Healthcare and the LGBT community

According to Katherine A. O'Hanlan, lesbians "have the richest concentration of risk factors for breast cancer [of any] subset of women in the world." Additionally, many lesbians do not get routine mammograms, do breast self-exams, or have clinical breast exams.[44]

There are also policy documents from both the UK and US Government that stated there could be higher rates of breast cancer among lesbian and bisexual women despite insufficient evidence. In a 2009 report by the UK All Party Parliamentary Group on Cancer's Inquiry into Inequalities in Cancer, it was stated that "Lesbians may have a higher risk of breast cancer.[45]

Depression and anxiety are thought to affect lesbians at a higher rate than in the general population, for similar reasons.[44]

Domestic violence is reported to occur in about 11 percent of lesbian homes. While this rate is about half the rate of 20 percent reported by heterosexual women, lesbians often have fewer resources available for shelter and counselling.[44]

Lesbian and bisexual women are more likely to be overweight or obese.[46] Research shows that on average lesbians have a higher body mass index than heterosexual women.[44]

Lesbians often have high rates of substance use, including recreational drugs, alcohol and tobacco. Studies have shown that lesbian and bisexual women are 200% more likely to smoke tobacco than other women.[3]

Lesbian, bisexual, and queer women have many of the same reproductive and sexual health needs as heterosexual women. However, queer women face disparities when it comes to reproductive and sexual health. This may be in part due to lower socioeconomic status and lower rates of insurance, particularly for bisexual individuals. Additionally, sex education (in the U.S.) is largely heteronormative and may not provide information relevant for LGBTQ individuals (see LGBT sex education). Health care providers may not have adequate education regarding sexual orientation, so may not be offering their queer patients appropriate and needed services. In one survey of Ob/Gyn residents, 50% reported feeling unprepared to care for lesbian or bisexual patients and 92% reported a desire for more education on how to provide healthcare to LGBTQ patients.[47] Queer individuals may also face discrimination and bias in the health care setting (and in society more broadly), leading to lower quality health care or deterring individuals from seeking care at all. Given these factors, queer women have specific needs around reproductive and sexual health.

A lack of screening for cervical cancer is among the most obvious and most preventable risk factor for lesbians, bisexual, and queer women in the development of invasive late-stage cervical cancer.[48] Lesbian, bisexual, and queer women are less likely to receive appropriate screening for cervical cancer than heterosexual women,[49] which leads to later detection of cervical cancer.

Lesbian, bisexual, and queer women need access to contraception, both to prevent pregnancy and for a variety of non-contraceptive benefits.[50] Estimates suggest that 3.8 million cisgender lesbian, bisexual and queer women may be using contraceptives in the United States.[51] However, lesbian, bisexual, and queer women are less likely to use contraceptive methods, even when they are engaging in sex that could result in pregnancy.[52][53]

Lesbian, bisexual, queer, and women who identify with a sexual minority identity seek abortion care. The Guttmacher Institute estimates that approximately 5% of abortion patients in the United States identify as lesbian, bisexual, or queer.[54] Studies relying on measures of self-reported abortions suggest that abortion is common across queer women's lives. Bisexual adolescents are more likely to terminate a pregnancy than their heterosexual counterparts, a difference that persists into adulthood.[55][56] Across their lifetimes, women who identify with a sexual minority identity were more likely than heterosexual women to experience an unwanted pregnancy or terminate a pregnancy.[57]

There have been several studies that discuss healthcare experiences of pregnant lesbian women. Larsson and Dykes conducted a study in 2009 about lesbian mothers in Sweden. The participants wanted their healthcare providers to confirm and recognize both parents, not just the biological mother. They also wanted their healthcare providers to ask questions about their "life styles" to demonstrate their openness about sexuality. Most of the women in the study commented that they had good experiences with healthcare. However, birth education tended to focus on mother and father dynamics. The forms that were also used tended to be heterosexist (see Heterosexism), only allowing for mother and father identities.[58] To account for these differences, Singer created a document about how to improve the prenatal care of lesbian women in the United States. She found that curiosity about a patient's sexuality can take over an appointment, sometimes placing the patient into a situation where they end up educating the provider. To be inclusive, Singer recommended that healthcare providers should be more inclusive in their opening discussions by saying "So tell me the story of how you became pregnant". Healthcare providers should, according to Singer, use inclusive language that can be used for all types of patients. Healthcare providers were also not aware of how much reproductive health care cost for lesbian couples and they should openly recognize this issue with their lesbian patients.[59] Pharris, Bucchio, Dotson, and Davidson also provided suggestions on how to support lesbian couples during pregnancy. Childbirth educators should avoid assuming that parents are heterosexual or straight couples. They recommend using neutral language when discussing parent preferences. Forms, applications, and other distributed information should be inclusive of lesbian parents. They suggest using terms such as "non-biological mother, co-parent, social mother, other mother and second female parent" are good examples. Asking parents was also a suggested way to figure out what term should be used. Parents may also need help navigating legal systems in the area.[60]

