Lgbtq [plus] Individuals, Health Inequities, and Policy Implications

• Publication year: 2022

52 Creighton L. Rev. 427. LGBTQ [PLUS] INDIVIDUALS, HEALTH INEQUITIES, AND POLICY IMPLICATIONS

LGBTQ [PLUS] INDIVIDUALS, HEALTH INEQUITIES, AND POLICY IMPLICATIONS

HEATHER A. MCCABE ^[*]
M. KILLIAN KINNEY ^[**]

I. INTRODUCTION

When the Office of Disease Prevention and Health Promotion ("ODPHP") released its Healthy People 2020 goals and objectives, it recognized the public health needs of the lesbian, gay, bisexual, and transgender ("LGBT") community for the first time. ^[1] The stated goal of Healthy People 2020 is to "improve the health, safety, and well-being of [LGBT] individuals." ^[2] One barrier to obtaining the needed information for achieving this goal is a lack of necessary data collection, particularly as it regards the LGBTQ+ community. This paper will provide a basic overview of health inequities experienced by the LGBTQ+ community and introduce interventions of interest to the legal and public health communities.

II. DESCRIPTION OF LGBTQ+ COMMUNITY

A. ALL COMMUNITIES ARE NOT THE SAME

While the LGBTQ+ community is frequently discussed as one community, it is actually a collection of unique communities. The LGBTQ+ community is inclusive of both sexual orientation and gender identity ("SOGI") minorities. It is important to note both the similarities and the differences between the groups in order to adequately examine health inequities in a way which meaningfully provides avenues to lower the impact of marginalization and increase wellbeing. The discussion of the LGBTQ+ community as a whole, without considering the unique differences among the groups, can gloss over meaningful differences, both in gender experiences and sexual orientation. Additionally, there are those whose attraction and behaviors encompass same-sex persons but who do not define themselves as nonheter-osexual. ^{[3] [4]} Despite the need to engage in a discussion regarding the distinctions between the groups within the LGBTQ+ collective, Ilan H. Meyer notes that "LGBT people share remarkably similar experiences related to stigma, discrimination, rejection, and violence across cultures and locales." ^[5]

1. Lesbian

The term lesbian generally refers to women who are romantically or sexually attracted to other women. ^[6] These women include all female-identified individuals. For example, a transgender woman ^[7] who is attracted to women could be a lesbian, although she may identify as queer or pansexual. Likewise, women who like women ("WLW") may prefer to be called gay or queer instead. ^[8]

2. Gay

The term gay generally refers to persons who are attracted to members of the same sex. ^[9] This includes transgender men who like men and transgender women who like women. Recently, the term gay has been applied most commonly to men, though some WLW prefer the term gay rather than lesbian. ^[10]

3. Bisexual

The bisexual community is diverse. It generally includes those who are attracted to more than one sex. ^[11] Some use this term only for those who identify within the gender binary, ^[12] while others prefer the term pansexual for those who are attracted to a person regardless of gender identity or sex. Most data collection processes will include in the term bisexual anyone attracted to more than one sex or gender. The term is about the attraction, not the current relationship. ^[13] So, even if a person is currently in a heterosexual relationship, ^[14] that person may still identify as bisexual.

4. Transgender and Nonbinary

Transgender is a broad term for those whose gender identity does not comport with their assigned sex at birth ("ASAB"). Persons who are transgender may identify as a man or woman, or they may find their gender identity does not fit on the gender binary and identify as nonbinary. Nonbinary identities include anyone who does not identify as exclusively male or female, including those who identify as gender-queer or gender fluid. Transgender and nonbinary identities are about gender and not sexual orientation. Persons who are trans-gender or nonbinary may identify as straight, gay, lesbian, bisexual, pansexual, etc. in terms of their sexual orientation. Sexual orientation will be in reference to their gender identity, not their ASAB. For example, transgender women who are attracted to women identify as lesbians. ^[15]

