Inversion, Homosexuality, and the Origins of Contemporary Notions of Sexual Orientation

Although heterosexual and homosexual behaviors and attractions are ubiquitous across human societies, the idea that individuals can be meaningfully defined or categorized in terms of their patterns of sexual attraction and behavior emerged in science and medicine only in the nineteenth century. When this discourse emerged, its initial focus was on individuals who were perceived as deviating from cultural definitions of gender and sexual “normalcy.”

The category of “the sexual invert” historically preceded that of “the homosexual” as a target for medical and scientific scrutiny. During the 1860s, Ulrichs proposed that male inverts, or “Urnings,” should be understood as “individuals who are born with the sexual drive of women and who have male bodies” (Ulrichs, 1994b, vol. 1, p. 35). Hirschfeld supported this argument and later posited that inverts represented an intermediate sex, reflecting both male and female qualities (Hirschfeld, 2000). Sexual inversion originally described the individual in totality, with sexual conduct being only one of various aspects (Chauncey, 1982–1983). Male inverts were believed to possess “feminine” qualities, including passivity, weakness, and sexual attraction to “masculine” males. Female inverts were believed to manifest “masculine” qualities, including an active interest in sexuality—an abnormal quality in the eyes of a society that believed femininity was inherently passive (Chauncey, 1982–1983).

The modern notion of sexual orientation—defined in terms of whether one's sexual attractions and interest are directed toward men or women—is usually traced to Sigmund Freud (Freud, 1953). He introduced a distinction between the sexual aim (i.e., preferences for particular types of sexual activity) and the object toward which that aim is directed. Freud's theory and clinical practice focused on the sexual object, with “homosexuals” and “heterosexuals” being understood entirely in terms of their sexual object (respectively, a person of the same or the other sex). The construct of “the invert,” which focused on the individual's sexual aim (passive sexuality among male inverts, active sexuality among females), fell into disuse (Chauncey, 1982–1983; Freud, 1953). However, the modern construct of “transgender” has similarities to the notion of sexual inversion insofar as both involve crossing socially defined boundaries of gender.¹

Homosexual Conduct as a Crime, Homosexuality as a Diagnosis

Throughout much of the twentieth century, consensual same-sex sexual behavior was illegal, and homosexuality was considered a form of mental illness. This dual stigma historically attached to homosexual behaviors and persons has, as noted earlier, shaped the experiences of many people living today and has influenced many contemporary institutions that affect health.

Long before Freud articulated his theory of sexuality, theological doctrine and secular law sought to regulate sexual behaviors and attached punishments to a variety of sex acts that were nonprocreative or occurred outside of marriage. Proscribed sexual behaviors were often referred to collectively as sodomy, a term that was not clearly defined in most religious and legal texts but included homosexual behavior as well as other nonprocreative and extramarital sexual acts (Jordan, 1997). U.S. sodomy laws, which existed in all of the states until 1961, when Illinois eliminated its statute, were the legacy of these prohibitions. Their language varied from state to state, and they outlawed various types of sexual behavior, including some forms of homosexual behavior. The main effect of sodomy laws was not prosecution for homosexual acts—such prosecutions were relatively infrequent. However, the laws were regularly used to justify differential treatment of sexual minorities in a variety of arenas, including employment, child custody, and immigration (Leslie, 2000).

The expansion of discourse about sexuality from the domains of law and theology into medicine, psychiatry, and psychology was considered a sign of progress by many at the time because it offered the hope of treatment and cure (rather than punishment) for phenomena that society generally regarded as problematic. Nevertheless, after Freud, the division of people into “heterosexuals” and “homosexuals” involved stigmatization of the latter. Many early physicians and sexologists regarded homosexuality as a pathology, in contrast to “normal” heterosexuality (e.g., Krafft-Ebing, 1900), although this view was not unanimous (e.g., Ellis, 1901; Ulrichs, 1994a). Freud himself believed that homosexuality represented a less than optimal outcome for psychosexual development, but did not believe it should be classified as an illness (Freud, 1951). In the 1940s, however, American psychoanalysts broke with Freud, and the view that homosexuality was an illness soon became the dominant position in American psychoanalysis and psychiatry (Bayer, 1987).

Thus by the beginning of World War II, sodomy laws continued to criminalize same-sex sexual behavior, even when it occurred in a private setting between consenting adults, while psychiatry and psychology generally regarded homosexuality as an illness. Around this time, the illness model became part of government personnel policies when the U.S. military incorporated psychiatric screening into its induction process and developed formal procedures for rejecting homosexual recruits. Whereas same-sex sexual behavior previously had been classified as a criminal offense under military regulations prohibiting sodomy, the armed services now sought to bar homosexual persons from their ranks (Berube, 1990). However, the screening process was often superficial, especially during the early years of the war when troops were desperately needed. Indeed, many lesbians and gay men served successfully in the military, often with the knowledge of their heterosexual comrades (e.g., Berube, 1990; Black et al., 2000; Menninger, 1948).

When the need for recruits diminished during the war's waning years, however, policies prohibiting homosexual personnel were more vigorously enforced, and many gay men and lesbians received undesirable discharges as sexual psychopaths (Berube, 1990). Such discharges had severely negative consequences. Denied benefits under the GI Bill of Rights and socially ostracized in civilian life, gay and lesbian veterans with undesirable discharges often could not secure employment. As Berube (1990, p. 229) notes, “Sometimes their lives became so unbearable as exposed homosexuals that they had to leave home or tried to kill themselves.”

Ironically, the mass courts martial and discharges may have contributed to the development of modern lesbian and gay communities in U.S. urban centers. D'Emilio (1983) observed that, rather than returning to their hometowns after the war, many men and women chose to settle in major port cities and centers of war industry, such as Los Angeles, San Francisco, and New York. Still others later migrated to these cities to join the growing communities. Thus, large gay communities began to emerge in many American cities after World War II ended.

Although gay and lesbian civilians often found some degree of tolerance in the relative anonymity of these large cities, they nevertheless experienced negative consequences related to stigma. Because of the criminalization of homosexual acts and the stigmatization of homosexual identity, local police generally had the freedom to harass and pursue gay men and lesbians at will. Sexual minorities risked arrest when they gathered, even in private homes. Gay bars provided a venue for gay men and lesbians to socialize openly, but they also served as targets for harassment. Police raids were common, with bar patrons routinely being charged with offenses such as disorderly conduct, vagrancy, public lewdness, and solicitation (Boyd, 2003; Johnson, 2004). At the national level, a U.S. Senate committee issued a 1950 report concluding that homosexuals were not qualified for federal employment and that they represented a security risk because they could be blackmailed about their sexuality (Subcommittee on Investigations of the Senate Committee on Expenditures in the Executive Departments, 1950). In response to this report, President Eisenhower issued an executive order dismissing all homosexuals from federal employment, both civilian and military. Reporting on the government's campaigns against gay, lesbian, and bisexual employees by daily newspapers across the country reinforced the anxiety experienced by sexual minorities (D'Emilio, 1983).

In 1952, the newly created DSM listed homosexuality as a sociopathic personality disturbance, along with substance abuse and sexual disorders (American Psychiatric Association, 1952; Bayer, 1987). This classification of homosexuality was used as the basis for laws and regulations that denied homosexuals employment or prohibited them from being licensed in many occupations. Thousands lost their jobs (D'Emilio, 1983). Many states also passed sexual psychopath laws that applied to homosexuals as well as rapists, pedophiles, and sadomasochists. In an effort to prevent sex crimes, some psychiatrists encouraged the state to confine sexual nonconformists, including homosexuals, until they were declared “cured” (Chauncey, 1993).

