The Health of Lesbian, Gay, Bisexual, and Transgender People Building a Foundation for Better Understanding (2011) / Chapter Skim
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5 Early/Middle Adulthood
5 Early/Middle Adulthood
Pages 185-250
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From page 185... ...
The journey through adulthood is often characterized by the physical manifestations of midlife, career achievements and transitions, relationship and family development and changes, and changes in interpersonal ties and community participation. These same domains and issues characterize the experiences of LGBT adults, albeit often in different forms.
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From page 186... ...
The following sections describe research on LGBT adults in the areas of the development of sexual orientation and gender identity; mental health status; physical health status; risk and protective factors; health services; and contextual influences, including demographic characteristics and the role of the family. The final section presents a summary of key findings and research opportunities.
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From page 187... ...
In a review of the effects of social context on black homosexual males, Peterson and Jones (2009) note that studies reveal that, relative to men of other racial groups, black men experience higher levels of internalized homophobia, are less likely to disclose their homosexual orientation, and are more likely to perceive that their friends and neighbors disapprove of homosexuality.
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From page 188... ...
In examining the social, sexual, and psychological milestones for their sample, the authors found that the milestones occurred at an earlier age in younger cohorts, but the changes in age at occurrence by cohort are occurring at different rates. For instance, while sexual behavior milestones (age at first sexual contact with another male)
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From page 189... ...
. Transgender women who did not conform to gender roles in childhood tend to come out at an early age, either before or during early adulthood, and if so desired, change gender roles and feminize their body through hormone therapy and/or surgery (Bockting and Coleman, 2007; Lawrence, 2010)
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From page 190... ...
examined specific quality-of-life indicators by behaviorally defined sexual orientation categories (heterosexual, homosexual, bisexual since age 18 and within the last 12 months)
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From page 191... ...
While more research has been conducted on mental health than on physical health conditions among LGBT adults, large gaps still remain in our understanding of mental health issues among LGBT people. There is conflicting evidence on the mental health status of LGB adults, and the existing research examining the mental health of transgender adults has limitations.
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From page 192... ...
examined differences in the prevalence of psychiatric syndromes among sexually active individuals. Behavioral sexual orientation was compared between respondents who reported exclusively other-sex sex partners (n 5 9,714)
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From page 193... ...
The results revealed that gay/bisexual men had a higher prevalence of panic attacks than heterosexual men, while lesbian/ bisexual women had a higher prevalence of generalized anxiety disorder than heterosexual women. However, the authors note the limited number of participants who reported a homosexual or bisexual orientation.
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From page 194... ...
Homosexually active women were no more likely than exclusively heterosexual women to evidence major depression syndrome. Cochran and colleagues (2003)
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From page 195... ...
Bisexual women who had disclosed their sexual orientation to a majority of friends, family, and coworkers were twice as likely to have reported suicidal ideation relative to heterosexual women. Among sexual minorities who had not disclosed their sexual orientation to a majority of friends, family, and coworkers, lesbians were 90 percent more likely to have ever made a suicide attempt, and bisexual women were three times more likely than heterosexual women to have done so (Koh and Ross, 2006)
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From page 196... ...
As defined by sexual behavior, same-sex sexual orientation was significantly associated with lifetime suicidal ideation and attempted suicide, even after adjustment for substance use and other depressive symptoms. However, the authors note limitations of the study due to their sampling design and selection criteria.
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From page 197... ...
. In a study mentioned earlier involving participants in a sexual health seminar intervention, 47 percent of transgender persons reported suicidal ideation or attempts in the last 3 years, compared with 31 percent of men who have sex with men and 32 percent of behaviorally bisexual women (Bockting et al., 2005a)
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From page 198... ...
Eating Disorders/Body Image Some research, using small samples, suggests that sexual-minority status may be a risk factor for eating disorders among men. Far less research has been conducted among lesbians and bisexual women to determine whether there is an association -- either positive or negative -- between sexual orientation and eating disorders or body image.
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From page 199... ...
• For genital reconstructive surgery -- Evaluation and recommenda tion by two mental health professionals with competency in the as sessment and treatment of sexual and gender identity disorders; 12 months of continuous hormone therapy (if applicable) ; 12 months of living full time in the preferred gender role (referred to as real life experience)
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From page 200... ...
Nonetheless, the standards have been criticized by transgender community members with respect to the stigmatizing effect of a diagnosis of gender identity disorder, whether psychotherapy should be required before hormone therapy or surgery, whether a period of real life experience before hormone therapy is helpful or potentially harmful, and the value and length of the real life experience before surgery (see Bockting et al., 2009b, for a critical review)
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From page 201... ...
. Until recently, hormone therapy, the real life experience, and surgery were considered three steps in a linear process of sex reassignment.
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From page 202... ...
PHYSICAL HEALTH STATUS While LGBT adults have all of the same health concerns as the general population, there are some areas of physical health that are known to be distinct for sexual and gender minorities. Sexual/Reproductive Health Very little research has been conducted on the sexual health of LGBT people, and most of it has focused on sexual dysfunction among gay and bisexual men.