5. The Q+ in LGBTQ+

The Q in LGBTQ+ can stand for queer or questioning. For purposes of this paper, Q+ is inclusive of the many SOGI minorities in addition to the definitions above. Examples may include those who are questioning their sexual or gender identity. While queer has had a controversial history as a slur, as well as an empowered reclaimed term, a resurgence of individuals are identifying as queer or pansexual because they are sexual identities that are inclusive of many genders, including transgender and nonbinary. Others who do not identify within a specific group on the LGBT spectrum and do not fit into the cisgender, heterosexual framework, such as the asexual and intersex communities, also fit under the Q+ umbrella term. ^[16]

6. Intersectional Identities Within the LGBTQ+ Community

The LGBTQ+ community is wildly diverse in age, race, ethnicity, gender, geography, and other demographics. Although the community is often seen as monolithic with white cisgender gay men front and center, the community is far more diverse than it is often represented. Despite this diversity, studies rarely explore comparisons between intersectional identities, particularly concerning intersections between sexual orientation, gender, race, and ethnicity. ^[17] Studying intersectional identities, ^[18] particularly studying gender along with race and ethnicity, ^[19] could increase understanding of within-group (e.g., by age, race, ASAB) ^[20] and between-groups (e.g., binary transgender and nonbinary) ^[21] comparisons.

A recent article advocates for LGBTQ research to be conducted with an intersectional approach that explores the differences between sexual orientation, gender, and the identities within each group. ^[22] Such an intersectional approach is crucial because when between-groups comparisons are included, unique experiences can be understood which serve to inform policy and practice. A statewide study of transgender and nonbinary individuals in Colorado conducted a differential analysis between gender identity, sexual orientation, and age. The study found individuals who were older and heterosexual were less likely to delay care due to anticipated discrimination ^[23] as compared to young and queer individuals. Compared to transfeminine respondents, transmasculine respondents were twice as likely to delay care and nonbinary individuals were 25% less likely to delay care. ^[24] A similar study exploring the intersectional identities of gender and LGB on outness and well-being found that those who identify as a gender minority scored significantly lower on well-being and thriving scales than those who identified as cisgender and LGB. ^[25] Recent studies that have focused on intersectional identities within the LGBTQ+ community have demonstrated a need within the scientific and medical communities to view gender from a multi-dimensional and intersectional perspective. ^[26]

In addition to experiencing homophobia and racism from society at large, LGBTQ people of color ("POC") may experience intragroup marginalization, such as racism within an LGBTQ community or homophobia within an ethnic community. ^[27] Research has shown that Black LGBTQ people experience a disproportionate level of disapproval for their sexual identity, which may lead to a conflict of identity. ^[28] However, presence and awareness of LGBTQ POC has been shown to ameliorate conflict between LGBTQ and racial and ethnic identities. ^[29] Acceptance plays a key role in a person's ability to remove competition between their sexual identity and racial identity. ^[30] When a person does not feel a sense of belonging as part of a minority group, it can lead to further self-marginalization. ^[31] Findings from another study exploring the tacit and implicit self-marginalization of black nonbinary students emphasized the invisibility of nonbinary identities, and even more so black nonbinary individuals, not only within the larger society but also within transgender spaces. ^[32] Feeling connected to the LGBTQ community is the strongest predictor of involvement within both LGBT communities and POC communities. ^[33]

Understanding intersectionality of LGBTQ identities can be aided through an approach rooted in anti-oppressive theory ("AOT"), which posits that individuals and their experiences are intersectional and fluid because their experiences and individuality are inextricable from their identities. ^[34] Exploring how these identities interact together can aid in understanding oppression, how oppression is experienced, and discovering different methods of disrupting oppression.

III. HEALTH INEQUTIES DESCRIBED

A. BEHAVIORAL HEALTH

Members of the LGBTQ community have an enormous risk of health inequities in the field of behavioral health. Overall, the community experiences an increase in the incidence of mental health challenges, especially suicide when compared to their cisgender and heterosexual counterparts. ^[35] A systematic review of mental health disorders among LGB individuals showed that depression, anxiety, and substance misuse were at least one-and-a-half times...