by a 60–39 cloture vote, which ended debate and sent the bill to the floor where it was approved by a voice vote.

Statement by Matt Foreman, Executive Director
National Gay and Lesbian Task Force, Inc.

At long last, Congress is putting a bill on the president’s desk to condemn and respond to violent crimes based on hatred of a person’s sexual orientation, gender, gender identity or disability. Laws ultimately reflect a nation’s values and today’s vote says that America rejects all forms of hate violence, including bias-motivated crimes against lesbian, gay, bisexual and transgender people. This victory is all the more sweet given the right wing’s hysterical, defamatory and lying campaign against it.

We are deeply disappointed by President Bush’s past statements that he would veto hate crimes legislation. The president has also threatened to veto the larger Department of Defense reauthorization bill to which this measure is attached. We call upon the president to work with—rather than oppose—the Congress, the overwhelming majority of the public and national and local law enforcement leaders in enacting this important legislation.

Violence against lesbian, gay, bisexual and transgender people has escalated over the past 25 years. Since establishing our groundbreaking Anti-Violence Project in 1982, we have been working to get the federal government to take a stand against this epidemic. Until today, sadly, little progress has been made in the 17 years since Congress passed the Hate Crimes Statistics Act, because right-wing forces would rather see hate crimes against lesbian, gay, bisexual and transgender people ignored than have the words “sexual orientation” or “gender identity” appear alongside other protected classes in federal law.

Background

The Local Law Enforcement Hate Crimes Prevention Act of 2007 (LLEHCPA) extends federal authority for investigation and prosecution of hate violence to crimes based on the victim’s actual or perceived sexual orientation, gender, gender identity, or disability. Current federal hate crimes law covers crimes motivated by race, religion, and national origin. LLEHCPA also removes the existing limitation on federal involvement that a victim of a bias-motivated crime must have been attacked because the victim was engaged in a specific federally protected activity such as serving on a jury or attending public school. The Department of Justice will now have the authority to provide assistance to local law enforcement agencies in addressing all forms of hate violence.

Lesbian, gay, bisexual, and transgender people are disproportionately affected by hate violence. In fact, lesbian, gay, and bisexual people are more likely to be victims of hate-motivated physical assaults than other minorities, including African Americans, Jews, and Muslims. According to the FBI, 14% of hate crime victims in 2005 were victims of crimes motivated by hatred of lesbian, gay, or bisexual people. Moreover, reports produced by the National Gay and Lesbian Task Force (NGLTF, 1984–1993) and the National Coalition of Anti-Violence Programs (1994–present) have documented more than 35,000 anti-LGBT crimes over the last 22 years. It is important to note that these statistics are based on reports from only a handful of local LGBT crime victim assistance agencies.

The version of the hate crimes bill passed today includes crimes based on a victim’s actual or perceived gender identity. The clear inclusion of transgender people in hate crimes laws is especially important because violence against transgender people is widespread, largely underreported, and disproportionately greater than the number of transgender people in society. In 2005, the National Coalition of Anti-Violence Programs reported that 11% of the 2,306 victims of reported hate crimes identified as transgender. (NGLTF, 2007)

Social rejection

On a personal and emotional level, a very damaging consequence of stigma is rejection by the family and friends. Many families and friends are not prepared and do not know how to react when they learn one of their loved ones is lesbian, gay, bisexual, or transgender, and they sometimes react in hurtful ways. These reactions can range from mildly harmful to extremely harmful. Some LGBTQ youth have been ejected from their homes; some LGBTQ adults have been treated as if they never existed. Some find support and a path toward ultimate acceptance, but the hurt and damage is devastating for everyone involved, especially when initial negative responses cannot be overcome or healed. Many LGBTQ people remain closeted to their families and friends because of the fear, and the probable reality, of rejection. Rejection can occur in any setting, including schools, religious institutions, neighborhoods, and workplaces. Issues of social rejection in the workplace are discussed in chapter 9. People who are visibly identifiable as LGBTQ are also likely to experience social rejection from strangers in public places as the example below highlights.

The women’s room is a war zone for my girlfriend and me, as well as for countless other butch lesbians across the United States. Dressed in leather jackets, jeans, button-down men’s shirts, and boots, with our haircuts barely brushing the tops of our ears, we strike fear into many women’s hearts, as they glance pointedly from the sign on the door to us…. Not uncommonly, a braver woman will walk up and tap one of us on the shoulder and say, “This is the ladies room.” This happens with such frequency that I enter a public restroom with trepidation. I smile and try to appear nonthreatening, attempting to diffuse any hostility or confusion. Yet I am still stared at. (Inness, 1998, p. 233). In October of 2007, a 28-year-old African American lesbian, Khadijah Farmer, filed a lawsuit against a New York City restaurant after a bouncer kicked her out of the restroom because he thought she was a man, and he refused to look at her identification.

Imagine how you would feel if you had this experience nearly every time you used public facilities? How would you react?

Discrimination in employment and education

Many LGBTQ people remain in the closet in their public lives because of the fear or the reality of stigma and discrimination that they would face if they revealed their sexual or gender identity. They fear job discrimination, and loss or lack of access to educational opportunities. In schools, many LGBTQ children and teens are often afraid to come out to peers, and if they do, often suffer extreme bullying in school, with negative consequences on their grades, mental health, and intentions to continue their education (Harris Interactive & Gay, Lesbian, Straight Education Network [GLSEN] 2005).

There is a stereotype that lesbian and gay people have higher incomes than heterosexuals—an argument often used by the religious right to deny any legal protections to LGBTQ people. The reality is much more complicated. Badgett (1997) found that between one fourth and two thirds of LGB people reported that they had lost a job or promotion because of their sexuality, even in “tolerant” professions such as academics, law, and medicine. When she studied LGB and heterosexual workers with the same qualifications, the LGB workers earned less. Transgender individuals are at even higher risk for employment discrimination. One survey in San Francisco found nearly half had experienced employment discrimination (National Center for Lesbian Rights & Transgender Law Center, 2003), and the rates of unemployment are much higher among transgender individuals than any other group. Even those who are postoperative and employed may not be able to get health benefits, or they stand to lose their benefits if their gender identity is revealed to insurers (National Coalition for LGBT Health Eliminating Disparities Workgroup, 2004).

The U.S. military epitomizes the sentiment of contemporary culture, with their “don’t ask, don’t tell” policy. Under this policy, military recruiters cannot ask about a person’s sexuality, and LGBTQ people can enlist in the service if they do not reveal their sexuality. What constitutes the “don’t tell” part of the policy once a person has enlisted has never been clear. LGBTQ people have been dismissed for belonging to an LGBTQ chat room on the Internet or receiving LGBTQ literature in the mail. Instituted in 1993, the policy was intended to be an improvement over the former armed services view that “homosexuality is incompatible with military service,” and it was supposed to reduce the rates of harassment and expulsion from the service. However, the policy’s implementation has actually resulted in an increase in the number of discharges based on sexual orientation. According to the Servicemembers Legal Defense Network (SLDN, 2004), more than 9,000 service members have been discharged under the “don’t ask, don’t tell” policy at a cost of more than a quarter billion U.S. dollars to taxpayers. A Defense Department inspector general survey (Department of Defense, 2000) showed that

- 80% of service members had heard offensive speech, derogatory names, jokes, or remarks about gays in the previous year;

- 85% believed such comments were tolerated by authorities; and

- 37% reported that they had witnessed or experienced direct, targeted forms of harassment, including verbal and physical assaults and property damage. Overwhelmingly, service members did not report the harassment for fear of retaliation.

In July 1999, Pfc. Barry Winchell was brutally beaten with a baseball bat in his barracks at Fort Campbell, KY, and died as a result of the attack. Fellow soldiers testified that the death came after months of antigay name-calling, harassment, rumors, and inquiries into his private life. An army inspector general report in July 2000 found that before and after the murder, Maj. Gen. Robert Clark, the commanding general at Fort Campbell, had not provided required training on the “don’t ask, don’t tell” policy. Following the report, President George W. Bush twice nominated Clark for a promotion to lieutenant general, the army’s second highest rank. Owing to controversy surrounding Clark’s previous command at Fort Campbell, the Senate Armed Services Committee did not act on his promotion in 2002. (The Human Rights Campaign)

According to SLDN, women are disproportionately affected by the policy. Whereas women made up 15% of the armed forces in 2002, they accounted for 31% of those discharged under the law. Women are affected in part because of a phenomenon known as “lesbian baiting.” Lesbian baiting occurs, for example, when a woman superior is accused of being a lesbian in retaliation for receiving a poor performance review, after refusing a man’s sexual advances, or after reporting a man for sexual harassment. Many heterosexual women have been discharged, or left the military, because of lesbian baiting as well.

Discrimination in housing

A study done in 30 cities and suburbs in the state of Michigan, sending out same-sex and other-sex pairs of testers posing as life partners, revealed discrimination in 27% of the cases involving the same-sex testers. In Detroit, one landlord handed the testers a list of “forbidden” activities that included homosexuality along with drug use, prostitution, and one-night stands. A real estate agent in a small town told a lesbian couple that he “kind of liked it” that they were lesbians and told them to call him anytime (Michigan Fair Housing Center, 2007). Other LGBTQ people have reported harassment from neighbors.

Effects of living in the “closet”

The consequences of living the inauthentic existence of the closet are far-reaching. When LGBTQ people are closeted to their families, they are never able to share openly in family events such as holiday and family celebrations, often having to choose between their lover/partner and their family of origin for these important occasions. On the job, LGBTQ people sometimes are not able to bring their lover or partner to social events where heterosexual partners are welcome. In casual conversations with coworkers who frequently and casually mention “my wife” or “my husband,” LGBTQ people remain silent. Pictures of loved ones are displayed prominently on desks of heterosexual people; closeted LGBTQ people refrain from such displays. To add to the stress, closeted LGBTQ people also experience fear and dread of being “discovered,” and to avoid this, they carefully monitor their language, where they go, and with whom. Imagine, or better yet, try going to work one day without mentioning your significant other, chosen family, or best friends, or talking about what you did on the weekend or evenings. How would this affect your relationship with coworkers? Unfortunately, the closet may be a place of necessity for some people where the threat of loss of job, custody of children, or of safety may feel like too high a risk. It is important to keep in mind that most LGBTQ people are on a continuum of being “out”—few people are completely out of completely closeted—and that the closet has a revolving door.

Stigma has a great impact on the LGBTQ person’s ability to lead the “normal” life that is taken for granted by heterosexual couples and individuals. The rights that LGBTQ people are requesting are the ability to marry (and receive the financial and legal benefits and protections for their families), adopt and raise children, and live free of discrimination, harassment, and violence. In short, LGBTQ people just want to be themselves and be accepted.

Conclusions

This chapter has tackled the difficult concept of stigma, showing how the invisible privileges conferred in our culture set up the boundaries of what is designated as normal/abnormal and natural/unnatural. Stigma works through the dominant discourses and societal-level power structures that facilitate individual prejudice and allow for discriminatory behaviors, even violence. The negative attitudes toward LGBTQ people can become internalized and result in shame, doubt, and guilt, which are risk factors for unhealthy coping mechanisms. The effects of stigma are potentially profound, from the inability to have “legitimate” relationships and families to employment discrimination and violence. The everyday effects of social rejection and invalidation are pervasive. Chapter 7 deals with the consequences of stigma on individual physical and mental health.

Reflection Questions

Awareness

1. Were you aware of these terms or concepts before reading this chapter? How have you observed stigma at work in your own community?

2. Who is “in” and who is not in your workplace or family? How does stigma affect people in your own workplace?

Sensitivity

1. Can words contribute to discrimination and violence? If so, how?

2. What are some examples of subtle or overt discrimination against LGBTQ people that you have witnessed?

3. Think of a time when you were treated badly in some setting. How did you feel and behave the next time you were in that setting?

4. Think of someone in your circle of friends or family whose sexual identity is different from your own. Is this person treated differently than you are? How?

Knowledge

1. In 1996, the Defense of Marriage Act was passed. This federal law defined marriage as a legal union between one man and one woman. What kind of stigma does this represent? How does allowing same-sex couples to marry potentially “damage” heterosexual marriage? In other words, why does heterosexual marriage need defending?

2. List all the things you “know” about LGBTQ people. How do you know if these things are accurate?

Chapter 4: Myths and Facts About Sexual Orientation and Gender Identity

On any spring midafternoon the following events may occur. As three elementary school students play tag, one calls another, “faggot”: a talk show listener worries about his twelve-year old daughter who has yet to outgrown her “tomboy stage”; a stand-up comic begins his five-minute routine about gays in the military with a shower joke;…these vignettes represent various manifestations of homophobia and heterosexism…[and are] damaging to a society characterized by diversity and championed as just.

(Sears, 1997, p. 13)

Myths are widely held beliefs that are false; when they are consistently applied to a group of people with a shared identity, they may also be called stereotypes. Many myths prevail in most of the world concerning lesbian, gay, bisexual, transgender, and queer people. Most of the myths begin to enter people’s awareness during childhood and adolescence—a time in life when people are the most impressionable and can be easily swayed by the attitudes, feelings, and behaviors of people around them. For many, including LGBTQ people themselves, unlearning myths can take a lifetime. Even when you know on an intellectual level the difference between fact and myth, the feelings associated with the myths can persist on an unconscious level. This can affect an individual’s attitudes toward LGBTQ people, including those who identify as LGBTQ. In this chapter, we present some of the most common myths and provide a brief discussion of what is currently known to be a fact. We have divided the myths/facts into two sections. The first section includes those myths/stereotypes associated with sexual orientation, and the second section discusses myths based on gender and gender identity, although we recognize that there can be considerable overlap. Many of the stereotypes about LGBQ people are based on perceptions that those individuals violate gender norms, and many of the stereotypes about transgender people are based on the belief that they are really gay people who are trying to be heterosexual by changing their bodies.

Jorge remembers when he was 5–6 years old, hearing a group of boys on the playground taunt an unathletic boy day after day, calling him “fag” and “sissy.” Jorge notes that he did not know the meaning of the words at the time, but he observed the look of fear and humiliation on the face of the taunted boy, and the attitudes of superiority and domination of the pack of popular boys doing the taunting. He still winces whenever he hears the terms as an adult.

Stereotypes are sometimes contradictory (e.g., that lesbians hate men and that lesbians want to be men), and some reflect positive characteristics (e.g., that lesbians are strong and gay men are good friends to women). When a heterosexual person has one of the characteristic traits usually associated with LGBTQ people, they are considered the exception. Even positive stereotypes can be bad, because they make assumptions that everyone with the same label has exactly the same characteristics. They dehumanize people. Of course, some LGBTQ people seem to fit some of the stereotypes because these are statements that do fit some people of any identity, and this reinforces the stereotype. Keep in mind the discussion from chapter 3 about how stereotypes work to produce stigma, and how stereotypes or prejudice plus power create oppression. Each myth/stereotype listed in this chapter contributes to the stigma of being LGBTQ.

Reflection: List as many stereotypes as you can about each of five groups: lesbians, gay men, bisexual men, bisexual women, and transgender people. Where/how did you learn these stereotypes? In general, there are many more stereotypes about gay men and lesbians than about bisexual and transgender people. Why do you think that is?

Myths Related to Sexuality

Myth 1: People could change their sexual orientation if they wanted to.

Fact: Scientific evidence suggests that sexual orientation is something that people are born with or develop fairly early in life. The evidence is sufficiently clear that the American Psychological Association, American Psychiatric Association, American Medical Association, and many other professional organizations have taken the position that therapies designed to change people’s sexual orientation (often called reparative or conversion therapy) are unethical (American Psychiatric Association, 1998; Zucker, 2006). For many people, awareness of sexual orientation first emerges in childhood or early adolescence prior to any sexual experience (D’Augelli, 2006b), and some LGBTQ people report feeling different from a very early age, long before they labeled the difference as related to gender or sexuality. Sexual orientation reflects who or what kind of person one is sexually attracted to, and may or may not be the same as one’s sexual identity, the label one attaches to one’s own sense of sexuality.

The American Psychiatric Association (2000) noted, “Recent publicized efforts to repathologize homosexuality by claiming that it can be cured are often guided not by rigorous scientific or psychiatric research, but sometimes by religious and political forces opposed to full civil rights for gay men and lesbians…. As a general principle, a therapist should not determine the goal of treatment either coercively or through subtle influence. Psychotherapeutic modalities to convert or ‘repair’ homosexuality are based on developmental theories whose scientific validity is questionable…. In the last four decades, ‘reparative’ therapies have not produced any rigourous scientific research to substantiate their claims of cure…. The ‘reparative’ therapy literature uses theories that make it difficult to formulate scientific selection criteria for their treatment modality. This literature not only ignores the impact of social stigma in motivating efforts to cure homosexuality; it is a literature that actively stigmatizes homosexuality as well.” (wwwpsych.org/psych_pract/copptherapyaddendum83100.cfm?pf = y)

Myth 2: Minority sexual orientation is caused by sexual trauma in childhood.

Fact: Not all LGBTQ people were abused or experienced traumas as children, although many were, as were many heterosexual people (Balsam et al., 2005; Holmes & Slap, 1998; Hughes, Johnson, & Wilsnack, 2001; Matthews, Hughes, & Tartaro, 2006; Peters & Cantrell, 1991; Saewyc et al., 2004). Heterosexual people and LGBTQ people may have been abused as children, and the abuse can interfere with a person’s ability to relate to others in a healthy way or to trust others in intimate relationships. But childhood abuse has not been identified as a cause of sexual orientation. It is a sad fact that some children are abused but there is no single cause or effect of abuse. Some children may have been abused because they were perceived to be gender-nonconforming, because they were exposed to a perpetrator in their families or community, because they ran away from homes and were at risk for abuse on the street, or other reasons related to stigma, not to their sexuality (Friedman, Koeskey, Silvestre, Korr, & Sited, 2006). To “blame” sexual orientation on child sexual abuse would be analogous to “blaming” left-handedness on child sexual abuse. There may be an association between child sexual abuse and later sexual orientation or behaviors, but no research to date has identified a causative link. We take the position that sexual identity is part of normal human variation. There is also no credible evidence that LGBTQ people are more likely to come from broken homes or to have experienced dysfunctional parenting.

Myth 3: Gay men hate women, and lesbians hate men.

Fact: Gay men and lesbians, like heterosexual people, have dear friends and acquaintances who vary in sex/gender and sexual orientation. Hatred toward any group of people is generally recognized in the LGBTQ community as prejudice and is actively opposed. Like anyone else, LGBTQ people have personal preferences concerning those individuals they like to be around and choose as friends, and most people prefer being together in groups and communities with others who share their own values and identities. But preferring to have certain types of people as friends, or to have an affectionate attraction to a particular type of person, does not mean that one hates or even dislikes those who are outside that circle. In other words, if you really like apples, it does not mean that you dislike or hate oranges! The majority of heterosexual people also select their friends and potential partners from a pool of people who are similar to them in race/ethnicity, age, sexual identity, religion, education, and other social variables (Laumann, Gagnon, Michael, & Michaels, 1994).

Myth 4: Gay men want to be women; lesbians want to be men.

Fact: This is an interesting stereotype when coupled with the one above—why would you want to be something you hate? Sexual identities are not based on gender—they are two separate (though related) concepts. Most gay men are quite happy being men; they just want the freedom to be whatever kind of man they are. The same is true for lesbians. The stereotype may stem from the fact that some LGBTQ people are drawn to careers or interests that are usually associated with someone of the other sex. For example, because they are less constrained by societal gender norms, gay men may be more likely than heterosexual men to choose nursing, cosmetology, or flight attendant schools, whereas lesbians may be more likely than heterosexual women to choose construction work, law enforcement, and firefighting. But some heterosexual people chose to break from gender stereotypes as well. The stereotypes that relate to beliefs that gay men and lesbians do not fit well with the characteristics of their sex/gender generally do not apply to bisexuals. There are few or no stereotypes about the careers, interests, or physical appearance of bisexual men or women.

Reflection: Look back at the list of stereotypes you generated about bisexual people. Why do you think: are there fewer stereotypes about bisexuals than about gay men and lesbians? Perhaps it is because bisexuality has not been thought to be a “legitimate” identity or because there are fewer gender-related beliefs associated with bisexuality. How many of the stereotypes about lesbians and gay men that you generated were related to gender?

Myth 5: Gay men want to look like women, and lesbians want to look like men.

Fact: It is not possible to tell if someone is a gay man or a lesbian from observing how he or she looks. Some gay men and some lesbians do dress or have behaviors that are more typical of the other sex (see the definition of gender expression in chapter 2). Some heterosexual women or men also dress or behave more typically as the other sex. However, these patterns of dress or behavior do not come from a desire to be or to look like the other sex. Instead, these choices are based on personal preference and refusal to conform to the stereotypes or social expectations for male or female dress and behavior. For lesbians, choice of dress, hairstyle, and whether to wear makeup often has much more to do with comfort and ability to physically navigate than it does with wanting to appear masculine. But many lesbians do dress and act in a manner consistent with social norms for women, and many gay men do dress and act consistent with social norms for men. It is not possible to tell if a person is lesbian, gay, bisexual, transgender, or queer or, for that matter, heterosexual, by the way he or she dresses or acts. This stereotype is partly related to people’s confusion about the differences between sexual identity and gender identity. Some people erroneously believe that all gay men and lesbians are cross-dressers. The fact is that preferences in clothing, hairstyles, makeup and accessories change rapidly in our fashion conscious world, and these trends change societal expectations about what men and women are supposed to look like.

Myth 6: LGB people have uncontrolled sexual urges and try to “hit on” anyone they can.

Fact: The range of sexual drive and variety of sexual practices is similar among LGB people and heterosexual people (Coleman & Rosser, 1996; Matthews et al., 2006). This myth may come from the fact that LGBQ people are defined by their sexual behavior—the term homosexual was coined, it was not characterized as “homo-relational” or “homo-affectional.” In fact, LGBQ people do not stalk straight people for casual sex any more frequently than straight people seek out casual sex, nor do they necessarily have sex more often. Like anyone else, there are many factors that influence an LGBQ person’s identity besides sex, such as the social groups one belongs to, career or job roles, religious beliefs, and so forth. This myth of being oversexed particularly affects bisexual men and women who are often perceived to be hypersexual because of the potential to be attracted to people of either sex (Eliason, 1998). Many heterosexual people express considerable distress at the prospect of being “hit on” by someone of the same sex. How does this experience differ from being “hit on” by a member of the other sex when one is not interested?

If you were to analyze this myth by gender, you will find some differences. Men in contemporary society, whether gay, bisexual, or heterosexual, on average, report a higher sex drive and a more frequent desire for engaging in sexual activities than do women (Laumann et al., 1994). When men have other men for sexual partners, who also seek more frequent sex, it stands to reason that gay and bisexual men, as a group, may have sex more frequently. This myth about the “hypersexuality” of LGBTQ people is related to our cultural anxieties about “promiscuity.” How many partners or how much sex is too much? If sexual activity is between adults, consensual, and safe, do the numbers or frequency matter? An older study by Masters and Johnson (1979) compared sexual activity in heterosexual couples, gay male couples, and lesbian couples. One of the main differences they reported was that gay and lesbian couples took more time in lovemaking, with much more touching, caressing, and focusing on mutuality than heterosexual couples. Perhaps heterosexual couples could learn something about sexual relationships from their gay and lesbian counterparts?

Myth 7: LGBTQ orientation may be “contagious.”

Fact: Most LGBTQ people were raised by heterosexual parents, but that did not make them heterosexual; sexual orientation/identity is likely to have genetic components and perhaps other biological influences (Byne, 2007). Therefore, it cannot be “caught.” People who are comfortable with a heterosexual identity will not be influenced to become LGBTQ, just as an LGBTQ person will not be influenced to become straight if he or she spends time with heterosexuals.

Myth 8: Children should not be exposed to LGBTQ people nor should adults even discuss LGBTQ issues, as children might be unduly influenced.

Fact: LGBTQ people do not “recruit.” This myth is often used as the rationale for keeping LGBTQ people away from children and affects the ability of some people to be openly LGBTQ daycare workers, teachers, or parents. Evidence of the fallacy of this myth comes from the study of children of same-sex parents—if too much exposure to LGBTQ people makes people become LGBTQ, those children should be mostly LGBTQ as they grow up. In fact, the majority of children of same-sex couples grow up to be heterosexual (Tasker, 2005).

One of the authors was flipping channels 1 day in June and found a televangelist telling the audience that gay pride parades and rallies were dangerous because “impressionable” children might see them and then grow up to want to be LGBTQ because the parades look like fun. She remembered that when she herself was an impressionable child, she was often exposed to Shriner’s parades, with grown men driving tiny cars wearing silly hats. She had no desire to be a Shriner when she grew up, despite this overexposure to men having fun.

Myth 9: Gay men are child molesters.

Fact: One of the most damaging stereotypes involves the conflation of child sexual molestation with a gay sexual orientation. They are, in fact, entirely different phenomenon. A study published in the Journal of Pediatrics (Jenny, Roesler, & Poyer, 1994) reported that a child was 100 times more likely to be abused by a heterosexual man than by a gay man. So where does this myth come from? It is perpetuated by the terminology used in the psychiatric and legal literature to describe child molesters, sometimes called pedophiles. Men who are attracted to prepubescent girls are labeled as heterosexual pedophiles (and make up 60%–65% of convicted pedophiles) and men who are attracted to prepubescent boys (about 30% of pedophiles) are called homosexual pedophiles. About 20% of pedophiles are attracted to both boys and girls (Cohen & Galynker, 2002). The terms homosexual and heterosexual are misused here and do not refer to the sexual orientation of the adult relationships of the pedophile. Although more pedophiles report attraction to girls, there are more male victims than female victims because of circumstances. Boys have much greater social freedom and less supervision by adults than girls; thus, pedophiles can have more ready access to boys. In addition, the nature of the sexual acts differs (fondling or exhibitionism occurs more often with boys, activities that are quick and can be done anywhere). Sexual abuse of children is condemned by all LGBTQ social and political organizations, and there is as much concern about child sexual abuse by LGBTQ individuals as there is among heterosexuals.

Controversial issue: The North American Man Boy Love Association (NAMBLA) was founded in 1978 as a political and educational organization that supports the rights of all people, regardless of age, to participate in consensual sexual activities. They oppose having any age of consent laws and believe that it is best for children to be initiated into sex by experienced adults. Parent and Friends of Lesbians and Gays (PFLAG) released the following statement in 1997: “As a family organization, PFLAG strongly condemns the sexual exploitation of children by any individual, group, or organization, in any form and under any circumstance…. NAMBLA is a pedophile organization whose sole purpose is to facilitate sex between adult men and young boys. PFLAG, therefore, repudiates NAMBLA and its aims.” In 1994, another organization, the Gay and Lesbian Alliance Against Defamation (GLAAD), said: “GLAAD deplores NAMBLA’s goals, which include advocacy for sex between adult men and boys and the removal of legal protections for children. These goals constitute a form of child abuse and are repugnant to GLAAD…. As a group of people who historically have not had legal rights and protections, gay men and lesbians have always worked with and built coalitions with others whose rights are at risk. The true gay and lesbian agenda is ultimately about free human rights for all people.”

But what about the first amendment protection of speech? In 2000, the ACLU released a statement about defending the free speech of unpopular organizations, stating that it is not incompatible to support the right of an organization to exist and state its mission, and to oppose that mission, and noted, “Those who do wrong are responsible for what they do; those who speak about it are not. The defense of freedom of speech is most critical when the message is one most people find repulsive. That was true when the Nazis marched in Skokie. It remains true today.” What do you think?

Myth 10: Most LGBTQ people are white; there are practically no LGBTQ people among other ethnic groups.

Fact: The proportion of people who have same-sex attractions or behaviors and who are gender-variant is thought to be the same in all racial and ethnic groups, and perhaps in all cultures in the world (Adams, 1986; Herdt, 1994). However, social and familial acceptance of LGBTQ people varies tremendously among cultures. Because there are wide cultural variations in understandings of the concepts of sexuality and gender, fewer people of color or people from non-Western countries may adopt an open sexual identity as LGBTQ because that is a western concept (Dykes, 2000). In some cultures, revealing one’s self as LGBTQ can be very costly personally and socially, even dangerous. Canada, Australia, New Zealand, many European countries, and the United States (all predominantly white populations) have experienced several decades of growing acceptance, which has made it more possible for LGBTQ people of all ethnicities to acknowledge who they are. But even if they are able (or want) to come out publicly, LGBTQ people of color often encounter racism from white LGBTQ communities; therefore, these individuals may be less likely to be involved in predominantly White social and political organizations and also less visible in the LGBTQ communities (Battle & Crum, 2007; Fieland, Walters, & Simoni, 2007; Ramirez-Vallez, 2007). We discuss this issue in more detail in chapter 6.

Myth 11: LGBTQ people do not have long-term, stable, or monogamous relationships.

Fact: Despite the fact that LGBTQ people do not have the same legal and social support for their relationships that heterosexual people have, many LGBTQ people form long-term, monogamous, and committed relationships, and consider themselves as much a family as any heterosexual married couple (Kurdek, 2004; Kurdek & Schmitt, 1986; Peplau & Fingerhut, 2007). Many heterosexual people have trouble forming and maintaining stable long-term relationships as do some LGBTQ people. The myth that LGBTQ people are incapable of long-term relationships may stem partly from the inability to marry. The lack of social and legal recognition of partner relationships and families in LGBTQ communities may have led to more creative relationship and family formations that do not get validated as authentic. This issue is explored in more depth in chapter 5.

Myth 12: Homophobia, biphobia, and transphobia exist only among heterosexual people.

Fact: Everyone, regardless of sexual identity/orientation, experiences negative attitudes based in fear, shame, guilt, or hatred about LGBTQ people or same-sex feelings in themselves. LGBTQ people have internalized these feelings just as heterosexual people have and, as a result, often have feelings of self-hatred and lack of self-acceptance at some point in the life span (Herek, 2007; Meyer, 1995; Szymanski & Chung, 2003). For many young people who are beginning to be aware of their LGBTQ identities, this can lead to devastating consequences—depression, suicide, and self-destructive behaviors. They need as much support as possible from everyone around them to overcome the fear and self-hatred. As they “come out” and learn more about themselves and others in the LGBTQ community, their internalized oppression will begin to decrease. For this reason, it is imperative that issues related to sexuality and gender be discussed in schools, health care settings, homes, and as many other places as possible so that youth do not internalize the negative stereotypes and the self-hatred that put them at risk for significant health problems (Elia & Eliason, in press). Homophobia operates differently when it occurs among heterosexual people, because they have the power of the dominant institutions supporting their prejudicial beliefs; thus, they have the ability to discriminate against LGBTQ people. When an LGBTQ person has homophobia, it becomes internalized. This internalization can result in enough self-hate to cause or sustain major depression, anxiety, and suicide, or they avoid, verbally denigrate, or abuse other LGBTQ people. An LGBTQ person can have negative stereotypes about heterosexuals, but because they have no significant societal power to support them, the beliefs lack the strength of homophobia/biphobia that is sustained by heterosexual privilege.

Myth 13: A person is not lesbian or gay if he or she has ever had sex with the other sex.

Fact: Many lesbian, gay, and bisexual people have had sex with someone of the other sex, even when they know they are not heterosexual. Sometimes this occurs in an effort on individuals’ part to hide or overcome what they know to be their lesbian or gay identity, or for a host of other reasons such as love or attraction for a specific person, curiosity, or peer pressure. In fact, a recent article identified 237 reasons why people have sex (Meston & Buss, 2007). Diamond (2003) pointed out that sexual desire and romantic love can be two separate things; heterosexual people may have sex with persons of the same sex at some point in their lives, but this behavior does not necessarily affect their identity. Sexual orientation, identity, and sexual behavior are not always consistent. The question, “How do you know that you are gay, lesbian, or bisexual if you have never had sex with a person of the other sex?” is often asked. No one asks, “How do you know you are heterosexual if you have never had sex with a person of the same sex?” Human beings explore a variety of behaviors that may or may not affect their core social or sexual identities, and gender and sexuality are not discrete, binary concepts, but each is on a continuum. Kinsey, Pomeroy, and Martin (1948) were among the first to operationalize a sexual behavior continuum. They used a 7-point scale ranging from 0 (exclusively heterosexual) to 6 (exclusively homosexual). The points between these extremes included bisexual behavior. Other theorists have expanded on the work of Kinsey et al. to develop continua not only of sexual behavior but of sexual attractions, preferences for romantic partners, preferences for social relationships, and other dimensions of sexuality (e.g., Klein, Sepekoff, & Wolf, 1985).

Myth 14: LGBTQ people are blatant; they flaunt their sexuality.

Fact: What is labeled as “flaunting” in the LGBTQ person is considered normal among heterosexual couples: holding hands, kissing goodbye or hello, having a picture of a significant other on their desk at work, and so on. Heterosexual relationships are celebrated in many ways; however, even the mere mention of a same-sex partner or relationship can make some people uncomfortable. Some LGBTQ activists may deliberately engage in public behaviors to challenge heterosexual norms, but the typical same-sex couple do not “flaunt” their relationship any more than do a heterosexual couple. In fact, many refrain from any public displays of affection for fear of retaliation.

Reflection: List all of the ways that heterosexual people “flaunt” their sexuality. You may be stumped at first, but as the list grows, you may notice many ways that heterosexual people are allowed to express their sexual orientation in public—ways that are considered “normal” for heterosexuals and “flaunting” for LGBT people. For example, heterosexual people can put pictures of significant others and family on their desks at work, and they can hold hands in public, kiss goodbye when one drops off the other for work, and have their picture printed in the newspaper when they have relationship milestones (engagement, wedding, anniversary, even divorce). Some people have even argued that the tradition of decorating the bride and grooms’ car and driving around town honking their horns is a “heterosexual pride parade.”

Gay pride parades and rallies are often mentioned as examples of flaunting behavior, but similar kinds of celebrations in other communities are rarely scrutinized this way. There are many community celebrations of ethnic pride, cultural diversity, or religious pride that serve similar purposes of community building as gay pride celebrations.

Myth 15: LGBTQ people are not happy; many are mentally ill.

Fact: There is no indication that LGBTQ people are any less happy than heterosexual people. Many LGBTQ people do suffer from oppressive, discriminatory, and stressful social circumstances that cause a great deal of suffering (Gilman et al., 2001). But, at the same time, many individuals also find a rich source of support and joy in social groups within LGBTQ communities. Hollywood portrayals of lesbian, gay, and bisexual people seldom provide accurate depictions and reinforce the stereotypes of LGBTQ people as unhappy, or engaging in bizarre, outlandish behaviors (think of the character of Jack in Will & Grace). The American Psychiatric Association (1973, 1998, 2000) and American Psychological Association (1975, 1997) have determined that LGBT identities are not mental illnesses. Stigma, not sexual identity, creates the risk for mental health problems. This issue is discussed further in chapter 7.

An extraordinary ally: Evelyn Hooker (1907–1996) was a pioneer as one of the few women psychologists of her day—no easy feat in the male-dominated world of the sciences. In the early 1950s, on the urging of a former student, a gay man, Dr. Hooker received an NIH grant to study the adjustment of a nonclinical sample of gay men compared with a heterosexual comparison group. This was the first nonclinical study of gay men—the earlier studies were done in prisons and mental institutions and did not include adequate comparison groups. It was remarkable that the government funded this study during the highly oppressive McCarthy era, where people with same-sex desires were being routed out of government service as “communists.” Dr. Hooker’s groundbreaking study published in 1957 showed that experts were unable to distinguish gay men from heterosexual men on the basis of the most widely accepted personality measures of the day and that there were no reliable differences in ratings of adjustment. Studies by other researchers quickly confirmed her findings, but it took political activists putting pressure on the American Psychiatric Association to result in the removal of homosexuality as a mental illness from the Diagnostic and Statistical Manual of Mental Disorders. This did not occur until 1973.

Myth 16: The Bible or other religious organizations/systems say that it is wrong to be LGBTQ.

Fact: There is considerable variation in religious doctrines and writings about gender and sexuality. We will focus only on Christianity in this discussion, because it is the most common religious discourse in the U.S. Several Christian churches welcome LGBTQ people and a few ordain openly LGBTQ people to be religious leaders like priests, ministers, or bishops. Many religious denominations are struggling with the best way to deal with issues of sexuality and gender in a changing world, recognizing that the Bible, both the Old Testament and the New Testament, which are based on wisdom teachings that are 2,000 years old, cannot provide the guidance needed to address all contemporary issues. In general, both Christian and other fundamentalist and evangelical religions that take the Bible, or some other religious text, as the literal word of God are the most negative about LGBTQ people, because they tend to promote a belief that any same-sex activity is a form of sin to be punished. Some religions have programs for converting homosexuals (Exodus International is the largest of these), but research suggests that these programs have been unsuccessful in their goals. In one study, out of 202 people who underwent conversion therapy, only 6 (3%) were “converted” (Schroeder & Shidlo, 2001; Shidlo & Schroeder, 2002).

An example of an inclusive religious denomination is the United Church of Christ (UCC). In 1973, the United Church Coalition for Gay, Lesbian, Bisexual and Transgender Concerns was formed. In 1975, their General Synod passed a resolution in support of full civil liberties and equal protection under the law to persons of all “affectional or sexual preferences.” In 1977, the Church passed a resolution, which “deplored the use of scripture to generate hatred, and the violation of civil rights of gay and bisexual persons and called upon individual members, local churches … to continue to work for the enactment of civil rights legislation at the federal, state, and local levels of government.” Ordination of openly LGBTQ ministers was formally accepted by the denomination in 1980. UCC clergy are also free to bless same-sex unions. Local associations of UCC congregations have the authority to decide on their own ordination policies. In 1985, the General Synod formally urged local churches to welcome gay and lesbian members and advocate in their behalf against discrimination and persecution. In 2005, the UCC issued a statement in support of same-sex marriage.

Myth 17: An LGBTQ person cannot be religious.

Fact: The answer depends on the kind of religion. Affiliating with a fundamentalist church is a strong predictor of homophobia (Eagly, Diekman, Johannesen-Schmidt, & Koenig, 2004; Whitley & Kite, 1995), but religious and spiritual beliefs are complex and contradictory in the individual. Some studies have found that participation in organized religion is detrimental to the mental health of LGBTQ people (Gage-Davidson, 2000; Rodriguez & Ouellette, 2000), but less research has focused on LGBTQ people who belong to welcoming congregations or churches that specifically serve LGBTQ communities, such as the Metropolitan Community Church. Lease, Horne, and Noffsinger-Frazier (2005) found that belonging to an LGBTQ affirming faith was related to lower levels of internalized homophobia. On the other hand, having a strong, personal spirituality, whether belonging to a formal religion or not, also predicts better health. There is a growing spirituality movement among LGBTQ communities, just as there is in the general population, with people exploring diverse ways to express their spirituality within or outside of formal religious institutions (Helminiak, 2000, 2006).

Myth 18: LGBTQ people want special rights.

Fact: This was a ploy used by antigay activists in recent years to imply that LGBTQ people were asking for more than what the general population has. They claim that LGBTQ people are already covered under federal and state laws (as human beings); therefore, they do not need or deserve any further legal protections. All that LGBTQ activists have ever asked for is to be treated with the same respect and dignity, and to obtain the same legal protections, rights, and benefits that other citizens already have. Theoretically, LGBTQ people are protected under some laws, but as it became clear in regards to women’s rights and protections and civil rights related to race/ethnicity and religion, sometimes laws are needed to send a clear message to society that harassment, discrimination, and violence against any group of people are not to be tolerated.

Myth 19: Bisexuals can choose heterosexual privilege.

Fact: There is considerable debate in the literature over how much voluntary control anyone has about his or her sexual attractions—people choose whether to act on them or not, but attraction does not seem to be voluntary. People who are bisexual may be attracted to a person of the other sex and choose to develop a relationship with that person. Although the relationship may look on the surface like a heterosexual relationship, the person’s core identity as bisexual is not changed. One or both partners may be bisexual. Bisexual people can choose whether or not to reveal their sexual identities, as can many gay and lesbian people, but because they face negative attitudes from both heterosexual people and gay and lesbian people, they do not get much “privilege” of any sort, regardless of their relationships. This myth may be expressed differently, depending on who expresses it. For example, a heterosexual man might say, “If you are attracted to both men and women, why not choose to be with someone of the opposite sex and be ‘normal?’” A lesbian might say, “That person calls himself bisexual, but by being in a public relationship with a woman, does nothing to further the cause of gay rights.” Both viewpoints deny the legitimacy of a bisexual identity.

Myth 20: Bisexuals are confused about whether they are gay or straight; they are really gay or lesbian, but just cannot commit. In other words, there is no such thing as a true bisexual.

Fact: Nearly everyone is confused about his or her sexuality at some time in life—bisexual people certainly have no corner on the market of confusion. Because there is much less discussion about and less visibility of bisexual people in our culture, it would stand to reason that there may be more confusion about bisexual identity (Balsam & Mohr, 2007), but the majority of bisexual people report a stable sexual identity over time (Diamond, 2005). The increase in confusion reported by a small subset of bisexual people may be related to being early in the coming-out process, the greater stigma attached to bisexuality than gay or lesbian identities, the greater fluidity of bisexual experience, and the greater likelihood of questioning when relationships change. For example, a man’s experience of leaving a relationship with a man and entering one with a woman may represent what Rust (1996) called changes in the “sexual landscape,” and being adaptable and more fluid in one’s identity is an advantage to healthy adjustment. As to the legitimacy of a bisexual identity, the majority of researchers of sexual orientation have identified a continuum of sexual attraction/behavior rather than a binary, either/or sexuality. This leaves room for a wide variety of identities. For example, some women call themselves “lesbian-identified bisexuals,” denoting that they have sexual attractions for men but tend to prefer women as partners and belong to lesbian social and political organizations.

Myth 21: Bisexuality is just a phase.

Fact: Many well-intentioned persons may tell bisexual people that they are just going through a phase and will eventually find their true identities as gay or lesbian. This stems from the stereotype that bisexuality does not exist and that it is a transitional point on the way to homosexual identity (Mohr & Rochlen, 1999). Some people do indeed label themselves as bisexual early in their coming-out process and then later identify as gay or lesbian, but just as many people first label themselves as gay or lesbian and then later as bisexual (Rust, 2000). This myth could apply to all LGBTQ people. To tell some persons that they are “going through a phase,” whether they tell you they are LGBT or Q, is to trivialize the very difficult process of sexual and gender identity formation and to deny the reality of their lived experience. There is considerable evidence that many people are bisexual in their sexual behavior, and that some of them adopt a bisexual identity that is stable throughout their lifetimes (Diamond, 2005), just as lesbian, gay, and transgender people adopt stable identities.

Myths Related to Gender Identities

A woman is made, not born. —Monique Wittig

There may be even more strongly held stereotypes about gender than about sexuality. A binary gender system is deeply imbedded in contemporary Western culture, affecting the way that we perceive people who do not clearly fit into neat categories of male and female. Many languages, including the English language, enforce the idea of two genders by use of two and only two pronouns: she/he and his/hers. Most legal institutions also systematize gender, requiring that people must be categorized as male or female on birth certificates, driver’s licenses, passports, and marriage certificates. Transgressions from gender norms are severely punished. Think about how early in life we begin to categorize people by their gender, and start making lists in our heads about the nature of gender. We develop schemas of girls (what girls like, what they do, how they behave, how they look), boys, women, and men based on our interactions with parents, teachers, peers, and what we see in the media. Adults generally recognize these schemas as stereotypes, but they continue to deeply influence our behavior, often on an unconscious level. Have you ever caught yourself saying or thinking something that is totally based in stereotype, like attributing the erratic behavior of the car ahead of you to a “woman driver” or assuming that your nurse would be female? Gender stereotypes hurt us all but impact LGBTQ people in unique ways. In particular, transgender people are denied existence by strict binary gender stereotypes.

Reflection: List all the stereotypes you can think of about men and women. How many of these stereotypes fit you personally? In what ways have the stereotypes about your own sex/gender affected your life?

