Table of contents(15 chapters)
Purpose: The goal of Volume 21 of Advances in Medical Sociology, entitled Sexual and Gender Minority Health, is to showcase recent developments and areas for future research related to the health, well-being, and healthcare experiences of LGBTQA+ (Lesbian, Gay, Transgender, Queer, Asexual, and related communities that do not identify as heterosexual) persons and communities.
Approach: In this introduction to the volume, we trace the historical development of research on sexual and gender minority (SGM) health, discussing how priorities, theories, and evidence have evolved over time. We conclude with brief suggestions for future research and an overview of the articles presented in this volume.
Findings: Research on SGM health has flourished in the past two decades. This trend has occurred in conjunction with a period of intense social, political, and legal discourse about the civil rights of SGM persons, which has increased understanding and recognition of SGM experiences. However, recent advances have often been met with resistance and backlash rooted in enduring social stigma and long histories of discrimination and prejudice that reinforce and maintain health disparities faced by SGM populations.
Value: Our review highlights the need for additional research to understand minority stress processes, risk factors, and resiliency, particularly for those at the intersection of SGM and racial/ethnic or socioeconomic marginality.
Part I Health Disparities: Risk Factors, Minority Stress, and Intersectionality
Purpose: We review theory and research to suggest how research on sexual and gender minority (SGM) population health could more completely account for social class.
Approach: First, we review theory on social class, gender, and sexuality, especially pertaining to health. Next, we review research on social class among SGM populations. Then, we review 42 studies of SGM population health that accounted for one or more components of social class. Finally, we suggest future directions for investigating social class as a fundamental driver of SGM health.
Findings: Social class and SGM stigma are both theorized as “fundamental causes” of health, yet most studies of SGM health do not rigorously theorize social class. A few studies control socioeconomic characteristics as mediators of SGM health disparities, but that approach obscures class disparities within SGM populations. Only two of 42 studies we reviewed examined SGM population health at the intersections of social class, gender, and sexuality.
Research implications: Researchers interested in SGM population health would benefit from explicitly stating their chosen theory and operationalization of social class. Techniques such as splitting samples by social class and statistical interactions can help illuminate how social class and SGM status intertwine to influence health.
Originality: We synthesize theory and research on social class, sexuality, and gender pertaining to health. In doing so, we hope to help future research more thoroughly account for social class as a factor shaping the lives and health of SGM people.
Purpose: In the current work, we provide a portrait of heavy alcohol use, cigarette smoking, mental health, and suicide ideation by sexual orientation among a large sample of US adults aged 25 years and older.
Design/methodology/approach: We produce a repository of information on sexual orientation, substance use, mental well-being, and suicide ideation for adults aged 25 years and older using Behavioral Risk Factor Surveillance System (BRFSS) surveys for nine US states from 2011 to 2018. We establish baseline differences on these outcomes for gay, lesbian, and bisexual (GLB), relative to heterosexual, adults and then use regression techniques to adjust the estimates for important sociodemographic, socioeconomic, and relationship status variables.
Findings: Disparities by sexual orientation across substance use, mental health, and suicide ideation are concerning, some alarmingly so. Bisexuals, particularly women, face pronounced challenges across outcomes. Sexual minority men and women report significantly more poor mental health days and much higher odds of suicide ideation. To illustrate, gay men, lesbians, and bisexual men and women, relative to their heterosexual counterparts, have odds of seriously contemplating taking their own lives that are two to four times higher even after adjusting for relevant controls.
Originality/value: Existing knowledge connecting GLB identity and mental well-being has focused largely on adolescent and young adults. We provide a representative study on older adult differences across four different behavioral health outcomes by sexual orientation. The scale of the disparities we report here, and their implications for overall well-being across groups, deserves national attention and action.
Purpose: Sexual minority youth are more likely than their heterosexual peers to consider and attempt suicide, in part due to victimization experienced within schools. While existing research suggests that rates of school victimization and suicidality among sexual minority students vary by school and community context, less is known about variation in these experiences at the state level.
Methodology: Using data from a large, representative sample of sexual minority and heterosexual youth (2017 Youth Risk Behavior States Data, n = 64,746 high school students in 22 states), multilevel models examine whether differences between sexual minority and heterosexual students in victimization and suicide risk vary by state-level policies.
Findings: Results suggest that disparities between sexual minority and heterosexual boys in bullying, suicide ideation, and suicide attempt are consistently smaller in states with high levels of overall policy support for LGBTQ equality and nondiscrimination in education laws. Sexual minority girls are more likely than heterosexual girls to be electronically bullied, particularly in states with lower levels of LGBTQ equality. Disparities between sexual minority and heterosexual girls in suicide ideation are lowest in high equality states, but state policies are not significantly associated with disparities in suicide attempt among girls.
