LGBT people pervasively experience health disparities, yet many are still grappling to understand the health care challenges leaving LGBT people to experience worsened health outcomes. Bodies and Barriers informs health care professionals, students in health professions, policymakers, and fellow activists about these challenges, providing insights and a road map for action that could improve queer health. Through artfully articulated, data-informed essays by twenty-six well-known and emerging queer activists, Bodies and Barriers illuminates the ubiquitous health challenges LGBT people experience and challenges conventional wisdom about health care delivery. It probes deeply into the roots of these disparities and empowers activists with crucial information to fight for health equity through clinical, behavioral, and policy changes. The activist contributors in Bodies and Barriers look for tangible improvements, drawing lessons from the history of HIV/AIDS in America and from struggles against health care bias and discrimination.
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About the Author
Adrian Shanker is an award-winning activist and organizer whose career has centered on the LGBT community. Rachel L. Levine, MD, is the secretary of health for the Commonwealth of Pennsylvania and Professor of Pediatrics and Psychiatry at the Penn State College of Medicine. Kate Kendell led the National Center for Lesbian Rights for twenty-two years.
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Human Rights and Health for LGBT Youth
Health interventions for LGBT youth are typically framed in medical not legal terms. But a human rights perspective offers a powerful tool to address health disparities and improve outcomes for LGBT youth. A human right is a right that all people, regardless of their background or citizenship, possess simply because they are human. When something is recognized as a human right, states are obligated to respect, protect, and promote that right. Health is related to human rights in two distinctive ways. First, the right to health is itself a human right, enshrined in a wide range of human rights treaties and affirmed by countries around the globe. The Universal Declaration of Human Rights, adopted by the United States and other states at the United Nations after the horrors of World War II, recognizes the right to a standard of living adequate for health and well-being. This right is affirmed in treaties like the International Covenant on Economic, Social and Cultural Rights, the Convention on the Rights of the Child, and the Convention on the Elimination of All Forms of Discrimination Against Women. And, second, the promotion and protection of human rights can improve health by discouraging violence and discrimination, minimizing stressors, and empowering people to voice their needs and seek out resources.
A rights respecting approach is important to improving health outcomes for LGBT youth. By canvassing some of the health disparities that LGBT youth experience, we are able to discuss human rights violations that can contribute to those disparities and explore some of the reasons that promoting human rights can help improve health outcomes. Respecting the rights of LGBT youth is not only a legal obligation or a way to convey affirmation and support. It is also a crucial strategy to improve LGBT youth's health and well-being, with positive effects that can last throughout their lives.
Health Disparities among LGBT Youth
Researchers have identified a range of physical and mental health issues that LGBT youth are more likely to experience than their heterosexual, cisgender peers. These health disparities are avoidable — they are created and exacerbated by conditions that put LGBT youth at risk and make it more difficult for them to obtain care.
The physical health disparities that LGBT youth encounter may not be as pronounced as those that LGBT adults might face later in their lives, but they can still be evident from an early age. In 2017, the U.S. government collected nationally representative data on health and well-being from students in grades nine to twelve, including questions about sexual identity. In that study, 21.9 percent of LGB students reported that they had been physically forced to have sexual intercourse against their will in the year before the survey — nearly four times the rate of heterosexual students. Similarly, 22.2 percent of LGB students had experienced sexual violence — defined as being forced to do sexual acts they did not want to do — at almost three times the rate of heterosexual students. In dating and relationships too LGB youth reported significantly higher rates of sexual dating violence and physical dating violence. Data collection is more limited for transgender youth, but federal data released in 2019 indicate that 23.8 percent had been forced to have sexual intercourse and 26.4 percent had experienced physical dating violence in the year prior to the survey and had faced higher rates of violence than cisgender youth. From a sexual health perspective, LGBT youth are at heightened risk of HIV and sexually transmitted infections compared to their peers. In 2016, young gay and bisexual men made up 81 percent of new HIV diagnoses among youth in the United States, with particularly high infection rates among young Black, Latino, and/or bisexual men. Data suggest transgender youth are less likely to have been tested for HIV than their cisgender peers.
