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Sel J. Hwahng
Michelle R. Kaufman Editors
Research, Policy, Practice, and Pathways
Global LGBTQ Health
Global LGBTQ
Health
Global LGBTQ Health
Series Editor
SelJ.Hwahng, Department of Women’s and Gender Studies
Towson University
Towson,MD,USA
In general, global health is viewed as a pressing topic within public health, which is
aligned with the increasing globalization of scientic and academic inquiry and
practice. Over the last few decades there has also been increasing awareness of the
importance in recognizing and identifying LGBTQ health issues and disparities.
However, there is a dearth of research and scholarship that examines LGBTQ health
through global and comparative perspectives. This book series lls this gap by
examining LGBTQ health cross-culturally and comparatively across regional and
country contexts.
The aims of the Global LGBTQ Health book series are the following: 1) to
examine and discuss LGBTQ health cross-culturally and comparatively; 2) to
examine and discuss LGBTQ health across regional and country contexts; 3) to
provide socio- political- cultural contexts for LGBTQ health in specic countries
and/or regions; 4) to facilitate greater socio-political-cultural awareness, sensitivity,
and competence with regards to the health of LGBTQ populations; 5) to identify
cross-cutting global LGBTQ health disparities and issues; 6) to identify LGBTQ
health disparities and issues that are the most pressing within specic regional and
country contexts; and 7) to provide directives and recommendations for increasing
health-related capacities of agencies, organizations, and institutions across countries
and/or regions.
Some volumes will focus on global-level analyses, while other volumes may
focus on comparative analyses within specic geographic regions.
Sel J. Hwahng • Michelle R. Kaufman
Editors
Global LGBTQ Health
Research, Policy, Practice, andPathways
ISSN 2946-5575 ISSN 2214-8019 (electronic)
ISBN 978-3-031-36203-3 ISBN 978-3-031-36204-0 (eBook)
https://doi.org/10.1007/978-3-031-36204-0
© The Editor(s) (if applicable) and The Author(s) 2024
Open Access This book is licensed under the terms of the Creative Commons Attribution 4.0
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Paper in this product is recyclable.
Editors
Sel J. Hwahng
Department of Women’s
and Gender Studies
Towson University
Towson, MD, USA
Michelle R. Kaufman
Department of Health, Behavior & Society
and Department of International Health
Johns Hopkins University
Bloomberg School of Public Health
Baltimore, MD, USA
. This book is an open access publication.
v
Acknowledgments
We thank Frankie Wong, Bonnie Wright, Casey Xavier Hall, and the Center of
Population Sciences for Health Equity at Florida State University for funding and
supporting the open access publication of this edited volume.
We are grateful to Janet Kim, Senior Editor in Public Health and Social Work, for
her guidance and patience, as well as the editorial team at Springer Nature. Much
appreciation to Alicia Bazell, former master’s student advisee and research assistant
to Michelle. She came into the program wanting to better the health of LGBTQ
populations and has gone on to similar work in her post-graduate career. We could
not have put this book together without her support on all the pieces. Alicia was a
stellar student and is now a stellar colleague! Finally, we thank all the authors in this
edited volume for their expertise, patience, and cooperation in collaborating with
us, including the case study authors (Alicia Bazell, Sara Wallach, John Mark
Wiginton, and Wenjian Xu).
From Sel First, my deepest gratitude to Michelle R.Kaufman who partnered with
me in compiling this edited volume over the last several years. I acknowledge her
wisdom, patience, and tenacity. I also thank my mentors, advisors, and colleagues
over the years including Larry Nuttbrock, Danielle Ompad, Don Des Jarlais, Cathy
Zadoretzky, Anneliese Singh, Bali White, Stephanie St. Pierre, Casey Rebholz,
Cindy Gissendanner, Ashley Kilmer, Pooja Brar, Shawn HaeDong Kim, Staci
Rensch, Christopher Cayari, Corine Tachtiris, Neil Simpkins, Yi (April) Wang,
Mairin Barney, Christopher Adam Mitchell, and José Esteban Muñoz for various
forms of inspiration, mentorship, and/or support that contributed to the manifesta-
tion and execution of this project. I also thank the following departments, programs,
and organizations for inspiration and/or support: Women’s and Gender Studies
Department at Towson University; College of Liberal Arts at Towson University;
Department of Epidemiology at Johns Hopkins University, Bloomberg School of
Public Health; Women and Gender Studies Department at Hunter College, City
University of New York; National Development and Research Institutes, Inc.;
LGBT Caucus of the American Public Health Association; Center for the Study of
Ethnicity and Race, Columbia University; OutRight Action International (formerly
vi
The International Gay and Lesbian Human Rights Commission); National Center
for Faculty Development and Diversity; the Being a Leader and the Effective
Exercise of Leadership course and Creating Course Leaders program; and Landmark
Worldwide. Finally, thank you to my parents who taught me to prioritize matters of
health in all realms of life.
From Michelle Thank you, Sel Hwahng, for noticing that yer for my Global
LGBTQ Health course in the halls of the Hampton House at Johns Hopkins and
inviting me to join you in this important work. You earnestly try to make the world
a better place, and I have enjoyed supporting that effort on this book. We all need
colleagues like you! Thank you to my many mentors over the years, especially Al
Forsyth, Mary Crawford, Seth Kalichman, and Carl Latkin, for teaching me how to
conduct social justice-minded research, particularly for gender and sexual minori-
ties. Thank you also to my life partner, Ken Murray, for supporting each and every
one of my ambitious projects. You told me early in our relationship that my work
would make the world better, and you wanted to support my efforts. You really lived
up to that promise. Thank you to my child, Ellis, currently age 6, for inspiring me
daily. Never did I imagine I would have complex discussions of gender diversity
with such a small, open-minded being. And thank you to my father. You taught me
persistence and how to ignore social norms. I took that to heart and pursued this
eld of work even though it made you uncomfortable. I wish you were here to see
this book in print.
Acknowledgments
vii
Contents
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Sel J. Hwahng and Michelle R. Kaufman
2 LGBTQ Stigma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Valerie A. Earnshaw, Carmen Logie, Jeffrey A. Wickersham,
and Adeeba Kamarulzaman
3 Global LGBTQ Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Richard Bränström, Tonda L. Hughes, and John E. Pachankis
4 If You Don’t Ask, You Don’t Count: Elements to Consider
in Understanding Global Sexual and Gender Minority
Data on Noncommunicable Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Jane A. McElroy and Bennett J. Gosiker
5 Sexual and Gender Minority Population’s Health Burden
of Five Noncommunicable Diseases: Cardiovascular Disease,
Cancer, Diabetes, Asthma, Chronic Obstructive
Pulmonary Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Jane A. McElroy and Bennett J. Gosiker
6 Community and Social Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Chichun Lin and Sel J. Hwahng
7 HIV/AIDS Among Sexual and Gender Minority
Communities Globally . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
S. Wilson Beckham, Jennifer Glick, Jowanna Malone,
Ashleigh J. Rich, Andrea Wirtz, and Stefan Baral
viii
8 Global Epidemiology and Social-Ecological Determinants
of Substance Use Disparities, Consequences of Use,
and Treatment Options Among Sexual and Gender
Minority Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Matthew J. Mimiaga, Lynn Klasko-Foster,
Christopher Santostefano, Harry Jin, Taryn Wyron,
Jackie White Hughto, and Katie Biello
9 Victimization and Intentional Injury in Global
LGBTQI Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
Casey D. Xavier Hall, G. Nic Rider, Nova Bradford,
Eunice M. Areba, and Katy Miller
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
Contents
ix
About the Editors
SelJ.Hwahng, PhD (they/them/their), is assistant
professor in the Department of Women’s and Gender
Studies, Health and Sexuality track at Towson
University. They are also pursuing an ScM degree in
Cardiovascular Epidemiology at Johns Hopkins
University, Bloomberg School of Public Health.
Their current research focuses on women of color
and LGBTQ nutritional and cardiometabolic health
disparities utilizing social, behavioral, and epidemi-
ological methods. They also lead an ontological-
based leadership course at higher education
institutions. They are a recipient of grants, awards,
and fellowships from organizations/institutions such
as the National Institute on Drug Abuse, National
Institutes of Health, American Public Health
Association, International AIDS Society, Association
for Women in Psychology, and American Heart
Association. Publications include over 30 articles
and book chapters in peer-reviewed journals and
edited volumes. Dr. Hwahng is also editor of the
book series Global LGBTQ Health in which this vol-
ume is featured.
Photo credit: Dr. Raju Bhandari
x
MichelleR.Kaufman, PhD (she/her/hers), is associ-
ate professor in the Department of Health, Behavior
and Society and the Department of International Health
at the Bloomberg School of Public Health, Johns
Hopkins University in Baltimore, Maryland, USA.She
is a social psychologist by training. Dr. Kaufman’s
research focuses on the social determinants of health,
particularly the role of gender and sexual identity. She
has spent over 20 years studying sex, gender, and sexu-
ality as predictors of health disparities in more than 12
countries using mixed and interdisciplinary research
methods. Her work is focused primarily in low- and
middle-income settings and has been funded by the
NIH, USAID, CDC, Fulbright, Gates Foundation, and
Bloomberg Philanthropies. Currently she leads the Data
for Health Gender Equity Unit, an initiative focused on
improving health data systems in 40+ low- and middle-
income countries to ensure people of all genders are
counted in health data.
