Bisexual: An adjective that refers to people who relate sexually and affectionately to both women and men.

Heterosexism: An institutional and societal reinforcement of heterosexuality as the privileged and powerful norm.

Sexual identity: The inner sense of oneself as a sexual being, including how one identifies in terms of gender and sexual orientation.

Much professional literature has documented the negative social attitudes toward sexual minorities [23]. These negative attitudes have been frequently referred to as "homophobia." The term was coined in 1967 and defined very specifically as "the dread of being in close quarters with [gay people]...the revulsion toward [gay people] and often the desire to inflict punishment as retribution" [16]. Some in the general population believe that the word "homophobia" always includes a component of violence. The condition was classified as a phobia and operationalized as a prejudice. The phobia manifests as antagonism directed toward a particular group of people, leading to disdain and mistreatment of them [16].

A more appropriate term for the phenomenon of negative social attitudes may be "heterosexism" because it focuses on the normalization and giving of privilege to heterosexuality [25]. The term encompasses the prejudice and social stigma from institutional and interpersonal sources encountered by sexual minorities, including a range of discriminatory experiences, not only those related to phobias and violence [26]. Implicit and explicit forms of discrimination have been included in the definition of heterosexism. For example, the use of noninclusive questions while conducting a patient's sexual history could be considered implicit discrimination because the questions reflect a possible lack of awareness and inclusivity. Mean-spirited, antigay statements or actions by an individual or an institution could be considered explicit discrimination because the action is undeniably direct. A hospital visitation policy that prevents GSM individuals from visiting their partners is another form of discrimination included in the definition of heterosexism.

The subtle and pervasive ways that discomfort with GSM individuals may be manifested have been examined and, in some instances, categorized as "cultural heterosexism," which is characterized by the stigmatization in thinking and actions found in our nation's cultural institutions, such as our educational and legal systems [27]. "Cultural heterosexism fosters individual antigay attitudes by providing a ready-made system of values and stereotypical beliefs that justify such prejudice as natural" [28]. Perhaps the paucity of information about the GSM community in basic professional education textbooks has been a reflection of cultural heterosexism. Writers, funding sources, and publishers have been exposed to the same cultural institutions for many years.

The manifestations of heterosexism and homophobia have inhibited our learning about the LGBTQIA population and its needs [9]. Gay patients have feared open discussion about their health needs because of potential negative reactions to their self-disclosure. Prejudice has impacted research efforts by limiting available funding [8]. All of these factors emphasize that the healthcare education system has failed to educate providers and researchers about the unique aspects of LGBTQIA health [29,34].

Many myths surround homosexuality; a few are outlined below. The origin of these myths may be better understood after examining the history of homosexuality as well as the attitudes toward human sexuality in general. The history of the development of societal norms related to homosexuality includes misconceptions developed during times when research was not available on which to build a scientific knowledge base [1,35,36,37].

Myth: Sexual orientation is a choice.

Fact: No consensus exists among scientists about the reasons that an individual develops his/her sexual orientation. Some research has shown that the bodies and brains of gay men and women differ subtly in structure and function from their heterosexual counterparts; however, no findings have conclusively shown that sexual orientation is determined by any particular factor or set of factors. Many people confuse sexual orientation with sexual identity. The reader may consider reviewing the definitions of these terms when further considering this myth.

Myth: Gay men and lesbians can be easily identified because they have distinctive characteristics.

Fact: Most gay and lesbian individuals conform to the majority of society in the way they dress and act. While some gay men and lesbian women may fit the stereotypes that society holds, LGBTQIA individuals generally look and act like everyone else. Most people never suspect the sexual orientation of a GSM individual.

Myth: Gay individuals are child molesters.

Fact: According to experts in the field of sexual abuse, the vast majority of those who molest children are heterosexual. The average offender is a White heterosexual man whom the child knows.

Myth: Gay people want to come into our schools and recruit our children to their "lifestyle."

