The world has changed a lot in the last few years for lesbian, gay, transgender and questioning individuals, for the better in a lot of ways. Yet, significant challenges remain in the quest for equality and its effects on well-being. Sexual and gender minorities face legal discrimination in many areas, and the battle for equality is far from over. The U.S. attorney general has worked to roll back legal protections, for example, and the president has announced a ban on transgender individuals in the military.
Not so long ago, most of the American public thought relationships between same-sex consenting adults should be illegal. The right for same-sex couples to marry was unthinkable in most states, many of which even amended their constitutions to prevent it from happening.
But the marriage law changed in 2015 with a ruling from the U.S. Supreme Court, and public opinion has shifted dramatically, with acceptance rising and overt, anti-gay sentiments falling into general disfavor.
“We’ve come a long way since the days when being gay meant a life of complete and utter rejection and social isolation.”
Still, struggles and stigma remain. And the stress of being in the minority, still facing bias and discrimination, continues to contribute to the challenges for LGBTQ (lesbian, gay, bisexual and transgender and queer) people to live healthy lives.
“We’ve come a long way since the days when being gay meant a life of complete and utter rejection and social isolation,” wrote American Civil Liberties Union LGBT Project director James Esseks in the Daily Beast. “We can wave rainbow flags and see ourselves represented on television. We can even get married in all 50 states.”
But he added, LGBT people still are not treated the same under the law and in life. They still risk being fired from their jobs and denied apartments because of their sexual and gender identities.
“The fact remains that we’re not there yet,” Esseks wrote. “Until the laws catch up and protect us, and the fear dwindles into nothing more than a footnote in a history book, we’ll have our work cut out for us.”
The June 2015 U.S. Supreme Court decision legalizing same-sex marriage across the United States has already had unexpected benefits not directly linked to romantic relationships, including reducing stigma faced by LGBTQ high school students.
Unfortunately, discrimination and rejection continue to exist. Mark Potok of the Southern Poverty Law Center told PBS Newshour that “LGBT people are targeted for violent hate crimes at a rate of two times that of… Muslims or black people, four times that of Jews, and 14 times that of Latinos.”
LGBT employees account for one out of every 25 complaints about workplace discrimination. And after the Supreme Court marriage ruling, state legislatures introduced hundreds of bills to restrict LGBT civil rights, many of which became law.
In the face of that, LBGTQ people have formed strong, supportive communities, often looking out for each other when abandoned or shunned by family, providing solace and support.
Issues for LGBTQ individuals are greater in some geographical areas than others. For example, 35 percent of LGBT people live in the south, where they have fewer protections against employment discrimination and are less likely to have insurance. Earning less than $24,000 a year on average, they report trouble affording food and medical care.
While the vast majority of LGBTQ individuals lead healthy and productive lives, many face risks that affect their health and endanger their well-being.
A growing body of evidence points to differences in certain health conditions and risks between LGBTQ individuals and the rest of the population. Some of these issues may be linked to stress associated with experiencing prejudice.
One study showed that sexual minorities who experienced prejudice were three times as likely to have a physical health problem — including cancer, flu and high blood pressure — in the next year as someone who had not.
This phenomenon, which has been dubbed minority stress theory, suggests that experiencing prejudice can be more harmful to health than other stressful life events.
According to research by the Williams Institute, compared to straight people, lesbian, bisexual and gay people generally experience higher prevalence and earlier onset of physical disabilities, such as those that require some kind of walking assistance. They also face higher rates of asthma and allergies, as well as osteoarthritis and chronic gastrointestinal problems.
Physical inactivity, obesity and smoking, which have been found to be more prevalent among lesbians than other women, raise their risk of heart disease, according to data from the Substance Abuse and Mental Health Services Administration (SAMHSA). That data also show that bisexual. Bisexual women have higher smoking rates and higher rates of high blood pressure than straight women and lesbians. They also have higher body mass index than straight women and higher cholesterol levels than other women. Moreover, they have higher rates of alcohol use than straight women. Consequently, bisexual women have higher rates of heart disease than heterosexual women, but lower than lesbians.
With higher rates of tobacco and alcohol use, bisexual men also face higher rates of heart disease.