Photo credit: Sean Gallagher/@imseangallagher
About the Editors
xi
Contributors
Eunice M. Areba School of Nursing, University of Minnesota, Minneapolis,
MN, USA
Stefan Baral Department of Epidemiology, Division of Infectious Disease
Epidemiology, Bloomberg School of Public Health, Johns Hopkins University,
Baltimore, MD, USA
S. Wilson Beckham Department of Health, Behavior and Society, Bloomberg
School of Public Health, Johns Hopkins University, Baltimore, MD, USA
Katie Biello Department of Behavioral and Social Sciences, School of Public
Health, Brown University, Providence, RI, USA
Nova Bradford Health Policy, School of Medicine, Stanford University,
Stanford, CA, USA
RichardBränström Department of Clinical Neuroscience, Karolinska Institute,
Stockholm, Sweden
Valerie A. Earnshaw Human Development and Family Sciences, University of
Delaware, Newark, DE, USA
JenniferGlick Department of Health, Behavior and Society, Bloomberg School of
Public Health, Johns Hopkins University, Baltimore, MD, USA
Bennett J. Gosiker Kaiser Permanente Bernard J. Tyson School of Medicine,
Pasadena, CA, USA
Tonda L. Hughes Department of Psychiatry, School of Nursing, Columbia
University, New York, NY, USA
Jackie White Hughto Departments of Behavioral and Social Sciences and
Epidemiology, School of Public Health, Brown University, Providence, RI, USA
SelJ.Hwahng Department of Women’s and Gender Studies, Towson University,
Towson, MD, USA
xii
Harry Jin Department of Epidemiology, School of Public Health, Brown
University, Providence, RI, USA
Adeeba Kamarulzaman Faculty of Medicine, University of Malaya, Kuala
Lumpur, Malaysia
Michelle R. Kaufman Department of Health, Behavior and Society and
Department of International Health, Bloomberg School of Public Health, Johns
Hopkins University, Baltimore, MD, USA
Lynn Klasko-Foster Department of Psychiatry and Human Behavior, Warren
Alpert Medical School, Brown University, Providence, RI, USA
Chichun Lin Master of Marriage and Family Therapy Program, Faculty of
Education, The University of Winnipeg, Winnipeg, Manitoba, Canada
CarmenLogie Factor-Inwentash Faculty of Social Work, University of Toronto,
Toronto, ON, Canada
JowannaMalone Exponent, Inc., Washington, D.C., USA
Jane A. McElroy Department of Family & Community Medicine, School of
Medicine, University of Missouri, Columbia, MO, USA
KatyMiller Children’s Minnesota, Minneapolis, MN, USA
MatthewJ.Mimiaga UCLA Center for LGBTQ+ Advocacy, Research & Health,
Department of Epidemiology, UCLA Fielding School of Public Health, Los
Angeles, CA, USA
John E. Pachankis Department of Social and Behavioral Sciences, School of
Public Health, Yale University, New Haven, CT, USA
AshleighJ.Rich Center for Health Equity Research, University of North Carolina,
Chapel Hill, NC, USA
G.NicRider Department of Family Medicine and Community Health, University
of Minnesota, Minneapolis, MN, USA
Christopher Santostefano Center for Gerontology and Healthcare Research,
School of Public Health, Brown University, Providence, RI, USA
Jeffrey A. Wickersham Department of Internal Medicine, School of Medicine,
Yale University, New Haven, CT, USA
Andrea Wirtz Department of Epidemiology, Johns Hopkins University,
Baltimore, MD, USA
TarynWyron Reconstructionist Rabbinical College, PA, USA
CaseyD. XavierHall College of Nursing, Florida State University, Tallahassee,
FL, USA
Contributors
1
Chapter 1
Introduction
SelJ.Hwahng andMichelleR.Kaufman
1.1 Why Global LGBTQ Health?
This edited volume seeks to excavate a new eld focusing on global LGBTQ health.
Why is there a need for this? This question can be answered in several ways. First,
there have been a number of edited volumes that have focused mostly on LGBTQ
health in the United States, North America, and/or the Global North (Eckstrand &
Potter, 2017; Follins & Lassiter, 2016; Makadon etal., 2015; Meyer & Northridge,
2007; Ruth & Santacruz, 2017; Stall et al., 2020). There have also been active
LGBTQ health research initiatives in various regions of the world, although a vast
majority of this research has been focused on HIV risk among MSM (men who have
sex with men) and, more recently, on transgender women (albeit transgender women
are often problematically subsumed within the MSM category). Such research has
often been siloed within the country or region where the research occurred. These
US/Global North-focused edited volumes and the HIV in MSM research conducted
in various regions of the world have been highly inuential in raising the impor-
tance and visibility of LGBTQ health. Given this previous work, it seems that one
of the next progressions in advancing LGBTQ health is to examine LGBTQ health
from a global perspective, including emphasizing Global South issues, research,
and concerns.
Thus, we present this interdisciplinary edited volume as an acknowledgment of
prior research that has been conducted on LGBTQ health within various regions of
the world and to impact the formation of a new eld that focuses on global LGBTQ
S. J. Hwahng (*)
Department of Women’s and Gender Studies, Towson University, Towson, MD, USA
e-mail: shwahng1@jhmi.edu
M. R. Kaufman
Department of Health, Behavior and Society and Department of International Health,
Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
e-mail: michellekaufman@jhu.edu
© The Author(s) 2024
S. J. Hwahng, M. R. Kaufman (eds.), Global LGBTQ Health, Global LGBTQ
Health, https://doi.org/10.1007/978-3-031-36204-0_1
3
health. This was accomplished through the integration of research ndings that
either focused on specic contexts and factors that impacted health or on the health
outcomes themselves.
1.2 Genesis ofThis Book
Sel rst got involved in public health research in 2004 focusing on HIV and drug
use in behavioral science. In 2005, Sel also started teaching as an adjunct professor
at the Center for the Study of Ethnicity and Race at Columbia University and, in
2007, developed and taught a course entitled “Transnational Trans/gender-variant
Social Formations,” in which the examination of public health was a key component
of this course. Sel would go on to teach this course or variations of this course mul-
tiple times. Several years later, Sel served as Program Chair-elect and Program
Chair of the LGBT Caucus of the American Public Health Association from 2012 to
2016, which provided many opportunities for Sel to program and support the dis-
semination of emerging research ndings on LGBTQ health.
Informed by Sel’s research, teaching, and administrative experiences, this book
was rst conceived by Sel who was awarded a contract for a book series on global
LGBTQ health by Springer Nature in early 2018. Around this same time, Sel
decided to pursue a master’s degree in epidemiology and applied to several pro-
grams, including the Sc.M. program in epidemiology at Johns Hopkins University,
Bloomberg School of Public Health (“JHU BSPH”). While visiting JHU BSPH
during an “Admitted Students Day,” Sel came across a yer for a course being
taught by Michelle Kaufman on “Global LGBTQ Health” through the Department
of Health, Behavior and Society (“HBS”) at JHU BSPH.This seemed to be a fortu-
itous and exciting coincidence. Although Sel was aware of courses being taught on
US-focused LGBTQ health at several institutions, this was the rst time Sel had
come across a course focused on global LGBTQ health.
As it turns out, Sel did choose to pursue their degree in epidemiology at JHU
BSPH, and soon after starting their program in 2018, contacted Michelle Kaufman
who was then an Assistant Professor in HBS (and now an Associate Professor in
HBS and International Health). In addition to the course she taught, Michelle had
research expertise in gender and sexuality as social determinants of health. She had
studied these issues, including sexual and gender minority populations, in several
global contexts, particularly in the Global South. Together, Sel and Michelle assem-
bled the proposal for this edited volume, which was subsequently accepted by
Springer Nature in 2019.
1 Introduction
4
1.3 On COVID-19
After the book proposal was accepted, Sel and Michelle began the task of securing
authors for the various chapters of this edited volume. At that time, Sel and Michelle
did not anticipate that the most pivotal health-related event of the twenty-rst cen-
tury was about to occur, which was the global COVID-19 pandemic. This pandemic
greatly interrupted the progress of this edited volume, often in the form of unantici-
pated caregiver responsibilities that were suddenly thrust upon them. This pandemic
also gave rise to a new eld examining LGBTQ populations and the COVID-19
infection, including COVID-19 surveillance (Sell & Krims, 2021), COVID-19 test-
ing (Martino etal., 2021), and COVID-19 vaccine hesitancy (Garg etal., 2021), as
well as impacts on health inequalities/disparities (Adamson etal., 2022; Krause,
2021; Phillips, 2021; Sachdeva etal., 2021; Wallach et al., 2020), mental health
(Akré et al., 2021; Chen et al., 2022; Gato et al., 2021; Gonzales et al., 2020;
Gorczynski & Fasoli, 2020; Lucas et al., 2022; Ormiston & Williams, 2022;
Parchem etal., 2021; Salerno etal., 2020; Salerno & Boekeloo, 2022; Sampogna
etal., 2022), sexual behavior and HIV (Grifn et al., 2022; Tomar etal., 2021),
disordered eating and nutrition ((Hart etal., 2022; Joy, 2021; Tabler etal., 2021),
LGBTQ youth (Fish et al., 2020; Gato et al., 2021; Gill & McQuillan, 2022;
Gonzales etal., 2020; Ormiston & Williams, 2022; Parchem etal., 2021), LGBTQ
older adults (Jen etal., 2020), and other health issues and outcomes (Martino etal.,
2022; Rosa etal., 2020; Washburn etal., 2022; Wypler & Hoffelmeyer, 2020).
In addition, special issues of journals and sections of journals have also focused
on LGBTQ populations and the COVID-19 pandemic (Bowleg & Landers, 2021;
Drabble & Eliason, 2021), although there is also a dire need for more research on
LGBTQ populations and COVID-19 (L.Bowleg & Landers, 2021; Chatterjee etal.,
2020; Kaufman etal., under review). Because of the timeline of when the chapters
for this edited volume were drafted, much of COVID-19-related research, which
has been published more recently, was not included. However, in general it is useful
to consider how the COVID-19 pandemic may have exacerbated many of the nega-
tive health outcomes discussed in this volume.
1.4 History, Culture, andReligion
In examining global health, it is important to contextualize health issues and out-
comes within the historical-sociocultural contexts of a given country or region. This
type of contextualization can further clarify how given health outcomes may be a
result of dynamics between these environments and individuals/populations living
within these respective settings. This may be especially important when examining
Global South populations, especially for Global North readers and researchers to
fully grasp particular health issues and outcomes in the Global South. This may also
circumvent the tendency for Global North readers and researchers to unwittingly
S. J. Hwahng and M. R. Kaufman
5
impose Global North contexts and understandings on the Global South. In addition,
an informed grasp of historical-sociocultural contexts can also provide greater
opportunities for the development of interventions that are culturally tailored and
culturally sensitive, based on evidence gathered from a “bottom-up” approach, with
a greater chance of being more effective than standard unadapted interventions
(Henderson et al., 2011; Horne et al., 2018; Jongen et al., 2017; Kalibatseva &
Leong, 2014).
For example, in the Mental Health chapter (Chap. 3), there is a discussion of
culture-bound syndromes among Global South populations. To date, there does not
seem to be research specically examining culture-bound syndromes among Global
South LGBTQ populations, and this line of inquiry may be productive in research-
ing and developing mental health interventions that may be particularly salient. In
the Community and Social Support chapter (Chap. 6), a section is devoted to
examining various forms of LGBTQ-inclusive organized religions and spiritual tra-
ditions. Health interventions integrating specic religious and spiritual traditions—
and disseminated by LGBTQ-inclusive religious and spiritual organizations—may
be particularly effective in reaching certain targeted LGBTQ subpopulations (Alvi
& Zaidi, 2021; Codjoe etal., 2021; Escher etal., 2019; Fair, 2021).
