#61794: Promoting the Health of Gender and Sexual Minorities

The GSM population, like the general U.S. population, is a diverse group that may be defined as a subculture, which includes all ages of gay men, lesbian women, bisexual and transgender individuals, and those questioning their sexual identity. Ethnic or racial and cultural backgrounds, education, income, and places of residence further diversify this subculture. One's intrapersonal acceptance or rejection of societal stereotypes and prejudices, the acceptance of one's self-identity as a sexual minority, and how much one affiliates with other members of the GSM community varies greatly among individuals [8]. Some authors stress the diversity within the GSM community by discussing "GSM populations" [9]. For example, it is understandable that a GSM population living in rural areas of the United States would have little in common with a GSM population living in urban areas or "gay-friendly" neighborhoods. Additionally, mental health experts have suggested that "GSM community" symbolizes a single group of individuals who express their sexuality differently than the majority of heterosexual individuals. However, four distinct communities have been identified: lesbian, gay, bisexual, and transgender [10]. Each community is different from the other as well as different from the heterosexual community. A culturally competent healthcare provider should keep this diversity in mind so that vital differences among these smaller groups are not lost when thinking of the GSM population in general.

Commonalities exist among the GSM communities as well. For example, many adolescents, whether gay, lesbian, bisexual, transgender, or questioning their sexual identity, lack sexual minority role models to assist with successful psychosocial development [10].

Until recently, most professional literature about the GSM population was limited to psychology and sociology publications, with a focus on the prevalence of illnesses in the GSM community, such as depression, suicide, chemical dependency, and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) [8]. Though some information has been gathered, researchers have indicated that much more research and literature development must be done [10]. A body of knowledge related to sexual minority youth has been developed, but scant knowledge exists that addresses aging sexual minorities.

Textbooks and curricula in some professional education programs have begun to include information about the GSM community and its health needs, both medical and psychosocial. Illustrations used in classroom discussions about special populations include GSM populations as well as examples drawn from racial, ethnic, and other diverse groups. In the United States, the media has been presenting healthy portrayals of gay characters (younger characters more so than elderly, however). Still, many GSM individuals have not revealed their sexual identity or suspicion about being a sexual minority. As a result, their unique health and safety needs have been less understood by healthcare professionals, educators, counselors, and others.

A growing number of professional organizations have called for the development of more information about sexual minorities [9,11,12,13,14,15]:

Cass was the first to articulate a model of LGBTQ identity [48]. Believing that individuals have an active role in the acquisition of a LGBTQ identity, Cass suggested that individuals pass through six non-age-specific stages [48]:

Cass believed that individuals could be in more than one stage at a time and that they could return to a stage already passed through without it being considered regression.

In 1989, Troiden posited four age-specific stages in the LGBTQ identity process, which contrasted with Cass's non-age-specific stages [49]. Troiden's four stages are: sensitization, identity confusion, identity assumption, and commitment. The sensitization stage, which begins before puberty, finds the individual experiencing LGBTQ feelings without understanding the implications for self-identity. The identity confusion stage, which occurs during adolescence, is when the individual realizes that he or she may be LGBTQ. During the identity assumption stage, the individual comes out as a GSM person, usually first to the LGBTQ community and later to the heterosexual community. During the commitment stage, the individual lives as a GSM individual.

Other models have been developed, as well. For example, it has been suggested that the Kübler-Ross theory of grieving might serve as a sexual identity model [50,51]. While the stages of grieving (i.e., denial, anger, etc.) are not clearly demarcated, the Kübler-Ross model has been helpful to understanding what an individual experiences during the coming-out process. The model has also been useful to understanding the responses of family members to self-disclosure by a LGBTQIA individual [41].

Regardless of the model considered, many LGBTQIA youth become aware that they are experiencing sexual thoughts and feelings different from those of their peers at a time when they are trying to master the developmental tasks of adolescence, including achievement of identity, self-esteem, and social skills [52]. While gay adolescents must go through the same developmental tasks as heterosexual adolescents, GSM youth have additional identity development factors to incorporate into their self-concept [53]. For example, they are forced to learn to manage a stigmatized identity often without active support and modeling from their parents and family [54]. Thus, a GSM youth is trying to manage at least two tasks simultaneously: human maturation and establishment of self-identity as a sexual minority youth. A GSM youth from a racial minority is working concurrently on a third task related to developing personal identity, that of incorporating a racial identity into the personal identity.

Little research has examined the influence that ethnicity has on sexual identity development. Because the social category of ethnicity includes a complex interaction of factors, such as culture, religion, family, country of origin, and social experience, researchers have found it difficult to identify which of these factors is responsible for the observed differences being studied. In an effort to begin to identify general ethnic group differences and to create a foundation for research of the factors that influence ethnic and sexual minority development, some researchers have begun exploring the aspects of sexual identity development among male youths. They have found that Latino youth may report the earliest awareness of same sex attractions because of the role that masculinity plays in their culture. For these youth, as well as for African American and Asian American youths, the process of developing one's sexual identity cannot be well understood through the application of the traditional models discussed earlier. This is because these models suggest a uniform timing and sequencing of "coming out" events that has not been demonstrated in these minority youth populations [55,56].

Table 1 and Table 2 present select summary statements from the research related to ethnic sexual minority male youths [55]. These summary statements do not capture human differences or explain the development of or role of cultural norms that should be kept in mind while considering ethnic sexual identity development.

Using data from the first national probability sample of Black, White, and Latinx sexual minority people in the United States, researchers examined whether and how sexual identity development timing and pacing differs across demographic subgroups [57]. The sample included 1,491 participants 18 to 60 years of age from three distinct birth cohorts. The sexual identity development milestones measured included first same-sex attraction, first self-realization of a sexual minority identity, first same-sex sexual behavior, first disclosure to a straight friend, and first disclosure to a family member. Participants from more recent cohorts reported earlier and accelerated pacing of milestones relative to those from older cohorts. Subgroups defined by sex and sexual identity varied in milestone timing and pacing, with gay males reporting an earlier onset of some milestones. Participants who used newer identity labels (e.g., pansexual, queer) reported younger ages of milestones relative to bisexual participants but similar ages to lesbian and gay participants. Black and Latinx participants reported some milestones at younger ages than White participants [57].

