Equality in healthcare has not yet been achieved, but what has been accomplished is an increase in sexual orientation and gender identification data collection. 35 This information will assist in identifying disparity, increasing recognition of the need to obtain unbiased social and sexual histories, and increasing provider education related to sexual minorities and social determinants of health to increase the potential for culturally competent care. 34 Social Stressors and Mental Health Social stressors contribute to increased rates of mental health issues, suicide, substance abuse, obesity, and victimization in this population. Chronic stress resulting from stigma, discrimination, and prejudice in the social environment has been referred to as minority stress and is a topic of interest in sexual minority individuals. 35 One frequently used framework for understanding the factors involved in the health disparities experienced by members of the LGBTQ community is the minority stress model. 37 Meyer 37 identifies the processes of minority stress, as related to LGBTQ populations, as having distal to proximal factors. These factors include experiencing external objective stressors, expecting such events to take place and the vigilance this expectation entails, and internalizing negative attitudes. Individual response to stressors varies as do stress-relieving factors. Many minority groups respond with group solidarity, which serves to support the morale and protect individuals from adverse stressors. 37 When a person does not have access to group-level resources, it can lead to increased stress and alienation. Mental health issues are prevalent among LGBTQ people of all ages. Much of the risk for mental health conditions is thought to result from discrimination, bullying, violence, and loss of support. LGB identified youth were more than eight times more likely to have attempted suicide if their family rejected them than LGB peers with low or no level of family rejection. 38 LGB individuals have a two-to-six-time higher lifetime risk of suicide and/ or depression. 39 A 2015 US study on transgender individuals found that 81.7% contemplated suicide and 40.4% had attempted suicide at some point. 39 In addition to risk factors common to the non-transgender public, elevated risks of suicidal thoughts and attempts were more likely among transgender people who report heavy substance use, have poor general health, have a disability, or have experienced recent homelessness or an arrest. 39 In addition to stress and mental health issues, people who identify as LGBTQ are at risk for misuse of tobacco, alcohol, and other substances. In 2016, the Centers for Disease Control and Prevention (CDC) reported that 20.5% of LGB adults smoked compared to 15.3% of heterosexual adults. 40 This report means that about one LGB adult in five is a person who smokes. While limited information exists on transgender tobacco use, it is reported to be higher than among the general population. 40 Although actual substance abuse rates are
unknown, the Substance Abuse and Mental Health Services Administration (SAMHSA) reports rates of 20% to 30% vs. 9% for the general population. 41 In 2019, 7.6 million LGB adults > 18 had a mental health or substance use disorder. That figure is a 20.5% increase from 2018. 42 Although, historically, intimate partner violence has not been widely recognized or reported among the LGBTQ population, studies show that it is experienced as frequently or more frequently by LBGTQ individuals compared to those who identify as cis-gender. 43 Clinicians should include gender-neutral screening tools, such as the Partner Violence Screen, and be prepared with appropriate resources for positive screening results. 6 Violence against transgender people, especially transgender women of color, continues to occur in the United States. People who identify as transgender are 2.2 times more likely to experience physical IPV and 2.5 times more likely to experience sexual IPV compared to those who identify as cisgender. 44 Social stigmatization and other factors may lead to an under-reporting of acts of violence committed against transgender people. 44 Findings from several studies illustrate the seriousness of criminal and interpersonal violence in transgender communities. • The Human Rights Campaign began tracking fatal violence against transgender people in 2013. In 2020, 44 transgender or gender non-conforming people were killed. In November of 2021, 47 fatalities had already been recorded. 45 • In 2016, the National Coalition of Anti-Violence Programs received information on 1,036 • incidents of hate violence from 12 antiviolence organizations across the United States. The information showed 21% self-identified as transgender women and 5% as transgender men. 46 Despite the known risk, 13 states do not have hate crime laws that cover sexual orientation or gender identity, and four states and three US territories do not have hate crime laws at all. In addition, only 12 states require hate crime training for law enforcement that includes crimes based on sexual orientation or gender identity. 47 Moreover, 20 states and five territories do not require hate crime data collection, 47 suggesting that the true crime numbers are higher. Medical Risk Factors Although cardiovascular deaths have declined since 2010 in the US, there remain significant differences in cardiovascular death rates based on race, sex, and income. 48,49 Caceres and colleagues 50 found that sexual minority persons experienced a higher prevalence of elevated cardiovascular (CVD) risk because of largely modifiable conditions than their heterosexual peers. For women, these risks included tobacco, alcohol, and illicit drug use, mental health issues, and elevated body mass index. For men, the risks were tobacco use, illicit drug use, and poor mental health. 50
Repeat exposure to interpersonal stress (discrimination, family rejection, expectation of stigma), general stress (financial, life adversity, childhood trauma), and the potential for additional physical stress from hormone or antiretroviral treatments, combined with risks of tobacco, illicit drugs, excess alcohol, and elevated BMI, are believed to increase CVD risk. These findings were based on subjective data rather than physical markers and show the need for further research. According to Caceres and colleagues, 49 cardiovascular health research in sexual minorities has not been prioritized because of other health concerns such as HIV/AIDS and substance use. In 2018, there were 37,968 new diagnoses of HIV in the US and its territories, with 69% being among gay and bisexual men. 51 A 2019 systematic review found 14% of transgender women have HIV, with 44% of these individuals identifying as African American, 26% as Hispanic/Latino, and 7% as White transgender women. 52 Sixty-four percent of new cases of HIV are among men who have sex with men (MSM), ages 13 to 34, with higher representation in African American and Hispanic/Latino groups. Use of pre-exposure prophylaxis is lower among these two racial/ethnic groups than among White MSM. 51 Sexually transmitted infections (STIs) are also more prevalent among MSM, with more than 8 in 10 new cases of gonorrhea and primary and secondary syphilis, 10% of new hepatitis A, and 20% of new hepatitis B cases are found in this group. 2 Lesbian and bisexual women are less likely to obtain routine care, are more likely to be overweight or obese, and less likely to receive screening mammography. 6,53,54 Lack of insurance or lack of knowledge about cervical cancer risk may contribute to the fact that only 74.6% of lesbian women obtain cervical screening compared to 83.3% of heterosexual and 77.9% of bisexual women. 54 As a group, lesbian and bisexual women have breast cancer risks from a higher BMI, higher frequency of nulliparity, socioeconomic disparity, delay in care, and potential lack of provider relationship, which should spur a conversation about screening mammogram before age 50. 56 When considering screening for cancer, clinicians should remember the maxim “screen what you have” in addition to considering surgical history and use of hormones to ensure thorough screening. 6 Caring for LBGTQ Youth In the 1960s, Kohlberg hypothesized that gender-related development begins in infancy and continues progressively throughout childhood following three key concepts: gender constancy, gender consistency, and gender identity. On average, children develop gender constancy – stability across time in the identification of their gender – between ages 3 to 4 and gender consistency – recognition that gender remains the same across situations – between ages 4 to 7. 57,58 The development of gender identity appears to be the result of a complex interplay between biological, environmental, and psychological factors. 5,59
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