Mike C. Parent1 and Teresa Gobble2
1Department of Psychological Sciences, Texas Tech University, Lubbock, TX, USA
2Department of Educational Psychology, University of Texas at Austin, Austin, TX, USA
Sexual orientation and gender minority health has been a topic of interest for health researchers for decades. Sexual orientation minorities are persons whose sexual behaviors or attractions are not exclusively heterosexual. The term LGB (meaning lesbian, gay, and bisexual; the order of letters may vary) has often been used to describe such persons, but there is increasing recognition that this term does not capture a full range of potential manifestations of human sexual expression. For example, some individuals may engage in sexual behaviors with individuals of the same gender exclusively, or with both men and women, yet identify as heterosexual. Sexual orientation minority is used as a broad term, to include persons with non‐heterosexual behaviors, attractions, and identities. However, it is important to note that differences exist within this group, including differences in health disparities. Gender minorities are persons for whom a gender assigned at birth does not align with a felt sense of gender identity. A commonly used term for individuals in this group is transgender (in contrast to cisgender, or persons for whom gender assigned at birth and felt sense of gender identity match), though the more broad term of gender minority may also include other gender identities that persons may identify as, including non‐binary gender identities. Again, it is important to note that differences exist within the gender minorities group (e.g., between persons who are transitioning from female to male or from male to female and also among persons who desire different degrees of transition). Further, although sexual orientation minority persons and gender minority persons share many of the same concerns, they also have many differences between the groups that are relevant to health (Donatone & Rachlin, 2013; Moradi, Mohr, Worthington, & Fassinger, 2009).
Research on health disparities among sexual orientation and gender minority persons, until relatively recently, has tended to focus on non‐heterosexual and non‐cisgender identities as themselves reflective of pathology. That is, the locus of health disparities was often placed within sexual orientation and gender minority individuals themselves. In recent decades, awareness has shifted away from viewing sexual orientation and gender minority persons as intrinsically pathologized to understanding the social context of living as a sexual orientation or gender minority individual. In light of this, research has increasingly turned toward understanding person–environment interactions and the ways in which one's circumstances may exacerbate typical stressors or present unique stressors for sexual orientation and gender minority persons. The leading theory of the influence of social structures on the well‐being of sexual orientation and gender minority persons is the minority stress model (Meyer, 1995, 2003).
The minority stress model describes the ways in which psychological distress is perpetrated by unique, chronic, and socially based stressors for sexual orientation and gender minority persons. It was initially developed to describe how heterosexism, or behavior that grants preferential treatment to heterosexual people, reinforces the idea that heterosexuality is preferred or more highly valued over minority sexual orientations. Heterosexism is also associated with homophobia or biphobia, which includes a variety of negative attitudes (e.g., anger, fear, discomfort, resentment, or disgust) that an individual may have toward sexual minority persons. Heterosexism or homo/biphobia may include behaviors such as discrimination against sexual orientation minority persons, for example, in employment or housing. Indeed, in much of the world and including in many parts of the United States, sexual orientation and gender minority persons may face hiring or promotion discrimination, in some cases without legal recourse for such discrimination. Heterosexism may also include experiences of violence inflicted upon an individual due to actual or perceived status as a sexual orientation or gender minority. Such experiences of violence can begin early, such as in school bullying, and persist into adulthood, such as in experiences of workplace harassment. Heterosexism and homo/biphobia may also be experienced at a social level. For example, laws may be passed that uniquely impact the well‐being of sexual and gender minority persons. Experiences of violence may also take on a range of manifestations but may include experiences such as being assaulted. Consistent exposure to homophobic or biphobic messages can lead to internalization of those messages, meaning that sexual orientation minority persons may feel similar feelings of fear, anger, discomfort, resentment, or disgust for themselves and other sexual orientation or gender minority persons. Although initially developed to understand the experiences of sexual orientation minorities, the model was quickly applied to gender minority populations and proved useful in research on the health of gender minorities (Bockting, Miner, Swinburne Romine, Hamilton, & Coleman, 2013).
