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2 Context for LGBT Health Status in the United States
Pages 25-88

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From page 25...
... DEFINING GENDER IDENTITY, GENDER EXPRESSION, AND SEXUAL ORIENTATION To discuss the context surrounding the health of LGBT populations, the committee has adopted working definitions for a number of key terms. Sex is understood here as a biological construct, referring to the genetic, hormonal, anatomical, and physiological characteristics on whose basis one is labeled at birth as either male or female.
From page 26...
... . This dysphoria can manifest itself in a persistent unease with one's primary and secondary sex characteristics, a sense of inappropriateness in one's gender role, and a strong and persistent identification with and desire to live in the role of the other sex, which has been classified as gender identity disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)
From page 27...
... There is no consensus in the research literature as to whether, when describing a transgender person's sexual orientation, sexual orientation labels should be based on the person's sex at birth or gender identity. However, transgender people themselves, especially those who live full time in the cross-gender role, more often than not anchor their sexual orientation on gender identity (e.g., a male-to-female transsexual woman who is attracted primarily to women is most likely to refer to herself as lesbian rather than heterosexual or straight)
From page 28...
... As explained in Chapter 3, most adults exhibit consistency across the three categories (e.g., they are exclusively heterosexual or homosexual in their attractions, sexual behavior, and self-labeled identity) , but some do not.
From page 29...
... . Data from a 2005 national probability sample reveal that gay men (n 5 241)
From page 30...
... As noted above, however, the sexes overlap considerably on these dimensions. The extent to which patterns of same-sex sexual behavior differ across racial and ethnic groups is not clear.
From page 31...
... . Another study, conducted in Houston, Texas, with a nonprobability sample of 1,494 black, Latino, Asian, and white men and women, found that concordance rates between sexual behavior and identity varied across racial and ethnic groups (Ross et al., 2003)
From page 32...
... . HISTORICAL PERSPECTIVE Contemporary health disparities based on sexual orientation and gender identity are rooted in and reflect the historical stigmatization of LGBT people.
From page 33...
... This dual stigma historically attached to homosexual behaviors and persons has, as noted earlier, shaped the experiences of many people living today and has influenced many contemporary institutions that affect health. 1 Personal communication, J
From page 34...
... Their language varied from state to state, and they outlawed various types of sexual behavior, including some forms of homosexual behavior. The main effect of sodomy laws was not prosecution for homosexual acts -- such prosecutions were relatively infrequent.
From page 35...
... Because of the criminalization of homosexual acts and the stigmatization of homosexual identity, local police generally had the freedom to harass and pursue gay men and lesbians at will. Sexual minorities risked arrest when they gathered, even in private homes.
From page 36...
... , including psychotherapy, hormone treatments, aversive conditioning with nausea-inducing drugs, lobotomy, electroshock, and castration (e.g., American Psychological Association, 2009b; Feldman, 1966; Katz, 1976; Max, 1935; Thompson, 1949)
From page 37...
... published an extensive review of cross-cultural and cross-species studies of sexual behavior, concluding that same-sex sexual behavior occurs in many animal species and that homosexual behavior of some sort was considered normal and socially acceptable in a majority of the societies for which detailed ethnographic data were available (Ford and Beach, 1951)
From page 38...
... A detailed history of the impact of the AIDS epidemic on sexual and gender minorities is beyond the scope of this report and has been addressed elsewhere (see, e.g., various In 2 The diagnosis of homosexuality was replaced with a new, more restrictive diagnosis, "ego dystonic homosexuality," indicated by a persistent lack of heterosexual arousal, which the patient experienced as interfering with initiation or maintenance of wanted heterosexual relationships, and persistent distress from a sustained pattern of unwanted homosexual arousal. This new diagnostic category, however, was widely criticized by mental health professionals and was eliminated in 1986.
From page 39...
... This concern received additional impetus when the U.S. Supreme Court upheld the constitutionality of state sodomy laws in 1986 (American Psychological Association and APHA, 1986)
From page 40...
... Many men who contracted AIDS were involuntarily "outed" by the disease, but many others chose to come out in an attempt to reduce sexual stigma and prejudice. Social psychological research indicated that heterosexuals who reported knowing one or more gay men and lesbians personally were indeed more likely than others to be accepting and supportive of sexual minorities generally (e.g., Herek and Capitanio, 1996; Pettigrew and
From page 41...
... If the epidemic had never occurred, those networks would today be a source of social and emotional support as their members continued through their life course. Yet while the epidemic had considerable impact on individual lives, it also changed the LGBT community, creating an infrastructure of organizations dedicated to meeting the health and social needs of LGBT individuals.
From page 42...
... Inequalities in the law can affect fundamental aspects of the lives of LGBT people and can directly impact their ability to access quality health care. While federal laws and policies govern some areas of import to LGBT populations (e.g., military personnel policy, U.S.
From page 43...
... Hate Crimes Prevention Act, enacted in 2009, expanded federal hate crime law to allow federal prosecution of crimes motivated by a victim's sexual orientation and gender identity. It also mandated the collection of data on crimes motivated by bias against a particular gender or gender identity (FBI, 2010)
From page 44...