During this time, many psychiatrists and psychologists attempted various “cures” (i.e., attempts to change homosexuals into heterosexuals), including psychotherapy, hormone treatments, aversive conditioning with nausea-inducing drugs, lobotomy, electroshock, and castration (e.g., American Psychological Association, 2009b; Feldman, 1966; Katz, 1976; Max, 1935; Thompson, 1949). These methods proved to be largely unsuccessful (American Psychological Association, 2009b; Friedman and Downey, 1998; Haldeman, 1994).

In summary, lesbians and gay men faced extensive stigma during the World War II era and the years immediately following. Although many of them served in the military during the war, substantial numbers were dishonorably discharged as the war concluded. Public disclosure of one's sexual orientation could lead not only to personal rejection and ostracism, but also to unemployment and even arrest, fostering a need for considerable secrecy in one's daily life. Gay men and lesbians were officially classified as mentally ill. Many were pressured to seek psychiatric treatment to become heterosexual, although interventions purporting to change sexual orientation were generally ineffective. At the same time, emerging gay and lesbian communities and enclaves in large urban centers offered their members the opportunity to meet others who shared their sexual orientation. These communities provided a basis for the development of organizational and individual challenges to the stigmatized status of homosexuality.

Creating Community and Change

In the post–World War II era, most gay men and lesbians accepted their stigmatized status as inevitable. However, some organized politically, forming groups that began quietly to endeavor to change societal attitudes and laws while also serving as safe havens for their members. Homophile organizations, such as the Mattachine Society and the Daughters of Bilitis, were, of necessity, highly secret groups whose initial goal was to provide social support and assistance. By the early 1960s, however, some of their members began to advocate for a strategy of publicly confronting anti-homosexual discrimination.

Meanwhile, some scientific research challenged the illness model. In 1948 and 1953, Alfred Kinsey and his colleagues published their groundbreaking reports on human sexual behavior (Kinsey et al., 1948, 1953), demonstrating that same-sex attraction and behavior were common among American adults. Also around this time, Ford and Beach (1951) published an extensive review of cross-cultural and cross-species studies of sexual behavior, concluding that same-sex sexual behavior occurs in many animal species and that homosexual behavior of some sort was considered normal and socially acceptable in a majority of the societies for which detailed ethnographic data were available (Ford and Beach, 1951).

In a landmark study funded by the National Institute of Mental Health, psychologist Evelyn Hooker directly tested the assumption underlying homosexuality's inclusion in the DSM, namely, that homosexuality was inherently linked with psychopathology. Based on her data, Hooker (1957) concluded that homosexuality is not inherently associated with psychopathology and is not a clinical entity, a conclusion that received extensive support in subsequent empirical research (e.g., Gonsiorek, 1991) and eventually became the consensus view of mainstream mental health professionals in the United States (see below). The scholarship of Kinsey, Ford and Beach, and Hooker challenged widespread assumptions that homosexuality was a rare and pathological form of sexuality, practiced only by a small number of social misfits.

By the 1960s, homophile activists had begun to challenge publicly the idea that homosexuality was an illness and to seek an end to job discrimination and harassment. The Mattachine Society of Washington, DC, for example, began working to change Civil Service Commission policies regarding the employment of sexual minorities. In 1965, the group organized small demonstrations at locations such as the White House to protest discrimination against homosexuals in government employment (D'Emilio, 1983). And in 1966, the Washington Mattachine Society passed a resolution stating that “in the absence of valid evidence to the contrary, homosexuality is not a sickness, disturbance, or other pathology in any sense, but is merely a preference, orientation, or propensity, on par with, and not different in kind from, heterosexuality” (D'Emilio, 1983, p. 164). Although the homophile movement achieved some small success in its attempts to ensure civil rights for homosexual persons, its membership remained small until the end of the 1960s.

A watershed event occurred on June 27, 1969, in response to a routine police raid on the Stonewall Inn, a New York City gay bar. Such raids were a common occurrence, and police typically encountered little resistance. That night, however, the Stonewall patrons, along with neighborhood residents and passersby, resisted the police in a confrontation that escalated into a riot that continued for several nights. The Stonewall Rebellion, as it is now called, is widely considered to have marked the beginning of the contemporary movement for sexual-minority civil rights. In the wake of Stonewall, the movement grew rapidly and inspired many sectors of society to reevaluate long-standing assumptions about homosexuality (Adam, 1995). Many lesbians and gay men “came out”—that is, they publicly revealed their sexual orientation—in the professions, academia, churches, and the military.

In the face of rapidly changing cultural views about homosexuality, and recognizing that empirical data to support the illness model were lacking, the American Psychiatric Association's board of directors voted in December 1973 to remove homosexuality as a diagnosis from the DSM (Bayer, 1987; Minton, 2002).² Their decision was affirmed by a subsequent vote of the Association's membership (Bayer, 1987). In 1975, the American Psychological Association strongly endorsed the psychiatrists' actions and urged its members to work to eradicate the stigma historically associated with a homosexual orientation (Conger, 1975).

The 1970s saw the growth of gay and lesbian communities across the United States. A wide variety of organizations, associations, businesses, and self-help groups formed. More than half of the states repealed their sodomy laws, and some municipalities passed legislation prohibiting discrimination on the basis of sexual orientation. Meanwhile, businesses and social organizations catering to a gay clientele proliferated, and lesbian and gay communities expanded significantly in major cities (Faderman, 1991; Levine, 1979). Nevertheless, gay people remained widely stigmatized. Many gay rights statutes that were passed in the early and mid-1970s were subsequently overturned by voters (Adam, 1987). By the beginning of the 1980s, candidates and organizations that opposed the gay community's modest gains were increasingly visible in national politics.

The AIDS Epidemic

The first cases of what would come to be known as AIDS were detected in gay men in 1981 (Gottlieb et al., 1981). AIDS has since claimed the lives of a significant portion of the generations of gay and bisexual men who came of age during and after the World War II era, and has dramatically altered the LGBT community in numerous ways. A detailed history of the impact of the AIDS epidemic on sexual and gender minorities is beyond the scope of this report and has been addressed elsewhere (see, e.g., various Institute of Medicine/National Research Council reports on AIDS, including IOM, 1991a,b,c, 2005; NRC, 1989, 1990, 1993, 1995; see also Epstein, 1996; Levine et al., 1997). Nor can the complete history of AIDS yet be written. HIV continues to spread throughout the world and in the United States, where newly diagnosed infections occur disproportionately among black and Latino men who have sex with men.

To better illuminate the historical context for understanding contemporary health disparities among sexual and gender minorities, this section highlights several long-term effects of AIDS. A detailed look at the AIDS epidemic is presented later in the chapter to illustrate a number of themes of particular relevance to the health of LGBT populations that pervade the discussion in the ensuing chapters.

First, AIDS was responsible for the deaths of thousands of gay and bisexual men in the United States. Apart from the individual tragedy represented by the loss of each of these lives, the cumulative loss inevitably affected the entire community. Several AIDS researchers (e.g., Levine, 1998; Martin et al., 1989) likened the epidemic to natural disasters such as floods and hurricanes, albeit without the physical destruction. Writing about AIDS, Levine (1989) noted that disasters can destroy a community's preexisting sociocultural order and foster both collective and individual trauma among survivors. Collective trauma refers to the loss of communality, that is, the network of relationships and shared meanings that provide intimacy, support, and a sense of self and that tie individuals to the social order. Individual trauma denotes the emotional response to death and devastation, that is, feelings of shock, disorientation, guilt, emotional depletion, and numbness (Levine, 1989; see generally Erikson, 1976).

