The US National Academies report Understanding the Well-Being of LGBTQI+ Populations (2020) edited by Charlotte J. Patterson, Mart n-Jos Seplveda and Jordyn White comments
At more than 11 million, the number of self-identified lesbian, gay, bisexual, and transgender (LGBT) individuals living in the United States is roughly equivalent to the population of Ohio. The LGBT population has increased substantially over the past decade, with much of this growth driven by younger generations, women, bisexual people, and racial and ethnic minorities. In a shift from prior years, a majority of Americans now approve of same-sex relationships and support legal protections to ensure fundamental civil liberties on the basis of sexual orientation and gender identity.
The laws, too, have changed: in 2015 the U.S. Supreme Court ruling in Obergefell v. Hodges (576 U.S. 644) extended marriage equality for same-sex couples nationwide. In 2020, the Supreme Court ruled in Bostock v. Clayton County (140 S. Ct. 1731) that the prohibition of sex discrimination in Title VII of the Civil Rights Act protects individuals from discrimination based on sexual orientation or gender identity in employment. Many states, municipalities, and private corporations have expanded nondiscrimination protections in workplaces, health care settings, and schools to include sexual orientation and gender identity. The demographic shifts observed in LGBT populations challenge researchers and policy makers to collect more and better data and to consider the degree to which research questions, media discussions, and policy decisions reflect the most pressing needs of these populations and the contemporary challenges they face (Conclusions 3-1, 3-2).
As the population evolves, so do the terms used to describe individuals who identify as or exhibit attractions to people outside of the traditional male-female gender binary. The acronym LGBTQ is often used in place of LGBT, in which the “Q” may refer to queer or questioning. In some contexts, the acronym is expanded further to include “I” for intersex, “A” for asexual or ally, or “+” as an acknowledgment of the diversity of non-binary and gender-nonconforming individuals.
Throughout this report, the phrase “sexual and gender diverse” is used to describe individuals who identify as lesbian, gay, bisexual, transgender, queer, intersex, non-binary, or who exhibit attractions and behaviors that do not align with heterosexual or traditional gender norms. The committee acknowledges that no term is perfect or completely inclusive, and our intention is not to promote the phrase or its acronym, SGD, for widespread use. Instead, the goal is to highlight the variety of identities and communities within SGD populations and the need for greater understanding of the differences that exist within and between them.
A growing need for advanced data collection
Despite the population trends, many current national surveys and other data collection instruments lack measures of sexual orientation, gender identity, and sexual behavior and attraction, which makes it difficult to accurately report the size and other characteristics of SGD populations. Questions about sexual orientation and gender identity that do appear in data collection instruments are presented inconsistently with differing terms and are often separated from other demographic measures (Conclusion 4-1).
Gaps in gender identity data collection preclude insights into trends in transgender population size over time, and population-level data about people with intersex traits are not available at all. In addition, little research has been conducted on sexual attraction and behaviors, and almost no population-level data exist for people with intersex traits (Conclusion 4-2).
To address the lack of broad and consistent data, the National Academies of Sciences, Engineering, and Medicine convened a committee of experts to review the available evidence and identify future research needs related to the well-being of sexual and gender diverse populations across the life course. The committee focused on eight domains of well-being: the effects of various laws and the legal system on SGD populations; the effects of various public policies and structural stigma; community and civic engagement; families and social relationships; education, including school climate and level of attainment; economic experiences (e.g., employment, compensation, and housing); physical and mental health; and health care access and gender-affirming interventions. The well-being of an individual can be thought of as an outcome of experiences with family and personal relationships, as well as interactions with many societal sectors and such systems as education, employment, and government.
Changes to the Legal Landscape
SGD populations come into contact with the law in a variety of contexts, including employment, health care, housing, public accommodations, interactions with the criminal justice system, and government-administered systems, such as foster care, adoption, and immigration. In some of these realms, there have been important reforms that have enhanced the quality of life for SGD people; in others, mistreatment and discrimination remain frequent occurrences, especially for marginalized groups within the SGD population. In the face of changing public attitudes as well as evolving law, the effect of the legal system on the well-being of these groups is uneven and, at times, contradictory (Conclusion 5-1).