Models of the sexual identity process suggest that there are certain behaviors that a healthcare professional might observe related to the different stages of "coming out." Application of cognitive dissonance theory helps to explain the origins of behaviors that could be matched to some of the stages of a model. According to this theory, there is a tendency for individuals to seek consistency among their cognitions (i.e., beliefs and opinions) because they want to conform to society's expectations and attitudes. When individuals perceive that their beliefs and opinions do not conform to those of society, intrapersonal tension and discomfort develop. In an effort to reduce the tension or dissonance, individuals will try to adjust their thoughts, attitudes, and behaviors, thus attempting to conform. Those individuals who first recognize feelings of same-sex attraction may experience emotional turmoil. When discrepancy between attitudes and behaviors exists, the attitude will most likely change to accommodate the behavior [58,59]. Using data collected through interviews and focus groups, one study analyzed the coming-out narratives of 20 transgender people [60]. The analysis revealed that coming out requires navigating others' gender expectations, others' reactions, and the threat of violence. Transgender individuals do not simply decide to "come out" and then stay out. Rather, they make strategic decisions about gender and gender identify disclosure based on specific social contexts. Coming out is an ongoing, socially embedded, skilled management of one's gender identity [60].

Common health problems associated with the stages of a four-stage model of the sexual identity (coming-out) process have been identified. For example, during the identification stage, the health picture has been described as "rather gloomy" and includes feelings of severe guilt, reduced self-esteem, overwhelming aloneness, and physical manifestations, such as ulcers and other health problems [61,62]. More recently, LGBTQ identity formation and the implications for healthcare practice have been addressed [63]. Healthcare professionals must understand the importance of demonstrating awareness of gay or lesbian existence through, for example, the use of inclusive interviewing techniques. Antigay attitudes and stereotypes may hinder the healthy development of a child at the respective stages [64]. For example, positively managing the developmental task of industry versus inferiority may be impaired when youth experience a sense of little or no worth as a result of rejection.

Results from the 2021 National School Climate Survey, which included 22,298 LGBT student participants, have illustrated this risk [66]. A note about the 2021 Survey: Because of the COVID pandemic, the authors had to adapt and modify some survey questions according to changes in school structures and instructional methods. The report continues to include findings about LGBTQ+ students' school experiences overall, but also discusses key findings about the differences between students in online only, in-person only, and hybrid learning environments [66]. Schools nationwide are hostile environments for a distressing number of LGBTQ+ students, the overwhelming majority of whom routinely hear anti-LGBTQ+ language and experience victimization and discrimination at school. As a result, many LGBTQ+ students avoid school activities or miss school entirely [66]. The 2021 Survey found [66]:

The vast majority (83.1%) of LGBTQ+ students who attended school in-person at some point during the 2021–2022 academic year experienced in-person harassment or assault based on personal characteristics, including sexual orientation, gender expression, gender, religion, actual or perceived race/ethnicity, and actual or perceived disability. Among LGBTQ+ students who were in in-person only or hybrid learning environments [66]. An estimated 76.1% experienced in-person verbal harassment (e.g., called names or threatened) specifically based on sexual orientation, gender expression, and gender at some point in the past year. Nearly 61% of LGBTQ+ students were verbally harassed based on their sexual orientation, 57.4% based on gender expression, and 51.3% based on gender. The Survey also found that 31.2% were physically harassed (e.g., pushed or shoved) in the past year based on based on their sexual orientation, gender expression, or gender; 22.4% were physically harassed at school based on their sexual orientation, 20.6% based on gender expression, and 20.5% based on gender. In addition, 12.5% of LGBTQ+ students were physically assaulted (e.g., punched, kicked, injured with a weapon) in the past year based on their sexual orientation, gender expression, or gender. The number of LGBTQ+ students were harassed or assaulted at school based on other characteristics included 34.4% based on actual or perceived disability, 29.0% based on religion, and 23.3% based on actual or perceived race/ethnicity. Further, 53.7% of LGBTQ+ students were sexually harassed (e.g., unwanted touching or sexual remarks) in the past year at school.

LGBTQ+ students who attended school online at some point during the 2020–2021 academic year were asked about their experiences with online harassment based on personal characteristics during the school day by students from their school. Among those who attended school online at some point during the 2021–2022 academic year [66]:

Students who were in online-only learning environments experienced higher rates of online harassment based on sexual orientation, gender, and gender expression than those who were in hybrid learning environments. Additionally, many LGBTQ+ students reported online harassment based on other characteristics [66]:

There is some evidence that students may be less likely to report harassment and assaults related to their gender and sexual identity, perhaps because of a lack of trust in authority figures. In the 2021 Survey, 61.5% of LGBTQ+ students who were harassed or assaulted in school did not report the incident to school staff, most commonly (69.6% of students) because they did not think school staff would do anything about the harassment even if they did report it [66].

Students in in-person learning environments reported harassment to school staff at higher rates than did students in online only or hybrid settings; 49.5% of students who attended school online (both online only and hybrid) stated that they did not report victimization online and instead only reported these experiences to staff when they attended school in person [66]. Of those students who did report an incidence, 60.3% said that school staff either did nothing in response or told the student to ignore it [66]. Staff responses to reports of harassment and assault were similar across all three types of learning environments [66].

Most LGBTQ+ students (58.9%) has experienced LGBTQ+-related discriminatory policies or practices at school. Some of the most common discriminatory policies and practices experienced are those that targeted students' gender, potentially limiting their ability to make gender-affirming choices and negatively impacting their school experience [66]:

Many LGBTQ+ students also experienced other forms of discrimination [66]:

LGBTQ+ students who had only been in in-person learning environments during the academic year were far more likely to experience any form of LGBTQ+-related discrimination than those in the other types of learning environments. A hostile school climate affects students' academic success and mental health. LGBTQ+ students who experience victimization and discrimination at school have worse educational outcomes and poorer psychological well-being [66].