Historically, health research, with its focus on quantitative methodology, analy-
sis, and presentation of ndings, has often failed to provide historical-sociocultural
contextualization of health issues and outcomes with much meaningful breadth and
depth (Hwahng, 2016). A future direction for LGBTQ health research could be to
further contextualize health issues and outcomes within the historical-sociocultural
contexts of a given country or region, which is important to comprehensively
address health in both Global South as well as Global North countries.
1.5 Racial/Ethnic Stratication andIndigeneity
We also address racial/ethnic minorities and indigenous people who are LGBTQ in
this edited volume. For example, it is well known that LGBTQ people of color and
indigenous people (sometimes collectively referred to as “BIPOC”) who live in a
white-dominant society will often experience multiple forms of marginalization,
also known as multiple jeopardy, which can result in experiencing more extreme
forms of stressors compared to white LGBTQ people (Balsam etal., 2011; Bowleg
etal., 2003). The HIV chapter (Chap. 7) scrutinizes the overrepresentation of racial/
ethnic minorities among those living with HIV in Global North countries such as
the United States. This overrepresentation of disease burden can be attributed to
multiple and compounded stressors and racial discrimination that exist within a
framework of racial stratication (Hwahng & Nuttbrock, 2007). In the Victimization
and Intentional Injury chapter (Chap. 9), distal and proximal factors are examined
in relation to various LGBTQ populations, including indigenous LGBTQ people.
This chapter discusses how colonization and historical trauma are key structural
factors within processes of victimization and intentional injury.
1 Introduction
6
A future direction of LGBTQ health research could be to further understand the
role of race, ethnicity, and indigeneity by not only examining racial/ethnic minori-
ties and indigenous people within Global North but also within Global South coun-
tries. For example, Brazil, China, India, Indonesia, Kenya, Malaysia, Mexico, South
Africa, and Taiwan all contain a diversity of racial/ethnic groups as well as indige-
nous groups. It would thus be interesting, for example, to research the health of
indigenous LGBTQ people in Taiwan and how these health outcomes would com-
pare, say, to the health of indigenous LGBTQ people in Canada.
In addition, examining the health of white populations in the Global North or
racially dominant populations in the Global South may yield surprising discoveries.
It is often assumed that the “white privilege” (McIntosh, 1990; Rothenberg, 2008)
ascribed to white racially dominant populations in Global North countries automati-
cally confers optimal health and is the standard against which the health of other
non-white groups is measured. Thus, white LGBTQ populations may experience
sexual and/or gender minority stress (Meyer, 1995, 2003) but will also experience
white privilege. Because of this white privilege, it is assumed that white LGBTQ
people will experience fewer negative health outcomes compared to non-white
LGBTQ people. However, through the “construction of whiteness” (Guess, 2006)
that was historically used to reinforce racism, there may be detrimental health
effects, such as limited abilities to develop resiliency or adverse mental health
effects due to hyper-individualism (Borell, 2021; Casey, 2020; Huang etal., 2010)
that may be particularly salient among white LGBTQ people.
1.6 Intersectionality
One approach to examining how various aspects of identity converge and affect one
another within structural systems and processes is intersectionality, which origi-
nated in US Black feminism, indigenous feminism, third-world feminism, and
queer and postcolonial theory (Collins, 1993; Crenshaw, 2013a, b; Hankivsky &
Cormier, 2009). Structural systems and processes can privilege one type of identity
in a category (e.g., white race) and simultaneously oppress another identity in that
same category (e.g., non-white race and/or Black race), while also guiding how
these racial identities impact one another. As a research and policy paradigm
(Bowleg, 2012; Collins, 1993; Crenshaw, 2013a, b; Hankivsky & Cormier, 2009),
intersectionality has been considered to more accurately reect the complexity of
social identity compared to approaches that focus primarily on a single identity
category. Historically, intersectionality has been mostly utilized in the qualitative
social sciences, although this paradigm has been encroaching into other elds,
including public health (Hankivsky, 2012; Hankivsky & Cormier, 2009; Larson
etal., 2016; McGibbon & McPherson, 2011; Springer etal., 2012).
A pivotal construct of intersectionality subdivides the concept into three main
types: anti-categorical, intra-categorical, and inter-categorical intersectionality
(McCall, 2005). From a public health perspective, anti-categorical intersectionality
S. J. Hwahng and M. R. Kaufman
7
may occur as nonsensical because it is derived from a humanities-based post-
structuralist approach in which the categorization of identities itself is rejected or
“problematized,” lending to a near-impossibility of measurement on a population
level. On the other hand, intra-categorical intersectionality is most likely the approach
to “intersectionality” in which public health research and discourse have most
engaged. This approach, also known as the “additive” approach, is comprised of start-
ing with a single identity category and then adding identity categories together, with-
out examining the relationships between these categories. Oftentimes these categories
are also not examined in relation to greater sociopolitical-cultural systems and
processes.
Within feminist discourse, inter-categorical intersectionality is considered ideal.
This concept examines how aspects of identity (such as race/ethnicity, gender, class,
sexuality, geography, age, dis/ability, citizenship/immigration status, and religion)
mutually constitute each other within “interlocking systems” of power (Collins,
1993). For example, an individual’s race constitutes their sexuality and vice versa,
and their gender constitutes their class status and vice versa, within systems of
power, privilege, and oppression. Thus, these mutual constitutions result in differen-
tial access to power and resources depending on the respective social contexts.
Furthermore, within an inter-categorical intersectionality paradigm, aspects of iden-
tity are meaningless by themselves, and it is only at the intersections of these iden-
tity aspects that actual lived experience can be accurately described and measured.
Historically, research utilizing an inter-categorical intersectionality approach has
been best undertaken through qualitative methods. Given that population health, with
the attendant emphasis on quantitative methods, is a major cornerstone of public
health research, a challenge has emerged as to how to incorporate inter- categorical
intersectionality. In recent years, literature has emerged on quantifying inter-
categorical intersectionality in which questions and best practices for sampling, mea-
surement, and analysis have been examined (Bauer, 2014; Bowleg & Bauer, 2016).
Regarding analytic methodologies, additive-scale interaction, effect measure modi-
cation, mediation, moderated mediation, relative risk due to interaction (RERI), the
synergy index, and attributable proportion are considered possible approaches and
tools that are appropriate for inter-categorical intersectionality (Bauer, 2014). Some
researchers advocate that mixed-methods research may provide the most accurate pic-
ture of lived experiences when combining rigorous statistical approaches with in-
depth narratives (Bowleg & Bauer, 2016; Creswell & Creswell, 2017). Thus, future
directions for LGBTQ research could include designing, measuring, and analyzing
data from LGBTQ people within an inter-categorical intersectionality framework
along with designing and implementing more mixed-methods research.
1.7 Areas ofFocus
The Stigma chapter (Chap. 2) begins with denitions and key concepts including
functions and contexts of stigma and an examination of intersectional stigma.
Manifestations and experiences of stigma include structural stigma in the form of
1 Introduction
8
common and/or civil laws, religious teachings and laws, and historical traumatic
assaults. Another form of structural stigma is institutional and organizational poli-
cies that are outside of civil and religious laws. In examining how stigma manifests
on the individual level, there are those who perceive stigma, as well as those who
are targets of stigma. Stigma impacts health in a wide variety of ways and can lead
to social isolation, limits access to resources, and is associated with a range of bio-
logical, psychological, and behavioral responses. This chapter ends with a discus-
sion of interventions to address stigma including structural change, reducing stigma
among perceivers, and developing resilience among targets.
Differences in mental health between LGBTQ and cisgender, heterosexual peo-
ple are rst examined in the Mental Health chapter (Chap. 3). Types of mental
health problems and varying cultural contexts to understand mental health are then
examined. A diversity of mental health outcomes exists among the LGBTQ popula-
tion including differences across age and sex, sexual identity and gender identity,
socioeconomic status, race/ethnicity, and migration status. Geographic variations
are also discussed among various regions. Determinants of LGBTQ mental health
include minority stress, which has been shown to have cross-cultural relevance;
structural stigma in societal attitudes, laws, and policies; barriers to societal integra-
tion; and conversion therapy. This chapter next examines interventions that reduce
LGBTQ stigma as well as interventions that promote coping with stigma. Finally,
future directions are discussed, including improving research methodologies, con-
ducting more comparative cross-cultural research, disseminating LGBTQ-afrming
mental health interventions, and developing more research on aging-related demen-
tia and cognitive decline.
A general discussion of how contemporary global health issues are increasingly
shifting from infectious diseases to noncommunicable diseases (NCDs) is at the
beginning of the Introduction to Noncommunicable Diseases chapter (Chap. 4).
The impact of COVID-19 on NCDs is next examined, followed by discussions of
the effect of chronic stress on the immune system and factors contributing to NCDs.
Health disparities theories, including fundamental cause theory, compression of
morbidity theory, and cumulative disadvantage hypothesis, are then discussed. The
chapter ends with a focus on methodological considerations, including sample size
and sampling considerations.
The Noncommunicable Diseases chapter (Chap. 5) focuses on cardiovascular
disease (CVD), cancer, diabetes, asthma, and chronic obstructive pulmonary dis-
ease (COPD). These ve disease outcomes were selected because of their high
global prevalence from an extensive literature review that was completed on NCDs
among the LGBTQ population. Globally, countries were categorized as either
emerging, developed, or mature. Each section examines the global burden of a spe-
cic NCD followed by a discussion of the epidemiological ndings among sexual
minority, transgender, and non-binary gender populations within each respec-
tive NCD.
A wide variety of LGBTQ support structures and mechanisms are examined
from a global perspective in the Community and Social Support chapter (Chap.
6). The chapter begins with a general discussion of how community and social
S. J. Hwahng and M. R. Kaufman
9
support can be an antidote to sexual and gender minority stress. The rst main sec-
tion examines support in families, including parental and sibling support. Support in
schools is next discussed, followed by an examination of support in intimate partner
relationships, parenting and family-building, and among colleagues in the work-
place. Support for and within LGBTQ communities in various regions of the world
is next discussed, including elders, same-sex communities, bisexual communities,
transgender and non-binary gender communities, intersex communities, asexual/
aromantic communities, online communities, religious and spiritual groups, and
BDSM/leather and polyamory communities. Finally, a focus on both global and
local LGBTQ-related organizations is presented.
The HIV chapter (Chap. 7) begins with a discussion of key SGM subpopulations
at high HIV risk: gay, bisexual, and other cisgender men who have sex with men and
transgender women and transfeminine people who have sex with cisgender men.