Evidence suggests that LGB youth are also less likely to be physically active than their heterosexual counterparts. In federal data from 2017, LGB students consistently reported lower rates of physical activity, participation in team sports, and attendance in physical education classes and were more likely to play video or computer games or watch television more than three hours a day. LGB youth were also slightly more likely to be obese or overweight — and more likely to perceive themselves as overweight and be trying to lose weight — than heterosexual youth.
Moreover, LGBT youth are more likely than their heterosexual, cisgender peers to engage in behaviors that jeopardize health. LGBT youth consistently demonstrate higher rates of alcohol, tobacco, and other drug use, and research shows these disparities persist into adulthood. In data collected in 2017, students questioning their sexual orientations were even more likely than LGB students to have used cocaine, inhalants, heroin, methamphetamines, hallucinogenic drugs, and injection drugs, though both groups used these drugs — as well as synthetic marijuana, ecstasy, and prescription painkillers — at higher rates than heterosexual students. In federal data on substance abuse, transgender youth were more likely than cisgender youth to have used every substance listed except marijuana.
Yet disparities are particularly pronounced in the field of mental health. While many LGBT youth do not struggle with mental health issues, research has powerfully shown that LGB youth as a population are at an elevated risk of depression, anxiety, and suicidality. In keeping with these factors, researchers have noted that a "higher risk for suicide ideation attempts among LGB groups seems to start at least as early as high school." While data has been more limited for transgender youth, existing research suggests they also experience disproportionately high rates of depression, eating disorders, self-harm, and suicidal ideation and behavior.
Disparities in physical and mental health are neither inevitable nor intractable. In many cases, laws, policies, and practices that restrict human rights have demonstrably negative effects on LGBT youth health. A rights respecting approach to LGBT issues in youth can help to advance a range of human rights — including the right to the highest attainable standard of physical and mental health.
Human Rights Violations Faced by LGBT Youth
The persistence of health disparities has led researchers to examine why, holding other demographic and environmental factors equal, LGBT youth tend to be at higher risk of worsened health outcomes. One key finding in recent years is that human rights violations, as well as more subtle and persistent forms of marginalization, can play a powerful role in generating or exacerbating the health risks that youth face.
Among the most common issues that LGBT youth experience are bullying and harassment, which too often go unchecked by staff. In interviews I conducted in 2015, Alexander S., a sixteen-year-old transgender boy in Texas, described how he had been verbally and physically bullied since elementary school for his gender expression and began suffering from depression and suicidal thoughts from a young age. When he turned to teachers and the school and they failed to intervene, he kept the persistent harassment to himself.
Unfortunately, Alexander's story is one of many. According to federal data collected in 2017, one-third of gay, lesbian, and bisexual students had been bullied on school property in the year before the survey, compared to 17.1 percent of heterosexual students. According to GLSEN's National School Climate Survey in 2017, verbal harassment is also common, with 70.1 percent of LGBT students experiencing harassment based on their sexual orientation and 59.1 percent experiencing harassment based on their gender identity. Verbal harassment is not only at the hands of peers; 56.6 percent of students had heard homophobic remarks and 71.0 percent had heard transphobic remarks from teachers or staff. According to federal data collected in 2017, LGB students experienced cyberbullying at more than double the rate of heterosexual students who reported similar experiences. In qualitative interviews, LGBT students have reported being targeted for cyberbullying because of their gender or sexuality, being catfished with fake dating profiles, or being intentionally misgendered online as a form of humiliation. Despite these alarming statistics, only twenty states and the District of Columbia have laws prohibiting bullying on the basis of sexual orientation and gender identity.