The minority stress model conceptualizes these and related experiences of stress as aspects of minority stress. Stress in general is a chronic engagement of taxing coping mechanisms to the extent that the individual does not have the capacity to endure further, leading to mental health and medical concerns. Social stress in particular describes the effect that social environmental events and conditions, above and beyond personal events, can have a deleterious effect on individuals. The minority stress model further emphasizes that the specific stressors faced by sexual orientation and gender minority persons are unique, chronic, and socially based. The stresses are unique, because they are based upon actual or perceived sexual orientation identity. That is, they are not experienced by persons who are, or who are perceived to be, heterosexual or cisgender. The stressors are chronic because they are not reflective of merely random and isolated events, but rather reflect a pervasive negative social attitude that promotes their reoccurrence across time, location, and context. Relatedly, the stressors are socially based because they are based in dominant social views within a society, which are socially constructed and maintained. It is important to note that the minority stress model emphasizes ways in which multiple minority identities can serve as both protective and risk factors for behaviors and experiences related to health disparities. For example, sources of stress and health concerns may differ significantly between gay men and lesbian women, or for sexual orientation and gender minority people of color compared with White sexual orientation and gender minority individuals. Indeed, the minority stress model has been applied several times to understand the experiences of ethnically and racially diverse populations since its conception in 1995 (Meyer, 1995).
The minority stress framework has been instrumental in helping to understand health disparities within their context. Numerous health disparities exist for sexual orientation and gender minority populations. Such disparities are known to begin early, being demonstrated even among adolescents who identify as sexual orientation and gender minorities. Sexual orientation and gender minority youth report higher levels of emotional distress and depressive symptoms than their heterosexual and cisgender counterparts. These symptoms are also associated with elevated levels of suicidal ideation and suicide attempts, as well as self‐harm behaviors. Further, these disparities have been replicated across multiple countries, across racial/ethnic groups, and across genders. Transgender youth appear to be at specific and elevated risk for self‐harm (McConnell, Birkett, & Mustanski, 2015; Peterson, Matthews, Copps‐Smith, & Conard, 2017). Among adults, these health disparities persist and are linked to other negative outcomes for sexual orientation and gender minority individuals.
In minority stress theory, stresses are differentiated based on whether they arise from outside or within an individual. Outside stresses include circumstances in the environment. Such circumstances speak to the intersectional interactions of multiple minority statuses in considering minority stress. One clear example of circumstances in the environment is poverty. Poverty would impact factors such as access to basic needs such as healthcare, access to food (i.e., in a food desert), access to transportation, or safe housing. Unfortunately, limited empirical research has been conducted on the intersection of sexual orientation and gender minority identity and poverty, from within the minority stress framework. Nevertheless, sexual orientation and gender minority persons, especially adolescents, face levels of poverty and homelessness far higher than their heterosexual and cisgender peers (Keuroghlian, Shtasel, & Bassuk, 2014). Other circumstances in the environment may also depend on the specific circumstances of the individuals involved; for example, in considering a same‐sex couple who wish to adopt, specific state laws regarding same‐sex adoption may be an especially relevant circumstance in the environment. Such laws may ebb and flow in their relevance to individuals; for example, if a same‐sex couple has adopted a child in a state in which adoption laws were being called into question, they may worry about the status of their legal rights as adoptive parents. Similarly, such stresses may arise of sexual orientation or gender minority persons when the legality of same‐sex marriage is called into question. In prior research with sexual orientation minority persons, in states in which constitutional amendments to define marriage as between a man and a woman were on the ballot, sexual orientation minority persons reported higher exposure to negative media, higher negative affect, and higher levels of distress compared with persons in states where such laws were not on the ballot (Fingerhut, Riggle, & Rostosky, 2011). Myriad other circumstances in the environment may ultimately impact the well‐being of sexual orientation and gender minority persons, including persons with multiple minority statuses or other relevant personal characteristics.