HIV risk among transgender men, transmasculine people, and sexual minority
women is next examined. The chapter has a focus on the ethical challenges in global
HIV research, including concerns about the stigma and safety of research partici-
pants and mistrust of the medical research community. Methodological issues in
global HIV research are also highlighted, including challenges with recruitment and
enrollment, sampling, and cultural conceptualizations of gender identity and sexual
orientation. Multi-level factors and interventions relevant to HIV are presented, and
a focus on chronic disease and HIV is also considered. The chapter ends with a
discussion of future directions for global HIV research among LGBTQ people.
The categorization of various types of substances is rst outlined in the Substance
Use chapter (Chap. 8). Epidemiological ndings by region are next presented. Each
region is further divided focusing on sexual minority men, sexual minority women,
and transgender populations. Social-ecological determinants are then examined
including the minority stress model; psychosocial factors; social, interpersonal, and
cultural factors; and contextual, environmental, and structural factors. Consequences
of substance use are highlighted, including HIV, hepatitis C, and other sexually
transmitted infections, chronic disease outcomes, incarceration, and social isola-
tion. Finally, intervention and treatment options for alcohol use, smoking, stimulant
use disorder, and opioid use disorder are presented as well as a need for integrated
services.
The Victimization and Intentional Injury chapter (Chap. 9) begins with frame-
works for understanding intentional injury and victimization in LGBTQ popula-
tions. These frameworks include syndemics, minority stress and multilevel
inuences, colonization and intergenerational/historical trauma, and human rights.
Types of intentional injury and victimization are next delineated, including state-
sanctioned victimization, community and organizational victimization, and inter-
personal victimization. State-sanctioned victimization includes criminalization and
the death penalty, police violence and harassment, forced surgeries on intersex chil-
dren and gay/bisexual adults, and victimization of asylum seekers. Community and
organizational victimization include stigma-motivated assault and homicide, vic-
timization through employment discrimination, and workplace harassment.
Interpersonal victimization includes adverse childhood experiences, intimate
1 Introduction
10
partner violence, sexual violence, and elder abuse. Polyvictimization, which is
experiencing multiple forms of victimization, is then discussed. Structural, com-
munal, and individual risk factors for victimization are next examined, followed by
a focus on health consequences. Various forms of prevention and interventions are
then presented, including decolonization, structural/policy interventions, organiza-
tional and community interventions, and individual interventions.
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15
Chapter 2
LGBTQ Stigma
ValerieA.Earnshaw, CarmenLogie, JeffreyA.Wickersham,
andAdeebaKamarulzaman
Lesbian, gay, bisexual, transgender, and/or queer (LGBTQ) individuals face sig-
nicant stigma globally. As examples, Viccky Gutierrez, a young transgender
woman from Honduras, was the rst of two dozen transgender women to be
killed in the United States in 2018 (Human Rights Campaign Foundation 2019).
In early January, she was stabbed to death before her body was set on re in her
Los Angeles home. By summer, the Humans Rights Campaign would character-
ize fatal violence toward transgender women of color as a “national epidemic” in
the United States. In August 2018, police and government ofcials raided a
LGBTQ night club in Kuala Lumpur, Malaysia (Ellis-Peterson 2018). Twenty
men were detained and ultimately ordered into counseling, and a government
ofcial released a statement that “hopefully this initiative can mitigate the LGBT
culture from spreading into our society.” News broke of a “gay purge” in
Chechnya in December, wherein approximately 40 men and women were
detained and tortured, and two killed, upon suspicion of being sexual minorities
(Vasilyeva 2019). This is only the most recent of a series of “detentions, torture
and killings of gay people” in Chechnya, some of which were reported in 2017.
V. A. Earnshaw (*)
Human Development and Family Sciences, University of Delaware, Newark, DE, USA
e-mail: earnshaw@udel.edu
C. Logie
Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
e-mail: carmen.logie@utoronto.ca
J. A. Wickersham
Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA
e-mail: jeffrey.wickersham@yale.edu
A. Kamarulzaman
Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
Monash University Malaysia, Subang Jaya, Malaysia
e-mail: adeeba.kamarulzaman@monash.edu
© The Author(s) 2024
S. J. Hwahng, M. R. Kaufman (eds.), Global LGBTQ Health, Global LGBTQ
Health, https://doi.org/10.1007/978-3-031-36204-0_2
16
Globally, stigma experienced by LGBTQ individuals ranges from extreme
acts of violence, including those described above, to more subtle yet pervasive
forms of marginalization and social exclusion, including being socially
rejected, denied employment opportunities, and receiving poor healthcare.
Stigma has been identified as a fundamental cause of health that leads to sig-
nificant health inequities (Carroll & Ramón Mendos 2017; Hatzenbuehler,
Phelan & Link 2013). Public health researchers, practitioners, policy makers,
and other stakeholders have a key role to play in addressing stigma to improve
the wellbeing of LGBTQ individuals worldwide. In this chapter, we summarize
research and theory that defines LGBTQ stigma, documents ways in which
stigma is manifested and experienced by LGBTQ individuals, articulates how
stigma leads to health inequities among LGBTQ populations, and identifies
evidence-based intervention strategies to address LGBTQ stigma. In doing so,
we provide recommendations to readers for addressing stigma to promote
LGBTQ health equity globally.
2.1 Stigma Denitions andKey Concepts
Theorists and researchers from several disciplines, including sociology, anthro-
pology, psychology, and public health, have dened stigma and articulated key
concepts relevant to stigma and health inequities. In 1963, Erving Goffman
dened stigma as social devaluation and discrediting (Goffman, 1963). In 1981,
Virginia Brooks introduced minority stress theory (Brooks, 1981). Ilan Meyer
built on this theory when he characterized LGBTQ stigma as a signicant and
chronic stressor that undermines the health of gay men (Meyer, 1995). Minority
stress theory, which was developed in the United States, continues to be the
most widely used theory for understanding and addressing LGBTQ stigma glob-
ally (Nakamura & Logie, 2019). It is applied by LGBTQ communities around
the world that have found it to be useful for their local socio-cultural contexts.
Theorists have moved beyond individual- level conceptualizations of stigma by
adopting a sociological lens, and stigma has been described as a social process
that exists when labeling, stereotyping, separation, status loss, and discrimina-
tion occur within a power context (Link & Phelan, 2001). This social process is
expressed or experienced as stigma manifestations within structures (e.g., codi-
ed within laws) and individuals (e.g., experienced as discrimination), and in
turn, these stigma manifestations affect the health of stigmatized individuals
both directly and through mediating mechanisms (Hatzenbuehler etal., 2013;
Stangl etal., 2019). In this way, stigma leads to health inequities or disparities
among stigmatized groups, which are avoidable health differences between
groups of people (Braveman, 2006). In the sections below, we further elaborate
on stigma manifestations and describe how they are related to health outcomes
among LGBTQ people. First, we highlight several key concepts related to
stigma and health inequities.
V. A. Earnshaw et al.
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2.1.1 Functions ofStigma
Stigma is theorized to play societal functions across socio-cultural contexts
(Kurzban & Leary, 2001). Phelan, Link, and Dovidio theorize that LGBTQ stigma
operates to “keep people in” their expected gender roles, enforcing social norms
surrounding sexuality and gender (2008). Although we used the term LGBTQ
stigma, we recognize there are rich bodies of literature that focus on stigma toward
sexually diverse persons (lesbian, bisexual, gay, and queer, among other nonhetero-
sexual identities; Herek, 2007) as well as a growing body of literature documenting
stigma targeting transgender persons (Hughto White etal., 2015). Sexually diverse
persons may be cisgender (identify their gender with the sex they were assigned at
birth), transgender (do not identify their gender with the sex assigned at birth), non-
binary (identifying with no gender, or across genders), or other genders. The impli-
cations are that persons under the LGBTQ umbrella may experience both sexual
stigma and trans stigma; for instance, a gay trans man can experience marginaliza-
tion due to their sexuality and gender identity.
Stigma functions to dene the boundaries of acceptable sexual and gender identi-
ties, practices, expressions, and communities and creates social consequences for
violating these boundaries. Heterosexism operates across social, cultural, religious,
political, and legal domains to erase the representation of, and devalue, sexual and
gender diversity and to produce heterosexuality as normal, natural, and universal
(Rubin, 1994). This has been conceptualized as compulsory heterosexuality: where
all persons are assumed to be heterosexual and where it is assumed that all persons
should be heterosexual (Fish, 2008). Compulsory heterosexuality is enacted in soci-
ety by punishing persons who are not heterosexual (e.g., with stigma) and by having
incentives at material (e.g., ability to marry) and ideological (e.g., acceptance by
religion) levels for heterosexual persons (Rich, 1980). The parallel term cisnorma-
tivity refers to the ways in which sociocultural norms and expectations surround
gender in ways that assume all persons are, and should be, cisgender (Bauer etal.,
2009). Compulsory heterosexuality maps onto what Phelan, Link, and Dovidio
describe as functions of LGBTQ stigma and other stigmas to “keep people in” (i.e.,
keep people within the “in group” by enforcing social norms) and may be applied to
characteristics that are perceived to be voluntary or chosen. LGBTQ stigma repro-
duces the discourse that persons who do not adopt heterosexual and/or binary gen-
der norms do so voluntarily, and thus, their sexuality and gender can be changed.
There continues to be a long-standing debate over whether or not gender and sexual-
ity are innate (something that one is born with) or whether they are uid and chang-
ing (thus may change over one’s life). Regardless of this debate, stigma reproduces
inequities that pressure conformity with hegemonic gender norms and punish those
that do not conform.
Historically, compulsory heterosexuality and cisnormativity were often introduced
during colonization, thereby creating new hegemonic gender norms within colonized
societies. In some places, such as among many indigenous societies in the Americas,
compulsory heterosexuality and cisnormativity were enforced among people who
2 LGBTQ Stigma
18
previously recognized and accepted gender and sexual diversity (Jacobs etal., 1997).
In other places, such as among the Yorùbá in Western Africa, gender binaries were
introduced to people who had not previously recognized an overarching gender sys-
tem (Oyěwùmí, 1997). By introducing and enforcing compulsory heterosexuality and
cisnormativity, LGBTQ stigma was essentially created in some societies where it did
not previously exist. The creation of hierarchical social categories, spanning sexual
orientation, gender, race, and other lines, was a tool of exploitation that helped colo-
nizers establish power and control over indigenous people (Lugones, 2010).
