_____________________________________________ Promoting the Health of Gender and Sexual Minorities
emotional attractions, cultural affiliation, and those aspects of sexual orientation that may change across developmental periods [16]. The term “transgender” is also difficult to define and measure, partly because it has been less examined than other terms, such as “heterosexual,” “homosexual,” “bisexual,” “gay,” or “lesbian.” Generally, the term “transgender” includes several populations, including transsexuals and crossdressers. Further defining each of these populations creates additional challenges [8]. Consensus on the definitions of “youth” and “elderly” and other demographic terms is needed as well. Second, construct valid and reliable measures of sexual orienta- tion and transgender identity that accurately represent their definitions. Without clear conceptual definitions, development of valid and reliable measures is difficult to achieve. Different measures exist, but there is no consensus. In addition, there is limited literature discussing when and where the measures should be used [8]. Third, sample rare and hidden populations [8]. Large-scale random surveys are expensive, and researchers often must conduct smaller studies and use samples of convenience [9]. This sampling method may result in biased and uninformative data. For example, studies examining the prevalence of suicide among lesbian and gay youths and adults have yielded incon- sistent results, in part because of the absence of good data. Additionally, researchers have had to rely on retrospective data from individuals after they self-label, disclose, and volunteer to participate in research projects [41]. Other factors may also impact sampling. For example, while studying GSM elderly, qualitative research sampling has been affected by deaths and memory changes, resulting in incomplete interviews [42]. Homophobia and heterosexism place LGBTQIA studies outside the mainstream in terms of importance as well as allocation of resources [9]. While difficulties with sampling have been used as a rationale for denying funding for research into LGBTQIA matters, effective sampling methods have been developed for surveying other rare populations, for example, ethnic minority groups or age groups [8]. These same methods can be used with the LGBTQIA community [9]. The fourth challenge is to undertake the study of sensitive topics [8]. Sensitive research has been defined as “studies in which there are potential consequences or implications, either directly for the participants in the research or for the class of individuals represented by the research” [43]. Clearly, research related to the LGBTQIA community must be considered sensi- tive, especially as the research relates to health. Subjects may have unresolved health issues relating to their sexual identity, they may find it difficult to reveal their sexual orientation or transgender identity, or they may be concerned about violence or discrimination if their responses are not kept confidential [44]. Also, because some states consider certain sexual behav- iors illegal (despite many existing state laws, including sodomy laws, being invalidated by the Supreme Court), revealing one’s sexual orientation could result in legal action or discrimina- tion [9; 43]. Maintaining confidentiality is vital. One study
suggests that online approaches to sensitive social research (e.g., online surveys) may provide opportunities to make visible the “silenced and invisible voices” of both the GSM and other marginalized, hard-to-access populations in an environment that is safe and provides anonymity [45]. SEXUAL IDENTITY MODELS Understanding gay identity development is required to provide adequate care for LGBTQIA youth [46]. This is applicable to all ages of LGBTQIA individuals. Interest in the study of sexual identity development substan- tially increased in 1969, which is generally accepted as the year that the Gay Liberation Movement was born [47]. In the early morning hours of June 28, New York City police raided the Stonewall Inn, a known gay bar in New York’s Greenwich Village. The police conducted a “routine” raid of the bar, making arrests. Gays had been accustomed to this oppressive action, but on that morning, the bar patrons and their sup- porters fought back [47]. The same thing happened the next evening, but the crowds had grown in number, strength, and unity. Those events, known as the “Stonewall Riots,” created movement toward awareness of the LGBTQIA community, its concerns, and its needs. This and subsequent events led to an increase of GSM individuals identifying themselves to family, friends, and others. Interest in the concept of sexual identity and its development also subsequently grew. Some knowledge of this watershed event helps to explain the increased awareness of the LGBTQIA community, which includes the study of the sexual identity development process. Conducting research about this process is difficult because the developmental task of establishing personal identity, which includes establishing sexual identity, may not yet have been completed. Consequently, LGBTQIA youth may be unaware of or unclear about their sexual identity. Coming-out models have generated much interest in devel- opmental concerns related to sexual identity, thus bringing attention to gay and lesbian youth. However, the models may not be applicable to all individuals. The models, which have been developed from exclusively male samples, have not fully considered the diversity that exists among individuals of different backgrounds, ethnicities, and genders. Using theoretical models with female sexual minority samples has not always been helpful. Using data from young men also has been problematic because not all young men use sex to help them determine their identity; rather, they often know who they are prior to engaging in gay sex [41]. Initially proposed more than 30 years ago, coming-out models describe the arrival of same-sex identity by means of a series of steps or stages. These stages delineate when, in the develop- ment of same-sex identity, recognition of, making sense of, naming, and publicizing oneself as lesbian or gay occurs. The models are nearly universal in their stage sequence regarding
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