Myth 22: There are two and only two sexes: male and female.

Fact: There is considerable diversity in biological bodies, no matter how sex is defined. We think of sex as determined by chromosomes: people with an XY are male and people with an XX are female. But what about the variations of chromosomal patterns? How about people with XO (Turner syndrome), XXY (Klinefelter syndrome), XXX, XYY, XXYY, and many other variations of sex chromosomes? How about hormones? Both men and women have testosterone and estrogen, just in different proportions at different phases of life. If hormones define sex, then sex can be bought at the local pharmacy. Well, then, what about genitals? Does having a penis make one male and having a vagina make one female? Men can have accidents that result in loss of the penis—are they no longer men? About 1% of infants in the United States are born with an intersex condition where genitals or internal organs of reproduction are not clearly male or female and about 4% have some form of intersex condition that may not be apparent at birth (Fausto-Sterling, 1993, 2000). See http://www.isna.org/ for more information about those born with intersex conditions.

“The world is not divided into sheep and goats. Not all things are black and white. It is a fundamental of taxonomy that nature rarely deals with discrete categories. Only the human mind invents categories and tries to force facts into separated pigeon-holes. The living world is a continuum in each and every one of its aspects. The sooner we learn this concerning human sexual behavior the sooner we shall reach a sounder understanding of the realities of sex ” (Kinsey et al., 1948, p. 639). This statement applies equally well to sex/gender.

Myth 23: Men and women are different mainly because of their biology, not because of their socialization.

Fact: That is an almost impossible statement to evaluate. How does one go about separating out the effects of biology and environment, when we are born into a culture with stereotypes and beliefs about the nature of men and women? Babies begin the socialization process even before they are born, when their parents decorate their nurseries, select toys, give them gendered names, and start to attribute gender characteristics to them immediately. Considering that the human genome is more than 99% alike in men and women, the biological differences are probably much less compelling than the effects of gender socialization.

Myth 24: Transgender identity is rare.

Fact: Current classification systems rarely count transgender people, because questions on survey instruments and medical intakes ask only for male or female. Most transgender people consider themselves to be male or female based on their gender identity and check the box that matches their identity. One study in the early 1990s (Bakker, van Kesteren, Gooren, & Bezemer, 1993) suggested that 1 in 10,000 people in the general population were male-to-female transsexuals (MTF or transgender women) and 1 in 30,000 were female-to-male transsexuals (FTM or transgender men). However, a recent survey of the number of sex reassignment surgeries done in the United States revealed that 1 in 3,100 individuals undergo this procedure in their lifetimes (Horton & Goza, 2007), and the numbers of FTM and MTF transgenders are roughly equivalent. If these figures are correct, it means that most health care professionals will work with transgender clients fairly regularly, whether they know it or not. The actual number of people who undergo sex reassignment surgery is a small fraction of the transgender community, so the numbers may be much higher.

Myth 25: Transgender people are mentally ill.

Fact: Higher rates of depression and other mental disorders among transgender populations are due to stigma: societal attitudes and treatment of transgender individuals (Ettner, 1996; Mallon, 1999). Newfield, Hart, Dibble, and Kohler (2006) reported significantly reduced mental health–related quality of life among 446 female-to-male transsexual and transgender individuals and suggested that additional research was needed to determine the cause of this distress. Some older studies have found no increase in serious psychopathology among transsexual populations (Cole, O’Boyle, Emory, & Meyer, 1997), but the enormous amount of stigma and discrimination can certainly affect emotional adjustment—studies report very high rates of harassment and discrimination in transgender individuals. In one study, 60% of transgender individuals had experienced harassment or violence in their lifetimes and 27% had been the victim of violence. In the past year, they reported experiencing the following: verbal abuse from strangers on the street (34%), being followed or stalked (9%), being assaulted (7%), having objects like rocks or bottles thrown at them (7%), and rape (3%) (Lombardi, Wilchins, Priesing, & Malouf, 2001). These events are certainly likely to affect one’s mood and psychological well-being.

Myth 26: Transgender people are actually lesbian and gay people who cannot accept their sexuality, so try to change their bodies to be heterosexual.

Fact: This stereotype comes from the idea that sex/gender causes sexuality and denies the possibility that gender and sexual identities can be experienced separately. In reality, transgender individuals report a wide diversity of sexual identities, as shown in Table 4.1 from a study of transgender persons (Clements-Nolle, Marx, Guzman, & Katz, 2001). Everyone has a gender and everyone has a sexual identity, and for most people, they are relatively separate.

Table 4.1 Sexual Identification of People Who Reported a Transgender Identity

Myth 27: Transgender identity stems from a biological disorder of sex hormones, chromosome anomalies, or brain dysfunction.

Fact: There is no consensus on the origins of a transgender identity (or any sexual identity for that matter). No studies have conclusively demonstrated differences in any biological structures or functions between transgender individuals and typically gendered individuals (Gooren, 2006). Most people who have been studied by researchers have been in university gender clinics and identify as transsexual. They have been indistinguishable from people in the general population on dimensions of their physical bodies, hormone levels, and psychological adjustment. The only consistent difference is their perception of psychological gender. We know very little about people who identify as transgender, but have no wish to biologically alter their bodies.

Reflection. Many transgender individuals begin to experience gender dysphoria or dissatisfaction with their physical bodies early in childhood. For those individuals, puberty is a particularly traumatic event as their bodies grow more and more out of alignment with their psychological gender. We have the medical capability to arrest pubertal development (preventing menstruation in girls and erections and nocturnal emissions in boys), and such treatment is reversible. Under what circumstances do you think this type of treatment could be considered?

Conclusions

Stereotypes are damaging because they remove any individuality from the person who adopts the stigmatized identity, and they are used to oppress individuals within the category and keep them powerless. Stereotypes imply that one identity completely defines the person, thus erasing their unique histories, varied temperaments and personalities, and the extraordinary diversities within any group that uses a common label. As we saw in the last chapter, stereotypes support stigma at the institutional level, and interfere with building positive relationships at the individual level. If health care professionals rely on myths and stereotypes rather than asking patients about their lives, they are likely to make erroneous assumptions that can lead to inappropriate care of, and disrespect toward, the individual patient.

Reflection Questions

Awareness

1. What was the first thing you can remember ever hearing about LGBTQ people? How old were you? Who/what provided this information? How do you feel about it now?

2. Can you remember the first time you thought about yourself as a boy or a girl? Did your internal feelings match what you looked like on the outside?

3. When you see a baby in a stroller, what are the cues about its sex/gender?

Sensitivity

1. In what ways have gender stereotypes about how men and women should behave affected your own life?

2. If you were not restrained by societal norms about gender, in what ways would you be different?

3. Who were your s/heroes when you were very young? Did they fit gender stereotypes or challenge them?

Knowledge

1. How can you use the factual information that challenges stereotypes in your own work?

Chapter 5: LGBTQ Families

When we take our children to a hospital, we never know if we are going to have a problem with how we are treated as a family. One of us as a parent may be discounted, and only one parent permitted to sign consents, be listed as the parent on forms, or be allowed into the ICU or ER to visit the child. Forms that we and our children have to fill out never reflect the diversity of our families. There are check boxes for male and female but there are some transgender parents who don’t fit either box, or fit both.

(Rabbi Levi Alter, president of FTMInternational, cited in Wilson et al., 2007, p. 8)

The terms family and/or family of choice are frequently used among LGBTQs to refer to an affinity circle that has significant meaning for its members (Weston, 1991). Some LGBTQ individuals have been rejected by their families of origin, so they create their own family networks composed of the people who share, support, and care for them, including partners, close friends, and often ex-lovers and/or ex-spouses (Weston).

As the opening quote indicates, many LGBTQ families fear exclusion and discrimination from health care providers and institutions. These fears extend beyond self to include fear of exclusion of partners from decision making and fear of being excluded from partner’s and children’s care. Hospitals and clinics often use narrow definitions of family that are sanctioned by laws in most states, which define family as adult legal relationships between one man and one woman and the offspring of those unions, parents, or siblings. This narrow definition may exclude LGBTQ family members from critical health care decisions and settings if the family does not fit legal definitions. On the other hand, The Joint Commission that accredits health care settings defines family much broader than blood or legal ties as:

Person(s) who plays a significant role in an individual’s life. This may include a person(s) not legally related to the individual. This person(s) is often referred to as a surrogate decision maker if authorized to make care decisions for the individual should he or she lose decision-making capacity. (The Joint Commission, quoted in The Human Rights Campaign/Gay and Lesbian Medical Association, 2007, p. 14)

A respondent in one study told the story of an older lesbian couple, one who underwent surgery. After her partner died on the operating table, the doctor left the life partner in the waiting room while he told the biological family—not the partner—that her partner had died. To compound this tragic oversight, the biological family went home without telling the woman about the death of her partner. (Saulnier, 2002, p. 360)

Over the centuries, the structures, functions, and the definitions of family have changed. In the 21st century, some of the most diverse and creative family structures have been forged by LGBTQ people. LGBTQ families can include couples in legal marriages, civil unions (e.g., see Solomon, Rothblum, & Balsam, 2004), domestic partnerships, legally unrecognized, long-term, committed relationships, open relationships, or group families (e.g., a lesbian couple and a gay couple conceive and raise children together). Table 5.1 shows where in the world some types of same-sex relationships are afforded some legal protection.

Children can come into the family from previous heterosexual relationships, alternative insemination procedures, adoption, and coparenting. And, contrary to stereotypes about LGBTQ people as unable to reproduce and sustain relationships, many are parents. Rosser, Oakes, Bockting, and Miner (2007) reported that among transgender individuals, 38% of male-to-female transgenders have children and 10% of female-to-male transgenders are parents. Among same-sex couples, the 2000 Census data indicated that 13% of same-sex households reported having at least one child (compared with 47% of the other-sex households). The census data do not distinguish among LG and B people, does not count single LGBTQs, and probably underestimates the LGBTQ population. Other data from national probability sampling suggests that 14% of gay male couples and 28% of lesbian couples are parents (Black, Gates, Sanders, & Taylor, 2000). The census data also suggest that people of color in same-sex relationships are much more likely to be parents than White people in same-sex relationships. For example, in California, more African American (43%), Asian/Pacific Islander (45%), and Latina/o (62%) same-sex couples are raising children than do White same-sex couples (18%), but these ethnic minority households are doing so with fewer economic resources. “Latino/a same-gender couples are over three times as likely to be raising children, on less than half the average household income of White same-gender couples” (Wilson et al., 2007, p. 2).

Table 5.1 Legal Protection of Same-Sex Relationships

Language is a serious limitation when discussing LGBTQ families. There is no one widely used term for significant others—terms such as partner, spouse, wife, husband, lover, girlfriend, boyfriend, and others are used to denote these important relationships. Ex-lovers often remain centrally involved in each other’s lives. There is inadequate language to distinguish a lifelong committed partner from an intimate friendship or from a more casual relationship, and there is insufficient language for all the variety of parenting and child roles that can occur. Does a child with two fathers call them both Dad? What happens when Dad becomes a woman? If a child is reared in a group home, are there primary parents and secondary parents? In some cases, Mom’s best friend and ex-partner may play a parental role in a child’s life and a biological father may have little or no role. Our language needs to be broad enough to capture the diverse relationships that two or more individuals may forge.

Reflection: How do you currently ask clients about their family relationships? The most common is to ask, "Are you married?" But today, many people, even heterosexuals, do not marry. It is important to encourage all patients/clients to tell you about themselves and their various family situations in their own words. Ask about family relationships without necessarily referring to a "husband" or a "wife," or a "mother" or a "father." For example, you might say, "Who do you count on for support?" or "Who's family to you?" Don't ever ask, "Who's the `real' mother/father?"

This chapter reviews basic concepts related to LGBTQ families, including coming out to family members, significant other relationships, parenting, and family-related health care issues.

Disclosure to Family

One of the most traumatic experiences in the lives of LGBTQ people is coming out to family and friends. This section reviews some of the common issues faced by individuals across the life span who come out to parents, children, or spouses. The experiences and the potential consequences may differ depending on the age/developmental stage of the person coming out, as well as the dynamics of the family relationships, but there are some common experiences shared by many LGBTQ people.

Coming out to parents

One of the biggest fears related to disclosure is parental rejection (Ben-Ari, 1995), so first disclosures are rarely to parents but to friends and siblings (Savin-Williams, 1998). For most individuals, there is a gap of at least a year between coming out to self and coming out to another person (Savin-Williams & Cohen, 2007). D’Augelli, Hershberger, and Pilkington (1998) found that most LGB youth were first aware of being different at around age 10, but they did not disclose to another person until around 16. This means that the youth has had several years to think about their sexuality or gender and has come to terms with it, but their parents are often caught off guard and had not considered the possibility of having an LGBTQ child. This often forces parents into the closet themselves as they work through their own reactions. In general, mothers tend to be more accepting than fathers, but disclosure often precipitates a family crisis. Parental reactions can include guilt, loss, and shame. For youth who disclose while still living with parents, there is a potential for loss of economic support and rejection. Coming out as an adult has fewer negative consequences in some ways, but the fear of family rejection can still be very strong regardless of the age of the individual.

Some studies have suggested that coming out earlier (before age 18) carries more risks. According to Friedman, Marshal, Stall, Cheong, and Wright (2007), the early disclosures among gay and bisexual men showed that they were more likely to experience victimization, forced sex, suicide attempts, and later in life, depression and HIV/AIDS than were those who came out in young adulthood. Younger individuals are developmentally more immature, have less life experience, and may have fewer support systems than do young adults.

Interviews with 29 Turkish transgender individuals about their experiences coming out to their families revealed that more than half of the families were aware that the transfamily member was different for more than 5 years prior to the disclosure, with most of the families aware around the time of puberty. Most of the families tried to conceal the difference (65%), and about the same number reported that they had no information about transgender issues to help them. At the time of the disclosure, most families reported severe sorrow (70%), tried to change the person by talking to them or through force (51%), or felt outrage (16%). However, 38% had been supportive from the beginning. At the time of the interviews, 46% of the families were totally accepting, 38% partially accepting, and 16% were still rejecting (Polat, Yuksel, Genc, & Meteris, 2002). Lev (2004) proposed four stages of reactions of family member on the disclosure of a transgender family member:

1. Discovery/disclosure: It can include reactions such as betrayal, shock, fear, shame, revulsion, and anxiety.

2. Turmoil: After the initial disclosure, family members begin to wonder why, and spouses/partners may question their own sexuality.

3. Negotiation: This phase involves wishes or efforts to get the “old person” back.

4. Finding balance: Finally, family members come to terms with the transition.

Donna Orchard of Mobile, AL, said:

Eight years ago, while driving home from a movie, my nineteen-year old college son began to visibly shake, white knuckles grabbing the steering wheel. The light-hearted mood suddenly changed when he said, “I have something to tell you.”

“Okay.” His step-dad and I nodded our heads.

“I’m gay.”

I turned to look at my beautiful son who had brought me to school only once in twelve years, now on the dean’s list, working his way through college as a tenor section leader in an Episcopal church in Birmingham, AL. At first there was a typical response. I squalled about AIDS and not having grandbabies. I cried those crocodile tears that he had cried in the mall when he looked up at me discovering there was no Santa. Thirty minutes later, before we got home, we hugged, and until this day I can’t imagine Benjamin not being gay.

My fears, however, did not end there. Even with a supportive husband, I worried, “In the worse case scenario, my son will be considered a pedophile, at best he will be seen as a comic character on Saturday Night Live.”

In fact, most of the attitudes about gays were not just disrespectful but downright unacceptable to me. I was scared.

“And he’ll have to leave Alabama. What if he walked into the wrong bar? Well, that could happen anywhere. He’ll have to live far away from me, in New York or San Francisco, forever. At least he’ll be safe. What if someone does hurt him?” I was scared.

This mother found her local chapter of Parents and Friends of Lesbians and Gays (PFLAG) and got the support she and her family needed. See http://www.pflag.org/I_have_something_to_tell_you.1132.0.html for many more stories such as this one.

Coming out to children

Because individuals can come out at any point in the life span, some already have children before they come out, and others have families after coming out, but must decide how and when to inform their children of their sexual or gender identification. When possible, disclosure when the children are young (early childhood) is the most successful and least traumatic (Lynch & Murray, 2000; White & Ettner, 2007). If the children are adolescents, when peer pressures are greater and the child is also undergoing identity formation, the disclosure can create greater family drama (Bigner, 1996). Lynch and Murray (2000) reported that parents’ decisions about disclosure to children are based on two types of concerns: potential for loss of custody and the potential effects of the disclosure on the child’s life. One study found that lesbians who had children before coming out to themselves were somewhat less likely to be out to others because of a perceived need to protect their families (Morris, Balsam, & Rothblum, 2002). Another study found that previously “out” lesbian mothers became more discrete as their children grew into childhood and adolescents, as an attempt to protect their children (Gartrell, Deck, Rodas, Peyser, & Banks, 2005). In general, children’s reactions depend on a host of factors: the comfort level of the parent when they disclose, the age and developmental stage of the child, the stability and closeness of the parent–child relationship, and others. A child’s first reaction is generally, “How will this affect me?”

Coming out to spouses

Many LGBTQ people marry people of the other sex before coming out. The stress of telling a spouse may be equal to or greater than coming out to family of origin. Most LGBTQ people marry people they genuinely love, so coming out to them feels like a major betrayal of that love.

Erhardt (2007) is a counselor who has worked with more than 300 transgender and cross-dressing clients and interviewed women whose husbands had come out as transsexual or cross-dressers. One woman who found out that her husband wanted to permanently change his gender had this experience:

My initial reaction was one of complete shock and devastation…. A lot of my discomfort was a result of the fact that I simply didn’t understand. There were lots of tears and plenty of talking over the months that followed … eventually the crying stopped. I knew I loved him/her no matter what, and that I would stick by my partner. (p. 106).

LGBTQ people may have been in heterosexual marriages before coming out to themselves, as an attempt to “normalize” their sexuality, and/or because they fell in love with the person. Transgender individuals, as well, often seek heterosexual relationships, or sometimes same-sex relationships, before initiating a transition. Many continue to feel love for their spouses/partners after they come out.

The PFLAG is a national organization with local chapters in every state in the United States. Its mission is to help family and friends learn to be supportive allies for their LGBTQ family members and peers. For more information, see www.pflag.org.

Significant Other Relationships

Are LGBTQ significant other relationships different from heterosexual relationships? So much of the traditional heterosexual relationship is based on gender stereotypes about men being breadwinners and women being the nurturers, that there are bound to be some differences, but the existing literature suggests that these differences are relatively small. Some LGBTQ individuals are engaged in family formation through polyamory, defined as the “philosophy and practice of loving more than one person at a time with honesty and integrity” (McCullough & Hall, 2003), but the majority of LGBTQ people are couples.

With regard to gay male relationships, stereotypes about gay men being promiscuous and unable to have stable relationships still abound. However, the majority of gay men forge stable, long-term relationships, although they may be more diverse than heterosexual relationships. Some gay men have “marriages,” whether legal or not, that are similar to heterosexual marriage—they are monogamous and long-term commitments. Other gay men have a primary partner, but they have an open or nonmonogamous relationship, men being somewhat more able than women to separate love and sex. Some research has found both types of relationships to be equally satisfying and secure (LaSala, 2004). Factors that seem to predict relationship success among gay men include self-acceptance and being secure in one’s own sexuality (van Wormer, Wells, & Boes, 2000); psychological complementarity (when gender role expectations are absent, gay men are freer to select partners on individual needs and wishes; Laird, 1993); and extended family support.

Lesbians are equally freed from gender role expectations in some regard, but they are also socialized to value intimacy and connectedness more so than men. This means that lesbians may forge deep intimate relationships with other women rather quickly (Parks & Humphreys, 2006). There is a joke about lesbians taking a U-haul on the second date, implying that the move from dating to serious relationship is very fast. Once lesbian relationships are formed, they do not differ greatly from heterosexual relationships in terms of satisfaction or challenges (Kurdek, 2001), but they do differ in terms of societal acceptance and division of labor. Lesbian relationships tend to be much more egalitarian than heterosexual relationships (Matthews, Tartaro, & Hughes, 2003). Lesbian couples are twice as likely as gay male couples to seek out civil unions where they are available, but it may have to do with parental status, because lesbian couples are also twice as likely as gay male couples to have children (Solomon et al., 2004).

There is very little empirical research on relationships among bisexual individuals. Some of this research finds bisexual people to be more likely to engage in nonmonogamous relationships (Weinberg, Williams, & Pryor, 1994). McLean (2004) surveyed 60 Australian bisexual men and women and found that about one fourth of the sample participants were in monogamous relationships, and they were satisfied with these arrangements. Those in nonmonogamous relationships discussed the challenges of negotiating the ground rules for these relationships—generally, levels of trust, honesty, and a high degree of communication must be present for these relationships to thrive.

Finally, relationships are complicated for transgender individuals as well, because they represent all varieties of sexual identity from lesbian, gay, bisexual, heterosexual, and asexual. When gender and sexuality combinations are considered together, new hybrid relationships are possible, as the following example illustrates:

Kate Bornstein is a performance artist, born male, and transitioned to become a woman as an adult. As a man, Kate had been married to a woman. After transitioning, Kate was in a relationship with a woman who considered herself a lesbian, but later transitioned to a male role. Currently, Kate’s partner is another MTF transgender woman. So what kind of relationships has Kate had? Heterosexual, then lesbian, then heterosexual, then lesbian? These terms have little meaning when gender difference is added to the mix, and this example highlights the inadequacy of our language.

Rosser et al. (2007) in an Internet survey of transgender individuals found that 28% of MTF and 6% of FTM reported that they were currently legally married. We know much less about other types of relationships among transgender individuals. A recent article addressed men who have sex with transgender women as a possible new sexual identification category (Operario, Burton, Underhill, & Sevelius, 2008)—do these men have different risk factors than MSM or heterosexual men? We do not know much about all the unique varieties of sexual desires and sexual relationships.

Becoming Parents

Historically, LGBTQ people became parents through heterosexual relationships or at least heterosexual sex. In the past 20 years, increasing numbers of same-sex individuals and couples are now creating families through adoption, foster-parenting, biological parenting by using reproductive technologies, and step-parenting. However, only eight states and the District of Columbia offer the legal option of second-parent adoption, which grants a same-sex partner of the biological or adoptive parent equal parental rights and responsibilities. Without such rights, parents may be denied custody, visitation, or decision making privileges for their own child. But parenting discrimination does not begin at birth. Lesbian couples seeking coverage for fertility consultations and treatments that are necessary but expensive are often delayed and discouraged by insurance coverage rates that are tailored to heterosexual couples. In addition, lesbians may be denied fertility treatment altogether owing to discrimination by the clinician. Gay men, bisexual, and transgender individuals may be denied outright in their applications to become foster parents or to adopt.

Guadalupe Benitez, age 33, sought fertility treatments in San Diego in 1999 because she and her partner, Joanne Clark, wanted to have a family. She was denied artificial insemination because the doctor said that it was against her religious beliefs to perform the procedure for a lesbian. Benitez sued the doctor and the clinic. Ms. Benitez went outside of her insurance plan to find a physician who would provide treatment, and she subsequently gave birth to a son. Her case, hoping to set precedent for other LGBTQ people seeking to have children, was at the California Supreme Court at the time of this writing. What do you think—can physicians refuse to treat someone on the basis of his or her religious or moral belief?

Most early studies about LGBTQ individuals and parenting were directed toward the physical and psychosocial outcomes for the children. More recent work has included the experiences of the parents themselves (e.g., Epstein, 2002; Ross, Steele, & Sapiro, 2005; Tasker, 2005). The Committee on Lesbian, Gay, and Bisexual Concerns, the Committee on Children, Youth, and Families, and the Committee on Women in Psychology of the American Psychological Association (APA) conducted a comprehensive review of the published research about lesbian and gay parenting since the 1960s. The report concluded that

there is no evidence to suggest that lesbian women or gay men are unfit to be parents or that psychosocial development among children of lesbian women or gay men is compromised relative to that among the offspring of heterosexual parents. (APA, 2005, p. 15)

LGBTQ parents are as diverse as heterosexual parents. They face many of the same challenges and have the same desires for themselves and their children. What is different, as we have seen in previous chapters, is that prejudice affects their lives and restricts many of their choices. For example, even becoming parents may be complicated (Baetens, Camus, & Devroey, 2003). Although all parents consider where and how to raise their children, LGBTQ parents must also consider the effects that stigma may have on play dates, preschool, and all of the years of schooling to follow. These parents may face additional worries about their children being bullied because of the sexual orientation of the parents (Clarke, Kitzinger, & Potter, 2004). Prejudice may result in negative outcomes whether from judges, legislators, professionals, or the public (ACLU Foundation Lesbian and Gay Rights Project, 2002). And, when there are multiple diversities as with ethnicity and economic circumstances, the situation can become even more complicated.

Even among individuals who believe that LGBTQ adults should be allowed the same civil rights as others, there is a subset that believes that LGBTQ people should not be allowed to be parents on the basis of religious doctrine or other beliefs, such as it would be unfair to the children because they might be teased or harassed. However, the stereotypes they believe are simply not supported by contemporary data (APA, 2005). A parallel might be drawn with global warming. Despite the preponderance of scientific verification, and even the evidence of daily newscasts about wildfires, drought, and melting polar ice caps, there are those who do not believe that global warming exists. That is their opinion, but it is not fact.

My parents divorced when I was four, and my mom came out as a lesbian. When I was young I went through a lot of teasing. I changed schools, then changed again. At my school now, only a few people know and they’re very supportive. My mom has taught me to love all types of people. Because of my mom, I’m not like everyone else. I’m different and I love it. Claire V. (15 yrs), Berkeley, CA (cited in Wilson, 2007)

Child outcomes

In addition to research about LGBTQ parents, there is some information from the children’s perspective about what it is like to have lesbian or gay parents (Howey & Samuels, 2000; Perrin, 1998; Rafkin, 1990). Also, in the comprehensive review published by the APA (2005), there is a section about children of lesbian and gay parents. The authors focused on research about the children’s sexual identity, social relationships, and other aspects of personal psychological development. Within sexual identity, they included gender identity, gender role behavior, and sexual orientation. The development of gender identity among children of lesbian parents followed expected patterns, although there were no reported studies of gender identity formation for the children of gay fathers. There were no differences between children of lesbian and heterosexual parents on gender role behavior; again, no studies about gay fathers were reported. In most studies, the majority of children of both lesbian mothers and gay fathers described themselves as heterosexual. The authors reported that these children have “positive relationships with peers and that their relationships with adults of both sexes are also satisfactory” (APA, 2005, p. 12). They concluded that there was no evidence to date to indicate that children of lesbian and gay parents are disadvantaged relative to children of heterosexual parents (APA, 2005, p. 15). It is important to note that although studies about lesbian mothers and gay fathers have been conducted, they are relatively few and research about bisexual or transgender parents has not yet been reported.

Most of the research has focused on lesbian mothers, probably because lesbians are more likely to be parents than gay men (Solomon et al., 2004). The National Lesbian Family Study started in 1986 with lesbians who enrolled during their insemination periods or pregnancies, and they have been followed since (Gartrell et al., 2005). This is the largest prospective study of lesbian families in the literature, but it must be viewed with some caution because the participants are 93% White and highly educated, and because they all had children via donor insemination (i.e., planned families). The most recent report from this study summarizes the interviews done when the children were 10 years of age. In general, the children were healthy and well-adjusted. They had comparable rates of developmental disorders (15%), such as learning and attention problems, as the general population of children (17%) but lower rates of sexual abuse experiences (5% of the girls and none of the boys), and none reported physical abuse. They were also comparable with children in the general population on the Child Behavior Checklist, with one exception. Girls in lesbian families had fewer externalizing behavior problems than girls in the general population. Most (85%) of the children were doing well academically, but 43% had experienced homophobic instances, mostly at school. Those who reported homophobia had slightly higher rates of behavior problems than those who did not experience homophobia. Many of the children, however, had been prepared for these incidents by their mothers and coped well with teasing or homophobic comments.

One kid said one time that he didn’t like gays and lesbians and I said, “You mean like my mom?” and he said, “I didn’t know your mom was.” So I told him that if he had a friend and he was Black, would he stop being his friend and he said, “No.” I told him it was the same thing. (Gartrell et al., 2005, p. 522)

In another study (Bliss & Harris, 1999), teachers of children raised by lesbian and gay parents reported that the children had more problems with social interactions, but they were more mature, tolerant, and self-confident than their peers from heterosexual parents. As one respondent said about school: “Teachers don’t allow kids to make negative comments about skin color or gender, but they don’t stop them from saying negative things about gays” (Gartrell et al., 2005, p. 522).

Reflection: One study (Gartrell et al., 2000) found that 17% of the grandparents of children with lesbian mothers had refused to recognize them as full-fledged grandchildren. How do you feel about that? Who loses out in this situation?

Health-Related Family Issues

There are three categories of legal concerns related to health care for same-sex parents with children: consent for medical procedures/treatment, involvement in sharing of information and decision making, and visitation rights. These issues are discussed in chapter 8. On top of the legal concerns are the issues we discuss elsewhere in this book concerning the potential for poor quality treatment or even refusals of treatment based on one’s perceived sexuality or gender—or in this case, the parents’ sexuality or gender.

My partner and I were vacationing and my daughter became ill and had to be taken to the emergency room at a local hospital. Even though she was sitting in my lap, calling me mommy, and I had her insurance card, the professional staff all looked to my partner (who is not her biological mother) when they talked about my daughter. I look androgynous, and I believe it made them uncomfortable and unable to “see” me as her mother. It’s not the first time it happened, and it probably won’t be the last, but it still makes me angry. (J. DeJoseph, personal communication, 2007)

Conclusions

LGBTQ people come from families of origin that vary in how they respond to the person’s disclosure of sexuality and gender, and they create their own families. Sometimes these new families are indistinguishable from the kinds of families created by heterosexual couples, and sometimes they differ. However, all families deserve support, respect, and validation in health care settings. If our society is truly committed to “traditional family values,” then it must encourage laws and policies that support all families.

Reflection Questions

Awareness

1. Do you know anyone who was raised by same-sex parents or an LGBTQ single person? What was his or her experience?

Sensitivity

1. How would you react if a child of yours came out as LGBTQ (or how did you react if a family member came out)?

2. How would other family members react?

3. What if your spouse came out as transgender?

Knowledge

1. How would you find out what policies your work setting has that might impact LGBTQ families?

2. In your work setting, how is family defined and for what purposes (decision making, consent, visitation, sharing of information, etc.)?

Chapter 6: Cultures Within Cultures Diversity and LGBTQ Communities

Since every identity has meaning only because it is named against other identities, there can never be an identity that is all-inclusive. By saying who we are and what we are fighting for, we are necessarily saying what we are not and what we are not fighting for.

Kumashiro (2001, p. 6)

As Kumashiro so astutely noted, our focus on LGBTQ identities in this book can have the effect of rendering other social identities invisible, or to seem less important. No individual can be characterized by only one of his or her multitude of identities, but is, in reality, an amalgam of many, sometimes conflicting, and constantly shifting identities. Which identities a person chooses to evoke in any given situation depends on the context. LGBTQ people represent every form of diversity known within human experience. Thus far, however, LGBTQ health research is still in infancy, and little attention has been paid to subgroup variations or the influence of intersecting identities within LGBTQ populations. It is likely that some demographic and personal characteristics are equally or more important in influencing health than sexual and gender identities. Consider the potential differences among these individuals, all of whom might be lumped together in a study of the effects of sexual stigma on health:

- Sam is a 15-year-old Asian American (second-generation Japanese) youth who thinks he might be gay, but fears more harassment at school (he is already harassed for being Asian). Sam has a family that does not discuss topics related to sexuality openly, and he relies completely on his parents for health care services.

- Mary is a 43-year-old White woman who is newly divorced from a man to whom she was married for 17 years. She finds herself very attracted to her new neighbor, a single woman. While married, she had an excellent health care plan, but since the divorce, she has very limited insurance.

- Lee, a 66-year-old American Indian who does not use terms like male/female or LGBTQ, has been considered “two spirit” since childhood and serves a healer role in the community. Lee, by western standards, has a male body, but by traditional standards, is a “third gender.” Lee, who is severely disabled with emphysema and mobility problems, lives on a reservation with a 45% unemployment rate.

- Lauretta is 50, African American, and was raised as a devout Catholic. She entered a convent at age 18, but left a few years later when she fell in love with a fellow nun. She works as a receptionist in a small business in a Black neighborhood and does not talk about her personal life to coworkers. She has no insurance. Her partner of 18 years, Joyce, is a bus driver with insurance, but it does not cover domestic partners.

- George is a 26-year-old Latino, bisexual man who contracted HIV in his youth, before he was employed. He is healthy now and works full time but cannot get insurance because of the “preexisting condition.” He lives in a rural area with few services for people with HIV.

- Rami is a 22-year-old Arab man who fell in love with his roommate Jim in college. They were together for 4 years, but now Rami’s visa is up for renewal and he cannot stay in the United States. Jim would not be welcomed by Rami’s family or community; in fact, they would risk severe violence in Rami’s homeland.

- Mary is a 34-year-old Jewish lesbian with cerebral palsy. She uses a wheelchair to get around and is frustrated by the lack of accessible events in the lesbian community. She also attends a support group for women with disabilities, but she is the only lesbian in the group and must constantly challenge their heterosexism. She fights the stereotype of the asexual woman with disability constantly within the larger society and the lesbian community.

- Samantha is a 10-year-old Latina from a large Catholic family. From as long as she can remember, Samantha has thought of herself as a boy and has rebelled against her family’s efforts to make her into a “girly girl.” She wants her family to call her Sam and treat her like a boy. Her family thinks she is far too young to know these things, and they are ashamed of her difference.

These individuals have identities or characteristics that affect their ability to access health care and that affect how others perceive and treat them. They may or may not use terms such as LGBT or Q to describe themselves. The forms of oppression are intersecting in contemporary society, and stress related to multiple diverse identifications is additive. Historically, LGBTQ identity politics have sometimes inadvertently, and sometimes deliberately, excluded discussion of other oppressed minorities in an attempt to unify under one label (usually the sexuality label). Kumashiro (2001) pointed out that

any attempt to focus on “queer” is simultaneously a process of separating queer genders and sexualities from other identities, thereby leaving unmarked those (nonqueer) identities that are traditionally privileged (such as White American and male identities)…. Similarly, some civil rights movements based on race or ethnicity have excluded gender and sexual minority identifications, sometimes in a deliberate move to “normalize.” LGBTQ identities are labeled as “a white thing” and to adopt an LGBTQ identity as a person of color is to be a “race traitor.” (p. 4)

A truly inclusive approach to health disparities would attempt to take into account the many different identities that impact one’s health status, a challenging but necessary task for those who work in health care settings. In this chapter, we address just a few of the common forms of diversity within any LGBTQ community. We addressed sex and gender in other chapters, so in this one, we briefly discuss age, race/ethnicity, religion/spirituality, ability/disability status, and gender expression. Keep in mind that the divisions are artificial, and that in reality, all people experience all of their identities more or less simultaneously and often cannot sort out the influence of any one identity in isolation of the others.

Age Differences

Most of the health-related research on LGBTQ individuals has focused on risk factors, such as victimization, HIV risk, suicide, substance abuse, and mental health, and very little research has focused on “normal” developmental transitions, resilience, and common experiences such as dating and negotiating relationships. Many human characteristics unfold in a predictable, linear manner, such as language development, motor skills, and cognitive development. Others, such as social identities, are more cyclical or nonlinear, and more bound by social context and influenced by overall developmental stage in the life span. Children, adolescents, young adults, midlife adults, and older adults have different patterns of life transitions, some established by our biology and some by our culture. Table 6.1 summarizes some of the ways that having a minority sexual or gender identification might impact those common developmental transitions. These developmental issues are discussed in more detail below.

LGBTQ children

As children are exposed more to communication technologies, particularly the Internet, and as media portrayals of LGBTQ people proliferate, they are able to adopt labels for their perceived differences earlier than ever before. The age of first coming out has declined over the past 20 years. How will it affect the achievement of developmental milestones if an individual comes out prior to puberty? We know next to nothing about this but can speculate that the individual might meet great resistance from family, teachers, and others because of a widespread belief that sexual identities develop at puberty or later, so someone younger could not possibly know if they are LGBTQ. Yet, if you ask LGBTQ people when they first were aware of their sexual or gender difference, many will tell you that they knew before puberty. One longitudinal study found that three fourths of LGB individuals reported feeling different as children, at an average age of 8 (D’Augelli & Grossman, 2001). People who identify as transgender later in life often report similar ages of being aware of their difference (Pazos, 1999). Younger children who are aware of their differences from others may feel that they have no one to talk to, and they may fear parental and peer rejection or resistance. We can only speculate about their experiences, because human subjects review panels and funding agencies are very sensitive about research that asks minor children about issues related to sexuality, so we have very little empirical data on this age group.

Reflection: Imagine yourself as a child who feels different. You have a male body, but you are not interested in typical boy activities such as sports, war games, or playing with trucks and cars. Instead, you like music, dancing, and playing house with your sister. At school, you are harassed by bullies who call you “sissy,” and “fag.” At home, your father disapproves of you playing with your sister, and sometimes punishes you by sending you to your room. As you move into your adolescent years, your mother tries to arrange dates for you through her church network. She and your father bring you to a minister who talks to you about your “manly responsibilities.” School is becoming an increasingly hostile place for you because the bullies now do more than taunt you. You have experienced physical attacks twice this year. You form a close friendship with a girl who encourages you to join the Gay Straight Alliance (GSA) with her. Instead of giving up, you resolve that you will survive school. You throw yourself into your studies hoping to get a scholarship for college to get you out of your neighborhood. At 17, you fall in love for the first time. It feels glorious, but the only people you can tell are the members of the GSA because your parents and other family members, the minister, and most of your peers at school would be appalled. You long for the escape to college where you can start living an authentic, open life.

Table 6.1 Developmental Milestones and LGBTQ Identities/Stigma

LGBTQ adolescents

Much of the research about LGBTQ youth is focused on how their sexual orientation or gender identity is related to unhealthy choices such as tobacco use, unsafe sexual behaviors, or suicide (e.g., Remafedi, 2007; Spirito & Esposito-Smythers, 2006). LBGTQ adolescents also face the potential for violence from others because of their sexual orientation, gender identity, or gender-role behavior. One frequently cited example is the Matthew Shepard case. Matthew Shepard, a 21-year-old college student, was murdered in an antigay hate crime in Laramie Wyoming in October of 1998. Transgender youth are also vulnerable to violence and disruption of their physical and mental health (Mallon & DeCrescenzo, 2006). In one study of transgendered youth aged 15–21, participants noted that there were four major problems in health-related areas, including lack of safe environments, poor access to physical health services, inadequate resources to address their mental health concerns, and a lack of continuity of caregiving by their families and communities (Grossman & D’Augelli, 2006). The Gwen Araujo murder in 2002 in Newark, CA, is a horrific reminder of some of the difficulties faced by transgender youth. Whereas violence is at one end of the anti-LGBTQ continuum, bullying and harassment are nearly everyday events for most youth. Experiencing bullying and homophobic/biphobic/transphobic remarks at school have been linked to higher rates of suicidal ideation (Rivers, 2004) and poorer school achievement (Gay, Lesbian, Straight Education Network, 2006).

There is some information about the protective factors and resilience of LGBTQ adolescents (Eisenberg & Resnick, 2006; Sanders & Kroll, 2000), particularly related to having social support from parents and school. In addition, models of integrated assessment of needs and program planning have been proposed (Berberet, 2006). Perhaps, the most encouraging factor is that the broad range of issues of LGBTQ youth are now being studied, and their findings and recommendations will inform all health care professionals.

As one example, there is a growing body of research on dating experiences of LGBTQ youth. According to stereotypes, LGBTQ youth are isolated and afraid to come out, and if they do, face victimization in their schools, families, and communities. Do LGBTQ youth, then, miss out on dating, a developmental milestone that allows youth to rehearse intimate relationships and explore their gender, sexuality, and communication skills? Diamond (2002) found that most young lesbian and bisexual women (like their heterosexual peers) have intense, passionate same-sex friendships in adolescence, and most of these are nonsexual. When they do become sexual relationships, they provide a catalyst for exploring sexual identity labels. Diamond noted that many women reported having an intense same-sex relationship in youth that is never repeated, and therefore does not affect the sexual identity label of the person in adulthood (Diamond, 2002). These intense emotional relationships may play the same role as dating in rehearsing communication, emotional intimacy, and physical affection for those who later adopt a lesbian or bisexual identity. Elze (2002) studied 112 lesbian and bisexual female youth aged 13–18 from New England and found that contrary to stereotypes, most of them do date. Lesbian and bisexual women sometimes met their partners at sexual minority youth meetings (22%), but they more typically found those partners at the same venues as heterosexual youth—at school (24%), through friends (13%), and at events or recreational settings (27%). Some of the risks that Elze identified were the intensity of breakups: about one fourth of those who had experienced a breakup in the past 6 months reported that they felt suicidal in response to the breakup. In addition, about 44% of bisexual women’s relationships and 25% of lesbian relationships had involved physical or verbal abuse, suggesting that LGBTQ youth, as much as heterosexual youth, need education about healthy relationships to guard against intimate partner violence.

Another researcher in the field, Savin-Williams (2005) noted that youth are “increasingly redefining, reinterpreting, and renegotiating their sexuality such that possessing a gay, lesbian, or bisexual identity is practically meaningless” (p. 1). In fact, youth are constantly creating a whole new language to refer to gender and sexuality: gayish, metrosexual, boidyke, polygendered, onmisexual, queerboi, and a host of other creative labels. Some do continue to use labels such as LGBT or Q, so those who work with youth must stay open to a wide and shifting continuum of labels, refusals to use labels, and new combinations of sexual attractions and gender expressions.

LGBTQ young adults

Research literature about LGBTQ adults has addressed some of the same issues as the research conducted among heterosexual adults. One issue is related to parenting (see chapter 5) and another to specific disease states such as breast cancer or HIV (see chapter 7). However, some of the research is associated specifically with being LGBTQ: for example, dealing with heterosexism (Burn, Kadlec, & Rexer, 2005) and the processes of coming out (D’Augelli, 2006b; Floyd & Bakeman, 2006). Other investigators have noted the effect that an individual’s level of being “out” has on health (Hubner & Davis, 2005; Koh & Ross, 2006; Ragins, Singh, & Cornwell, 2007). There is also a growing body of research about multiple and intersecting identities among LGBTQ individuals, such as culture and ethnicity with sexual orientation (Balsam, Huang, Fieland, Simoni, & Walters, 2004; Cochran, Mays, Alegria, Ortega & Takeuchi, 2007; Guarnero, 2007; Parks, Hughes, & Matthews, 2004). Some research about LGBTQ adults focuses on the experiences of violence, whether from antigay hate bias (Russell & Richards, 2003), the result of bullying while an adolescent (Rivers, 2004), or violence within intimate partner relationships (Bornstein, Fawcett, Sullivan, Senturia, & Shiu-Thornton, 2006; Ristock, 2003).

There are some encouraging trends in recent research about LGBTQ adults. The first is recognition about the similarities between LGBTQ and heterosexual individuals (Kurdek, 2004; Means-Christensen, Snyder, & Negy, 2003). Another trend is a decrease in the number of studies that consider sexual orientation or gender identity as the reason for all physical, mental, emotional, and social difficulties experienced by LGBTQ people (the “blame the victim” approach). Instead, there is a deepening understanding that “minority stress” may offer a conceptual framework for understanding mental health issues and other health-related experiences among LGBTQ adults (Meyer, 2003). Population sampling techniques are also being employed to place the experiences of LGBTQ individuals in the same nonclinical groups as heterosexuals (Bradford et al., 2004; Case et al., 2004; Cochran & Mays, 2007). Another trend is a consideration of the amazing resilience of many LGBTQ individuals (Bowleg, Craig, & Burkholder, 2004; Oswald, 2002).