2.1.2 Stigma Contextualized
Norms surrounding gender and sexuality vary across cultural contexts, and thus
LGBTQ stigma manifests differently across cultural contexts. For example, holding
hands is a normative behavior for heterosexual men in many areas of the world, includ-
ing Saudi Arabia, India, and Bangladesh. In these contexts, holding hands is within the
boundaries of acceptable masculine behaviors, and there are no negative social conse-
quences associated with the behavior. In many Western countries, however, holding
hands, as well as other casual physical contacts between men, is not normative and
violates accepted norms of masculinity. In these settings, two men holding hands is a
clear violation of the proscribed norms of masculinity, and such behaviors are policed
by others in the culture who may respond with behaviors ranging from disapproving
looks to physical assault (Logie etal., 2016). Yet the expectations to adhere to gender
norms, and the stigma and negative consequences that follow from breaking these gen-
der norms, reect the concept of hegemonic masculinity (Gibbs etal., 2014). Relational
approaches to conceptualizing gender suggest that gender hierarchies underpin the
ways that masculinity and femininity are constructed and controlled (Connell, 2012).
Although gender and sexuality norms may vary between contexts, most are centered
on gender inequity and the use of violence as a way of gaining power and reproducing
adherence to gender norms (Gibbs etal., 2014; Torres etal., 2012).
Stigma is further theorized to be dependent on, or rooted in, specic historical,
social, and cultural contexts (Crocker & Major, 1989; Yang etal., 2007). Although
stigma seems to exist everywhere, the extent to which certain characteristics and
identities are stigmatized, the ways in which stigma is manifested, and how stigma
affects health may vary across time and place. For example, the transgender stigma
has both waxed and waned in India over the last several centuries (Michelraj, 2015).
Historically, India recognized a “third sex” called hijras, which included persons
who do not conform to binary conceptions of gender. Throughout history, hijras
played socially valued positions within society, including as political advisors and
generals. Starting in the eighteenth century, however, hijras were criminalized under
British colonial law, leading to a growing anti-transgender sentiment in India and
stigma toward the hijra community. During this time, myths spread that hijras kid-
napped young boys for sex, and many hijras were forced to turn to sex work as other
forms of employment and economic empowerment were denied to them (Nanda,
1986). In 2014, India’s Supreme Court ofcially recognized a third gender, both
reecting and contributing to weakening transgender stigma.
V. A. Earnshaw et al.
19
Yang and colleagues (Yang etal., 2014) propose that stigma undermines indi-
viduals’ capacity to participate in “what matters most” within a cultural context,
thereby preventing individuals from achieving full status within their cultural group.
For example, contributing to family lineage through heterosexual marriage and hav-
ing children is valued in many Asian cultures (Raymo etal., 2015). South Asian gay
men describe experiencing shame and bringing dishonor to their families if they do
not participate in these social obligations (Mckeown etal., 2010). In African and
Caribbean cultures, wherein heterosexual conceptualizations of masculinity are val-
ued, being gay is viewed as a “white/European” disease, and African and Caribbean
gay men are accused of rejecting their cultural background (Mckeown etal., 2010;
Semugoma etal., 2012).
2.1.3 Intersectional Stigma
Intersectionality theory emphasizes that individuals live with multiple intercon-
nected identities and characteristics that represent dimensions of both marginaliza-
tion and privilege (Crenshaw, 1991; hooks, 1990; Rosenthal, 2016). In addition to
experiencing stigma associated with their sexual orientation and/or gender identity,
LGBTQ individuals may experience stigma associated with other identities and
characteristics such as their race or ethnicity, socio-economic status, or physical or
mental health. Similarly, LGBTQ individuals may also experience privilege associ-
ated with other identities and characteristics. Thus, intersectionality theory draws
attention to the great amount of variability in stigma-related experiences among
LGBTQ individuals. For example, a gay man from NewYork City in the United
States may experience stigma very differently than a lesbian woman from Islamabad
in Pakistan. Although both individuals may experience stigma related to their sexual
orientation, the ways in which they experience and respond to this stigma, and the
extent to which it undermines their health, may be shaped by how their sexual iden-
tity intersects with their other identities including race, ethnicity, gender, and/or
religion (Logie, 2014). The current chapter focuses on LGBTQ stigma but considers
how experiences related to individuals’ other identities and characteristics intersect
with their experiences of LGBTQ stigma.
2.2 LGBTQ Stigma Manifestations andExperiences
2.2.1 Structural Stigma
LGBTQ stigma is manifested at multiple levels, and stigma at each level has both
direct and indirect effects on LGBTQ health inequities. At the structural level,
stigma is manifested within common and/or civil laws, religious teachings and laws,
and historical traumatic assaults. Notably, the overlap between common/civil and
religious law exists on a continuum globally (Sands, 2007). That is, there is much
2 LGBTQ Stigma
20
overlap between common/civil and religious law in some countries, wherein reli-
gious law dictates or overlaps with common/civil law. For example, in some Islamic
countries, there is a great deal of overlap between Shariah law, which is Islamic law,
and common/civil law. In other countries, there is a greater separation of common/
civil and religious laws. We differentiate between common/civil and religious law
below but recognize the overlap between the two in many areas of the world.
2.2.1.1 Common andCivil Law
Worldwide, there are a range of government laws that criminalize the gender expres-
sion and/or sexual practice of LGBTQ individuals. According to the International
Lesbian, Gay, Bisexual, Trans and Intersex Association’s State-Sponsored
Homophobia Report, 71 countries (37% of all UN countries) criminalized same-sex
acts between men, and 45 countries criminalized acts between women in 2017
(Carroll & Mendos, 2017). For example, Burundi’s Article 567 states, “Whoever
has sexual relations with someone of the same sex shall be punished with imprison-
ment for three months to two years and a ne of fty thousand to one hundred
thousand francs or one of those penalties” (Carroll & Mendos, 2017). This law
applies to both men and women. Some countries with such laws enforce them very
rarely or never, but Article 567 was enforced in Burundi between 2014 and 2017.
Eight countries apply the death penalty as a consequence of violation of the law. For
example, areas held by Daesh (i.e., ISIS/ISIL) in Iraq and Syria have a law entitled
“Punishment for Sodomy,” which states, “The religiously sanctioned penalty for
sodomy is death, whether it is consensual or not. Those who are proven to have
committed sodomy, whether sodomiser or sodomised, should be killed.” Several
additional countries, including Afghanistan, Pakistan, Qatar, the United Arab
Emirates, and Mauritania, have codied the death penalty into the law but have not
enforced it for same-sex practices in recent years.
There are also laws that criminalize the gender expression of transgender indi-
viduals and/or deny the afrmation of their gender identity. Malaysian states have
had laws prohibiting a “male person posing as woman” or “female person posing
as man” (Human Rights Watch, 2014). In 2014, 16 Malaysian transgender women
were arrested for engaging in so-called cross-dressing behavior and sentenced to
seven days in jail. The ruling was appealed, and the appeals court ruled the cross-
dressing law to be unconstitutional, describing it as “discriminatory and oppres-
sive and denies the appellants the equal protection of the law” (Human Rights
Watch, 2014). In Iran, the law requires individuals to wear “gender-appropriate”
clothes in public (Bagri, 2017). As examples, women must wear the hijab and
cover their heads, arms, and legs, and men cannot have long hair or plucked eye-
brows. Transgender individuals in Iran report frequent harassment from the police
for violating clothing laws. Laws limiting access to bathrooms and locker rooms
that match individuals’ gender identity, which have been proposed and some-
times passed in the United States, represent additional forms of structural stigma
(Barnett etal., 2018).
V. A. Earnshaw et al.
21
In addition to civil laws criminalizing same-sex practices or gender expression
specically, 19 countries (10% of UN countries) had promotion (“propaganda”) and
morality laws limiting freedom of expression related to sexual orientation and gen-
der identity in 2017 (Carroll & Mendos, 2017). For example, Article 198 of Kuwait’s
Penal Code states: “Whoever makes a lewd signal or act in a public place or such
that one may see it or hear it from a public place, or appears like the opposite sex in
any way, shall be punished for a period not exceeding one year and a ne not exceed-
ing 1000 Dinar or one either of these punishments.” In the United States, seven
states have enacted local laws that restrict health/sexuality education teachers from
discussing LGBTQ people and/or topics in a positive light (GLSEN, 2019). The
Gay, Lesbian and Straight Education Network has criticized these laws because
they prevent LGBTQ students from learning important health information and pro-
vide false, misleading, and/or incomplete information about LGBTQ people.
Moreover, 25 countries (13% of UN countries) have laws preventing the formation,
establishment, or registration of LGBTQ-related nongovernmental organizations
(NGOs; Carroll & Mendos, 2017). These laws prevent nonprot advocacy and ser-
vice organizations from formally representing LGBTQ groups in national and inter-
national forums, wherein they can advocate for LGBTQ rights. For example,
Bahrain’s Law 21 Article 3 details that groups which “contradict(s) the public order
or moral” or undermine the “social order” are illegal.
2.2.1.2 Religious Teaching andLaw
LGBTQ stigma is further manifested at the structural level within religious teach-
ings and laws. The most popular religions globally include Christianity (31.2% of
the world population in 2015), Islam (24.1%), and Hinduism (15.1%) (Hackett &
McClendon, 2017). Notably, there is variability in how members of all religions
view and treat LGBTQ individuals, with some sects and members of each religion
adopting more accepting and welcoming approaches than others. Given the focus of
this chapter, we focus on stigmatizing aspects of religious teachings and laws herein
but acknowledge this variability.
Christianity has historically held that sex should be engaged in for reproductive
purposes only, and nonreproductive sex, including sex between men or women, was
deemed unnatural and immoral (Sands, 2007). Many Christian denominations teach
that same-sex practices are sinful. Several denominations acknowledge that attraction
to members of the same sex is not voluntary, or a personal choice, but recommend that
individuals who are attracted to members of the same sex practice chastity. Christian
organizations have supported conversion therapy and camps, which aim to change the
sexual orientation, gender identity, and/or gender expression of LGBTQ people
(Mallory etal., 2018). The Williams Institute estimates that 698,000 LGBT adults
have received conversion therapy in the United States, about half of whom were
exposed to this therapy as adolescents. Although several professional health associa-
tions, including the American Medical Association and American Psychological
Association, have issued statements opposing conversion therapy, they remain legal in
2 LGBTQ Stigma
22
most states in the United States and countries globally (Mallory etal., 2018). Notably,
some Christian denominations, including the Church of England, are changing their
stances and calling for bans on conversion therapy (Sherwood, 2017).