While there is some evidence that societal attitudes are less oppressive than in the past, contemporary GSM youth will nevertheless experience a lifetime of exposure to entrenched negative societal attitudes. Consequently, healthcare professionals who have an awareness of and sensitivity to sexual minority youth and their unique health and safety concerns are in a position to assist the youth to manage their developmental tasks and address their health needs as they mature. The goal should be to encourage young adults to be comfortable with themselves, thus becoming more likely to demonstrate sound health practices.

The "homosexual adolescent" was first acknowledged by empirical social science in 1972 [69,70]. Additional empirical research reports were not available until the late 1980s, and sexual minority youth continued to remain largely invisible, even within the lesbian and gay community, until the 1990s [71]. Fortunately, the body of professional literature related to GSM youth has been evolving quickly.

Many LGBTQIA youth say they knew at an early age that the sexual thoughts and feelings they were experiencing were somehow different from other youth, but they did not understand the meaning of the difference. Although much variability among GSM youth exists, the average age of same-sex attractions is approximately 10 years of age for boys and 11 years of age for girls [72]. It is not until adolescence, when the capacity for abstract thought has been developed, that youth are able to analyze their responses to others and place these responses and associated feelings in a larger context [73]. Behaviors and feelings that adolescents recognize as gender atypical may result in fear of humiliation or physical violence, shame, and judgment as unhealthy or deviant [74].

Events in our nation's schools have contributed to public awareness of the prevalence of humiliation and violence among students. The school environment must be considered when thinking about the unique health and safety needs of LGBTQIA youth. "Because young people spend so much time in schools, and because of the relationship between academic achievement and later accomplishments, these settings are of crucial importance to understanding the transition of lesbian, gay, and bisexual youth into early adulthood" [69]. Survey results from public school educators and administrators have revealed that while public school educators acknowledge that problems for LGBTQIA youth exist in schools, administrators believe there are adequate programs already in place to handle the needs of the LGBTQIA youth population [75]. Several sources, documenting the dangerous and punishing atmosphere in school for some LGBTQIA youth, have challenged this perception [65]. This and other problematic attitudes in the schools have a significant impact on the academic performance and goals of LGBTQIA students, including absenteeism, lower grades, and foregoing post-secondary education [66]. Heterosexist peer cultural norms make LGBTQIA youth extremely vulnerable in the school setting.

Middle and high school students report that sexual orientation and gender expression are among the top three reasons students in their schools are bullied or harassed. LGBT students in middle school may face more bullying and harassment than their high school peers, which mirrors the environment among the general student population [66]. The National School Climate Survey revealed that 68.0% of LGBT students felt unsafe at school because of their sexual orientation and 43.2% because of their gender expression [66]. In one study, approximately 73% of students interviewed indicated that they would be "very upset" if someone called them gay or lesbian, but only 61% indicated that they would report its occurrence, even when it was done to someone they knew personally [76]. In addition, 76.1% of LGBTQIA students report having been bullied and harassed at school in the past year, and more than one-half reported experiencing some form of electronic harassment ("cyberbullying") in the past year [66]. The most frequent types of harassment are deliberate exclusion, being the target of mean rumors or lies, and sexual harassment.

Some parents and teachers believe that verbal harassment, which belittles, demeans, and ridicules, is normal teasing and common among teens. This is reflected in comments such as, "Those are just words the kids use these days." It has been suggested, however, that while teasing appears to be a positive experience for most young people, ridicule is clearly not desirable. Ridicule has been connected with low self-esteem and several clinical symptoms, such as hostility, depression, and interpersonal sensitivity. Peer ridicule may also be a tremendous source of stress for some youth, and the effects of frequent, repeated ridicule have been found to be cumulative [77]. Also, self-labeling at an earlier age exposes the GSM youth to verbal harassment and/or assault for a longer period of time. This longer exposure increases the risk of stress and the potential for damaging effects on the youth's health unless access to helping resources is provided. This increased risk for GSM youth may be the result of externalized and internalized homophobia that is more pronounced during adolescence than at other times in the life cycle [78].

The effects of ridicule should also be applied to transgender youth. Young gay men are more likely than heterosexual men to experience increased harassment, especially if they display behaviors that are interpreted as feminine [72]. The effects of prolonged, chronic stress associated with discrimination may contribute to health problems, such as hypertension, in adult gay men [79].

The American Academy of Child and Adolescent Psychiatry recommends that clinicians should inquire about circumstances commonly encountered by youth with sexual and gender minority status that confer increased psychiatric risk, including bullying, substance abuse, and suicide.

(https://www.jaacap.org/article/S0890-8567(12)00500-X/fulltext Last Accessed: September 27, 2024)

Level of Evidence: Expert Opinion/Consensus Statement

LGBTQIA youth may employ many coping strategies in an attempt to understand themselves and their place in society. Some may withdraw physically and emotionally, perhaps in an effort to avoid discovery. Others may turn to substance use or develop eating disorders. Among LGBTQIA youth, the rates of suicide ideation and attempts have been reported to be alarmingly high [80]. Some LGBTQIA youth strive for academic or athletic achievement, perfectionism, or become overly involved in extracurricular activities in an effort to avoid their feelings [10]. Still others, as a reaction against unacceptable thoughts and attractions, may exaggerate their heterosexuality and engage in promiscuous behavior [81]. Many become homeless. According to a report published by the National LGBTQ Task Force (NLGBTQTF), an estimated 20% to 40% of the 1.6 million homeless American youth are LGBT [82]. Some of these youth, when they came out to their parents or guardians, were told to leave home. Some left home to escape physical, sexual, or emotional abuse. Youth who end up at homeless shelters have also reported being threatened, belittled, and abused by shelter staff [82].