Approximately 50 percent of the U.S. population lives where there is a state law that explicitly protects SGD people from at least one form of discrimination. The laws pertaining to such issues as gender markers on essential documents, family proceedings, and religious exemptions from anti-discrimination vary greatly in scope between levels of government and across states (Conclusion 5-2).
Mistreatment during interactions with the police and the prison system is a common experience for SGD people (Conclusion 5-3).
The criminalization of HIV exposure and the criminalization of sex work disproportionately affect homeless youth and transgender women, especially transgender women of color. Data suggest that sexual orientation and gender identity bias and hate crimes have increased since 2013, and although they account for a small share of all hate crimes, they tend to be more violent and result in severe bodily injury.
Effects of public policy and stigma
Policies seldom change without outside social forces organizing to create that change. Policy advocates and social movements can activate public opinion by drawing attention to social problems. Recently, the attitudes of adults in the United States have undergone a massive shift in accepting SGD populations and on numerous policies that would further the well-being of SGD people. However, the pursuit of policies likely to garner public favorability can potentially stigmatize or erase certain SGD groups, such as bisexual and transgender people (Conclusion 6-1).
The attitudes of the general public affect public policies both directly and indirectly. In general, the emergence of more inclusive laws and policies is often perceived as a signal that society has changed to be less stigmatizing to SGD populations (Conclusion 6-2).
The well-being of SGD populations is affected by stigma, which can occur at individual, interpersonal, and structural levels. The concept of stigma helps explain how dominant cultural beliefs and differences in access to power can lead to labeling, stereotyping, separation, status loss, and discrimination for those who do not align with societal norms. Structural stigma— which includes institutional policies and practices, as well as public attitudes—is an important mechanism that contributes to inequalities for sexual and gender diverse populations across numerous domains that are essential for living healthy, productive, and fulfilling lives, including socioeconomic well-being, physical and mental health, and physical safety (Conclusion 6-3).
There is now a growing body of evidence that structural stigma affects the health and well-being of people of diverse sexualities and genders, but there has been little research on the ways in which structural stigma develops and evolves over the life course. Furthermore, most structural stigma research has focused on gay men and lesbian women and has not considered intersectional characteristics such as race, ethnicity, gender identity, geography, and socioeconomic status (Conclusion 6-4).
Community and civic engagement
SGD communities represent a variety of racial, ethnic, and cultural identities and experiences. Over the past several years, spaces for public convening and engagement in social, cultural, and personal activities have diminished substantially for SGD people. Online SGD communities often arise out of the need for information, connection, and support. Because access to space is linked to participation in public culture, which is also influenced by the intersections of race, gender, sexuality, and social class, less visible and marginalized SGD groups, as well as SGD people of color, do not always have access to the same spaces as do SGD people of other races and classes (Conclusion 7-1).
The past several years have seen the insurgence of LGBTQ+-affirming churches, denominations, and non-institutional spiritual practices, as well as gay-straight alliances on school, college, and university campuses. Community connectedness has been shown to help SGD people address health disparities by connecting them to important resources (Conclusion 7- 2).
In civic affairs, lesbian, gay, and bisexual adults tend to be more civically and politically engaged than heterosexual adults (Conclusion 7-3).
In addition, transgender people are registered to vote at higher rates than the cisgender population. Connectedness to other SGD people is a strong predictor of sociopolitical involvement.
Families and social relationships
Close, supportive, and stable relationships foster health and well-being, and relationships early in life have implications for the quality and stability of social ties in adolescence and adulthood. SGD youth are at higher risk of depressive symptoms, anxiety, and suicidality than other similarly situated youth. Parental acceptance of their SGD youth is associated with positive adjustment; conversely, parental rejection is associated with a range of emotional and behavioral health problems. Supportive teachers are among the most important nonfamily adults in the lives of contemporary SGD youth. Maintaining friendships throughout and following the coming out process supports positive adjustment for SGD youth.