Similar to Christianity, sex outside of marriage is prohibited within Islam, and
marriage must be between a man and a woman (Siker, 2007). Shariah law, or Islamic
religious teachings, denes various punishments for same-sex sexual practices in
different contexts, ranging from nes, ogging, and imprisonment to death (Sands,
2007). As an example, sexual intercourse between men is dened as a misdemeanor
under Shariah law in Saudi Arabia (Carroll & Mendos, 2017). Although same-sex
sexual practices are not specically described as punishable by death, same-sex
marriage is not legal, and having sex outside of marriage is punishable by death by
stoning. Shariah law additionally targets the gender expression of transgender indi-
viduals by prohibiting men from “posing” as women or women from “posing” as
men (Human Rights Watch, 2014). Gender-afrming surgery is treated differently
in various Muslim countries. For example, gender-afrming surgery among
Muslims in Malaysia is prohibited by a fatwa (i.e., religious ruling) (Human Rights
Watch, 2014). Although this rule does not technically apply to non-Muslims, trans-
gender individuals of all faiths have difculty accessing gender-afrming surgery.
In contrast, Iran partially subsidizes gender-afrming medication and surgery
(Bagri, 2017; Carter, 2010). A fatwa permits sex changes for individuals with gen-
der identity disorders, which may be diagnosed by a doctor, judge, or Imam (Carter,
2010). Medication and surgery are offered, in part, because transgender individuals
are viewed as having a psychological problem in need of treatment. Moreover, med-
ication and surgery reinforce traditional conceptualizations of binary genders. The
alternative to undergoing medication and surgery is the death penalty (Bagri, 2017).
In Hinduism, religious law is somewhat more ambiguous in its treatment of
same-sex practices (Sands, 2007). Several religious texts, including the Dharma and
Arthaśāstra, forbid and/or penalize same-sex sexual practices. Yet, some traditional
aspects of Hinduism support same-sex sexual practices. The Kama Sutra includes
instruction on same-sex sexual pleasure, and hijras represent a third-sex tradition
who are born male but may assume feminine identities and have sex with men. In
2014, India’s supreme court recognized transgender people as an ofcial third gen-
der, thereby granting hijras legal status, protections, and rights (Khaleeli, 2014).
2.2.1.3 Historic Traumatic Assaults
Recent stigma scholarship has increasingly recognized the role of historical traumatic
assaults on health inequities (Sotero, 2006). Historic traumatic assaults include histori-
cal examples of extreme discrimination, typically at the structural level, toward LGBTQ
people. The spread of criminalization of same-sex sexual practices under British colo-
nialism represents a key example of historic traumatic assaults that has had a pro-
nounced and lasting legacy (Han etal., 2014). Starting in 1860, the British Empire
spread legal codes to its colonies that criminalized same- sex sexual practices with pun-
ishments including nes and lengthy imprisonment. For example, Section 377 of the
V. A. Earnshaw et al.
23
British Penal Code criminalized “unnatural” sexual acts, including those between men
(Carroll & Mendos, 2017). These codes were designed to prevent both British soldiers
and colonial administrators from engaging in same-sex sexual practices as well as
enforce heterosexual Christian values (Han etal., 2014). Today, former British colonies
are more likely than others to have laws that criminalize same-sex sexual practices
(Han etal., 2014). For example, countries including Bangladesh, Brunei, Malaysia,
Myanmar, Pakistan, Singapore, and Tanzania continue to uphold Section 377. Some
have commented on the “irony of African homophobia,” whereby countries that kept
colonial laws have been constructed as “backward” by former colonizers such as
Britain who has since changed those laws (Semugoma etal., 2012).
More recently, the Nazis persecuted LGBTQ populations as part of their efforts
to morally and culturally purify Germany (Plant, 1986; United States Holocaust
Memorial Museum, 2019). Between 1933 and 1945, an estimated 100,000 men
were arrested for violating laws against homosexuality, 50,000 were sentenced to
prison, and 5000 to 15,000 were sent to concentration camps. During this time
period, the police raided the Institute for Sexual Science in Berlin and burned a col-
lection of tens of thousands of books and pictures documenting LGBTQ culture.
Other examples of historical trauma may be characterized as less violent in nature,
but still impactful. In the United States, the Diagnostic and Statistical Manual of
Mental Disorders pathologized homosexuality until 1973 (Drescher, 2015). This
licensed psychologists and physicians to attempt to “cure” sexual minorities via a
range of so-called “conversion therapies.” Although the impact of historic traumatic
assaults on health inequities is understudied in comparison to other stigma manifes-
tations, evidence suggests that awareness of these historic events and traumas leads
to psychological distress and unhealthy behaviors (e.g., elevated substance use, per-
haps as a coping mechanism) (Sotero, 2006).
2.2.1.4 Other Institutional andOrganizational Policies
Structural stigma is further manifested within institutional and organizational policies,
which exist outside of civil and religious laws. These include institutional policies that
prohibit the changing of gender or sex and name on identication cards, legal docu-
ments, and medical records, thereby denying transgender individuals’ afrmation of
their gender identity. There are also policies that prohibit same-sex couples from
adopting children, thereby denying gay and lesbian couples rights to parenthood. This
structural stigma may additionally affect the health of LGBTQ individuals who live
in, work for, or receive healthcare from these institutions and organizations.
2.2.2 Individual Level
At the individual level, stigma is manifested both among people who do not identify
as LGBTQ as well as people who do identify as (or are perceived by others to be)
LGBTQ.People who do not identify as LGBTQ may be referred to as “perceivers”
2 LGBTQ Stigma
24
or “perpetrators” (Bos etal., 2013) These may include members of the general pub-
lic, healthcare workers, the police, religious leaders, friends and family members,
employers and coworkers, and others. Stigma is further manifested among LGBTQ
individuals who may be referred to as “targets” of stigma (Bos etal., 2013).
2.2.2.1 Perceivers
Stigma among perceivers is manifested as perceived stigma, prejudice, stereotypes,
and discrimination. Perceived stigma involves the awareness of and perception that
people with minority sexual orientations and gender expressions/identities are
socially devalued and discredited (Herek, 2007; Stangl et al., 2019). Prejudice
involves negative emotions and feelings that people feel toward LGBTQ individu-
als, such as discomfort and disgust (Herek, 2007; Stangl etal., 2019). Stereotypes
are thoughts and beliefs that people hold about LGBTQ individuals, such as gay
men being effeminate or lesbian women being masculine (Herek, 2007; Stangl
etal., 2019). Discrimination includes unfair or unjust treatment of LGBTQ indi-
viduals (Herek, 2007; Stangl etal., 2019). As previously noted, discrimination may
range from subtle treatment, such as social rejection, to more extreme treatment,
such as physical violence. Evidence suggests that prejudice, stereotyping, and dis-
crimination may be explicit, wherein perceivers are aware of their own bias toward
LGBTQ individuals, or implicit, wherein perceivers are unaware of their own bias
toward LGBTQ individuals (Dovidio etal., 2008; Dovidio & Gaertner, 2004).
There is a great deal of variability in these individual-level stigma manifestations
globally. In 2016, the International Lesbian, Gay, Bisexual and Trans and Intersex
Association and RIWI (Real-Time Interactive World-Wide Intelligence) Corp sur-
veyed 96,331 people in 54 countries about their attitudes toward LGBTI (lesbian,
gay, bisexual, transgender, and intersex) people (Carroll & Robotham, 2016).
Responses to several survey items, including indicators of prejudice and discrimina-
tion, are displayed in Fig.2.1. Results generally suggest the most negative attitudes
toward LGBTI people among respondents in Africa, followed by Asia, the Americas,
and Europe, and the most positive attitudes in Oceania.
Stigma theory suggests that individual-level stigma manifestations are shaped, in
part, by sociocultural context. A 2009 study including data from individuals in 19
countries found that 29% of the variance in individuals’ attitudes toward LGB peo-
ple was shaped by their country context (i.e., between-nation variance), with the
remainder shaped by individual beliefs and characteristics (i.e., within-nation vari-
ance, including sociodemographics and religious afliation) (Adamczyk & Pitt,
2009). This study additionally found that individuals living in Muslim-majority
countries have more disapproving attitudes toward LGB people than individuals
living in Catholic- and Protestant-majority countries, regardless of their personal
religious afliation. Finally, individuals living in nations characterized by survival-
ist orientations, which often arise from political and economic uncertainty and inse-
curity, had more disapproving attitudes toward LGB people.
V. A. Earnshaw et al.
25
70
60
50
40
30
20
10
0Africa Asia Americas Europe Oceania
Uncomfortable with gay or lesbian
neighbour
Unacceptable for male child to
dress and express self as girl
Same-sex marriage should be\
illegal
Being gay, lesbian, transgender,
or intersex should be a crime
Same-sex desire is western
world phenomenon
Percentage agreement
Fig. 2.1 Regional differences in attitudes toward LGBTI people. (Data are from the 2016 ILGA/
RIWI Global Attitudes Survey on LGBTI People (Carroll & Robotham, 2016))
2.2.2.2 Targets
Similar to perceivers of stigma, targets may experience perceived stigma. That is,
they may be aware of LGBTQ stigma and perceive that people with minority sexual
orientations and gender expressions/identities are socially devalued and discredited
(Herek, 2007; Logie etal., 2016, 2018b, c; Stangl etal., 2019). Targets of stigma
may additionally experience several unique stigma mechanisms, including internal-
ized stigma, enacted stigma, and anticipated stigma. Internalized stigma has also
been called internalized homophobia and self-stigma, and refers to the degree to
which LGBTQ individuals are aware of the negative beliefs and feelings about
LGBTQ individuals and apply them to the self (Herek, 2007; Stangl etal., 2019).
According to minority stress theory (Meyer, 1995), LGBTQ people are aware of
these negative beliefs and feelings early in life, even before they begin to develop
their own sexual and gender identities. As LGBTQ individuals begin to become
aware of their sexual and gender identities, they may also begin to apply these nega-
tive beliefs and feelings to the self. On average, internalized stigma is theorized to
be highest during the early stages of LGBTQ identity development and then
decreases over time (Meyer, 1995). Internalized stigma may be shaped, in part, by
sociocultural context. For example, LGBTQ individuals with strong Christian reli-
gious and spiritual afliations describe intense feelings of shame, fear, and guilt
during adolescence that led to psychological distress (Kubicek etal., 2009). With
time, some LGBTQ individuals report beginning to more critically evaluate reli-
gious messages and develop stronger coping mechanisms, ultimately leading to
decreased internalized stigma. This critical reection and reframing of religious
values and cultural identities can also be done in solidarity and conversation with
other LGBTQ persons, as observed in Swaziland, Lesotho, and Jamaica (Logie
etal., 2016, 2018c). For instance, participatory theater has been used to represent
stories of stigma experienced by LGBTQ individuals in Swaziland and Lesotho
2 LGBTQ Stigma
26
(Logie etal,. 2019a). Audience members are called upon to identify stigmatizing
experiences portrayed within a skit and develop solutions, which promotes self-
reection, empathy, and solidarity.