Lesbians are also at greater risk of developing breast cancer than heterosexual women. This is partly due to the fact that they bear fewer children and don’t benefit from the protective hormones released during pregnancy and breastfeeding. This also may increase the risk of ovarian and endometrial cancers among bisexual women. They also tend to have fewer mammograms and are less likely to visit a doctor.
Gay men experience more migraine headaches and urinary incontinence and face an increased risk of prostate, testicular, and colon cancers, according to SAMHSA. Anyone who has anal sex, including bisexual men who are sexually active with men, is at higher risk for anal cancer. In fact, gay and bisexual men are estimated to have 17 times more risk of anal cancer than straight men.
Research into the physical health risks of hormone therapy on transgender individuals is very limited. Some evidence suggests an association between feminizing hormone therapies and an increased risk of venous thromboembolic disease. Masculinizing hormones may be associated with higher liver enzymes, loss of bone density and higher risk of ovarian cancer.
Among older LGBT adults, 9 percent have HIV disease. Cancer is reported in 19 percent of older LGBT adults, including 16 percent of lesbians, 20 percent of bisexual women, 21 percent of gay men, 24 percent of bisexual men and 16 percent of transgender older adults.
Cardiovascular disease is significantly higher for bisexual men than for gay men, according to SAMHSA. Older transgender adults have higher rates of obesity, cardiovascular disease, asthma and diabetes than other adults, but significantly lower rates of cataracts, and hepatitis.
Research shows that lesbians are more likely to be overweight than straight women, while straight men have higher obesity rates than gay men.
The 2014 national health survey showed that 30.7 percent of straight men were obese, significantly higher than the 23.2 percent of obese gay men. Among women, bisexuals had a 40.4 percent obesity rate while 36.7 percent of lesbians were obese, compared with 28.3 percent of straight women. Some other data, however, suggests that bisexual women are more likely to be underweight than other women.
A 2015 study found an association between stressors from being a sexual minority youth and unhealthy eating in up to 71 percent of female and 12 percent of male sexual minorities. Unhealthy eating, as well as behaviors such as binging and purging, may be a means of coping with stress faced by sexual minorities, such as stigmatization and higher rates of bullying.
Sexual minorities are also more likely to suffer from depression and anxiety, which may also contribute to disparities in weight, particularly among females.
Some research has suggested that adult lesbians aren’t physically active enough. Barriers to this include fatigue, lacking lesbian-focused physical activity groups and the lack of same-sex memberships to fitness facilities.
On the other hand, gay men more commonly deal with problems with body image than straight men. Gay men are more likely to have eating disorders, such as bulimia or anorexia nervosa.
Safe sex practices have succeeded in reducing the rate of HIV infections in the gay community. Scientific advancements and the development of antiretroviral drugs have turned AIDS from a death sentence to a chronic and manageable disease. The percentage of gay men in the U.S. who are infected with HIV has steadily gone down.
However, recent data have suggested that unsafe sex practices may be returning, and HIV still disproportionately affects the LGBT community.
There are between 48,000 and 64,500 new HIV infections annually. In total, about 1.1 million Americans have HIV, according to the Centers for Disease Control and Prevention. Men who have sex with men continue to make up the greatest proportion of those numbers. More new HIV infections among men who have sex with men happen in the South than in any other part of the United States.
The rate of new HIV diagnoses in the United States among men who have sex with men is 44 times that of other men, according to CDC statistics.
Young, African-American men are hit the hardest by HIV/AIDS, with twice as many between the ages of 13 and 24 being diagnosed with HIV or AIDs in 2006 as their white or Hispanic peers, according to information compiled by SAMHSA. They are also generally infected at a younger age, between 13 and 29, compared with white men who have sex with men and generally become infected between 30 and 39.
Despite having longer lives than HIV-infected individuals in the past, people with HIV still have challenges, including higher rates of poor health, disability, depression, and anxiety.
Sexually active gay men are also at higher risk for other sexually transmitted diseases, including syphilis, gonorrhea, chlamydia, pubic lice, and human papillomavirus (HPV), according to SAMHSA data. HPV is suspected of playing a role in the increased rates of anal cancers among men.