Developmental transitions for young adulthood include career development and relationships and family. We addressed relationship and family issues in chapter 5, so we focus on career here. How do LGBTQ adults decide whether to be out at work? Being out at work can increase the potential for harassment and verbal and physical threats (Bradford, Ryan, & Rothblum, 1994; Herek, 1995), and for job loss (Badgett et al., 1992). Some researchers have noted that hiding one’s sexuality is draining and results in lost work productivity and decreased job satisfaction (Boatwright, Gilbert, Forrest, & Ketzenberger, 1996). Rostosky and Riggle (2002), in a study of lesbian and gay adults, found that being out was related to an individual’s level of self-acceptance (interpreted as having low levels of internalized homophobia), having a nondiscrimination policy at work, and having a partner who also worked in a setting with a nondiscrimination policy.

Transgender individuals may have more difficult with obtaining and keeping “legitimate” employment than nearly any group of people. Xavier, Honnold, and Bradford (2007) reported that many transgender Virginians reported being denied a job (21% of male-to-female [MTF] and 18% of female-to-male [FTM]) or being fired from a job (15% of MTF and 9% of FTM) because of their gender expression. Many male-to-female transgender people, especially those with less education and who come from racial/ethnic minority groups, end up in sex work to survive (Nemoto, Operario, Keatley, Han, & Soma, 2004; Reback, Simon, Bemis, & Gatson, 2001). LGBTQ employees generally report higher work-related stress than heterosexual people because of the potential stigma from bosses and coworkers, and lack of institutional support such as health insurance and sick leave policies.

LGBTQ midlife

Discussions of midlife transitions in the general population often focus on menopause and “empty nest” syndrome for women, and career and goal aspirations for men. It is sometimes described as a time of reflection on earlier life, of deepening spirituality, and of “generativity.” How does having a minority sexual or gender identification impact the midlife phase of life?

Starting with women, menopause may have different meanings for lesbian, bisexual, and transgender women. There may be less concern about the physical appearance changes of aging among those in same-sex relationships, as, in general, lesbian and bisexual women’s communities do not place as much emphasis on youth as other groups. Bisexual and transgender women who are in relationships with men or dating men may experience pressures more like heterosexual women experience. LBT women without children do not experience empty nest syndrome, whereas those with children may experience the launching of the children in similar ways to heterosexual women. One difference might be related to the coparent, who is often not acknowledged as having a parental role, and thus may not receive any validation or recognition of the difficulties she experiences when the children leave home. Another potential difference is the experience of menopause for those with same-sex partners. Kelly (2005) interviewed 20 lesbians about menopause experiences. Here are a few of their comments about the differences:

I think that the lesbian community would provide the atmosphere for sharing about menopause that heterosexual women may not have. Having a woman partner and lesbian friends makes it so normal to talk about it, and not only talk about it, but understand from a woman’s point of view. I can’t imagine a heterosexual woman in menopause would get the same support and understanding from a male partner. (p. 168)

For lesbians who are childless, being past childbearing is no consequence. Losing your attractiveness to males isn’t within our reality, and menopause—a sign of getting older—does not bring the same fears as hets [heterosexuals] would feel. As a feminist lesbian the experience is a positive one. (p. 171)

And, as some respondents noted, the deepened reflection and scrutinizing of one’s life that may be prompted by menopause may result in coming out. A woman who came out while in menopause talked of her experience of letting go of the expectations of others and learning to focus on her own needs and desires (Kelly, 2005, p. 181). Coming out at 50 may be a very different experience from coming out at 16 or 25 or even 40.

Gay, bisexual, and trans men are less likely to have children, so career and aging concerns may be higher than family concerns. “Gay culture” is youth and beauty-oriented, so GBT men may have more difficulty adapting to the changes of aging. As Kooden and Flowers (2000) noted, “Gay men are deeply invested in their bodies, and many feel that their body is their best asset—not only for sex, but for feelings of attractiveness, power, and success” (p. 28). This focus on the body can result in significant loss of self-esteem during midlife, but it can be balanced by focusing on cultivating emotional intimacy and de-emphasizing the purely physical aspects of sexuality. Career concerns and evaluating whether one has achieved his or her goals in life is a common theme for heterosexual men, and it is likely experienced by GBT men as well. If workplaces have been hostile or not accepting, career satisfaction may be lower, and if oppression has affected one’s ability to achieve life goals, there may be a greater experience of a midlife “crisis.”

Very little is known about midlife experiences of bisexuals because they are subsumed under the category of lesbian or gay if in same-sex relationships and heterosexual if in other-sex relationships. Weinberg, Williams, and Prior (2001) followed a group of bisexual individuals over 20 years, and at midlife, they found that about half reported being sexually active with only one gender of partner: one-third were exclusively heterosexual and one-fifth exclusively with same-sex partners, but the majority were firm in their bisexual identities—that is, the type of relationship did not affect their individual sense of sexual identification as bisexual. For some, the stresses of biphobia that comes from both heterosexual and lesbian and gay communities might continue to affect their health and well-being into midlife (Grossman, D’Augelli, & Hershberger, 2000).

For transgender individuals, midlife may be the time of transition or discovery/adoption of a transgender identity, or it may be a later stage in the process. Xavier et al. (2007) reported that 33% of MTF and 16% of FTM began their transition after the age of 40. Ironically, biologically born women can easily get hormones in midlife if they wish to treat menopause symptoms, but a transgender woman must get a letter from a mental health care provider confirming that she is “sane” before she can receive the same hormones at the same doses as a perimenopausal biological woman. Cook-Daniels (2006) outlined five potential concerns of transgender individuals as they move from midlife to older adulthood:

1. Chronic health problems: The onset of heart disease, diabetes, and other chronic illnesses may affect treatment such as hormonal therapies and surgeries.

2. Entrenched social roles: The older we get, the greater the chance that we find it difficult to make changes in our social roles (such as relationships with partners, spouses, and family members) and our behaviors (speech patterns, physical mannerisms); therefore, an older transgender person may not learn to “pass” as the other sex as well as a younger person.

3. Dating: The combined stigmas of transphobia and ageism may severely limit dating opportunities, and the transgender person often must learn dating patterns of the other sex.

4. Legal concerns: Changing one’s sex on legal documents can be costly and time-consuming. As a person ages, it is imperative to make sure that documents such as social security records, VA records, hospital and clinic reports, and pension papers are accurate and up-to-date so that health care is not delayed.

5. Employment (see the previous section).

For all individuals at midlife, one major milestone is the development of generativity, the feeling that one has left a legacy that will live on after them. For some LGBTQ people, generativity can be achieved through parenting, whereas others address this need through mentoring, teaching, cultural production (novels, plays, artwork, nonfiction work, research), and/or community activism. Midlife is often a time of giving back to one’s community.

Finally, another common change in midlife is a greater seeking of spirituality. As one processes issues of mortality, there is a need to make sense of the world and have hope for the future. Among many LGBTQ people, the AIDS epidemic heightened awareness of mortality even in younger people. A section later in this chapter addresses spirituality and religion.

LGBTQ elders

As strong as I am today … when I’m at the gate of the nursing home, the closet door is going to slam shut behind me. (Fred Riley, aged 75, gay male quoted in the New York Times; Gross, 2007)

Figure 6.2 Examples of a continuum of formal Christian religion’s stands on LGBTQ identities/behaviors. Note. MCC = Metropolitan Community Church.

In the last two decades in the United States, the number of people older than 65 years has been increasing twice as fast as the rest of the population. It also means that there are now more LGBTQ individuals older than 65 years than there have ever been. How do stereotypes about aging and about LGBTQ people intersect to affect the lives of LGBTQ elders? Adjustment to aging is heavily influenced by the sociocultural context in which the person came out, and for many LGBTQ elders, this was the period prior to the gay liberation movement. The experiences of much greater societal stigma and need for secrecy may deeply affect LGBTQ elders today, but as the current baby boomer generation ages into maturity, they will be more open and out about their identities than the current generation (Wierzalis, Barret, Pope, & Rankins, 2006).

In the 1980s, Kehoe (1988) began the first nationwide study of lesbian elders to learn about their experiences and concerns as they aged. Other researchers have confirmed some of the same findings: LGBTQ elders have many of the same issues that other elders do (Brotman, Ryan, & Cormier, 2003; Claes & Moore, 2000; Fox, 2007; McMahon, 2003). They have concerns about their present and their future. They are worried about their physical and mental health, their families of origin and/or choice, loneliness, and, perhaps most of all, their economic security. Again, stigma and prejudice may affect many of their decisions. They may have additional concerns about where they will live, because many retirement communities will not allow a same-sex couple to live together in the same unit. LGBTQ elders may also face ostracism from others living in those centers (Johnson, Jackson, Arnette, & Koffman, 2005) and/or the staff in these centers who have little or no training about LGBTQ elders. Advance care planning and end-of-life care may be more complicated for them than for heterosexuals (Stein & Bonuck, 2001). The elderly face what every LGBTQ individual faces daily about coming out and its consequences. It may be even more difficult for the elderly because their choices may be decreased. However, it would be incorrect to ignore the vibrant contributions many LGBTQ elderly persons make daily to their families and communities, although as yet there is little research to support the anecdotal evidence.

Whenever I looked for employment, though I was willing and eager, people did not usually want to employ "someone like me." Because the jobs that I could get were usually at gay bars, working as a bartender "off the books" I have nothing in my social security account, which means that when I turn 65 I will have no financial security. As a result of the discrimination that I have experienced, I have often had to depend on public assistance like welfare to survive. (Tina Donovan, a 61-year-old transgender woman; Donovan, 2001, p. 20)

Because so many LGBTQ people have had to fight gender stereotypes all of their lives, they often highly value independence—many have learned to cook, clean, change the oil in the car, and fix the toilet as they are more free of gender stereotypes. Therefore, any loss of independence may be felt even more keenly by LGBTQ elderly persons than heterosexual people who adhered more to gender stereotypes. Disability may be considered even more negatively by LGBTQ seniors as a result (O’Toole, 2000). Chapter 7 deals with some of the chronic health problems that are reported at higher rates among LGBTQ people. Most of these studies have not had sufficiently large samples to examine the rates of illness by age group, but as in the general population, the rate of chronic illness increases with age. One study (Grossman, D’Augelli, & O’Connell, 2001) specifically examined the health and well-being of LGB elderly persons (age ranging from 60 to 91, with a mean age of 68.5). The authors reported that although half of the sample reported that they were in a current relationship, many of the couples did not live together. Two-thirds lived alone. Factors associated with greater physical health problems included living alone, having less income, having more experiences of victimization in their lifetimes, and having a more limited social network. Factors associated with greater mental health problems included living alone, less income, and lifetime victimization experiences. Mental health disorders were also associated with greater suicide ideation, lower self-esteem, loneliness, alcohol and drug problems, and more negative views of their own sexuality. It is important to note, however, that living alone is not always associated with loneliness. Many LGBTQ elderly persons may have significant others and rich social support networks, but they choose to live alone (Appelbaum, 2007), so assessments should address loneliness not just living status.

Race/Ethnicity

White male doctors make it their job to see to it that Black women do not have anymore babies…. Whenever I went in [to a doctor’s office] they would never let up when I said, no, I don’t need birth control. So sometimes I would come out as a lesbian, just to get them to move on to other things. The doctors would fumble around and say something like, “Oh … I’m sorry.” It was so awkward … I always felt harassed because I am black and because I am a lesbian. (Stevens, 1998, p. 84)

It is difficult to make any definitive statements about how LGBTQ identities are expressed among the different cultures of the world and within the United States. Some cultures do not even have terms or concepts that are equivalent to our western notions of sexual identity and gender identity. In academic circles in the west, we differentiate sex/gender from sexual identity/orientation, but many other cultures do not. A good example of this is the noncorrespondence of western sex/gender/sexuality terms to the North American indigenous people’s concept of “two spirit.” There are vast tribal differences in concepts of sex/gender, but in the 1990s, the term two spirit was adopted by many as a unifying label for indigenous people who experienced their sex/gender/sexuality as a spiritual identity, and as a means of rejecting western concepts that were irrelevant to their own heritages and experiences. The identity of two spirit represents a blending of gender and sexuality (Walters, Simoni, & Horwath, 2001).

Figure 6.1 Racial/ethnic distribution of households: other-sex and same-sex couples in 2000 U.S. Census. From Census Snapshot, by A. P. Romero, A. K. Baumle, M. V. I. Badgett, and G. J. Gates, 2007. Los Angeles: The Williams Institute, UCLA. Asian/PI = Asian/Pacific Islander; AmIndian = American Indian.

At least within the United States, we can be fairly certain that LGBTQ people exist in all racial/ethnic groups at about the same rate as in the heterosexual population. U.S. Census data has collected information about same-sex households in recent years. Figure 6.1 shows how same-sex households were distributed by race/ethnicity compared with other-sex households (Romero, Baumle, Badgett, & Gates, 2007).

Racial/ethnic minority communities are extraordinarily diverse, varying by immigration status, language, degree of acculturation, income levels, education, religion, and a host of other dimensions. Any discussion of the impact of race/ethnicity, like discussions of sexuality and gender, are generalizations that may or may not apply to any given individual. The differences in households of same-sex people of color may (or may not) be related to the following:

- Being less “out,” because potential costs of being out are much higher. Support from family and community, religious leaders, and ethnic social justice organizations may be critical to support oneself against racism and classism (Grov, Bimbi, Nanin, & Parsons, 2006).

- There may be rejection of terms considered to be “White” concepts, such as LGBT and Q, and therefore, they may not use labels or use different ones, such as “same-gender loving,” “family,” and others.

- Political affiliations may be with groups that focus on race/ethnicity rather than sexuality/gender, because there are few that truly integrate both identities (Rosario, Schrimshaw, & Hunter, 2004).

- Racism affects income status, thus LGBTQ individuals and their families of color are more likely to live in poverty and have less access to quality health care—and experience more discrimination when they do access health services than do White LGBTQs.

- People of color are more likely to have been raised in and continue to belong to conservative religions, such as Catholicism (many Latinos, Filipinos), evangelical Christian Protestant denominations (African Americans), and Islam (African Americans). Religious affiliation may be a more potent marker of homophobia in these communities than race/ethnicity per se.

- Some cultures have taboos against talking openly about topics related to sexuality and/or attitudes that private sexual behaviors are one’s own business as long as in public they fulfill their familial “duties” (many Asian cultures).

Reflection: The media furor a few years ago about African American men on the "downlow" is an example of "racialized sexism" (Miller, Andre, Ebin, & Bessonova, 2007). It targets Black men who have sex with men without telling their female partners. The issue is that some men from all cultural backgrounds engage in this behavior. Why have Black men been targeted in this media attention? Battle and Crum (2007) proposed that poverty is the major factor in the higher rates of HIV among African Americans, not men on the "downlow." Binson, Michaels, Stall, and Coates (1995) found that Black men were only slightly more likely to be behaviorally bisexual than White men, however, these numbers are still very small and cannot account for the higher rates of HIV (see also Mays, Cochran, & Zamudio, 2004).

Religion/Spirituality/Moral Beliefs

I was scared because the preacher would say stuff like, “We ain’t hatching no faggots up in here.” And the whole church, including my mother, would scream, “Amen!” I knew what a faggot was because my brothers called me that. (Respondent in a study of African American gay men; Miller, 2007, p. 57)

LGBTQ people are born into families that represent the entire continuum of religious and spiritual belief systems. The influence of religion and spirituality are difficult to study because of the multitiered sets of influences. We begin with a discussion of religion. For example, let us say that Ray, an African American bisexual man, was raised in a southern Baptist church. The message from minister and elders of the church may or may not reflect the doctrine of the larger Baptist organization, and Ray’s family may or may not model or espouse the beliefs of the larger church or even their local church. The church leaders who teach Sunday school or Bible study classes may present yet another interpretation. Perhaps, the choir leader is known to be gay, but he is widely liked and accepted in the church? Maybe that gay choir leader is Ray’s uncle. If Ray gets a stronger message of “love thy neighbor” than “homosexuals will go to hell,” he may have an easier time of reconciling his faith with his sexuality than if the “hell” message is emphasized. Figure 6.2 shows the continuum of Christian churches’ stands on sexual orientation. Fewer of them have direct policies about gender identity. Ex-gay ministries (programs designed to “cure” homosexuality) are found primarily in the “damning” category. LGBTQ people are raised in, and sometimes remain steadfast, to the beliefs of religions across the entire continuum from damning to welcoming.

In the general population, religion has been found to have positive health benefits and affect quality of life (Koenig, McCullough, & Larson, 2001), but less is known about the impact of religious involvement for LGBTQ people. Many LGBTQ people are affiliated with religious denominations or groups. Maher (2006) documented more than 450 LGBTQ religious groups located between the West Coast and the Mississippi River from 1989 to 1993. He defined “gay group” as a group focused on LGBT issues in religion or a group/congregation consisting of 50% or more LGBTQ people. Historically, the first LGBT ministry within a mainstream church was at the Glide Memorial Church in San Francisco, started in 1962. In 1968, the Metropolitan Community Church (MCC), an LGBTQ affirmative nondenominational Christian, was created in Los Angeles by Reverend Troy Perry. MCC churches are found in nearly every state in the United States, as well as in 24 other countries. In 1969, Dignity, a group of LGBTQ and supportive ally Catholics, was formed, and went national in 1973. The United Church of Christ ordained the first openly gay pastor in 1972. The same year, the first LGBTQ Jewish synagogue opened in Los Angeles. The purpose of these congregations and groups was to help people integrate their faith and their sexuality/gender. Gorman (1997) suggested that the increase in LGBTQ religious groups in recent years may be due to two factors. The first is the aging of the baby boomer, post-Stonewall generation, which may share in common with their heterosexual counterparts an increased search for spirituality and meaning in their lives as they age. The second factor is the AIDS epidemic, which highlighted issues of mortality and search for meaning in people across the life span.

Bishop Gene Robinson is the first openly gay person to be ordained to the position of bishop in the Episcopal Church, but his ordination was not without great controversy. Robinson was married and had two children before coming out. He has the full support of his family. In 2003, he was elected to the position of bishop in New Hampshire, a move that has forced considerable discussion of the position of the church on homosexuality.

Race/ethnicity and religion intersect in the lives of many LGBTQ people. For example, the “Black church” has been described as a homophobic environment for LGBTQ people by some, but as an “open closet” by others who describe the common scene of “gay men singing in the choir while homosexuality is denounced from the pulpit” (Miller, 2007, p. 53). Leaders among some of the more conservative religious/cultural institutions of the African American community are strongly homophobic, as this quote from the leader of the Nation of Islam, Louis Farakhan indicates:

Now brother, in the Holy world you can’t switch [mimicking an effeminate man]. No, no no … in the Holy world you better hide that stuff ‘cause see if God made you for a woman, you can’t go with a man…. You know what the penalty of that is in the Holy land? Death … Sisters get to going with another sister—both women [are decapitated]. (Quoted in Simmons, 1991, p. 222)

Among Latinos, involvement in the Catholic Church is high, and it may be associated with more negativity about LGBTQ people or at least same-sex behaviors. The paradox of “love the sinner, hate the sin” is important to highlight. Among LGBTQ people, same-sex expression and gender expression are parts of the person’s core identity, so to be construed as “sin” means a rejection of the person as well as the behavior. In addition, many people may not truly make this distinction of “love the sinner and hate the sin.” In a study of substance-abuse counselors (Eliason, 2000), scores on a homophobia scale did not differ between the groups that endorsed statements “Love the sinner but hate the sin” and “LGBT people are sinful and immoral.” Both groups were equally negative and significantly more homophobic than people who endorsed, “I accept LGBT people and behavior as normal.”

Other world religions also vary on their doctrines related to sexual orientation. Most religions have a conservative/traditional and a more liberal branch, with the conservative wing being more negative about gender and sexual minorities than the liberal branch. Some LGBTQ people have turned to Buddhism, because it is more a life philosophy than a formal religion, but there are certainly segments of the Buddhist community that are anti-LGBTQ as well.

Because of the difficulties that many LGBTQ people have experienced in the religions of their childhood, some of them have rejected religion entirely and sought out alternative ways to express their spirituality. Some join existing groups such as Wiccan and Neopagan movements that are open and affirming to all genders and sexualities. Others form their own groups, develop highly individual spiritual practices, and/or adopt Buddhism as philosophy rather than a religion. Having a strong spiritual belief system and practices may be protective against the stresses of oppression, whether that spirituality is accessed through a formal religion or other means.

Ability/Disability status

People ask me which I am: Woman, disabled, Asian. I tell them I am all three, it’s like a triangle. It just depends on what is on top right now. (Cupolo, Corbett, & Lewis, 1982, p. 3)

There is very little research on disability and LGBTQ people, for both disability and sexuality are taboo topics. Like any other persons, LGBTQ people might be born with disabilities or acquire them at any point in life. Some of the recent data (described in chapter 7) suggest that among LGBTQ adults, minority stress might combine with chronic health problems to create greater disability and debilitation (Cochran & Mays, 2007), meaning that as LGBTQ people age, they may be even more likely than people in the general population to become disabled. People with HIV/AIDS may also be more likely to suffer disabilities than those without HIV/AIDS. O’Toole (2000) noted several issues that lesbians with disability might have to deal with. These issues are probably relevant for other sexual and gender minority individuals as well:

- The presumption of heterosexuality or asexuality by caregivers, health care professionals, and potential dates.

- Invisibility in both LGBTQ communities and disability communities.

- Facing the LGBTQ’s high value placed on self-reliance.

- Absence of relevant sexuality education/information.

- Potential sexual abuse and/or exploitation.

- Absence of role models.

- Legal issues (e.g., guardianship, ability to freely choose partners if institutionalized).

On the other hand, the goals of the LGBTQ and the disability communities overlap to a great extent. As a lesbian poet with disability put it, “There is a disability culture and at the core of this culture is empowerment, pride, and a flat-out, no apologies celebration of difference” (Cheryl Marie Wade, quoted in O’Toole, 2000, p. 215). LGBTQ communities are making efforts to make their events accessible and to be more inclusive of the diversity found within the community.

Gender Expression Within Sexual Identities

We discussed gender expression in an earlier chapter about transgender identity, but there is also much greater diversity of gender expression among people who are not transgender, but label their sexuality as lesbian, gay, or bisexual. Being on the margins of society can be liberating in some ways, and being freed, to some extent, from the social pressures to conform to heterosexual forms of femininity and masculinity, LGB people may express themselves in a variety of ways.

Among lesbian and bisexual women, there is an entire subculture built around the practices of “butch–femme” identities. Historically, these practices arose in the 19th century (Faderman, 1991) and were codified in urban working class cultures of the 1940s and 1950s as an erotic style, with butch women more masculine in appearance and behavior and defined by their desire for femme women (Kennedy & Davis, 1993). With the rise of feminism in the late 1960s and 1970s, White butch–femme couples were denounced as “mimicking” heterosexual relationships, and there was pressure on lesbian and bisexual women to appear more androgynous (Faderman, 1991). However, butch–femme relationships only superficially looked like heterosexual relationships—they were polarized by gender, masculine and feminine, but a masculine woman is not a man and division of labor did not follow typical heterosexual patterns (Kennedy & Davis, 1993). Another shift in thinking occurred in the 1990s with the rise of queer theory and postmodern feminism movements that encouraged individual expression of gender and sexuality (Inness & Lloyd, 1996). Now butch–femme relationships are considered a form of self-identification, mostly accepted, and not related to class status, although many women do not identify with these labels. In addition, there are butch–butch relationships and femme–femme relationships. It seems that sexual attractions are quite unique and varied from one person to another—what one person finds erotic, another might find a turnoff. Some lesbians/bisexual women are attracted to others with a particular kind of gender presentation and some are not. There is a stereotype that all same-sex female relationships need to have one partner play the “man” and the other the “woman”; however, butch–femme is not equivalent to male–female, and the majority of lesbians do not seek out butch–femme relationships. In one examination of personal advertisements (Smith & Stillman, 2002), 75% of the advertisements had no mention of butch–femme identities or preferences. Of the self-identified femmes (n = 55 of 388), most requested femme partners (56%). Among self-identified butch lesbians (n = 45), 74% requested femme partners. All women fall somewhere on a continuum between extremely masculine and extremely feminine, and whereas most lesbian/bisexual women can categorize themselves, the majority do not seek partners who are on the “opposite” end of the spectrum. Being more “masculine” or gender-nonconforming can lead to an earlier adoption of a lesbian identity. Levitt and Horne (2002) reported that femme women recognized their sexuality at a later age (22 years) than did butch women (15 years).

Gay and bisexual men do not have the same political history with feminism that women do, but they also benefited from feminist and queer movements that opened up the concepts of gender. Some men choose to adopt a hypermasculine physique, with almost slavish devotion to the gymnasium. However, this masculine physical appearance may or may not be paired with traditional masculine behaviors. Other men express their feminine natures more, and at the extreme end of the continuum, might be described as “queens.” Yet others shift roles and deliberately play with their gender. The majority of LGBTQ people, however, fit into some vaguely defined “normal” gender expression, conforming at least to some extent to gender stereotypes for their biological sex.

Resiliency

It is rather amazing that in the face of so much societal pressure to be heterosexual and to be clearly male/masculine or female/feminine that so many LGBTQ people thrive and are psychological and physically healthy. The concept of resiliency may be pertinent here. Facing and surviving adversity may make a person stronger. They must learn coping strategies and build creative and strong social support networks. LGBTQ people have found ways to have loving and strong families in the absence of legal and societal support; they have built community structures, such as LGBTQ community centers, bookstores, restaurants, coffee shops, religious and spiritual groups, political advocacy organizations, and a host of local community events from pride festivals to weekly potlucks and dances. In addition, the Internet opened up the world to more isolated LGBTQ people, who have built social support and found information to help them survive. Growing media coverage of LGBTQ issues and portrayal of those with “normal” lives has increased the acceptability of being LGBTQ in families and communities at large. Russell and Richards (2003) studied resiliency factors in LGB people in Colorado following a yearlong campaign for an antigay referendum that created deep emotional responses in many citizens. The authors found that there were five major sources of resilience for dealing with the antigay sentiment:

1. The ability to place antigay comments and actions into a political context (of oppression)

2. Confronting internalized homophobia

3. Being able to express one’s anger and other emotions about the stress, which often propelled people to action

4. Being witnessed—having support from family, friends, coworkers, public officials, and others, especially heterosexual people who stepped up to challenge the antigay rhetoric

5. Support and validation from the LGBTQ community

Conclusions

There is enormous diversity among LGBTQ people and their families. The fact that people may experience stress and oppression on multiple levels makes the study of the origins, processes, and prevention of health disparities very difficult. All the various social identities tend to coexist in the individual, and a person often cannot sort out the sources of stress or resiliency among these different identities. Life is usually perceived as a whole, not broken down into aspects of the personality or specific identities. On the other hand, these multiple identities are what bring texture to life and make us all unique. The key to successful inclusion of all persons in health care settings is to be open to this diversity and complexity and see each person as unique.

Reflection Questions

Awareness

1. What are your core identities?

2. How does your gender, sexuality, race/ethnicity, class status, religion, nationality, and other aspects of your total identity affect your daily life?

Sensitivity

1. How have racism, sexism, or heterosexism affected your own life, or the lives of people you know?

2. How are these forms of oppression replicated in your workplace?

Knowledge

1. How can awareness of diversity and systems of oppression be applied to making your workplace more inclusive of all patients/clients and workers?

2. Does your workplace have diversity training? If so, what does it include? Does it examine the intersections of identities?

3. If you belong to a formal religion, where does it fall on the continuum?

Part II Basic Health Care Applications

Now that we have reviewed the basic concepts related to sexuality and gender, stigma, and minority stress, and examined family structures and forms of diversity within the LGBTQ communities, we are ready to tackle health care applications of this knowledge. Health care professionals and systems often perpetuate the same invalidation, harassment, discrimination, and even violence on LGBTQ people that they experience in the larger world. In 1995, Tyra Hunter, a 24-year-old transgender African American woman, was in a car accident in Washington, DC, but when the emergency team members saw that she had a male body, they stopped providing critical care and made derogatory remarks. Ms Hunter died as a result of this negligence and more at the admitting hospital. Her mother was awarded nearly 3 million U.S. dollars after overwhelming evidence of the horrible care her child received in the health care system.

Chapter 7 addresses the effects of stigma on mental and physical health and explores how minority stress contributes to elevated risk for health problems. This chapter also describes issues related to disclosure of sexuality and gender to health care professionals and how stigma affects the treatment that LGBTQ people get in health care settings. Chapter 8 focuses on the structural or systems-level barriers to quality care, such as legal issues and health care policies and procedures. An important component is the language used on health care forms and in verbal communications with patients. In chapter 9, we describe what life is like for LGBTQ health care professionals, and how stigma affects their ability to be the most productive workers. Finally, we end with a call to action, outlining 10 concrete things that health care professionals can do right now to improve care of their LGBTQ clients.

Chapter 7: The Effects of Stigma on Health

The study of why some people swim well and others drown when tossed into a river displaces the study of who is tossing whom into the current—and what else might be in the water.

Krieger (2001, p. 670)

In chapter 3, we reviewed the effects of stigma on the everyday lives of LGBTQ people, including lack of recognition of significant others and family, hate crimes, social rejection, and employment discrimination. This chapter addresses the effects of stigma on the health of LGBTQ people. It is easy to fall into an individual focus when discussing health problems and assign individual responsibility for overcoming these problems, such as telling LGBTQ people that they should seek out health care earlier, comply with health care proscriptions, and/or learn better coping strategies. Nancy Krieger’s astute comment that begins this chapter grounds the discussion, reminding us that stigma arises from societal-level influences that impact the individual. Not all LGBTQ people will have overt health problems related to stigma, but the overall hostile climate of society in general and health care institutions in particular creates the conditions for health disparities to develop and fester.

Social stigma refers to severe disapproval and discrimination that is directed by one group toward others based on their perceived or actual membership in a particular group. It is based on prejudice and stereotypes that unjustly judge the other as deficient, evil, abnormal, inferior, sick, subhuman, immoral, or criminal. These attitudes, reviewed in chapters 3 and 4, marginalize LGBTQ people from the mainstream of society, deny them basic and fundamental rights of citizenship, create an atmosphere of fear and hatred, and endanger their well-being. Stigma affects society as a whole, because it creates an atmosphere of hatred, hostility, and intolerance, robs the community of the benefits that could be gained by full participation and contribution of those who are stigmatized, increases the health burden of the LGBTQ community, and interferes with the development of potentially supportive relationships among people of differing sexualities and genders.

Stigma can result from visible or relatively invisible human characteristics. Some authors argue that individuals with a concealable stigma can easily hide and therefore avoid the prejudice and resultant discrimination that goes along with visible differences (e.g., Goffman, 1963). Recent research suggests, however, that the effort of hiding a stigmatized identity takes an enormous toll and may adversely impact the individual’s life. Whereas people with visible differences (such as obvious skin color differences or in a wheelchair) are constantly “out,” people with hidden forms of difference must continually make decisions about disclosure, sometimes multiple times in the course of a day. LGBTQ people must weigh “whether, when, how, and to whom to disclose their stigma” (Pachankis, 2007, p. 328), always wondering whether the reaction will be positive or negative. Some authors refer to this internal cognitive processing as “stigma management” (Meyer, 2007), and it adds a level of stress to daily life that heterosexual people may never have imagined.

In the United States, stigma regarding sexual and gender identities stems primarily from one of the following two sources:

- Medicine: based on ideas of disease or biological abnormality, particularly beliefs drawn from the field of psychiatry about sickness, abnormality, or mental illness, and

- Religion: the idea of sin or immorality.

Sin and sickness discourses coexist in much of the anti-LGBTQ rhetoric throughout the past century. Medical sciences have focused on a search for the cause of minority sexual and gender orientations, but not for the cause of heterosexuality, and for a biological basis for male–female differences rather than focusing on the similarities. By not equally studying how heterosexuality arises, and by making the assumption that men and women have different skill sets, personalities, or behaviors because of biological differences, medical sciences tend to reify sexual and gender difference rather than highlight the myriad similarities among people with differing gender and sexuality. In 1973, the American Psychiatric Association removed sexual orientation from its diagnostic categories of mental illness from the Diagnostic and Statistical Manual of Mental Disorders (DSM), but there continues to be a minority of psychiatrists and psychologists who advocate “reparative” therapies to attempt to change the sexual orientation of LGB people (see, e.g., the National Association for Research and Therapy for Homosexuality [NARTH]). The presence of reparative therapy, which has considerable overlap with religious beliefs and religious conversion experiences, perpetuates the myth that minority sexual/gender identifications are associated with mental illness and abnormality, and this contributes to the stigma of being openly LGBTQ.

We discussed the role of religion on attitudes about LGBTQ people briefly in chapter 4. A recent rise in fundamentalism has resulted in renewed attacks on the civil liberties of LGBTQ people, most notably in the areas of marriage and an increase in the number of “ex-gay” ministries (Hedges, 2006), which are ministries devoted to changing people from LGBTQ to heterosexual through prayer, isolation, and pseudopsychological techniques. Erzen (2006) studied men in one of the oldest ex-gay ministries in the United States and proposed that “ex-gay” had become yet another social identity in place of LGBTQ, and that few of the men actually converted to or considered themselves as heterosexual even after years of prayer, social isolation, and religious intervention. Rather, they learned to suppress their sexual desires by associating only with “safe” people—mostly other “ex-gays” and to deal with frequent relapses and persistent same-sex desires. Research on conversion and reparative therapies confirms Erzen’s position—few if any people engaging in these therapies are able to change their sexual attractions or desires (Shidlo, Schroeder, & Drescher, 2001). The overwhelming lack of evidence that reparative therapy, whether based in religion or in psychological theory, changes sexual orientation, and the voluminous anecdotal evidence of the harm inflicted by the attempt to change one’s sexuality have led the majority of medical and psychological associations in the United States to denounce reparative therapy as unethical (e.g., the American Medical Association, the American Psychiatric Association, the American Psychological Association, the National Association of Social Workers).

The United States is supposedly built upon a separation of church and state, meaning that public institutions that serve the needs of the population are not to inflict any particular religious viewpoint upon their clients. Whereas most health care professionals may not conduct or refer clients to reparative therapy, some of them impose their religious beliefs in other ways. Unfortunately, far too many clients are exposed to unwanted proselytizing when they attempt to access health care, as the following example illustrates.

When J. went to the doctor’s office in her Florida town, the last thing she expected to receive was a packet of antigay propaganda referring to homosexuality as “sinful” and “impure” and advising lesbians and gay men to change their sexual orientation. “When I opened the sealed packet, I was shocked and outraged,” says J. “I was extremely offended and I felt like I had been violated.” J. made a formal complaint with the office manager, who informed her that their office routinely disseminates the antigay materials to patients. When she retrieved her medical records, J. was in for yet another shock. On her chart was written “Scripture references were given regarding homosexuality and lesbianism” (reported on the Web site of the Mautner Project, 2007).

If you were J, what would you have done?

The sin and sickness discourses have impacted health care institutions in other ways as well, limiting access to health care services and affecting the quality of care received once in the system. Heck, Sell, and Sheinfeld-Gorin (2006) studied a random national sample of U.S. households and compared same-sex households with other-sex households on four indicators of health care access. Women in same-sex households were less likely to have health insurance, less likely to have a primary care doctor, less likely to have seen a health care provider in the past year, and more likely to have unmet health needs because of cost considerations than women in other-sex households who had the ability to marry. Men in same-sex households were roughly equivalent to men in other-sex relationships, but there was a trend toward less access to health care as well.

Marion is a male-to-female postoperative transgender woman and is a pediatrician in a large suburban practice in the Midwest. She is concerned that being “out” would jeopardize her career in her conservative community, so she has told no one of her gender identity. She lives with her partner of 5 years, a lesbian named Shelly, who has been introduced at work as Marion’s roommate. They have a very small circle of friends in the lesbian community but restrict their public social activities with those friends for fear of being seen by patients or coworkers. Marion needs to find a primary care physician for herself and is in turmoil about finding a discrete provider who will not reveal her gender and sexual identities to colleagues. The stress of concealing her identities has affected Marion in many ways—she is paranoid and suspicious at work and coworkers think of her as “stand-offish.” She occasionally has panic attacks, and the secrecy is affecting her relationship with Shelly, who wants to be out and open about their relationship, but fears rejection by the lesbian community as well as by Marion’s heterosexual coworkers. If Marion worked in the health care setting where you work or receive care, how do you think she would be treated if her gender and sexual identities were known?

Effects of Stigma on Health

The stress related to minority identification can affect people from any disenfranchised or oppressed group. Minority Stress refers to the additional stresses experienced specifically because of identification with an oppressed minority group. Minority stress

1. is unique and adds more stress on top of the general life stressors that many people experience;

2. is chronic; and

3. comes from social processes, institutions, or structures rather than from individual risk factors such as biological or genetic variables. (Meyer, 2007, pp. 243–244)

Mays and Cochran (2001) found that LGB people were more likely to report discrimination in jobs, housing, education, health care, and other settings than heterosexual people (see Table 3.2 in chapter 3). Being denied health care or receiving inferior care was reported by 7% of lesbian/bisexual women, 3% of gay/bisexual men, 3% of heterosexual women, and 4% of heterosexual men (Mays & Cochran, 2001). Xavier, Honnold, and Bradford (2007) reported that 27% of transgendered Virginians had no health insurance, 38% did not have a regular physician, 36% felt uncomfortable talking to health care professionals about transgender-specific health issues, and 24% had experienced discrimination from a health care professional. Very little is known about bisexual people’s experiences with health care (Miller, Andre, Ebin, & Bessonova, 2007).

Minority stress can come from internal and external sources. Some authors discuss the internalized effects of stigma, called variously in the literature internalized homophobia, internalized oppression, or internalized heterosexism. Internalization occurs when individuals believe the negative stereotypes related to their identities and, as a consequence, develop shame, guilt, and self-hatred (Meyer, 2003). They may expect poor treatment from others. However, even well-adjusted LGBTQ people who have rejected the negative stereotypes must deal with minority stress from external sources, such as discrimination, harassment, and threat of violence from others who hold the negative stereotypes. Minority stress results in a heightened sense of vigilance in situations where the person anticipates that discrimination, harassment, or violence may occur. Unfortunately, health care settings are among the places where that increased vigilance is at play (Eliason & Schope, 2001; Hitchcock & Wilson, 1992; Stevens, 1994). The increased vigilance takes its toll. It is stressful and energy-demanding to always be on one’s guard.

The high level of internal and external stress can result in new disorders or worsen existing health problems and may be compounded by lack of access to quality health care. Emotional status and reactions to the environment can have enormous impact on physical and mental health. It is important to recognize when stress is causing or contributing to illness because conventional treatments may not be as effective if the root source of stress is not addressed. People who have experienced chronic stress may no longer recognize the stress because it has become part of their daily existence, so helping them become aware of stress and finding ways to reduce the stress are important components of treatment. Recognizing that they are not to blame for the negative attitudes of other people is another critical aspect of treatment.

Stress can impact nearly any organ system, but we will focus on the areas where there is a substantial evidence base about the impact of minority stress related to sexual and gender identification. We discuss these adverse effects on health in two general categories: mental and physical health problems, although we recognize that there is considerable overlap among these categories. Mental health problems include substance abuse, depression, anxiety, suicide attempts, domestic violence, and body image and eating disorders, and physical health disorders include chronic physical ailments, cancer, and sexually transmitted infections (STIs). We end the chapter with a section on the impact of stigma on the quality of care provided in health care settings.

So, you know, in the lesbian community and being gay and being a person of color, being a big person, you know, its all those stresses. They take a toll on you. And sometimes you just dont want to feel it. You just want to, like, be out and have fun. And sometimes you need alcohol or drugs or whatever, because then you dont feel so self-conscious about being who you are. And thats sad. . . respondent in Gruskin, Byrne, Kools, & Altschuler, 2006, p.110).

Mental Health Problems

Substance abuse

Alcohol use and abuse

Several studies have identified higher rates of alcohol-related problems in LGBTQ persons (Bloomfield, 1993; Crosby, Stall, Paul, & Barrett, 1998; Dibble, Roberts, Robertson, & Paul, 2002; Drabble & Trocki, 2005; Garofalo, Mustanski, McKirnan, Herrick, & Donenberg, 2007; Halkitis, Palamar, & Mukherjee, 2007; Hughes, 2003; Hughes et al., 2006; McKirnan & Peterson, 1989; Skinner & Otis, 1996), although the research on rates of current heavy or problematic drinking is less clear. A recent study of U.S. midlife adults reported that rates of alcohol dependency in the past year were higher for gay men (9%) and lesbians (12%) than for heterosexual men (6%) or heterosexual women (3%) (Mays & Cochran, 2001).

LGBTQ people who are in young adulthood may drink at comparable rates to their peers, whereas older LGBTQ people may drink at higher rates (McKirnan & Peterson, 1989; Skinner & Otis 1996). In the general population, most adults “mature out” of heavy drinking that occurs mostly in late adolescence and young adulthood. As people marry, have children, and get established in their careers, they go to bars less often and, in general, party less. A subset of LGBTQ people who do not (or cannot) marry, do not have children, and/or live in neighborhoods or communities where bars or parties with alcohol are readily available may continue to drink at higher rates through their midlife, especially if they have found their partners and close friends through these drinking circles. For a more detailed discussion of risk and protective factors for substance abuse, see Hughes and Eliason (2002).

Drug abuse

There is evidence of higher lifetime and current use of illicit drugs in LGBTQ populations (Drabble & Trocki, 2005; McKirnan & Peterson, 1989; Skinner & Otis, 1996), with different patterns of use in lesbians and gay men. Drabble and Trocki (2005) found that lesbians were almost five times more likely and bisexual women six times more likely than heterosexual women to report past-year marijuana use. Other illegal substances (e.g., cocaine, methamphetamine, heroin) are used at low frequencies among lesbians as well as among heterosexual women.

Gay men often use a constellation of substances that differs from lesbians and from heterosexual men. They are more likely to use stimulant drugs as sexual enhancers, such as “club drugs” like ecstasy, poppers, and methamphetamine (Halkitis, Green, & Mourgues, 2005; Koblin et al., 2003; Stall et al., 2001). These drugs, particularly methamphetamine, enhance both the emotional and physical pleasure of sex and prolong sexual encounters, which also increases the risk for STIs such as HIV infection and hepatitis. The drug and sexual activities may become linked so that after treatment and/or abstinence from the drug, sex itself may be a relapse trigger for drug use (Diaz, Heckert, & Sanchez, 2005; Halikitis, Fischgrund, & Parsons, 2005; Semple, Zians, Grant, & Patterson, 2006).

Transgender women, particularly those who are sex workers, have very high lifetime rates of illicit drug use. A study in San Francisco reported the following lifetime rates: marijuana, 90%; cocaine, 66%; speed, 57%; LSD, 52%; poppers, 50%; crack, 48%; and heroin, 24% (Clements-Nolle, Marx, Guzman, & Katz, 2001). For many sex workers, drugs are used to cope with the stigma, and drug use/dealing and sex work often go hand in hand. In addition, some transgender women inject silicone or other oils to give them “curves” that allow them to better pass as women and thus be safer on the street. In some urban areas, rates of injecting silicone may be as high as 25%–33% (Reback, Simon, Bemis, & Gatson, 2001). Often done under unsanitary conditions, with dirty or shared needles, and drugs obtained from the street (with unknown purity), the practice carries risk of HIV infection and hepatitis, systemic illness, disfigurement, and even death, if the oil enters the blood stream. Over time, silicone succumbs to gravity and settles around the ankles and feet. It is important for health care professionals to assist transgender individuals in identifying safe medical access to hormones and cosmetic procedures and provide accurate information about the dangers of silicone. Other hormones, such as estrogen and testosterone, can also be obtained on the street and therefore carry risks related to purity and dosage.