Midwife(wives) and Doula(s) have provided care for lesbian women and couples who are pregnant. In an article in Rewire News, there was a discussion of how midwives and doulas are attempting to improve the overall care of lesbian couples by having specific training based on providing care to these couples as well as having inclusive processes.[61] In a study of lesbian and bisexual women in Canada about using healthcare services, researchers Ross, Steele, and Epstein found that the women in the study loved working with doulas and midwives. Midwives were considered helpful advocates with other healthcare providers that they encountered.[62] Midwives also discuss their perspectives. Röndahl, Bruhner, and Lindhe conducted a study in 2009 about lesbian pregnancy experiences of women in Norway. They found that midwives were the ones who were responsible for creating a space to discuss sexuality. However, midwives in the study felt that they were inadequate about having the communication tools to create this space. Additionally, the researchers found that lesbian couples were seen as different compared to straight couples. The partners have a sense of both love and friendship. Their differences were also seen when trying to find the roles for the lesbian co-mothers (non-biological mothers), as the language and questions asked did not fit their roles. Finally, the researchers found that there needed to be a balance of asking questions and being overly assertive. Midwives could ask questions about the patients' sexuality, but asking too many questions caused discomfort in the patients.[63]

Gay men are more likely to internalize their mental health issues than others in the LGBT community.[64] Studies by Cochran et al. (2003) and Mills et al. (2004), among others, suggest that depression and anxiety appear to affect gay men at a higher rate than in the general population.[65][66]

According to GLMA, "the problem may be more severe for those men who remain in the closet or who do not have adequate social supports. Adolescents and young adults may be at particularly high risk of suicide because of these concerns. Culturally sensitive mental health services targeted specifically at gay men may be more effective in the prevention, early detection, and treatment of these conditions."[65] Researchers at the University of California at San Francisco found that major risk factors for depression in gay and bisexual men included a recent experience of anti-gay violence or threats, not identifying as gay, or feeling alienated from the gay community.[66]

Results from a survey by Stonewall Scotland published in early 2012 found that 3% of gay men had attempted suicide within the past year.[67] Despite progress in LGBT rights globally, gay men continue to experience high rates of loneliness and depression after coming out.[68] Suicide rates among men in same-sex relationships fell significantly in Sweden and Denmark after the legalization of same-sex marriage. Researcher Annette Erlangsen suggested that along with other gay rights legislation, same-sex marriage may have reduced feelings of social stigmatization among some homosexual people and that "being married is protective against suicide".[69]

Men who have sex with men are more likely to acquire HIV in the modern West, Japan,[70] India,[71] and Taiwan,[72][73] as well as other developed countries than among the general population,[74] in the United States, 60 times more likely than the general population.[75] An estimated 62% of adult and adolescent American males living with HIV/AIDS got it through sexual contact with other men.[76] HIV-related stigma is consistently and significantly associated with poorer physical and mental health in PLHIV (people living with HIV).[77] The first name proposed for what is now known as AIDS was gay-related immune deficiency, or GRID.[78] This name was proposed in 1982, after public health scientists noticed clusters of Kaposi's sarcoma and Pneumocystis pneumonia among gay males in California and New York City.[79] There is an unspoken fear of getting HIV tested in gay men. This can be because of fear of sexual rejection, not knowing where of how to get tested, and fear of friends/family distancing.[80]

The US Center for Disease Control recommends annual screening for syphilis, gonorrhea, HIV and chlamydia for men who have sex with men.[3]

Black gay men have a greater risk of HIV and other STIs than white gay men.[81] However, their reported rates of unprotected anal intercourse are similar to those of men who have sex with men (MSM) of other ethnicities.[82]

Men who have sex with men are at an increased risk for hepatitis, and immunization for Hepatitis A and Hepatitis B is recommended for all men who have sex with men. Safer sex is currently the only means of prevention for the Hepatitis C.[65]

Human papilloma virus, which causes anal and genital warts, plays a role in the increased rates of anal cancers in gay men, and some health professionals now recommend routine screening with anal pap smears to detect early cancers.[65] Men have higher prevalence of oral HPV than women. Oral HPV infection is associated with HPV-positive oropharyngeal cancer.