In addition, several cities, including, Chicago, Seattle, San Francisco, Miami and New York, have seen outbreaks of syphilis among men who have sex with men, SAMSHA reports. Contracting syphilis increases the chance of acquiring or transmitting HIV, and these areas have also seen high rates of men who have both syphilis and HIV.
Gay men are at higher risk for hepatitis, and health officials recommend that all men who have sex with men be immunized for hepatitis A and B viruses, according to the CDC. Safe sex practices also reduce the risk of hepatitis and are the only way to prevent hepatitis C.
Some bisexual men report less risky sexual behavior with males, but are more likely to have sex with female prostitutes and to have anal sex with women, according to SAMSHA. Other bisexual men, including HIV-positive individuals who inject drugs, are more likely to engage in unprotected sex than gay and bisexual men who have not used drugs, according to some research.
Studies suggest bisexual women engage in more high-risk sexual activities than straight women, such as sex with multiple partners, sex with an HIV positive man, sex with partners who inject drugs, and sex with a partner who had sex with a prostitute.
Lesbian women, and bisexual women with more female partners, are at risk for vaginal infections.
Estimates vary widely (from 5 percent to 68 percent) on the prevalence of HIV among transgender women, with the highest rates among transgender women of color. HIV prevalence among transgender men is believed to be between 2 percent and 3 percent. Data suggests a shortage of available HIV treatment services for transgender women, in spite of the high rates of the disease in that population.
The theory of minority stress has been used to understand disparities in mental health between sexual minorities and other individuals.
Lesbian and bisexual women who were out as teenagers had more emotional stress and were up to 2.5 times as likely to have suicidal thoughts in the past year as straight women. Lesbian and bisexual women who were not out were more likely than straight women to have attempted suicide.
Another study found that women with same-sex partners had more mental-health disorders, including depression, phobia and post-traumatic stress disorder.
Bisexuals suffer some of the same mental-health problems, with some research suggesting they have the lowest level of emotional well-being, according to SAMHSA. Bisexuals also report higher levels of depression than straight individuals.
The data on mental-health disorders among transgender individuals are limited, according to SAMHSA. The available studies have produced differing results. One study found transgender women more likely to have suicidal thoughts and attempts at suicide, more likely to take psychotropic drugs and more likely to abuse alcohol than heterosexual women and non-transgender men. But the study found no difference in this respect between transsexual women and lesbians.
Overall, older LGBT adults surveyed in one study rated their mental health as good, or about a 71 on a scale in which 100 is excellent. Among this population, 74 percent reported being satisfied with life.
The enactment of legally recognized marriage for same-sex couples has provided an added bright spot for mental health.
Research by the Williams Institute shows that lesbian, gay, bisexual people who are legally married to a person of the same sex have less stress than those who are not legally married. The study showed no significant differences in psychological distress between straight people and lesbian, gay and bisexual people in legally recognized, same-sex relationships.
This may be connected to reduced feelings of social exclusion and stigma. In addition, married straight people have better mental health than single counterparts, so marriage itself appears to have a positive effect on well-being.
LGBTQ youth come out at younger ages than in the past, and they face a far more supportive society in general. And even when faced with adversity, most LGBTQ youth grow into healthy, productive adults.
Researchers have theorized that the fact that youth come out at an earlier age is posing a risk because the process is coinciding with an adolescent developmental period in their lives when they and their peers face intense social pressure related to gender and sexuality, including homophobia.
So feeling the freedom and ability to be more open about their identities is actually leaving some LGTBQ youth vulnerable because of the developmental issues of adolescence.
Lesbian, gay and bisexual high school students face challenges their straight peers don’t.
Coming out puts youth at risk for harassment and losing close friends — something that is less likely for adults who come out. On the other hand, despite the risk, LGBTQ individuals who were out in high school reported lower levels of depression and greater overall well-being as young adults, while those who concealed their identities were still susceptible to being victimized.
The statistics paint a horrifying picture of the perils.
Research has shown that LGBTQ teens are far more likely to be bullied and to be victims of physical and sexual violence than other students, according to research by the Centers for Disease Control and Prevention. In fact, according to a CDC report, lesbian, gay and bisexual students were more than four times as likely to be bullied at school as straight students.
