Judith Bradford, PhD Director, Center for Population Research in LGBT Health

1. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding Judith Bradford, PhD Director, Center for Population Research in LGBT Health Co-Chair, The Fenway Institute The Fenway Institute at Fenway Health

2. What Will Be Covered Today? • Overview of the Institute of Medicine (IOM) Report on The Health of Lesbian, Gay, Bisexual, and Transgender (LGBT) People • Examine diversity within LGBT communities. How the issue of race & gender identity intersects with sexual orientation. (Intersectionalities) • Examine health disparities within LGBT populations. What we know and do not know.

3. IOM Report: Findings, Recommendations, and Implications for Public Health Agencies

4. Charge to the Committee from National Institutes of Health (NIH) • Conduct a review of the health status of LGBT populations • Identify research gaps and opportunities • Outline a research agenda • Consider research training needs to foster the advancement of knowledge about LGBT health

5. Process • 18 months consensus study • 3 public meetings (2 in DC, 1 in SF) • 2 closed meetings and 3 conference calls • Extensive literature review • 14 external reviewers

6. Structure of the Report Adopted a broad definition of health. “Health encompasses multiple dimensions including physical, emotional, and social well-being and quality of life.” Used 4 conceptual frames: • Life Course – events at each stage of life influence subsequent stages; experiences are shaped by age and historical context. • Minority Stress – LGBT people experience chronic stress from societal discrimination and stigma. • Intersectionality – individuals have multiple identities that interact with each other, including race/ethnicity, income, gender, sexual orientation and gender non-conformity. • Social Ecology – relationships with families, communities, and society influence the health of LGBT people.

7. Life Course Areas examined across 3 life stages*: • Development of sexual orientation and gender identity • Mental health status • Physical health status • Risk and protective factors • Health services • Contextual influences ___________________________________________ * childhood/adolescence, early/middle adulthood, later adulthood

8. Minority Stress Theory Meyer, I. Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and Research Evidence. Psychol Bull. 2003 September: 129(5): 647-697.

9. Identity Framework for Sexual and Gender Minorities Intersectionality…Ethnic and sexual identity developed concurrently during adolescence among black and Latino gay youth 16-22, but the processes were different and not related. • Ethnic identity development was shaped by growing awareness of ethnic and cultural heritage, supported by peers, family members, and cultural markers (food, music, holidays). • Sexual identity development was supported by community-based organizations, peers and information from the Internet. • Sexual identity development was described as a private process; ethnic development was viewed as a more public process.

10. Social Ecology…Health is not just an individual matter McElroy KR, Bibeau D, Steckler A, Glanz . An ecological perspective on health promotion programs. Health Education Quarterly 15:351-377, 1988.

11. Conceptual Perspectives for LGBT Health The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. IOM: 2011

12. Health Disparities:LGBT Populations Across the Lifespan

13. Background on LGBT Research • Research has been conducted unevenly, with more research on gay men and lesbians and less on bisexual and transgender individuals. • Most research has focused on adults, with less on adolescents and few studies on LGBT elders. • Research has not adequately examined subpopulations, particularly racial and ethnic groups.

14. What do we know about health disparities among sexual and gender minorities? • During childhood and adolescence • During early/middle adulthood • During later adulthood

15. During Childhood and Adolescence Tobacco • Sexual minority adolescents report higher prevalence than heterosexuals. Lesbian and bisexual girls, 9.7% were more likely to have smoked at least weekly. • Gay and bisexual boys were as likely to smoke as heterosexual boys, but less likely to have tobacco dependence. • Among college students, women with both-sex partners were significantly more likely to smoke than women with exclusively other-sex partners.

16. Alcohol Consumption and Drug UseLGBT Youth May Be at Greater Risk • Adolescent males and females with “both-sex” attractions were more likely to drink alcohol. • Significantly higher rates of episodic drinking were reported among behaviorally bisexual than heterosexual females. • Self-identified and behaviorally bisexual males were significantly less likely than heterosexual males to engage in heavy episodic drinking.

17. Alcohol Consumption and Drug UseLGBT Youth May Be at Greater Risk • Bisexual females were more likely than heterosexual and homosexual students to have used illicit drugs. • Among young MSM, methamphetamine use was correlated with high-risk sexual behavior as well as sexualized social contexts.

18. Mental Health Concerns • LGB youth are at increased risk for suicidal ideation, attempted suicide and depression. • Studies with small samples suggest this is also true for transgender youth. • Potential risk factors include sexual-minority status, homophobic victimization and stress, and family rejection. • LGB youth may demonstrate higher rates of disordered eating.