... Currently, federal law does not explicitly prohibit school-based harassment based on sexual orientation or gender identity or expression. A minority of states explicitly prohibit bullying and harassment in public K–12 schools on the basis of sexual orientation or gender identity (Biegel and Kuehl, 2010)
From page 45...
... In addition, some state and local government entities offer limited benefits for the same-sex partners of their employees (e.g., access to group health insurance plans) , as do many private employers.
From page 46...
... In 2010, President Obama issued a memorandum directing the U.S. Department of Health and Human Services to adopt regulations requiring all hospitals receiving Medicaid or Medicare dollars to permit visitation by a designated visitor without regard to sexual orientation or gender identity and requiring those hospitals to respect all patients' advance directives.
From page 47...
... In a 2005 Internet survey with a national probability sample of self-identified lesbian, gay, and bisexual adults, approximately 35 percent of lesbians and 8 percent of gay men reported having at least one child, as did 67 percent of bisexual women and 36 percent of bisexual men (Herek et al., 2010)
From page 48...
... Over the past century, many transgender people have been a part of the larger gay and lesbian community. Transgender individuals played a key role in the Stonewall Rebellion, and they were instrumental in the organization of a more active gay and lesbian community in the 1970s (Bullough and Bullough, 1993)
From page 49...
... Although he refused to endorse sex reassignment surgery for nonintersex patients, David Oliver Cauldwell coined the term transsexual in his 1949 essay "Psychopathia Transexualis" to describe individuals whose sex assigned at birth, based on the appearance of their external genitalia, did not match their gender identity (Cauldwell, 1949)
From page 50...
... . Gender dysphoria was defined as serious discomfort with one's gender identity or gender role, thus acknowledging a spectrum of clinical presentations for which sex reassignment could be therapeutic and broadening the narrowly defined criteria originally used in the early sex reassignment programs (Laub and Fisk, 1974)
From page 51...
... study claiming that sex reassignment surgery did not "confer [any] objective advantage in terms of social rehabilitation" led to the closing of the Hopkins Gender Identity Clinic, and a number of other, smaller clinics followed (Meyerowitz, 2002)
From page 52...
... . Today, the existence of gender identity disorder and its inclusion in the DSM remains controversial and is the subject of intense debate, complicated by the potential implications of further depathologization and removal of the diagnosis for access to transgender-specific health care, particularly treatment of gender dysphoria and the medical interventions of hormone therapy and surgery that continue to be medically necessary for many (Drescher, 2010)
From page 53...
... As explained in Chapter 3, few such surveys currently include data on sexual orientation and gender identity; some examples of the types of questions asked on these surveys are presented in that chapter. Even when data are derived from probability samples, racial and ethnic minorities and other subgroups of the population may not be represented in sufficient numbers to permit meaningful conclusions to be drawn about their demographic characteristics.
From page 54...
... Sexual behavior was assessed with questions about the respondents' sexual acts with males and with females during three time periods (the past 30 days, the past 12 months, and since adolescence)
From page 55...
... , the margin of error associated with these estimates is fairly 13 All but three of the men and women in this group also reported having engaged in samesex sexual behavior.
From page 56...
... . More recent data from the 2002 NSFG, conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics, also provide estimates for sexual orientation identification, same-sex sexual behaviors, and same-sex attraction.
From page 57...
... Data from these and other national probability samples, as well as U.S. census data, reveal other demographic characteristics of LGBT populations.
From page 58...
... Using data from the NHSLS, Black and colleagues (2000) found that, depending on whether sexual orientation was defined in terms of exclusively same-sex sexual behavior during the previous year or self-labeled identity, between 18.5 percent and 28.6 percent of gay men were partnered at the time they were surveyed; partnership rates among women during the same period were 41.6–43.8 percent.
From page 59...
... census yields an estimate of the absolute number of cohabiting sexual minorities: nearly 1,200,000 individuals indicated that they were cohabiting in same-sex relationships. Recent numbers from the American Community Survey indicate that this number is growing more rapidly than the overall U.S.
From page 60...
... Age As is the case for heterosexual people, all age groups include lesbians and gay men. Similarly, all age groups include transgender individuals (Rosser et al., 2007)
From page 61...
... 5) characterized stigma as "an undesired differentness." Sexual stigma refers specifically to the stigma attached to any nonheterosexual behavior, identity, relationship, or community (e.g., Herek, 2009a)
From page 62...
... Personal-Level Barriers Personal-level barriers are created by the attitudes, beliefs, and behaviors of individuals within the health care system -- both providers and patients. Individual expressions of sexual and transgender stigma create significant personal barriers for LGBT people attempting to access highquality care.
From page 63...
... suggested this explanation after demonstrating significant disparities in health care access for gay men and lesbians compared with heterosexuals. In addition, many LGBT individuals do not disclose their sexual orientation because of fear of provider bias, although it should be noted that many patients, regardless of sexual orientation, are unwilling to disclose information about their sexual behaviors to a health care provider (Jillson, 2002)
From page 64...