In general, injection drug use carries the highest physical health risks of any substance use. One third of transgender individuals in San Francisco reported lifetime use of intravenous drugs (Zevin, 2000) and 22% had a steady sex partner who injected drugs (Nemoto, Luke, Mamo, Ching, & Patria, 1999). Injection drug use among gay men and lesbians is lower than alcohol and noninjection drug use but still significantly higher than for heterosexual samples. One study of lesbian and bisexual women from low-income households found a lifetime rate of injection drug use at 22% compared with 3% for heterosexual women (Scheer et al., 2002, 2003). For gay men (or MSM in general), incidence of injection drug use varies. In one study of young MSM in New York City, nonhomeless MSM had very low rates of current injection drug use (0.3%), homeless youth had higher rates (6%), and MSM who were regular speed users had the highest rates, at 11.9% (Clatts, Goldsamt, & Yi, 2005; see also Kipke, Weiss, & Wong, 2007; Kral et al., 2005).

There are a few LGBTQ-specific treatment programs in the United States, including Pride Institute (Eden Prairie, MN; Arlington, TX; Summit, NJ), Alternatives (Minneapolis, MN; Los Angeles, CA; New York City, NY; Palm Springs, CA), New Leaf Services for Our Community (San Francisco), Van Ness Recovery House (Los Angeles), and the LGBTQ Community Centers in Los Angeles and New York City. There are more than 500 Alcoholics Anonymous or Narcotics Anonymous groups specifically for LGBTQ people. Most LGBTQ people attend treatment programs or self-help groups that are designed for heterosexual people. In these programs, LGBTQ people face the same prejudices and discrimination from staff and other clients as they do in everyday life, but at a time when they are even more vulnerable and need support (see B. N. Cochran, Peavy, & Cauce, 2007; Eliason, 2000; Eliason & Hughes, 2004). There are training materials related to LGBTQ substance abuse available for free from the Prairielands Addiction Technology Transfer Center for those who want more information (http://www.public-health.uiowa.edu/pattc/lgbttrainingcurriculum/home.html).

Smoking

Smoking is the number 1 cause of preventable death in the world, contributing to the morbidity and mortality statistics by underlying heart disease, cancer, stroke, and a myriad of lung diseases and other physical health consequences. Of the studies that have gathered information about smoking rates among LGBTQ people, nearly all of them report higher rates than the general population or heterosexual comparison groups (Greenwood & Gruskin, 2007; Tang et al., 2004). Theoretically, nicotine is the ideal drug for stress relief—it is highly portable, widely available, legal, and quick acting, so it is not surprising that people with high levels of stress might be more likely to smoke. High rates of smoking may be one of the primary causes of chronic physical health problems in LGBTQ people. For example, Heck and Jacobsen (2006) reported rates of lifetime diagnosis of asthma in 13.5% of men who reported male partners, 14.3% of women who reported female partners, 7.6% of heterosexual men, and 10.2% of heterosexual women. The disparity of smoking rates between people in same-sex relationships and people in other-sex relationships is illustrated in Figure 7.1 from a random household survey of people in the states of Washington and Oregon (Dilley et al., 2005).

Transgender people have not been well-studied in regards to smoking, although one study from the state of Virginia identified even higher rates of smoking than in LGB individuals, with 62% of female-to-male transgenders and 55% of male-to-female transgender reporting current smoking (Xavier et al., 2007).

Figure 7.1 Rates of smoking in sexual minorities and heterosexual respondents. From “Response Letter to: Tang H, Greenwood GL, Cowling DW, Lloyd JC, Roesler AG, Bal DG. Cigarette Smoking Among Lesbians, Gays, and Bisexuals: How Serious a Problem?,” by J. A. Dilley, J. E. Maher, M. J. Boysun, B. A. Pizacani, C. H. Mosbaek, K. Rohde, et al., 2005, Cancer Causes and Control, 16(9), pp. 1133–1134.

It is difficult to address drinking, drug use, and smoking separately, as they so often go hand in hand. However, people who seek solution for their alcohol and drug problems often are not counseled about tobacco use, so rates of smoking remain high even after recovery from alcohol and drug abuse (Eliason & Worthington, 2004). Substance abuse treatment facilities and LGBTQ alcohol- and drug-related support groups or self-help groups would be an ideal place for smoking cessation counseling and interventions, as this is the highest risk group for smoking.

One study examined treatment experiences of LGBTQ smokers (Bye, Gruskin, Greenwood, Albright, & Krotski, 2005). This study was a random digit dial survey of Californians, and LGBTQ people were compared with the general population. Overall, LGBTQs were similar to the general population in terms of quit attempts—that is, LGBT people were just as likely to want to quit smoking and just as likely to attempt to quit as heterosexuals (63% of LGBTQ smokers tried to quit in the past year). Of the methods used to quit smoking, 25% of the LGBT sample had used nicotine replacement therapy compared with 16% of general population who used NRT. Unfortunately, fewer LGBTQ people visiting a health care provider were advised to quit than heterosexuals. Regarding prevention issues, 37% felt that antismoking campaigns ignore LGBTQ people, and only 32% of men and 20% of women thought that smoking was a bigger problem for LGBTQs than for heterosexuals.

Summary: Substance abuse

Stigma contributes to substance abuse in many ways, through the mechanisms of internalized oppression (homo/bi/transphobia), and heterosexism. One effect of external sources of minority stress is that gay bars became one of the central institutions for social support, and one of the few safe spaces where LGBTQ people can congregate and be themselves (Warwick, Douglas, Aggleton, & Boyce, 2003). Smoking and drinking are the primary activities in a bar, and if one meets friends and partners in bars, they are more likely to develop social networks of smokers and drinkers (Weinberg, 1994). Some LGBTQ people, particularly those from racial/ethnic or religious backgrounds that are more negative about same-sex behaviors and those who engage in same-sex behaviors but do not label themselves as LGBTQ, may use substances to overcome shame and guilt about sexual activities (Amadio, 2006; Semple, Patterson, & Grant, 2002) or to offer an excuse for same-sex behaviors (“I was drunk and didn’t know what I was doing”).

Tobacco and alcohol companies have recognized the niche market in LGBTQ communities and target advertisements to these groups (Smith, Offen, & Malone, 2005). Oppressed minority populations are ripe for targeted advertising, because they do not often see themselves reflected in the media. Advertising that addresses them specifically may be appealing and validating and thus more influential than it is for mainstream audiences. Many LGBTQ-oriented publications receive money from tobacco and alcohol advertising and may promote images of smoking as glamorous in photo shots on covers and stories about celebrities. For example, in 2006, a cover of the newsmagazine, The Advocate, drew fire from public health advocates. The cover depicted an actress from the popular lesbian soap opera, The L Word. The caption read “Smokin’ Kristanna Loken” and showed the actress scantily clad, holding a cigarette and exhaling smoke over text at the top of the page that ironically read “health matters.”

There are a few LGBTQ-specific smoking prevention and intervention campaigns. In California and spreading to some other locations is a curriculum called, The Last Drag, which is a group intervention for LGBTQ smokers. The Gay American Smoke-Out Web site contains posters and information about smoking cessation. The Mautner Project sponsored a media campaign called “Delicious Lesbian Kisses” to counter the smoking advertisements in lesbian communities. See the Appendix for some of these resources.

Axis I mental health disorders: Depression and anxiety

Mental health disorders are biopsychosocial entities, and some are more influenced by genetics and biological factors whereas others have a firmer foundation in environmental circumstances. It is likely that LGBTQ people have about the same rate of the more biologically based disorders such as schizophrenia and bipolar disorder, but higher rates of disorders that are more directly affected by stress and stigma. LGBTQ individuals report higher rates of depression and anxiety disorders than does the general population (Cochran & Mays, 2000a, 2000b; Gilman et al., 2001; Mills et al., 2004; Warner et al., 2004). LGBTQ people of color have even higher rates of depression and anxiety than white LGBTQ people (Cochran, Sullivan, & Mays, 2003, Cochran & Mays, 1994; Gilman et al., 2001; Greene, 1997), supporting the idea that multiple sources of stigma add more minority stress to life. Jorm, Korten, Rodgers, Jacob, and Christensen (2002) reported that bisexual people had the poorest mental health of any of the sexual identity groups in their study, reflecting the even greater stigma attached to bisexual identity than to gay or lesbian identity.

A study of midlife adults found that 26% of LGB respondents reported current high levels of psychological distress, compared with 17% of heterosexuals (Mays & Cochran, 2001). Table 7.1 shows data from the midlife adult sample regarding mental health problems and treatment seeking in the past year.

Table 7.1 Rates of Depression, Anxiety, and Mental Health Treatment Seeking in LGB Versus Heterosexual Respondents

Notice that more LGB people attended self-help groups than heterosexual individuals—this may represent a cost- and time-effective mode of treatment that is acceptable to LGB persons. Tjepkema (2008) also found higher use of self-help groups among LGBs in Canada. Some LGBTQ people, especially White lesbians, value therapy as a means of improving the quality of life, but finding mental health providers with a good understanding of the impact of stigma based on sexual and gender identifications can be a challenge (Jones & Gabriel, 1999; Page, 2004). Focusing only on individual-level factors in therapy, and ignoring the sociopolitical basis of stigma, can be victim-blaming and counterproductive to improvements in mental health (Kitzinger & Perkins, 1993). Page (2004) surveyed bisexual individuals about their experiences with mental health providers and found that 10% reported having a provider who was moderately or extremely unaccepting of their bisexuality and felt that these providers invalidated or pathologized their identities. Similarly, a survey of lesbians and gay men found that 25% had experienced a therapist who was “unreceptive … judgmental, discouraging, or dismissive” of their sexuality issues (Jones & Gabriel, 1999, p. 214).

Transgender individuals fight an additional battle along with the mental health effects of enormous societal stigma—their very identities are still pathologized by the inclusion of Gender Identity Disorder in the DSM-IV. In addition, the amount of discrimination, harassment, and threatened or actual violence that they experience is a source of constant stress. Many clinics and hospitals that provide hormone therapy and/or perform gender reassignment surgeries require that transgender individuals undergo extensive counseling and receive clearance from a mental health care professional before they can have surgery. Finding mental health providers with an expertise in transgender counseling is difficult at best, and putting the mental health care provider in a “gate-keeper” role may be a barrier to a productive, therapeutic relationship (Hale, 2007). The need to get clearance from a mental health care provider also puts an additional financial burden on transgender individuals. Few insurance plans cover any of the costs of transition.

Along with the higher rates of depression are higher rates of suicidal ideation and attempts (Safren & Heimberg, 1999). Among transgender individuals, rates of suicidal ideation are as high as 64%, with the rate of suicide attempts at 16%–37% (Grossman & D’Augelli, 2006; National Coalition on LGBT Health, 2004). Cochran and Mays (2000) reported that among MSM, 19.3% had a lifetime suicide attempt, compared with 3.6% of heterosexual men. Lhomond and Saurel-Cubizolles (2006) examined French women and found that 10.4% of WSW reported a lifetime suicide attempt compared with 3.9% of exclusively heterosexual women. Nearly every study conducted on suicide attempts and suicide ideation has reported higher rates among LGBTQ people (Ferguson, Horwood, Ridder, & Beautrais, 2005).

Body image and eating disorders

This section will review two types of problems: obesity and overweight, and body image issues. Obesity is a serious problem in the United States, with some experts projecting that it will soon surpass tobacco use as the leading cause of preventable death and disability. Rates of obesity tend to be higher in medically underserved and stigmatized populations, although the impact of stigma on weight appears to differ substantially by gender in LGBTQ communities. Lesbians tend to have greater body mass indices than heterosexual women (Case et al., 2004; Valanis et al., 2000; Yancey, Cochran, Corliss, & Mays, 2003), which increases the risk for many chronic health problems including heart disease, diabetes, and orthopedic problems. Higher rates of obesity and overweight in lesbian/bisexual women may be related to the combination of minority stress plus less pressure to conform to heterosexual women’s body image standards. Table 7.2 shows data from a study of lesbian and bisexual women in Los Angeles county by racial/ethnic group, demonstrating again the additive effect of racism, sexism, and heterosexism on health risks.

Table 7.2 Percentage of Lesbian and Bisexual Women Who Were Overweight or Obese by Racial/Ethnic Group

Lesbians appear to be less affected by cultural imperatives for women to be thin and have higher body self-esteem than heterosexual women (French, Story, Remafedi, Resnick, & Blum, 1996; Share & Mintz, 2002). Some authors suggest that relating to other women sexually can lead lesbian and bisexual women to appreciate and know their own bodies more thoroughly and become more confident about their sexual attractiveness, and thus the cultural standards about women’s bodies lose some of their power (Beren, Hayden, Wilfley, & Grilo, 1996). Being freed from unrealistic standards of physical size and shape may allow stress from stigma to trigger dysfunctional overeating or binge eating, increasing the risk for obesity.

Gay and bisexual men have different pressures—to be lean and muscular (a desire shared by many heterosexual men as well). They are more likely to experience body dissatisfaction than heterosexual men and may be more prone to eating disorders such as anorexia and bulimia (Carlat, Camargo, & Herzog, 1997; Martins, Tiggeman, & Kirkbride, 2007). One study that compared groups by gender and sexuality found the rates of eating disorders to be the highest in gay men (17%), followed by heterosexual women (14%), lesbians (4%), and heterosexual men (3%) (Siever, 1994).

As heterosexual men’s bodies are increasingly objectified in the media, as women’s bodies have been for years, men’s body images have been suffering. Gay male culture has a long history of objectifying men’s bodies in print and in videos and tends to place strong emphasis on physical attractiveness and youthfulness, particularly in a hypermasculine body (Brand, Rothblum, & Solomon, 1992)—a concept that one commentator called “body fascism.” This cultural critic, Michael Signorile noted, “I think it’s because we were all insecure, we all feel inferior …gay men are made to feel effeminate, and that’s seen as being bad. One way to feel superior is to overcompensate in being macho” (quoted in Mann, 1998, p. 348).

Body image problems are a major component of the transition process for transgender individuals, although the extent to which any individual experiences body dissatisfaction will vary widely. On one extreme, a few transgender individuals are so dissatisfied with their bodies that they mutilate their genitals, perhaps as many as 1 in 18 has thought about self-mutilation (Israel & Tarver, 1997). Others inject silicone or other oils to appear more feminized or take excessive amounts of testosterone to masculinize their appearance. Some transgender individuals are happy with their bodies, but change their names, clothing, hairstyles, or other outward trappings to match their image of themselves. The common theme is aligning outward appearance with an internal image of oneself. For those who need to align their physical bodies, genital reconstructions, mastectomies, facial reconstructions, and other cosmetic surgical interventions may be necessary. The vast majority of those who have surgical interventions are satisfied with the results—one study of 218 postoperative transgender individuals 4–24 years after surgery found that only 3.8% regretted their decision later (Landen, Walinder, Hambert, & Lundstrom, 1998). Another study reported high levels of body satisfaction and self-confidence in postoperative transgender men and women (Kraemer, Delisignore, Schyder, & Hepp, 2008). Hormone therapies are also effective in creating some of the changes that align the physical body with the psychological image, and speech training, gender coaching, and fashion advice may also help (see Kirk & Kulkarni, 2006, and Lawrence, 2007, for specific health care issues related to transition).

Reflection: Many people in the press and on talk shows have questioned the sanity of genital reconstructions because they are permanent. However, rarely do we question the sanity of a person having a face lift, nose job, or Botox injection, procedures that are also relatively permanent and carry risk. Why do we put genitals in a different category than other body parts?

Domestic violence/intimate partner violence

Much of the literature on domestic violence, or intimate partner violence (IPV) in heterosexual relationships, particularly by feminist researchers, has focused on power imbalances based on gender and explores why men are overwhelmingly the perpetrators of violence and women the victims. This focus on power imbalance based on sexism rendered the possibility of same-sex IPV invisible for years. As more research examined IPV, it has been noted that the incidence of IPV in same-sex couples is about equal to or higher than in other-sex couples (Balsam, Rothblum, & Beauchaine, 2005; Greenwood et al., 2002; Tjaden, Thoennes, & Allison, 1999). Gender is not the only source of power imbalance in relationships, and it is rare to find couples who are truly equal in all ways. Imbalances in finances, social support outside the relationship, drug and alcohol abuse, the degree of “neediness,” fear of being outed, and the stress of stigma (minority stress), as well as sexism and heterosexism, are factors in same-sex IPV.

A probability-based study of MSM living in four large cities identified a very high rate of interpersonal violence, with 34% reporting psychological battering, 22% physical violence, and 5% sexual violence within a relationship in the past 5 years (Greenwood et al., 2002). HIV-infected and younger men were more vulnerable to violence than HIV-negative and older men. In a population study of 8,000 women, 11% of lesbians reported violence from a female intimate partner and 30% reported violence from a former male intimate partner, compared with 20% of heterosexual women who experienced physical violence from a male intimate partner. Therefore, lesbians may be at greater risk from violence from former male partners than heterosexual women. In addition, LGBTQ people are equally likely to experience psychological and physical violence within their intimate relationships, presumably because the stresses of same-sex relationships are greater (Balsam et al., 2005). One way that domestic violence might differ in same-sex relationships is that the abusive partner may use the threat of outing the individual to their boss, parents, or other people, and use that threat to isolate the partner from potential social support (Pitt & Alpert, 2007). In addition, the abusing partner might use the threat of stigma to deter the victim from seeking help (“the police never believe queers”) or state that no one would believe the victims story (“no one is going to believe that a woman could be the perpetrator” or “no one would believe that men can be victims”).

The underlying reasons for violence are often the same as in other-sex relationships (power, finances, fears of abandonment, etc.), but the resources for intervention/treatment are much more limited. Battered women’s shelters often do not know how to deal with female same-sex relationship issues, where the line between perpetrator and victim is sometimes more blurred. Women’s shelters usually do not accept men or transgender individuals at all. Men who are battered have very few or no community resources and may face ridicule or denial that a man could be a victim of abuse. Men who are victimized are seen as “sissies” and stereotyped as inferior men. They often experience secondary victimization from police, hospital staff, social workers, and other health care professionals.

Figure 7.2 Race/ethnicity of men who have sex with men (MSM) living with HIV/AIDS, 2005. From “HIV/AIDS Among Men Who Have Sex With Men,” by Centers for Disease Control and Prevention, 2007, http://www.cdc.gov/hiv/topics/msm/resources/factsheets/msm.htm

Transgender individuals who are sex workers, much like biological women sex workers, face much higher risks for abuse from strangers/clients, but little is known about their risk for violence within their intimate relationships. One study reported that 10% of transgender people had experienced intimate relationship violence (Xavier et al., 2000), but many more experience verbal abuse and harassment from parents (22%), siblings (17%), and other relatives (14%) as well as police officers (37%) (Reback et al., 2001). The National Gay & Lesbian Task Force commissioned a report on issues of transgender individuals in homeless shelters that addresses some of the same problems that transgender people would encounter in domestic violence shelters—this may serve as a useful starting point for those health care professionals who work in any kind of residential setting (Mottet & Ohle, 2003). An unexplored potential source of domestic violence among transgender individuals may be their significant others at the time that they “come out” as transgender. As one partner of a transperson put it,

I don’t always think staying together is the most positive outcome for a couple. Some SOs [significant others] are much happier when they leave, and it’s right for them to do so. Often the transperson is happier too, especially vis-à-vis transition … especially those who had wives who denigrated them for the cross-dressing for a long time. There’s a huge potential for (mostly verbal) abuse of transpeople by partners that no one is really talking about much yet. (Erhardt, 2007, p. 5)

Table 7.3 Selected Physical Health Disorders in Women by Sexual Orientation/Behavior Categories

Physical Health Disorders

Chronic health disorders

A few large population studies in recent years have examined self-reported physical health disorders in LGBTQ populations, and these studies support and extend the findings of earlier studies that relied on convenience samples (e.g., Bakker, Sandfort, Wanwesenbeeck, van Lindert, & Westert, 2006; King & Nazareth, 2006; Tjepkema, 2008; Wang, Hausermann, Vounatsov, Aggleton, & Weiss, 2007). One recent study (Cochran & Mays, 2007) reviewed data from the California Quality of Life Survey with more than 2,000 individuals, oversampling for LGB people. Four groups were formed: heterosexual (n = 1999), lesbian or gay (n = 158), bisexual (n = 67), and “homosexually experienced heterosexuals” (n = 51). The later were people who said that their identity was heterosexual, but they had recent same-sex experiences. Respondents were asked if they had heart disease, hypertension, cancer diagnosed within the past 3 years, diabetes, liver disease, digestive problems (ulcer, enteritis, colitis), urinary problems, migraines or headaches, asthma, arthritis, back problems, chronic pain, chronic fatigue syndrome or fibromyalgia, HIV infection, and AIDS/HIV disease. Because of the complexity of having two genders and four sexuality groups, the findings are not so straightforward. Tables 7.3 (data for women) and 7.4 (data for men) summarize some of the key findings.

Heterosexual women had higher rates of diabetes, but the other three groups reported higher rates of most of the other physical health problems assessed. Those who were bisexual or heterosexual with same-sex behavior reported very high rates of some stress-related disorders such as migraines/headaches, asthma, and back problems. The patterns were similar for men. Heterosexual men had the lowest rates of most health problems, and heterosexual men with same-sex experiences had among the highest rates of physical ailments. HIV infection rates were highest among the gay men. Unfortunately, this study did not report rates of smoking, drinking, weight, or other factors that could explain some of the health problems. Tjepkema (2008) reported data from a Canadian national probability sample and found that bisexual men and women reported the poorest overall health, followed by gay men and lesbians, and heterosexual respondents with the highest levels of health. LGB people had higher rates of unmet health care needs in the past 12 months, even in Canada, where everyone has access to health care. There appear to be complex relationships between health and sexuality, which differ depending on whether an individual adopts an LGBTQ identity, which might imply that they have some level of community and sense of unity around the label, versus those who engage in same-sex behavior without adopting an identity label.

Table 7.4 Fictitious examples of various components of sex/gender and sexuality

Cancer

Cancer risks have been discussed in some studies. Cancer burden is not distributed equally in the population, and most racial/ethnic minority groups have lower survival rates from cancer (American Cancer Society, 2004), suggesting that stigma creates health disparities around cancer treatment. Only a few studies have examined cancer risk and cancer incidence among LGBTQ people. In a study of 324 sister pairs, where one sister was a lesbian, the lesbian sisters were found to have higher risk factors for breast cancer than their heterosexual sisters (Dibble, Roberts, & Nussey, 2004). Among the few studies to look at cancer diagnosis, Cochran and Mays (2007) asked respondents from a random sample of Californians about new cancer diagnoses in the past year. There were no differences among women by sexual identity or behavior, but among men, those who called themselves heterosexual but had same-sex experiences had higher rates of cancer diagnoses (4.3%) than heterosexual (1.1%), gay (0.8%), or bisexual men (0). A Danish study found no difference between women registered in same-sex relationships compared with women in heterosexual marriages on cancer rates (Frisch, Smith, Grulich, & Johansen, 2003). One small-scale study found higher rates of breast cancer among lesbians than among heterosexual women (Roberts, Dibble, Scanlon, Paul, Davids, 1998).

Among women, most of the research has focused on breast cancer risk factors and proposes that the risks may be higher for lesbians/bisexual women than for heterosexual women because lesbian/bisexual women are less likely to bear children, more likely to be overweight, and more likely to be current or past smokers (Cochran et al., 2001; Dibble et al., 2002, 2004; Roberts & Sorensen, 1999). In addition, some studies have reported that lesbians are less likely to get Pap tests and mammograms (Cochran et al., 2001; Diamant, Schuster, & Lever, 2000; Koh, 2000; Rankow & Tessaro, 1998; Valanis et al., 2000; White & Dull, 1997); therefore, cancers may not be identified as early.

Literature on cancer among gay and bisexual men has focused primarily on anal cancer and cancers related to HIV status. Men who engage in anal sex should have annual anal Pap tests to screen for cancer (Goldstone, 1999) as some data suggest MSM are at higher risk. There are high rates of human papillomavirus infection among MSM, which may be associated with higher rates of anal cancer (Frisch et al., 2003). Rates of anal cancer in the general population are about 1 case per 100,000 people, but one study suggested rates in MSM might be closer to 35 per 100,000 (Darragh & Winkler, 2004). LGBTQ people who are HIV positive must be monitored closely for a wide variety of cancers that are associated with HIV, such as Kaposi’s sarcoma and lymphoma (Engels, 2007; Martro et al., 2007). Little is known about cancer risks among transgender individuals. There is growing evidence that about half of transgender men, many of whom still have a uterus and cervix, do not get regular Pap tests because the transgender men themselves or the health care providers are uncomfortable with physical examinations (Rachlin, Green, & Lombardi, 2008).

Table 7.5 HIV Infection by Exposure Category

The higher smoking rate among LGBTQ people warrants more attention to rates of lung cancer as well. Thus far, there have not been focused studies on the health effects of smoking among LGBTQ people, but it is likely that there are higher rates of COPD and lung cancer among older LGBTQ individuals. The lack of findings of increased cancer rates in the studies cited above may have to do with the age of the respondents, as cancer rates increase with age.

Another area of concern is the appropriate screening and preventive care for transgender individuals. Some providers consider male-to-female transgender individuals to be biologically male and thus do not consider gynecologic screening. Female-to-male transgender individuals who have a cervix need to have regular Pap tests. Thus far, no studies have examined cancer risks in transgender individuals.

Sexually transmitted disease (STD) or sexually transmitted infection (STI)? Whats in a word? Many specialists are using the more accurate term STI to describe acute illnesses that are transmitted sexually. We do not refer to a cold or the flu as diseases, but as acute illness. Most of the STIs are also acute, thus the less stigmatizing term is warranted.

Sexually transmitted infections and HIV/AIDS

Sexual orientation and gender identity are not risk factors for HIV/AIDS or STIs. Instead, specific sexual behaviors that can be performed by any person, or combination of persons, carry risk only if one of the partners is infected. Sexual activities are often stigmatized in our society, and in spite of the proliferation of sexual images in the media, most of the culture is rather sex phobic. Therefore, we have judgments about whether women should express that they like sex, about how many partners, and what kind of partners are appropriate, and what behaviors are acceptable forms of sex and which are not. The number of sexual partners and the types of sexual activities are not in and of themselves risk factors—they are only risky if the partner has HIV infection or an STI. Some activities are more likely to transmit an STI than others, if one partner is infected. Where stigma increases the risks for LGBTQ people to contract STIs is the lack of adequate sex education about how to have sex safely. One could argue that heterosexuals are equally lacking in adequate sex education as youth, but there are many sources of accurate information available once heterosexuals become late adolescents or young adults. Some LGBTQ communities have focused safer sex education campaigns, but on the whole, LGBTQ people do not get comprehensive, LGBTQ focused sexuality education from school, home, or health care professionals. Table 7.5 shows the exposure categories recorded by the Centers for Disease Control and Prevention (CDC) for AIDS through 2006. Male-to-male contact still leads the list for men.

Because the risks for HIV infection and STIs vary by sexual identity group and gender, we will explore these risk factors separately by gender, starting with discussion of women. A large British probability sample of nearly 6,400 women aged 16–44 years offers some useful information about sexual risk factors (Mercer et al., 2007). The sexuality measures in this study included both same-sex behavior and attraction. About 5% of the women reported that they had ever had a female partner, and 2.8% had a same-sex partner in the past 5 years. Eleven percent of the women reported that they had ever felt sexually attracted to a woman, but only 0.2% of the women were exclusively and only attracted to women in their lifetimes. The sample was divided into three groups to examine their risk factors for STIs. Table 7.6 shows these data, indicating that women who have sex with men and women have the greatest sexual risk behaviors and are also the most sexually active of the three groups.

Table 7.6 Sexual Risk Factors for Women by Behavioral Categories

Exclusive lesbians had the lowest number of male partners in their lifetimes as expected and were as likely as heterosexual women to be currently partnered. Interestingly, “unsafe sex” was not even reported for lesbians in this study, yet there is evidence that HIV infection and other STIs can be transmitted from woman to woman and that lesbians need to have education about safer sex (Dolan, 2005). The CDC does not have a category for female-to-female transmission of HIV, so an HIV-positive lesbian would be queried about her other risk factors, and if none is found, her risk exposure would be listed as “other.” This exclusion of female-to-female transmission means that we do not know the extent of the risk of transmitting HIV from one woman to another.

For men, studies regarding STIs have focused more on sexual behavior than identity, so this section will use the term MSM—men who have sex with men (regardless of whether they have sex with women as well). Some sexual activities that are common to MSM carry greater risk for spread of HIV and other STIs than others. For example, anal sex carries more risk than oral sex. Among urban men, the rate of HIV infection at the end of the 1990s was reported to be 17% overall, but 25% for African American MSM, and 40% for MSM who inject drugs (Catania et al., 2001). Figure 7.2 shows the data from the CDC about the racial/ethnic distribution of HIV/AIDS cases for MSM (CDC, 2007). MSM are also at higher risk for viral hepatitis; thus, the CDC has recommended vaccination for all MSM since 1991. For more information on STIs and HIV/AIDS, see the CDC Web site for extensive information. Transmission of many STIs and HIV can be reduced dramatically by consistent use of condoms, and by also using ample lubrication for anal sex.

Transgender individuals, particularly MTF, have among the highest rates of HIV infection of any group, ranging from 14% in San Juan (Rodriguez-Madera & Toro-Alfonso, 2005), 21% in Chicago (Kenagy & Bostwick, 2001), 22% in Los Angeles (Reback et al., 2001), 32% in Washington, DC (Xavier, 2000), and 47% in San Francisco (Nemoto, Operario, Keatley, Han, & Soma, 2004). The elevated rates are related to the very high number of transgender women who cannot find safe employment and must engage in sex work to survive. Transgender women of color are at particular risk (Nemoto, Operario, & Keatley, 2005; Sausa, Keatley, Operario, 2007). Recently, one study addressed the potential risks to men who have sex with transgender women—they, too, might represent a specific group at higher risk for HIV and are not currently reflected in the CDC risk-exposure categories (Operario, Burton, Underhill, & Sevelius, 2008).

Table 7.7 Risks for Acquiring HIV

Table 7.7 shows the risk of acquiring HIV infection by the different risk exposure categories, suggesting that blood-sharing activities are much more potent transmitters of HIV than are sexual activities, yet same-sex sexual behaviors are even more stigmatized in society than injection drug use.

The Role of Stress/Distress on Health

It appears that minority stress is one of the major factors that influence the health of LGBTQ people. In the study by Cochran and Mays (2007) when the analysis controlled for psychological distress, most of the differences by sexual orientation on physical health for women nearly disappeared, suggesting that stress was the major underlying factor. For men, physical health problem differences remained even after controlling for psychological distress. Sandfort, Bakker, Schellevis, and Vanwesenbeeck (2007) found that the type of coping strategies for stress in gay men accounted for a considerable portion of their excess mental and physical health problem when compared with heterosexual men. Amadio (2006) found internalized heterosexism to be associated with greater number of adverse consequences from drinking (see also McKirnan & Peterson, 1989). Reilly and Rudd (2007) found an association between internalized oppression and body image in gay men. Warner et al. (2004) found that mental health disorders were associated with demographic factors but also conflict between religion and sexuality and being insulted in school and in the past 5 years—these same factors predicted suicide risk. There are too few studies to say conclusively that minority stress or stigma is the primary culprit, but there is growing evidence to support that statement.

Stress can be buffered by the protective factors such as accurate information, family acceptance, social support, and healthy coping strategies. Figure 7.3 depicts the possible relationships among these protective and risk factors—living in the cultural soup of negative stereotypes that create stigma, the LGBTQ individual can have external environmental risk factors (stigma, negative stereotypes) and personal risk factors (internalized oppression, stigma consciousness (a heightened sensitivity to stigma) that facilitate the development of physical and mental health problems. Theoretically, if the protective factors outnumber the risk factors, the individual may have strong boundaries to defend against stigma and stay healthy. It is important to keep in mind that many LGBTQ people have strong layers of protection and inner strength that keep them healthy. We do not want to imply that all or even most suffer from physical or mental health problems due to stigma. It is equally important to keep in mind that minority stress and stigma might have impact on the health of family members such as parents, who worry about their LGBTQ children or fear negative repercussions from their communities if their children’s identities are known. Minority stress models might also apply to the heterosexual children of LGBTQ parents or to siblings and other family members of LGBTQ individuals, although little research has focused on these groups.

Figure 7.3 Risk and protective factors that impact LGBTQ people’s health.

The Impact of Stigma on Health Care Professionals’ Knowledge, Attitudes, and Skills

It would be very damaging if you got into interactions with health care providers in which you were considered deviant…. It is like putting your life in someone’s hands who really hates you. (respondent in Stevens & Hall, 1988, p. 71)

Health care systems are a microcosm of society, where institutionalized heteronormativity and gender normativity affect policies and procedures and maintain the negative stereotypes that influence the behavior of individual health care professionals. There is little or no formal education about LGBTQ issues in health care training programs to counter the stigma (Corliss, Shankle, & Moyer, 2007; Tesar & Rovi, 1998; Wallick, Cambre, & Townsend, 1992). This means that an LGBTQ person entering the health care system already wounded by the stress of stigma must face additional minority stress while trying to heal from minority stress. People are at their most vulnerable when they are facing serious illness, and fear of negative treatment compounds the stress of the illness. Chapter 8 addresses the policies and procedures that impact LGBTQ people seeking care, so this section will focus on individual health care professional attitudes and behaviors.

Accessing health care means running a gauntlet of strangers, each one potentially negative or ambivalent about LGBTQ people, from the receptionist in admitting to the floor nurses and dieticians to the physicians, physician assistants, and social workers, just to name a few. Patients in hospital settings often have to repeat their histories and current symptoms multiple times as they are quizzed by medical students, nursing students, residents, attending physicians, and staff nurses. This means multiple “coming-out” stories, each accompanied with the pang of anxiety about the reaction that might be evoked. A survey of about 1,000 LGB Canadians revealed that 87% had been discriminated against and 70% had been insulted in a health care setting because of their sexual orientation (Project Affirmation, 1995; reported in Robinson & Cohen, 1996). A survey of more than 2,000 LGB individuals in New Zealand showed that 83% of women and 66% of men reported that their health care provider assumed that they were heterosexual; 72% of the women and 65% of the men disclosed their sexuality (Neville & Henrickson, 2006). Why do all LGBTQ people not disclose their sexuality in a health care setting? The following sections review what we know about health care provider knowledge, attitudes, and skills. These issues are discussed in more detail in chapter 9 from the perspective of health care professionals who identify as LGBTQ.

Physicians and medical schools

Smith and Mathews (2007) reported on a follow-up survey of Southern California physicians’ attitudes—the first survey was conducted in 1982 (Mathews, Booth, Turner, & Kessler, 1986), and it was repeated in 1999. While there was considerable improvement in attitudes over that time, with the percent of respondents who were strongly homophobic dropping from 58% in 1982 to 19% in 1999, some of the findings continued to indicate negative attitudes in a substantial number (one in five still being strongly homophobic, e.g.). Lena, Wiebe, Ingram, and Jabbour (2002) found that 70% of pediatricians said they do not address sexual orientation in their patients for fear of offending them and for lack of knowledge, and 59% were unfamiliar with local resources for gay youth.

There have been a few studies of medical students. Klamen, Grossman, and Kopacz (1999) surveyed 2nd-year medical students at one institution and found that one fourth of them believed that homosexuality is immoral and dangerous to the institution of family and 9% thought homosexuality was a mental disorder. Sanchez, Rabatin, Sanchez, Hubbard, and Kalet (2006) conducted an online survey of 3rd- and 4th-year medical students in one school in New York City and found that the majority did not ask about same-sex activity when they took histories, and 28% said they were uncomfortable addressing the health needs of LGBT patients. They found that most (over 90%) had dealt with at least one LGBT patient during medical school, and those with more frequent clinical exposure to LGBT patients were more accepting, more likely to take sexual histories, and more knowledgeable about LGBT health concerns.

Nurses and nursing schools

In the 1990s, a few studies of nurses and nursing students began to emerge. These studies often focused on attitudes about lesbians, because of the historical lesbian-phobia of nursing, a discipline plagued by “lesbian witch hunts.” A study of nurse educators in the mid-1980s found that the majority had negative attitudes about lesbians, with 58% stating that lesbians are “unnatural,” 35% stating that lesbians are “disgusting,” and 17% stating that they are “immoral.” Half of them had never discussed lesbian issues in the classroom, and 28% said they would be very uncomfortable talking about lesbian issues. Ten percent thought that lesbians should not be allowed to teach in schools of nursing (Randall, 1989). A substantial proportion of nursing students were also “lesbian phobic” during this time period. One study found that 26% thought that lesbians were “unacceptable” and would endeavor to avoid all contact with a lesbian (Eliason & Randall, 1991), and a follow-up study found that 38% of female nursing students were afraid of “being hit on” by a lesbian. Thirteen percent objected to lesbians on moral or religious grounds (Eliason, Donelan, & Randall, 1992).

A series of recent studies by Swedish nurse researchers has identified a number of issues related to the nursing care of LGBT patients. A study of nursing staff members from one infectious disease clinic found that 36% of the staff nurses surveyed would not care for LGBT patients if given the option, although only 9% of nursing students said they would refuse care (Röndahl, Innala, & Carlsson, 2004a). Nurses who believed that homosexuality is congenital (58%) had more positive attitudes than nurses who thought it is acquired (35%) (Röndahl, Innala, & Carlsson, 2004b). Finally, in a qualitative study of 27 gay men and lesbians about their experiences with nursing, nearly all the informants reported that nursing situations were heteronormative. “They take for granted that I’m heterosexual until I say that I’m not, and then everything comes to a halt” (p. 376). Partners were rendered invisible “I wasn’t told anything, nothing…. they only spoke to X, didn’t even look at me. I didn’t exist” (Röndahl, Innala, & Carlsson, 2006, p. 378).

Other health care professionals

There is a small body of research on health care professionals other than physicians and nurses. Harris, Nightengale, and Owen (1995) compared nurses, social workers, and psychologists, and found that nurses were more homophobic and less knowledgeable about LGBT issues than the other professions. It may be useful to explore why nurses differ from the other professions. More, Whitehead, and Gonthier (2004) studied dental school programs and found little support for LGBTQ students or patients, and little in the curriculum to inform dental students of LGBTQ health issues. In fact, 33% of the administrators did not know if they treated any LGBTQ patients—a sure sign of the heterosexism found in many health care settings. Willging, Salvador, and Kano (2006a) interviewed providers of mental health services in a rural state and found that most providers declared that there were no differences between LGBTQ and heterosexual patients. The authors felt that this attitude stifled discussion of sexuality and gender and led to further isolation and alienation of LGBTQ clients.

LGBTQ People’s Experiences With Health Care

Disclosure decisions

…I told him that I was gay because if there was a problem I’d rather know right away than build a relationship with a physician and then find out that it was going to be a problem. (Beehler, 2001, p. 140)

…in kind of the introductory notetaking that the doctor does when they ask you about your medical history, pregnancies, are you on birth control, anything kind of hormonally related. And there’s usually some question that I just, you know, around pregnancies and stuff and the use of birth control that I usually say I’m in a lesbian relationship so that’s not applicable. And I do that proactively, to put them on notice that I’m out about my sexuality and we can deal with this like adults. So I usually make a kind of proactive move somewhere in that interview process, work it into the conversation. (Boehmer & Case, 2004, p. 1886)

Decisions to disclose one’s sexuality to a health care professional are rather complex and may vary according to generation, race/ethnicity, couple status, gender, and reason for seeking care. Some people have greater mistrust of health care professionals than others and withhold information about sexuality until they feel comfortable, and others disclose on the first visit. Eliason and Schope (2001) studied disclosure experiences of highly educated lesbian, gay, and bisexual individuals from one Midwestern city. Disclosure was defined as:

- active disclosure: directly told a health care professional;

- passive disclosure: indirectly informed the professional via naming a same-sex partner, wearing a T-shirt or button that proclaims one’s sexuality;

- active nondisclosure: lied about their sexuality; and

- passive nondisclosure: don’t ask, don’t tell (the provider did not ask, so the patient did not tell).

There were differences in both the types of disclosure and other experiences with health care by gender, with women being more likely to actively disclose (43% compared with men 29%). Women used more protective strategies while in health care settings, such as bringing someone along for support, closely monitoring the health care provider’s behavior, scanning the environment for clues of acceptance, and controlling information until feeling safe, than did men. It was suggested that women are more vigilant for two reasons—they are operating under at least two oppressive systems, sexism and heterosexism. The White gay men in this study at least had male privilege, if not heterosexual privilege.

Figure 7.4 Factors that influence disclosure decisions.

Figure 7.4 depicts a model for understanding the factors related to disclosure. On the level of the individual client or patient, age, gender, racial/ethnic identity, religion, comfort with own sexuality, comfort with own gender, degree of internalized homophobia, experience with health care, type of presenting problem (one might be less likely to disclose for an acute problem and more likely for a problem that involves ongoing care), and whether the individual has a partner (whether there is someone who needs to be involved in health care decision making or not). At the provider level, personal characteristics such as age and gender might be important. Some studies suggest that LGBTQ people are more likely to choose female physicians/health care professionals because women tend to be more accepting of diverse sexual identities; some perceive younger health care professionals to be more likely to be accepting than older one. Other considerations are body language, verbal language, reputation in the community, and whether the health care professional provides an opportunity for patients/clients to disclose. At the institutional level are the policies and procedures such as nondiscrimination policies, staff training, whether benefits are extended to domestic partners of same-sex couples, the written language on the forms, the atmosphere of the waiting room/reception areas, and so on. Which of these factors could you modify in your own work settings?

The research on the percent of LGBTQ people who disclose their sexual and gender identities to health care professionals ranges widely, because the overall numbers do not reflect the complexity of the question. Most of the recent research suggests that about three fourths of LGB people disclose (less is known about transgender individuals), but this figure may be quite misleading. The LGBTQ people who volunteer to complete surveys about health are probably more “out” in many realms than people who refuse to participate or are never reached through the sampling procedures. People who label themselves as heterosexual but have significant same-sex experiences have not been studied in terms of health care experiences but are probably less likely to disclose because of the enormous stigma attached to their behavior. They would not be identified unless a health care professional asked directly about both sexual identity and same-sex behaviors.

Reactions/responses from health care providers

In the study by Eliason and Schope (2001), most respondents reported that they had a positive (over 50%) or neutral response from their disclosure to a health care professional. However, some reported anger, hostility, discomfort, disgust, embarrassment, fear, and shock on the part of the provider. Several studies have gathered the stories of negative experiences. Some of these are recounted below:

When one doctor asked me if I was sexually active (yes) and about what kind of birth control I used, I responded that I didn’t use any since I was a lesbian. The attending nurse burst into giggles and flew from the room and the doctor and I finished the exam in silence. This wasn’t malicious of course, but did little for my sense of comfort with being open with my health care providers (lesbian, age 43). (Eliason & Schope, 2001, p. 130)

What I got from him was this judgmental statement like, well, if you should wind up HIV-positive…. And he started going into all this stuff like scare tactics, you know. I felt like a thirteen-year-old being lectured about smoking … it took me aback. (Beehler, 2001, p. 138)

One doctor I just transferred from interpreted every illness in terms of my being gay. Not overtly anti-gay but came not to trust him or feel comfortable discussing my health with me (gay man, age 52). (Eliason & Schope, 2001, p. 130)

“Following an episode of… ‘weird’ behavior, his family took him to an American Indian charismatic healther who identified ‘devil possession’ … told Leroy that ‘homosexuality is wrong … and set up a time for an exorcism.” This gay man had sought help for his grief over losing a family member. (Willging, Salvador, & Kano, 2006b)

Treatment of partners and family

Another stressor related to health care is how and when the partner or family will be involved in care, and how they will be treated. In states with no recognition of same-sex relationships, partners without power of attorney (see chapter 8) may have no legal recourse and may be denied access to their loved ones and have difficulty receiving information about their progress.

