25 Sexual Bias and Misconceptions

Lesbian, Gay, Bisexual, and Transgender Health

People who are lesbian, gay, bisexual, or transgender (LGBT) are members of every community. They are diverse, come from all walks of life, and include people of all races and ethnicities, all ages, all socioeconomic statuses, and from all parts of the country. The perspectives and needs of LGBT people should be routinely considered in public health efforts to improve the overall health of every person and eliminate health disparities.

In addition to considering the needs of LGBT people in programs designed to improve the health of entire communities, there is also a need for culturally competent medical care and prevention services that are specific to this population. Social inequality is often associated with poorer health status, and sexual orientation has been associated with multiple health threats. Members of the LGBT community are at increased risk for a number of health threats when compared to their heterosexual peers. Differences in sexual behavior account for some of these disparities, but others are associated with social and structural inequities, such as the stigma and discrimination that LGBT populations experience.

Public Health Approach for Advancing Sexual Health

Lesbian, Gay, Bisexual, and Transgender (LGBT) sexual health and well-being is affected by numerous social and cultural challenges across the life course, contributing to negative health outcomes and posing barriers to attain such protective health indicators as marriage and family formation, community support, and inclusion in faith communities.

The incidence of hate crimes, continued discrimination promulgated though denial of marriage rights, and policies such as, “don’t ask, don’t tell,” in the armed forces contribute to the continuation of homophobia as a structural norm. Psychological, interpersonal, and cultural scripts perpetuate attitudes that homophobia is normal, that discrimination is okay, and that high levels of society approve of homophobia. As a result of cultural and societal discriminations, LGBT people suffer an added burden of stress and experience health disparities.

U.S. culture has historically disapproved of LGBT people as evidenced by “sodomy” laws and institutional recognition that homosexuality was a psychiatric disorder. In addition, the LGBT population experiences health disparities and minority-related stress based on their marginalized social status. Sexual attraction is established early, and LGBT youth are susceptible to the added burden of emotional and physical trauma.Some research suggests that sexual attraction is established by the ages of 9–10 years in humans. Around the ages of 13–14 years, young LGBT persons typically have their first sexual experience (13.5 for males, 15.5 for females). However, some studies have indicated that many young LGBT persons aspire to save themselves for love or more committed relationships when they are older. Societal values and norms may preclude sexual expression, as LGBT youth are stigmatized early. Young gay men experience disproportionate rates of sexual victimization and pre-pubertal LGBT youth are often marginalized or victimized in schools. Violence and harassment against LGBT students is widespread.

Knowledge of young adult sexual behavior and related negative health outcomes proves to be critical when implementing interventions to ensure the health of this population. The majority of new HIV diagnoses are made in young MSM, with the bulk occurring in black and Latino MSM. The Internet is used as a source of sexual health information, pornography, and as a main source for “hooking up” in the MSM population. Also, recent research indicates that women are more sexually fluid, changing lesbian identification and indicating a higher degree of bisexuality. LGBT seniors face many barriers to successful aging. Unlike heterosexuals, LGBT seniors can’t count on legal and biological families, which poses a tremendous challenge when assessing basic needs as they age. Further, along with incurring past and present stigmas, elderly LGBT are more likely to be more single and to have less good health care, and thus, must come to rely upon their friends or “families of choice” as a primary source of social support.

Gay and Bisexual Men’s Health

Gay and bisexual men and other men who have sex with men (MSM) represent an incredibly diverse community. Gay and bisexual men have both shared and unique experiences and circumstances that affect their physical health and mental health needs as well as their ability to receive high-quality health services.

Stigma and Discrimination

Homophobia, stigma, and discrimination persist in the United States and negatively affect the health and well-being of gay, bisexual, other men who have sex with men (MSM), and other members of the LGBT community. Homophobia, stigma, and discrimination are social determinants of health that can affect physical and mental health, whether MSM seek and are able to obtain health services, and the quality of the services they receive. Such barriers to health need to be addressed at different levels of society, such as health care settings, work places, and schools in order to increase opportunities for improving the health of MSM.

Homophobia and stigma persist in the United States even though acceptance of same-sex relationships has been steadily increasing. For example, a Gallup poll conducted in May 2010 found that more than half (52%) of Americans believed that gay and lesbian relationships were acceptable. Forty-three percent of Americans believed that gay and lesbian relationships are not morally acceptable.

The Effects of Negative Attitudes About Homosexuality

Negative attitudes about homosexuality can lead to rejection by friends and family, discriminatory acts and violence that harm specific individuals, and laws and policies that adversely affect the lives of many people; this can have damaging effects on the health of MSM and other sexual minorities. Homophobia, stigma and discrimination can:

• Limit MSM’s ability to access high quality health care that is responsive to health issues of MSM
• Affect income, employment status, and the ability to get and keep health insurance
• Contribute to poor mental health and unhealthy behaviors, such as substance abuse, risky sexual behaviors, and suicide attempts
• Affect MSM’s ability to establish and maintain long-term same-sex relationships that reduce HIV & STD risk
• Make it difficult for some MSM to be open about same-sex behaviors with others, which can increase stress, limit social support, and negatively affect health

The effects of homophobia, stigma and discrimination can be especially hard on adolescents and young adults. Young MSM and other sexual minorities are at increased risk of being bullied in school. They are also at risk of being rejected by their families and, as a result, are at increased risk of homelessness. A study published in 2009 compared gay, lesbian, and bisexual young adults who experienced strong rejection from their families with their peers who had more supportive families. The researchers found that those who experienced stronger rejection were:

• 8.4 times more likely to have tried to commit suicide
• 5.9 times more likely to report high levels of depression
• 3.4 times more likely to use illegal drugs
• 3.4 times more likely to have risky sex

Reducing the Effects of Stigma and Discrimination

MSM and their family and friends can take steps to reduce the effects of homophobia, stigma and discrimination and protect their physical and mental health. One way to cope with the stress from stigma and discrimination is social support. Some studies show that gay men who have good social support—from family, friends, and the wider gay community—have:

• higher self-esteem
• a more positive group identity

Lesbian and Bisexual Women’s Health

What challenges do lesbian and bisexual women face in the health care system?

Lesbians and bisexual women face unique problems within the health care system that an hurt their health. Many health care professionals have not had enough training to know the specific health issues that lesbians and bisexuals face. They may not ask about sexual orientation when taking personal health histories. Health care professionals may not think that a lesbian or bisexual woman, like any woman, can be a healthy, normal female.

Things that can stop lesbians and bisexual women from getting good health care include:

• Being scared to tell your doctor about your sexuality or your sexual history
• Having a doctor who does not know your disease risks or the issues that affect lesbians and bisexual women
• Not having health insurance. Many lesbians and bisexuals don’t have domestic partner benefits. This means that one person does not qualify to get health insurance through the plan that the partner has (a benefit usually available to married couples).
• Not knowing that lesbians are at risk for STIs and cancer

For these reasons, lesbian and bisexual women often avoid routine health exams. They sometimes even delay seeking health care when feeling sick. It is important to be proactive about your health, even if you have to try different doctors before you find the right one. Early detection—such as finding cancer early before it spreads—gives you the best chance to do something about it. That’s one example of why it’s important to find a doctor who will work with you to identify your health concerns and make a plan to address them.