Circumstances in the environment are inextricably tied to minority statuses. There are innumerable personal characteristics that a minority of persons may possess, but do not represent socially stigmatized identities (e.g., having green eyes or completely attached earlobes). Minority stress theory focuses on stresses that arise due to social influence, and thus categories of stigmatized identities are socially defined and may intersect. For example, recent research has explored ways in which sexual orientation and gender or race may intersect. Such investigations have indicated that there may be some pervasive mental health issues that cut across different groups when faced with minority stress (e.g., psychological distress or depression, substance use) but also some specific concerns that may be especially relevant to specific groups. For example, obesity, obesogenic behaviors, and resultant health conditions (e.g., cardiovascular disease) appear to be a specific concern relevant to lesbian and bisexual women, use of club drugs or anabolic steroids may be relevant to gay and bisexual men, and risk behaviors for HIV or other sexually transmitted infections (STIs) may be relevant to men who have sex with men. Thus, specific minority identities, and the interactions among identities, may impact both which circumstances in the environment are relevant and potential outcomes of minority stress processes.
Because minority stress theory focuses on socially defined identities, a concept similar to minority status is minority identity and its characteristics. Individuals may differ in the extent to which their identities align with the categories into which researchers or others may desire to put them. For example, the term “men who have sex with men” was coined, in part, to capture the experiences of men who have sex with men but who may not identify as gay or bisexual. Minority identity itself is closely tied to the characteristics of minority identity, such as prominence of that identity or integration of that identity into everyday life. Such processes have implications for the health of sexual orientation and gender minority populations. For example, among men who have sex with men, the desire to be perceived by others as heterosexual has been associated with decreased likelihood of asking for an HIV test when visiting a doctor (Parent, Torrey, & Michaels, 2012). Other investigations have linked integration of sexual minority identity with lower internalized heterosexism and lower psychological distress. At the same time, outness has also been associated with more experiences of heterosexism, which may exacerbate minority stress processes. In addition, outness has not always clearly been linked to health variables, with some studies finding no relationship between outness and instances of domestic violence among lesbian and bisexual women (Balsam & Szymanski, 2005; Velez, Moradi, & Brewster, 2013). Thus, the relationships among outness or other variables related to identity salience are not straightforward. Indeed, it is possible that in many circumstances, not being out may have some costs to personal well‐being but may have substantial benefits as well, for example, if coming out meant a risk for being physically assaulted by family members or kicked out of one's home.
Minority identity is also associated with stress processes. In minority stress theory, these processes are conceptualized as distal (arising directly from the behaviors of others, such as harassment or discrimination) or proximal (arising directly from within oneself, such as expectations of rejection or internalized homophobia). These proximal and distal stressors have been reliably associated with myriad health concerns for sexual orientation and gender minority persons (Meyer, 2003).
Finally, the minority stress model posits that coping and social support may moderate health outcomes for sexual orientation and gender minority persons. Notably, however, research has not always supported the posited roles of these variables. Some work has supported links between aspects of coping, such as spiritual coping, as a buffer between minority stressors and mental health outcome variables, such as substance use. Other work has demonstrated that emotional regulation mediates the relationship between minority status and depression and anxiety among sexual orientation minority adolescents (but also that sexual orientation minority adolescents demonstrate lower levels of emotional regulation than their heterosexual peers). However, other recent work has called into question the utility of concepts such as “coping” or “resilience” among minority persons who may face social or institutional discrimination, insomuch as those terms may refer to returns to baselines of emotional or cognitive content following experiences of minority stress. By conceptualizing such returns to baseline following experiences of harassment, discrimination, or violence, the impetus for change is placed on an individual experiencing such harassment, discrimination, or violence to deal with the implications of those experiences, rather than emphasizing the need for change in the social or institutional power structures that allow or even encourage those experiences. Experiences of posttraumatic growth, transformative coping, or personal growth following minority stress may be fruitful areas to explore and may lead to a more clear understanding of the relationship between minority stresses and adaptive responses (Meyer, 2015). Regarding social support, a number of studies have supported social support as a buffer of the relationship between experiences of minority stress and negative outcomes. At the same time, involvement with the LGBT community is not always synonymous with social support and has indeed, in some cases, been linked with negative health outcomes for sexual orientation and gender minority persons. For example, more often attending clubs and parties has been linked to increased body image concerns and substance use among gay and bisexual men (Mattison, Ross, Wolfson, & Franklin, 2001).