The health of transgender youth is also directly compromised by discriminatory policies that do not recognize their gender identity. Susanna K., the mother of a transgender boy in Utah, told me that her son began suffering from bladder infections in junior high, and that she eventually discovered that it was because he did not feel safe in male or female bathrooms at school. When she enrolled him at a charter school that respected his gender identity, the bladder infections stopped. When transgender students are required to use bathrooms and other facilities according to their sex assigned at birth, they are highly vulnerable to harassment and assault. Many transgender students thus avoid using these facilities at all. Students have described how they limit fluid intake or wait until the school day ends to relieve themselves, which can lead to dehydration, bladder infections, urinary tract infections, and other health complications. When transgender students generally are not allowed to participate in sports and other extracurriculars consistent with their gender identity — a rule adopted by nine US states — they frequently forego participation in athletics, depriving them of the physical, mental, and social benefits that other youth enjoy.
One of the ways that LGBT youth have traditionally found support is through the formation of gay-straight alliances or other LGBT student groups. For many LGBT youth, participation in an LGBT student group is essential to reducing feelings of social isolation and accessing information. Schools that have attempted to deny registration to these groups or that have created unfair burdens, such as requiring parental notification for students to participate, have been stopped by federal courts, which have found that these groups must be treated on the same terms as all other extracurricular student organizations. Nonetheless, research suggests that schools across the country still interfere with the formation or operation of LGBT student groups, by dragging out their registration, imposing requirements on those groups that they do not impose on other student organizations, monitoring their meetings, or prohibiting them from discussing certain topics. Such restrictions not only violate LGBT students' freedom of expression, assembly, and association but prevent LGBT students from forming communities that alleviate isolation, bolster self-esteem, and affirm their identities.
The use of conversion therapy, whether on the basis of sexual orientation or gender identity, has also been recognized as a human rights violation — in some instances, a form of torture. Practices of conversion therapy can threaten physical health, for example, when practitioners use aversive therapy to physically punish any sign of interest in same-sex activity. These practices can also threaten mental health. According to the American Psychological Association, conversion therapy can produce negative effects like "anger, anxiety, confusion, depression, grief, guilt, hopelessness, deteriorated relationships with family, loss of social support, loss of faith, poor self-image, social isolation, intimacy difficulties, intrusive imagery, suicidal ideation, self-hatred, and sexual dysfunction." Refusing to recognize trans youth can also exacerbate gender dysphoria and related forms of psychological distress. When trans youth who want to physically transition are denied access to transition-related care, they may seek out alternatives, including black market hormones, silicone, and unsupervised modifications to their bodies with potentially serious and lasting repercussions for their health.
Rejection can impair health in slightly more attenuated ways as well. In large part because of family rejection, LGBT youth are at a significantly higher risk of homelessness than their heterosexual, cisgender peers. In 2012, the Williams Institute estimated that LGBT youth made up about 40 percent of homeless youth in the United States — a disproportionately high figure relative to the percentage of LGBT youth in the population overall. Failing to protect LGBT youth from homelessness not only deprives them of the right to adequate housing but puts them at heightened risk of other human rights violations, including violations of their physical and mental health.
Silence around LGBT issues can also exacerbate health disparities. While many youth in the United States lack access to comprehensive sexuality education, that absence is especially acute for LGBT youth. It is extremely rare for LGBT youth to receive information about safer sex that pertains to their needs. In six states, laws specifically prohibit discussions of same-sex activity in sexuality education classes — a policy that often has a chilling effect across the school curriculum. Such policies, like filtering out age-appropriate LGBT content on school computers or banning LGBT books from school libraries, unduly restrict LGBT youth's right to access information as well as their right to health.
Other forms of discrimination jeopardize LGBT well-being as well. In some instances, LGBT youth are unable to bring their partners to school dances or are punished for displays of affection that teachers ignore with their heterosexual, cisgender peers. In some cases, transgender youth have been required to adhere to a gender-based dress code for yearbook photos or graduation and have been forced to wear clothing that is in opposition to their gender identity. Discrimination is overtly codified for many transgender youth, who are unable to use their names and pronouns, wear clothing conforming with their gender identity, access school facilities, or otherwise be themselves in school environments. Without support, these suggestions that LGBT youth are invalid or unwelcome can adversely affect their mental health and sense of belonging in schools.