Gay men are more likely than straight men to develop eating disorders such as bulimia or anorexia nervosa.[83] The cause of this correlation remains poorly understood, but is hypothesized to be related to the ideals of body image prevalent in the LGBT community.[84] Obesity, on the other hand, affects relatively fewer gay and bisexual men than straight men[85]

David McDowell of Columbia University, who has studied substance use in gay men, wrote that club drugs are particularly popular at gay bars and circuit parties.[86] Studies have found different results on the frequency of tobacco use among gay and bisexual men compared to that of heterosexual men, with one study finding a 50% higher rate among sexual minority men,[3] and another encountering no differences across sexual orientations.[87]

Youth who reported having sex with both males and females are at the greatest risk for disordered eating, unhealthy weight control practices compared to youth who only have same- or other-gender sex.[89] Bisexual women are twice as likely as lesbians to have an eating disorder and, if they are out, to be twice as likely as heterosexual women to have an eating disorder.[90]

Bisexual females are higher on suicidal intent, mental health difficulties and mental health treatment than bisexual males.[91] In a survey by Stonewall Scotland, 7% of bisexual men had attempted suicide in the past year.[67] Bisexual women are twice as likely as heterosexual women to report suicidal ideation if they have disclosed their sexual orientation to a majority of individuals in their lives; those who are not disclosed are three times more likely.[90] Bisexual individuals have a higher prevalence of suicidal ideation and attempts than heterosexual individuals, and more self-injurious behavior than gay men and lesbians.[92] A 2011 survey found that 44 per cent of bisexual middle and high school students had thought about suicide in the past month.[93]

Female adolescents who report relationships with same- and other-sex partners have higher rates of hazardous alcohol use and substance use disorders.[94] This includes higher rates of marijuana and other illicit drug use.[95][96][97] Behaviorally and self-identified bisexual women are significantly more likely to smoke cigarettes and have been drug users as adolescents than heterosexual women.[98]

Bisexual women are more likely to be nulliparous, overweight and obese, have higher smoking rates and alcohol drinking than heterosexual women, all risk factors for breast cancer.[99] Bisexual men practicing receptive anal intercourse are at higher risk for anal cancer caused by the human papillomavirus (HPV).[100]

Most research on HIV/AIDS focuses on gay and bisexual men than lesbians and bisexual women. Evidence for risky sexual behavior in bisexually behaving men has been conflicted. Bisexually active men have been shown to be just as likely as gay or heterosexual men to use condoms.[101] Men who have sex with men and women are less likely than homosexually behaving men to be HIV-positive or engage in unprotected receptive anal sex, but more likely than heterosexually behaving men to be HIV-positive.[102] Although there are no confirmed cases of HIV transmitted from female to female, women who have sex with both men and women have higher rates of HIV than homosexual or heterosexual women.[103]

In a 2011 nationwide study in the United States, 46.1% of bisexual women reported having experienced rape, compared to 13.1% of lesbians and 17.4% of heterosexual women,[104] a risk factor for HIV.

Transgender individuals are often reluctant to seek medical care or are denied access by providers due to transphobia or a lack of knowledge or experience with transgender health. Additionally, in some jurisdictions, health care related to transgender issues, especially sex reassignment therapy, is not covered by medical insurance.[105]

The World Professional Association for Transgender Health (WPATH) Standards of Care provide a set of non-binding clinical guidelines for health practitioners who are treating transgender patients.[106] The Yogyakarta Principles, a global human rights proposal, affirms in Principle 17 that "States shall (g) facilitate access by those seeking body modifications related to gender reassignment to competent, non-discriminatory treatment, care and support.[107]