Legal events have occurred that demonstrate a growing awareness of the specific legal needs of the GSM youth population. For example, in 1996, a gay student in the Wisconsin public school system was awarded over $900,000 in damages when a federal jury found school officials liable for not protecting the student, who had experienced several years of harassment, including physical and psychological assault. During the years of harassment, the student had dropped out of school twice, required surgeries for injuries from assaults, run away from home, and tried to kill himself several times. He was subsequently diagnosed with post-traumatic stress disorder [83]. In the spring of 2009, an 11-year-old Massachusetts boy died by suicide after enduring constant bullying at the middle school he attended, including being called "gay" and "faggot," even though the boy had not identified himself as gay [84]. Just two weeks later, the suicide of an elementary school student in Georgia was also attributed to anti-LGBT bullying. This student also had not identified himself as gay. Their deaths prompted the introduction of the Safe Schools Improvement Act, H.R. 2262. This act (which amends the Safe and Drug-Free Schools and Communities Act of 1994) requires schools to implement comprehensive antibullying policies and to include bullying and harassment data in their needs assessment reporting. Any school that receives federal funding must implement an antibullying policy that identifies categories often targeted by bullies, such as race, religion, sexual orientation, and gender identity/expression [85].

GSM youth must eventually develop interpersonal skills that allow them to meet other GSM youth. Like other adolescents, they must develop a sense of personal attractiveness and a healthy self-esteem while learning that risky sexual activity, more common among these adolescents, does not promote emotional health. They must learn same-sex relationship skills while integrating their public and private selves to create their LGBTQ identity. Not all LGBTQIA youth experience difficulties; many are resilient and resourceful, manage stressors well, and develop into productive and healthy adults [86]. Research exploring development of this resiliency is needed.

There is a vital connection between a sense of community and psychological well-being. While other minorities have family to role model for them and protect them, sexual minority youth usually do not have such support. Sexual minority adults who could serve as positive role models may fear that they will be accused of "recruiting members" or behaving inappropriately [10]. Sexual minority adults are often sensitive to stimulating false beliefs among the general population.

Although many LGBTQIA youth are self-disclosing at younger ages, many factors affect the decision to do so. For example, disclosure of one's sexual orientation to healthcare providers may depend on where in the sexual identity process the individual finds herself or himself [62]. Physical factors, such as being deaf, or social factors, such as financial support, may also have an impact on the coming-out process. Disclosing too early could jeopardize the support that already exists [87]. Studies have demonstrated that disclosing sexual orientation to family members during the high school years may create some danger for LGBTQIA adolescents, including, as previously discussed, abuse and the threat of being made homeless [82].

Not all GSM youth are aware of their right to medical confidentiality. LGBTQIA youth who know their rights have been found to be more likely to discuss sexual orientation and concerns with their healthcare providers. Most who do not discuss sexual orientation have said that they would have done so had they known that their confidentiality was protected [46,88].

Many resources are available to LGBTQIA youth and their families, particularly in metropolitan regions. For example, Parents, Families, and Friends of Lesbians and Gays (PFLAG), an organization that works to unite GSM individuals with family and friends, offers support, education, and advocacy through online information sharing and community chapter efforts. Additional resources, including hotlines for youth, are provided at the conclusion of this course. Before recommending a resource, healthcare professionals should assess it for absence of social bias and provision of a professionally neutral environment [2].

LGBTQIA adults have also experienced increased incidents of violence. The Federal Bureau of Investigation (FBI) has consistently ranked antigay violence as the second most frequent form of bias-motivated crime. In 2022, the FBI reported that 17.2% of the total 11,288 reported single-bias incidents had been motivated by bias related to sexual orientation [67]. Additionally, the National Coalition of Anti-Violence Programs reported a slight decrease (compared to the previous year) in the number of incidents of anti-LGBT violence (825 incidents) but a significant increase in incidents involving physical and sexual violence [68].

Health maintenance and promotion are important to the LGBTQIA community, but these issues have received little attention in the general public's health-related media. Many Internet sites provide health information related to sensitive topics for the general population as well as the GSM population. However, a difference exists between the general population and the LGBTQIA population when the GSM individual cannot talk further with a healthcare professional about a sensitive topic because of fear of stigmatization or discrimination. Some Internet sites have been able to address, in part, the sensitive health information needs of the GSM community (see Resources).

Distress caused by the experiences of marginalization, stigma, prejudice, discrimination, and internalized homophobia is a consistent theme of the professional literature. Research has suggested that most gay men and lesbians adopt negative attitudes toward their sexuality early in their developmental histories. As previously discussed, because health problems often begin in youth, internalized homophobia may also affect health indirectly, especially when operating below consciousness in adults [18]. The coming-out process has been identified as a source of chronic stress, resulting in psychogenic suppression of the immune response for the LGBTQIA individual. A direct correlation has been found between where in the coming-out process an individual is and an increased incidence of physical illness, such as malignancies and some infectious disease processes other than HIV/AIDS [89]. Internalized homophobia has also been associated with high-risk sexual behaviors, such as practicing unsafe sex. Research has explored the potential influence of these negative attitudes on health experiences and behaviors, particularly those of gay men as related to HIV and AIDS. Difficulties with intimacy and other aspects of relationships may manifest as well, including an inability to disclose HIV status to sex partners [90]. African American men who have sex with men have been found to be less likely to identify themselves as gay, more likely to report having sex with women, and less comfortable discussing their behavior with friends. They have also been found to exhibit higher levels of internalized homophobia [90].