Experiences of bullying appear to be ubiquitous among sexual orientation and gender minority youth, with nearly all reporting some level of bullying or harassment. More severe forms of bullying including persistent bullying, threats of violence, or actual violence, are also common. Some of these instances of violence can result in physical harm, and sexual orientation and gender minority youth report that often these instances are either not reported to school officials or law enforcement, and if they are, that nothing is done about the behavior. Both harassment and violence are known to persist into adulthood, with sexual orientation and gender minority youth reporting workplace harassment and discrimination in housing or employment. Some disparities appear to be particularly relevant for specific groups within the sexual and gender minority umbrella. In particular, transgender persons may be especially vulnerable to experiences of violence (Berlan, Corliss, Field, Goodman, & Austin, 2010; Kim & Leventhal, 2011). As well, sexual orientation and gender minority persons who are sex workers are also at elevated risk for exposure to violence, again especially including transgender persons and especially male‐to‐female transgender persons (Nemoto, Bödeker, & Iwamoto, 2011).
Use of substances is also elevated among sexual orientation and gender minority persons, and this finding has been replicated in several countries. Rates of use of all substances are elevated among gender and sexual orientation minority adolescents, though rates of hard drugs and club drugs are markedly elevated, and rates of smoking tobacco are also markedly higher among sexual orientation and gender minority adolescents compared with their cisgender counterparts. This elevation is occurring concurrently with marked drops in smoking behaviors in the general population. Regarding substance use in general, among adolescents, girls appear to have somewhat higher risk for substances than boys, and bisexual adolescents appear to be at somewhat greater risk than gay/lesbian adolescents. Gay and bisexual adolescent boys also appear to be at specific risk for use of anabolic–androgenic steroids. Among adults, rates of substance use remain elevated, including use of tobacco, alcohol, steroids, recreational drugs, and club drugs. Use of such substances may be related to attempts to cope with stresses such as discrimination and violence but also potentially linked to aspects of community engagement. For example, use of illicit substances is common in clubs and circuit parties (large dance parties). As well, use of steroids may facilitate development of a highly muscular body, which facilitates access to a larger number of potential sexual partners (and, potentially, increases risk for exposure to STIs). Among female‐to‐male transgender persons, use of steroids may also facilitate development of a highly masculinized physique, potentially increasing “passing” as male and decreasing risks associated with being perceived as transgender (Guss, Williams, Reisner, Austin, & Katz‐Wise, 2017; Halkitis, Moeller, & DeRaleau, 2008; Lee, Matthews, McCullen, & Melvin, 2014; Marshal et al., 2008).
Sexual risk behaviors are also relevant to sexual orientation and gender minority individuals. Most research on sexual health behaviors has focused on boys and men and potential contraction or spread of STIs. Within this domain, health disparities have been found to emerge early. Adolescent gay and bisexual boys report greater risky sexual behaviors than their heterosexual counterparts, with some studies finding bisexual adolescent boys to be at particular risk. These risks persist into adulthood for gay and bisexual men and appear to be exacerbated by use of substances and engaging in sex while intoxicated. Most research in this domain focuses on risk for HIV infection, and HIV rates remain elevated among gay and bisexual men. Although use of pre‐exposure prophylaxis (PrEP) (i.e., medication taken to drastically lower the risk of HIV infection should exposure occur) is increasingly common among men who have sex with men, use of PrEP does not protect individuals from other STIs, and rates of STIs among men who have sex with men on PrEP remain elevated (Rosario et al., 2013; Scott & Klausner, 2016).
Obesity is also a concern among sexual orientation and gender minority persons. This disparity appears to be most prevalent among lesbian and bisexual women and appears to arise relatively early in life as adolescent girls who identify as lesbian and bisexual report higher rates of obesity compared with heterosexual peers. Obesity, and engagement in obesogenic behaviors, may interact with other stressors such as unemployment or underemployment, further complicating health status. However, obesity is not markedly elevated among gay and bisexual men or among transgender persons. The precise cause of specific health disparities among sexual orientation minority women is not known. Indeed, predictors of overweight status and obesity among sexual orientation minority women and heterosexual women are similar (Bowen, Balsam, & Ender, 2008; Yancey, Cochran, Corliss, & Mays, 2003).