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From page 203... ...
. The survey results indicated that sexual satisfaction was influenced in both groups by similar factors, including relationship satisfaction and sexual functioning, suggesting that gender may play a greater role than sexual orientation in sexual satisfaction.
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From page 204... ...
Little research exists on patterns of motherhood or access to assisted reproductive technology among sexual-minority women. The American Society for Reproductive Medicine explicitly states that programs should treat all requests for assisted reproduction equally without regard to marital status or sexual orientation, and the American College of Obstetricians and Gynecologists states that sexual orientation should not be a barrier to fertility services for achieving pregnancy (American College of Obstetricians and Gynecologists, 2005; Ethics Committee of the American Society for Reproductive Medicine, 2009)
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From page 205... ...
As some of these risk factors are associated with other cancers, most notably lung cancer (smoking) , it is likely that women who have sex with women may be at greater risk for some cancers than heterosexual women.
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From page 206... ...
For example, there have been no long-term prospective studies of breast cancer among transgender women. However, case reports have been published of breast cancer among transgender women who have taken feminizing hormones (Ganly and Taylory, 1995; Pritchard et al., 1988; Symmers, 1968)
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From page 207... ...
One study of 4,135 women aged 18−64 in Los Angeles County examined cardiovascular health among self-identified lesbian, bisexual, and heterosexual women. Results showed that lesbians were significantly more likely than heterosexuals to receive a diagnosis of heart disease.
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From page 208... ...
They found that lesbians were more likely to be obese or overweight than bisexual women, heterosexual women, and women who identified as "something else." These data, in conjunction with findings of earlier studies, suggest that lesbians may be at greater risk for obesity and the health problems it may cause. A number of studies have examined why lesbians, and in some cases bisexual women, are more obese and overweight than heterosexual women.
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From page 209... ...
identified a number of risk factors for transgender women. Specifically, they found that transgender women in these studies had multiple sex partners who were predominantly male, had casual sex, and had sex while they were intoxicated or high.
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From page 210... ...
, prevalence rates of HIV among women who have sex with both women and men were higher than those among exclusively heterosexual or exclusively homosexual women. More recently, it has been noted that while female-to-female transmission of HIV appears to be possible, there have been no confirmed cases (CDC, 2008)
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From page 211... ...
Lack of knowledge about risk behavior and disease transmission was also notable in this population. Transgender-Specific Physical Health Status As mentioned in the discussion of mental health status, some research has been conducted on the impact of hormone therapy and surgery on gender dysphoria.
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From page 212... ...
. Other studies with nonprobability samples also have shown that lesbian, gay, and bisexual adults are at risk for victimization because of their sexual orientation (Herek et al., 1999; Huebner et al., 2004; Otis and Skinner, 1996)
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From page 213... ...
. Research with convenience samples of transgender people in various communities across the United States highlights a high prevalence of enacted stigma and discrimination based on gender identity.
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From page 214... ...
, based on a probability sample of 405 lesbian, gay, and bisexual adults, found that 32 percent of the sample had ever been targeted for violence because of their sexual orientation. In a study using data from the Knowledge Networks panel (n 5 662)
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From page 215... ...
Sexual orientation was based on self-reports of same-gender behavior. The authors found that the homosexually experienced women were more likely than the exclusively heterosexually experienced women to currently smoke.
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From page 216... ...
. The authors found that, relative to the exclusively heterosexual women, the odds of past-year tobacco use were more than three times greater in the bisexual women and two times greater in the heterosexual women reporting same-sex partners.
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From page 217... ...
Few significant differences were found among men by sexual orientation, with the only significant finding being that the gay men had lower abstention rates than the exclusively heterosexual men. By contrast, both the heterosexual women with same-sex partners and the bisexual women had significantly lower abstention rates than the exclusively heterosexual women.
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From page 218... ...
, data from convenience samples suggest that substance use may be a major concern among transgender people as well. Eighteen percent of 392 transgender women and 4 percent of 123 transgender men in San Francisco and 23 percent of 332 transgender women of color in San Francisco reported injection drug use.
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From page 219... ...
Using data from the NHSII, Austin and colleagues (2008) compared rates of childhood abuse among self-identified lesbian, bisexual, and heterosexual women.
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From page 220... ...
. In a nonprobability sample of 181 transgender seminar participants in Minnesota, 23 percent of participants reported childhood sexual abuse and 38 percent childhood physical abuse (Bockting et al., 2005b)
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From page 221... ...
. Many of the protective factors of health among sexual minorities may be considered to contribute to their resiliency.
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From page 222... ...
The limited amount of research on transgender people has focused less on protective factors than on the factors associated with positive outcomes of sex reassignment. These factors, mentioned earlier in this chapter, include psychological adjustment, family support, psychological treatment, and good surgical outcomes (Carroll, 1999; Lawrence, 2003)
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From page 223... ...
found that bisexual men and women were less likely to seek help for sexual orientation issues and rated services as less helpful relative to lesbian and gay respondents in comparable research. Some research suggests that use of preventive screening may be less frequent among lesbians and bisexual women than among heterosexual women.