In my experience as both patient and close relative, it’s been worse to be the relative—as a patient, they pretty much have to take care of me, but as a relative they can ignore me—like my being there makes the patient homosexual—if I weren’t there, she would just be another patient in the lot. But since she had me with her—she suddenly became something else—and it’s probably easier to just close your eyes and pretend I’m not there—but I can really only interpret it as if they didn’t accept that we had a homosexual relationship—they would much rather talk to our parents, even though we are adults (woman, 30 years). (Rondahl et al., 2006, p. 378)

Dr. X, on the other hand, had a problem and he asked [my partner] to wait outside. I said you know what? I’m not talking to you without her here. He said, well, we can only talk to a spouse or you know, a family member. I said well, she’s both. She’s my wife and she’s my family. She’s my next of kin. I said you know, my mind is not clear and I’m not hearing half the things that are being said. I want her present. I want her here. So he called her in. But when we were talking…. He would only look at me and he would only talk to me. (Boehmer & Case, 2004, p. 1887)

As soon as I said I was a lesbian, the nurses started giving me disgusting looks. They were nasty to my partner. (Stevens & Hall, 1988, p. 72)

Use of Health Care Services

In spite of the stresses of disclosure and the actual negative experiences of many LGBTQ people, some recent research shows that LGBTQ people use health care services at an equivalent or even higher rate than the general population. For example, Bakker et al. (2006) found that gay men were 2.17 times more likely to see a medical specialist than heterosexual men, and 1.6 times more likely to see a mental health care professional. Lesbians were 2.06 times more likely to see a mental health care provider, but equivalent to heterosexual women in seeing medical specialists (see also Tjepkema, 2008). On the other hand, some research suggests that LGBTQ people might be more likely to use alternative and complementary therapies because of discrimination or mistrust of mainstream health care. Matthews, Hughes, Osterman, and Kodl (2005) found that 42% of lesbians had experienced discrimination in health care compared with 35% of heterosexual women, and the lesbians were more likely to use meditation/visualization, chiropractic services, massage, and mental health support groups than were heterosexual women. Similarly, Tjepkema (2008) found that LGB people in Canada were more likely to use alternative care providers than heterosexual people.

There is some inconsistency in this literature on accessing health care. Lewis, Derlega, and Clarke (2006) noted that sexual minority individuals often expect to encounter discrimination and prejudice when they access services and as a result, may delay, not access services, or not disclose or feel reluctant to talk about their experiences as LGBTQ to health care professionals. More research is needed to address whether those individuals who accessed services more often actually disclosed their sexual or gender identities to the health care professional.

Conclusions

Stigma, operating through minority stress, is the major contributor to the elevated risk for physical and mental health disorders in LGBTQ people, working in complex and interactive ways to increase health problems and to decrease access to quality health care. The stress of stigma also exacerbates underlying health problems stemming from other causes, making them more debilitating. The burden of stigma-related health disorders can be reduced somewhat by welcoming and inclusive health care environments, but interventions are needed at all levels of society to truly improve the health of LGBTQ individuals. Minority stress related to heterosexism, gender normativity, racism, classism, and other forms of oppression need to be reduced via education (such as individual empowerment for clients and culturally appropriate care training for health care professionals), health care agency policy change, and broader societal change. The next chapter addresses institutional factors such as agency climate and policies and procedures.

Reflection Questions

Awareness

1. Were you surprised by any of the elevated health risks for LGBTQ individuals?

Sensitivity

1. How has stress impacted your own life?

2. Have you experienced minority stress related to any of your social identities? How did that feel?

Knowledge

1. What are some of the potential solutions for reducing the effects of minority stress?

2. What obligations, if any, do health care systems have in reducing health disparities?

Chapter 8: Structural Barriers to Quality Care

There is no validation for lesbians in the health care system. When you go in, the receptionist calls you Mrs. The magazines tell you all about how to make yourself attractive for a man or cook him a meal…. The forms you fill out make you feel like they have never heard of lesbians. Nothing matches anything about your life.

Respondent in Stevens (1995, p. 27)

Mainstream health care settings are typically heterosexist, rendering LGBTQ people invisible or worse. Because of the stigma in society, LGBTQ people face more barriers to accessing health care and negotiating the health care system than do heterosexuals. The first section of this chapter reviews the health care climate, policies, and procedures, including oral and written language, and describes how documents and agency policies can be made more inclusive. The second part of this chapter reviews some of the legal barriers to quality health care, including access to health insurance and the legal documents needed to protect relationships. Health care professionals need to be aware of the legal aspects that apply to their own settings.

Making Health Care Settings Inclusive

The waiting/reception area

The first entry into a hospital, clinic, or private practice is the waiting room or reception area. Several studies have found that LGBTQ patients scan the environment for clues that the setting might be safe (Eliason & Schope, 2001; Hitchcock & Wilson, 1992; Stevens, 1994). Visual clues that a health care setting is inclusive and welcoming to LGBTQ individuals can include, but are not limited to, the following.

- A nondiscrimination statement or patient rights policy that explicitly names sexual orientation and gender identity is prominently displayed at check-in or near admissions.

- Posters or artwork that depict same-sex couples and gender-variant people are displayed on the walls.

- There are magazines targeted to the LGBTQ community such as the Advocate, Curve, Genre, Out, Poz, Transgender Tapestry.

- There are patient pamphlets that deal with LGBTQ issues.

- Local community LGBTQ newsletters or fliers are displayed.

The Web site for the Gay and Lesbian Medical Association (GLMA) has a pamphlet on creating a welcoming environment (see www.glma.org for more information) that may serve as a useful starting point for your work setting.

Activity: Search the Internet for patient pamphlets that focus on or incorporate LGBTQ issues that are relevant to your health care setting. Some relevant sites might include your professional organization, LGBTQ community health center sites (e.g., Fenway Institute of Boston; Whitman-Walker Clinic in Washington, DC), or national LGBTQ organizations such as the GLMA, The Human Rights Campaign, the National Gay and Lesbian Task Force, and the National Coalition for LGBT Health.

Health Care Intake Forms

They take for granted that I’m heterosexual until I say that I’m not, and then everything comes to a halt. It’s typical of the health care system … it’s a very old-fashioned way to look at it. (Röndahl, Innala, & Carlsson, 2006, p. 376)

The language on the intake forms can put LGBTQ patients at ease or on the defensive. There is virtually no research on the impact of language on comfort levels of patients and clients, but we know anecdotally that these things matter. Inclusive language in intake forms is another clue that LGBTQ clients use to determine whether they can trust a clinician with information about their sexual orientation, gender identity, and relationship status. For instance, Table 8.1 shows examples of inclusive and not so inclusive language that could be found on forms.

Table 8.1 Examples of Language on Forms: Inclusive and Noninclusive

Clinician–personal interaction with the client

When taking a history, the clinician’s task is aided by using inclusive terms and language. Inclusive language should not make assumptions about a patient’s sexual identity, sexual behavior, or gender identity, particularly in situations in which patients do not volunteer such information. Some examples of questions that assume heterosexuality and gender normativity are as follows:

- “Are you married or single?”

- Asking a female patient, “Do you have a boyfriend?”

- Asking a male patient, “When did you first become interested in girls?”

- Asking a male patient, “How about those…[insert the sports team]?” or other gender-stereotypical statements.

Some examples of inclusive questions are as follows:

- Are you dating anybody?

- Do you have a partner or significant other?

- Is your partner male, female, or another identification?

- Are you currently in an intimate relationship?

- Who should be included in decisions about your health?

- What’s your level of commitment in your relationship?

- Are you comfortable with your gender?

Inclusive language also conveys to the LGBTQ patients that the interviewer is potentially open to hearing about their sexual identity, gender variation, and relationships. The accuracy and completeness of the information elicited will reflect the patient’s level of comfort with the process. The goal of the interview is to work in the patient’s best interest. We offer some suggestions in Table 8.2, but the questions need to be tailored to the specific patient/client audience. For example, Garofalo and Bush (2007) propose this introduction for interviewing adolescents:

Some of my patients your age begin to find themselves attracted to other people. Have you been romantically or sexually attracted to boys, girls, or both? (p. 82)

or

It is normal for young people to sometimes be confused about their feelings and experiences. Do you have any questions you’d like to ask me or things you would like to talk about? (p. 83)

Table 8.2 More Examples of Inclusive and Noninclusive Languages

Confidentiality

Confidentiality is the cornerstone of all clinician–patient relationships and assurances of confidentiality are crucial to taking a history. This is done by informing patients that any information they provide will not be shared with others. In cases in which complete confidentiality cannot be ensured, a clinician should clarify the limits of confidentiality from the onset and respect patients’ decision as to how much information about their sexuality or gender that they are willing to reveal to others. Details about someone’s sexual orientation or gender variation should not be placed in the medical record without asking permission from the client. In these instances, it helps create a code so that clinicians can remember the client’s information without having the specific documentation in the record. Suggested ways to chart sexual identity without directly saying it include “no need for birth control” (women in same-sex relationship), “has domestic partner,” or a special code. This is important because there is still considerable stigma attached to minority sexual and gender identifications, and some LGBTQ people will not want this information recorded on their medical files. LGBTQ people still routinely lose jobs or denied promotions, lose custody of children, and lose the support of family, friends, and communities when they disclose their identities. In addition, many LGBTQ people have directly experienced poor quality of care, refusals of care, and/or unprofessional voyeurism or gossip in health care settings.

LGBTQ people have often experienced negative comments from health care providers. These types of comments are distressing at any time, but particularly when one is a patient and feeling vulnerable. As one respondent in Stevens and Hall’s (1988) research said, “it’s like putting your life in someone’s hands who really hates you” (p. 72). Sometimes these inappropriate comments are violations of privacy and sometimes they are in the form of malicious gossip or voyeurism, two forms of unprofessional practice.

Think about how you might deal with confidentiality issues and recording of information about sexuality and gender in patient records as well as in verbal communications among staff. What special codes might help you remember a patient's information from one visit to another without revealing his or her sexuality or gender identifications?

Special caution needs to be taken when working with children, adolescents, and young adults who may not have shared their concerns about sexual orientation or gender identity with their parents. Children and adolescents are particularly unlikely to share their intimate feelings unless their wishes and sensitivities are recognized. Special caution also needs to be taken when working with the elderly who may not have shared their sexual orientation or gender identity with their children or caregivers. Other situations in which special caution needs to be taken include cases in which revealing information may affect the outcome of a legal case such as child custody, divorce, or guardianship of an elderly dependent, or a patient who is in the military.

Confidentiality of records and the Health Insurance Portability and Accountability Act are legal mandates, but many LGBTQ people also report that their rights to privacy and dignity have been violated in health care encounters. For example:

During a pelvic exam, one lesbian said, “So he went to examine me, and halfway through the internal examination he said, ‘Well, I don’t really know much about these relationships. Can you tell me what your sexual practice is? What do you do?’ …and it was absolutely awful. I didn’t know what to say, so I didn’t say anything…. I decided I’d never go back to the GP ever again. When I got home I felt like I’d been abused…. I had to go and have a shower and I felt horrible.” (Platzer & James, 2000, p. 196)

Making Referrals

Clinicians should be aware of not only the inclusivity of their own health care setting but also any referral sources that the health care agency uses for support services for their patients. This issue can be critical in settings in which group treatments are the standard, such as substance abuse treatment settings—the LGBTQ client may have to face negative reactions or lack of understanding from counselors and other clients (Eliason, 2000). Another example might be referrals to clergy. Most clergy in health care settings are highly professional and provide client-centered services, but some may have negative attitudes about LGBTQ patients that hinder the health care experience.

I have had a female doctor say she was fine with it and then try to coerce me into saying sexual identity is purely a choice. My worst experience, the doctor lectured me on the Bible and changed her diagnosis [when she discovered I was gay]. (Respondent in Eliason & Schope, 2001, p. 130)

Health Care Setting Policies

Equitable policies and procedures help ensure that all patients/clients are treated fairly and help eliminate health disparities. Inequitable policies and procedures are one of the barriers for LGBTQ people in seeking health care, and as a result, many LGBTQ people wait until conditions are far advanced before seeking care. Once in the health care system, inequitable policies/procedures create greater levels of stress for the patient and the family that compound the stress of the illness and its treatment.

Bill Flanigan and his partner, Robert Daniel, were in the Washington, DC, area in 2000. Robert was admitted to a hospital because of complications from AIDS. Bill was not allowed to see Robert and the hospital staff would not give Bill any information about what was happening because he "wasn't family." The couple had durable power of attorney documents and were registered as domestic partners in the state of California. This information was disregarded, as were Bill's request not to insert a breathing tube, per Robert's wishes. Only when Robert's sister and mother arrived 4 hr later did Bill get to see his partner. By this time, Robert was no longer conscious, his eyes were taped shut, and a breathing tube had been inserted. The two men never had the chance to say goodbye before Robert died (Lambda Legal Defense Fund).

Healthcare Equality Index

In 2007, the GLMA and the Human Rights Campaign Foundation began a project, called the Healthcare Equality Index (HEI), to rate whether U.S. hospitals have equitable policies and procedures for their LGBTQ patients and families. A questionnaire was sent out to hundreds of hospitals across the country, and the report provides information on 88 institutions from 21 states. Although certainly not a scientific study, the report outlines equitable policies and procedures, and the exercise of answering the questionnaire may prompt more hospitals to change their policies. Table 8.3 shows the questions on the survey. Some of the highlights of the report include the following:

Of the 88 participating hospitals (keep in mind that this is not a representative sample)

- 86 had a written policy that prohibits discrimination on the basis of sexual orientation, and 58 prohibited discrimination on the basis of gender identity;

- 60 allowed LGBTQ domestic partners the same access to visitation as spouses and next of kin;

- 59 allowed same-sex parents the same access to visitation as other-sex parents of minor children;

- 77 recognized advance health care directives such as durable power of attorney to give LGBTQ partners’ rights over decision making for their incapacitated partners, but only 56 had a policy that allows same-sex parents the same rights for medical decision making as other-sex parents regarding their children;

- 61 provided diversity training to personnel that include issues related to LGBTQ people;

- 74 prohibited discrimination in employment on the basis of sexual orientation;

- 51 barred discrimination in employment based on gender identity or gender expression; and

- 82 offered health insurance coverage to employees’ same-sex domestic partners.

Activity: Use the questions in Table 8.3 to rate the hospital in which you work or receive care.

Health insurance

About 80% of adults between the ages of 18 and 64 in the United States obtain health insurance from their own job or the job of a family member (Ash & Badgett, 2006). Because of the gay rights movement, the workplace trend toward domestic partner benefits is improving the lives of some committed couples, regardless of sexual orientation or marital status. Unfortunately, same-sex couples are less likely to be insured than married couples. In fact, about 20% of same-sex couples (18.8% men and 21.4% women) had absolutely no health insurance in contrast to 11.5% of married couples (Ash & Badgett, 2006). Even if health insurance were available for all same-sex partners, the federal government has determined that married couples have special rights. Although the Internal Revenue Service allows the cost of health benefits for married spouses and dependents to be tax deductible, it has not yet given the same rights to unmarried same-sex couples. So the amount of money that the employer pays for health insurance for an unmarried partner and any children will be included as taxable income on W-2 of the employee. In addition, the domestic partners must disclose their sexuality to an employer, which is not safe in some situations.

In addition, the federal Family and Medical Leave Act, which allows employees in larger companies to take paid or unpaid sick leave to care for a partner, child, or parent with a serious medical condition for up to 12 weeks in a year, does not apply to most same-sex partners or to a partner’s legal children, though some individual employers provide similar coverage.

Legal Issues

LGBTQ people have some unique legal challenges due to their inability to legally formalize their relationships in the state, national, or international arenas, which renders their families invisible and unprotected. It is important for all health care providers to become aware of the extra legal documents required to protect LGBTQ patients and their families. Although many of these forms can be downloaded and completed without the assistance of a lawyer, an estate-planning specialist concentrating on LGBTQ issues is an excellent source of information and help. The following information has been adapted from National Center for Lesbian Rights’ and Rainbow Laws’ Web sites available at http://www.nclrights.org/site/DocServer/NCLR_LIFELINES.pdf?docID=521 and http://www.rainbowlaw.com/free.htm, respectively.

Table 8.3 The Healthcare Equality Index Questionnaire

Living will/medical directive

In every state, people can sign documents describing their wishes concerning life-prolonging medical care. Depending on the state, this document may be called by any one of several different names including living will, medical directive, health care directive, directive to physicians, or declaration regarding health care. This document contains directions to health care professionals about what the person wants to be done when he or she is no longer capable of making or communicating choices regarding life-prolonging and other medical care.

Durable power of attorney for health care/health care proxy

A durable power of attorney for health care (which is also sometimes called a health care proxy) allows a designated person to make medical decisions for another person in the event he or she is unable to do so. This is a very important document for LGBTQs because the person may not want his or her biological family making health care decisions on his or her behalf.

Hospital visitation authorization

A hospital visitation authorization allows the naming of specific individuals to visit them in the event individuals are no longer able to communicate their wishes.

Authorization for consent to medical treatment of minor

The medical treatment of a minor requires authorization by the legal parents. This form allows the legal parents to permit someone other than a child’s legal parents to authorize a doctor or other health care professional to provide medical services to a minor child. In states that do not recognize both parents in a same-sex couple as legal parents, this form is critical so that all parents and appropriate grandparents are able to consent to emergency medical treatment for the child. For couples who are about to have children, it is very important to complete this document before the birth mother goes into the hospital. Although this form may not be legally binding, hospitals will usually honor the authorization.

Durable power of attorney for finances

A durable power of attorney for finances allows a designated person, the “agent,” to take care of finances when a person is not able to do so. A general power of attorney for finances authorizes this designated agent to control a broad range of financial matters, including paying medical bills, cashing checks, or receiving benefits.

Wills

A will is a legal document that allows a person to designate who will receive his or her property when he or she dies. When someone dies without a will, his or her property is distributed to his or her legal heirs. With the exception of five states (California, Connecticut, Hawaii, Massachusetts, and Vermont), a same-sex partner is not considered to be a legal heir and therefore is not legally entitled to inherit property when an individual dies without a will. This is true regardless of how long people have been with their partners and regardless of the quality of their relationship with their relatives.

Trusts

Another way to designate who and/or what charities will receive property upon death is through a revocable living trust. A living trust is similar to a will in that it allows one to say who should get what; it differs from a will in that property left by a will must go through the court probate process, which means that the will must be proven valid, and the person’s debts must be paid before the property is distributed. The probate process often takes about a year. With a living trust, this process is avoided and the property goes directly to the people and/or charities named in the trust. In some circumstances, transferring the property through a living trust rather than a will also helps reduce or avoid some estate taxes.

Nomination of a conservator or guardian for a minor

The care and custody of a child to another responsible adult in the event that the child’s legal parents die or becomes physically or psychologically incapable to care for the child can be problematic if a guardian for the child(ren) has not been legally named. This is especially challenging for the child(ren) when the birth mother dies without providing for her children’s future. Usually, a person who is appointed to be the child’s guardian is given physical custody of the child and authority to manage the child’s financial matters.

Elder guardian/conservator

If the time comes when the LGBTQ elderly are unable to manage their affairs, who will handle these matters? If someone has not been named through a durable power of attorney, an advanced medical directive, and/or a trust, then someone will have to seek to qualify as a guardian and/or a conservator. A petition will have to be filed in the circuit court of the city or county of residence asking the judge to appoint an individual to serve as a guardian and/or a conservator. A guardian is appointed to be responsible for the person, that is, to take care of physical needs, medical treatment, medication, and living arrangements. A conservator is appointed to attend financial affairs, protect assets, pay bills, invest funds, and preserve resources of the LGBTQ elderly. The best option is for the LGBTQ elderly to carefully plan for this eventuality and memorialize it in writing, yet hope that they can maintain control over their own environment and care.

Autopsy and disposition of remains

In the absence of written instructions, nearly every state gives relatives the right to control the disposition of a body, including funeral arrangements, upon death. As is true for wills and power of attorney for health care, with the exception of married spouses in Massachusetts and California, civil union spouses in Vermont and Connecticut, and reciprocal beneficiaries in Hawaii, this right to control disposition of remains is not provided automatically to a same-sex partner.

Table 8.4 Are You Legally Protected?

In 1983, Sharon Kowalski met with a serious car accident in Minnesota. While Sharon was comatose in the hospital, her partner of 4 years, Karen Thompson, was unable to get information about her condition until Sharon's family of origin arrived. Karen was excluded from Sharon's care by her family, who successfully went to court to prevent her from visiting Sharon who was severely brain injured. Her family, who rarely visited her, moved Sharon to a nursing home far from Karen and Sharon's home. This is every LGBTQ person's nightmare. Karen sued for guardianship in a battle that took 8 years to accomplish, but finally in 1991, she was able to bring Sharon home. Prior to the accident, Sharon was not "out" to her family and did not have the legal paperwork that would protect their relationship.

Tables 8.4 and 8.5 provide checklists that health care professionals can use with their LGBTQ clients to ensure that they are adequately protected. This information could be put into a pamphlet format and displayed in the waiting or reception area of a health care setting.

Conclusions

In other chapters, we have focused mostly on the individual-level factors associated with stereotypes, stigma, discrimination, and differential treatment. Clearly, changes need to be made on the individual provider level, but these changes will not improve the quality of care that LGBTQ patients receive unless the system changes as well. System-level factors such as policies, procedures, written forms, and the climate of the setting must be addressed simultaneously with provider education for real social change to occur.

Table 8.5 Protection of Loved Ones Checkup: Is Your Family Protected?

Reflection Questions

Awareness

1. Were you aware of all the legal documents outlined in this chapter? How many of them would be helpful to you personally?

Sensitivity

1. Imagine what the cost might be for a same-sex couple with children to fully protect their family. How many of the legal documents would they need?

2. How do policies or forms in your own work setting include or exclude LGBTQ people?

Knowledge

1. How did your local hospital or health service fare on the HEI?

2. How do unfair policies and noninclusive language hurt non-LGBTQ people?

Chapter 9: LGBTQ Health Care Professionals

I was team teaching a community health course. I wanted to include LGBT health issues. The other faculty member was adamant about not doing this. This person was also a friend of mine. I felt very betrayed…. She would not have tolerated this exclusion if it was a religious, ethnic, or racial group. Faculty who are supposed to be our colleagues who work against you…. I was the only out LGBT person, others were not going to risk their standing by being out.

Respondent to GLMA Nurses Survey (2004)

Like racism and other attitudes that sustain barriers between people, negative attitudes in health care toward LGBTQ people have far-reaching negative effects on employees in those settings. These attitudes also negatively influence the education of health care professionals, and ultimately, both the quality of health care for patients/clients and the general climate of the health care setting. Unfortunately, there has been little research on the experiences of openly LGBTQ health care providers, and most of this has focused on gay men and lesbians who are relatively “out.” There is virtually no knowledge about how closeted LGBTQ health care professionals negotiate the workplace, the price exacted by being closeted in a health care setting, or the experiences of bisexual and transgender health care professionals.

Although there is very little research evidence that conclusively points to the negative effects of discrimination based on sexual and gender identities among LGBTQ health care professionals, we have collected many stories from qualitative research studies and the personal experiences of health care providers who identify as lesbian, gay, bisexual, transgendered, or queer. The personal consequences for those affected by hostile or unwelcoming workplaces limit their ability to practice to their fullest, just as they are limited in their ability to live life to the fullest. Consider the following example:

Jane, a longtime faculty member and full professor, was appointed as the dean of the School of Nursing, and highly respected among the faculty. She provided leadership for the start of a new PhD program in nursing, taught at all levels in the school, and served on many university committees throughout her years of service. Her appointment as dean was partly because of the support of the faculty. Jane had always been a closeted lesbian, thinking that no one guessed about her sexual identity. She assumed that by living a very strict double life, and even making frequent derogatory jokes about nurse faculty who might be seen as lesbians ("they live together but claim to have separate bedrooms---ha ha"), that her own identity was well concealed. About a year into her deanship, she was suddenly fired, with no explanation from the university administrators. People closest to her urged her to fight back, knowing that the action came about because of "leaks" to the university administrators that she was a lesbian. Her performance as dean had been highly respected, and in 1 short year, she had accomplished many things on behalf of the school. Jane refused to fight back and, instead, removed herself from all contact with friends, moved far away to another city, and was not able to reconnect with nursing for several years.

In the next few sections, we review the limited research on the various health care professions. Most of the existing work has been done with physicians and nurses. We supplement the empirical research with comments and stories from LGBTQ health care professionals, such as this one from a transgendered nurse:

Despite declaring their comfort with my transition, most of my coworkers have a very difficult time with pronouns, now 9 months later. I “pass” as a male with strangers, have facial hair and a deep voice, and yet my coworkers very often refer to me as “she” or try to do without pronouns altogether. The hard part is playing pronoun police and their embarrassed reactions to me drawing attention to their misuse. (Respondent in GLMA Nurses Survey, 2004).

Physicians and Medical Schools

…in a single day, a gay doctor might find himself “passing” to avoid homophobia but also revealing his homosexual identity to show affinity with a gay patient or as a desexualization strategy to resolve problems in examining a woman patient…. This movement between different personas can generate real tensions, as, for example, professionals ponder what will happen if attempts to “pass” are undermined by the subsequent discovery of sexual[ity]. (Hughes, 2004, p. 1211)

There is a small body of research on LGBTQ students and physicians’ experiences within medical schools and medical settings. Schatz and O’Hanlan (1994) surveyed the members of the American Association of Physicians for Human Rights, an LGBT medical association, now called the Gay and Lesbian Medical Association (GLMA), and open to health care professionals from all disciplines. Of 1,311 members, 711 completed the surveys, representing 46 states, and more than 50 medical subspecialties. These respondents represented the continuum of “outness,” with about 24% saying that more than 90% of their colleagues knew of their sexuality and 22% saying that less than 10% of their colleagues knew. The authors found that

- 17% of LGBT physicians had been refused privileges or denied promotion or employment on the basis of their sexuality;

- 16% had been denied referrals;

- 34% had experienced verbal harassment from their professional colleagues; and

- 37% had been socially ostracized.

Shockingly, 88% had heard colleagues disparage LGBTQ patients, 52% had directly witnessed substandard care or denial of care to LGBT patients, and 14% had been victims of gay-bashing. Here are some of their comments:

I am a medical student and very in the closet as a bisexual woman. As a perceived straight woman, I hear the nasty comments. One of my residents supervising me in the 4th year in medicine spoke of a gay man with HIV in the ICU. He told me that he believed HIV was God’s punishment for homosexuality, that he deserved to die, and that, in fact, all gay or lesbian people should be dead. I find it depressing and very angering that people like this man take care of gay and lesbian people.

When I applied for residency as an out gay man, one of my interviewers asked me if I would have sex with my patients. I am sure no other candidate was asked this question.

A chief resident to a lesbian medical student: “I don’t want to have gay patients because they’d all come in all the time for rectal exams.”

In the post-operative recovery room after my lover’s operation for breast cancer, a nursing assistant saw me holding my lover’s hand and heard me call her “lover” and “honey.” She walked by, shoved me a bit, and said, “queer.” What is unsettling to me is that I work for this hospital. (All quotes from Schatz & O’Hanlan, 1994)

One study found that 95% of students applying for medical school did not disclose their sexuality for fear of discrimination, and 46% did not disclose when applying for a residency (Merchant, Jongco, & Woodward, 2005). The following studies suggest that the fears of disclosure are valid:

- Brogan, Frank, Elon, Silvanesan, and O’Hanlan (1999) reported that 41% of lesbian physicians surveyed had experienced harassment in health care settings, and a later study reported that lesbian physicians weighed more and were more likely to have histories of depression than heterosexual female physicians, suggesting that added stress impacted the health of even these highly educated women (Brogan, O’Hanlan, Elon, & Frank, 2003).

- In another study, 25% of family practice program directors said that they would hesitate to match openly gay residents to their programs (Oriel, Madlon-Kay, Govaker, & Mersy, 1996).

- A study in Canada showed that 12% of randomly selected adults said that they would refuse to see an LGB family physician (50% because they perceived the LGB physician would be incompetent); older respondents were more likely to refuse to see LGB physicians than younger respondents (Druzin, Shrier, Yacowar, & Rossignol, 1998).

- Regarding heterosexual doctors and medical students, the coworkers of LGBTQ health care professionals, one study of more than 1,000 physicians in New Mexico (Ramos, Tellez, Palley, Umland, & Skipper, 1998) found that 11% would not refer a patient to an LGBTQ physician.

- A study of 2nd-year medical students in Chicago (Klamen, Grossman, & Kopacz, 1999) found that 25% believed that homosexuality is immoral and 9% believed it is a mental illness.

- A study of internists in Canada revealed that 30% had been subjected to homophobic remarks by patients on three or more occasions (Cook, Griffith, Cohen, Guyatt, & O’Brien, 1995).

- Finally, Sanchez, Rabatin, Sanchez, Hubbard, and Kalet (2006) surveyed nearly 250 3rd- and 4th-year medical students from one school in New York City, and they found that students with more clinical exposure to LGBTQ patients were more likely to take sexual histories on all their patients, had more positive attitudes about LGBTQ people, and had more accurate knowledge about LGBTQ health than did students with limited clinical exposure. Overall, less than half of the students always asked their patients about same-sex behaviors, and the majority said that they rarely or never discovered a patient’s sexual orientation. The majority who did discover sexual orientation did not ask patient’s permission to record this information in the medical record (81%). A significant subset of students (28%) said that they were uncomfortable addressing an LGBTQ patient’s health needs.

No wonder health care professionals are hesitant to come out at work. There is little in the medical school curriculum to counter such negative attitudes. Tesar and Rovi (1998) found that more than half of medical school curriculum had no information about LGBT people, and Wallick, Cambre, and Townsend (1992) reported that for programs that do have LGBT content, there is less than 1 hr of content per year over the 4-year curriculum. McGarry, Clarke, Landau, and Cyr (2008) surveyed the program directors of U.S. internal medicine residency programs about their inclusion of vulnerable populations in the curriculum. Whereas 58% covered health of racial/ethnic minorities, only 30% addressed health of gay men and 11% health of lesbians. Twenty-two percent devoted less than 1 hr to racial/ethnic populations than 37% for gay men’s health and 73% for lesbian health topics.

This lack of education reinforces heterosexism within the health care professions, implying that LGBTQ issues are not important enough to be included in the curriculum. In addition, the placement of the content, when it is so limited, becomes a critical factor in maintaining stereotypes. If the LGBTQ content is found only in a unit on human sexuality, where it is most often found if it exists at all in the curriculum, this reinforces a stereotype that sexual identities are all about sex and nothing else. If the LGBTQ content is found only in a unit on ethics, there is an implication that LGBTQ people are one of the populations that physicians “have to” care for whether they like it or not. Finally, if the LGBTQ content is found only in a unit on HIV/AIDS and/or other sexually transmitted infections (STIs), it implies that this is the only health problem in the LGBTQ community (and that being LGBTQ is all about sex). We address this issue of placement again later. The lack of education on the part of physicians interacts with the stigma of sexuality and internalization of shame and guilt on the part of some patients/clients, or as one gay man said,

It’s just a bad combination—there’s shame on one side, and untrained professionals on the other. So [sexuality] doesn’t get dealt with, and it’s avoided. And when it comes up as an issue professionally, you’re dealing with people who are really dealing with it on a personal level than a professional level. [Providers] don’t see how it … integrates into this holistic health kind of concept. (Beehler, 2001, p. 138).

There is some evidence that brief educational interventions are helpful. Kelley, Chou, Dibble, and Robertson (2008) conducted pre and posttests with 2nd-year medical students who received a 2- to 3-hr educational intervention related to LGBT health care. The students rated the curriculum positively and showed significant positive change in attitudes and knowledge on 4 of the 16 items on the survey.

Some professional organizations within medicine are beginning to address LGBTQ issues. The American Medical Association has a GLBT advisory committee; the American Medical Student Association has an LGBT action committee, and their Web site contains information on starting local chapters as well as excellent educational resources. Many specialty associations also have LGBTQ interest groups or committees, such as the Society for Adolescent Medicine. There is a free-standing Association of Gay and Lesbian Psychiatrists.

Nurses and Nursing Schools

The first articles about LGBTQ issues in nursing journals appeared in the 1960s and seem incredibly dated by today’s standards. For example, Juzwiak (1964) recommended:

The female nurse dealing with a homosexual patient ought to avoid behavior that, while potentially pleasing to a heterosexual male, might be irritating or seem threatening to the homosexual male. Specifically, she should avoid being flirtatious with him, or unduly pressuring…. The male nurse or attendant working with a male homosexual patient should bear in mind the possibility that normal friendly and solicitous behavior might be misinterpreted. (p. 57)

…the degree to which she is able to view the homosexual person as a human being with a special problem rather than as an unspeakable and frightening “pervert” will not only help her to work with such patients but will also beneficially influence the attitudes of other hospital personnel who come into contact with them. (p. 118)

In the 1970s, the tone of articles began to change. Lawrence (1975), writing as an openly gay man, called for nurses to treat patients with respect and noted, “To endure a hospital stay may be one of the most bitter and unpleasant of any of the oppressive experiences that homosexual persons are subject to daily” (p. 308). By the mid-1980s and early 1990s, studies began to appear about the nursing curriculum and attitudes of nurses and nursing students. Randall (1989) surveyed 100 midwestern nurse educators and found that 52% believed that lesbians are “unnatural,” 34% thought lesbians “disgusting,” and 23% considered lesbians “immoral.” Four percent would refuse to care for a lesbian patient, and 13% said they would not allow a lesbian nurse to care for them. More than 50% of these educators had never addressed lesbian health issues in a clinical setting or the classroom, and 10% thought that lesbians should not be allowed to teach in schools of nursing.

Studies of nursing students found similar attitudes. In one study, 26% of students said lesbians were unacceptable and that they would try to avoid any contact with one (Eliason & Randall, 1991), and a follow-up study of nearly 200 nursing students identified common stereotypes about lesbians. Nursing students worried that lesbian coworkers or patients would try to “hit on them” (38%) or “push their beliefs on me” (29%). About one third of students thought that lesbians could be identified by their masculine appearance, and 13% objected to working with lesbian on the basis of their moral or religious beliefs. A more recent study of undergraduate nursing students and faculty (Dinkel, Patzel, McGuire, Rolfs, & Purcell, 2007) found relatively low homophobia scores, but the authors speculated that they might reflect neutrality and/or heterosexist attitudes rather than acceptance. Fewer studies have focused on the experiences of gay men in nursing, although the stereotype is that all men in nursing are gay. Nursing is constructed as “women’s work”; thus, any man who enters the profession is suspect (Harding, 2007). Some studies have found higher rates of homophobia among heterosexual male nursing students (Eliason, 1998; Eliason & Raheim, 2000).

Any wonder that LGBTQ nurses might not always disclose their sexuality to coworkers? Rose (1993) surveyed 44 lesbian nurses and found that 25% were not out to anyone at work. Half of those who were open about their sexuality at work reported that coming out had been a very difficult process. Many had witnessed discriminatory behaviors by their nurse coworkers, including refusal to care for an LGB person (25%). One nurse in this study commented, “I have experienced other nurses/doctors refusing to give a gay man a painkilling suppository in case ‘he enjoyed it’” (Rose, 1993, p. 51). Blackwell (2006) conducted a random sample survey of Florida nurses and found that 22% had high scores on a homophobia scale. Those in their 20s were the least homophobic, suggesting that there is hope for the future.

Giddings and Smith’s (2005) research on the experience of lesbian nurses revealed seven themes in the stories of their experiences in nursing: closeting of lesbianism in nursing; isolating and hiding from self and others; living a double-life; self-loathing and shame; experiencing discrimination from others; keeping safe; and threatening other nurses who are closeted. They concluded that the experiences of the nurses they interviewed point to a double standard in which nurses claim to embrace diversity but fail to respect the differences represented by lesbian experience.

In 2004, two board members of the GLMA (Sharon Deevey and Ed Craft) drafted an online survey for LGBTQ nurses, and we did a preliminary analysis of the data (DeJoseph, Dibble, Chinn, & Eliason, xxxx). It was distributed to all contacts in their membership and newsletter lists who indicated that they were nurses. Of the responding nurses (n = 264), 88% were currently practicing nurses, 21% were students; 54% were female, 44% were male, and three were transgendered. By sexual identity, 44% were lesbians, 43% gay, 6% bisexual, and the rest noted “other.” Figure 9.1 shows data for the percentage of respondents who reported that they were out to all or most of these individuals in their lives—the vast majority of respondents were out to their family and only a few were out to patients.

Figure 9.1 How “out” LGBT physicians were in their lives? From Anti-Gay Discrimination in Medicine: Results of National Survey of Lesbian, Gay, and Bisexual Physicians, by B. Schatz and K. O’Hanlan, 1994. San Francisco: American Association for Human Rights.

Most of the survey consisted of open-ended questions to elicit positive and negative experiences within the practice of nursing. When asked whether the respondents worked in an “LGBT-friendly” environment, 78% said yes. The factors that appeared to make an environment LGBT friendly included having openly LGBTQ colleagues, having open-minded and accepting heterosexual colleagues, having institutional policies such as nondiscrimination policies and domestic partner benefits, and working in LGBT-specific settings. Although nearly 80% said their work environment was LGBT friendly, their qualitative responses about what makes it friendly suggested that they may have had somewhat low expectations for what an LGBT-friendly environment was. For example:

I guess it’s not that it’s friendly so much as not hostile. For the most part, people just accept things and do the work that needs to be done.

People know and are not hostile about it. Also, they know about my partner and include her in conversations. I am not sure that this makes it a friendly environment, but I am not threatened that others know.

A tolerant group of people except for a few who make off the cuff remarks without thinking.

The question is hard to answer. Nobody disdains me, or anyone else. But it is not an open environment where it is discussed as easily as any other topic. For example, I have no idea who else is GLBT in the organization. It is just not talked about.

Basic tolerance … I would not go overboard in calling it friendly, however.

Yes and no, it’s an environment of don’t ask don’t tell.

Those who reported that their work environment was unfriendly had these things to say:

I was told by colleagues when I wanted to do research on lesbian issues that I would “be boiled in oil” and that I had a “Jesus Christ complex,” critics may have been closeted themselves.

I lost my job after posting my wedding in the local paper, after over a decade at the same job. Never underestimate the power of a Catholic hospital.

A resident doctor who made fun of an effeminate male nurse; when that guy tried to commit suicide, the resident merely said, “He was a pansy.”

Being outed by a colleague at a faculty party. Although all of my evaluations had been excellent and I had just completed my masters, I did not have my contract renewed. I had been teaching in the program for 9 years. It may have had nothing to do with me being gay but it was awfully coincidental.

The expectation that as a gay man in nursing, that I am only interested in sexual health issues.

Received e-mail from nurse manager that included a “you should repent” type of message.

I have a senior coworker who has been here 20+ years who deems it necessary to harass me about my sexual identity. Particularly making sexual comments and then covering with, “You know I’m kidding, right?”

At this point in time, no national nursing organization and only a few state nursing organizations include sexual orientation and/or gender identity in their human rights statements, have committees, interest groups, or task forces for LGBTQ nurses, or acknowledge the presence of LGBTQ nurses in their documents or Web sites, even within discussions of diversity. As one example, the Oncology Nursing Society does include sexual orientation in their human rights statement.

When I moved to $\ldots$ begin nursing education, I was warned by heterosexual nurses and physicians $\ldots$ that an open lesbian could not be a nurse$\ldots$. So after seven years of being out at work as a file clerk, I became a closeted nursing student. The sudden reversal to a double life was jolting, because it takes different sets of skills, compromises, and self-justifications to live either openly or in the closet$\ldots$. After nursing school, I became more secretive again, because I was afraid of losing my new career. In each of my work settings, I saw gay and lesbian patients laughed at, mistreated, or denied. I was effectively intimidated by medical, nursing, and social work colleagues who challenged my tentative efforts at lesbian and gay patient advocacy. (Deevey, 1993, p. 21)

The LGBT Nursing Forum is an online networking forum for LGBT nurses and allies to share information and resources and bring LGBT issues forward in nursing practice, education, and research. We work together to support full human rights and better health care for all LGBT people. To become a member of this forum, go to http://groups.yahoo.com/group/LGBT-Nursing-Forum/, and click "Join"!

Other Health Care Professions

More, Whitehead, and Gonthier (2004) sent surveys to student affairs administrators of all dental schools in the United States and asked about LGBT student and staff issues. They obtained a response rate of 87%. They found that 62% of administrators reported that they had LGBT dental students, but 38% reported no LGBT students or faculty members in their programs. The majority did have nondiscrimination policies that included sexual orientation (75%), but most of the administrators were unaware of whether their school had LGBT support services, and only two schools had LGBT support groups in the dental school. Five administrators reported that they had experienced an incident of LGBT discrimination, 33% did not know if they treated LGBT patients, and the majority reported that the curriculum contained less than 2 hr of content on LGBT issues. There are no other articles related to sexuality or gender identity in the dental literature. The American Dental Association has a Gay-Straight Alliances Special Interest Group.

The American Public Health Association has had an LGBT Caucus since 1975, and the American Journal of Public Health did its first special issue on LGBTQ health in 2001. This does not mean that the curriculum of public health programs necessarily is more inclusive of LGBTQ issues than other health disciplines. Corliss, Shankle, and Moyer (2007) surveyed 102 faculty of 35 public health programs in the United States and Puerto Rico and found that most of the schools included sexual orientation in their nondiscrimination policies (71%), but fewer than half offered benefits to domestic partners (49%). Less than one-third (31%) had an LGBT student group within their program, and the same number reported that they had an out LGBT faculty member. When asked, “Did your department offer a course in the past two years that covered LGBT health topics extending beyond HIV/AIDS,” only 9% said yes. Nearly one half (43%) of respondents felt that their curriculum inadequately addressed LGBT health issues.

Some other professions that might be found in health care settings, such as social work and psychology, have a longer history of having LGBT advocacy groups within their professional organizations and have passed LGBTQ-affirmative policies and resolutions. For example, the American Psychological Association passed a resolution on the “normalcy” of homosexuality in 1975 (although it was slower to recognize bisexual and transgender issues). However, there continues to be significant numbers of professionals even in these professions that lack knowledge or hold negative attitudes (Division 44 Committee on LGB Concerns, 2000; Morrow & Messinger, 2006).

General Recommendations for Health Care Training

The majority of LGBTQ health care professionals have experienced and/or witnessed discriminatory treatment in their own work environments. Ironically, having open LGBTQ role models in the health care professions at educational programs and clinical sites could help change the climate and change attitudes; however, many are afraid to be out at work. What will it take to improve this situation? We propose three sets of interventions to make the health care workplace safer for its LGBTQ workers.

Policies

Workplaces that had nondiscrimination policies, including sexuality and gender, and that had domestic partner benefits were perceived as more LGBTQ friendly in the GLMA survey. Historically, the civil rights movement demonstrated that changing laws and policies is the first step in achieving equality—attitude change often follows. In health care as in the general population, there is a greater tendency to agree that LGBTQ people deserve equal rights than there is to agree that LGBTQ identities are a normal expression of human diversity. Sanchez et al. (2006) found that the attitudes varied in medical students in New York City, with a greater number of students agreeing that LGBT patients deserve quality care than those that agreed that same-sex behavior is “normal.” Table 9.1 shows these data.

These findings suggest that appealing to heterosexual health care professionals’ sense of social justice and civil rights might be an effective first step in changing the climate for LGBTQ health care professionals. Once the legal and policy protections for civil rights are in place, LGBTQ people can feel freer to be open and share their life experiences with coworkers, a strategy that may foster more personal attitude change.

Table 9.1 Medical Students’ Endorsement of Statements About Lesbian and Gay Patients and Same-Sex Behaviors

Better training and education

Clearly, there is a need to improve training programs for health care professionals to be more inclusive of LGBTQ people and their families. Ideally, this information should be integrated throughout the curriculum. For example,

Courses or lectures on life span development can include the coming-out process and how it differs across the life course.

Lectures on discrimination, health disparities, and social justice can include the concepts of minority stress, heterosexism, and gender normativity.

Units on family can discuss the myriad ways that people, including LGBTQ individuals, forge families and urge broadening our definitions of family.