In the UK, the NHS is legally required to provide treatment for gender dysphoria.[108] As of 2018, Wales refers patients to the Gender Identity Clinic (GIC) in London, but the Welsh government plans to open a gender identity clinic in Cardiff.[109]

In India, a 2004 report claimed that hijras 'face discrimination in various ways' in the Indian health-care system, and sexual reassignment surgery is unavailable in government hospitals in India.[110]

In Bangladesh, health facilities sensitive to hijra culture are virtually non-existent, according to a report on hijra social exclusion.[111]

The 2008-2009 National Transgender Discrimination Survey, published by National Gay and Lesbian Task Force and the National Center for Transgender Equality in partnership with the National Black Justice Coalition,[112] shed light on the discrimination transgender and gender non-conforming people face in many aspects of daily life, including in medical and health care settings. The survey reported that 19% of respondents had been refused healthcare by a doctor or other provider because they identify as transgender or gender non-conforming and transgender people of color were more likely to have been refused healthcare.[113] 36% of American Indian and 27% of multi-racial respondents reported being refused healthcare, compared to 17% of white respondents. In addition, the survey found that 28% of respondents said they had been verbally harassed in a healthcare setting and 2% of respondents reported being physically attacked in a doctor's office. Transgender people particularly vulnerable to being assaulted in a doctor's office were those who identify as African-Americans (6%), those who engaged in sex work, drug sales or other underground work (6%), those who transitioned before they were 18 (5%), and those who identified as undocumented or non-citizens (4%).

An updated version of the NTDS survey, called the 2015 U.S. Transgender Survey, was published in December 2016.[114]

Section 1557 of the Affordable Care Act contains nondiscrimination provisions to protect transgender people. In December 2016, however, a federal judge issued an injunction to block the enforcement of "the portion of the Final Rule that interprets discrimination on the basis of 'gender identity' and 'termination of pregnancy'".[115] Under the Trump administration, Roger Severino was appointed as civil rights director for the U.S. Department of Health and Human Services (HHS). Severino opposes Section 1557[116] and HHS has said it "will not investigate complaints about anti-transgender discrimination," as explained by the National Center for Transgender Equality.[117] When a journalist asked Severino if, under the HHS Conscience and Religious Freedom division whose creation was announced in January 2018, transgender people could be "denied health care," he said "I think denial is a very strong word" and that healthcare "providers who simply want to serve the people they serve according to their religious beliefs" should be able to do so without fear of losing federal funding.[118] On May 24, 2019, Severino announced a proposal to reverse this portion of Section 1557,[119][120] and, as of April 23, 2020, the Justice Department was reportedly reviewing the Trump administration's "final rule" which HHS acknowledged would reverse Section 1557's gender identity protections.[121]

On April 2, 2019, Texas Senate Bill 17 passed by a vote of 19–12. It would allow state-licensed professionals such as doctors, pharmacists, lawyers, and plumbers to deny services to anyone if the professional cites a religious objection. To reveal the motivations behind the bill, opponents proposed an amendment to prohibit discrimination based on sexual orientation or gender identity; the amendment failed 12–19.[122][123]

On October 15, 2019, federal judge Reed O'Connor vacated the part of the Affordable Care Act that protects transgender people. The ruling means that federally-funded healthcare insurers and providers may deny treatment or coverage based on sex, gender identity or termination of pregnancy, and that doctors aren't required to provide any services whatsoever to transgender people—even if they're the same services provided to non-transgender people, and even if they're medically necessary.[124]

Hormone treatment for transgender youth is illegal in Tennessee. On May 18, 2021, Governor Bill Lee signed a healthcare bill specifically prohibiting healthcare providers from prescribing hormone treatment for gender dysphoria in prepubertal minors, specifically allowing other hormone treatments to be prescribed for conditions such as growth deficiencies.[125][126]

Legislators in 25 US states have introduced bills to restrict access to gender-affirming medical care for minors in the past two years. As of August 2022, these bills have become law in Alabama, Arkansas, Arizona, and Tennessee. Relevant professional organizations including The American Medical Association, The American Academy of Pediatrics, The American Psychiatric Association, and The American Academy of Child & Adolescent Psychiatry have explicitly voiced opposition to these laws.[127] Most of these laws include sections that would penalize any healthcare providers that would acknowledge gender affirming care for transgender youth.[127]

Although they are not the only uninsured population in the United States, transgender people are less likely than cisgender people to have access to health insurance and if they do, their insurance plan may not cover medically necessary services.[128] The National Transgender Discrimination Survey reported that 19% of survey respondents stated that they had no health insurance compared to 15% of the general population. They were also less likely to be insured by an employer. Undocumented non-citizens had particularly high rates of non-coverage (36%) as well as African-Americans (31%), compared to white respondents (17%).