Enacted stigma, which has also been called the experienced stigma, involves
perceptions of experiences of discrimination from others in the past or future
(Herek, 2007; Stangl etal., 2019). LGBTQ individuals report a wide range of expe-
riences of enacted stigma in a variety of social contexts (e.g., familial, employment,
housing, and medical care) globally (Logie et al., 2018a). The Human Rights
Campaign and Human Rights Watch have documented often extreme forms of
physical and sexual violence toward LGBTQ individuals globally, including those
described in the introduction to this chapter. In addition to its acute and blatant
forms, enacted stigma may also be chronic and subtle. Recent scholars have devel-
oped a taxonomy of subtle forms of enacted stigma, sometimes referred to as micro-
aggressions (Nadal et al., 2016). According to Nadal and colleagues, prominent
forms of microaggressions that impact LGBTQ people include exposure to hetero-
sexist or transphobic terminology (e.g., “that’s so gay”), being fetishized, encoun-
tering denial of LGBTQ stigma, and being expected to hide one’s sexual orientation
and/or gender identity or expression. Additional forms of subtle, yet pernicious,
enacted stigma experienced by transgender individuals may include dead-naming
(i.e., using the birth name of someone who has since changed their name) or mis-
gendering (i.e., referring to someone with a pronoun or word that does not reect
their gender identity).
Anticipated stigma involves expecting to experience discrimination from others
in the future (Stangl etal., 2019). Given that minority sexual orientation and gender
expression/identity are often concealable, LGBTQ individuals may worry about
how others will respond to them if and when they learn of their LGBTQ identity.
This may include fear or worry of social rejection, physical or sexual violence, or
other consequences if others learn of one’s LGBTQ identity. Importantly, individu-
als do not have to personally experience enacted stigma to anticipate stigma. They
may anticipate stigma based on perceiving stigma in their environment or becoming
aware of other LGBTQ people experiencing enacted stigma. This can result in per-
sons hiding and concealing their sexual and/or gender identities, which in turn can
contribute to isolation and depression.
2.3 Processes Linking LGBTQ Stigma withHealth
Stigma undermines a wide range of health outcomes among LGBTQ individuals,
including those focused on within other chapters of this book. Several key mediat-
ing mechanisms linking stigma with health have been identied, including social
isolation; access to resources; and psychological, behavioral, and biological
responses (Chaudoir etal., 2013; Hatzenbuehler etal., 2013). Each of these mediat-
ing mechanisms represents pathways through which stigma affects health outcomes.
V. A. Earnshaw et al.
27
2.3.1 Social Isolation
Stigma leads to social isolation, which undermines health. LGBTQ people throughout
the world experience rejection from family members. This rejection may be particu-
larly harmful within cultures wherein social relationships are interdependent (as in
many Global South societies), in part, because individuals’ perceptions of themselves
are more strongly inuenced by their relationships with their family members (i.e.,
interdependent self-construal) (Chow & Cheng, 2010; Markus & Kitayama, 1991).
Therefore, rejection from family members may result in more internalized stigma.
Among lesbian women in Hong Kong, for example, lower perceived social support
from family was shown to be associated with greater shame and less outness to friends,
which may lead to greater social isolation and less social support (Chow & Cheng,
2010). Social support, including comfort, information, and/or assistance from others,
is a powerful predictor of positive health outcomes; social isolation prevents individu-
als from drawing on this health-promoting resource.
Social rejection and isolation often begin at an early age (Ryan etal., 2009) and
may be experienced throughout the lifespan. LGBTQ youth experience elevated rates
of bullying from peers in school, which is often characterized by social distancing and
rejection, and is associated with an increased risk of suicidal ideation, attempts, and
completion (Earnshaw etal., 2017). Social isolation continues into middle and older
adulthood. In Thailand, relationships between young transmasculine “toms” and
young cisgender women are viewed as protecting cisgender women from engaging in
“real sexual” relationships with cisgender men before marriage (Sinnott, 2004). Yet,
these partnerships to preserve cisgender women’s virginity are often only temporary:
Once cisgender women are ready to enter into heteronormative marriages, they end
their relationships with their transmasculine partners (Sinnott, 2004). This results in a
multitude of middle-aged and older transmasculine tom adults who are stigmatized
for being LGBTQ and single. Research in Jamaica additionally describes the role that
stigma plays in preventing close, intimate, and lasting same-sex relationships, once
again increasing the likelihood of persons not being able to benet emotionally and
nancially from long-term relationships, if they chose (Logie etal., 2018a). In Brazil,
social rejection from family members leads some transgender women of color to
become overly dependent on support from romantic partners, some of whom take
advantage of them (Kulick, 1998). Moreover, although LGBTQ older adults are more
likely to receive caregiver support from friends, they are less likely to receive support
from family members as older adults (Croghan etal., 2014).
2.3.2 Access toResources
Stigma constrains access to resources that promote health in a wide range of contexts.
For example, Badgett documented the exclusion of LGBTQ individuals from educa-
tion and employment settings in India (Badgett, 2014). Educational opportunities may
2 LGBTQ Stigma
28
be denied to LGBTQ Indians, and LGBTQ Indians may leave educational settings
due to enacted stigma from fellow classmates and teachers. This results in lower rates
of literacy and educational achievement among LGBTQ Indians, including transgen-
der individuals and men who have sex with men. LGBTQ Indians report being denied
workplace opportunities, harassed by co-workers, and overhearing anti-gay com-
ments at work. Badgett concludes that stigma in education and employment settings
plays a role in elevated rates of poverty observed among LGBTQ Indians, which in
turn affects health. Badgett further identies LGBTQ stigma as leading to homeless-
ness among LGBTQ Indians, who report having difculty obtaining housing. Poverty
and housing insecurity are powerful determinants of health.
Stigma additionally creates roadblocks to accessing healthcare. As documented
earlier in this chapter, transgender individuals have difculty accessing gender-
afrming medications, surgeries, and treatment in many areas of the world, often
due to structural stigma. At the individual level, research suggests that stigma
endorsed by healthcare providers is associated with the provision of worse care to
stigmatized individuals (Dovidio etal., 2008). For example, our previous work has
documented substantial prejudice toward men who have sex with men among medi-
cal students in Malaysia (Jin etal., 2014), which is related to intentions to discrimi-
nate against this group within healthcare settings (Earnshaw etal., 2016b). We have
found similar dynamics among medical doctors in Malaysia, who endorse prejudice
toward and intend to discriminate against transgender patients (Vijay etal., 2018).
Additional work suggests that providers who endorse greater LGBTQ stigma are
less likely to prescribe pre-exposure prophylaxis (PrEP; i.e., an HIV prevention
mediation) to men who have sex with men (Calabrese etal., 2017).
Moreover, LGBTQ individuals may avoid healthcare settings and delay needed
care because they have experienced or expect to experience stigma from healthcare
providers. In Jamaica, misgendering and judgment from nurses present barriers for
LGBTQ persons accessing HIV testing (Logie et al., 2018a). Moreover, stigma
regarding same-sex practices among men presents barriers for gay and bisexual men
purchasing condoms and lubricants, and many order lubricants online from the
United States to reduce experiences of stigma and discrimination when accessing
these sexual health resources (Logie etal., 2018a). In Swaziland, lesbians also expe-
rience stigma and judgment from healthcare providers, including “virginity” tests
where healthcare providers examine the hymen to assess if women have had pene-
trative sex (Logie etal., 2018c). This suggests the role that compulsory heterosexu-
ality (not believing persons who state they are lesbian/gay) plays in shaping LGBTQ
persons’ healthcare experiences.
2.3.3 Biological, Psychological, andBehavioral Responses
Stigma is additionally associated with a range of biological, psychological, and behav-
ioral responses that have implications for health. Stress is highlighted as a central
mechanism through which stigma gets “under the skin” and leads to LGBTQ health
V. A. Earnshaw et al.
29
inequities (Hatzenbuehler etal., 2009; Meyer, 1995, 2010). Stigma results in physical
stress and psychological stress, or perceptions that demands in the environment exceed
one’s capacity (Cohen etal., 2007). Acute experiences of stress have an immediate
impact on the body, including activation of the sympathetic nervous system, which
leads to increases in blood pressure and heart rate, and hypothalamic- pituitary- adrenal
axis, which leads to the production of corticosteroids including cortisol (Taylor &
Stanton, 2007). Chronic experiences of stress, which include threats that last over long
periods of time, effect the regulation of immune and inammatory processes that may,
over time, lead to a range of diseases including coronary artery disease, autoimmune
disorders, cancer, and many others (see Chaps. 4 and 5) (Baum, 1990; Cohen etal.,
2012, 2007). Importantly, LGBTQ individuals may experience stigma in both acute
ways, such as an episode of enacted stigma involving physical violence, and chronic
ways, such as anticipated stigma involving constant worry over treatment from others,
all of which may undermine health. Stress additionally leads to problems with emo-
tional regulation and cognitive processing, which increase risks for mental illness,
including depression and anxiety (see Chap. 3) (Hatzenbuehler, 2009). Individuals may
cope with stress resulting from stigma with health-compromising behaviors. For exam-
ple, LGBTQ individuals who experience greater stigma may also engage in greater
substance use and sexual practices that put them at risk for sexually transmitted infec-
tions (e.g., sex without a condom, transactional sex) (Diaz etal., 2004; Hatzenbuehler,
2009). In this way, LGBTQ stigma may play a role in HIV/STI disparities experienced
by men who have sex with men and transgender women globally.
2.4 Interventions toAddress LGBTQ Stigma
It is critical to develop and implement efcacious interventions that address stigma to
improve the health of LGBTQ people globally. Recent theorists have emphasized that
stigma interventions must be multilevel to be efcacious, spanning both structural and
individual levels (Cook etal., 2014; Rao etal., 2019). Below, we summarize interven-
tion strategies to change structural stigma, reduce stigma among perceivers, and
enhance resilience to stigma among targets, many of which have been implemented
globally. Cook etal. (2014) emphasize that the effects of stigma- reduction interven-
tions are often bidirectional and reinforcing both within and between social-ecologi-
cal levels. For example, an intervention to reduce stigma among perceivers may
ultimately lead to structural change, which may in turn reduce stigma among targets.