In addition to individual and collective trauma, the LGBT community faced the challenge of how to respond to AIDS in a society they perceived as already hostile to them. Many sexual- and gender-minority individuals wondered whether they would all be targeted for increased ostracism, discrimination, and stigmatization as a result of AIDS (Bayer, 1989). Mandatory testing of the members of so-called “risk groups” (especially gay and bisexual men) was widely discussed in the larger society, and many LGB individuals feared that such testing could lead to the development of government lists of sexual-minority people for subsequent quarantine and discrimination (Bayer, 1989). Concern was also widespread that state sodomy laws, many of which had been repealed during the 1960s and 1970s, would be reinstated on the pretext of preventing AIDS. This concern received additional impetus when the U.S. Supreme Court upheld the constitutionality of state sodomy laws in 1986 (American Psychological Association and APHA, 1986). One argument made for retaining sodomy laws was that they would contain the spread of AIDS, although an amicus brief filed jointly by the American Public Health Association and the American Psychological Association rebutted this argument (American Psychological Association and APHA, 1986).

Faced with the challenge of providing care and support to its members, the LGBT community responded by organizing self-help groups and community-based organizations that offered a variety of medical, psychological, and social services to people with AIDS. It also created and maintained community-based prevention programs that disseminated information about sexual risk reduction and promoted norms that encouraged the practice of “safer sex.” Although organizations in major urban centers—including the San Francisco AIDS Foundation, AIDS Project Los Angeles, and the New York Gay Men's Health Crisis—achieved national prominence, the organizing extended into midsized cities, towns, and rural areas as well. Funded by community donations, private foundations, and government entities, these organizations grew in size and sophistication as the epidemic wore on. They helped create the infrastructure for the provision of health and social services that currently exists in the LGBT community (NRC, 1993).

At the same time, the epidemic fostered widespread activism to speed the testing and approval of new AIDS treatments and to increase government funding for research and prevention. Frustrated by the slow pace of much AIDS-related biomedical research, LGBT activists teamed with health care workers to organize community-based research studies to test promising AIDS drugs. These efforts fostered a new model for health care in which patients and advocates played a highly active role in identifying and implementing treatment strategies (Epstein, 1996). Coalitions also were formed between community activists and public health workers to devise strategies for monitoring HIV transmission that would be sensitive to community concerns about stigma and discrimination.

AIDS probably changed public perceptions of sexual minorities. Although the epidemic was often ignored by the mass media or portrayed in sensationalist ways during its early years (Shilts, 1987), later coverage presented the lives of gay men with AIDS as multilayered. It also showed that many of these men were rejected by their biological relatives and were cared for by same-sex partners and extended gay and lesbian families (Herek, 2009c). In addition, the epidemic provided the impetus for unprecedented numbers of gay, lesbian, and bisexual people to disclose their sexual orientation to family members, friends, neighbors, coworkers, and society at large. Many men who contracted AIDS were involuntarily “outed” by the disease, but many others chose to come out in an attempt to reduce sexual stigma and prejudice. Social psychological research indicated that heterosexuals who reported knowing one or more gay men and lesbians personally were indeed more likely than others to be accepting and supportive of sexual minorities generally (e.g., Herek and Capitanio, 1996; Pettigrew and Tropp, 2006). Thus as a result of the epidemic, many heterosexuals began to think about gay men and lesbians in ways that went beyond sexuality: as family members and friends, coworkers, contributors to society, and members of a besieged community (Herek, 2009c). These changes in perceptions of sexual minorities may have contributed to decreases in negative attitudes toward homosexuality that were observed in public opinion polls during the 1990s (e.g., Sherrill and Yang, 2000; Herek, 2009d).

Coincident with the first years of the AIDS epidemic was increased public recognition of individuals who identify as bisexual. Although bisexual people began forming social and political groups in the 1970s (Udis-Kessler, 1995; Weinberg et al., 1994), an organized bisexual community did not emerge until the 1980s (Herdt, 2001; Paul, 1983; Rust, 1995; Udis-Kessler, 1995). By the early 1990s, the inclusion of bisexual individuals in the organized gay movement was reflected in the addition of “bisexual” to the names of lesbian and gay organizations and events. It was also in the late 1980s and early 1990s that bisexuals were recognized as a group at heightened risk for HIV infection (Doll et al., 1992).

In summary, although the AIDS epidemic continues to ravage sexual minority communities today, some of its long-term consequences are already apparent. Many HIV-positive gay and bisexual men are surviving and thriving today thanks to the development of new HIV treatments. Nevertheless, most of them require ongoing medical care and must adhere to drug regimens that are extremely expensive and often have debilitating side effects. Many uninfected gay and bisexual men, especially those who came of age before the era of AIDS, have lost life partners as well as entire networks of male friends and acquaintances. The lives of many lesbians and bisexual women similarly have been altered by extensive experiences with loss. If the epidemic had never occurred, those networks would today be a source of social and emotional support as their members continued through their life course. Yet while the epidemic had considerable impact on individual lives, it also changed the LGBT community, creating an infrastructure of organizations dedicated to meeting the health and social needs of LGBT individuals.

The Last 20 Years: Laws and Policies

During the 1990s and 2000s, the visibility of the LGBT community increased dramatically in most facets of U.S. society. The last 20 years have seen various events that have affected the lives of sexual minorities, including the U.S. Supreme Court decision in Lawrence v. Texas³ that struck down all sodomy laws. This section focuses on some of these events, as well as trends that are particularly relevant to the health concerns of the contemporary LGBT community, with particular emphasis on the development of laws and policies that continue to shape the experience of sexual minorities today. Although the extent of legal inequalities experienced by LGBT individuals has declined during recent decades, sexual and gender minorities still enjoy overall fewer legal rights, protections, and benefits than the non-gender-variant, heterosexual population. Inequalities in the law can affect fundamental aspects of the lives of LGBT people and can directly impact their ability to access quality health care.

While federal laws and policies govern some areas of import to LGBT populations (e.g., military personnel policy, U.S. Food and Drug Administration [FDA] policy banning men who have sex with men from donating blood), many issues are determined by the laws of the individual states and, at times, those of smaller jurisdictions within the states. Because states vary in their treatment of these issues, the effects of laws and policies on LGBT individuals often depend on where they live or travel.

Criminal victimization and harassment. As noted above, sexual and gender minorities have long been subjected to violence and harassment because of their sexual orientation and gender identity. As early as the 1960s, LGBT communities began to organize to respond collectively to such attacks. By the 1980s, many community-based antiviolence organizations around the United States were conducting community patrols, documenting violent incidents, providing victim services, working with local law enforcement agencies, and organizing violence prevention programs (e.g., Herek, 1992; Wertheimer, 1992). These programs were part of an emerging national movement against hate crimes—criminal actions that are motivated in whole or in part by bias against the victim's perceived race, religion, ethnicity, sexual orientation, or disability (Department of Justice, 2009; see generally Jenness and Grattet, 2001).

During the 1980s, some states passed laws mandating the collection of data to document the occurrence of hate crimes, including those based on the victim's sexual orientation. In 1990, Congress passed and President George H. W. Bush signed the Hate Crimes Statistics Act, which mandated the collection of such data on a national scale by the Federal Bureau of Investigation (FBI). Throughout the 1990s and 2000s, antiviolence projects based in sexual- and gender-minority communities continued to collect data and provide related services as more states enacted hate crime laws. In addition to mandating the local collection of data on the extent of hate crimes, many states imposed sentencing enhancement (i.e., a more severe penalty than would otherwise be imposed) for such crimes. The federal Hate Crimes Sentencing Enhancement Act of 1994 directed the U.S. Sentencing Commission to provide a sentencing enhancement for hate crimes, including those based on the victim's sexual orientation. This law's impact was limited because it applied only to existing federal crimes, which, in the case of sexual orientation, included only crimes committed on federal property or during the course of federally protected activities. The Matthew Shepard and James Byrd, Jr. Hate Crimes Prevention Act, enacted in 2009, expanded federal hate crime law to allow federal prosecution of crimes motivated by a victim's sexual orientation and gender identity. It also mandated the collection of data on crimes motivated by bias against a particular gender or gender identity (FBI, 2010).