Units about specific diseases or disorders can include some case studies that depict the issues that an LGBTQ person might experience, such as the difficulties of an FTM transgender person seeking routine gynecological care, or how a gay man might experience recovery from a heart attack, or how a bisexual person is perceived on a psychiatric unit, or how a lesbian seeking fertility treatments to conceive might face additional barriers to conception.

Gerontology modules might address health disparities and discuss how the LGBTQ elderly might be treated in institutional settings.

Sexual health units can include LGBTQ issues that extend beyond HIV and STIs. For example, discussing use of Viagra among gay and bisexual men, treatment of sexual dysfunction resulting from estrogen use in transgender women, or dealing with childhood sexual abuse experiences among lesbian and bisexual women.

Until health care training programs commit to inclusive and integrated educational models, there will continue to be a need for separate LGBTQ content. We would recommend that the best placement of the introductory information on LGBTQ issues is within an introduction to clinical care unit or a diversity course rather than the usual first (and often only) mention within human sexuality or ethics modules.

Support and advocacy

Finally, LGBTQ health care professionals need support in their local work environments and their professional organizations. This can include support groups within hospitals and schools, LGBTQ committees or social/political groups, and recognition. For example, some hospitals have LGBTQ Pride Days in June when Pride celebrations occur in most communities, or celebrate October 11, National Coming Out Day. Professional organizations need to take a stand for social justice and pass resolutions, form interest groups or task forces, and change their policies to be inclusive. LGBTQ health care providers can find support and advocacy in organizations such as the GLMA, a national agency for all LGBTQ health care professionals. We urge all health care professionals to force their mainstream professional organizations to be more inclusive, if they are not already.

From the Web site: www.glma.org: As the leading LGBT health advocacy organization in North America, the GLMA works to ensure that LGBT patients are treated competently and with respect in the health care system. It also fights discrimination against LGBT health care professionals, while providing them with a community for networking and mutual support.

Conclusions

LGBTQ health care professionals are still largely invisible in their places of employment, and LGBTQ health care issues are absent in the training of health care professionals. Minority stress stemming from fear of discrimination, harassment, or even loss of job may affect the health and well-being of employees and adversely affect their ability to be open and proud role models and resources in their work settings. This chapter has outlined some strategies for making the workplace and health care training more welcoming and inclusive of LGBTQ employees and patients.

Reflection Questions

Awareness

1. How many LGBTQ coworkers do you have in your work setting?

2. Are there some coworkers that you suspect, but do not know, are LGBTQ?

Sensitivity

1. If there are suspected, but not “out,” LGBTQ coworkers in your work setting, why do you think they have not come out? What is the climate like where you work?

Knowledge

1. Does your workplace have a nondiscrimination policy that includes sexual orientation? Gender identity?

2. Does your workplace provide health care coverage for domestic partners?

Chapter 10: Conclusions and a Call to Action

This book has summarized some of the important terms and concepts related to sexuality and gender identifications and outlined the potential role of minority stress in affecting access to health care, quality of health care, and development of physical and mental health problems. The book offers a starting point for understanding the health disparities experienced by many LGBTQ people, as well as describing the unwelcoming environment of many health care settings. The hostile climate in society as a whole and health care institutions in particular stem from historic prejudices that became imbedded in the very fabric of society, permeating the legal system, religion, education, medicine and health care policy and systems, and politics. Changing this environment means that dedicated people must work to change these systems, not just educate people about LGBTQ health care issues. The first section of this final chapter outlines the different levels of interventions needed to create a welcoming and inclusive environment.

A Levels Approach to Change

One way to consider how to implement the action steps needed to improve health care is to examine the interventions that need to be taken at different levels of the system, from the individual to the institutional to the larger societal level. These are outlined briefly in the following text. We expand on the individual-level interventions in the final section of this chapter.

Individual level

- Seek out continuing education/inclusive education about LGBTQ health care.

- Get experienced (ask your patients/clients about sexual and gender identities and their impact on health).

- Get to know your LGBTQ coworkers if you do not already know them.

- Use inclusive language.

- Study your own body language and evaluate your attitudes.

- Talk to LGBTQ community members and find out what issues affect your own region.

Institutional and community levels

- Encourage/initiate changes in policies and procedures, such as nondiscrimination policies, visiting hours, and definitions of family and relationships.

- Demand staff training at all levels that covers all types of diversity.

- If you have children, find out what they learn about LGBTQ people at school and other settings. Advocate for comprehensive sexuality education that includes LGBTQ issues. By doing this, you are positively impacting the future.

- Support education and dialogue about sexuality and gender in your larger community through social and political practices, such as urging your faith communities to be open and accepting, making your neighborhoods safe for LGBTQ people to live in, and fostering social justice in all aspects of community life.

Societal level

- Vote for politicians who support civil rights for LGBTQ (and all) people.

- Learn about legislation and national issues related to LGBTQ people.

- Join social justice movements or coalitions.

- Encourage state and national professional organizations to which you belong to be inclusive of LGBTQ people if they are not already.

Social justice change requires working at all three of these levels. It may be helpful to assess your own health care setting in terms of a continuum, from very rejecting and actively negative about LGBTQ people to one that embraces sexual and gender difference. Figure 10.1 outlines a continuum with five levels of environments. Which one best describes your workplace? Which one best describes the setting in which you receive health care? The final section outlines the steps that you as an individual can take to move your agency or institution up the continuum to welcoming and inclusive.

Figure 10.1 Levels of acceptance in health care environments.

The 10 Things Health Care Professionals Can Do

We would like to end the book with our top-10 list of things that health care professionals can do to improve the quality of care for their LGBTQ patients/clients. These 10 things are in no particular order. We offer them for readers who are ready to take action for social justice.

In spite of the lack of research in many areas and the gaps in knowledge that we have pointed out throughout the book, we know enough to start making changes in health care systems and individual health care professionals who begin the process of improving the quality of health care. We know about concepts of equity, respect, social justice, and human dignity and can build on those values that are already central to health care practice. There is a useful cultural model that focuses on awareness, sensitivity, and knowledge (Lipson & Dibble, 2005). Building on the knowledge and skills presented in this book, we offer an action plan, based on the top-10 things that health care providers can do to be culturally appropriate with their LGBTQ clients/patients.

Number 10: Understand the far-reaching effects of social stigma on LGBTQ people, their families, and communities

If nothing else, the content of this book should have resulted in greater awareness of the myriad ways that stigma impacts LGBTQ people, from lack of validation of relationships and families to employment discrimination to experiencing harassment and violence in public to being ignored or humiliated in health care settings. Stigma has affected access to health care because same-sex relationships are not legal in most locales, resulting in many partners not being covered by health insurance. In addition, many LGBTQ people experience discrimination, harassment, and invisibility in health care systems, and these experiences may lead them to delay or avoid mainstream health care systems. Stigma has also created minority stress, which contributes to the onset and maintenance of a wide variety of physical and mental health problems such as depression, anxiety disorders, substance abuse, cancers, and asthma. Stigma impacts the ways that health care professionals interact with LGBTQ clients and the likelihood that LGBTQ patients will feel safe to disclose their sexuality or gender identities. To reduce stigma, we first must make it visible and health care systems need to acknowledge it.

Action steps

1. Share this knowledge with others—coworkers, fellow students, family members, your children, etc. In other words, break the silence about sexuality and gender. You can start by saying, “I just read this book and learned…. Did you know that?”

2. Examine your own practice—do you unwittingly allow invisibility, harassment, or discrimination to occur unremarked? When you see the effects of stigma at work, name it as such. If you hear an anti-LGBTQ joke, tell others that it is offensive. When you see an LGBTQ coworker ignored or treated differently, speak up. When you treat LGBTQ patients who experience shame and guilt, help them to see that the stigma is not their fault. Show compassion to all of your patients in every way you can.

Number 9: Know inclusive language and how to use it in written and oral communications

Most of the forms and assessments used in health care settings render LGBTQ people invisible. Words have a great deal of power and being rendered invisible is alienating. Take a look at the language used in your setting, and also examine how comfortable you are with the language. Can you say “lesbian, gay, bisexual, and transgender” without feeling discomfort or being self-conscious? Are you comfortable asking patients/clients about their sexual identities and discussing their concerns about sexuality and gender? It may take practice for some health care professionals to include sexual histories as a natural part of the history-taking process. For those who are direct care providers, was it easy to ask about bowel habits at first? Most of what we do as health care professionals takes practice before we are comfortable and competent at it. Becoming comfortable talking to patients about sexuality will benefit all of your patients or clients and could improve communications within your own family and intimate relationships as well.

Action steps

1. Point out to administrators or coworkers if your forms are not inclusive, but do not wait for the forms to change—you can change your own language and oral communication immediately.

2. Volunteer to be on a committee or task force to recommend changes in official documents and forms.

3. Request training on LGBTQ issues and sexual history taking for all staff.

4. Make changes in your own individual history-taking or intake process to be inclusive if you are not already (e.g., use terms such as partner, ask about sexuality, and gender).

Number 8: Develop written policies that are inclusive of LGBTQs and their families

As we have seen, most LGBTQ relationships and families are not protected by existing laws, and LGBTQ families are often invisible in hospital and clinic policies and procedures. Examine your own work setting and determine whether there is equality for LGBTQ patients, clients, and staff members. The policies to examine include human rights or nondiscrimination policies, patient rights statements, definitions of family, visiting policies, and policies governing staff conduct. Employee partner benefits and staff training policies are also important.

Action steps

1. Point out to administrators or coworkers if your policies are not inclusive.

2. Volunteer to be on a committee or task force to recommend changes.

3. Learn about the laws in your own state and local region that address LGBTQ people, such as same-sex marriage, domestic partner registries, civil unions, adoption laws, employment nondiscrimination, and hate crimes. Remember that some of these policies may include sexual orientation but not gender identity. Policies need to include both sexuality and gender to be truly inclusive.

Number 7: Recognize the broad diversity and creativity of LGBT family structures

Examine how family is defined where you work, live, or receive your own health care. Why do we focus on legal relationships or blood to define family? Should not family be the people we care most about and want around us in the times of stress? The people who support us in making important decisions about our health? Examine the rationale for current policies, for example, why do so many settings limit visitors in EDs or intensive care units to legal spouses or blood relatives? Are not there many heterosexual individuals who rely on people other than those sanctioned individuals for their support? Making policies more inclusive could benefit more than just LGBTQ people.

Action steps

1. Advocate for the broadest possible definitions of family that allow patients/clients to choose who gets to be involved in health care decision making and who gets to visit and support them while hospitalized.

2. Respect and include families, whatever form they take, in the care of patients/clients.

3. Make sure that agency/institution documents, posters, flyers, brochures, and other written materials reflect the diversity of the families that the institution serves.

Number 6: Develop policies and procedures for how to deal with confidentiality issues and recording of information about sexuality and gender in patient records and for dealing with inappropriate comments in verbal communications among staff

We have seen that some LGBTQ people are afraid to disclose their sexual/gender identities to health care professionals. Are those fears valid in your work setting? What happens now when a patient is known to be LGBTQ? Is it recorded on his or her records without his or her consent? Do staff members gossip about the sexuality or gender identities of patients? If so, how do we convey to staff a professional procedure to protect client–patient confidentiality and to maintain patient’s dignity? What are the sanctions for unprofessional behavior?

Action steps

1. Make it policy to ask permission from patients to record sexual or gender identity on medical records.

2. Develop a code that allows you to remember this information from one visit to another for patients/clients who do not want the information on their records. Respect patients’ reasons for not disclosing whether you think the reason is valid or not. They are the only ones who can determine what is safe for them.

3. Develop employee policies that contain sanctions for breaking patient confidentiality.

4. Set a tone of professional conduct among staff members—be a role model for respecting the privacy and dignity of patients/clients.

Number 5: Recognize the legal issues: Have forms or information available for LGBTQ families for release of information, power of attorney for health care, guardianship, etc.

Because of the lack of legislation that protects LGBTQ relationships in many parts of the world, other legal documents are needed. Many LGBTQ people are unaware of these legal protections, or do not know how to go about accessing the forms. All health care settings should provide information about the legal documents needed to protect families without recourse to the benefits of marriage, in the same way that information is provided about living wills and organ donation. In some cases, LGBTQ people have produced legal documents such as power of attorney and they have not been honored. Staff members need training about these documents, and health care settings need a mechanism for recording that such documents exist. Finally, they must be honored in emergency situations. Chapter 8 contained detailed information about these legal issues.

Action steps

1. Inform yourself about the state and local laws related to power of attorney and guardianship in your region.

2. Keep copies of the relevant forms, or information about how to get these forms available, and ask every patient/client if he or she needs this information.

3. Have a designated place to keep copies of these documents or record that there are such documents.

Number 4: Know the potential consequences of stress related to stigma: Assess for substance abuse, including tobacco dependence, mental health problems, body image and weight issues, unsafe sexual practices, and domestic violence as well as physical health problems

We know that there are higher rates of most physical and mental health disorders in LGBTQ people, at least of the disorders that are influenced by stress. Stigma has enormous impact on individual’s lives. As a health care professional, you can educate your patients/clients about their risk factors. Many LGBTQ people do not recognize the impact of stress on their health—they have lived with the stress for so long that it has become “normal.” You can help them name the stress, learn more positive coping strategies, and recognize the role of minority stress to relieve individual self-blaming.

Action steps

1. Recognize that the higher rates of illness are due to stigma, not due to sexual or gender identity.

2. Help clients/patients understand this fact as well, so they do not blame themselves. Help them reduce internalized oppression if they suffer from it by treating them as worthy, unique individuals.

3. Share the information you learned in this book with coworkers, so they do not “blame the victim” and assume that health problems in LGBTQ people are due to their “lifestyles.”

Number 3: Celebrate the diversity of LGBTQ communities, based on differences in age, racial/ethnic identities, geography, immigration status, language, socioeconomic class, and education

LGBTQ people are as diverse in every way as any other client/patient. Some of their other identities may influence health as much or more than their sexual or gender identities, because minority stress can stem from the oppression based on race/ethnicity, social class, age, and other human differences, as well as from sexuality and gender variations. All health care professionals need reminders to resist stereotypical thinking, based on any of these characteristics, and examine social justice issues that occur in the workplace.

Action steps

1. Treat every patient/client as a unique individual and do not assume that you know anything about him or her on the basis of some visible presenting characteristic.

2. Make sure that assessments take into account patients/clients’ understandings of the role of their diverse identities in their illness or treatment needs. Listening to patients’ own cultural understandings of health and illness will lead to better treatment planning.

3. Seek out diversity training that considers the intersections of multiple oppressed identities rather than viewing each one separately.

4. Examine the power dynamics in your own workplace. Who has power and authority and who does not?

Number 2: Understand the effects of homophobia/biphobia/transphobia in the health care workplace setting for LGBTQ employees

We have described the far-reaching effects of stigma not only on patients and clients but also on LGBTQ health care professionals. As we have seen, many LGBTQ health care professionals are afraid to be “out” in their workplaces. They fear how they will be treated by coworkers as well as by patients/clients. How does oppression play out in your work setting? How ironic is it that settings that are supposed to be about “caring” and “healing” are so often among the most hostile and uncaring places where LGBTQ people may work?

Action steps

1. Examine employee policies. Do they prohibit discrimination on the basis of sexual orientation? How about gender identity? If they do not, advocate for policy change.

2. What about sexual harassment policies? Do they include sexual and gender identities?

3. What happens if someone does harass or mistreat an employee on the basis of sexual identity and gender identity? Are there any sanctions? If not, propose that there be consequences for acting in a discriminatory way.

4. Consider the overall climate. Even when inclusive policies are in place, are LGBTQ employees expected to be invisible? Are they treated differently? How could this climate be changed? You can start the change process by being a role model of acceptance and inclusivity.

Number 1: Reflect on what it might be like to be an LGBTQ patient in your health care setting—do you have realistic concerns about how an LGBTQ person might be treated? If they are not realistic, how can you convey to patients that your environment is safe?

This recommendation requires that you put yourself in the shoes of an LGBTQ patient in your work setting. How would you feel about the waiting or reception area, the pamphlets and the patient education materials, and the forms and the policies? Several of these action steps have focused on the policies and language in the written forms. What about the physical environment? Is it friendly and inclusive in the types of magazines, the patient education brochures or pamphlets, or the artwork on the walls? What about the staff members with whom a patient/client had first encounter? Have they had diversity training? How can you make it feel safe and welcoming to as many patients/clients as possible? Your health care setting exists within a larger community, and many communities have some LGBTQ resources that health care agencies have not utilized. What resources does the local community have for LGBTQ people? Are there LGBTQ social service or political organizations and social outlets? Are there community activists who could help your setting become more inclusive and welcoming? Sometimes health care institutions have “bad” reputations in LGBTQ communities and do not even know it. The reputation could stem from one incident years before and could be improved by even a small outreach to the LGBTQ community.

Action steps

1. If it is hard for you to put yourself in the place of an LGBTQ patient, ask someone from the LGBTQ community to do a “walk-through” or review policies, procedures, and climate issues with you and your coworkers. Even if you are LGBTQ yourself, it may be hard to see your own workplace objectively.

2. Conduct a needs assessment of the local LGBTQ community to find out the reputation of your setting and identify strengths and weaknesses of your setting.

3. Identify LGBTQ-specific materials to place strategically in the setting—these could include local or national LGBTQ newsletters or magazines, health education pamphlets, and/or books that depict LGBTQ families.

4. Advertise in LGBTQ community newspapers or at LGBTQ centers or social institutions.

Conclusions

We hope that this book has been helpful to you personally and will serve as a resource to you. We have tried to balance information with thought-provoking questions and real-life stories to facilitate the learning. Knowledge and attitudes are one component of change, but real change also requires action. This final chapter, in particular, has outlined a number of steps that you can take as an individual to improve the climate in health care settings, and society as a whole, for LGBTQ people. There are numerous other resources that you can access to continue the process of being an inclusive and welcoming provider of health care services, including books, Web sites, and organizations. We offer many of these resources in the appendix. We invite you to continue on this path of social justice and leave you with these final words.

Never doubt that a small group of thoughtful, committed citizens can change the world.

Indeed, it is the only thing that ever has.

Margaret Mead

References

Aaron, D., Markovic, N., Danielson, M., Honnold, J., Janosky, J., & Schmidt, N. (2001). Behavioral risk factors for disease and preventive health practices among lesbians. American Journal of Public Health, 91, 972–975.

Adams, B. D. (1987). The rise of a gay and lesbian movement. Boston: G.K. Hall.

Amadio, D. (2006). Internalized heterosexism, alcohol use, and alcohol-related problems among lesbians and gay men. Addictive Behavior, 31(7), 1153–1162.

American Cancer Society. (2004). Cancer facts and figures. Retrieved Month XX, XXXX, from www.acs.org

American Civil Liberties Union. (2000). Statement on defending free speech of unpopular organizations. New York: Author.

American Civil Liberties Union Foundation Lesbian and Gay Rights Project. (2002). Too high a price: The case against restricting gay parenting. New York: American Civil Liberties Union.

American Psychiatric Association. (1973). Position statement on homosexuality and civil rights. Approved December.

American Psychiatric Association. (1998). Position statement on psychiatric treatment and sexual orientation. American Journal of Psychiatry, 156, 1131.

American Psychiatric Association. (2000, May). Therapies focused on attempts to change sexual orientation (reparative or conversion therapies). Position paper approved.

American Psychological Association. (2004). http://www.apahelpcenter.org/articles/article.php?id=31

American Psychological Association. (2005). Lesbian & gay parenting. Washington, DC: Author. Retrieved Month XX, XXXX, from www.apa.org/pi/lgbc/

Appelbaum, J. (2007). Late adulthood and aging: Clinical approaches. In H. J. Makadon, K. H. Mayer, J. Potter & H. Goldhammer (Eds.), The Fenway guide to lesbian, gay, bisexual, and transgender health (pp. 135–158). Philadelphia: American College of Physicians Press.

Ash, M. A., & Badgett, M. V. L. (2006). Separate and unequal: The effect of unequal access to employment-based health insurance on same-sex and unmarried different-sex couples. Contemporary Economic Policy, 24(4), 582–599.

Austin, S. B., Ziyadeh, N., Fisher, L. B., Kahn, J. A., Colditz, G. A., & Frazier, A. L. (2004). Sexual orientation and tobacco use in a cohort study of US adolescent girls and boys. Archives of Pediatric and Adolescent Medicine, 158(4), 317–322.

Austin, S. B., Ziyadeh, N., Kahn, J. A., Camargo, C. A., Jr., Colditz, G. A., & Field, A. E. (2004). Sexual orientation, weight concerns, and eating-disordered behaviors in adolescent girls and boys. Journal of the American Academy of Child & Adolescent Psychiatry, 43(9), 1115–1123.

Badgett, M. V. L. (1996). Choices and chances: Is coming out at work a rational choice? In B. Beemyn & M. J. Eliason (Eds.), Queer studies: An LGBT anthology (pp. 298–308). New York: NYU Press.

Badgett, M. V. L. (1997). Beyond biased samples: Challenging the myths on the economic status of lesbians and gay men. In A. Gluckman & B. Reed (Eds.), Homo economics: Capitalism, community, and lesbian and gay life (pp. 65–71). New York: Routledge.

Badgett, M. V. L., & Williams, C. R. (1992). The economics of sexual orientation. Feminist Studies, 18(3), 649–658.

Baetens, P., Camus, M., & Devroey, P. (2003). Counseling lesbian couples: Requests for donor insemination on social grounds. Reproductive Biomedicine Online, 6(1), 75–83.

Bailey, J. V., Farquhar, C., Owen, C., & Mangtani, P. (2004). Sexually transmitted infections in women who have sex with women. Sexually Transmitted Infections, 80(3), 244–246.

Bailey, J. M., Kim, P. Y., Hills, A., & Linsenmeier, J. A. (1997). Butch, femme, or straight acting? Partner preferences of gay men and lesbians. Journal of Personality and Social Psychology, 73(5), 960–973.

Bakker, F. C., Sandfort, T. G. M., Wanwesenbeeck, I., van Lindert, H., & Westert, G. P. (2006). Do homosexual persons use health care services more frequently than heterosexual persons: Findings from a Dutch population study. Social Science and Medicine, 63, 2022–2030.

Bakker, F. C., van Kesteren, P. J., Gooren, L. J. G., & Bezemer, P. D. (1993). The prevalence of transsexualism in the Netherlands. Acta Psychiatrica Scandinavica, 87, 237–238.

Balsam, K. F., Beauchaine, T. P., Mickey, R. M., & Rothblum, E. D. (2005). Mental health of lesbian, gay, bisexual, and heterosexual siblings: Effects of gender, sexual orientation, and family. Journal of Abnormal Psychology, 114(3), 471–476.

Balsam, K. F., Huang, B., Fieland, K. C., Simoni, J. M., & Walters, K. L. (2004). Culture, trauma, and wellness: A comparison of heterosexual and lesbian, gay bisexual, and two-spirit Native Americans. Cultural Diversity and Ethnic Minority Psychology, 10(3), 287–301.

Balsam, K. F., & Mohr, J. J. (2007). Adaptation to sexual orientation stigma: A comparison of bisexual and lesbian/gay adults. Journal of Consulting Psychology, 54(3), 306–319.

Balsam, K. F., Rothblum, E. D., & Beauchaine, T. P. (2005). Victimization over the life span: A comparison of lesbian, gay, bisexual, and heterosexual siblings. Journal of Consulting and Clinical Psychology, 73(3), 477–487.

Barbara, A. M., Quandt, S. A., & Anderson, R. (2001). Experiences of lesbians in the health care environment. Women and Health, 34(1), 45–61.

Basson, R., & Schultz, W. W. (2007). Sexual sequelae of general medical disorders. The Lancet, 369(9559), 409–424.

Battle, J., & Crum, M. (2007). Black LGB health and wellbeing. In I. H. Meyer & M. Northridge (Eds.). The health of sexual minorities: Public health perspectives on lesbian, gay, bisexual, and transgender populations (pp. 320–352). New York: Springer.

Beehler, G. P. (2001). Confronting the culture of medicine: Gay men’s experiences with primary care physicians. Journal of the Gay and Lesbian Medical Association, 5, 135–141.

Ben-Ari, A. (1995). The discovery that an offspring is gay: Parents’, gay men’s, and lesbians’ perspectives. Journal of Homosexuality, 30(1), 89–112.

Berberet, H. M. (2006). Putting the pieces together for queer youth: A model of integrated assessment of need and program planning. Child Welfare, 85(2), 361–384.

Beren, S. E., Hayden, H. A., Wilfley, D. E., & Grilo, C. M. (1996). The influence of sexual orientation on body dissatisfaction in adult men and women. International Journal of Eating Disorders, 20(2), 135–141.

Binson, D., Michaels, S., Stall, R., & Coates, T. J. (1995). Prevalence and social distribution of men who have sex with men: United States and its urban centers. Journal of Sex Research, 32, 245–254.

Bitzer, J., Platano, G., Tschudin, S., & Alder, J. (2007). Sexual counseling for women in the context of physical diseases: A teaching model for physicians. International Society for Sexual Medicine, 4, 29–37.

Black, D., Gates, G., Sanders, S., & Taylor, L. (2000). Demographics of the gay and lesbian population in the United States: Evidence from available systematic data sources. Demography, 37(2), 139–154.

Blackwell, C. (2006). Registered nurses’ attitudes toward the protection of gays and lesbians in the workplace: An examination of homophobia and discriminatory beliefs. Paper presented at the Gay and Lesbian Medical Association Annual Conference, San Francisco.

Blank, T. O. (2005). Gay men and prostate cancer: Invisible diversity. Journal of Clinical Oncology, 23(12), 2593–2596.

Bliss, G. K., & Harris, M. B. (1999). Teachers’ views of students with gay or lesbian parents. Journal of Gay, Lesbian, and Bisexual Identity, 4(2), 149–171.

Bloomfield, K. (1993). A comparison of alcohol consumption between lesbians and heterosexual women in an urban population. Drug and Alcohol Dependence, 33(3), 257–269.

Blumstein, P., & Schartz, P. (1983). The American couple. New York: Simon and Schuster.

Boatwright, K. J., Gilbert, M. S., Forrest, L., & Ketzenberger, K. L. (1996). Impact of identity development upon career trajectory: Listening to the voices of lesbians. Journal of Vocational Behavior, 48, 210–228.

Boehmer, U., & Case, P. (2004). Physicians don’t ask, sometimes patients tell: Disclosure of sexual orientation among women with breast carcinoma. Cancer, 101, 1882–1889.

Bornstein, D. R., Fawcett, J., Sullivan, M., Senturia, K. D., & Shiu-Thornton, S. (2006). Understanding the experiences of lesbian, bisexual and trans survivors of domestic violence: A qualitative study. Journal of Homosexuality, 51(1), 159–181.

Bos H. M., van Balen F., & van den Boom, D. C. (2005). Lesbian families and family functioning: An overview. Patient Education and Counseling, 59(3), 263–275.

Bos, H. M., van Balen, F., & van den Boom, D. C. (2007). Child adjustment and parenting in planned lesbian-parent families. American Journal of Orthopsychiatry, 77(1), 38–48.

Bowen, D. J., Bradford, J. B., Powers, D., McMorrow, P., Linde, R., Murphy, B.C., et al. (2004). Comparing women of differing sexual orientations using population-based sampling. Women’s Health, 40(3), 19–34.

Bowleg, L., Craig, M. L., & Burkholder, G. (2004). Rising and surviving: A conceptual model of active coping among Black lesbians. Cultural Diversity and Ethnic Minority Psychology, 10(3), 229–240.

Bradford, J. B., Ryan, C., & Rothblum, E. D. (1994). National Lesbian Health Care Survey: Implications for mental health care. Journal of Consulting and Clinical Psychology, 62(2), 228–242.

Brand, P., Rothblum, E. D., & Solomon, L. J (1992). A comparison of lesbians, gay men, and heterosexuals on weight and restrained eating. International Journal of Eating Disorders, 11(3), 253–259.

Brogan, D. J., Frank, E., Elon, L., Silvanesan, S., & O’Hanlan, K. A. (1999). Harassment of lesbians as medical students and physicians. JAMA, 282, 1290–1292.

Brogan, D. J., O’Hanlan, K. A., Elon, L., & Frank, E. (2003). Health and professional characteristics of lesbian and heterosexual women physicians. Journal of the American Medical Women’s Association, 58(1), 10–19.

Brotman, S., Ryan, B., & Cormier, R. (2003). The health and social service needs of gay and lesbian elders and their families in Canada. Gerontologist, 43(2), 192–202.

Burke, L., & Follingstad, D. (1999). Violence in lesbian and gay relationships. Clinical Psychology Review, 19(5), 487–512.

Burn, S. M., Kadlec, K., & Rexer, R. (2005). Effects of subtle heterosexism on gay, lesbians, bisexuals. Journal of Homosexuality, 49(2), 23–38.

Bye, L., Gruskin, E., Greenwood, G., Albright, V., & Krotski, K. (2005). California lesbians, gays, bisexuals, and transgender (LGBT) tobacco use survey–2004. Sacramento: California Department of Health Services.

Byne, W. (2007). Biology and sexual minority status. In I. Meyer & M. Northridge (Eds.), The health of sexual minorities (pp. 65–90). New York: Springer Science.

Carlat, D. J., Camargo, C. A., Jr., & Herzog, D. B. (1997). Eating disorders in males: A report on 135 patients. American Journal of Psychiatry, 154(8), 1127–1132.

Case, P., Austin, S. B., Hunter, D. J., Manson, J. E., Malspeis, S., Willett, W. C., et al. (2004). Sexual orientation, health risk factors, and physical functioning in the Nurses’ Health Study II. Journal of Women’s Health, 13(9), 1033–1047.

Cass, V. (1979). Homosexual identity formation: A theoretical model. Journal of Homosexuality, 4, 219–236.

Catalan, J., & Meadows, J. (2000). Sexual dysfunction in gay and bisexual men with HIV infection: Evaluation, treatment and implications. AIDS Care, 12(3), 279–286.

Catania, J. A., Osmond, D., Stall, R. D., Pollack, L., Paul, J. P., Blower, S., et

al. (2001). The continuing HIV epidemic among men who have sex with men. American Journal of Public Health, 91(6), 907–914.

Centers for Disease Control and Prevention. (2006). Surveillance report: Cases of HIV infection and AIDS in the U.S. and dependent areas. Atlanta, GA: Author.

Centers for Disease Control and Prevention. (2007). HIV/AIDS among men who have sex with men. Retrieved Month XX, XXXX, from http://www.cdc.gov/hiv/topics/msm/resources/factsheets/msm.htm

Chng, C. L., Wong, F. Y., Park, R. J., Edberg, M. C., & Lai, D. S. (2003). A model for understanding sexual health among Asian American/Pacific Islander MSM in the United States. AIDS Education and Prevention, 15(Suppl. 1), 21–38.

Ciano-Boyce, C., & Shelley-Sireci, L. (2002). Who is mommy tonight? Lesbian parenting issues. Journal of Homosexuality, 43(2), 1–13.

Claes, J. A., & Moore W. (2000). Issues confronting lesbian and gay elders: The challenge for health and human services providers. Journal of Health and Human Services Administration, 23(2), 181–202.

Clarke, V., Kitzinger, C., & Potter, J. (2004). ‘Kids are just cruel anyway’: Lesbian and gay parents’ talk about homophobic bullying. British Journal of Social Psychology, 43(Pt. 4), 531–550.

Clatts, M. C., Goldsamt, L. A., & Yi, H. (2005). An emerging HIV risk environment: A preliminary epidemiological profile of an MSM POZ Party in New York City. Sexually Transmitted Infections, 81(5), 373–376.

Clements-Nolle, K., Marx, R., Guzman, R., & Katz, M. (2001). HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons. American Journal of Public Health, 91, 915–921.

Coates, T. (2004). Depression, gay men, and HIV acquisition. Focus, 19(10), 5–6.

Cochran, B. N., & Cauce, A. M. (2006). Characteristics of lesbian, gay, bisexual, and transgender individuals entering substance abuse treatment. Journal of Substance Abuse Treatment, 30(2), 135–146.

Cochran, B. N., Peavy, K. M., & Cauce, A. M. (2007). Substance abuse treatment providers’ explicit and implicit attitudes regarding sexual minorities. Journal of Homosexuality, 53(3), 181–207.

Cochran, S. D., & Mays, V. M. (1994). Depressive distress among homosexually active African American men and women. American Journal of Psychiatry, 151(4), 524–529.

Cochran, S. D., & Mays V. M. (2000a). Lifetime prevalence of suicide symptoms and affective disorders among men reporting same-sex sexual partners: Results from NHANES III. Journal of Consulting and Clinical Psychology, 90(4), 573–578.

Cochran, S. D., & Mays, V. M. (2000b). Relation between psychiatric syndromes and behaviorally defined sexual orientation in a sample of the US population. American Journal of Epidemiology, 151(5), 516–523.

Cochran, S. D., & Mays, V. M. (2007). Physical health complaints among lesbians, gay men, and bisexual and homosexually experienced heterosexual individuals: Results from the California Quality of Life Study. American Journal of Public Health, 97(6), 10.2105/AJPH,2006.087254.

Cochran, S. D., Mays, V. M., Alegria, M., Ortega, A. N., & Takeuchi, D. (2007). Mental health and substance use disorders among Latino and Asian American lesbian, gay, and bisexual adults. Journal of Consulting and Clinical Psychology, 75(5), 785–794.

Cochran, S. D., Mays, V. M., Bowen, D., Gage, S., Bybee, D., Roberts, S. J., et al. (2001). Cancer-related risk indicators and preventive screening behaviors among lesbians and bisexual women. American Journal of Public Health, 91(4), 591–597.

Cochran, S. D., Sullivan, J. G., & Mays, V. M. (2003). Prevalence of mental disorders, psychological distress, and mental health services use among lesbian, gay, and bisexual adults in the United States. Journal of Consulting and Clinical Psychology, 71 (1), 53–61.

Cohen, L., de Ruiter, C., Ringelberg, H., & Cohen-Kettenis, P. T. (1997). Psychological functioning of adolescent transsexuals: Personality and psychopathology. Journal of Clinical Psychology, 53(2), 187–196.

Cohen, L. J., & Galynker, I. I. (2002). Clinical features of pedophilia and implications for treatment. Journal of Psychiatric Practice, 8(5), 276–289.

Colapinto, J. (2000). As nature made him: The boy who was raised as a girl. New York: HarperCollins.

Cole, C. M., O’Boyle, M., Emory, L. E., & Meyer, W. J. (1997). Comorbidity of gender dysphoria and other major psychiatric diagnoses. Archives of Sexual Behavior, 26(1), 13–26.

Coleman, E., & Rosser, B. R. S. (1996). Gay and bisexual male sexuality. In R. Cabaj & T. Stein (Eds.), Textbook of homosexuality and mental health (pp. 707–722). Washington, DC: APA Press.

Cook, D. J., Griffith, L. E., Cohen, M., Guyatt, C. H., & O’Brien, B. (1995). Discrimination and abuse experienced by general internists in Canada. Journal of General Internal Medicine, 10, 565–572.

Cook-Daniels, L. (2006). Trans aging. In D. Kimmel, T. Rose, & S. David (Eds.), Lesbian, gay, bisexual, and transgender aging: Research and clinical perspectives (pp. 20–35). New York: Columbia University Press.

Corliss, H. L., Shankle, M. D., & Moyer, M. B. (2007). Research, curricula, and resources related to lesbian, gay, bisexual, and transgender health in US schools of public health. American Journal of Public Health, 97(6), 1023–1027.

Crosby, G. M., Stall, R. D., Paul, J. P., & Barrett, D. C. (1998). Alcohol and drug use patterns have declined between generations of younger gay-bisexual men in San Francisco. Drug and Alcohol Dependence, 52, 177–182.

Cupolo, A., Corbett, K., & Lewis, V. (1982). No more stares. Berkeley, CA: Disability Rights Education and Defense Fund, Inc.

Darragh, T. M., & Winkler, B. (2004). The ABCs of anal–rectal cytology. College of American Pathologists. Retrieved February, 16, 2008, from http://www.cap.org/apps/docs/cap_today-pap_ngc/NGC_analrectalcyto.html

D’Augelli, A. R. (2006a). Coming out, visibility, and creating change: Empowering lesbian, gay and bisexual people in a rural university community. American Journal of Community Psychology, 37(3/4), 203–210.

D’Augelli, A. R. (2006b). Developmental and contextual factors and mental health among LGB youths. In A. Omoto & H. Kurtzman (Eds.), Sexual orientation and mental health (pp. 37–53). Washington, DC: APA Press.

D’Augelli, A. R., & Grossman, A. (2001). Sexual orientation victimization of lesbian, gay, and bisexual youth. Paper presented at American Psychological Association, San Francisco.

D’Augelli, A. R., Hershberger, S. L., & Pilkington, N. W. (1998). Lesbian, gay, and bisexual youth and their families: Disclosure of sexual orientation and its consequences. American Journal of Orthopsychiatry, 68(3), 361–371; discussion 365–372.

Dean, L., Meyer, I., Robinson, K., et al. (2000). Lesbian, gay, bisexual, and transgender health: Findings and concerns. Journal of the Gay and Lesbian Medical Association, 4(3), 101–151.

Deevey, S. (1993). Lesbian self-disclosure: Strategies for success. Journal of Psychosocial Nursing and Mental Health Services, 31(4), 21–26.

DeJoseph, J., Dibble, S. L., Chinn, P., & Eliason, M. J. (xxxx). Survey of LGBT nurses: Workplace issues. San Francisco: Gay and Lesbian Medical Association. Manuscript in preparation.

DeMino, K. A., Appleby, G., & Fisk, D. (2007). Lesbian mothers with planned families: A comparative study of internalized homophobia and social support. American Journal of Orthopsychiatry, 77(1), 165–173.

Department of Defense. (2000). Report on the military environment with respect to the homosexual conduct policy. Arlington,VA: Author.

Devor, A. H. (2004). Witnessing and mirroring: A fourteen stage model of transgender identity formation. Journal of Gay and Lesbian Psychiatry, 8(1/2), 41–67.

Diamant, A. L., Schuster, M. A., & Lever, J. (2000). Receipt of preventive health care services by lesbians. American Journal of Preventative Medicine, 19(3), 141–148.

Diamond, L. (2002). “Having a girlfriend without knowing it”: The relationships of adolescent lesbian and bisexual women. Journal of Lesbian Studies, 6, 5–16.

Diamond, L. (2003). What does sexual orientation orient? A biobehavioral model distinguishing romantic love and sexual desire. Psychological Review, 110, 173–192.

Diamond, L. (2005). A new view of lesbian subtypes: Stable vs fluid identity trajectories over an eight-year period. Psychology of Women Quarterly, 29, 119–128.

Diamond, L. (2006). What we got wrong about sexual identity development: Unexpected findings from a longitudinal study of young women. In A. Omoto & H. Kurtzmann (Eds.), Sexual orientation and mental health: Examining identity and development in LGB people (pp. 73–94). Washington, DC: APA Press.

Diaz, R. M. (1998). Latino gay men and HIV: Culture, sexuality, and risk behavior. New York: Routledge.

Diaz, R. M., & Ayala, G. (2001). Social discrimination and health outcomes: The case of Latino gay men and HIV risk. New York: National Gay and Lesbian Task Force, Policy Institute.

Diaz, R. M., Heckert, A. L., & Sanchez, J. (2005). Reasons for stimulant use among Latino gay men in San Francisco: A comparison between methamphetamine and cocaine users. Journal of Urban Health, 82(1, Suppl. 1), i71–i78.

Dibble, S., Eliason, M. J., & Christiansen, M. (2008). Chronic illness care for lesbian, gay, and bisexual individuals. Nursing Clinics of North America, 42, 655–674.

Dibble, S. L., Roberts, S. A., & Nussey, B. (2004). Breast cancer risk profiles between lesbians and their heterosexual sisters. Women’s Health Issues, 14, 60–68.

Dibble, S. L., Roberts, S. A., Robertson, P. A., & Paul, S. M. (2002). Risk factors for ovarian cancer: Lesbian and heterosexual women. Oncology Nursing Forum, 29(1), E1–E7.

Dibble, S. L., Vanoni, J. M., & Miaskowski, C. (1997). Women’s attitudes toward breast cancer screening procedures: Differences by ethnicity. Women’s Health Issues, 7(1), 47–54.

Dilley, J. A., Maher, J. E., Boysun, M. J., Pizacani, B. A., Mosbaek, C. H., Rohde, K., et al. (2005). Response letter to: Tang H, Greenwood GL, Cowling DW, Lloyd JC, Roeseler AG, Bal DG. Cigarette smoking among lesbians, gays, and bisexuals: How serious a problem? Cancer Causes and Control, 16(9), 1133–1134.

Dinkel, S., Patzel, B., McGuire, M. J., Rolfs, E., & Purcell, K. (2007). Measures of homophobia among nursing students and faculty: A midwestern perspective. International Journal of Nursing Education Scholarship, 4, Epub, November 30, 2007.

Division 44 Committee on LGB Concerns. (2000). Guidelines for psychotherapy with LGB clients. Washington, DC: American Psychological Association.

Dolan, K. A., (2005). Lesbian women and sexual health: The social construction of risk and susceptibility. New York: Haworth.

Donovan, T. (2001). Being transgender and older: A first person account. In D. C. Kimmel & D. L. Martin (Eds.), Midlife and aging in gay America (pp. 19–22). New York: Haworth Press.

Dowd, S. A. (1994). African American gay men and HIV and AIDS. In S. Caldwell, R. Burnham & M. Forstein (Eds.), Therapists on the frontline: Psychotherapy with gay men in the age of AIDS (pp. 319–338). Washington, DC: American Psychiatric Press.

Downs A. C., & James S. E. (2006). Gay, lesbian, and bisexual foster parents: Strengths and challenges for the child welfare system. Child Welfare, 85(2), 281–298.

Drabble, L., & Trocki, K. (2005). Alcohol consumption, alcohol-related problems, and other substance use among lesbian and bisexual women. Journal of Lesbian Studies, 9(3), 19–30.

Druzin, P., Shrier, I., Yacowar, M., & Rossignol, M. (1998). Discrimination against gay, lesbian and bisexual family physicians by patients. Canadian Medical Association Journal, 158(5), 593–597.

Dykes, B. (2000). Problems with defining cross-cultural ‘kinds of homosexuality” and a solution. Journal of Homosexuality, 38(3), 1–18.

Eagly, A., Diekman, A., Johannesen-Schmidt, M., & Koenig, A. (2004). Gender gaps in sociopolitical analysis. Journal of Personality and Social Psychology, 87, 796–816.

Eisenberg, M. E., & Resnick M. D. (2006). Suicidality among gay, lesbian and bisexual youth: The role of protective factors. Child Welfare, 85(2), 299–316.

Elia, J. P. & Eliason, M. J. (in press). Discourses of exclusion. Journal of LGBT Youth.

Eliason, M. J. (1995). Accounts of sexual identity formation in heterosexual students. Sex Roles, 32, 821–834.

Eliason, M. J. (1996a). An inclusive model of lesbian identity. Journal of Gay, Lesbian, and Bisexual Identity, 1(1), 3–19.

Eliason, M. J. (1996b). Identity formation for lesbian, bisexual, and gay persons: Beyond a minoritizing view. Journal of Homosexuality, 30(3), 35–62.

Eliason, M. J. (1996c). Who cares: Institutional barriers to health care for lesbian, gay, and bisexual people. New York: National League for Nursing Press. Pub. No. 14-6762.

Eliason, M. J. (1997). The prevalence and nature of biphobia in heterosexual undergraduate students. Archives of Sexual Behavior, 26(3), 317–326.

Eliason, M. J. (1998). Correlates of prejudice in nursing students. Journal of Nursing Education, 37(1), 27–29.

Eliason, M. J. (2000). Substance abuse counselors’ attitudes about lesbian, gay, bisexual, and transgendered clients. Journal of Substance Abuse, 12, 311–328.