Fact: There have been efforts to bring issues related to LGBTQIA history and rights into schools but certainly not to convert anyone. The intent has been to teach adolescents not to mistreat gay and lesbian classmates who are often the subjects of harassment and physical attacks. There is no evidence that people could be "recruited" to a gay sexual orientation, even if someone wanted to do this.

Myth: Sexual orientation is a choice.

Fact: No consensus exists among scientists about the reasons that an individual develops his/her sexual orientation. Some research has shown that the bodies and brains of gay men and women differ subtly in structure and function from their heterosexual counterparts; however, no findings have conclusively shown that sexual orientation is determined by any particular factor or set of factors. Many people confuse sexual orientation with sexual identity. The reader may consider reviewing the definitions of these terms when further considering this myth.

First, establish clear definitions of the populations. Because there is no consensus on the definitions, it is impossible to accurately estimate the percentage of the population that would be classified as gay or lesbian. For example, the 2010 U.S. Census counted same-sex couples but did not count single gays or lesbians. Estimates of these singles range from 2% to 20% of the U.S. population [8,38,39]. Community survey data for 2019 indicates that 980,000 households in the United States were same-sex couple households (about 1.5% of total coupled households). Among these, approximately 58% consisted of married couples and 42% consisted of unmarried partner households [39]. For 2020, the census form included separate categories for "opposite-sex" and "same-sex" spouses and unmarried partners; however, the U.S. Census Bureau does not ask individuals about their sexual orientation or gender identity [40]. While different definitions and measures of sexual orientation have been used since the 1860s, the definition of sexual orientation should include self-identity, behavior, emotional attractions, cultural affiliation, and those aspects of sexual orientation that may change across developmental periods [16]. The term "transgender" is also difficult to define and measure, partly because it has been less examined than other terms, such as "heterosexual," "homosexual," "bisexual," "gay," or "lesbian." Generally, the term "transgender" includes several populations, including transsexuals and crossdressers. Further defining each of these populations creates additional challenges [8]. Consensus on the definitions of "youth" and "elderly" and other demographic terms is needed as well.

Second, construct valid and reliable measures of sexual orientation and transgender identity that accurately represent their definitions. Without clear conceptual definitions, development of valid and reliable measures is difficult to achieve. Different measures exist, but there is no consensus. In addition, there is limited literature discussing when and where the measures should be used [8].

Third, sample rare and hidden populations [8]. Large-scale random surveys are expensive, and researchers often must conduct smaller studies and use samples of convenience [9]. This sampling method may result in biased and uninformative data. For example, studies examining the prevalence of suicide among lesbian and gay youths and adults have yielded inconsistent results, in part because of the absence of good data. Additionally, researchers have had to rely on retrospective data from individuals after they self-label, disclose, and volunteer to participate in research projects [41]. Other factors may also impact sampling. For example, while studying GSM elderly, qualitative research sampling has been affected by deaths and memory changes, resulting in incomplete interviews [42].

Third, sample rare and hidden populations [8]. Large-scale random surveys are expensive, and researchers often must conduct smaller studies and use samples of convenience [9]. This sampling method may result in biased and uninformative data. For example, studies examining the prevalence of suicide among lesbian and gay youths and adults have yielded inconsistent results, in part because of the absence of good data. Additionally, researchers have had to rely on retrospective data from individuals after they self-label, disclose, and volunteer to participate in research projects [41]. Other factors may also impact sampling. For example, while studying GSM elderly, qualitative research sampling has been affected by deaths and memory changes, resulting in incomplete interviews [42].

Homophobia and heterosexism place LGBTQIA studies outside the mainstream in terms of importance as well as allocation of resources [9]. While difficulties with sampling have been used as a rationale for denying funding for research into LGBTQIA matters, effective sampling methods have been developed for surveying other rare populations, for example, ethnic minority groups or age groups [8]. These same methods can be used with the LGBTQIA community [9].