Since 1991, the FBI has recorded a substantial number of hate crimes based on sexual orientation annually (FBI, 2010). Through 2009 (the most recent year for which data were available when this report went to press), approximately 17,500 incidents based on sexual orientation had been reported to the FBI. The FBI's hate crime reports underestimate the actual number of such incidents for several reasons, including that the reports rely on the voluntary cooperation of local law enforcement agencies, that many victims do not report the crime to the police, and that many hate crimes are not accurately classified as such (e.g., Herek and Sims, 2008). Data from the National Crime Victimization Survey, conducted annually by the U.S. Bureau of Justice Statistics with a sample of approximately 42,000 households, suggested an annual average of 210,430 hate crime victimizations in the United States in 190,840 separate incidents between July 2000 and December 2003. Hate crimes were more likely to occur in urban than in suburban or rural settings. More than 37,800 (17.9 percent) of these victimizations were motivated by the victim's sexual orientation. Approximately 42 percent of those crimes were reported to police authorities (Harlow, 2005).

In addition to hate crimes, other long-standing forms of harassment based on sexual orientation or gender identity or expression were the focus of community organizing and government response during the 1990s and 2000s. Such harassment emerged as a special concern for LGBT youth, who can face harassment and bullying in school because of their actual or perceived sexual orientation or gender identity (see Chapter 4).

An extensive national study released in late 2008 by the Gay, Lesbian, and Straight Education Network found that 86.2 percent of public school LGBT students reported being verbally harassed because of their sexual orientation, 44.1 percent reported being physically harassed, and 22.1 percent reported being physically assaulted. In addition, 32.7 percent of the LGBT students surveyed reported missing a day of school because of feeling unsafe, compared with only 4.5 percent of a national sample of secondary school students (Kosciw et al., 2008). The nonprobability sample of students (n = 6,219, age range = 13–21 in grades 6–12) was recruited through community-based LGBT youth groups and Internet listservs and websites. The majority of these students did not report the incidents to school officials, believing that little to no action would be taken or that the situation might even be exacerbated if reported.

Currently, federal law does not explicitly prohibit school-based harassment based on sexual orientation or gender identity or expression. A minority of states explicitly prohibit bullying and harassment in public K–12 schools on the basis of sexual orientation or gender identity (Biegel and Kuehl, 2010).

Marriage and relationships. Perhaps one of the most striking developments over the past two decades has been the prominence of debate in the United States and around the world concerning societal recognition of the family relationships of sexual- and gender-minority persons. People in same-sex couples have long sought ways to solemnize and formalize their relationship, including through legal recognition (e.g., Nardi, 1997). In the 1980s, some California municipalities enacted statutes to recognize same-sex relationships (in the form of “domestic partnerships”) and provided the same-sex partners of city employees some of the benefits granted to married heterosexual couples. Throughout the 1990s, other jurisdictions enacted similar legislation, and debate about the issue of marriage equality for same-sex couples began to emerge on a national level (for historical background, see Chauncey, 2004; Lewin, 1998; Nardi, 1997).

A 1996 Hawaii Supreme Court decision⁴ raised the prospect that marriage rights might eventually be granted to same-sex partners in that state. In response, Congress passed the Defense of Marriage Act (DOMA). DOMA defines marriage as a legal union between one man and one woman for the purposes of federal law, and exempts states from recognizing marriages performed in another state between two people of the same sex (Defense of Marriage Act, 1996). Most states subsequently passed their own versions of DOMA through statute or constitutional amendment (Peterson, 2004; Vestal, 2009).

In 1999, California became the first state to pass a statewide bill recognizing same-sex couples. Although that law bestowed only limited rights, subsequent legislation gave same-sex couples many of the rights of heterosexual married couples. In 2000, Vermont passed the nation's first civil unions bill, which gave registered same-sex couples all of the same benefits and responsibilities accorded by the state to heterosexual married couples. Other states, including New Jersey, Washington, Oregon, Illinois, and Nevada, subsequently enacted legislation recognizing civil unions or domestic partnerships. Civil unions entitle couples to most of the spousal rights and obligations accorded by the state to different-sex married couples, while the level of rights conveyed by domestic partnerships varies among states. In addition, some state and local government entities offer limited benefits for the same-sex partners of their employees (e.g., access to group health insurance plans), as do many private employers.

Late in 2003, the Massachusetts Supreme Court ordered that state to begin recognizing marriages between same-sex couples within 6 months.⁵ Since then, six other states and the District of Columbia have allowed same-sex couples to marry, either through legislation (Maine; New Hampshire; Vermont; Washington, DC) or as a result of a state court ruling (California, Connecticut, Iowa). However, voters passed constitutional amendments that revoked the right to marry in California and prevented the Maine statute from going into effect.

Because same-sex couples are not legally recognized in most states, and because the legal recognitions extended by a handful of states are not recognized by the federal government, same-sex couples are denied a large number of the rights and benefits associated with marriage. At the federal level, DOMA denies same-sex couples access to more than 1,138 federal rights and obligations (GAO, 2004), ranging from spousal immigration rights to the spousal exemption under federal estate tax law.⁶ In addition, because of DOMA, same-sex couples are ineligible for spousal or survivor benefits from social security, a federal benefit plan (Goldberg, 2009). Even in states where couples with same-sex partners can legally marry, state law cannot require employers to recognize same-sex married couples for the purposes of benefits administered under the Employee Retirement Income Security Act, which governs the health care and retirement benefit plans of many employers (Goldberg, 2009). In states that do not grant same-sex partners the right to marry or do not have civil unions or extend full recognition to domestic partnerships, same-sex couples also are denied a variety of benefits at the state level in such areas as income taxes; inheritance rights; community property; and state-funded benefit programs providing for basic needs, including health care.

The lack of recognition of marriage between two partners of the same sex has other health implications as well. A large body of research has shown that positive health outcomes are associated with marriage (Herdt and Kertzner, 2006; Herek, 2006). These positive effects are derived in part from the increased social support and relative stability associated with a legally recognized commitment (Herek, 2006). One recent study conducted with a nonprobability sample via the Internet (n = 2,677 lesbian, gay, and bisexual adults) found that same-sex couples in legally recognized relationships experienced fewer depressive symptoms, lower levels of stress, and more meaning in their lives compared with participants in similar long-term relationships that lacked legal recognition (Riggle et al., 2010).

Denial of legal recognition of marriage between same-sex couples also has a direct impact on LGB individuals' interactions with the health care system. In many cases, employer-sponsored health insurance is not extended to same-sex partners, affecting their access to affordable health care. In addition, LGB individuals often are unable to take medical leave from work to care for an unmarried same-sex partner to the same extent as married couples. In 2010, the U.S. Department of Labor expanded the scope of the Family and Medical Leave Act to ensure that employees would be allowed unpaid leave to care for the children of unmarried same-sex partners; however, the act still does not extend this leave to care for unmarried same-sex partners themselves. Some states have extended medical leave to unmarried same-sex partners, but most have not. LGB people also have experienced the denial of hospital visitation rights for same-sex partners and disregard for advance directives⁷ with respect to the care of same-sex partners. In 2010, President Obama issued a memorandum directing the U.S. Department of Health and Human Services to adopt regulations requiring all hospitals receiving Medicaid or Medicare dollars to permit visitation by a designated visitor without regard to sexual orientation or gender identity and requiring those hospitals to respect all patients' advance directives. If a visitor is not designated or an advance directive is not in place before a patient is incapacitated, however, same-sex partners may still be disregarded in terms of visitation or medical decision making.

