Introduction
Although there have been some positive changes in social attitudes and legal protections in the last few decades, lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) individuals continue to live and work in environments that are heterosexist, homophobic, and transphobic. LGBTQ youth remain much more likely to be kicked out of their homes than their cisgender heterosexual peers, and 40% of homeless youth identify as LGBTQ (Durso & Gates, 2012).
Transgender and gender diverse individuals face even higher rates of discrimination than their LGB peers. In the 2015 National Transgender Discrimination Survey, 27% of those who held or applied for a job during the past year reported being fired, denied a promotion, or not being hired for a job they applied for because of their gender identity or expression (James et al., 2016). Some states and municipalities have enacted nondiscrimination laws that protect individuals on the basis of gender identity and expression in various settings. Federally, the legal landscape has been murky and largely unsupportive, though in June 2020 the Supreme Court of the United States ruled that Title VII of the Civil Rights Act of 1964 - which prohibits employment discrimination on the basis of sex - applies to sexual orientation and gender identity. This is a promising decision, though it remains unclear exactly how it will be interpreted by other courts.
Transgender women may be at especially elevated risk of discrimination and violence, as male-assigned children are generally afforded less flexibility in gender roles, and adults who are assigned male can have more trouble being viewed as female than their trans male counterparts. The trans author Julia Serano argues that a unique form of discrimination affects trans women, who face both transphobia and misogyny. She calls this transmisogyny (Serano, 2007). LGBTQ people of color, especially trans women of color, are most vulnerable. For example, the 2013 Anti-Violence Project report showed that 67% of LGBTQ homicide victims were transgender women of color (Anti-Violence Project).
Due to their environments and experiences, LGTBQ people are more likely to develop mental disorders than the general public. The Minority Stress Model is a theory that explains the connection between discrimination and increased mental health burden (Meyer, 1995). The Minority Stress Model is supported by findings that conditions such as depression, anxiety, and substance use are more common among LGBTQ individuals. These conditions are more strongly influenced by social and environmental factors, as compared to biologically-based disorders such as bipolar disorder or schizophrenia, which are not necessarily more common among LGBTQ individuals (Carmel & Erickson-Schroth, 2016; Schulman & Erickson-Schroth, 2017).
While LGBTQ people have higher documented rates of depression, suicidality, and substance use disorders than the general population, there are no studies to date that demonstrate higher prevalence of post-traumatic stress disorder or personality disorders. However, given the nature of the environment in which LGBTQ people live, it is likely that trauma-related disorders are more prevalent in LGBTQ patients.
Hospital and clinic settings are not immune from both implicit and explicit biases which may negatively impact patient care (Sharman, 2016). Although medical training institutions are working to improve education about LGBTQ issues, the educational experiences that students and residents receive is not standardized and varies greatly between institutions. A Stanford study showed that medical students, on average, receive only 5 hours of LGBTQ-related content over their entire 4 years of medical school (Obedin-Maliver et al., 2011). In a Lambda Legal survey, 89.4% of transgender people felt there were not enough health professionals adequately trained to care for them, and 26% said they had been refused health care because they were transgender (Lambda Legal, 2010). Psychiatry, in particular, has had a fraught relationship with LGBTQ patients given the historical pathologization of LGBTQ identities and the ongoing perception of gatekeeping related to hormones and surgeries for transgender individuals.
CME Question:
Lesbian, gay, bisexual, transgender, and queer (LGBTQ) people have elevated rates of all of the following EXCEPT:
Substance use disorders
Bipolar disorder and schizophrenia
Depression
Suicidal thoughts and attempts
Answer: 2