While a majority of U.S. insurance policies expressly exclude coverage for transgender care, regulations are shifting to expand coverage of transgender and gender non-conforming health care.[128] A number of private insurance carriers cover transgender-related health care under the rubric of "transgender services", "medical and surgical treatment of gender identity disorder", and "gender reassignment surgery".[129] Nine states (California, Colorado, Connecticut, Illinois, Massachusetts, New York, Oregon, Vermont, and Washington) and the District of Columbia require that most private insurance plans cover medically necessary health care for transgender patients.[130]

Depending on where they live, some transgender people are able to access gender-specific health care through public health insurance programs. Medicaid does not have a federal policy on transgender health care and leaves the regulation of the coverage of gender-confirming health care up to each state.[131] While Medicaid does not fund sex reassignment surgery in forty states,[132] several, like New York[133] and Oregon,[134] now require Medicaid to cover (most) transgender care.

Cancers related to hormone use include breast cancer and liver cancer. In addition, trans men who have not had removal of the uterus, ovaries, or breasts remain at risk to develop cancer of these organs, while trans women remain at risk for prostate cancer.[105] The likelihood of prostate cancer in transgender women taking anti-androgens is significantly lower than in cisgender men.[135]

According to transgender advocate Rebecca Allison, trans people are "particularly prone" to depression and anxiety: "In addition to loss of family and friends, they face job stress and the risk of unemployment. Trans people who have not transitioned and remain in their birth gender are very prone to depression and anxiety. Suicide is a risk, both prior to transition and afterward. One of the most important aspects of the transgender therapy relationship is management of depression and/or anxiety."[105] Depression is significantly correlated with experienced discrimination.[136] In a study of San Francisco trans women, 62% reported depression.[137] In a 2003 study of 1093 trans men and trans women, there was a prevalence of 44.1% for clinical depression and 33.2% for anxiety.[138]

Suicide attempts are common in transgender people. In some transgender populations the majority have attempted suicide at least once. 41% of the respondents of the National Transgender Discrimination Survey reported having attempted suicide. This statistic was even higher for certain demographics – for example, 56% of American Indian and Alaskan Native transgender respondents had attempted suicide. In contrast, 1.6% of the American population has attempted suicide.[139] In the sample all minority ethnic groups (Asian, Latino, black, American Indian and mixed race) had higher prevalence of suicide attempts than white people. Number of suicide attempts was also correlated with life challenges - 64% of those surveyed who had been sexually assaulted had attempted suicide. 76% who had been assaulted by teachers or other school staff had made an attempt.

In 2012 the Scottish Transgender Alliance conducted the Trans Mental Health Study. 74% of the respondents who had transitioned reported improved mental health after transitioning. 53% had self-harmed at some point, and 11% currently self-harmed. 55% had been diagnosed with or had a current diagnosis of depression. An additional 33% believed that they currently had depression, or had done in the past, but had not been diagnosed. 5% had a current or past eating disorder diagnosis. 19% believed that they had had an eating disorder or currently had one, but had not been diagnosed. 84% of the sample had experienced suicide ideation and 48% had made a suicide attempt. 3% had attempted suicide more than 10 times. 63% of respondents who transitioned thought about and attempted suicide less after transitioning. Other studies have found similar results.[139]

Trans women appear to be at greater risk than trans men and the general population of dying of suicide.[140] However, trans men are more likely to attempt suicide than trans women.[141]

Personality disorders are common in transgender people.[142]

Gender identity disorder is currently classed as a psychiatric condition by the DSM IV-TR.[143] The upcoming DSM-5 removes GID and replaces it with 'gender dysphoria', which is not classified by some authorities as a mental illness.[144] Until the 1970s, psychotherapy was the primary treatment for GID. However, today the treatment protocol involves biomedical interventions, with psychotherapy on its own being unusual.