Transgender people also face some uncertainty concerning access to marriage. No court has issued a published decision regarding the validity of a marriage in which one of the spouses undergoes sex reassignment after the marriage has taken place, although many state agencies, many public and private employers, and several federal agencies have held that such marriages are valid.⁸ Few courts have ruled on the validity of a marriage in which one of the spouses undergoes sex reassignment before the marriage has taken place, although in practice, the great majority of couples in this situation do not encounter legal problems. One appellate court decision has recognized the validity of such a marriage,⁹ and a number of trial courts have done so.¹⁰

Parenting and children. Before the emergence of visible gay communities in the United States, many lesbians, gay men, and bisexual people married heterosexually for a variety of reasons, including social and family pressures, a desire to avoid stigma, and a perception that such marriages were the only available route to having children. Sometimes individuals have recognized their homosexuality or bisexuality only after marrying a person of the other sex (e.g., Higgins, 2006). Many lesbian, gay, and bisexual individuals became parents through such marriages. In more recent times, many lesbian, gay, and bisexual adults have conceived and reared children while in a same-sex relationship. Other same-sex couples and sexual-minority individuals have adopted children. In a 2005 Internet survey with a national probability sample of self-identified lesbian, gay, and bisexual adults, approximately 35 percent of lesbians and 8 percent of gay men reported having at least one child, as did 67 percent of bisexual women and 36 percent of bisexual men (Herek et al., 2010). These numbers may be higher among younger sexual-minority individuals. Data from the 2002 National Survey of Family Growth (NSFG) indicate that more than 35 percent of lesbians aged 18–44 had given birth and that 16 percent of gay men in that age group had a biological or adopted child (Gates et al., 2007). Fewer sexual-minority than heterosexual individuals are parents, but there are many lesbian mothers and gay fathers in the United States today (Patterson, 2000, 2009).

Thus, many children are currently being reared by one or more sexual-minority parents. The legal status of those parents and of their children varies from state to state. For example, states differ on whether they consider a parent's sexual orientation to be relevant to custody or visitation in divorce proceedings (Patterson, 2009). In recent years, some states have enacted laws or policies forbidding gay and lesbian individuals or couples from foster-parenting or adopting children; other states have considered laws banning same-sex couples, or all unmarried couples, from foster-parenting or adopting children (Gates et al., 2007; Joslin and Minter, 2009; Patterson, 2009). A long-standing ban on adoptions by lesbian or gay parents in Florida was overturned in 2010. As discussed in later chapters, this variability in legal status has implications for the health of sexual-minority parents and their children.

Transgender people also can face difficulty in court disputes over custody of their children. Many courts have denied or restricted custody or visitation for transgender parents, or even terminated their parental rights, solely because of their gender identity or expression. Only a few state courts have held that a parent's transgender status is irrelevant absent evidence of harm to the child. Transgender people who have no biological or adoptive relationship to the children they are raising with a partner face even more difficulties, as they must first convince the court that a person who has raised a child without formal legal or adoptive ties is nonetheless entitled to custody or visitation (Joslin and Minter, 2009).

Hormone Therapy and Genital Reconstructive Surgery

Prior to the twentieth century, the term transsexual was not used to describe individuals with a gender-variant identity. Early sexologists Magnus Hirschfeld and Havelock Ellis defined the term “transvestism,” or “eonism,” as a category distinct from homosexuality that included cross-gender identification as well as cross-dressing (Ellis, 1933; Hirschfeld, 1991). However, the notion of changing one's sex through surgery or other means existed well before the term transsexual became commonly used. In the early twentieth century, European scientists began to experiment with “sex transformation,” first with animals and then with humans. In Germany, doctors at Magnus Hirschfield's Institute for Sexual Science started performing sex-change operations in the 1920s and 1930s (Meyerowitz, 2002).

It is not clear when the first complete “sex-change” operation was performed in the United States, but by the early 1920s, reports emerged of men and women who convinced physicians to perform castrations or hysterectomies as a means of changing their sex (Yawger, 1940). During the 1930s, endocrinologist Harry Benjamin became one of the first physicians in the United States to routinely administer hormone therapy to individuals desiring to change their sex (Benjamin, 1966; Drescher, 2010). During the next 20 years, a few American physicians privately performed sex reassignment surgery on nonintersex patients (Meyerowitz, 2002). However, it was not until the 1950s that the term transsexual became widely used to describe individuals who desired to change their sex.

Although he refused to endorse sex reassignment surgery for nonintersex patients, David Oliver Cauldwell coined the term transsexual in his 1949 essay “Psychopathia Transexualis” to describe individuals whose sex assigned at birth, based on the appearance of their external genitalia, did not match their gender identity (Cauldwell, 1949). Although transsexual individuals who met these criteria later gained access to sex reassignment, many psychiatrists remained critical of sex reassignment surgery as a legitimate form of treatment; they maintained that transsexual individuals were mentally disordered, and they objected to using hormones and surgery to treat these patients irreversibly (Drescher, 2010). Yet over time, understanding and acceptance grew, confirmed by a body of follow-up research (Green and Fleming, 1990; Pfäfflin and Junge, 1992). During this same period, stories of “sex changes” were publicized in sensationalist American magazines and newspapers. However, individuals seeking sex reassignment from physicians were routinely denied and informed that surgery was only for cases of intersexuality (Meyerowitz, 2002).

Much of the popular knowledge about sex reassignment surgery changed in 1952 when Christine Jorgensen, born George Jorgensen, emerged as a public figure in a front-page article of the New York Daily News (White, 1952). Jorgensen underwent sex reassignment surgery in Denmark and lived out the rest of her life as a woman. In the popular press, Jorgensen's story was unique because she was heralded as the first nonintersex individual to undergo such surgery (Meyerowitz, 2006). Extensive coverage of Jorgensen's transformation demonstrated to other transsexual people that sex reassignment surgery was feasible. Jorgensen's story also led to greater awareness of a concept that would later become known as gender identity, a term coined by Robert Stoller (1968) and popularized by John Money (1985, 1994) in his attempt to explain the sexual development of intersex and transsexual individuals (Drescher, 2010). In 1966, The Johns Hopkins University announced its program to perform and evaluate the efficacy of sex reassignment surgery, thus providing professional legitimacy for sex reassignment as a treatment for transsexualism (Meyerowitz, 2002). This was soon followed by similar programs at the University of Minnesota (Hastings, 1969; Hastings and Markland, 1978) and other university medical centers (Meyerowitz, 2002).

Psychiatric Classification

In 1979, an interdisciplinary group of physicians, therapists, and researchers created the Harry Benjamin International Gender Dysphoria Association, now known as the World Professional Association for Transgender Health (WPATH). Gender dysphoria was defined as serious discomfort with one's gender identity or gender role, thus acknowledging a spectrum of clinical presentations for which sex reassignment could be therapeutic and broadening the narrowly defined criteria originally used in the early sex reassignment programs (Laub and Fisk, 1974). The Benjamin Association defined standards of care to ensure and legitimize access to quality sex reassignment procedures. It also defined a number of eligibility criteria, including evaluation and recommendation by a mental health professional and, for surgery, a real life experience, referring to a set period of time in which to live full time in the gender role to which one is aspiring (WPATH, 1979).