19. During Early/Middle Adulthood Mental Health • LGB adults … • experience more mood and anxiety disorders than heterosexuals. • appear more likely to experience depression over a period of 12 months and over a lifetime. • are more likely to report suicidal ideation and behavior. • Sexual minority adults may access mental health services more often than heterosexuals.

20. During Early/Middle Adulthood • Tobacco and alcohol use appear to be greater among LGB older adults than heterosexual counterparts. • Gay men were found to have significantly higher rates of smoking and alcohol use than lesbians. • In several studies, LGB adults 60+ years of age were more likely than heterosexuals to have experienced childhood sexual abuse and/or incidences of physical assault.

21. During Early/Middle Adulthood • Lesbians and bisexual women… • May be at higher risk for breast cancer; these groups may have higher rates of risk factors. • May be at greater risk for obesity, although data on bisexual women are less clear; research to clarify risks is insufficient. • Gay and bisexual men may be at higher risk for eating disorders compared with heterosexual men. • Far less research has explored rates of eating disorders among lesbians, bisexual women and transgender people. • Gay men may have higher rates of erectile dysfunction. • Little research has focused on reproductive health among LGBT people.

22. During Early/Middle Adulthood Health Services • Very little research has been conducted on the quality of care experienced by sexual and gender minorities. • Lack of health insurance, fear of discrimination from providers, and dissatisfaction with services act as barriers to accessing health care for all LGBT groups. • LGBT adults appear to have different access and utilization patterns. • Limited data suggest that transgender patients report high satisfaction with transgender-specific health services when accessible from knowledgeable providers.

23. During Later Adulthood • Discrimination plays a significant, recurring, and pervasive role in the lives of LGBT persons and perhaps in the lives of older LGBT people in particular. • Cumulatively, LGBT elders have encountered stigma, discrimination and victimization across the life course. • Lesbian and gay elders are less likely than their heterosexual peers to have children, and their other kinship ties are not well understood.

24. During Later Adulthood • Transgender elders may experience negative outcomes as a result of long-term hormone use. • Studies of older gay men and lesbians have found elevated rates of depression – 30% of gay men 50-87 in a sample of gay men; 24% in a national non-probability sample of self-identified lesbians over age 55. • In a probability sample of men who have sex with men, 17% aged 50-69 and 5% aged 70 and older reported depression.

25. During Later Adulthood • It is important to note that LGBT people in later adulthood are typically well adjusted and mentally healthy. • In probability samples, the majority of older LGB adults do not report mental health problems. • Studies based on nonprobability samples show that the same is true for many if not most transgender adults.

26. Asked “In what ways, if any, has being LGBT helped you prepare for aging?” (MetLife 2010). Almost 3 quarters felt they were prepared by their sexual minority status, specifically by the personal/interpersonal strengths and experience of overcoming adversity: • being more accepting of others • not taking anything for granted • being more resilient or having greater internal strength • having greater self-reliance • being more careful in legal and financial matters • having a chosen family

27. Summary Report Key Findings • Lesbian, gay, bisexual and transgender individuals have unique health experiences and needs, but as a nation, we do not know exactly what these experiences and needs are. • Researchers face a number of challenges in understanding our health needs, including a lack of data. • Building a more solid data base is essential for development of this field.

28. Key Research Gaps and Opportunities • Demographic and Descriptive Information • Family and Interpersonal Relations • Health Services • Mental Health • Physical Health • Sexual and Reproductive Health

29. Research Needs Across the Life Course • Research opportunities: • exist across all stages of the life course. • are found in all six areas of concern. • In each of the following tables, we will see that some research gaps are of concern for all life stages. • Other research gaps are specific to one or two life stages, but not all.

37. To address these gaps and opportunities, the IOM report concluded withrecommendations to the NIH: NIH should implement a research agenda designed to advance knowledge and understanding of LGBT health. Standardize and include measures of sexual orientation and gender identity in government surveys. Support methodology studies of how best to gather information about the health of LGBT people.

38. Summary The IOM report : • gathered and organized available research about LGBT people and communities. • pointed out areas where research was especially lacking and opportunities exist for much-needed studies. • made recommendations about changes in federal infrastructure to facilitate LGBT health research. • has provided a scientific foundation for government initiatives to address key gaps in knowledge.

39. Key Questions to Ponder • As a state-level public health entity, what are your successes or challenges in obtaining LGBT data? • What specific data needs do you currently have? • With the information presented today, what are your walk-away ideas and thoughts?