Coming-out models have generated much interest in developmental concerns related to sexual identity, thus bringing attention to gay and lesbian youth. However, the models may not be applicable to all individuals. The models, which have been developed from exclusively male samples, have not fully considered the diversity that exists among individuals of different backgrounds, ethnicities, and genders. Using theoretical models with female sexual minority samples has not always been helpful. Using data from young men also has been problematic because not all young men use sex to help them determine their identity; rather, they often know who they are prior to engaging in gay sex [41].

Initially proposed more than 30 years ago, coming-out models describe the arrival of same-sex identity by means of a series of steps or stages. These stages delineate when, in the development of same-sex identity, recognition of, making sense of, naming, and publicizing oneself as lesbian or gay occurs. The models are nearly universal in their stage sequence regarding the ways that LGBTQIA youth move from a private, at times unknown, same-sex sexuality to a public, integrated sexuality. Development has been generally perceived as linear and universal among individuals who share some real or hypothesized commonalities. Bisexuality has been seldom addressed in the models [41].

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.

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.

Many similarities exist between the LGBTQIA population and the general population related to health and safety concerns. For example, all individuals of any age should feel safe, which is a foundational need [64]. Yet, differences between the populations do exist. Heterosexism and homophobia may create environments that place LGBTQIA individuals of any age at increased risk for safety and health concerns [30,65].

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 "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].

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].

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].

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].

Existing research about bisexual health is scarce in large measure because the health issues that directly affect the bisexual population have either been ignored or treated as identical to the issues that affect heterosexuals or gay men and lesbians. Bisexuals have been found to experience greater health disparities and a greater likelihood of experiencing depression than the broader population [97].

Breast cancer is one of the most researched topics in lesbian health [8]. Lesbians have a richer concentration of risk factors for breast cancer than any other subset of women in the world [30]. Obesity, alcohol consumption, smoking, and nulliparity contribute to the risk of developing breast cancer, and avoidance of a healthcare system that has been discriminatory of lesbians in the past may result in delayed cancer detection and treatment. Lack of health insurance for unmarried partners has created access barriers to quality health care, including screening and prevention [36,104]. While few differences between the diagnosis and treatment of lesbian and heterosexual women have been found, lesbian women have demonstrated a puzzling increase in the number of chemotherapy-induced side effects, possibly resulting from aspects of internalized homophobia, fear of compromised care, or other causes [105].

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].

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].

Despite the myth that intimate partner violence (IPV) is exclusively an issue in heterosexual relationships, many studies have revealed the existence of IPV among same-sex couples and found its incidence to be comparable to or higher than that among heterosexual couples. Additionally, unique features and dynamics are present in IPV among same-sex couples, such as identification and treatment of same-sex IPV in the community and the need to take into consideration the role of sexual minority stressors. The lack of studies that address same-sex couple IPV is partly attributable to the silence that has historically existed around violence in the LGBTQIA community, which has obstructed a public discussion on the phenomenon [138]. Homophobia makes accessing information and support services problematic for LGBTQIA individuals. Gay and lesbian victims may experience more maladaptive outcomes as a result of the unique components of same-sex IPV, their sexual minority status in American society, and the lack of appropriate services tailored to victims of this type of domestic violence [139]. Results from the National Longitudinal Study of Adolescent to Adult Health indicate that IPV within the context of same-sex relationships led to more depressive symptoms and greater involvement in violent delinquency, with the impact of IPV on violent delinquency being greater for victims of same-sex IPV compared with opposite-sex IPV [139].

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 healthcare professional can utilize a variety of strategies to promote personal sensitivity, awareness, and knowledge of the LGBTQIA population. Borrowing from the discipline of crosscultural counseling, four communication skill areas may provide a framework for strategies that the healthcare professional can use to be more culturally competent when interacting with the LGBTQIA subculture. The skill areas are [156]:

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.

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].

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].