Around the same time, a formal diagnosis of gender dysphoria was introduced in DSM-III (American Psychiatric Association, 1980), further legitimizing it as a psychiatric condition and providing guidance for treatment. DSM-III included two diagnoses: gender identity disorder of childhood (GIDC) and transsexualism (referring to gender dysphoria in adolescents and adults). In the 1987 revision of DSM-III, a third diagnosis was added: gender identity disorder of adolescence and adulthood, nontranssexual type. In 1994, the fourth edition of the DSM, DSM-IV, omitted this last diagnosis and consolidated GIDC and transsexualism under the diagnosis of gender identity disorder, with different criteria for children, adolescents, and adults (Zucker and Spitzer, 2005). In the last 15 years, however, these diagnoses have become increasingly controversial in the context of a transgender movement advocating for recognition of gender diversity and the depathologizing of gender variance (Bockting and Ehrbar, 2006; Bockting et al., 2009; Knudson et al., 2010).

Emergence of the Transgender Movement

As debate over the psychiatric classification and treatment of transsexualism and gender dysphoria continued for many years in the health field, transsexual and transgender people were frequently targets of stigma and discrimination from both the public at large and the police. The increasing number of medical centers willing to perform sex reassignment surgery raised the visibility of transsexual persons. By the 1960s, for example, the Tenderloin neighborhood in San Francisco had become a home for many gender- and sexual-variant people. With the changing dynamics of the neighborhood, tension had increased between residents and the police (Meyerowitz, 1998). In August 1966, that tension came to a head at Compton's Cafeteria, a 24-hour establishment where young male-to-females, cross-dressers, and gay men congregated. When the police attempted to raid the cafeteria and make arrests, the customers fought back, breaking windows and carrying the fighting into the street, including setting a nearby newsstand on fire (Stryker and Van Buskirk, 1996). A watershed event like the 1969 Stonewall Rebellion, the Compton's Cafeteria riot demonstrated an increasing collective consciousness among transsexual and transgender people. In 1969, a number of transsexual individuals in San Francisco formed the National Transsexual Counseling Unit from a number of smaller organizations (Meyerowitz, 2002).

As transsexual and transgender people fought for recognition and rights during the sexual revolution, they met with resistance from many sides. They were often excluded by gay men and lesbians from the gay liberation movement. However, they continued to advocate for their rights and equal treatment. In 1978, advocates in California successfully pushed for a state law that allowed transsexual individuals to change the name and sex designation on their birth certificate. Around this same time, the publication of Meyer and Reter's (1979) study claiming that sex reassignment surgery did not “confer [any] objective advantage in terms of social rehabilitation” led to the closing of the Hopkins Gender Identity Clinic, and a number of other, smaller clinics followed (Meyerowitz, 2002), although many critics of Meyer's study quickly came forward to defend the surgery (Fleming et al., 1980). A handful of university-based gender identity clinics survived, including clinics at Stanford University, the University of Texas, Case Western Reserve University, and the University of Minnesota. Their approach to care gradually changed as research and clinical experience evolved and as a generation of sex-reassigned transsexual individuals and other transgender individuals with various gender-variant identities and expressions continued to gain visibility (e.g., Kimberly, 1997; Stone, 1991; Warren, 1993).

These developments culminated in a paradigm shift away from changing sex toward facilitating a transgender coming-out process (Bockting, 1997, 2008; Bockting et al., 2009). Instead of viewing gender as binary and helping transgender and transsexual individuals conform, the transgender movement revealed a wide range of gender-variant identities and expressions, consistent with what had been documented in other cultures and throughout history (Coleman et al., 1992; Feinberg, 1996; Nanda, 1990; Roscoe, 1991; Williams, 1986). The focus of clinical management shifted to ameliorating the negative effects of stigma associated with gender variance and assisting transgender individuals in finding a gender expression that is comfortable and consistent with their gender identity (Bockting and Ehrbar, 2006). Psychotherapy now focuses on facilitating a transgender coming-out process that no longer emphasizes “transitioning” to become a “passing” member of the “opposite” sex, but instead emphasizes affirming a unique transgender identity. Hormone therapy and surgery continue to be options for feminizing or masculinizing the body to alleviate gender dysphoria. Instead of these interventions being viewed as two steps in a linear process toward sex reassignment, however, treatment now may use either hormones or surgery, both, or neither (Bockting, 2008). While research has clearly established the efficacy of sex reassignment that includes hormone therapy and a full-time gender role change followed by genital reconstructive surgery (Murad et al., 2010), virtually no studies have evaluated the contemporary approach to treatment whereby hormone therapy is not necessarily followed by surgery, and gender identity and expression do not conform to binary conceptualizations of sex and gender.

The 1990s saw the creation of many new organizations as transgender activists began to build a community identity, often facilitated by the Internet. In addition, transgender communities established lasting coalitions with gay, lesbian, and bisexual communities to support one another in similar struggles for increased awareness, acceptance, and human rights. In 1992, Minnesota became the first state in the nation to adopt human rights and antidiscrimination legislation that included not only gay men, lesbians, and bisexual men and women but also transgender people (Minnesota Department of Human Rights, 1993). Since then, a number of states and cities have followed suit (Bockting et al., 1999). Also during the 1990s, the National Gay and Lesbian Task Force began to include transgender people in its advocacy, and WPATH revised its standards of care and included transgender community representatives in its deliberations (Levine et al., 1998; Meyerowitz, 2002). Today, the existence of gender identity disorder and its inclusion in the DSM remains controversial and is the subject of intense debate, complicated by the potential implications of further depathologization and removal of the diagnosis for access to transgender-specific health care, particularly treatment of gender dysphoria and the medical interventions of hormone therapy and surgery that continue to be medically necessary for many (Drescher, 2010).

Early Attempts to Estimate Sexual Orientation

Perhaps the most well-known example of an attempt to describe the sexual behavior of the U.S. population is the work of Alfred Kinsey and his colleagues (1948, (1953). In their pioneering descriptive study of the sexual feelings and experiences of thousands of U.S. adults, the Kinsey researchers did not categorize research participants according to sexual orientation categories but instead reported the extent to which their sexual histories included heterosexual and homosexual desires and behavior. For example, Kinsey and colleagues (1948) reported that 37 percent of the males in their sample had had at least some overt homosexual experience to the point of orgasm between adolescence and old age, and another 13 percent had reacted erotically to other males without having overt homosexual contacts after the onset of adolescence. Generalizations from the Kinsey group's findings to the entire U.S. population are problematic for several reasons, including the fact that the data were not obtained from a probability sample.¹¹ However, this research demonstrated the feasibility of studying sexuality in the general population. It also showed that human sexual behavior is highly diverse and that a large number of people acknowledged having engaged in sexual behaviors that previously had been considered rare.

Despite Kinsey and colleagues' eschewal of sexual orientation categories, others extrapolated from their findings to estimate the proportion of the U.S. population in each of the different categories. Based on such an extrapolation (Voeller, 1990), the belief that 90 percent of the U.S. population was heterosexual and 10 percent was gay or lesbian became widely accepted during the early years of the U.S. gay rights movement. Data were lacking, however, with which to gauge the accuracy of this estimate.