Romantic relationships in youth are also supportive in many cases, although the risk of intimate partner violence is higher for SGD youth than for other youth (Conclusion 8-1).
Throughout adulthood, people who are more socially connected have better mental and physical health and lower mortality than those who are more socially isolated. Friends and chosen family members may also play an important role in SGD communities.
The legal status of romantic unions is associated with the health and well-being of SGD populations, as well as other markers of advantage and disadvantage—particularly socioeconomic status (Conclusion 8-2).
Those of higher socioeconomic status are more likely to marry, and marriage itself may also provide economic benefits. As with different-sex couples, legally recognized same-sex relationships are less likely than others to dissolve over time. Lesbian, gay, and intersex individuals are less likely than heterosexual individuals to become parents. Less is known about the prevalence of parenthood among bisexual and transgender people. Both children and adolescents have been found to enjoy supportive relationships with lesbian and gay parents, and children of lesbian and gay parents have shown the typical development of other children (Conclusion 8-3).
Additional research is needed on relationship development in adolescence, adult family formation among SGD (especially bisexual, transgender, and intersex) people, as well as family processes and couple dynamics among older SGD individuals and families.
Experiences that SGD students have in school are important not only because negative experiences undermine personal well-being, but also because school experiences set the groundwork for educational attainment, future occupational achievement, and socioeconomic status (Conclusion 9-1).
Although most research has focused on secondary schools, similar patterns of discriminatory behavior, bullying, and victimization have been documented for sexual minority and transgender students in higher education. Because SGD youth are coming out at younger ages than in previous years, research on school experiences that extended to elementary schools and continued through higher education could help researchers gain a clearer understanding of the way these experiences affect students over their life course. Although no federal law explicitly prohibits discrimination in education based on sexual orientation, gender identity or expression, or intersex characteristics, federal courts and agencies have found that such discrimination may be covered under the federal ban on sex discrimination. State and local K–12 education policies with clear language regarding protection of SGD students from bullying and discrimination (including sexual orientation and gender identity) are associated with positive school climates and with student well-being and success (Conclusion 9- 2).
In schools with such policies, teachers are also seen as being more supportive of LGBT students and are more likely to intervene in bullying.
Several small studies of same-sex couple families have shown that they may experience homophobia expressed by teachers and that teachers may exclude those parents from activities or events (Conclusion 9-4). Schools can adopt such strategies as professional education and training for teachers, administrators, and other personnel (e.g., bus drivers, cafeteria workers) to improve school experiences and promote a positive school climate for all students (Conclusion 9-3).
Students with access to LGBTQ-related resources are more likely to believe that adults care about them and that teachers are fair.
Evidence suggests that transgender people—and possibly bisexual people—have lower incomes and higher poverty than lesbian, gay, and cisgender heterosexual people (Conclusion 10-1). Research on individual earnings suggests that, after controlling for differences in income- related characteristics, gay and bisexual men earn less than heterosexual men, while lesbian and bisexual women earn less than heterosexual men but more than heterosexual women. Lesbian women and gay men may have mitigated some of the effects of discrimination on earnings and household income through adaptive strategies in education, occupations, and family decisions, but they still face discrimination in the labor force. Poverty and economic insecurity are more common among LGBT people than among cisgender heterosexual people. Among self-identified single and coupled LGBT people, bisexual and transgender people are more at risk of poverty and lesbian and gay people are at equal risk of poverty than self-identified heterosexual cisgender people of the same sex. Some subgroups of the LGBT population are at greater risk of poverty or low-income status: unmarried people, people with children, Black people, people living in rural areas, and people over age 50.
Studies based on self-report data show that many LGBT people believe that they have been treated unequally in the workforce (Conclusion 10-2).
Many individual employers have created their own nondiscrimination policies, but these are voluntary. SGD populations have also experienced compensation and benefit discrimination in the workplace. In 2020, the Supreme Court held in Bostock v. Clayton County that discrimination based on sexual orientation or gender identity is prohibited by Title VII, the federal law that is part of the 1964 Civil Rights Act. The efficacy of this nationwide anti-discrimination protection will depend on how well federal and state agencies and courts carry out its mandate.