Research has shown that in schools with policies against bullying and discrimination on the basis of sexual orientation and gender identity, LGBTQ youth are far less likely to be victimized and harassed. Students who live in communities that are generally supportive — places with gay-straight alliances, for example — are less likely to attempt suicide.
But when harassment occurs, youth are at higher risk for suicide, depression, addiction, poor grades in school, and other serious consequences.
These consequences were also reflected in the CDC report, which found lesbian, gay and bisexual youth more much more likely to feel sad or hopeless, more likely to attempt suicide and to use illegal drugs.
With general attitudes changing and same-sex marriage the law of the land, America’s lesbian, gay, bisexual and transgender adults say they feel more accepted by society and expect attitudes toward them to continue to improve.
Yet, many LGBT adults still feel stigmatized and nearly 40 percent in one national survey reported having experienced rejection by a family member or close friend because of their sexual orientation or gender identity. The survey by the Pew Research Center also showed 30 percent had been physically attacked and 29 percent had felt unwelcome in a place or worship, while 21 percent said they were treated unfairly by an employer. Nearly 60 percent had been the target of slurs or jokes.
So stigma, rejection, and all the repercussions continue to be very real issues, which play into the difficult, personal decision of when and whether to come out.
The process is different for every person who must control how and whether to share their true selves with people who may or may not love and accept them.
The process has also changed over time. An adolescent coming out in the 21st Century won’t have the same experience as a teen in the 1960s or any other time. And some people undergo changes in their sexual attractions and relationships over the course of their lives. People who are also part of racial and ethnic minorities have different experiences than people who are not.
Moreover, people who live in areas with fewer openly LGBT people may have less support and feel less comfortable sharing their identities, while people who live in more diverse areas with larger sexual and gender minority populations may feel more comfortable and safe.
That same survey by the Pew Research Center showed 56 percent of respondents saying they had come out to their mothers and 39 percent reporting they had told their fathers.
Coming out has ramifications beyond family and friend relationships, and even more than the workplace and interactions with strangers. In some instances, LGBT individuals don’t tell health care providers important information needed to facilitate the best care.
A December 2012 study at the Williams Institute at UCLA School of Law showed that bisexual men and women were less likely than gay men and lesbians to tell health care providers their sexual orientation. According to the study, which was funded by the National Institute of Mental Health and involved 396 people in New York City, 39 percent of bisexual men and 33 percent of bisexual women didn’t tell their medical providers their sexual orientation, while 14 percent of gay men and 10 percent of lesbians withheld that information.
But less than five years later, a study at Brigham and Women’s Hospital showed an interesting disconnect in emergency rooms. Nearly 80 percent of providers thought patients would not want to reveal their sexual orientation, while just over 10 percent of patients said they would refuse.
“This is important information that patients feel is relevant to their health, and in most cases, they want and expect their health care providers to ask them about it,” study author Dr. Adil Haider said. “Our patients are telling us that routinely asking all patients who come to the [emergency department] about this information creates a sense of normalcy toward people of all sexual orientations and signals that each patient is equally welcome here, including the 3 to 10 percent of Americans who identify as lesbian, gay or bisexual.”
The U.S. Department of Health and Human Services and the National Academy of Medicine recommend routine collection of sexual-orientation information in health-care settings. But it’s not done in most hospitals, and there are no clear guidelines on how it should be done.
A survey of 10,000 teenagers by the Human Rights Campaign found 91 percent saying they were out to close friends, 64 percent saying they were out to their classmates, and 56 percent saying they were out to their immediate family. Those who were out were more likely to report being happy than those who hadn’t shared their sexual or gender identity with those close to them.
The teens who were not out were less likely to have an adult they could talk to if they were sad, while those who were out were more likely to be happy, but also more likely to have been called names involving anti-gay slurs and slightly more likely to experience verbal harassment.
For those teens who didn’t share their identity with family members, 19 percent said they were scared of what the reaction would be, and 30 percent reported their families were not accepting or homophobic. Another 16 percent cited religious reasons for not telling family members. Said one: “They are very religious and hate gays and I don’t want them to hate or disown me. I don’t want to disappoint them or lose them.”
“They are very religious and hate gays and I don’t want them to hate or disown me. I don’t want to disappoint them or lose them.”