Value: Overall, findings suggest that state-level policies supporting LGBTQ equality are associated with a reduced risk of suicide among sexual minority youth. This study speaks to the role of structural stigma in shaping exposure to minority stress and its consequences for sexual minority youth's well-being.
Understanding Fear of Deportation and Its Impact on Healthcare Access among Immigrant Latinx Men Who Have Sex with Men
Purpose: Fear of deportation and its relationship to healthcare access has been less studied among immigrant Latinx men who have sex with men (MSM), a population at risk for HIV and characterized by their multiple minority statuses. The first step is to accurately measure their fear of deportation.
Approach: We used an exploratory sequential mixed methods design. Eligibility criteria were that research participants be ages 18–34 years; Latinx; cisgender male; having had sex with another male; residing in the District of Columbia metro area; and not a US citizen or legal permanent resident. In Study 1, we used in-depth interviews and thematic analysis. Using participants' interview responses, we inductively generated 15 items for a fear of deportation scale. In Study 2, we used survey data to assess the scale's psychometric properties. We conducted independent samples t-test on the associations between scale scores and barriers to healthcare access.
Findings: For the 20 participants in Study 1, fear of deportation resulted in chronic anxiety. Participants managed their fear through vigilance, and behaviors restricting their movement and social network engagement. In Study 2, we used data from 86 mostly undocumented participants. The scale was internally consistent (α = 0.89) and had a single factor. Those with higher fear of deportation scores were significantly more likely to report avoiding healthcare because they were worried about their immigration status (p = 0.007).
Originality: We described how fear of deportation limits healthcare access for immigrant Latinx MSM.
Research implications: Future research should examine fear of deportation and HIV risk among immigrant Latinx MSM.
Part II Resilience and Resistance: Identity, Social Relationships, and Community
Purpose: In this chapter, we develop a concept of social biographies which draws on social network and life course theories to examine how a diverse set of social relationships impacts health of sexual and gender minority (SGM) people over time.
Design/methodology/approach: We provide an overview of several decades of research on SGM people's social relationships, organizing this research within a social biographies framework.
Findings: We theorize about the importance of both the structure and content of SGM people's social networks for health, how these social relationships interact with each other, how these social biographies and their impacts shift across SGM cohorts and over the life course, and how they further are shaped by the intersection of a range of factors (e.g., race/ethnicity, social class).
Social biographies can remain constant or change over time, and relationships of all types and durations have the power to significantly improve or undermine health. This is in part because social ties both buffer and exacerbate the inimical effects of stress on health.
Originality/value: Traditional conceptualizations of relationships fail to reflect the diversity of relationships in SGM lives. Studying this diversity deepens our view of how social biographies influence health and how health inequities between SGM and cisgender and heterosexual (cishet) populations emerge. Studying social biographies of SGM people using theoretical and methodological tools from life course and social network perspectives reveals existing voids in the current literature, enabling researchers to better understand the shifting nature of social relationships in the twenty-first century.
Life Course Transitions, Personal Networks, and Social Support for LGBTQ+ Elders: Implications for Physical and Mental Health
Purpose: This chapter explores the role of life course transitions, personal networks, community, and social support in the physical and mental health of LGBTQ+ elders. Specifically, we review the literature on formal and informal supports and resources available to LGBTQ+ elders as they age.
Methodology: We use an intersectional lens that explores dimensions of social identity and social location among diverse subpopulations within sexual and gender minority (SGM) elders. We outline the implications of access (or lack of access) to formal and informal care for SGM elders' physical and mental health and well-being in late life. We examine the availability of these supports in the context of broad inequalities and life events that structure the life course for LGBTQ+ elders and have long-term health implications.
Findings: Our findings from this review demonstrate how social factors over the life course shape SGM mental and physical health later in life for aging LGBTQ+ populations. We reflect on how strained relationships and lack of acceptance compel some to seek alternative sources of support and relationships. Our analysis uncovers individual and institutional sources of support: personal social networks and formal spaces, such as healthcare settings, that connect elders with resources to develop social support and avoid social isolation.
Implications: The implications of our review reveal the unique needs and barriers to practical and social support that SGM older adults face. We explore alternative supports that LGBTQ+ elders need compared with their heterosexual cisgender peers, given the disproportionate rejection they face in a range of public and intimate spaces. We conclude by identifying and celebrating sources of support and resilience as LGBTQ+ elders have crafted alternate support networks and advocated for increased recognition, rights, and care.