Prejudice and fear of discrimination have resulted in difficulty accessing or avoidance in seeking health care [35]. While some healthcare providers have acknowledged that LGBTQIA individuals are part of their patient populations, they have determined that sexual orientation does not need to be addressed [8]. Others have indicated that they believe gay men and lesbians deserve to be ill or that they are unworthy of treatment. Reports exist of a "rough" or "violent" digital rectal exam on a patient after the patient was discovered to be gay [8]. One study examined both implicit and explicit bias against lesbian women and gay men among first-year heterosexual medical students with an emphasis on two predictors of such bias—contact and empathy [91]. A total of 4,441 students participated in the study. Nearly one-half (45.8%) of respondents with complete data on both bias measures expressed at least some explicit bias, and most (81.5%) exhibited at least some implicit bias. Amount and favorability of contact with gay/lesbian patients predicted positive implicit and explicit attitudes. Cognitive and emotional empathy predicted positive explicit attitudes, but not implicit attitudes [91]. Another study found that implicit preferences for heterosexual people versus GSM people are pervasive among heterosexual healthcare providers. The study examined attitudes among 2,338 medical doctors, 5,379 nurses, 8,531 mental health providers, 2,735 other treatment providers, and 214,119 nonproviders in the United States and internationally between 2006 and 2012 [92].

Prejudice has also resulted in legal and legislative actions with potentially negative consequences for the LGBTQIA population. For example, in 2004, the Michigan House of Representatives proposed a piece of legislation known as the "Conscientious Objector Accommodation Act" (House Bill 4660). This bill would have allowed healthcare providers the right to refuse to provide services that conflict with their beliefs [93]. While the bill did not pass, opponents expressed concern about its potential to harm the health of LGBTQIA persons. Other measures (introduced in Arkansas, Michigan, Rhode Island, South Dakota, Texas, Vermont, and West Virginia) would allow pharmacists and other healthcare providers to refuse treatment or medication to anyone by citing ethical, moral, or religious grounds. Georgia law already states that "it shall not be considered unprofessional conduct for any pharmacist to refuse to fill any prescription based on his/her professional judgment or ethical or moral beliefs" [94].

Some progress has been made, however. For example, in 2003, a California appeals court ruled that healthcare providers cannot discriminate against patients based on their sexual orientation. The decision was the result of a lawsuit filed by a gay woman who perceived discrimination based on the religious beliefs of providers at an infertility clinic [95].

The controversy surrounding same-sex marriage has led to unique healthcare access debates and decisions, including extension of health and other employment benefits to an employee's same-sex partner. Along with the Supreme Court ruling state-level same-sex marriage bans unconstitutional on June 26, 2015, there have also been significant changes to healthcare laws. Starting in 2015, any insurer that offers healthcare coverage to opposite-sex partners must also offer coverage to same-sex partners [96]. Married same-sex couples are also ensured the same tax credits and out-of-pocket costs as married opposite-sex couples on private plans in all states.

AMA Resolution 414 calls for recognition of the healthcare and other needs of the LGBTQ population, while acknowledging that more professional knowledge and skills about the LGBTQIA population are needed [13]. Health concerns among the LGBTQIA population include: cancer; family concerns, including domestic violence; immunizations; infectious diseases, such as sexually transmitted infections (STIs), HIV/AIDS, and hepatitis; mental health, including suicide, body image, and eating disorders; substance use; and violence [8,9].

Sexually Transmitted Infections and HIV/AIDS

STIs among the general population are well-known health problems. Stigmas associated with STIs and LGBTQIA sexual behaviors have made determining the prevalence rates of STIs in men who have sex with men difficult; however, these men appear to be at more risk than the general population [119]. The relatively high incidence may be related to multiple factors including individual behaviors, the number of lifetime or recent sex partners, rate of partner exchange, and frequency of sex without use of a condom [119]. Also problematic is the increased incidence of drug resistance. Gonorrhea in men who have sex with men has been reported to be resistant to fluoroquinolones [120].

AIDS has been diagnosed for more than half a million men who have sex with men. More than 300,000 have died since the beginning of the epidemic. Men who have sex with men comprised 67% of all new HIV infections in 2022 and account for more than half of the 1.2 million existing infections, even though only about 2% of men in the United States reported having sex with other men [121,122]. While a decline in the rates of STIs in gay and bisexual male groups was reported following the start of HIV/AIDS prevention programs, data has indicated a rise in reports of unprotected anal sex. Also, young men who have sex with men are reportedly at particular risk for HIV because they are more likely to engage in high-risk behaviors [8,121]. The effect of behavioral changes on HIV transmission has not been determined. According to the CDC, from 2021 to 2022, HIV diagnoses increased 5% among gay and bisexual men overall, but trends varied for different groups of gay and bisexual men [122]. From 2021 through 2022, the largest number of diagnoses of HIV infection was among gay and bisexual men 25 to 34 years of age. Of 37,981 men diagnosed with HIV infection in 2022, Black/African American gay and bisexual men accounted for the largest number (14,553 or 38%) of HIV diagnoses , followed by 12,167 Hispanic/Latino men (32%), and 9,112 White gay and bisexual men (24%). Three percent (1,056) of multiracial men were diagnosed, 2% (795) of Asian men, 1% (215) American Indian/Alaska Native gay and bisexual men (1%), and less than 1% (83) Native Hawaiian/Other Pacific Islander gay and bisexual men [122,123,124]. Many Black/African American and Hispanic/Latino gay and bisexual men, particularly young men, do not know that they are infected [122,123,124]. Research has suggested that non-gay-identified men may be more responsive to intervention education than gay-identified men. This has been attributed to less exposure to prior intervention messages, leading to a greater impact from initial exposure [125]. Additional research is needed to identify which behavioral strategies (e.g., reducing unprotected anal sex, having oral sex instead of anal sex, using condoms) most effectively reduce transmission of STIs and HIV/AIDS among gay men [125]. An increasing number of HIV cases among heterosexual Black women has drawn attention in the media to a phenomenon known as the "down low." While this phenomenon is too complex to address fully here, the term is used to describe the behavior of men who have sex with men as well as with women, but who do not identify themselves as gay or bisexual [126]. Often, their female partners are unaware that these men are also having sex with men. While the term is thought to have originated in the African American community, the behaviors associated with the term are not new and not specific to Black men who have sex with men [126]. The media has linked the "down low" to the Black AIDS epidemic, but the CDC has reported that there is no data to confirm or refute publicized accounts of HIV risk behavior associated with these men [126].