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From page 224... ...
About one-third of each group had not disclosed their sexual behavior, although they wanted to, because physicians had not asked. Another study examined LGB people's (n 5 88)
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From page 225... ...
. In a survey using a convenience sample of 248 transgender people of color in Washington, DC, 33 percent reported insensitivity or hostility from health care providers; 11 percent reported difficulty accessing transgender-specific health care procedures (counseling, hormone therapy, or surgery to alleviate gender dysphoria)
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From page 226... ...
experiences with psychotherapy and found that respondents viewed knowledge of bisexual-specific issues and validation of bisexual identity as important to a positive patient−provider relationship. As mentioned above, some research suggests that the quality of care received by transgender people is affected by a lack of culturally competent providers (Bockting et al., 1998; Clements-Nolle et al., 1999; Sperber et al., 2005)
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From page 227... ...
with a sample of self-identified heterosexual black and Latino women drawn from a population-based survey. She found that black and Latino lesbians and bisexual women had some negative health outcomes compared with heterosexual women, including higher rates of obesity and increased rates of tobacco and alcohol use; they also had lower rates of health insurance coverage.
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From page 228... ...
. As mentioned in Chapter 2, evidence also suggests that there are income differences based on sexual orientation.
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From page 229... ...
On the other hand, a study based on a convenience sample of 87 lesbian mothers in the United States and Canada revealed that those in the United States (who lived in states that did not provide legal recognition of marriage between same-sex couples) expressed more anxiety about legal problems and discrimination based on sexual orientation than those in Canada, whose family relationships enjoyed the protection of law (Shapiro
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From page 230... ...
. Findings of studies of representative samples of the children of lesbian and gay parents have been consistent with those of studies based on smaller and/or convenience samples.
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From page 231... ...
. In large part because of the absence of sexual orientation assessments in national survey data sets, large representative samples of these populations have rarely been studied.
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From page 232... ...
Physical Health Status • Very limited research suggests that gay men have higher rates of erectile dysfunction than heterosexual men. Little research has fo cused on reproductive health among LGBT people.
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From page 233... ...
• Although the research on protective factors for LGBT adults is limited, there is some indication that such factors as supportive living/working environments, support from family and friends, and a positive LGB identity may be protective. The limited amount of research on transgender people has focused less on protective factors and more on the factors associated with positive outcomes of sex reassignment (psychological adjustment, family support, psychological treatment, and good surgical outcomes)
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From page 234... ...
Research Opportunities Although a number of studies provide useful information on the health status of LGBT adults, very limited data exist in some areas. The research that has been conducted has been uneven in that it has been much less likely to focus on bisexual and transgender people, and within-group differences
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From page 235... ...
Similarly, research is needed to address the risk and protective factors associated with, as well as interventions to promote, health and well-being in LGBT populations. The following topics in LGBT health research would benefit from additional study: • Demographic and descriptive information, including the percentage of adults who are LGBT and how that percentage varies by demo graphic characteristics such as race, ethnicity, socioeconomic status, geography, and religion; also, the percentage of LGBT adults who are parents, as well as the general experiences and health status of LGBT adults and how these vary by demographic characteristics.
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From page 236... ...
2007. Adaptation to sexual orientation stigma: A comparison of bisexual and lesbian/gay adults.
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From page 237... ...
2004. Sexual orientation, health risk factors, and physical functioning in the Nurses' Health Study II.
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From page 238... ...
2008. A health profile of Massachusetts adults by sexual orientation identity: Results from the 2001–2006 Behavioral Risk Factor Surveillance System Surveys.
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From page 239... ...
2003. Sexual orientation and variation in physical and mental health status among women.
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From page 240... ...
International Journal of Eating Disorders 40(5)
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From page 241... ...
2001. Risk of psychiatric disorders among individuals reporting same-sex sexual partners in the national comorbidity survey.
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From page 242... ...
2007. Sexual orientation and mental health.
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From page 243... ...
2001. Inside-out: A report on the experiences of lesbians, gays, and bisexuals in America and the public's view on issues and policies related to sexual orientation.
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From page 244... ...
2010. Sexual orientation versus age of onset as bases for typologies (sub types)
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From page 245... ...
2003. Transgender identity and suicidality in a nonclinical sample -- sexual orientation, psychiatric history, and compulsive behaviors.
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From page 246... ...
2009b. Lifetime risk factors for HIV/sexually transmitted infections among male-to female transgender persons.
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From page 247... ...
2007. Making the invisible visible: Fear and disclosure of sexual orientation at work.
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From page 248... ...
2002. Utilization of mental health services: A comparison of lesbian and heterosexual women.
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From page 249... ...
American Journal of Public Health 75:1085–1087. Sperber, J., S
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From page 250... ...
2009. Epidemiology of gender identity disorder: Recom mendations for the standards of care of the world professional association for transgen der health.
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