Originality and Value: Despite some recent flourishing of research in SGM health, a road map for scholars, practitioners, and community members outlining future research in understudied areas such as LGBTQ+ aging and transgender health would help advance scholarship and policy. Our commentary highlights quantitative and qualitative studies and suggests avenues for research that put in conversation literatures on rural studies, urban sociology, and social networks; gerontology; health; and gender/sexuality studies.
Experiences of Gender and Sexual Minority Stress Among LGBTQ Families: The Role of Community Resilience and Minority Coping
Purpose: This paper presents an exploratory analysis of minority stress and resiliency processes among parents in LGBTQ families. The paper examines two unique minority stress processes – (1) parents experiencing sexual and/or gender minority stress due to the stigmatization of their own identities as individuals and (2) parents sharing the gender minority stress faced by their transgender and gender expansive (TGE) child, and in the context of their parent–child relationship.
Methodology: Between 2017 and 2018 in-depth, in-person qualitative interviews on the topics of gender, stress, and resilience were conducted with 12 parents in LGBTQ families. Audio recordings were transcribed and then open coded using ATLAS.ti qualitative data analysis software. Analyses of data were informed by critical intersectional theories that locate gender and sexuality within structures of social and racial oppression.
Findings: Interview data indicate that minority stress is experienced by parents experiencing sexual and/or gender minority stress due to the stigmatization of their own identities, as well as among parents sharing the gender minority stress faced by their TGE child in the context of their parent–child relationship. Parents described community resilience and minority coping through interpersonal, community, and institutional support. This paper provides evidence that sexual and gender minority stressors are enhanced and resiliency factors are reduced among those experiencing racism and economic disadvantage.
Research limitations: This is an exploratory study conducted with a small sample of parents in a specific geographic area.
Originality/Value: These data provide initial evidence to support further analyses of the dyadic minority stressors within parent–child relationships in LGBTQ families
Resisting and Reframing Explanations for “Lesbian Obesity”: LBTQA+ Young Women's Narratives of Sexual Identity as a Protective Factor
Purpose: To understand how lesbian, bisexual, transgender, queer, and asexual (LBTQA+) young women interpret the social construction of “lesbian obesity” in the context of their lived experiences and membership in the LGBTQ+ community.
Methodology: Individual, in-depth interviews were conducted with a convenience sample of 25 LBTQA+ women, ages 18–24, to explore how participants perceive and experience dominant discourses about gender, sexuality, and weight. Interviews were analyzed using a combination of deductive and inductive coding approaches.
Findings: Participants resisted public health discourse that frames obesity as a disease and the implication that their sexual identities put their health at risk. Many participants viewed their sexual identities and membership in the LGBTQ+ community as protective factors for their health statuses in general and their body image in particular.
Implications: Our findings suggest a need to reconsider the utility of the concept of “lesbian obesity” to characterize the significance of elevated rates of overweight and obesity in this population. Public health and clinical interventions guided by body positive approaches may be of greater relevance for sexual minority women.
Originality: This study centers the perceptions and experiences of LBTQA+ young women in order to examine how the intersections of sexual minority identity, dominant cultural ideals about weight, and obesity discourse inform their health.
Part III The Role of Institutions: Healthcare and Social Service Systems
Purpose: We analyze how medical providers use accountability processes or the regulatory means through which individuals hold themselves or others accountable to social norms, to uphold their medical authority. We use the case of trans medicine because in this medical domain, providers often have little to no expertise and few are trained specifically in delivering trans medicine or working with trans patients. As a result, providers experience uncertainty and are left without the typical tools and expertise on which they depend in most other areas of medical decision-making.
Design/methodology/approach: We conducted in-depth interviews with 23 medical providers and observations of transgender healthcare conferences in the United States between 2012 and 2015.
Findings: Our work offers insight into the provider side of patient-provider encounters and medical decision-making in gender minority health. The first accountability strategy providers employed was to invoke the language of evidence as a method to maintain their authority, in spite of the paucity of scientific evidence that undergirds this emergent medical domain. The second strategy was to mandate compliance by holding trans people accountable to the expectation of acquiescing to medical authority.
Originality/value: We contribute to the scholarship on gender minority health by examining how high power actors use accountability processes to restore order in interactions with trans and nonbinary patients. We demonstrate how enforcement to expectations through accountability processes is a plausible, though oft-overlooked, dimension of health inequalities.