According to the Centers for Disease Control and Prevention, women who have sex with women, particularly adolescents and young women as well as women with both male and female partners, might be at increased risk for STIs and HIV on the basis of reported risk behaviors. A continuum of sexual behaviors reported by these patients indicates the need for providers to not assume lower risk for women who have sex with women, highlighting the importance of an open discussion about sexual health.

(https://www.cdc.gov/std/treatment-guidelines/wsw.htm Last Accessed: September 27, 2024)

Level of Evidence: Expert Opinion/Consensus Statement

STIs are thought to be more common among women who have sex with women than among sexually active women who are heterosexual. Transmission risk may vary by the specific STI and sexual practice (e.g., oral-genital sex, penetrative sex items) [127]. Although disease incidence among these women appears to be less than among the heterosexual female population, HPV and other organisms are transmissible woman to woman [8]. Transmission of HPV can occur with skin-to-skin or skin-to-mucosa contact, which can occur during sex between women [127]. HPV has also been associated with the development of genital warts and invasive cervical cancer. The CDC has recommended that all women undergo Pap test screening according to national guidelines, regardless of sexual preference or sexual practices [127].

To address racial, ethnic, and geographic disparities that have contributed to HIV prevention gaps, the U.S. Department of Health and Human Services launched the Ending the HIV Epidemic in the U.S. (EHE) initiative in 2019. The goal of the initiative is to reduce new HIV infections in the United States by 90% by 2030 [128]. In July 2021, the CDC awarded $117 million in EHE funding to state and local health departments to rebuild and expand HIV prevention and treatment efforts in 57 priority jurisdictions. The jurisdictions include 50 local areas that account for more than half of new HIV diagnoses, and seven states with a substantial rural burden [128]. Approved EHE funding across all U.S. federal agencies was $613 million for fiscal year 2023 [128].

Although there are now more options than ever before to reduce the risk of acquiring or transmitting HIV, some options are more effective than others. Combining prevention strategies may be most effective [124].

Mental Health

The U.S. Preventive Services Task Force asserts that lesbian, gay, bisexual, transgender, and queer (LGBTQ) teens are at increased risk of depression and recommends screening for major depressive disorder in adolescents 12 to 18 years of age.

(https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-depression-suicide-risk-children-adolescents Last Accessed: September 27, 2024)

Level of Evidence: B (There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.)

The LGBTQIA population may be at increased risk for mental distress, mental disorders, substance abuse, and suicide because of their exposure to stressors related to society's antigay attitudes [8,31]. Studies examining the prevalence rates for suicide ideation have shown that the rates are elevated among gay and bisexual men as well as among lesbians, and particularly those who grow up in religious households as well as those for whom religion is important [8,129,130,131].

Clinical studies have indicated that sexual orientation may be a significant predictor of eating disorders. Gay men have demonstrated more dissatisfaction and a greater desire to be thin than heterosexual men [132]. Studies of the role that masculinity and femininity play in relation to men and women who develop eating disorders have shown that men and women with higher levels of femininity have greater levels of dieting behaviors [133]. A negative and inaccurate sense of body image (body dysmorphic disorder) is a primary cause of eating disorders in women and men [132].

Support systems and networks are known to be important to one's mental health maintenance. While social institutions, such as church, family, and the legal system, are generally thought to be less supportive of GSM individuals than they are of heterosexual individuals, important helpful changes have been occurring in many of these institutions [134]. Selected church leadership has been in public view related to the acceptance of openly LGBTQ theologians in the church. Families, as an institution, have spoken publicly and given support to their gay family members through organizations such as PFLAG. Also, where legal decisions in favor of the GSM community have been made, public awareness of potentially dangerous environments for GSM youth has increased.

Sampling difficulties have made it challenging to research the prevalence of substance use in the LGBTQIA community. For example, studies of alcoholism and drug use have sampled gay and lesbian individuals in bars, a location where higher alcohol and drug use might be expected [8]. Substance use rates for gay and lesbian individuals have been reported as high as 20% to 30%, compared to a rate of 10% among the general public when based on this sampling methodology [30]. However, studies using other sampling methodologies have generally disputed the high incidence of alcoholism and substance use [8]. Research suggests that sexual minority adolescents who reside in communities with a more supportive climate had lower odds of lifetime illegal drug use, marijuana use, and smoking. Specifically, in communities with more frequent LGBTQIA events, such as pride events, the odds of substance use among sexual minority adolescents was lower compared with sexual minority adolescents living in communities with fewer such supports [135].

The pressure of coming of age in a society that says that LGBTQIA individuals should not exist or act on their feelings contributes to the use of alcohol and drugs [136]. Internalized homophobia develops and creates feelings of denial, fear, anxiety, and even revulsion about being gay, socializing in the GSM community, and having gay sex. Substance use temporarily relieves these negative feelings, allowing feelings to be acted upon. The homophobic feelings return during drug withdrawal. Substance use occurs again, contributing to the self-hatred. Depression leading to a worsening self-esteem may result from the use of alcohol and many other drugs [136].

Participating in Alcoholics Anonymous and other recovery programs may be difficult for the LGBTQIA individual. Some of the programs suggest giving up old friends, especially fellow substance users, and staying away from parties and bars. These actions may be too difficult for an individual who has limited social contacts and no other available avenues of social outlet [136]. Someone who is socially withdrawn or insecure with his or her own social skills may have difficulty limiting contact with any friends they do have.

Other concerns related to recovery groups exist. Heterosexism in support groups makes coming out difficult for LGBTQIA participants. The difficulty of coming out or accepting one's own sexual orientation may become an excuse to resume alcohol or drug abuse [30]. National organizations, such as the National Gay and Lesbian Health Association and the Gay and Lesbian Medical Association, can assist with referrals to appropriate recovery groups [136].

Tobacco use among sexual minorities may be higher than in the general population, resulting in an increased rate of tobacco-related health problems [137]. Because LGBTQIA individuals may experience difficulty accessing the healthcare system, they are at an increased risk for missing health promotion activities. As a result, illness detection and treatment are delayed.