Eliason, M. J., Donelan, C., & Randall, C. E. (1992). Lesbian stereotypes. Health Care for Women International, 13, 131–143.

Eliason, M. J., & Hughes, T. L. (2004). Substance abuse counselor’s attitudes about lesbian, gay, bisexual, and transgender clients: Urban versus rural counselors. Substance Use and Misuse, 39(4), 625–644.

Eliason, M. J., & Raheim, S. (1996). Categorical measurement of attitudes toward lesbian, gay, and bisexual people. Journal of Gay and Lesbian Social Services, 4(3), 51–65.

Eliason, M. J., & Raheim, S. (2000). Experience and level of comfort with culturally diverse groups. Journal of Nursing Education, 39(4), 161–165.

Eliason, M. J., & Randall, C. E. (1991). Lesbian phobia in nursing students. Western Journal of Nursing Research, 13, 365–376.

Eliason, M. J., & Schope, R. (2001). Does “Don’t Ask, Don’t Tell” apply to health care? Lesbian, gay, and bisexual people’s disclosure to health care providers. Journal of the Gay and Lesbian Medical Association, 5(4), 125–134.

Eliason, M. J., & Schope, R. (2007). Shifting sands or solid foundation: Lesbian, gay, bisexual, and transgender identity formation. In I. H. Meyer & M. Northridge (Eds.), The health of sexual minorities (pp. 3–26). New York: Springer Science.

Eliason, M. J., & Worthington, L. (2004). Smoking and alcohol/drug use in participants at a Smoke-Free gay pride celebration. Unpublished manuscript. San Francisco: San Francisco State University Department of Health Education.

Elze, D. (2002). Against all odds: The dating experiences of adolescent lesbian and bisexual women. Journal of Lesbian Studies, 6(1), 17–29.

Engels, E. A. (2007). Infectious agents as causes of non-Hodgkin lymphoma. Cancer Epidemiology Biomarkers Prevention. Retrieved from http://cebp.aacrjournals.org/cgi/rapidpdf/1055-9965.EPI-06-1056v1.pdf

Epstein, R. (2002). Butches with babies: Reconfiguring gender and motherhood. Journal of Lesbian Studies, 6(2), 41–57.

Erhardt, V. (2007). Head over heels: Wives who stay with cross-dressers and transsexuals. New York: Haworth.

Ettner, R. (1996). Confessions of a gender defender: A psychologist’s reflections on life among the transgendered. Evanston, IL: Chicago Spectrum Press.

Erzen, T. (2006). Straight to Jesus: Sexual and Christian conversions in the ex-gay movement. Berkeley: University of California Press.

Faderman, L. (1991). Odd girls and twilight lovers: A history of lesbian life in twentieth century America. New York: Penguin.

Fausto-Sterling, A. (1993, March 12). The five sexes: Why male and female are not enough. New York Times. .pp. Op-ed.

Fausto-Sterling, A., (2000). Sexing the body: Gender politics and the construction of human sexuality. New York: Basic Books.

Fenway Community Health Center. (2001). Fact Sheet: Survivors of anti-LGBT violence, common reactions. Boston: Author.

Fergusson D. M., Horwood, J., Ridder, E. M., & Beautrais, A. L. (2005). Sexual orientation and mental health in a birth cohort of young adults. Psychological Medicine, 35, 971–981.

Fieland, K., Walters, K., & Simoni, J. (2007). Determinants of health among two-spirit American Indians and Alaska Natives. In I. H. Meyer & M. Northridge (Eds.), The health of sexual minorities: Public health perspectives on lesbian, gay, bisexual, and transgender populations (pp. 268–300). New York: Springer.

Floyd, F. J., & Bakeman, R. (2006). Coming-out across the life course: Implications of age and historical context. Archives of Sexual Behavior, 35(3), 287–296.

Fox, R. C. (1995). Bisexual identities. In A. R. D’Augelli & C. J. Patterson (Eds.), Lesbian, gay, and bisexual identities over the lifespan: Psychological perspectives (pp. 48–86). New York: Oxford University Press.

Fox, R. C. (2007). Gay grows up: An interpretive study on aging metaphors and queer identity. Journal of Homosexuality, 52(3/4), 33–61.

French, S. A., Story, M., Remafedi, G., Resnick, M. D., & Blum, R. W. (1996). Sexual orientation and prevalence of body dissatisfaction and eating disordered behaviors: A population-based study of adolescents. International Journal of Eating Disorders, 19(2), 119–126.

Friedman, M. S., Koeskey, G. F., Silvestre, A. J., Korr, W. S., & Sites, E. W. (2006). The impact of gender-role nonconforming behavior, bullying, and social support on suicidality among gay male youth. Journal of Adolescent Health, 38, 621–623.

Friedman, M. S., Marshal, M. P., Stall, R., Cheong, J. W, & Wright, E. R. (2007). Gay-related development, early abuse and adult health outcomes among gay males, AIDS Behavior, DOI: 10.1007/s10461-007-9319-3.

Frisch, M., Smith, E., Grulich, A., & Johansen, C. (2003). Cancer in a population-based cohort of men and women in registered homosexual partnerships. American Journal of Epidemiology, 157, 966–972.

Gage-Davidson, M. (2000). Religion and spirituality. In R. Perez, K. DeBord, & K. Bieschke (Eds.), Handbook of counseling and psychotherapy with LGB clients (pp. 409–433). Washington, DC: APA Press.

Garofalo, R., & Bush, S. (2007). Addressing LGBTQ youth in the clinical settings. In H. J. Makadon, K. H. Mayer, J. Potter, & H. Goldhammer (Eds.), The Fenway guide to lesbian, gay, bisexual, and transgender health (pp. 75–99). Philadelphia: American College of Physicians Press.

Garofalo, R., Mustanski, B. S., McKirnan, D., Herrick, A., & Donenberg, G. (2007). Methamphetamine and young men who have sex with men. Archives of Pediatric and Adolescent Medicine, 161, 591–586.

Gartrell, N., Banks, A., Reed, N., Hamilton, J., Rodas, C., & Deck, A. (2000). The National Lesbian Family Study: 3. Interviews with mothers of five-year-olds. American Journal of Orthopsychiatry, 70, 542–548.

Gartrell, N., Deck, A., Rodas, C., Peyser, H., & Banks, A. (2005). The national lesbian family study: 4. Interviews with the 10-year-old children. American Journal of Orthopsychiatry, 75(4), 518–524.

Gay and Lesbian Alliance against Anti-Defamation. (1994). GLAAD/USA Position Statement Regarding NAMBLA. Approved February.

Gay and Lesbian Medical Association and Human Rights Campaign Foundation. (2008). Healthcare equality index: Creating a national standard for equal treatment of gay, lesbian, bisexual, and transgender patients and their families. San Francisco: GLMA.

Gay, Lesbian, Straight Education Network. (2006). GLSEN 2005 school climate report. New York.

Geddes, V. (1994). Lesbian expectations and experiences with family doctors. Canadian Family Physician, 40, 908–920.

Giddings, L. S. (2005). Health disparities, social injustice, and the culture of nursing. Nursing Research, 54(5), 304–312.

Giddings, L. S., & Smith, M. C. (2001). Stories of lesbian in/visibility in nursing. Nursing Outlook, 49, 14–19.

Gilman, S. E., Cochran, S. D., Mays, V. M., Hughes, M., Ostrow, D., & Kessler, R. C. (2001). Risk of psychiatric disorders among individuals reporting same-sex partners in the National Comorbidity Survey. American Journal of Public Health, 91, 933–939.

Goffman, E. (1963). Notes on the management of spoiled identity. Englewood Cliffs, NJ: Prentice-Hall.

Goldstone, S. (1999). Anal dysplasia in men who have sex with men. AIDS Read, 9(3), 204–208, 220.

Gomez, C., & Marin, B. V. (1996). Barriers to HIV prevention strategies for women. Journal of Sex Research, 33, 355–362.

Gorman, E. M. (1997). A special window: An anthropological perspective on spirituality and religious thought. In G. D. Comstock & S. E. Henking (Eds.), Que(e)rying religion: A critical anthology (pp. 330–337). New York: Continuum.

Gooren, L. (2006). The biology of human psychosexual differentiation. Hormones and Behavior, 50, 589–601.

Greene, B. (1997). Ethnic minority lesbians and gay men: Mental health and treatment issues. In B. Greene (Ed.), Ethnic and cultural diversity among lesbians and gay men (pp. 216–239). Thousand Oaks, CA: Sage.

Greenwood, G. L., & Gruskin, E. P. (2007). LGBT tobacco and alcohol disparities. In I. H. Meyer & M. Northridge (Eds.), The health of sexual minorities: Public health perspectives on lesbian, gay, bisexual, and transgender populations (pp. 566–583). New York: Springer.

Greenwood, G. L., Relf, M. V., Huang, B., Pollack, L. M., Canchola, J. A., & Catania, J. A. (2002). Battering victimization among a probability-based sample of men who have sex with men. American Journal of Public Health, 92(12), 1964–1969.

Gross, J. (2007, October 9). Aging and gay, and facing prejudice in twilight. New York Times.

Grossman, A. H., & D’Augelli, A. R. (2006). Transgender youth: Invisible and vulnerable. Journal of Homosexuality, 51(1), 111–128.

Grossman, A. H., D’Augelli, A. R., & O’Connell, T. S. (2001). Being lesbian, gay, bisexual, and 60 or older in North America. In D. C. Kimmel & D. L. Martin (Eds.), Midlife and aging in gay America (pp. 23–40). New York: Haworth Press.

Grossman, A. H., D’Augelli, A. R., & Hershberger, S. L. (2000). Social support networks of lesbian, gay, and bisexual adults 60 years of age and older. Journal of Gerontology B: Psychology and Social Sciences, 55(3), P171–P179.

Grov, C., Bimbi, D. S., Nanin, J. E., & Parsons, J. T. (2006). Race, ethnicity, gender, and generational factors associated with the coming-out process among gay, lesbian, and bisexual individuals. Journal of Sex Research, 43(2), 115–121.

Gruskin, E., Byrne, K., Kools, S., & Altschuler, A. (2006). Consequences of frequenting the lesbian bar. Women Health, 44(2), 103–120.

Gruskin, E. P., & Gordon, N. (2006). Gay/lesbian sexual orientation increases risk for cigarette smoking and heavy drinking among members of a large Northern California health plan. BMC Public Health, 6, 241.

Guarnero, P. A. (2007). Family and community influences on the social and sexual lives of Latino gay men. Journal of Transcultural Nursing, 18(1), 12–18.

Hale, C. J. (2007). Ethical problems with the mental health evaluation standards of care for adult gender variant prospective patients. Perspectives in Biology and Medicine, 50(4), 491–505.

Halkitis, P. N., Fischgrund, B. N., & Parsons, J. T. (2005). Explanations for methamphetamine use among gay and bisexual men in New York City. Substance Use and Misuse, 40(9/10), 1331–1345.

Halkitis, P. N., Green, K. A., & Mourgues, P. (2005). Longitudinal investigation of methamphetamine use among gay and bisexual men in New York City: Findings from Project BUMPS. Journal of Urban Health, 82(1, Suppl. 1), i18–i25.

Halkitis, P. N., Palamar, J., & Mukherjee, P. (2007). Poly-club-drug use among gay and bisexual men: A longitudinal analysis. Drug and Alcohol Dependence, 89, 153–160.

Hamer, D., Hu, S., Magnusin, V., Hu, N., & Patatucci, A. (1993). A linkage between DNA markers on the X chromosome and male sexual orientation. Science, 261, 321–327.

Harding T. (2007). The construction of men who are nurses as gay. Journal of Advanced Nursing, 60 (6), 636–644.

Harris Interactive and GLSEN. (2005). From teasing to torment: School climate in America, a survey of students and teachers. New York: GLSEN.

Harris, M. B., Nightengale, J., & Owen, N. (1995). Health care professionals’ experience, knowledge, and attitudes concerning homosexuality. Journal of Gay and Lesbian Social Services, 2, 91–107.

Heck, J. E., & Jacobson, J. S.(2006). Asthma diagnosis among individuals in same-sex relationships. Journal of Asthma 43(8), 579–584.

Heck, J. E., Sell, R. L., & Sheinfeld-Gorin, S. S. (2006). Health care access among individuals involved in same-sex relationships. American Journal of Public Health, 96(6), 1111–1118.

Hedges, C. (2006). American fascists: The Christian right and the war on America. New York: The Free Press.

Hellman, R. E. (1996). Issues in the treatment of lesbian women and gay men with chronic mental illness. Psychiatric Services, 47(10), 1093–1098.

Helminiak, D. (2000). What the Bible really says about homosexuality. San Francisco: Alamo Square Press.

Helminiak, D. (2006). Sex and the sacred. New York: Haworth.

Hemphill, E. (1989). Excerpt from the documentary Tongues Untied by Marlon Riggs, MTR Production.

Herdt, G. (1994). Third sex, third gender: Beyond sexual dimorphism in culture and history. New York: Zone Books.

Herek, G. M. (1995). Psychological heterosexism in the United States. In A. R. D’Augelli & C. J. Patterson (Eds.), Lesbian, gay, and bisexual identities across the lifespan: Psychological perspectives (pp. 321–346). New York: Oxford University Press.

Herek, G. (2000). Sexual prejudice and gender: Do heterosexuals’ attitudes toward lesbians and gay men differ? Journal of Social Issues, 56(2), 251–266.

Herek, G. (2004). Beyond “homophobia:” Thinking about sexual prejudice and stigma in the twenty-first century. Sexuality Research and Social Policy, 1, 6–24.

Herek, G. (2007). Hate crimes and stigma-related experiences among sexual minority adults in the United States: Prevalence estimates from a national probability sample. Journal of Interpersonal Violence, pre-print.

Herek, G., Chopp, R., & Strohl, D. (2007). Sexual stigma: Putting sexual minority health issues in context. In I. H. Meyer & M. Northridge (Eds.), The health of sexual minorities: Public health perspectives on lesbian, gay, bisexual, and transgender populations (pp. 151–208). New York: Springer.

Hitchcock, J., & Wilson, H. (1992). Personal risking: Lesbian self-disclosure of sexual orientation to professional health care providers. Nursing Research, 41, 178–183.

Holmes, W., & Slap, G. (1998). Sexual abuse of boys: Definition, prevalence, correlates, sequelae, and management. JAMA, 280, 1855–1862.

Horton, M., & Goza, E (2007). Estimating the cost of transgender health benefits. Out and Equal LGBT Workplace Newsletter, Spring, p. 9.

Howey, N., & Samuels, E. (Eds.). (2000). Out of the ordinary: Essays on growing up with lesbian, gay, and transgender parents. New York: St. Martins Press.

Hubner, D. M., & Davis, M. C. (2005). Gay and bisexual men who disclose their sexual orientations in the workplace have higher workday levels of salivary cortisol and negative affect. Annals of Behavioral Medicine, 30(3), 260–267.

Hughes, D. (2004). Disclosure of sexual preferences and lesbian, gay, and bisexual practitioners. BMJ, 328(7450), 1211–1212.

Hughes, T. L. (2003). Lesbians’ drinking patterns: Beyond the data. Substance Use and Misuse, 38(11–13), 1739–1758.

Hughes, T. L., & Eliason, M. J. (2002). Substance use and abuse in lesbian, gay, bisexual, and transgender populations. Journal of Primary Prevention, 22(3), 261–295.

Hughes, T. L., Johnson, T., & Wilsnack, S. (2001). Sexual assault and alcohol abuse: A comparison of lesbian and heterosexual women. Journal of Substance Abuse, 12, 515–532.

Hughes, T. L., Wilsnack, S. C., Szalacha, L. A., Johnson, T., Bostwick, W. B., Seymour, R., et al. (2006). Age and racial/ethnic differences in drinking and drinking-related problems in a community sample of lesbians. Journal of Studies on Alcohol, 67(4), 579–590.

Human Rights Campaign and Gay and Lesbian Medical Association. (2007). Healthcare Equality Index: Creating a national standard for equal treatment of GLBT patients and their families (Report). New York: HRC.

Hussey, W. (2006). Slivers of the journey: The use of photovoice and storytelling to examine female to male transsexuals’ experience of health care access. Journal of Homosexuality, 51(1), 129–158.

Igartua, K. J., Gill K., & Montoro R. (2003). Internalized homophobia: A factor in depression, anxiety, and suicide in the gay and lesbian population. Canadian Journal of Community Mental Health, 22(2), 15–30.

Inness, S. (1998). Flunking basic gender training: Butches and butch style today. In D. Atkins (Ed.), Looking queer: Body image and identity in lesbian, bisexual, gay, and transgender communities (pp. 233–238). New York: Harrington Park Press.

Inness, S., & Lloyd, M. (1996). G.I. Joes in Barbieland: Recontextualizing butch in twentieth-century lesbian culture. In B. Beemyn & M. Eliason (Eds.). Queer studies: A lesbian, gay, bisexual, and transgender anthology (pp. 9–34). New York: NYU Press.

Israel, G. E., & Tarver, D. E. (1997). Trangender care: Recommended guidelines, practical information and personal accounts. Philadelphia: Temple University Press.

Jenny, C., Roesler, T., & Poyer, K. (1994). Are children at risk for sexual abuse by homosexuals? Pediatrics, 94(1), 41–44.

Johnson, M. J., Jackson, N. C., Arnette, J. K., & Koffman, S. D. (2005). Gay and lesbian perceptions of discrimination in retirement care facilities. Journal of Homosexuality, 49(2), 83–102.

Jones, M. A., & Gabriel, M. A. (1999). Utilization of psychotherapy by lesbians, gay men, and bisexuals: Findings from a nationwide survey. American Journal of Orthopsychiatry, 69(2), 209–219.

Jorm, A., Korten, A., Rodgers, B., Jacob, P., & Christensen, H. (2002). Sexual orientation and mental health: Results from a community survey of young and middle-aged adults. British Journal of Psychiatry, 180, 423–427.

Juzwiak, M. (1964). Understanding the homosexual patient. RN Magazine, 27(4), 53–59.

Kehoe, M. (1988). Lesbians over 60 speak for themselves. Journal of Homosexuality, 16(3/4), 1–11.

Kelley, L., Chou, C. L., Dibble, S. L., & Robertson, P. A. (2008). A critical intervention in LGBT health: Knowledge and attitude outcomes among second year medical students. Teaching and Learning in Medicine, 20(3), 248–253.

Kelly, J. (2005). Zest for life: Lesbians’ experiences of menopause. Melbourne, Australia: Spinifex Press.

Kenagy, G., & Bostwick, W. (2001). Health and social service needs of transgendered people in Chicago. Chicago: Jane Addams College of Social Work, University of Illinois, Chicago.

Kennedy, E. L., & Davis, M. (1993). Boots of leather, slippers of gold: The history of a lesbian community. New York: Routledge.

Kerker, B. D., Mostashari, F., & Thorpe, L. (2006). Health care access and utilization among women who have sex with women: Sexual behavior and identity. Journal of Urban Health, 83(5), 970–979.

Kipke, M. D., Weiss, G., & Wong, C. F. (2007). Residential status as a risk factor for drug use and HIV risk among young men who have sex with men. AIDS Behavior, 11(6, Suppl.), 56–69.

King, M., & Nazareth, I. (2006). The health of people classified as lesbian, gay and bisexual attending family practitioners in London: a controlled study. BMC Public Health, 6, 127.

Kinsey, A., Pomeroy, W., & Martin, C. (1948). Sexual behavior in the human male. Philadelphia: Saunders.

Kirk, S. C., & Kulkarni, C. (2006). The whole person: A paradigm for integrating the mental and physical health of trans clients. In M. Shankle (Ed.), The handbook of lesbian, gay, bisexual, and transgender public health: A practitioner’s guide to service (pp. 145–174). New York: Haworth.

Kitzinger, C., & Perkins, R. (1993). Changing our minds: Lesbian feminism and psychology. New York: NYU Press.

Klamen, D. L., Grossman, L. S., & Kopacz, D. R. (1999). Medical student homophobia. Journal of Homosexuality, 37(1), 53–63.

Klein, F., Sepekoff, B., & Wolf, T. (1985). Sexual orientation: A multi-variable dynamic process. Journal of Homosexuality, 11(1/2), 35–49.

Koblin, B. A., Chesney, M. A., Husnik, M. J., Bozeman, S., Celum, C. L., Buchbinder, S., et al. (2003). High-risk behaviors among men who have sex with men in 6 US cities: baseline data from the EXPLORE Study. American Journal of Public Health, 93(6), 926–932

Koenig, H. G., McCullough, M. E., & Larson, D. B. (2001). Handbook of religion and health. New York: Oxford University Press.

Koh, A. S. (2000). Use of preventive health behaviors by lesbian, bisexual, and heterosexual women: Questionnaire survey. Western Journal of Medicine, 172(6), 379–384.

Koh, A. S., & Ross, L. K. (2006). Mental health issues: a comparison of lesbian, bisexual and heterosexual women. Journal of Homosexuality, 51(1), 33–57.

Kooden, H., & Flowers, C. (2000). Golden men: The power of gay midlife. New York: Avon Books.

Kraemer, B., Delisignore, A., Schyder, U., & Hepp, U. (2008). Body image and transsexualism. Psychopathology, 41(2), 96–100.

Kral, A. H., Lorvick, J., Ciccarone, D., Wenger, L., Gee, L., Martinez, A., et al. (2005). HIV prevalence and risk behaviors among men who have sex with men and inject drugs in San Francisco. Journal of Urban Health, 82(1, Suppl. 1), i43–i50.

Krieger, N. (2001). Theories for social epidemiology in the 21st century: An ecosocial perspective. International Journal of Epidemiology, 30, 668–677.

Kumashiro, K. (2001). Troubling intersections of race and sexuality: Queer students of color and anti-oppressive education. Lanham, MD: Rowman & Littlefield.

Kurdek, L. A. (2001). Differences between heterosexual–nonparent couples and gay, lesbian and heterosexual–parent couples. Journal of Family Issues, 22, 727–734.

Kurdek, L. A. (2004). Are gay and lesbian cohabiting couples really different from heterosexual married couples? Journal of Marital and Family Therapy, 29(1), 69–83.

Kurdek, L. A., & Schmitt, J. P. (1986). Relationship quality of partners in heterosexual married, heterosexual cohabiting, and gay and lesbian relationships. Journal of Personality and Social Psychology, 51(4), 711–720.

Laird, J. (1993). Lesbian and gay families. In F. Walsh (Ed.), Normal family processes (pp. 238–283). New York: Guilford.

Landen, M., Walinder, J., Hambert, G., & Lundstrom, B. (1998). Factors predictive of regret in sex reassignment. Acta Psychiatrica Scandivania, 97(4), 284–289.

LaSala, M. (2004). Extradydactic sex and gay male couples: Comparing monogamous and nonmonogamous relationships. Families in Society, 85(3), 405–412.

Laumann, E. O., Gagnon, J. H., Michael, R. T., & Michaels, S. (1994). The social organization of sexuality: Sexual practices in the United States. Chicago: The University of Chicago Press.

Lawrence, A. A. (2007). Transgender health concerns. In I. H. Meyer & M. Northridge (Eds.) The health of sexual minorities: Public health perspectives on lesbian, gay, bisexual, and transgender populations (pp. 473–505). New York: Springer.

Lawrence, J. (1975). Homosexuals, hospitalization, and the nurse. Nursing Forum, 14, 305–317.

Lease, S., Horne, S., & Noffsinger-Frazier, N. (2005). Affirming faith experiences and psychological health for Caucasian LGB individuals. Journal of Counseling Psychology, 52(3), 378–388.

Lena, S. M., Wiebe, T., Ingram, S., & Jabbour, M. (2002). Pediatricians’ knowledge, perceptions, and attitudes towards providing health care for lesbian, gay, and bisexual adolescents. Annals of the Royal College of Physicians and Surgeons of Canada, 35(7), 406–410.

Lev, A. I. (2004). Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. New York: Haworth.

Levitt, H. M., & Horne, S. G. (2002). Explorations of lesbian–queer genders: Butch, femme, androgynous, and “other.” Journal of Lesbian Studies, 6(2), 25–39.

Lewis, R. J., Derlega, V. J., & Clarke, E. G. (2006). Stigma consciousness, social constraints, and lesbian well-being. Journal of Counseling Psychology, 53(1), 48–56.

Lhomond, B., & Saurel-Cubizolles, M. J. (2006). Violence against women and suicide risk: the neglected impact of same-sex sexual behaviour. Social Science and Medicine, 62(8), 2002–2013.

Lipson, J. G., & Dibble, S. L. (2005). Providing culturally appropriate health care. In J. G. Lipson & S. L. Dibble (Eds.), Culture & clinical care. San Francisco: UCSF Nursing Press.

Lombardi, E. (2007). Public health and transpeople: Barriers to care and strategies to improve treatment. In I. H. Meyer & M. Northridge (Eds.), The health of sexual minorities: Public health perspectives on lesbian, gay, bisexual, and transgender populations (pp. 607–638). New York: Springer.

Lombardi, E. L., Wilchins, R. A., Priesing, D., & Malouf, D. (2001). Gender violence: transgender experiences with violence and discrimination. Journal of Homosexuality, 42(1), 89–101.

London, A. S., Foote-Ardah, C. E., Fleishman, J. A., & Shapiro, M. F. (2003). Use of alternative therapists among people in care for HIV in the United States. American Journal of Public Health, 93(6), 980–987.

Lorde, A. (1980). The cancer journals. San Francisco: Spinsters/Aunt Lute Press.

Lucas, V. A. (1992). An investigation of the health care preferences of the lesbian population. Health Care for Women International, 13(2), 221–228.

Lynch, J. M., & Murray, K. (2000). For the love of the children: the coming out process for lesbian and gay parents and stepparents. Journal of Homosexuality, 39(1), 1–24.

Maccio, E. M., & Doueck, H. (2002). Meeting the needs of the gay and lesbian community: outcomes in the human services. Journal of Gay and lesbian Social Services, 14(4), 55–73.

Magnan, M. A., & Reynolds, K. (2006). Barriers to addressing patient sexuality concerns across five areas of specialization. Clinical Nurse Specialist, 20(6), 285–292.

Maher, M. J. (2006). A voice in the wilderness: Gay and lesbian religious groups in the western U.S. Journal of Homosexuality, 51(4), 91–117.

Malebranche, D. J., Peterson, J. L., Fullilove, R. E., & Stackhouse, R. W. (2004). Race and sexual identity: Perceptions about medical culture and healthcare among Black men who have sex with men. Journal of the National Medical Association, 96(1), 97–107.

Mallon, G. P. (1999). Social services with transgendered youth. New York: Haworth.

Mallon, G. P., & DeCrescenzo, T. (2006). Transgender children and youth: A child welfare practice perspective. Child Welfare 85(2), 215–241.

Mann, W. (1998). The men from the boys. New York: Penguin.

Mansergh, G., Shouse, R. L., Marks, G., Guzman, R., Rader, M., Buchbinder, S., et al. (2006). Methamphetamine and sildenafil (Viagra) use are linked to unprotected receptive and insertive anal sex, respectively, in a sample of men who have sex with men. Sexually Transmitted Infection, 82(2), 131–134.

Martins, Y., Tiggeman, M., & Kirkbride, A. (2007). Those speedos become them. The role of self-objectification in gay and heterosexual men’s body image. Personality and Social Psychology Bulletin, 33, 634–647.

Martro, E., Esteve, A., Schulz, T. F., Sheldon, J., Gambus, G., Munoz, R., et al., & Euro-Shaks Study Group. (2007). Risk factors for human Herpesvirus 8 infection and AIDS-associated Kaposi’s sarcoma among men who have sex with men in a European multicentre study. International Journal of Cancer, 120(5), 1129–1135.

Masters, W. H., & Johnson, V. E. (1979). Homosexuality in perspective. Toronto, Ontario, Canada; New York: Bantam Books.

Mathews, W., Booth, M., Turner, J., & Kessler, L. (1986). Physicians’ attitudes toward homosexuality: Survey of a California county medical society. Western Journal of Medicine, 144(1), 106–110.

Matthews, A. K., Brandenburg, D. L., Johnson, T. P., & Hughes, T. L. (2004). Correlates of underutilization of gynecological cancer screening among lesbian and heterosexual women. Preventative Medicine, 38(1), 105–113.

Matthews, A. K., Hughes, T. L., Osterman, G. P., & Kodl, M. M. (2005). Complementary medicine practices in a community-based sample of lesbian and heterosexual women. Health Care for Women International, 26(5), 430–447.

Matthews, A. K., Hughes, T. L., & Tartaro, J. (2006). Sexual behavior and sexual dysfunction in a community sample of lesbian and heterosexual women. In A. Omoto & H. Kurtzman (Eds.), Sexual orientation and mental health (pp. 185–205). Washington, DC: APA Press.

Matthews, A. K., Tartaro, J., & Hughes, T. L. (2003). A comparative study of lesbians and heterosexual women in committed relationships. Journal of Lesbian Studies, 12(3), 235–246.

Mays, V. M., & Cochran, S. D. (2001). Mental health correlates of perceived discrimination among lesbian, gay, and bisexual adults in the United States. American Journal of Public Health, 91, 1869–1876.

Mays, V. M., Cochran, S. D., & Zamudio, A. (2004). HIV prevention research: Are we meeting the needs of African American men who have sex with men? Journal of Black Psychology, 30(1), 78–105.

Mays, V. M., Yancey, A. K., Cochran, S. D., Weber, M., & Fielding, J. E. (2002). Heterogeneity of health disparities among African American, Hispanic, and Asian American women: Unrecognized influences of sexual orientation. American Journal of Public Health, 92(4), 632–639.

McCloskey, D. (1999). Crossing: A memoir. Chicago: University of Chicago Press.

McCullough, D., & Hall D. S. (2003, February 27). Polyamory—What it is and what it isn’t. Electronic Journal of Human Sexuality, 6.

McKirnan, D., & Peterson, P. L. (1989). Alcohol and drug use among homosexual men and women: epidemiology and population characteristics. Addictive Behaviors, 14, 545–0553.

McGarry, K. A., Clarke, J. G., Landau, C., & Cyr, M. G. (2008). Caring for vulnerable populations: Curricula in U.S. internal medicine residencies. Journal of Homosexuality, 54(3), 225–232.

McLean, K. (2004). Negotiating (non)monogamy: Bisexuality and intimate relationships. In R. Fox (Ed.), Current research on bisexuality (pp. 83–98). New York: Haworth.

McMahon, E. (2003). The older homosexual: current concepts of lesbian, gay, bisexual, and transgender older Americans. Clinical Geriatric Medicine, 19(3), 587–593.

Means-Christensen, A. J., Snyder, D. K., & Negy, C. (2003). Assessing nontraditional couples: Validity of the Marital Satisfaction Inventory–Revised with gay, lesbian, and cohabiting heterosexual couples. Journal of Marital and Family Therapy, 29(1), 69–83.

Meckler, G. D., Elliott, M. N., Kanouse, D. E., Beals, K. P., & Schuster, M. A. (2006). Nondisclosure of sexual orientation to a physician among a sample of gay, lesbian, and bisexual youth. Archives of Pediatrics and Adolescent Medicine, 160, 1248–1254.

Mercer, C. H., Bailey, J. V., Johnson, A. M., Erens, B., Wellings, K., Fenton, K. A., et al. (2007). Women who report having sex with women: British national probability data on prevalence, sexual behaviors, and health outcomes. American Journal of Public Health, 97(6), 1126–1133.

Merchant, R., Jongco, A., & Woodward, L. (2005). Disclosure of sexual orientation by medical students and residency applicants. Academic Medicine, 80, 786.

Meston, C. M., & Buss, D. M. (2007). Why humans have sex. Archives of Sexual Behavior, 36(4), 477–507.

MetLife®. (2006). Out and aging: The MetLife study of lesbian and gay baby boomers. In conjunction with Lesbian and Gay Aging Issues Network of the American Society on Aging and Zogby International. Retrieved from http://www.stonewallcommunities.com/PDF/metlife.pdf

Meyer, I. H. (1995). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 36, 38–56.

Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychological Bulletin, 129, 674–697.

Meyer, I. H. (2007). Prejudice and discrimination as social stressors. In I. H. Meyer & M. Northridge (Eds.), The health of sexual minorities: Public health perspectives on lesbian, gay, bisexual, and transgender populations (pp. 242–267). New York: Springer.

Michigan Fair Housing Center. (2007). Retrieved October XX, 2007, from www.fhcmichigan.org

Miller, M., Andre, A., Ebin, J., & Bessonova, L. (2007). Bisexual health: An introduction and model practices for HIV/STI prevention programming. New York: National Gay & Lesbian Task Force Policy Institute, Fenway Institute, and BiNet USA.

Miller, R. L., Jr. (2007). Legacy denied: African American gay men, AIDS, and the black church. Social Work, 52(1), 51–61.

Mills, T. C., Paul, J., Stall, R., Pollack, L., Canchola, J., Chang, Y. J., et al. (2004). Distress and depression in men who have sex with men: The Urban Men’s Health Study. American Journal of Psychiatry, 161, 278–285.

Mohr, J., & Rochlen, A. (1999). Measuring attitudes regarding bisexuality in lesbian, gay, and heterosexual populations. Journal of Counseling Psychology, 46(3), 353–370.

Morales, E. S. (1990). HIV infection and Hispanic gay and bisexual men. Hispanic Journal of Behavior Sciences, 12, 212–222.

More, F. G., Whitehead, A. W., & Gonthier, M. (2004). Strategies for student services for lesbian, gay, bisexual, and transgender students in dental schools. Journal of Dental Education, 68(6), 623–632.

Morin, S. F. (1977). Heterosexual bias in psychological research on lesbianism and male homosexuality. American Psychologist, 32, 629–637.

Morris, J. F., Balsam, K. F., & Rothblum, E. D. (2002). Lesbian and bisexual mothers and nonmothers: demographics and the coming-out process. Journal of Family Psychology, 16(2), 144–156.

Morrow, D. F., & Messinger, L. (2006). Sexual orientation and gender expression in social work practice: Working with gay, lesbian, bisexual, and transgender people. New York: Columbia University Press.

Mottet, L., & Ohle, J. M. (2003). Transitioning our shelters: A guide to making homeless shelters safe for transgender people. New York: National Gay and Lesbian Task Force Policy Institute.

National Center for Lesbian Rights and Transgender Law Center. (2003). Trans realities: A legal needs assessment of San Francisco’s transgender communities. San Francisco: Author.

National Center for Lesbian Rights. (2005). Marriage, domestic partnerships, and civil unions: An overview of relationship recognition for same-sex couples in the U.S. Retrieved from www.nclrights.org

National Coalition for LGBT Health Eliminating Disparities Workgroup. (2004). An overview of U.S. trans health priorities. Washington, DC: Author.

National Gay and Lesbian Task Force. (2007, September 27). Task Force, Inc., hails Senate passage of federal hate crimes legislation. Retrieved from www.ngltf.org

Nemoto, T., Luke, D., Mamo, L., Ching, A., & Patria, J. (1999). HIV risk behaviours among male-to-female transgenders in comparison with homosexual or bisexual males and heterosexual females. AIDS Care, 11(3), 297–312.

Nemoto, T., Operario, D., Keatley, J., Han, L., & Soma, T. (2004). HIV risk behaviors among male-to-female transgender persons of color in San Francisco. American Journal of Public Health, 382–384.

Nemoto, T., Operario, D., & Keatley, J. (2005). Health and social services for male-to-female transgender persons of color in San Francisco. In W. Bockting & E. Avery (Eds.), Transgender health and HIV prevention (pp. 5–20). New York: Haworth.

Neville, S., & Henrickson, M. (2006). Perceptions of lesbian, gay and bisexual people of primary healthcare services. Journal of Advanced Nursing, 55(4), 407–415.

Newfield, E., Hart, S., Dibble, S., & Kohler, L. (2006). Female-to-male transgender quality of life. Quality of Life Research, 15(9), 1447–1457.

Newman, F. (2004). The whole lesbian sex book: A passionate guide for all of us. San Francisco: Cleis Press.

Operario, D., Burton, J., Underhill, K., & Sevelius, J. (2008). Men who have sex with transgender women: Challenges to category-based HIV prevention. AIDS Behavior, 12(1), 18–26.

Oriel, K. A., Madlon-Kay, D. J., Govaker, D., & Mersy, D. J. (1996). Gay and lesbian physicians in training: Family practice program directors’ attitudes and students’ perceptions of bias. Family Medicine, 28(10), 720–725.

Oswald, R. F. (2002). Resilience within the family networks of lesbians and gay men: Intentionality and redefinition. Journal of Marriage and the Family, 64(2), 374.

O’Toole, C. J. (2000). The view from below: Developing a knowledge base about an unknown population. Sexuality and Disability, 18(3), 207–224.

Pachankis, J. (2007). The psychological implications of concealing a stigma: A cognitive–affective–behavioral model. Psychological Bulletin, 133(2), 328–345.

Padilla, M. D., Vasquez del Aguila, E., & Parker, R. G. (2007). Globalization, structural violence, and LGBT health: A cross cultural perspective. In I. H. Meyer & M. Northridge (Eds.), The health of sexual minorities: Public health perspectives on lesbian, gay, bisexual, and transgender populations (pp. 209–241). New York: Springer.

Page, E. (2004). Mental health services experiences of bisexual women and bisexual men: An empirical study. Journal of Bisexuality, 4(1/2), 137–160.

Parks, C. A., Hughes, T. L., & Matthews, A. K. (2004). Race/ethnicity and sexual orientation: intersection identities. Cultural Diversity and Ethnic Minority Psychology, 10(3), 241–254.

Parks, C. A., & Humphreys, N. A. (2006). Lesbian relationships and families. In D. F. Morrow & L. Messinger (Eds.), Sexual orientation and gender expression in social work practice (pp. 216–242). New York: Columbia University Press.

Pascoe, C. J. (2007). Dude you’re a fag: Masculinity and sexuality in high school. Berkeley: University of California Press.

Pattavina, A., Hirschel, D., Buzawa, E., Faggiani, D., & Bentley, H. (2007). A comparison of the police response to heterosexual versus same-sex intimate partner violence. Violence Against Women, 13, 374–394.

Paul, J. P., Pollack, L., Osmond, D., & Catania, J. A. (2005). Viagra (sildenafil) use in a population-based sample of U.S. men who have sex with men. Sexually Transmitted Diseases, 32(9), 531–533.

Pazos, S. (1999). Practice with female-to-male transgendered youth. In G. Mallon (Ed.), Social services with transgendered youth (pp. 65–82). Binghamton, NY: Haworth.

Peplau, L. A., & Fingerhut, A. W. (2007). The close relationships of lesbians and gay men. Annual Review of Psychology, 58, 405–424.

Perrin, E. C. (1998). Children whose parents are lesbian or gay. Contemporary Pediatrics, 15, 113–130.

Peters, D., & Cantrell, P. (1991). Factors distinguishing samples of lesbian and heterosexual women. Journal of Homosexuality, 21, 1–15.

Pitt, E. L., & Alpert, E. J. (2007). Violence and trauma: Recognition, recovery, and prevention. In H. J. Makadon, K. H. Mayer, J. Potter, & H. Goldhammer (2007). The Fenway guide to lesbian, gay, bisexual, and transgender health (pp. 249–270). Philadelphia: American College of Physicians Press.

Platzer, H., & James, T. (2000). Lesbians’ experiences of health care. NT Research, 5(3), 194–202.

Polat, A., Yuksel, S., Genc, A., & Meteris, H. (2002). Gender identity disorders and family acceptance. Retrieved from http://web.hku.hk/~sjwinter/Transgender ASIA/paper

Rachlin, K., Green, J., & Lombardi, E. (2008). Utilization of health care among female-to-male transgender individuals in the United States. Journal of Homosexuality, 54(3), 243–258.

Ragins, B. R., Singh, R., & Cornwell, J. M. (2007). Making the invisible visible: Fear and disclosure of sexual orientation at work. Journal of Applied Psychology, 92(4), 1103–1118.

Rafkin, L. (Ed.). (1990). Different mothers: Sons and daughters of lesbians talk about their lives. Pittsburgh: Cleis Press.

Ramirez-Valles, J. (2007). “I don’t fit anywhere”: How race and sexuality shape Latino gay and bisexual men’s health. In I. H. Meyer & M. Northridge (Eds.), The health of sexual minorities (pp. 301–319). New York: Springer Science.

Ramos, M. M., Tellez, C. M., Palley, T. B., Umland, B. E., & Skipper, B.J. (1998). Attitudes of physicians practicing in New Mexico toward gay men and lesbians in the profession. Academic Medicine, 73(4), 436–438.

Randall, C. (1989). Lesbian phobia among BSN educators: A survey. Cassandra: Racial Nurses’ Journal, 6, 23–26.

Rankow, E. J., & Tessaro, I. (1998). Cervical cancer risk and Papanicolaou screening in a sample of lesbian and bisexual women. Journal of Family Practice, 47(2), 139–143.

Reback, C., Simon, P. A., Bemis, C. C., & Gatson, B. (2001). The Los Angeles transgender health study: community report. Los Angeles: Department of Health Services, Office of AIDS Programs and Policy.

Reilly, A., & Rudd, N. A. (2007). Stress and dress: Investigating the relationship between social anxiety and appearance management among gay and straight men. Journal of Homosexuality, 52(3/4), 151–166.

Remafedi, G. (2007). Lesbian, gay, bisexual, and transgender youths: who smokes, and why? Nicotine Tobacco Research. 9(Suppl. 1), 565–571.

Renaud M. T. (2007). We are mothers too: childbearing experiences of lesbian families. Journal of Obstetrics and Gynecology and Neonatal Nursing, 36(2), 190–199.

Reynolds, K., & Magnan, M. (2005). Nursing attitudes and beliefs toward human sexuality: collaborative research promoting evidence-based practice. Clinical Nurse Specialist, 19(5), 255–259.

Ristock, J. (2003). Exploring dynamics of abusive lesbian relationships: Preliminary analysis of a multisite, qualitative study. American Journal of Community Psychology. 31(3/4), 329–341.

Rivers, I. (2004). Recollections of bullying at school and their long term implications for lesbians, gay men, and bisexuals. Crisis, 25(4), 169–175.

Roberts, S. A., Dibble, S. L., Nussey, B., & Casey, K. (2003). Cardiovascular disease risk in lesbian women. Women’s Health Issues, 13(4), 167–174.

Roberts, S. A., Dibble, S. L., Scanlon, J., Paul, S., & Davids, H. R. (1998). Differences in risk factors for breast cancer: Lesbians and heterosexual women. Journal of the Gay and Lesbian Medical Association, 2(3), 93–101.

Roberts, S. J., & Sorensen, L. (1999). Health related behaviors and cancer screening of lesbians: Results from the Boston Lesbian Health Project. Women’s Health, 28(4), 1–12.

Robinson, G., & Cohen, M. (1996). Gay, lesbian and bisexual health care issues and medical curricula. CMAJ, 155(6), 709–711.

Rodriguez, E., & Ouellette, S. (2000). Gay and lesbian Christians: Homosexual and religious identity integration in the members and participants of a gay-positive church. Journal for the Scientific Study of Religion, 39, 333–347.

Rodriguez-Madera, S., & Toro-Alfonso, J. (2005). Gender as an obstacle in HIV/AIDS prevention: Considerations for the development of HIV/AIDS prevention efforts for male-to-female transgenders. In W. Bockting & E. Avery (Eds.), Transgender health and HIV prevention (pp. 113–122). New York: Haworth.

Romanelli, F., & Smith, K. M. (2004). Recreational use of sildenafil by HIV-positive and -negative homosexual/bisexual males. Annals of Pharmacotherapy, 38(6), 1024–1030.

Romero, A. P., Baumle, A. K., Badgett, M. V. L., & Gates, G. J. (2007). Census Snapshot. Los Angeles: The Williams Institute, UCLA

Röndahl, G., Innala, S., & Carlsson, M. (2004a). Nurses’ attitudes towards lesbians and gay men. Journal of Advanced Nursing, 47(4), 386–392.