“Every Now and Then I Get Flagged for a Pap Smear”: Gender Transition, Embodiment, and “Sex-Specific” Cancer Screenings
Purpose: We respond to a call for studies of “embodied experiences of stigma in context” by investigating how transgender embodiment shapes perceived needs for access to and experiences of “sex-specific” cancer screenings (SSCS) (e.g., breast and prostate exams, Pap smears) in the North American healthcare system.
Design/Methodology/Approach: We analyze data from semistructured interviews with a diverse sample of 35 transgender-identified adults. Based on thematic narrative analysis, we explore four themes in relation to embodiment: discrimination; discomfort and hyperawareness of genitalia; strategic reframing and active management; and SSCS health care encounters as positive and gender affirming.
Findings: In relation to SSCS, transgender individuals experience discrimination, do emotion work, and actively manage situations to obtain needed health care, and sometimes forego care because barriers are insurmountable. Health care providers' responses to transgender embodiment can disrupt health care encounters, but they can also facilitate access and create opportunities for affirmation, agency, advocacy, and new forms of interaction. Embodiment- and gender-affirming interactions with health care providers, which varied by gender, emerged as key influences on participants' experiences of SSCS.
Research Limitations/Implications: Our sample primarily includes binary gender-identified individuals, and while our interview guide covered many topics, the SSCS question did not explicitly reference testicular exams.
Practical Implications: Cancer prevention and detection Cancer prevention and detection require health care professionals who are prepared for differently embodied persons. Preventive cancer screenings are not “sex-specific”; they are relevant to individuals with medically necessary needs regardless of gender identity or embodiment.
Originality/Value: Few medical sociologists have focused on transgender embodiment. Findings enhance our understanding of how transgender embodiment and minority stress processes influence access to needed SSCS.
Purpose: This chapter examines the implementation of lesbian, gay, bisexual, transgender, and queer (LGBTQ) health curricula in medical education, focusing on how this content is presented to students to understand if these curricula can fulfill goals of achieving healthcare equity for LGBTQ populations.
Methodology: This research draws on data from six months of participant observation of an academic medical center and school and 28 interviews with medical faculty, students, community members, administrators, and LGBTQ Health Center employees.
Findings: This research has three findings: (1) this medical school has variable definitions for LGBTQ health, making it a hybrid form of knowledge based in (a) understanding the unique health needs of; (b) being culturally competent to; and (c) being a (structural) advocate for LGBTQ patients; (2) LGBTQ health is integrated into multiple courses in the curriculum; and (3) LGBTQ health is becoming a medical specialty frequently delivered to students by LGBTQ health experts.
Research limitations and implications: This research used snowball sampling to recruit participants engaged in LGBTQ health at the institution; it therefore risks self-selection bias. Findings from this study are not generalizable.
Originality: This research argues that LGBTQ health experts engage in a new kind of diversity and inclusion work because (1) these health experts are not always LGBTQ identified; (2) this work is not necessarily unpaid or involuntary; and (3) it involves a hybrid knowledge requiring an understanding of LGBTQ identity, medical knowledge, and social science. Because these LGBTQ health experts opt into this work, and broadly define it, a message available to other physicians and students is that LGBTQ health remains elective.
“What Are We Going to Do with a Penis in the Room?”: Rape Crisis Centers and Treatment of Transgender Survivors
Purpose: Being the victim of sexual violence can lead to long-term health consequences. In response, rape crisis centers provide support to survivors of sexual violence including medical and mental health treatment or referrals to treatment. A history of exclusion and provision of service by cisgenderist binary categories limit the ability of rape crisis centers to serve transgender survivors of sexual violence. Can gender be a way to provide safe, inclusive healthcare or is it necessarily a way to enact gender oppression? How can rape crisis centers and other healthcare organizations become more inclusive of transgender people?
Methods: In addition to fieldwork at a rape crisis center that had a trans inclusion project, interviews were conducted with staff and volunteers at the rape crisis center.
Findings: I found that gender-based service provision is problematic, especially when based on an understanding of gender conflated with sex category. Even organizations aiming to challenge gender oppression can reproduce it.
Practical Implications: Options for health organizations to become more trans inclusive are presented.
Originality: Research on the transgender experience, particularly at rape crisis centers and other healthcare organizations that provide gender-segregated service, is limited That literature often presents those organizing women-only space as monolithic and struggles around the inclusion of trans people oversimplified. My research illuminates how gender inequality is reproduced in an organization aimed at challenging that inequality. My research shows the logics of those engaged within an organization reproducing oppression despite individuals' desires to challenge oppression.