Research challenges have made determining the size and other demographic and sociologic characteristics of the older GSM population very difficult. The LGBT Aging Center has estimated that approximately 1.5 million LGBT adults 65 years of age or older reside in the United States, with the number expected to double by 2030 [144]. Literature discussing the health and health needs of GSM elderly has also been limited. As a result, identifying problems and advocating for solutions for this population has been challenging [144,145].

Clearly, older GSM individuals experience the same marginalization due to age and ethnic or racial heritage as the nation's general population. Older gay adults experience additional marginalization related to sexual orientation. While federal and state governments offer a wide variety of social programs and services that aim to support the lives of older people, rarely do these programs recognize or support the families that LGBTQIA people build [145]. For example, in the past, same-gender partners have not received Social Security benefits, no matter how long partners had been together. As of June 2015, this has changed. A spouse, divorced spouse, or surviving spouse of a same-sex marriage or non-marital legal same-sex relationship may not only qualify to receive Social Security benefits (including death benefits) but is required to disclose their relationship, as their partner's income will affect their benefits [146].

Although limited, research findings have shed some light on LGBTQIA elderly. For example, older gay men are more likely to be angry after years of oppression than are non-gays. While some of these men have directed the anger constructively into their occupations or political activism or toward developing strong networks of friends, others have turned the anger inward and consequently experience anxiety, depression, and self-esteem problems related to internalized homophobia [147]. Older gays may also receive less sympathy and attention in general when dealing with the loss of a long-term lover or close friend. Because of problems from family members and reactions from healthcare providers and others, the GSM individual may also experience complications with the grieving process [147].

Another area of need for older GSM individuals is that for HIV/AIDS education. The stereotype that older people are not sexually active has contributed to making this an unnoticed population for AIDS educators and others [148,149]. As recently as the late 1990s, primary care physicians were less likely to discuss HIV or HIV risk reduction with patients older than 50 years of age than with those 30 years of age and younger [150]. Only within the GSM community itself have prevention campaigns targeted all age groups [149].

Researchers have reported striking differences between older and younger GSM people related to their attitudes toward public disclosure of their gay sexual orientation [41,151]. One of the most trying issues related to caring for older LGBTQIA individuals is the issue of patient self-disclosure [152]. In a study involving more than 2,500 LGBT persons 65 years of age or older, more than 20% did not disclose their sexual identity to their physician [153]. In general, elderly LGBTQIA individuals come from a highly stigmatized background in which they had been considered most of their lives to be ill and deviant. Consequently, they have learned to conceal their sexual orientation as a means of survival [154].

These older LGBTQIA individuals grew into adulthood during the Pre-Stonewall Riots period. This was a very oppressive time period for the LGBTQIA community and one during which there were no hate crime laws and no research on the incidences of antigay hate crimes. LGBTQIA individuals had to learn how to manage homophobia and heterosexism over a lifetime, an effort that requires tremendous daily emotional energy. The healthcare community might never know the full effect that internalized homophobia has had on older GSM Americans [154]. Having lived through years of stigma, before the ascendance of more positive attitudes toward homosexuality, older GSM individuals may think that disclosure to a healthcare provider cannot or should not be done.

LGBTQIA individuals also disagree within their community about self-disclosure, and they do so for a variety of complex reasons. For example, older GSM individuals who do self-disclose may view it as necessary to override heterosexist assumptions about non-straight sexuality. Or, they may feel that disclosure makes discrediting them more difficult [41]. The subculture's self-examination and discussion about self-disclosure has been dynamic and across intergenerational and intragenerational lines. As a result, healthcare professionals can anticipate that not all GSM individuals will be able to self-disclose. At any rate, asking older patients about their sexual orientation may not always be the best approach. By not asking, trust may be more likely to develop between the healthcare professional and the patient. At the same time, it is helpful to know the sexual orientation of the patient. In bereavement work, for example, the older patient should be free to reminisce about his or her life partner within a comfortable, trusting environment without fear of critique [152]. Clearly, this is an extremely difficult issue to navigate.

Intergenerational differences related to practical concerns also exist. For example, older LGBTQIA individuals have identified legal strategies for protecting property as an important concern. A home care option that would offer protection from homophobic atmospheres in nursing homes, allowing more care from significant others and friends, has been identified as another important issue. Emotional needs, such as trust, hope, worries about loss, spirituality, family rejection, and loneliness, have also been identified. Though topics of concern are similar among the LGBTQIA generations, manifestation of these topics may vary widely at different times over the individual's life span [151].

Health and loneliness may be more intertwined in the older LGBTQIA community [134]. For example, because older gay adults often have been closeted most of their lives, they may not know how to connect with existing health support systems provided by the GSM community [155]. Many older LGBTQIA individuals must also face the impact of HIV/AIDS on aging. AIDS has left many in this population with fewer friends and support networks. Many GSM community members do not have children, who are a major source of support for the heterosexual population. The fear of developing poor health and experiencing illness may lead the GSM individual to concerns about poor quality and quantity of care by healthcare providers who are unaware and insensitive to the gay subculture's unique healthcare needs and concerns [134].

Older gays and lesbians have many strengths, among them the learned importance of personal independence in planning for their own futures [154]. Growing older brings greater maturity, wisdom, and experience, resulting in a sense of empowerment for many [134]. Because of experiencing a lifetime of managing the many social stresses related to prejudice and discrimination, older gays and lesbians may be more prepared to cope with social discrimination and losses that accompany aging than are their heterosexual peers [79].

The first crosscultural communication skill is to be able to articulate and present a problem or issue as it is seen from another's perspective. To do this, the healthcare professional must learn about the culture in question. Studying the sexual identity models, reading about the history of the gay subculture, watching documentaries related to diverse human sexuality, exploring educational Internet sites, or attending professional workshops addressing gay-related topics are excellent strategies for increasing personal awareness, sensitivity, and knowledge about the LGBTQIA population. Because increased contact with minorities has been found to be a very effective strategy for promoting understanding, a healthcare professional could increase interactions with members of the GSM community to reduce negative stereotyping, prejudice, and discrimination [157]. Keep in mind that gaining access to a subculture requires sensitivity, patience, and understanding because one's interest in the community may be questioned by subculture members [158].