Recent Estimates

As noted, while the Kinsey report was important in pioneering the study of sexuality, sampling limitations make the generalizability of its findings uncertain. However, credible estimates of the size of different sexual orientation groups can be derived from the National Health and Social Life Survey (NHSLS), which was conducted by researchers at the National Opinion Research Center (NORC) at the University of Chicago in 1992. The NHSLS is widely regarded as the most authoritative national survey to date of adult sexuality in the United States. It included assessment of the number of people by sexual attraction, behavior, and sexual orientation identity in a large probability sample (n = 3,432) of U.S. adults.¹² As detailed in Chapter 3, sexual desire was assessed by asking respondents about who they were “sexually attracted to” (men, mostly men, both women and men, mostly women, only women). A separate question also asked about the appeal of having sex with someone of the same sex. Sexual behavior was assessed with questions about the respondents' sexual acts with males and with females during three time periods (the past 30 days, the past 12 months, and since adolescence). Identity was assessed by asking respondents whether they thought of themselves as heterosexual, homosexual, bisexual, or something else.

Among the NHSLS respondents, approximately 90 percent of men and 92 percent of women reported exclusively heterosexual attraction, behavior, and identity. About 2.8 percent of the men and 1.4 percent of the women labeled themselves homosexual or bisexual and reported same-sex desire.¹³ Others reported having had same-sex partners or some degree of same-sex desire, attraction, or appeal (Laumann et al., 1994a). As shown in Table 2-1, approximately 4 percent of women and 7 percent of men reported having same-sex partners at some point since puberty. More than 7 percent of both men and women reported same-sex desire, attraction, or appeal.

TABLE 2-1

Estimated Percentage of People by Sexual Orientation and Behavior from Selected Sample Surveys.

Because the absolute number of both men and women reporting any nonheterosexual attraction, behavior, or identity was quite small (143 men, 150 women), the margin of error associated with these estimates is fairly large, and any generalizations to the national population must be made with caution (Laumann et al., 1994a).

More recent data from the 2002 NSFG, conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics, also provide estimates for sexual orientation identification, same-sex sexual behaviors, and same-sex attraction. These estimates are for a more recent and younger cohort (aged 18–44) than those from the NHSLS. In the NSFG, sexual orientation identification was assessed with the question: “Do you think of yourself as heterosexual, homosexual, bisexual, or something else?” Among men aged 18–44, 90.2 percent identified as heterosexual, 2.3 percent as homosexual, 1.8 percent as bisexual, and 3.9 percent as something else; 1.8 percent did not report their orientation. Among women in this age range, 90.3 percent identified as heterosexual, 1.3 percent as homosexual, 2.8 percent as bisexual, and 3.8 percent as something else; again, 1.8 percent did not report their orientation. In terms of behavior, 6.2 percent of men reported same-sex oral or anal sexual behavior, while 11.5 percent of women reported a “sexual experience” with another woman. As Mosher and colleagues (2005) point out, this relatively high number of women may be due to the broad wording used for the question. As for attraction, 7.1 percent of men and 13.4 percent of women acknowledged some degree of same-sex attraction.

Two more recent surveys based on national probability samples provide estimates of LGB identification. Gates (2010) reports that in the 2008 General Social Survey (GSS), a survey with a national probability sample conducted by NORC, 2.2 percent of men identified as gay and 0.7 percent as bisexual, while 2.7 percent of women identified as lesbian and 1.9 percent as bisexual (n = 1,773 for the sexual orientation questions). As in the NHSLS and NSFG, data from the GSS show that rates of same-sex sexual behavior—reported by approximately 10 percent of individuals aged 18–44—are higher than rates of LGB self-identification. Estimates of the number of people who self-identify as LGB also are found in data from the recent 2009 National Survey of Sexual Health and Behavior, collected by Knowledge Networks (Herbenick et al., 2010). As the authors describe, Knowledge Networks generates a national probability sample using random-digit dialing and address-based sampling. Internet access and the necessary hardware are provided to participants who lack them. In this sample, 6.8 percent of men and 4.5 percent of women self-identified as lesbian, gay, or bisexual.

Differences in the rates reported in Table 2-1 are no doubt due in part to the time periods during which the surveys were administered. Differences are also likely to have resulted from age differences across the samples, as younger cohorts are more likely than older adults to report LGB identification and same-sex sexual behavior. Differences across studies may result as well from variation in the survey instruments used, mode of administration, and methods used to draw the samples. Finally, as discussed above with respect to the NHSLS, there is substantial sampling variation, as the estimates are based on relatively small samples. Consequently, the margin of error associated with each estimate is likely to be fairly large.

Data from these and other national probability samples, as well as U.S. census data, reveal other demographic characteristics of LGBT populations. It should be noted that, because of data limitations, most of the demographic characteristics reported here refer only to gay men and lesbians; demographic information on bisexual and transgender individuals are extremely limited.

Personal-Level Barriers

Personal-level barriers are created by the attitudes, beliefs, and behaviors of individuals within the health care system—both providers and patients. Individual expressions of sexual and transgender stigma create significant personal barriers for LGBT people attempting to access high-quality care. Three such expressions are discussed here: enacted stigma, felt stigma, and internalized stigma (Herek, 2009d).

Enacted stigma. Enacted stigma refers to explicit behaviors that express stigma. These behaviors can take the form of verbal epithets, shunning, overt discrimination, and even violence. Individuals are often targeted for enactments of sexual stigma because of their perceived gender nonconformity, and transgender individuals are often targeted because they are assumed to be homosexual. Thus, many stigma enactments against sexual and gender minorities alike are rooted in both sexual and transgender stigma.

Some LGBT individuals face discrimination in the health care system that can lead to an outright denial of care or to the delivery of inadequate care. There are many examples of manifestations of enacted stigma against LGBT individuals by health care providers. LGBT individuals have reported experiencing refusal of treatment by health care staff, verbal abuse, and disrespectful behavior, as well as many other forms of failure to provide adequate care (Eliason and Schope, 2001; Kenagy, 2005; Scherzer, 2000; Sears, 2009).

Felt stigma. Because any individual may be perceived to be gay, lesbian, or bisexual, virtually anyone—regardless of sexual orientation—can be the target of an enactment of sexual stigma. Most people, heterosexuals and nonheterosexuals alike, recognize this possibility, and that recognition often leads them to modify their own behavior to avoid such an experience. Heterosexuals and nonheterosexuals alike may modify or adapt their behavior in a variety of ways to avoid stigma; sexual-minority individuals may hide their sexual orientation from others, including health care providers. This awareness of the possibility that stigma will be enacted in particular situations is referred to as felt stigma. Felt stigma can be adaptive to the extent that it protects the individual from enacted stigma. At the same time, this adaptation has costs. Fear of stigmatization or previous negative experiences with the health care system may lead LGBT individuals to delay seeking care. Confidentiality also can be an issue, given that most health insurance is provided through an individual's place of employment. If he or she is not “out” as a sexual or gender minority in the workplace, and because there is no legal protection in many jurisdictions for sexual or gender minorities in the workplace, patients may fear loss of employment due to their sexual- or gender-minority status. Ponce and colleagues (2010) suggested this explanation after demonstrating significant disparities in health care access for gay men and lesbians compared with heterosexuals. In addition, many LGBT individuals do not disclose their sexual orientation because of fear of provider bias, although it should be noted that many patients, regardless of sexual orientation, are unwilling to disclose information about their sexual behaviors to a health care provider (Jillson, 2002). For example, in-depth qualitative interviews with LGBT individuals in a rural setting revealed that many would strategically remain silent to health care providers about their sexuality or gender status (Willging et al., 2006). Others may fail to complete advance directives and powers of attorney for partners as a way of concealing their sexual orientation.

Internalized stigma. A third way in which individuals manifest stigma is by accepting the legitimacy of society's negative regard for the stigmatized group. In non-gender-variant heterosexuals, this internalized stigma is expressed as prejudice against sexual minorities (commonly labeled sexual prejudice or homophobia) and transgender people (sometimes labeled transphobia and referred to here as transgender prejudice).