There is a greater risk of homelessness among LGBTQ youth than other youth, with elevated risk for LGBTQ youth of color. Adult homelessness may be particularly acute among transgender and gender-nonconforming populations. There are four main factors associated with LGBTQ homelessness: stigma, discrimination, and exclusion; mental health issues and substance use; sexual risks and vulnerability; and a lack of access to interventions and supports.
Some research finds that LGBT populations have lower homeownership rates than cisgender heterosexual people, which may point to discrimination in mortgage lending practices (Conclusion 10-3).
SGD populations may also face barriers in the markets for credit and rental housing. Nearly a quarter of respondents to the 2015 U.S. Transgender Survey said they had experienced housing discrimination in the past year. There is also evidence of differential and discriminatory treatment among men in same-sex couples compared with women in same-sex couples.
More research is needed to assess the economic well-being of transgender people, non- binary people, and people with intersex traits. There is also much more to be understood about how certain economic conditions affect SGD populations—particularly for groups identified as having bigger economic challenges, such as people in rural areas, older SGD people, and SGD people of color.
Physical and mental health
The physical and mental health of SGD populations is substantially affected by external influences that include discrimination, stigma, prejudice, and other social, political, and economic determinants of health. In addition to health disparities related to sexual orientation, gender identity, and intersex status, many SGD people also experience health disparities related to intersecting aspects of identity that include but are not limited to race and ethnicity (Conclusion 11-1).
Lesbian and bisexual women have higher odds of risk factors for cardiovascular disease, such as hypertension and diabetes, and they also have more risk factors for breast cancer than heterosexual women. Transgender adults may have elevated rates of cardiovascular disease and myocardial infarction than their cisgender counterparts. LGBT people and people with intersex traits are at risk of violence from family members, peers, intimate partners, and strangers as a result of their sexual orientation, gender identity, or intersex status. Some of the highest risks of violence affect bisexual women and transgender people, particularly transgender women of color. Black transgender women are also disproportionately affected by HIV, as are cisgender gay and bisexual men and other men who have sex with men.
Mental health disparities in SGD populations include heightened anxiety and depressive symptoms and greater suicidality among LGBT people in comparison with heterosexual or cisgender individuals. Substance use and behavioral health disparities include greater use of tobacco, alcohol, and other drugs among LGBT people than among heterosexual or cisgender individuals. Sexual minority individuals are also less likely than their heterosexual counterparts to report healthy sleep, and similar disparities may exist for transgender people.
Because both clinical and population research studies rarely include measures of sexual orientation, gender identity, and intersex status, the full scope and magnitude of physical and mental health disparities and their differential effects across and within SGD populations is not known (Conclusion 11-2).
There is a particular lack of longitudinal research, as well as a relative dearth of data on intersections with other aspects of identity such as race, ethnicity, age, and disability.
The disparities affecting SGD populations are driven by experiences of minority stress, which include both structural and interpersonal stigma, prejudice, discrimination, violence, and trauma (Conclusion 11-3). Another important concept in relation to minority stress is resilience, which is the ability to maintain normal physical and psychological functioning when stress and trauma occur. More research is needed to elucidate the origins, pathways, and health consequences of minority stress and factors that support resilience among SGD populations.
Evidence-based interventions are needed to prevent and address health inequities (Conclusion 11-4).
These interventions need to address the root causes and multilevel factors driving SGD health disparities. Leveraging resilience, including building on strategies SGD people have used to resist societal oppression, is an important part of optimizing SGD health and well-being.
Coverage, Access and Utilisation of Health Care
Access to comprehensive, affirming, and high-quality health care services is a human right for all people. Laws that guarantee access to health care services, health insurance coverage, and public health programs for all, regardless of sexual orientation, gender identity, and intersex status, are critical to the health and well-being of SGD people. Similarly, laws and policies that provide affordable, comprehensive health insurance coverage could combat health risks, such as uninsurance and poverty, among SGD populations.