Even for youth who are not directly subjected to physical or psychological violence, more ambient forms of alienation and stigmatization can shape health outcomes. One way that marginalization can adversely affect LGBT youth is through the cumulative effects of minority stress. Psychologists have developed the concept of minority stress "to distinguish the excess stress to which individuals from stigmatized social categories are exposed as a result of their social, often a minority, position." A 2011 report from the Institute of Medicine similarly underscored that "the disparities in both mental and physical health that are seen between LGBT and heterosexual and non-gender-variant youth are influenced largely by their experiences of stigma and discrimination during the development of their sexual orientation and gender identity and throughout the life course." Such stress can be acutely felt by LGBT youth, who are often in the early stages of exploring their sexual orientation or gender identity, grapple with stigma, lack support from family, friends, or community, have few LGBT role models, or find it difficult to create or access supportive spaces where they can meet and interact with other LGBT people.
As these examples show, much of the distress that LGBT youth experience is preventable. And in addition to stopping bad practices, supporters of LGBT youth can — and should — take concrete steps to respect their rights and affirm their identities.
Resilience and Support
While most research on LGBT youth has focused on health disparities and violations that exacerbate them, recent work has also explored how rights respecting initiatives can mitigate disparities between LGBT youth and their heterosexual, cisgender peers to improve health outcomes. As this research shows, LGBT youth are not inherently doomed to experience poor health; affirming interventions can make a measurable difference in their health and well-being. To advance a more rights respecting paradigm, it is worth describing some of the ways that advocates and providers might support LGBT youth in their work.
For any adults who might work with LGBT youth, research suggests that affirmation can have a positive effect on health outcomes. A supportive environment has been linked to better physical and mental health among LGBT youth, including lower levels of depression, hopelessness, substance use, and suicidality. Affirming transgender youth in the process of social transition has also been associated with better mental health outcomes. In one study that examined the use of chosen names at home, at school, at work, and with friends, for example, researchers found that transgender youth who could use their chosen names in a wider range of contexts were less likely to report depressive symptoms and suicidal ideation or behavior.(Continues…)
Excerpted from "Bodies and Barriers"
Copyright © 2020 Adrian Shanker.
Excerpted by permission of PM Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
Table of Contents
Foreword Rachel L. Levine, MD,
Introduction Adrian Shanker,
1 Human Rights and Health for LGBT Youth Ryan Thoreson,
2 Informed Consent for Intersex Children Katharine B. Dalke,
3 Navigating Pediatric Care for Transgender Youth Alisa Bowman,
4 Not Your Average Sex Talk Emmett Patterson,
5 Resiliency for Homeless Queer Youth Arin Jayes,
6 Beyond Duct Tape: Binding for Transmasculine Youth Preston Heldibridle,
7 Surviving Suicide Tyler Titus,
8 Sex and Safety in the Digital Age Jack Harrison-Quintana,
9 Living Proudly, Living Longer: Advocating for Queer Spaces to be Tobacco Free Adrian Shanker and Annemarie Shankweiler,
10 Queer Family Planning: A Remedy to Depression Kate Luxion,
11 Social Service Navigation for the LGBT Community Anthony Crisci,
12 That Ass Tho! Anal Health for the LGBT Community Adrian Shanker,
13 Addiction and Recovery in the Queer Community Atticus Ranck,
14 Without Wincing or Clenching: Bisexual People's Experiences with Health Care Professionals Robyn Ochs,
15 Gender, Cancer, and Me Liz Margolies,
16 "Laura Is a Transgender. Didn't the Surgeons Do an Amazing Job?" Laura A. Jacobs,
17 Tobacco-Free Queers: Prime Time to Quit Scout,
18 Challenging HIV Stigma Sean Strub,
19 Archiving AIDS: Intergenerational Education About an Epidemic Chris Bartlett,
20 Organizing against Social Isolation: Older Lesbians in Rural Communities Kat Carrick and Ntlotleng Mabena,
21 Caregiving Concerns for LGBT Older Adults Liz Bradbury,
22 Housing and Health for LGBT Older Adults Imani Woody,
23 Grieving Together: LGBT Bereavement Support Groups Justin Sabia-Tanis,
ABOUT THE EDITOR,