The idea of rejection is terrifying. As one teen said about his family, “They are very unaccepting. An aunt of mine actually took me aside when I was younger to tell me that ‘gays aren’t right in the head,’ Her goal was to scare me into being straight.”
And another youth said, “They would throw me out if I told anyone in my extended family. So I have to keep my mouth shut. Otherwise, I would end up penniless and homeless.”
That teen’s fears, unfortunately, are rooted in the real world faced by many peers. For LGBT youth, homelessness looms as a real and present threat.
Homelessness is a major issue for LGBT youth, who comprise between 20 percent and 40 percent of all homeless youth, even though estimates say that between 3 percent and 5 percent of the entire population is LGBT.
The most frequently cited factor contributing to LGBT homelessness was family rejection on the basis of sexual orientation or gender identity. Next most frequently cited factor was being forced out of their homes as the result of coming out. The next three cited reasons were physical, emotional, or sexual abuse at home; aged out of the foster care system; and financial or emotional neglect from family.
Nearly 70 percent of LGBT clients at homeless shelters reported experiencing rejection from family and more than half reported experiencing family abuse.
And inside the shelters, life for LGBT youth can be a nightmare. One study found that LGBT youth are physically and sexually victimized by an average of seven more people than other homeless youth. With few options, some are forced to engage in sex work and other unhealthy survival behaviors that increase the risk of problems, including substance abuse and exposure to sexually transmitted disease. The teens sometimes will engage in “survival sex,” exchanging sexual acts for needed things, such as food, clothes, drugs and shelter.
It’s also not uncommon at shelters for these young people to experience harassment, assault, and even rape. One shelter in Michigan forced LGBT teens to wear orange jumpsuits to easily identify them to staff and other residents. LGBT youth at a large facility in New York reported being threatened, belittled and abused by staff.
Life in homeless shelters is even worse for transgender youth, who may be assigned to beds according to the gender of their birth and not their identity, according to a report by the National Gay and Lesbian Task Force. Bathrooms, locker rooms, and dressing areas provide more opportunities for peril. Even some agencies that serve lesbian, gay, and bisexual clients may ostracize transgender youth. These individuals are also overrepresented in the homeless population, with some estimates that one in five transgender people needing or are at risk of needing a homeless shelter.
The issue of faith-based providers taking over homeless services can pose additional problems for LGBTQ youth, who may face discrimination from agencies run by religious institutions that oppose legal and social equality.
One statistic from the National Runaway Switchboard is that LGBT homeless youth are seven times more likely to be victims of crime than other homeless young people.
In general, homeless LGTBQ youth are particularly at risk for depression, loneliness, and psychosomatic sickness, withdrawn behavior, social problems and delinquency. These factors provide a path for many of the teens to abuse drugs and alcohol.
Tobacco, alcohol and other forms of substance abuse are prevalent among lesbians, gay men, bisexuals and transgender individuals, compared with other people. Studies have shown that compared to the general population, gender and sexual minorities have higher rates of substance abuse and are more likely to continue drinking into later life, according to SAMHSA.
Bisexual men and women have the highest rates of tobacco use, with smoking rates estimated at between 30 percent and 40 percent of the population. Lesbians (39.1 percent) are about twice as likely to smoke as straight women (19.4 percent).
A national survey taken in 2014 showed that 27.2 percent of gay men and lesbians and 29.5 percent of bisexual individuals reported being current cigarette smokers, compared to 19.6 percent of straight people. The main disparity showed up between the 27.2 percent of lesbians and 29.4 percent of bisexual women, compared with 16.9 percent of straight women who smoke. There were no significant differences in adult men.
According to SAMHSA, studies on tobacco use by transgender people vary widely, with estimates ranging from 45 percent to 74 percent. This is particularly dangerous for transgender women who take estrogen because smoking significantly increases the risk of blood clots. It’s also exacerbated health issues for transgender men who take testosterone, which, like smoking, increases the risk of heart disease.
Some studies have estimated that 20 percent to 25 percent of gay men and lesbians are heavy alcohol drinkers, compared with 3 to 10 of heterosexuals.