It is important to provide culturally responsive and clinically appropriate care for SGD populations. Health services and procedures that are particularly important for the health and well-being of SGD populations include but are not limited to pre- and post-exposure prophylaxis for HIV; HIV treatment and care; abortion, fertility, and other reproductive health services; affirming mental and behavioral health care services; and gender-affirming care for transgender people. SGD people also need access to timely and anatomically appropriate preventive screenings (Conclusion 12-1).
Gender-affirming care for transgender, non-binary and other gender diverse people is an essential intervention to improve health and well-being (Conclusion 12-2).
Provision of this care needs to be individualized and conducted in partnership between patients and their providers. Insurance coverage of gender-affirming services and procedures by public and private payers is necessary to facilitate access to these services and to avoid discrimination on the basis of sex and gender identity.
Conversion therapy to change sexual orientation or gender identity can cause significant trauma (Conclusion 12-3).
Elective genital surgeries on children with intersex traits who cannot participate in consent can be similarly detrimental to health and well-being.
The research recommendations are
Though trends in SGD population data collection have shifted, the data that exist and the research methodologies behind current study measures are not sufficient to capture and convey the richness of SGD communities or to underscore the varied effects that unique and intersecting identities have on health and well-being outcomes for SGD people. The 2011 report of the Institute of Medicine on the health of LGBT populations noted that SGD populations are often considered a single monolithic group, which obscures important differences among individuals and communities. This committee emphasizes an urgent need for robust scientific evidence that includes not just lesbian, gay, bisexual, and transgender people, but also intersex people, people with same-sex or same-gender attractions or behaviors, and people who identify as asexual, Two-Spirit, queer, or other terms under the SGD umbrella.
In the wake of social change and ongoing legal developments regarding protections for SGD people in employment, health care, military service, family formation, and other key areas of life, it is increasingly important to understand how the provision or the denial of access to opportunities and resources affects SGD people over the entire life course. A varied, comprehensive, and inclusive research infrastructure for SGD populations is essential in understanding the unique and shared challenges these individuals and communities face and for guiding actions to improve their well-being across domains, including social justice and legal equality, health and health care, employment, education, and housing. Effectively addressing disparities related to sexual orientation, gender identity, and intersex status will require collaborative and coordinated efforts among federal, state, and private stakeholders. In addition, it will be important to involve SGD communities themselves, including SGD people of color, in all aspects of the research process. Meaningful community participation is a critical way that SGD population research can retain accountability and accurately reflect the lives and experiences of the communities that are under study. In all research activities, SGD communities should be treated as partners rather than solely as research subjects, and all data should be collected and analyzed in ways that ensure respondent privacy and confidentiality and provide robust protections from discrimination.
The committee’s recommendations aim to identify opportunities to advance understanding of how individuals experience sexuality and gender and how sexual orientation, gender identity, and intersex status affect SGD people over the life course.
Our recommendations are in five categories:
(1) population data;
(2) measurement challenges related to understanding SGD populations;
(3) critical data gaps;
(4) improvement of the research community’s ability to use these data; and
(5) application of data to the development of high-quality, evidence-based interventions and programs.
In each category, the committee makes efforts to identify specific actors that are best positioned to respond to particular aspects of the research landscape. The committee has concluded that investing in research infrastructure and in a robust and comprehensive program of research in the ways described below will support the development of stronger, evidence-based policies and practices in the areas addressed in this report.
In order to make valid claims about the status of SGD populations in the United States, researchers, policy makers, and practitioners need accurate, consistent, and representative population-level data that describe SGD populations in all their complexity.
R 1: Entities throughout the federal statistical system; other federal agencies; state, local, and tribal departments and agencies; private entities; and other relevant stakeholders should consider adding measures of sexual orientation, gender identity, and intersex status to all data collection efforts and instruments, such as population-based surveys, administrative records, clinical records, and forms used to collect demographic data.