... These barriers operate regardless of the attitudes of individuals. Examples of such barriers include an employer-based health care system that limits LGBT individuals' access to marital benefits, including eligibility for health insurance; lack of training in LGBT health received by providers; and insurance practices that limit the types of care covered for LGBT individuals.
From page 65...
... With respect to the health care provided to LGBT people, a number of structural barriers result from providers' lack of training in the health needs of LGBT patients. Cultural competency, referring to a set of skills that allows providers to give culturally appropriate high-quality care to individuals of cultures different from their own, is an important aspect of care (IOM, 1999)
From page 66...
... Lack of health insurance is a major structural barrier to care, and LGBT people and their children are more likely to lack health insurance than heterosexual people and their children (Badgett, 1994; Cochran, 2001; Diamant et al., 2000; Ponce et al., 2010)
From page 67...
... Several themes pervade this discussion, including stigma, the resilience of LGBT communities and individuals, the importance of research funding, and persistent health inequities among racial and ethnic minority LGBT individuals. This section returns to the HIV/AIDS epidemic, whose history and impact were briefly described above, to set the stage for the following chapters by illustrating how these themes continue to influence LGBT health today.
From page 68...
... In numerous studies, respondents who expressed negative attitudes toward gay people were more likely than others to be poorly informed about AIDS, to overestimate the risks of HIV transmission through casual social contact, to endorse punitive and restrictive AIDS-related policies (e.g., mass quarantine) , and to stigmatize people with the disease (D'Augelli, 1989; Goodwin and Roscoe, 1988; Herek and Glunt, 1991; Pleck et al., 1988; Price and Hsu, 1992; Pryor et al., 1989; Stipp and Kerr, 1989)
From page 69...
... Community-based organizations were created and provided a variety of medical, psychological, and social services to people with AIDS and disseminated information about sexual risk reduction and "safer sex." These organizations were visible in major urban centers, but these kinds of activities extended into smaller cities and towns as well. It can be argued that the AIDS epidemic created a greater sense of community among LGBT people than had previously existed, with farreaching effects.
From page 70...
... Importance of Research Funding One of the major successes that emerged from the AIDS epidemic was the confirmation that funding for research can drive progress. "Beginning in 1981 with the allocation of several hundred thousand dollars for research, U.S.
From page 71...
... by the Department of Health and Human Services for HIV/AIDS from fiscal year 1981 to fiscal year 2008. It should be noted that much of the research that has been undertaken on LGBT health generally has been made possible through HIV funding.
From page 72...
... . Of the 1,447 American Indian/Alaska Native men with HIV/AIDS at the end of 2005, 74 percent had been infected through male-to-male sexual contact or male-to-male sexual contact combined with intravenous drug use (CDC, 2008)
From page 73...
... HIV in racial and ethnic minority communities, particularly the black community, is complicated by a range of issues, including, among others, a lower likelihood of getting tested, greater discomfort with the health care system and with medical institutions, lower levels of acceptance of same-sex and bisexual sexual behavior, and racism (Peterson and Jones, 2009)
From page 74...
... The available demographic data fail to adequately describe the variations within each LGBT population; however, existing research provides some pertinent findings: • Self-identification as lesbian, gay, or bisexual and disclosure of this identity may vary by race, ethnicity, income level, or geographic location. • If one examines the historical trajectory of LGBT populations in the United States, it is clear that stigma has exerted an enormous and continuing influence on the life and consequently the health status of LGBT individuals.
From page 75...
... on LGBT health status is lacking. Although limited data are available with which to assess how many individuals identify as lesbian, gay, bisexual, or transgender, as well as how many report same-sex sexual behavior, demographic data on LGBT populations from large-scale surveys are largely absent from the literature.
From page 76...
... 2009a. Report of the APA task force on gender identity and gender variance.
From page 77...
... Journal of LGBT Health Research 4(4)
From page 78...
... 2000. Health behaviors, health status, and access to and use of health care: A population-based study of lesbian, bisexual, and heterosexual women.
From page 79...
... Archives of Sexual Behavior 9(5)
From page 80...
... 2010. Sexual behavior in the United States: Results from a national probability sample of men and women ages 14–94.
From page 81...
... 2009a. Hate crimes and stigma-related experiences among sexual minority adults in the United States: Prevalence estimates from a national probability sample.
From page 82...
... 2010. Recommendations for revision of the DSM diagnoses of gender identity disorders: Consensus Statement of the World Professional As sociation for Transgender Health.
From page 83...
... 1989. The impact of AIDS on a gay commu nity: Changes in sexual behavior, substance use, and mental health.
From page 84...
... 1994. The concept of gender identity disorder in childhood and adolescence after 39 years.
From page 85...
... 2009. Gender identity affirmation among male-to-female transgender persons: A life course analysis across types of relationships and cultural/lifestyle factors.
From page 86...
... 2009. Delaware -- sexual orientation and gender identity law and documentation of discrimination.
From page 87...
... 1948. Kinsey's sexual behavior in the human male; some comments and criti cisms.
From page 88...
... 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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