There has been controversy about the inclusion of transsexuality in the DSM, one claim being that Gender Identity Disorder of Childhood was introduced to the DSM-III in 1980 as a 'backdoor-maneuver' to replace homosexuality, which was removed from the DSM-II in 1973.[145]

Transgender individuals frequently take hormones to achieve feminizing or masculinizing effects. Side effects of hormone use include increased risk of blood clotting, high or low blood pressure, elevated blood sugar, water retention, dehydration, electrolyte disturbances, liver damage, increased risk for heart attack and stroke.[105] Use of unprescribed hormones is common, but little is known about the associated risks.[146] One potential hazard is HIV transmission from needle sharing.[147] Transgender men seeking to get pregnant were once told that they needed to stop hormone therapy or testosterone treatment as it could be difficult to become pregnant or could cause potential birth defects, however it now seems that this may not be necessary.[148] More research needs to be conducted in this field in order to make a definitive conclusion.

Some trans women use injectable silicone, sometimes administered by lay persons, to achieve their desired physique. This is most frequently injected into the hip and buttocks. It is associated with considerable medical complications, including morbidity.[142] Such silicone may migrate, causing disfigurement years later. Non-medical grade silicone may contain contaminants, and may be injected using a shared needle.[105] In New York City silicone injection occurs frequently enough to be called 'epidemic', with a NYC survey of trans women finding that 18% were receiving silicone injections from 'black market' providers.[142]

Trans people (especially trans women – trans men have actually been found to have a lower rate of HIV than the general US population[113]) are frequently forced into sex work to make a living, and are subsequently at increased risk for STIs including HIV. According to the National Transgender Discrimination Survey, 2.64% of American transgender people are HIV positive, and transgender sex workers are over 37 times more likely than members of the general American population to be HIV positive. HIV is also more common in trans people of color. For example, in a study by the National Institute of Health more than 56% of African-American trans women were HIV-positive compared to 27% of trans women in general.[149] This has been connected to how trans people of color are more likely to be sex workers.[139]

A 2012 meta analysis of studies assessing rates of HIV infection among transgender women in 15 countries found that trans women are 49 times more likely to have HIV than the general population.[150] HIV positive trans persons are likely to be unaware of their status. In one study, 73% of HIV-positive trans women were unaware of their status.[151]

Latin American trans women have a HIV prevalence of 18%-38% as of 2016,[152] but most Latin American countries do not recognize transgender people as a population. Therefore, there are no laws catering to their health needs.

Transgender people have higher levels of interaction with the police than the general population. 7% of transgender Americans have been held in prison cell simply due to their gender identity/expression. This rate is 41% for transgender African-Americans.[113] 16% of respondents had been sexually assaulted in prison, a risk factor for HIV. 20% of trans women are sexually assaulted in prison, compared to 6% of trans men. Trans women of color are more likely to be assaulted whilst in prison. 38% of black trans women report having been sexually assaulted in prison compared to 12% of white trans women.

In a San Francisco study, 68% of trans women and 55% of trans men reported having been raped, a risk factor for HIV.[153]

Trans people are more likely than the general population to use substances. For example, studies have shown that trans men are 50% more likely, and trans women 200% more likely to smoke cigarettes than other populations. It has been suggested that tobacco use is high among transgender people because many use it to maintain weight loss.[154] In one study of transgender people, the majority had a history of non-injection drug use with the rates being 90% for marijuana, 66% for cocaine, 24% for heroin, and 48% for crack.[155] It has been suggested that transgender people who are more accepted by their families are less likely to develop substance use issues.[156]

In the Trans Mental Health Study 2012, 24% of participants had used drugs within the past year. The most commonly used drug was cannabis. 19% currently smoked.[139] A study published in 2013 found that among a sample of transgender adults, 26.5% had engaged in non-medical use of prescription drugs, most commonly analgesics.[157]

Transgender and nonbinary people often encounter additional unique barriers in attaining gynecologic and reproductive care. Providers and staff often make assumptions about gender identity or expression of patients in a "women's health" clinic and many providers lack cultural competence in caring for transgender and nonbinary patients. Furthermore, many providers are not adequately trained in order to help the LGBTQ+ community. There are still many gaps in knowledge when it comes to issues such as hormone therapy and how it may impact pregnancy or fertility. Challenges in accessing insurance coverage is another common barrier to Ob/Gyn healthcare for transgender and nonbinary patients.[158]