Gender minority persons may also face specific health concerns. Some, though not all, transgender persons may seek to undertake aspects of gender transition. Gender transition may involve numerous surgical and nonsurgical procedures. Gender transition processes may be social and legal changes, such as legal adoption of a new name; nonmedical alterations of physical appearance, such as changes in hair style, body hair management, or clothing choices; medical and not surgical, such as use of exogenous hormones; and medical and surgical. Medical and surgical changes also take on a range of manifestations, including breast reductions or breast implants, alterations to facial bone structure, and genital reconfiguration. Importantly, not all transgender persons wish to undergo all aspects of gender transition. Research supports that completing desired aspects of gender transition is associated with improvements in mental health and well‐being. However, numerous barriers exist to transition processes: primarily, the cost of the procedures and access to competent care providers. Due to these barriers, some gender minority individuals may seek to undergo transition processes outside of professional medical supervision. Such processes may include unsupervised use of illicit hormones or injection with silicone that may result in infection (Murad et al., 2010; Sanchez, Sanchez, & Danoff, 2009; Wilson, Rapues, Jin, & Raymond, 2014).
Sexual orientation and gender minority persons face a range of health disparities. The study of health disparities within this population has moved beyond views of sexual orientation and gender minority status as intrinsically pathological toward a contextual understanding of social and cultural origins of health disparities within this population. To this end, the minority stress model has been instrumental in framing our understanding of unique, chronic, and socially based stresses that may contribute to health disparities among sexual orientation and gender minority populations. Still, many disparities exist across health behaviors including substance use, obesity, and sexual risk behaviors, and many other disparities affect specific groups within the umbrella of sexual orientation and gender minority, and many opportunities exist for system‐ and individual‐level intervention and future research.
It is imperative to understand how public policy related to health impacts the well‐being of sexual orientation and gender minority populations. Within minority stress theory, such a focus would aim to reduce the institutional or structural supports for distal causes of health disparities for sexual orientation and gender minority individuals. For example, enactment of anti‐same‐sex marriage laws in the United States (prior to the Supreme Court ruling in favor of marriage quality across the country) has been associated with negative impacts on the mental health and well‐being of sexual minority persons (Riggle, Rostosky, & Horn, 2010). Similar research has explored how anti‐bullying legislation impacts experiences of bullying among sexual minority youth (Hatzenbuehler, Schwab‐Reese, Ranapurwala, Hertz, & Ramirez, 2015), though research indicates that specific implementations of such laws by teachers and in schools may affect their impact (Van Wormer & McKinney, 2003). It is important to explore ways in which public policy can be used to reduce health disparities, including ways in which individuals who work in the front lines of implementing such policy may be empowered to better advocate for sexual orientation and gender minority persons.
The minority stress model also emphasizes the importance of examining proximal, or within‐person, stressors related to health disparities. Such stressors may include expectations of rejection, internalized stigma, and concealment of sexual orientation (Meyer, 1995). Despite the large body of research on minority stress, very limited empirical research on the treatment of stress among sexual orientation and gender minority populations has been undertaken. Although some treatment guidelines for sexual orientation and gender minority populations have been developed (Pachankis, Hatzenbuehler, Rendina, Safren, & Parsons, 2015), there have been very few trials of interventions that specifically address constellations of minority stress. Studies that have been conducted have tended to be relatively low quality (e.g., including no‐treatment wait list groups as controls, having small sample sizes, and having relatively homogeneous samples). It is important to extend extant work on minority stress beyond theoretical investigations of relations among constructs, which have generally been well established in the literature, and integrate these constructs with empirically supported interventions to provide quality, patient‐centered care to sexual orientation and gender minority individuals.
Dr. Mike C. Parent earned his PhD in Counseling Psychology from the University of Florida in 2013. He is now an assistant professor in counseling psychology and counselor education at the University of Texas at Austin. His program of research focuses on gender, sexuality, and behavioral health, as well as professional issues in psychology. He is the author of more than 40 peer‐reviewed publications and has received numerous awards for his research and mentorship of students.
Teresa Gobble completed her BS in Psychology at the University of Central Florida. She is a doctoral student in the Counseling Psychology Program at the University of Texas–Austin. Her research focus includes examining risk factors for suicide in sexual and gender minority populations.