Gay men are significantly more likely than straight men to have used marijuana, psychedelics, hallucinogens, stimulants, sedatives, cocaine, and barbiturates. Data show that gay people are increasingly using party drugs, such as MDMA, also known as ecstasy, which can impair judgment and contribute to risky sexual behavior. The use of needles to inject drugs like methamphetamine creates a risk of HIV and hepatitis.
Bisexual women are also much more likely to binge drink, at 23.7 percent compared to 8.3 percent of straight women, according to SAMHSA. About 20 percent of both bisexual and heterosexual men binge drink, according to studies.
Studies have demonstrated a major issue with substance abuse among transgender people, with marijuana, crack cocaine and alcohol being the most commonly abused. In addition, up to 46 percent of transgender people use methamphetamine and as much as 40 percent inject unprescribed drugs.
Substance abuse and other factors, including experiences of abuse and negative reactions to coming out contribute to the reality that LGBT individuals are at higher risk for suicidal thoughts and attempts at suicide.
It should be noted that attempted suicide isn’t a strong predictor of completed suicide. For example, 80 percent of people who die by suicide are male, but 75 percent of those who make suicide attempts are female. There is little solid information available on suicide deaths among LGBT people.
Research has shown that on average, the age of serious suicide attempts among LGBT individuals coincided with major milestones associated with coming out, such as the age when a person recognizes his or her sexual identity. People whose first suicide attempt happened at an older age also had later coming out milestones. The reverse is also true for people with earlier suicide attempts.
Studies also show that LGBT youth experience higher rates of harassment and bullying than straight young people. Although the large majority of people who are bullied do not become suicidal, research shows that persistent bullying can contribute to feelings of isolation, rejection, exclusion, despair, and depression. And all of this can contribute to suicidal behavior.
Surveys in the United States have shown that LGBT individuals have two to six times higher rates of reported suicide attempts as straight people.
One survey found that lesbian and bisexual women who are out had felt more emotional stress as teens and were as much as 2.5 times more likely to have thought about suicide in the past year than straight women. On the flip side, lesbian and bisexual women who are not out are also more likely to attempt suicide than heterosexual women.
Research among transgender people has shown that between 38 percent and 65 percent have experienced suicidal thoughts, and between 16 percent and 32 percent have attempted suicide.
The good news is some things are getting better on this front.
The fact that same-sex marriage is now legal has apparently contributed to a reduction in adolescent suicide attempts, according to a study in February 2017 by researchers from Johns Hopkins and Harvard. That study found a 7 percent reduction in the proportion of high school students reporting a suicide attempt within the past year.
The study focused on data collected before the Supreme Court’s June 2015 ruling that made same-sex marriage the law of the land. It compared rates of suicide attempts among youths in states where same-sex marriage was legal with the rates among young people in states where it was not. In states where same-sex marriage was legalized, rates of suicide attempts dropped for all students, but the drop was most pronounced among gay, lesbian, and bisexual students.
The study was published in the journal JAMA Pediatrics and was accompanied by an editorial by Mark L. Hatzenbuehler, a public health specialist at Columbia University. Hatzenbuehler wrote that the study suggests that state laws carry a “structural stigma” that may be a consequential, but overlooked, factor contributing to suicidal behavior among LGBTQ youth.
More troubling research by the Williams Institute at UCLA raises questions about the ability of LGBTQ individuals to obtain effective help. According to that study in 2014, sexual and gender minorities who sought mental health treatment from health care providers were no less likely to attempt suicide than those who didn’t see any treatment at all.
Most disturbingly, sexual and gender minorities who sought help from religious or spiritual sources had higher odds of attempting suicide.
“The findings are troubling because seeking treatment is a recommended suicide prevention strategy and this study’s results show no more positive effect for people who sought treatment. More troubling is the finding that individuals who sought religious or spiritual treatment had higher odds of later attempting suicide than those who did not seek treatment at all,” said co-author Ilan H. Meyer.
“More studies are needed to assess the efficacy of treatment for LGB people with suicidal ideation in preventing future suicide attempts. But, even without further study, public health officials and health service providers ought to ensure that LGB individuals who seek mental health treatment, whether it is in medical or religious settings, receive competent mental health services that is relevant to their needs,” Meyer said.
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