Röndahl, G., Innala, S., & Carlsson M. (2004b). Nursing staff and nursing students’ emotions towards homosexual patients and their wish to refrain from nursing, if the option existed. Scandinavian Journal of Caring Sciences, 18(1), 19–26.

Röndahl, G., Innala, S., & Carlsson, M. (2006). Heterosexual assumptions in verbal and non-verbal communication in nursing. Journal of Advanced Nursing, 56(40), 373–381.

Rohrbaugh, J. (2006). Domestic violence in same-gender relationships. Family Court Review, 44(2), 287–299.

Rosario, M., Schrimshaw, E. W., & Hunter, J. (2004). Ethnic/racial differences in the coming-out process of lesbian, gay, and bisexual youths: A comparison of sexual identity development over time. Cultural Diversity and Ethnic Minority Psychology, 10(3), 215–228.

Roscoe, W. (1998). Changing Ones: Third and Fourth Genders in Native North America. New York: St Martin’s Press.

Rose, P. (1993). Out in the open? Lesbianism. Nursing Times, 89(30), 50–52.

Rosen, R. C., Catania, J. A., Ehrhardt, A. A., Burnett, A. L., Lue, T F., McKenna, K., et al. (2006). The Bolger conference on PDE-5 inhibition and HIV risk: Implications for health policy and prevention. Journal of Sexuality and Medicine, 3(6), 960–975; Discussion 973–965.

Rosik, C., Griffith, L., & Cruz, Z. (2007). Homophobia and conservative religion: Toward a more nuanced understanding. American Journal of Orthopsychiatry, 77(1), 10–19.

Ross, L. E., Steele, L., & Shapiro, B. (2005). Perceptions of predisposing and protective factors for perinatal depression in same-sex parents. Journal of Midwifery and Women’s Health, 50(6), e65–e70.

Rosser, B. R. S., Oakes, J. M., Bockting, W. O., & Miner, M. (2007). Capturing the social demographics of hidden sexual minorities: An Internet study of the transgender population in the United States. Sexuality Research and Social Policy, 4(2), 50–64.

Rostosky, S. S., & Riggle, E. D. B. (2002). “Out” at work: The relation of actor and partner workplace policy and internalized homophobia to disclosure status. Journal of Consulting Psychology, 49(4), 411–419.

Russell, G., & Richards, J. A. (2003). Stressor and resilience factors for lesbians, gay men, and bisexuals confronting antigay politics. American Journal of Community Psychology, 31(3/4). 313–328.

Russell, S. (2006). Substance use and abuse and mental health among sexual minority youths: Evidence from Add Health. In A. Omoto & H. Kurtzmann (Eds.), Sexual orientation and mental health: Examining identity and development in LGB people (pp. 13–36). Washington, DC: APA Press.

Rust, P. (1996). Sexual identity and bisexual identities: The struggle for self-description in a changing sexual landscape. In B. Beemyn & M. Eliason, (Eds.), Queer studies: A lesbian, gay, bisexual, and transgender anthology (pp. 64–86). New York: NYU Press.

Rust, P. (2000). Bisexuality in the U.S.: A social science reader. New York: Columbia University Press.

Saewyc, E., Bauer, G., Skay, C., Bearinger, L., Resnick, M., Reise, E., et al. (2004). Measuring sexual orientation in adolescent health surveys: Evaluation of eight school-based surveys. Journal of Adolescent Health, 35, 345–360.

Safren, S. A., & Heimberg, R. G. (1999). Depression, hopelessness, suicidality, and related factors in sexual minority and heterosexual adolescents. Journal of Consulting and Clinical Psychology, 67(6), 859–866.

Sanchez, T. H., & Gallagher, K. M. (2006). Factors associated with recent sildenafil (Viagra) use among men who have sex with men in the United States. Journal of Acquired Immune Deficiency Syndrome, 42(1), 95–100.

Sanchez, N. F., Rabatin, J., Sanchez, J. P., Hubbard, S., & Kalet, A. (2006). Medical students’ ability to care for lesbian, gay, bisexual, and transgendered patients. Family Medicine, 38(1), 21–27.

Sanders, G. L., & Kroll I. T. (2000). Generating stories of resilience: Helping gay and lesbian youth and their families. Journal of Marital and Family Therapy, 26(4), 433–442.

Sandfort, T. G., Bakker, F., Schellevis, F., & Vanwesenbeeck, I. (2007). Coping styles as mediator of sexual orientation-related health differences. Archives of Sexual Behavior.

Saulnier, C. F. (2002). Deciding who to see: Lesbians discuss their preferences in health and mental health care providers. Social Work, 47(40), 355–365.

Sausa, L., Keatley, J., & Operario, D. (2007). Perceived risks and benefits of sex work among transgender women of color in San Francisco. Archives of Sexual Behavior, 36(6), 768–777.

Savin-Williams, R. (1998). The disclosure to families of same-sex attractions by lesbian, gay, and bisexual youth. Journal of Research on Adolescence, 8, 49–68.

Savin-Williams, R. (2005). The new gay teenager. Cambridge, MA: Harvard University Press.

Savin-Williams, R., & Cohen, K. (2007). Development of same-sex attracted youth. In I. Meyer & M. Northridge (Eds.), The health of sexual minorities (pp. 27–47). New York: Springer Science.

Schatz, B., & O’Hanlan, K. (1994). Anti-gay discrimination in medicine: Results of a national survey of lesbian, gay, and bisexual physicians. San Francisco: American Association for Human Rights.

Scheer, S., Parks, C., McFarland, W., Page-Shafer, K., Delgad, V., Ruiz, J., et al. (2003). Self-reported sexual identity, sexual behaviors and health risks: Examples from a population-based survey of young women. Journal of Lesbian Studies, 7(1), 69–83.

Scheer, S., Peterson, I., Page-Shafer, K., Delgado, V., Gleghorn, A., Ruiz, J., et al. (2002). Sexual and drug use behavior among women who have sex with both women and men: Results of a population-based survey. American Journal of Public Health, 92(7), 1110–1112.

Schroeder, M., & Shidlo, A. (2001). Ethical issues in sexual orientation conversion therapies: An empirical study of consumers. Journal of Gay and Lesbian Psychotherapy, 5(3/4), 131–166.

Sears, J. (1997). Thinking critically/intervening effectively about heterosexism and homophobia: A twenty-five year retrospective. In J. Sears & W. Williams (Eds.), Overcoming heterosexism and homophobia: Strategies that work (pp. 13–48). New York: Columbia University Press.

Semple, S. J., Patterson, T. L., & Grant, I. (2002). Motivations associated with methamphetamine use among HIV+ men who have sex with men. Journal of Substance Abuse Treatment, 22(3), 149–156.

Semple, S. J., Zians, J., Grant, I., & Patterson, T. L. (2006). Methamphetamine use, impulsivity, and sexual risk behavior among HIV-positive men who have sex with men. Journal of Addictive Diseases, 25(4), 105–114.

Servicemembers Legal Defense Network. (2004). Conduct unbecoming: Tenth annual report on ‘Don’t ask, don’t tell.’ New York: Author.

Share, T. L., & Mintz, L. B. (2002). Differences between lesbians and heterosexual women in disordered eating and related attitudes. Journal of Homosexuality, 42(4), 89–106.

Sheldon, J. P., Pfeffer, C. A., Jayaratne, T. E., Feldbaum, M., & Petty, E. M. (2007). Beliefs about the etiology of homosexuality and the possible ramifications of discovering its possible genetic origin. Journal of Homosexuality, 52(3/4), 111–150.

Shidlo, A., Schroeder, M., & Drescher, J. (2001). Sexual conversion therapy: Ethical, clinical and research perspectives. New York: Harrington Park Press.

Shidlo, A., & Schroeder, M. (2002). Changing sexual orientation: A consumers’ report. Professional Psychology: Research and Practice, 33(3), 249–259.

Siever, M. D. (1994). Sexual orientation and gender as factors in socioculturally acquired vulnerability to body dissatisfaction and eating disorders. Journal of Consulting and Clinical Psychology, 62(2), 252–260.

Silverstein, C., & Picano, F. (2004). The joy of gay sex, revised & expanded third edition. New York: Harper Collins Publishers.

Simmons, R. (1991). Some thoughts on the challenges facing black gay intellectuals. In Hemphill, E. (Ed), Brother to brother (pp. 211–228). Boston, Alyson.

Skidmore, W. C., Linsenmeier, J. A., & Bailey, J. M. (2006). Gender nonconformity and psychological distress in lesbians and gay men. Archives of Sexual Behavior, 35(6) 685–697. Epub 2006, November 16.

Skinner, W. F., & Otis, M. D. (1996). Drug and alcohol use among lesbian and gay people in a southern U.S. sample: Epidemiological, comparative, and methodological findings from the Trilogy Project. Journal of Homosexuality, 30(3), 59–92.

Smith, C. S., & Stillman, S. (2002). What do women want? The effects of gender and sexual orientation on the desirability of physical attributes in the personal ads of women. Sex Roles, 46(9/10), 337–342.

Smith, E., Offen, N., & Malone, R. (2005). What makes an ad a cigarette ad? Commercial tobacco imagery in the lesbian, gay, and bisexual press. Journal of Epidemiology and Community Health, 59, 1086–1091.

Smith, D. K., Grohskopt, L., Black, R. et al. (2005). Antiretroviral post-exposure prophylaxis after sexual, injection, drug use, and other non-occupational exposure to HIV in the U.S. MMWR Recommendations Report, 54, 1–20.

Smith, D. M. & Gates, G. J. (2001). Gay and lesbian families in the United States: Same-sex unmarried partner households. A preliminary analysis of 2000 United States Census data. Human Rights Campaign Web site. Retreived from www.hrc.org

Smith, D., & Mathews, W. (2007). Physicians’ attitudes toward homosexuality and HIV: Survey of a California Medical Society–Revisited (PATHH-II). Journal of Homosexuality, 52(3/4), 1–10.

Solomon, S., Rothblum, E., & Balsam, K. (2004). Pioneers in partnership: Lesbian and gay male couples in civil unions compared with those not in civil unions and married heterosexual siblings. Journal of Family Psychology, 18(2), 275–286.

Spirito, A., & Esposito-Smythers, C. (2006). Attempted and completed suicide in adolescence. Annual Review of Clinical Psychology, 2, 237–266.

Stein, G. L., & Bonuck, K. A. (2001). Attitudes on end-or-life care and advance care planning in the lesbian and gay community. Journal of Palliative Care, 4(2), 173–190.

Stall, R., Paul, J. P., Greenwood, G., Pollack, L. M., Bein, E., Crosby, G. M., et al. (2001). Alcohol use, drug use and alcohol-related problems among men who have sex with men: The Urban Men’s Health Study. Addiction, 96(11), 1589–1601.

Stevens, P. E. (1994). Protective strategies of lesbian clients in home health care environments. Research in Nursing and Health, 17, 217–229.

Stevens, P. E. (1995). Structural and interpersonal impact of heterosexual assumptions on lesbian health care clients. Nursing Research, 44(1), 25–30.

Stevens, P. E. (1998). The experiences of lesbians of color in health care encounters. Journal of Lesbian Studies, 2(1), 77–94.

Stevens, P. E. & Hall, J. (1988). Stigma, health beliefs, and experiences with health care in lesbian women. Image, 20, 69–73.

Stryker, S. (2006). (De)subjugated knowledges: An introduction to transgender studies. In S. Stryker & S. Whittle (Eds.), The transgender studies reader (pp. 1–18). New York: Routledge.

Stryker, S. (2008). Transgender history. Berkeley, CA: Seal Press.

Szymanski, D., & Chung, Y. (2003a). Feminist attitudes and coping resources as correlates of lesbian internalized heterosexism. Feminism & Psychology, 13, 369–389.

Szymanski, D., & Chung, B. (2003b). Internalized homophobia in lesbians. In T. L. Hughes, C. Smith, & A. Dan (Eds.), Mental health issues for sexual minority women: Redefining women’s mental health (pp. 115–126). New York: Haworth Press.

Tafoya, T., & Rowell, R. (1988). Counseling gay and lesbian Native Americans. In M. Shernoff & W. Scott (Eds.), The sourcebook on lesbian/gay health care. Washington, DC: National Lesbian and Gay Health Foundation.

Tang, H., Greenwood, G. L., Cowling, D. W., Lloyd, J. C., Roeseler, A. G., & Bal, D. G. (2004). Cigarette smoking among lesbians, gays, and bisexuals: how serious a problem? (United States). Cancer Causes and Control, 15(8), 797–803.

Tasker, F. (2005). Lesbian mothers, gay fathers, and their children: A review. Journal of Developmental & Behavioral Pediatrics, 26(3), 224–240.

Tesar, C. M., & Rovi, S. L. (1998). Survey of curriculum on homosexuality/bisexuality in departments of family medicine. Family Medicine, 30(4), 283–287.

Tjaden, P., Thoennes, N., & Allison, C. J. (1999). Comparing violence over the life span in samples of same-sex and opposite-sex cohabitants. Violence and Victims, 14(4), 413–425.

Tjepkema, M. (2008). Health care use among gay, lesbian, and bisexual Canadians. Health Reports, 19(1), 53–62.

Troiden, R. (1988). Gay and lesbian identity. New York: General Hall.

Ulstad, V. (1999). Coronary health issues for lesbians. Journal of the Gay and Lesbian Medical Association, 3(2), 59–66.

Valanis, B. G., Bowen, D. J., Bassford, T., Whitlock, E., Charney, P., & Carter, R. A. (2000). Sexual orientation and health: comparisons in the women’s health initiative sample. Archives of Family Medicine, 9(9), 843–853.

Van Wormer, K., Wells, J., & Boes. M. L. (2000). Social work with lesbians, gays, and bisexuals: A strengths perspective. Boston: Allyn and Bacon.

Wallick, M. M., Cambre, K. M., & Townsend, M. H. (1992). How the topic of homosexuality is taught at U.S. medical schools. Academic Medicine, 67(9), 601–603.

Walters, K. L., Simoni, J. M., & Horwath, P. F. (2001). Sexual orientation bias experiences and service needs of gay, lesbian, bisexual, transgendered, and two-spirited American Indians. Journal of Gay and Lesbian Social Services, 13, 133–149.

Wang, J., Hausermann, M., Vounatsou, P., Aggleton, P., & Weiss, M. G. (2007). Health status, behavior, and care utilization in the Geneva Gay Men’s Health Survey. Preventative Medicine, 44(1), 70–75. Epub 2006, September 25.

Warner, J., McKeown, E., Griffin, M., Johnson, K., Ramsay, A., Cort, C., et al. (2004). Rates and predictors of mental illness in gay men, lesbians and bisexual men and women: Results from a survey based in England and Wales. British Journal of Psychiatry, 185, 479–485.

Warwick, L., Douglas, N., Aggleton, P., & Boyce, P. (2003). Context matters: The educational potential of gay bars revisited. AIDS Education and Prevention, 15, 320–333.

Weinberg, G. (1972). Society and the healthy homosexual. New York: St Martin’s Press.

Weinberg, M. S., Williams, C. J., & Pryor, D. W. (1994). Dual attraction: Understanding bisexuality. New York: Oxford University Press.

Weinberg, T. (1994). Gay men, drinking and alcoholism. Carbondale: Southern Illinois University Press.

Weston, K. (1991). Families we choose: Lesbians, gays, and kinship. New York: Columbia University Press.

White, J. C., & Dull, V. T. (1997). Health risk factors and health-seeking behavior in lesbians. J Womens Health, 6(1), 103–112.

White, T., & Ettner, R. (2007). Adaptation and adjustment in children of transsexual parents. European Child and Adolescent Psychiatry, 16(4), 215–221.

Whitley, B., & Kite, M. (1995). Sex differences in attitudes toward homosexuality. Psychological Bulletin, 117, 146–154.

Wierzalis, E. A., Barret, B., Pope, M., & Rankins, M. (2006). Gay men and aging: Sex and intimacy. In D. Kimmel, T. Rose, & S. David (Eds.), Lesbian, gay, bisexual, and transgender aging: Research and clinical perspectives (pp. 91–109). New York: Columbia University Press.

Wilchins, R. A. (1997). Read my lips: Sexual subversion and the end of gender. New York: Firebrand Books.

Williamson, I. R. (2000). Internalized homophobia and health issues affecting lesbians and gay men. Health Education Research, 15, 97–107.

Williams, D. R., Neighbors, H. W., & Jackson, J. S. (2003). Racial/ethnic discrimination and health: Findings from community studies. American Journal of Public Health, 93, 200–208.

Willging, C. E., Salvador, M., & Kano, M. (2006a). Pragmatic help-seeking: How sexual and gender minority groups access mental health care in a rural state. Psychiatric Services, 57(6), 871–874.

Willging, C. E., Salvador, M., & Kano, M. (2006b). Brief reports: Unequal treatment: mental health care for sexual and gender minority groups in a rural state. Psychiatric Services, 57(6), 867–870.

Wilson, B. (2007). Our families: Attributes of Bay Area lesbian, gay, bisexual, and transgender parents and their children. San Francisco: LGBT Family Collaborative.

Wilson, P. A., & Yoshikawa, H. (2007). Improving access to health care among African-American, Asian and Pacific Islander, and Latino LGB populations. In I. H. Meyer & M. Northridge (Eds.), The health of sexual minorities: Public health perspectives on lesbian, gay, bisexual, and transgender populations (pp. 609–637). New York: Springer.

Wolitski, R. J., Jones, K. T., Wasserman, J. L., & Smith, J. C. (2006). Self-identification as “down low” among men who have sex with men (MSM) from 12 US cities. AIDS and Behavior, 10(5), 519–529.

Woodyard, J., Peterson, J. L., & Stokes, J. (2000). Let us go into the house of the Lord: Participation in African American churches by African American MSM. Journal of Pastoral Care, 54, 451–460.

Xavier, J. (2000). Final report of the Washington Transgender Needs Assessment Survey. Washington, DC: Administration for HIV and AIDS, Govt of the District of Columbia. Retrieved from www.gender.org/resources/dge/gea01011.pdf

Xavier, J., Honnold, J. A., & Bradford J. (2007). The health, health-related needs, and life course experiences of transgender Virginians. Richmond: VA Department of Health.

Yancey, A. K., Cochran, S. D., Corliss, H. L., & Mays, V. M. (2003). Correlates of overweight and obesity among lesbian and bisexual women. Preventative Medicine, 36(6), 676–683.

Yoshikawa, H., Wilson, P. A., Chae, D. H., & Cheng, J. (2004). Do family and friendship networks protect against the influence of discrimination on mental health and HIV risk among Asian and Pacific Islander gay men? AIDS Education and Prevention, 16, 84–100.

Young, R. M., & Meyer, I. H. (2005). The trouble with ‘MSM’ and ‘WSW’: erasure of the sexual-minority person in public health discourse. American Journal of Public Health, 95(7), 1144–1149.

Zevin, B. (2000). Demographics of the transgender clinic at San Francisco’s Tom Waddell Center. San Francisco: University of California San Francisco.

Zucker, K. (2006). The politics and science of “reparative therapy.” In J. Drescher & K. Zucker (Eds.), Ex-gay research: Analyzing the Spitzer study and its relation to science, religion, politics, and culture (pp. 3–12). New York: Haworth Press.

Appendix LGBTQ Links and Resources on the Web

This list of Web sites is offered to help students and health care providers explore the wealth of health-related and human rights information that is available on the Web. Our inclusion on this list does not indicate our endorsement of the specific Web content that you will find. However, except for the last section in which we provide links to antigay Web sites, we have included only Web resources that meet these criteria related to quality and reliability of the Web site:

- The site is sponsored by or authored by a defined group or individuals, and there are clear links that locate these individuals and their credentials.

- The information on the site is reasonably traceable and can be corroborated by other sources.

- The site itself is likely to remain in place on the Web; the affiliations related to the site are generally known to have a relatively stable identity.

- The site provides evidence to support the information provided and/or clear rationales for their policies and positions.

Debunking Myths

PFLAG (Parents and Friends of Lesbians and Gays) FAQ’s: http://www.pflag.org/Frequently_Asked_Questions.comingout_faq.0.html

PFLAG’s frequently asked questions address many of the myths and provide information to help overcome them.

Texas Woman’s University Counseling Center: http://www.twu.edu/O-SL/counseling/SelfHelp042.html

It offers clarification of many of the lesbian, gay, bisexual, and transgender (LGBT) myths that abound, particularly for college students.

McGill Student Health Service (http://www.mcgill.ca/studenthealth/information/queerhealth/myths/) It offers a more extensive explanation of many of the myths.

Gay Church (http://www.gaychurch.org/Gay_and_Christian_YES/gay_and_christian_yes.htm)

It clarifies what the Bible really says about homosexuality.

Education and Support

Gay, Lesbian, and Straight Education Network (GLSEN): http://www.glsen.org/cgi-bin/iowa/all/home/index.html

This group focuses on advocacy for LGBT youth in schools. Their report card on the school climate provides information about the effects of harassment on LGBT youths grades, mental health, and dropout rates.

Parents and Friends of Lesbian and Gays: http://www.pflag.org/

It is an international organization with chapters in many countries that provide support for families and friends when they find out they have a loved one who is LGBT.

Asian Pacific Islander PFLAG (API PFLAG): http://www.pflag.gapsn.org/

Asian Pacific Islander (API) PFLAG works to help keep families together. API PFLAG support group meetings provide a safe space for LGBT, and questioning people to share their feelings and experiences, explore their identity, and seek the acceptance and unconditional love that our members have to offer. API PFLAG offers confidential e-mail and telephone support on coming-out issues and religious issues. We also support, educate, and advocate for equal civil rights for LGBT people.

Asian Pacific Islander (API) Family Pride: http://www.apifamilypride.org/

The mission of Asian and Pacific Islander Family Pride is to end the isolation of Asian and Pacific Islander families with LGBT members through support, education, and dialog. Our vision is the recognition and acceptance among Asian and Pacific Islander families of the sexual and gender diversity within our cultures.

Unid@s, the National Latina/o LGBT Human Rights Organization: http://www.unidoslgbt.org/index.html

Newly formed organization founded in 2007 with the spirit of community and Latin@ culture at the forefront. The primary focus is to fight for justice for all LGBT Latin@s and all people.

NIA Collective: http://www.niacollective.org/

The NIA Collective exists to create and provide a safe and healthy environment for the growth and empowerment of lesbians of African descent and the communities in which we live. The purpose is to collectively build a network through self-definition, self-acceptance, and acceptance of each other as lesbians, as people of African descent, and as women

BiNetUSA: http://www.binetusa.org/index.html

BiNet USA, an umbrella organization and voice for bisexual people, facilitates the development of a cohesive network of bisexual communities, promotes bisexual visibility, and collects and distributes educational information regarding bisexuality. BiNet USA provides a national network for bisexual organizations and individuals across the United States to encourage participation and organizing on local and national levels.

Intersex Society of North America: http://www.isna.org/

The Intersex Society of North America is devoted to systemic change to end shame, secrecy, and unwanted genital surgeries for people born with an anatomy that someone decided is not standard for male or female.

World Professional Association for Transgender Health: http://www.wpath.org/

Formerly known as the Harry Benjamin International Gender Dysphoria Association, Inc. (HBIGDA), World Professional Association for Transgender Health is a professional organization devoted to the understanding and treatment of gender identity disorders. As an international interdisciplinary, professional organization, the mission of the World Professional Association for Transgender Health is to further the understanding and treatment of gender identity disorders by professionals in medicine, psychology, law, social work, counseling, psychotherapy, family studies, sociology, anthropology, sexology, speech and voice therapy, and other related fields.

Tri-Ess – Support, Serenity, Service: http://www.tri-ess.org/

Tri-Ess is an educational, social, and support group for heterosexual cross-dressers, their partners, and the spouses of married cross-dressers and their families. We believe that we are blessed with an additional facet to our personalities. If we accept our cross-gendered side and explore it, we will find a broadening of the entire personality, which can be very fulfilling. We dress in emulation, rather than in mockery, of femininity.

National Association of Lesbian, Gay, Bisexual, and Transgender Community Centers: http://www.lgbtcenters.org/

The National Association of LGBT Community Centers exists to support and enhance LGBT community centers, which are engines of community organizing and liberation, and crucial to the health and strength of LGBT communities. The association offers technical assistance, leadership training, and networking opportunities to centers in all stages of formation and is a national voice for the LGBT community centers movement.

National Sexuality Resource Center: http://nsrc.sfsu.edu/

This center gathers and disseminates the latest accurate information and research on sexual health, education, and rights. Through active outreach to advocates, academics, researchers, policy makers, and diverse communities, it initiates constructive dialogues—both online and face-to-face—on sexuality to promote social justice and improve the quality of life in the United States. The goal of the center is to increase sexual literacy by providing training, articles on sexuality research and community work, as well as resources on sexual health, education, and rights. It also works to counter negative representations and distortions of sexuality by providing accurate, evidence-based information for academics, advocates, and the public.

Political Activist and Legal Groups

ACLU LGBT Project (http://www.aclu.org/getequal/aboutus.html)

It fights discrimination and moves public opinion on LGBT rights through the courts, legislatures, and public education.

Gay and Lesbian Alliance Against Defamation (http://www.glaad.org/) It promotes and ensures fair, accurate, and inclusive representation of people and events in the media as a means of eliminating homophobia and discrimination based on gender identity and sexual orientation.

Gay and Lesbian Advocates and Defenders: http://www.glad.org/

Gay & Lesbian Advocates & Defenders is New England’s leading legal rights organization dedicated to ending discrimination based on sexual orientation, HIV status, and gender identity and expression.

Gender Public Advocacy Coalition (GenderPAC): http://www.gpac.org/about/

“The Gender Public Advocacy Coalition works to ensure that classrooms, communities, and workplaces are safe for everyone to learn, grow, and succeed—whether or not they meet expectations for masculinity and femininity. As a human rights organization, GenderPAC also promotes an understanding of the connection between discrimination based on gender stereotypes and sex, sexual orientation, age, race, and class.”

Human Rights Campaign: http://www.hrc.org/

It works for equal rights for LGBT people by taking political action, education, and sponsoring action networks. The Web site has much important information on all aspects of LGBT civil rights, including healthcare.

Human Rights Watch: http://www.hrw.org/doc/?t=lgbt

Human Rights Watch is dedicated to protecting the human rights of people around the world by standing with victims and activists to prevent discrimination, uphold political freedom, protect people from inhumane conduct in wartime, and bring offenders to justice. Their work on behalf of LGBT rights is strong internationally; the HRW Web site provides information about LGBT rights organizations in many countries around the world.

Lambda Legal Defense and Education Fund: http://www.lambdalegal.org/

It is a national organization committed to achieving full recognition of the civil rights of lesbians, gay men, and people with HIV/AIDS through impact litigation, education, and public policy work.

National Gay and Lesbian Task Force: http://www.thetaskforce.org/

It aims to build the grassroots political power of the LGBT community to win complete equality. It organizes and trains people at the grassroots level to lobby to defeat anti-LGBT ballot initiatives and legislation and pass pro-LGBT legislation and other measures. It analyzes and reports on the positions of candidates for public office on issues of importance to the LGBT community.

National Center for Lesbian Rights: http://www.nclrights.org/

A national legal organization committed to advancing the civil and human rights of LGBT people and their families through litigation, public policy advocacy, and public education.

National Coalition for LGBT Health: http://www.lgbthealth.net/

National Coalition for LGBT Health is a coalition of organizations that promote research, policy, programs and services, professional and cultural competency, and the diversity of the national LGBT community. The specific goal of the coalition is to ensure equity in health status and participation in the decision-making process for individual members of the LGBT population and representative organizations.

Transgender Law and Policy Institute: http://www.transgenderlaw.org/

A comprehensive transgender legal resource, providing up-to-date publications, cases, briefs, and news on transgender legal issues.

Transgender Law Center: http://www.transgenderlawcenter.org/

The Transgender Law Center is a civil rights organization advocating for transgender communities. It utilizes direct legal services, public policy advocacy, and educational opportunities to advance the rights and safety of diverse transgender communities.

Health-–General Advocacy and Information Resources

American Psychological Association: http://www.apa.org/pi/lgbc/homepage.html

A strong organization with unequivocal positions on behalf of LGBT concerns and strong policy statements against any form of discrimination toward LGBTQ people. For specific policy statements, see http://www.apa.org/pi/lgbc/policy/pshome.html. For answers to questions about sexual orientation, see http://www.apa.org/topics/orientation.html

American Psychiatric Association Healthy Minds, Healthy Lives: http://healthyminds.org/glbissues.cfm

It provides basic information endorsed by the American Psychiatric Association concerning sexual orientation, homosexuality, effects of stigma on LGBT health, and the association’s opposition to reparative therapy or any approach to changing one’s sexual orientation.

American Medical Students Association LGBT Group: http://www.amsa.org/lgbt/

“…dedicated to supporting LGBT medical students by providing a safe and supportive environment, advocating for their rights against discrimination, and providing resources to make their medical education a positive experience. We also advocate for LGBT patients by supporting the inclusion of LGBT health issues in medical school curricula and improving the quality of patient care through physician sensitivity. Finally, we break down the prejudices and misconceptions concerning LGBT people that act as barriers to education and patient care, by providing medical students with the resources and tools they need to begin advocating for LGBT patients and peers at their institutions.”

Fenway Community Health: http://www.fenwayhealth.org/site/PageServer

“For more than thirty-five years, Fenway Community Health has been working to improve the physical and mental health of our community, especially those who are traditionally underserved like lesbian, gay, bisexual and transgender (LGBT) people, women, those living with HIV/AIDS, and people from communities of color.”

Gay and Lesbian Medical Association: http://www.glma.org/

This Web site contains several resources, including the survey used by a joint study of Gay and Lesbian Medical Association and the Human Rights Campaign to study hospital policies and procedures. You can download a pdf copy of the Healthcare Equality Index to use in your institution. There are also other documents on LGBT healthcare topics on this Web site.

GayHealth.com: http://www.gayhealth.com/templates/news/index.html

Health and wellness site dedicated to LGBT men and women. The site is staffed by LGBT professionals who strive to provide accurate, current, and vital health information to the LGBT community.

Lesbian Health Research Center: http://www.lesbianhealthinfo.org/

The center is dedicated to improving the health of lesbians, bisexual women, transgender people, and our families. To achieve this goal, we create comprehensive programs of research, education and trainings, public events, and community collaborations. The Web site includes results of research studies that the center has sponsored.

Lesbian Health: National Women’s Health Information Center: http://womenshealth.gov/faq/Lesbian.htm

It is the U.S. Federal Government source for women’s health information and addresses the challenges lesbians face in the health care system, information lesbians need to discuss with their provider, information about sexually transmitted diseases (STDs), and advice for lesbians to protect their health. It also provides links to specific health concerns such as cancer, heart disease, depression, and stress.

Atlanta Lesbian Health Initiative: http://www.thehealthinitiative.org/

A lesbian health organization serving the southeastern United States that provides services, education, outreach, and advocacy for lesbians who have been diagnosed with disease and for those who are committed to living healthier lives. The Web site includes links and resources related to specific lesbian health concerns.

Center for Young Women’s Health: Lesbian Health: http://www.youngwomenshealth.org/lesbianhealth.html

This Web site provides specific information for teens about lesbians and lesbian health. It includes specific answers to questions teens have about lesbians and being a lesbian, a list of books, Web sites, and phone numbers for more information and support.

Lesbian Teen Health Care: http://www.medem.com/medlb/article_detaillb.cfm?article_ID=ZZZKDI5LUSD&sub_cat=2004

Medical Library of the American Association of Obstetricians and Gynecologists Tool Kit for Lesbian Teen Care. It provides basic information about lesbian identity for teens, with an emphasis of how lesbian teens can take care of their health.

GLBT Health Access Project: http://www.glbthealth.org/

It provides training, technical assistance, and materials to help service providers learn more about the health care needs of GLBT populations and create welcoming environments for staff and clients.

Mautner: National Lesbian Health Organization: http://www.mautnerproject.org/home/

The goal of this Web site is to serve lesbians and women who partner with women by giving information, as well as providing assistance in finding local and national health services.

Howard Brown Health Center: http://www.howardbrown.org/

The Midwest’s premier LGBT health care organization is leading the region in addressing the comprehensive health care needs of people in the LGBT community. The multisite operation includes a main health center in Uptown, Triad Health practice at Illinois Masonic Hospital, the Broadway Youth Center, and four Brown Elephant resale stores in Chicago and Oak Park. Howard Brown provides an expansive network of programs and services, accomplished with a diverse and qualified staff of licensed doctors, nurses, health care practitioners, renowned research professionals, and prominent community leaders.

National Coalition for LGBT Health: http://www.lgbthealth.net/

It aims to ensure equity in health status and participation in the decision-making process for individual members of the LGBT population and representative organizations. Specific goals of the coalition are as follows:

• To increase knowledge regarding LGBT populations’ health status, access to and utilization of health care, and other health-related information.

• To increase LGBT participation in the formation of public and private sector policy regarding health and related issues.

• To increase availability of, access to, and quality of physical, mental, and behavioral health and related services for the LGBT population.

• To increase professional and cultural competencies of providers and others engaged in health and social service delivery to the LGBT population.

• To eliminate disparities in health outcomes of LGBT populations and the community including differences that occur by gender, race/ethnicity, education or income, disability, nationality, geographic location, age, sexual orientation, gender identity, or presentation.

African American Health and AIDS groups: http://www.blk.com/resources/o-health.htm

A listing of groups providing AIDS care, information, and resources for African Americans in the United States, Canada, England, Kenya, and South Africa.

Asian Pacific Islander Wellness Center: http://www.apiwellness.org/

A nonprofit organization that aims to educate, support, empower, and advocate for Asian and Pacific Islander communities, particularly A&PIs living with, or at risk for HIV/AIDS. It offers prevention services and testing for HIV/STD/hepatitis.

Health: Specific Health Concerns

Quit Smoking: http://www.gaysmokeout.net/resources.html

This Web site provides links to articles and research on smoking among LGBTQ groups, facts about tobacco company advertising targeted to LGBTQ groups, and, most important, information about how to quit and support for quitting.

LesbianSTD.com: http://depts.washington.edu/wswstd/

It provides information and resources regarding sexual health and STDs in women who have sex with women and to further our collective knowledge about lesbian STDs  through research.

Out with Cancer: http://www.outwithcancer.com/

Out with Cancer is the world’s first networking and online support program for LGBT men and women who are diagnosed with cancer.

Long Island Lesbian Cancer Initiative: http://lilci.org/

It is a grassroots, social justice, nonprofit organization dedicated to health and wellness with emphasis on cancer. Its purpose is to eliminate health disparities through education, advocacy, research, and services. Programs range from immediate support needs, such as peer support services, to eliminating heterosexism and homophobia from health care through cultural competency training and supporting our communities’ inclusion in health research.

Gay Men’s Health Crisis: http://gmhc.org/

“A not-for-profit, volunteer-supported and community-based organization committed to national leadership in the fight against AIDS. Our mission is to reduce the spread of HIV disease, help people with HIV maintain and improve their health and independence, and keep the prevention, treatment and cure of HIV an urgent national and local priority. In fulfilling this mission, we will remain true to our heritage by fighting homophobia and affirming the individual dignity of all gay men and lesbians. The GMHC Hotline responds to over 35,000 phone calls and Internet requests yearly in both Spanish and English with accurate information, emotional support, and an expansive referral service that includes over 10,000 service providers.

Hepatitis A and B Immunization-–Immunization Action Coalition: http://www.immunize.org/catg.d/p4115.htm

A guide for gay and bisexual men to protect themselves against hepatitis A and B infection.

Bullying and Gay Youth: http://www.nmha.org/go/information/get-info/children-s-mental-health/bullying-and-gay-youth

Mental Health America (formerly the National Mental Health Association) resource for schools, parents, and youth to end bullying directed at GLBT youth in schools.

Substance Abuse Treatment Training Materials: http://www.public-health.uiowa.edu/pattc/lgbttrainingcurriculum/

“Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals” provides both practitioners and administrators with familiarity and knowledge about the interaction between LGBT issues and substance use disorders. The curriculum offers skill-building knowledge enhancing practical skills to offer sensitive, affirmative, culturally relevant, and effective treatment to LGBT individuals in substance use disorders treatment. The Web site includes a link to the participant’s manual.

National Association of Lesbian & Gay Addiction Professionals: http://www.nalgap.org/

It is a membership organization founded in 1979 and dedicated to the prevention and treatment of alcoholism, substance abuse, and other addictions in LGBT communities. Its mission is to confront all forms of oppression and discriminatory practices in the delivery of services to all people and to advocate for programs and services that affirm all genders and sexual orientations. It provides information, training, networking, and advocacy about addiction and related problems and support for those engaged in the health professions, individuals in recovery, and others concerned about the health of gender and sexual minorities.

Association of Gay and Lesbian Psychiatrists: http://www.aglp.org/

A member organization for psychiatrists that educates and advocates on LGBT mental health issues. The goals of AGLP are to

- foster a fuller understanding of LGBT mental health issues;

- research and advocate for the best mental health care for the LGBT community;

- develop resources to promote LGBT mental health;

- create a welcoming, safe, nurturing, and accepting environment for members; and

- provide valuable and accessible services to our members.

Parenting and LGBT Families

Parenting: http://www.aclu.org/lgbt/parenting/11824res19990406.html

In this Web site, the American Civil Liberties Union’s position on LGBT parenting, information and resources, and an excellent summary of myths surrounding lesbian and gay parenting are provided.

Family Pride: http://www.familypride.org/

Committed to securing family equality for LGBT and queer parents, guardians, and allies, the Web site provides publications and action guides for LGBTQ parents and families.

Lesbian Family National Longitudinal Study: http://www.nllfs.org/

It follows U.S. lesbian mothers and their children who were conceived by donor insemination during the lesbian baby boom of the 1980s. The Web site provides pdf files of articles published based on, or related to, the study.

Camp Lavender Hill for children of LGBT families: http://camplavenderhill.org/

It offers a weeklong summer camp creating a safe and supportive environment for children (aged 9–14) of LGBT families. Children, adolescents, and young people of all ages have a strong need for acceptance, validation, and a sense of belonging. By providing these children with an alternative to traditional summer camp, Camp Lavender Hill offers them the opportunity to enhance self-esteem in a place where differences and diversity are celebrated.

Children of Lesbians and Gays Everywhere: http://www.colage.org/

This organization aims to engage, connect, and empower people to make the world a better place for children of lesbian, gay, bisexual, and/or transgender parents and families. It is the only national organization in the world specifically supporting children, youth, and adults with LGBT parent(s). It offers a diverse array of support, education, and advocacy by and for folks with LGBT parents.

Religious Groups

Gay Church: http://www.gaychurch.org/

Resources and support for LGBT Christians

ChristianGays.com: http://www.christiangays.com/index.shtml

An international organization providing a safe place to connect with others and to provide resources that LGBTQ people need to accept themselves as gay Christians.

DignityUSA: GLBT Catholics: http://www.dignityusa.org/

“DignityUSA envisions and works for a time when Gay, Lesbian, Bisexual and Transgender Catholics are affirmed and experience dignity through the integration of their spirituality with their sexuality, and as beloved persons of God participate fully in all aspects of life within the Church and Society.”

Metropolitan Community Churches: http://www.mccchurch.org/

Congregations worldwide offer a church home to all Christians. MCC churches are based on the premise of universal priesthood of all believers and all people have equality of access and opportunity, which is free from discrimination on grounds of gender, sexual orientation, race, age, physical challenge, HIV status, health status, gender identification, nationality, or economic status.

United Church of Christ LGBT Ministries: http://www.ucc.org/lgbt/

This organization is dedicated to a clear course of welcome and inclusion, calling for serious study of human sexuality, supporting the civil rights of LGBT people, and in 1985 adopting the Open and Affirming resolution.

Unitarian Universalist Church LGBT Community: http://www.uua.org/visitors/justicediversity/6252.shtml

A liberal religion that encompasses many faith traditions, including those who identify as Christians, Jews, Buddhists, Hindus, Pagans, Atheists, Agnostics, Humanists, and others.  As there is no official Unitarian Universalist creed, Unitarian Universalist followers are free to search for truth on many paths. Unitarian Universalism is one of the few religions that ordain openly LGBT people. We encourage our LGBT clergy to participate as fully in our faith as our heterosexual clergy.

In addition to welcoming LGBT people into our religious community, we also work to protect the civil and legal rights of LGBT people and families across the country. Unitarian Universalist has been at the forefront of the same-sex marriage debates, advocating for the right for each person to marry the partner of his or her choice.

Quaker Lesbian Conference: http://qlc.quaker.org/

“exists to be a loving time and space in which women (self-defined) familiar with Quakerism, who are lesbian, bisexual, transgendered or moving towards those identities, can connect with Spirit and with each other. We envision a community in which each woman shares worship, spiritual exploration and loving relationships in an environment that embraces diversity, individual leadings, struggle, and play.”

Human Rights—General Resources That Include LGBTQ Rights

The European Human Rights Centre: http://www.ehrcweb.org/sections.php

The European Human Rights Centre represents more than 100 nongovernmental and other not-for-profit organizations interested in the promotion of human rights throughout Europe and beyond. Scroll down on the Web site above to see their position on human rights and sexual orientation.

RESEARCH: PLANNING, FUNDING, AND CONDUCTING

Gay Data: http://www.gaydata.org/ds001_Index.html

“This website encourages the collection of sexual orientation data and the analysis of data sources that have already collected such data.” The Web site includes

- Data Sources: listing known surveys and studies that have collected LGBT data,

- Knowledge Index: summarizing known facts related to LGBT populations

- Measures: providing details of known definitions and survey items used to identify “sexual orientation”

- Sampling: a discussion of (1) probability sampling versus nonprobability sampling, (2) modes of sexual orientation data collection, and (3) sample size.

- Recommendations: guidelines for research design and method, suggested questions when including sexual orientation data, and the rationale for including these data in any research study.

The Williams Institute: http://www.law.ucla.edu/williamsinstitute/home.html

“a national think tank dedicated to the field of sexual orientation law and public policy. It advances law and public policy through rigorous independent research and scholarship.” Located at the University of California, Los Angeles, the institute promotes research and policy initiatives–related sexual orientation law and public policy. The institute provides small grants each year for research related to its mission.

Society for the Scientific Study of Sexuality: http://www.sexscience.org/

The oldest professional society dedicated to the advancement of knowledge about sexuality. The society funds several awards each year, recognizing scholars who have contributed to the field. They award two $1,000 grants each year to student members doing research related to human sexuality. The society publishes three journals: Sexual Science, Annual Review of Sex Research, and the Journal of Sex.

Department of Health and Human Services: http://grants.nih.gov/grants/guide/pa-files/PA-07-409.html

Funding Opportunity Announcement invites grant applications for biological, behavioral, social, addictive, and mental health research related to the health of LGBT, intersex, and other diverse populations. Proposed research should be appropriate for the missions of one or more of the participating institutes.

Lesbian Health Fund: http://www.glma.org/index.cfm?fuseaction=Page.viewPage&pageId=594&parentID=534

Since 1992, Lesbian Health Fund has granted over half million dollars for important studies needed by health care providers to address the health concerns of their lesbian patients. Its goals include educating health care providers about lesbian health needs, and lesbians about risk reduction, early diagnosis of health problems, and safe insemination techniques.

Antigay Web Sites and What You Need to Know About Them

There are several antigay groups that claim to provide “treatment” of homosexuality, that distribute grossly erroneous information, and that promote hatred and discrimination. An example of the kind of misinformation that is promoted by antigay groups is Exodus, International (http://www.exodus-international.org/), a fundamentalist Christian organization, which offers freedom from homosexuality through Jesus Christ.

The following resource on the Web provides an excellent overview of these groups and characteristics of the content you will find on Web sites that are sponsored by antigay groups. Brett Humphries, who maintains the Web watch, also provides links to a number of Web sites of antigay groups. http://www.pinktriangle.org.uk/glh/194/webwatch.html

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