In response to Recommendation 1, the Office of Management and Budget (OMB) should reconvene the Federal Interagency Working Group on Improving Measurement of Sexual Orientation and Gender Identity (SOGI) in Federal Surveys and charge it with developing government-wide standards for the collection of data on sexual orientation, gender identity, and intersex status. The establishment of measurement standards could bolster high-priority data collection activities throughout the relevant entities.
Because of the complicated ways that race, class, sex, gender identity, sexual orientation, and other factors interact to create people’s experiences, current measures do not always sufficiently reflect the lived experiences of these populations.
R 2: Federal statistical agencies, state, local, and tribal departments and agencies, private entities, and other relevant stakeholders should fund and conduct methodological research to develop, improve, and expand measures that capture the full range of sexual and gender diversity in the population—including but not limited to intersex status and emerging sexual and gender identities, sexual behaviors, and intersecting identities—as well as determinants of well-being for sexual and gender diverse populations.
The routine inclusion of sexual orientation, gender identity, and intersex status questions on federally supported surveys and in other research can also advance the generation and use of measures that help researchers understand how factors such as stigma and disclosure affect the health and well-being of SGD populations across the life course.
Critical Data Gaps
When focusing on underrepresented groups, it is sometimes necessary to employ alternative methods that capture adequate samples of the population in question for effective study. Some data gaps could be addressed through observational studies of specific populations, while others might require experimental studies, qualitative explorations of specific topics, or other methods.
R 3: Public and private funders should support, and researchers should conduct, studies using a variety of methods and sampling techniques--driven by the questions under study--in order to examine family and other social relationships, community, health, education, economic, and legal issues that will enhance understanding of sexual and gender diverse populations.
Data needs of this kind are particularly important for the study of small groups, such as transgender women of color, Native American Two-Spirit people, and people with intersex traits.
Once comprehensive, accurate data are collected, it is critical that researchers have the ability to access these data to address emerging research questions. By improving the research community’s ability to access, link, and use existing data, stakeholders could substantially advance the relevance and impact of research.
R 4: The U.S. Office of Management and Budget should convene federal, state, and private funders, as well as other relevant stakeholders, to address significant problems in linking data from different datasets to facilitate research on the health status and well-being of sexual and gender diverse people. These stakeholders will differ by content area but could include researchers, legal advocacy groups, research institutions and centers, think tanks, policy tracking groups, health, and surveillance organizations.
The goal of this recommendation is to allow data that have been housed within specific agencies or industries to be linked in ways that provide the research community a more complete picture of the prevalence, distribution, and lived experiences of SGD populations.
Evidence-based programming and interventions
The ultimate goal of collecting more accurate and relevant data should be to enhance understanding of the mediating factors that can highlight the positive differences and close the disparities that exist between SGD and heterosexual or cisgender populations. Comprehensive and accurate population-level data can play a critical role in the development, implementation, and evaluation of programs, services, and interventions that support the health and well-being of SGD populations. The data deficits described throughout this report have led to a relative dearth of programming to address the specific needs of these populations, as well as an absence of evidence-based processes to evaluate the programs.
R 5: Public and private research funders, together with federal statistical agencies, should prioritize research into the development, implementation, and evaluation of evidence-based services, programs, and interventions that promote the well-being of SGD populations.
Placing scientific evidence at the forefront of program planning will allow researchers, policymakers, and public and private stakeholders to develop services and interventions that will directly benefit SGD communities.
The increase in prevalence and visibility of SGD populations illuminates the need for greater understanding of the ways in which current laws, systems, and programs affect their well- being. Individuals who identify as lesbian, gay, bisexual, asexual, transgender, non-binary, queer, or intersex, as well as those who express same-sex or -gender attractions or behaviors, will have experiences across their life course that differ from those of cisgender and heterosexual individuals. Characteristics such as age, race and ethnicity, and geographic location intersect to play a distinct role in the challenges and opportunities SGD people face. This report underscores the need for researchers to seek to understand disparities and advance equity both within and across SGD populations