Sexual prejudice on the part of health care providers often underlies enactments of stigma. Although there has been little recent research investigating provider attitudes toward LGBT patients, earlier studies have shown that provider attitudes toward sexual-minority patients can be barriers to care (IOM, 1993; Jillson, 2002). From the available literature, it appears that many providers are uncomfortable with providing services to LGBT patients. In one study published during the 1980s, 40 percent of physicians surveyed reported being sometimes or often uncomfortable providing care to lesbian or gay patients (Mathews et al., 1986). In a survey conducted with a nonprobability sample of members of the Gay and Lesbian Medical Association (GLMA), 67 percent of respondents believed they had seen gay or lesbian patients receive substandard care because of their sexual orientation (Schatz and O'Hanlan, 1994). On the other hand, in a recent follow-up to the earlier Matthews and colleagues (1986) study, Smith and Mathews (2007) found that levels of sexual prejudice among health care providers had declined substantially.

Among sexual- and gender-minority individuals, internalized stigma leads to denigration of the self, termed self-stigma (this phenomenon has been labeled internalized homophobia in sexual-minority individuals). Self-stigma may cause sexual and gender minorities to feel that they do not deserve respect from their health care provider or the same access to health care as heterosexuals. As a result, they may not disclose key information to their provider, may avoid seeking treatment, or may refrain from challenging discrimination and other forms of enacted stigma.

Other personal barriers. As noted, in addition to stigma related to their sexual-minority status, LGBT individuals may face barriers to care due to other characteristics, such as their racial/ethnic minority status, education level, income level, geographic location, language, immigration status, knowledge, and cultural beliefs. The intersection of these dimensions with the stigma associated with sexual- and gender-minority status results in unique barriers and challenges to accessing high-quality care for many LGBT individuals.

Structural Barriers

Structural barriers relate to the health care system at the institutional level. These barriers operate regardless of the attitudes of individuals. Examples of such barriers include an employer-based health care system that limits LGBT individuals' access to marital benefits, including eligibility for health insurance; lack of training in LGBT health received by providers; and insurance practices that limit the types of care covered for LGBT individuals.

Structural stigma. Structural stigma (or institutional stigma) is the manifestation of stigma within the institutions of society (Corrigan et al., 2005). Structural stigma often perpetuates stigma-based differentials in status and power (Link and Phelan, 2001) and may operate even in the absence of prejudice on the part of individual members of an institution. For example, if a health maintenance organization provides care for members' different sex spouses but not their same-sex partners, its sexual-minority members have a lower status than their heterosexual counterparts, regardless of whether individual staff members are personally prejudiced against sexual minorities. Just as institutional racism works “to the disadvantage of racial minority groups even in the absence of individual prejudice or discrimination” (Link and Phelan, 2001), structural sexual stigma disadvantages and restricts the opportunities of sexual and gender minorities by perpetuating their lower status and power relative to non-gender-variant heterosexuals (Herek, 2009b).

As discussed earlier, structural stigma occurs in the health care system as well in society at large (e.g., with respect to employment benefits for same-sex couples and government rules and regulations regarding marriage between same-sex couples). For example, a major structural barrier is the lack of legal recognition of partners, which has prevented many hospitals and health care providers from according partners and family members of LGBT individuals the same rights to visit and access information that are provided to heterosexual spouses. There have been cases of legal refusal to recognize the partner of a sexual-minority patient as a health care proxy even when so designated by the patient (IOM, 1999).

Provider knowledge and training. With respect to the health care provided to LGBT people, a number of structural barriers result from providers' lack of training in the health needs of LGBT patients. Cultural competency, referring to a set of skills that allows providers to give culturally appropriate high-quality care to individuals of cultures different from their own, is an important aspect of care (IOM, 1999). Patient–provider communication is important. In fact, studies suggest that poor patient–provider communication is strongly associated with adverse health behaviors such as decreased levels of adherence to physician advice; it is also associated with decreased rates of satisfaction (Cortes et al., 2009; Inui and Carter, 1989; Stewart, 1995). Yet many providers are not trained to provide care for LGBT individuals, and providers themselves report a lack of knowledge about the issues facing their sexual- and gender-minority patients. Particularly for transgender patients, access to providers who are knowledgeable about transgender health issues is critical. In fact, few physicians are knowledgeable about or sensitive to LGBT health risks or health needs (IOM, 1999, p. 43). Medical schools teach very little about sexuality in general and little or nothing about the unique aspects of lesbian, gay, and bisexual health (Makadon, 2006; Tesar and Rovi, 1998; Wallick et al., 1993), and it is rare for medical students to receive any training in transgender health (AAMC GSA and AAMC OSR, 2007).

While the Association of American Medical Colleges issued recommendations for institutional programs and educational activities to address the needs of LGBT patients in 2007, including training in communication skills regarding sexual orientation and gender identity, it is not evident that all medical schools have embraced these recommendations. The Lesbian, Gay, Bisexual, and Transgender Medical Education Research Group, a group of medical students at Stanford University, surveyed deans of medical education at 116 universities in the United States and Canada. They found variability in the content and quality of the LGBT-specific instruction medical students received, with HIV, sexual orientation, and gender identity being the most common LGBT topics included in the curricula. Fully 70 percent of the deans rated their school's curriculum in this area as “fair” or worse (Obedin-Maliver et al., 2010).

While many providers report high levels of discomfort with taking the sexual history of any patient, this lack of training exacerbates this discomfort when providers are dealing with LGBT patients. A qualitative study involving 13 HIV providers found that discomfort with asking questions was one of their greatest issues with respect to the treatment and care of transgender patients (Lurie, 2005). Likewise, a survey of 60 pediatricians in Washington, DC, that examined their approach to the health of LGB youth found that discussions of sex and sexual orientation were difficult even for those who were well intentioned (East and El Rayess, 1998).

Health insurance. Lack of health insurance is a major structural barrier to care, and LGBT people and their children are more likely to lack health insurance than heterosexual people and their children (Badgett, 1994; Cochran, 2001; Diamant et al., 2000; Ponce et al., 2010). This is due at least partially to the fact that LGBT families often lack access to employer-sponsored health insurance (Ash and Badgett, 2006; Heck et al., 2006). As was noted in the earlier discussion of laws and policies, unmarried same-sex partners of employees often are ineligible for employer-sponsored health insurance. While 57 percent of Fortune 500 companies now extend domestic partner benefits to their LGB employees (HRC, 2010), this practice is much less common for smaller companies. Ponce and colleagues (2010) examined disparities in health insurance coverage faced by same-sex couples and found significant disparities in access to care. Using population-based data from California, the authors found that partnered gay men were less than half as likely (42 percent) as married heterosexual men to receive employer-sponsored dependent coverage, and partnered lesbians were 28 percent less likely to receive such coverage than married heterosexual women. As a result, gay men and partnered lesbians are more than twice as likely to be uninsured as married heterosexuals (Ponce et al., 2010).

Even when LGBT people have access to health insurance, they often are still at a disadvantage in relation to their heterosexual peers. Unlike most heterosexual married couples, employees are required to pay federal taxes on employer-provided health insurance for a same-sex partner (Badgett, 2007). Moreover, health plans often fail to cover many services that impact LGBT individuals, including infertility treatment for lesbians. In some instances, access to reproductive and fertility services is denied on the basis of marital status or sexual orientation (Ethics Committee of the American Society for Reproductive Medicine, 2009).

High levels of joblessness and poverty among transgender populations, particularly those of color, make lack of health insurance a problem for these individuals (Xavier et al., 2005). In addition, both private and public health care plans severely limit transgender people's access to sex reassignment surgery or other treatments related to transgender status. Most private insurance plans, as well as Medicare, contain explicit exclusions for such treatments.