The second crosscultural communication skill area involves recognizing defensiveness and resistance and knowing its cause [156]. Problem behaviors arise when the healthcare professional begins to impose personal values on others. Assuming that everyone is heterosexual and demonstrating a lack of knowledge about the health-damaging effects of stigma on the LGBTQIA population are two behaviors that may create defensiveness or resistance. Other problem behaviors involve making hostile or discriminatory statements, using slang, and telling or laughing at derogatory jokes about the GSM community. Because this active form of collusion furthers stereotypes, the healthcare professional should monitor his or her own behavior so that he/she remains sensitive and culturally competent.

Failure to have wording on patient history and intake documents that is inclusive of sexual minorities and partners could be problematic, as well. For example, do documents include space for a partner notation, or do they ask only for marital status (i.e., single, married, widowed, or divorced)? None of these words may be an honest answer in a gay patient's mind. The Gay and Lesbian Medical Association offers guidelines for creating a safe and comfortable clinical environment (see Resources). Intake information should also include an explanation about how confidentiality will be managed.

Disclosing a patient's sexual orientation without the patient's permission should be avoided. Not only might "outing" the patient lead to patient defensiveness, but information about a patient's sexual orientation is protected by the Health Insurance Portability and Accountability Act (HIPAA) [159]. In situations when a patient's disclosure may not remain confidential, some reassurance of respect could be provided if disclosure was always accompanied by the patient's consent.

Healthcare professionals should also be knowledgeable about the visitation policies of their healthcare agency. Policies and practices that are inclusive of partners and co-parents are valuable measures that demonstrate cultural competence.

The third crosscultural communication skill area requires taking actions to reduce feelings of defensiveness and resistance in oneself and others. One of the most important activities for the culturally competent healthcare professional is to examine one's own feelings, values, and stereotypes regarding culture and, in this case, regarding human sexuality [34]. Examining one's attitudes does not mean that the professional is approving or condoning a specific orientation or behaviors. The healthcare professional need not necessarily change personal beliefs to provide culturally competent care.

The healthcare professional must ask: "Can I recognize behaviors in others that may indicate feelings of defensiveness and resistance?" Related to youth, the school nurse should observe for individuals who may be trying to make themselves invisible by isolating themselves from others. For example, are there students who are avoiding settings that may place them in a position to be questioned [87]? Adults and the elderly may isolate themselves as well. It seems unlikely that a sexual orientation that has been concealed for a lifetime will be easily or quickly revealed to anyone, even a well-intentioned healthcare professional. Anger, illness, and other manifestations of stress may be evident. Fortunately, many strategies can be suggested to help reduce defensive and resistant feelings.

Promoting an atmosphere of openness and calm may be helpful. Displaying posters, educational materials, and other materials of interest that are positive about the LGBTQIA community may signal the existence of a safe environment. For example, a sign in the waiting area that says, "We do not discriminate on the basis of age, race, sex, sexual orientation, gender identity, religion, language, or disability," would be noticed by a GSM person. Showing equal respect for friends, partners, spouses, and relatives may also be helpful [160].

Being familiar with at least one of the sexual identity models discussed would assist the healthcare professional to assess at what point in the coming-out process an individual may be. For LGBTQIA youth, having this awareness could strengthen the planning related to their overwhelming need for anticipatory guidance [87].

Practicing nonjudgmental caring, by developing interviewing skills that employ inclusive terminologies, may also help reduce defensiveness. Speaking up when ridiculing remarks are made is vital. "That kind of joke has no place here" should be sufficient to send the message to a gay observer that the professional is sensitive to LGBTQIA concerns [161].

Demonstrating awareness that elderly LGBTQIA individuals may have fewer support systems is important. The American Association of Retired People provides Internet resources designed for elderly GSM persons. Individuals unable to use Internet services will need assistance with referral sources. Becoming familiar with appropriate LGBTQIA community referral sites is important as well. Contact local LGBTQIA support agencies for information about their services. Referring GSM individuals to a GSM-related referral site is like referring a diabetic to the American Diabetes Association [159].

The fourth crosscultural communication skill area requires acknowledging that mistakes will be made [156]. Heterosexual bias is not the fault of the individual healthcare professional, so expect to make honest mistakes. Some GSM individuals have children, so assuming, during conversation, that someone with children is not gay could lead to a communication mistake [87]. Communication with adolescents should focus on developing rapport. When discussing the subject of sexual orientation, teens feel more comfortable if the healthcare professional uses a non-confrontational, casual approach [65].

When communicating with older GSM individuals, remember that diverse views exist related to disclosure of their sexual orientation. Providing a comfortable clinical environment, one that visually demonstrates awareness of the LGBTQIA community, will assist with the decision to self-disclose. As a result, the opportunity for more complete health data collection is possible so that unique health and safety needs may be identified and addressed.

Learning communication recovery skills will help the healthcare professional accomplish more positive outcomes when providing healthcare or health consultation [156]. Recovery skills include apologizing for an error, focusing on another health need until rapport is re-established, or reversing roles and asking the patient to help you with a problem or information need [156]. For example, if a patient seems offended by something you have asked or said, simply apologize and offer a brief explanation about why the information is necessary to provide good care. Explain, if you can, why the mistake was made. Perhaps you did not have the awareness you needed. Later, if appropriate, you can ask about another health need (e.g., immunizations) and work toward re-establishing rapport. Learn from the mistake. Remember, it may take time for the LGBTQIA person to trust. Most errors will be forgiven if recovery efforts are made with sincerity.

Like all cultures, the gay subculture is dynamic. Many changes have and are taking place within the subculture and within the general population's attitudes toward the subculture. Ongoing education is necessary to remain culturally competent.