2.4.1 Structural Change
At the structural level, stigma interventions include legal and policy changes, as
well as education and social norm campaigns to reduce social stigma. Legal and
policy changes can target repealing stigmatizing civil and religious laws,
2 LGBTQ Stigma
30
including those reviewed within this chapter, as well as enacting protections for
LGBTQ people. These legal and policy changes are slowly happening throughout
the world. For example, the Supreme Court of India struck down Section 377, a
remnant of the British Penal Code that criminalized same-sex sexual practices, in
2018 on the basis that it violated the Constitution’s recognition that all persons are
equal before the law (Narrain, 2018). The ruling followed close to a decade of
court cases that both challenged (e.g., Naz Foundation vs. NCT Delhi in 2009) and
upheld (e.g., Kumar Koushal vs. Naz Foundation in 2013) the constitutionality of
Section 377. These cases coincided with a social movement characterized by
greater visibility and acceptance of LGBTQ people (e.g., as evidenced by the
release of movies with LGBTQ characters and public discourse surrounding sexu-
ality). In his judgment, Justice Chandrachud wrote, “It is difcult to right the
wrongs of history. But we can certainly set the course for the future. That we can
do by saying, as I propose to say in this case, that lesbians, gays, bisexuals, and
transgenders have a constitutional right to equal citizenship in all its manifesta-
tions” (p.15) (Narrain, 2018).
The Universal Periodic Review, conducted by the United Nations, has been
identied as a key mechanism for advocating for legal and policy changes
(Itaborahy & Zhu, 2014). It begins with an analysis of each country’s human
rights situation by other United Nations countries. The other countries then make
recommendations that the state under review may either accept or reject. Itaborahy
and Zhu observed that highly targeted recommendations (e.g., police education
and protections against violence) were more likely to be accepted than generalist
recommendations to end criminalization of or discrimination toward LGBTQ
people (Itaborahy & Zhu, 2014). Social media has additionally become an impor-
tant platform for LGBTQ activism for legal and policy change. For example,
Southern African LGBTQ organizations use digital strategies to raise global
awareness of human rights violations, share information with LGBTQ individuals
globally, and mobilize for activism (Mutsvairo, 2016).
In addition to decriminalizing LGBTQ identities, sexual practices, and expres-
sions, laws enacted to protect the rights of LGBTQ people can reduce stigma. As
of 2017, 9 countries prohibit discrimination based on sexual orientation within
their constitution, 72 prohibit discrimination in employment, and 43 criminalize
acts of violence based on sexual orientation and/or gender identity (Carroll &
Mendos, 2017). Moreover, 26 countries recognize joint adoption by same-sex
couples, and 22 legally recognize marriage for same-sex couples. Evidence sug-
gests that structural change can trickle down, beneting the well-being of
LGBTQ individuals. For example, sexual minority men living in the state of
Massachusetts in the United States had a decrease in mental health and medical
care visits after same-sex marriage was legalized in their state in 2003, indicating
improved mental and physical health among this population following the enact-
ment of this law (Hatzenbuehler etal., 2012).
V. A. Earnshaw et al.
31
2.4.2 Stigma Reduction Among Perceivers
Reducing LGBTQ stigma among people who do not identify as such is key to ensur-
ing that LGBTQ individuals are not exposed to negative treatment from others.
Popular intervention strategies for reducing stigma among perceivers include
enhancing education and providing opportunities for interpersonal contact (Cook
etal., 2014). Education involves building knowledge via courses, texts, online plat-
forms, and other venues and can help to challenge stereotypes that perceivers may
hold about LGBTQ people. Evidence from Europe, North and South America, Asia,
and Australia suggests that educational interventions can reduce stigma, but may
not eliminate stigma on their own (Cook etal., 2014). In Senegal, wherein same-sex
practices are criminalized (Carroll & Mendos, 2017), education strategies have been
implemented in conjunction with other stigma-reduction strategies to address
stigma among healthcare providers (Lyons et al., 2017). Interpersonal contact,
involving interaction between LGBTQ and non-LGBTQ individuals, is another
popular stigma reduction intervention strategy. Research from North and Latin
America, Europe, Israel, Australia, New Zealand, Africa, and Asia suggests that
intergroup contact reduces prejudice by enhancing knowledge about LGBTQ peo-
ple, lowering anxiety surrounding interactions with LGBTQ people, and increasing
empathy toward and perspective taking with LGBTQ people (Pettigrew & Tropp,
2006, 2008). For instance, as previously discussed, a participatory theater interven-
tion in Swaziland and Lesotho has been used to change attitudes toward LGBTQ
persons (Logie etal., 2019). Findings suggest that creative strategies that engage
persons in developing solutions to stigma, including healthcare providers, can
increase understanding and awareness of LGBTQ stigma and its harmful impacts,
can build empathy, and foster self-reection. Such approaches should be contextu-
ally tailored and provide examples of stigma that are grounded in the lived experi-
ences of LGBTQ persons. Importantly, the evidence indicates that contact must
occur under a set of “optimal conditions,” including equal status between LGBTQ
and non-LGBTQ people, common goals, intergroup cooperation, and support of
authorities (Pettigrew & Tropp, 2006).
It may be important to prioritize intervention efforts targeting individuals from
whom stigma is particularly detrimental to LGBTQ people. For example, childhood
and adolescence are sensitive periods during which individuals may be particularly
vulnerable to the negative health effects of LGBTQ bullying (Earnshaw et al.,
2016a, 2017). Therefore, it may be particularly important to implement interven-
tions to reduce LGBTQ stigma within school settings starting at young ages. The
results of a recent systematic review demonstrated that interventions to address
LGBTQ bullying are increasing overall but remain limited to North America,
Europe, and Oceania (Earnshaw etal., 2018). Stigma from family members can lead
to social rejection, which in turn leads to social isolation. The Family Acceptance
Project, which was developed in the United States and is now being implemented
internationally, aims to increase the acceptance of LGBTQ youth by family mem-
bers (Katz-Wise etal., 2017; Ryan, 2010). Moreover, stigma endorsed by medical
2 LGBTQ Stigma
32
doctors can lead to poor provision of medical care to stigmatized individuals
(Dovidio etal., 2008). In addition to enhancing education and providing opportuni-
ties for interpersonal contact, evidence suggests that interventions aiming to build
clinical skills for working with stigmatized populations can reduce stigma (Stangl
etal., 2013). This may involve teaching medical students and doctors about stigma-
free language, how to take medical and sexual histories of LGBTQ patients, and
how to deliver gender-afrming medical care to transgender individuals.
2.4.3 Enhancing Resilience Among Targets
History indicates that eliminating any kind of stigma, including LGBTQ stigma, at
the structural level and among perceivers will take time. While stakeholders develop,
test, and implement intervention strategies to eliminate LGBTQ stigma at these
levels, it is important to enhance resilience among LGBTQ people to attenuate the
effect of stigma on health. Minority stress theory emphasizes the importance of
enhancing resilience to buffer LGBTQ individuals from the effects of enacted and
anticipated stigma and/or reduce internalized stigma among LGBTQ individuals
(Meyer, 1995, 2010). In this section we discuss participatory theater approaches,
interventions that enhance coping, and interventions that enhance mindfulness.
Participatory theater approaches aim to enhance resilience to stigma among tar-
gets, reduce stigma among perceivers, and disrupt stigma within communities. Such
multilevel stigma reduction interventions are recommended to create more impact-
ful change than single-level interventions (Rao etal., 2019). Participatory theater
approaches originate in Theatre of the Oppressed, which is a pedagogical tool
developed in Brazil by Augusto Boal and inspired by Paulo Freire’s Pedagogy of the
Oppressed (Boal, 1974). Theatre of the Oppressed is designed to promote empower-
ment among targets of stigma, critical consciousness among targets and perceivers
of stigma, and social transformation within communities. Participatory theater
approaches have been shown to build self-acceptance and feelings of solidarity
among trans women of color in Canada (Logie etal., 2019b) and reduce LGBTQ
stigma among healthcare providers, educators, students, and community members
in Swaziland, Lesotho, Canada, and the United States (Logie etal., 2019a; Tarasoff
etal., 2014; Wernick etal., 2013). Thus, participatory theater approaches represent
a multilevel and multifaceted stigma-reduction tool that originated in the Global
South and has been applied in the Global North.
Interventions to enhance coping among targets aim to strengthen psychosocial
resources and strategies to mitigate the impact of enacted and anticipated stigma on
stress responses, ultimately buffering individuals from the effect of stigma on health
(Chaudoir etal., 2017). A recent systematic review of the intervention “toolkit” to
address sexual minority stress identied 12 interventions to bolster skills to cope with
stigma, most of which were developed in the United States (Chaudoir etal., 2017).
Examples of effective intervention strategies included cognitive behavioral therapy to
reduce depression and help individuals identify adaptive coping responses to stigma,
V. A. Earnshaw et al.
33
expressive writing to bolster cognitive and emotional processing of enacted stigma,
and attachment-based family therapy to help adolescents process stigma originating
within family relationships. Interventions addressing intersectional stigma experi-
enced by LGBTQ individuals are also being tested. The results of Still Climbin, a
group-based intervention among HIV-positive Black sexual minority men in the
United States, improved functional coping, humor-based coping, and cognitive/emo-
tional debrieng in response to enacted stigma (Bogart etal., 2018). Peer-based sup-
port approaches have been used to address HIV and LGBTQ stigma among men who
have sex with men in Senegal (Lyons etal., 2017). These approaches were based on
previous interventions developed in Senegal, Kenya, Vietnam, and Thailand.
Interventions to enhance mindfulness have shown some success in addressing
internalized stigma. Rather than attempting to reduce stigmatizing thoughts and
feelings directly, these interventions focus on the relationships between thoughts,
feelings, and behaviors (Luoma etal., 2008). For example, in acceptance and com-
mitment therapy, individuals are taught to observe their thoughts and fully feel their
emotions, including those reecting internalized stigma, and then enact actions that
will take them in valued directions, such as self-love and acceptance (Luoma etal.,
2008; Skinta etal., 2015). Acceptance and commitment therapy has been leveraged
to reduce internalized stigma among people with a range of stigmatized identities
and characteristics, including LGBTQ individuals (Luoma etal., 2008; Mittal etal.,
2012; Skinta etal., 2015; Yadavaia & Hayes, 2012). Other strategies to address the
internalized stigma that have been implemented in the Global South and North
include psychotherapy, psychoeducation, and community participation (Ma etal.,
2019). For example, one study conducted in Thailand increased interactions between
members of stigmatized groups, their families, and community members via educa-
tional, volunteer, and community events (Apinudecha etal., 2007).
2.5 Conclusion
Stigma is experienced by LGBTQ people worldwide and acts as a powerful and
pernicious determinant of global LGBTQ health inequities. As the eld moves
toward addressing stigma to achieve LGBTQ health equity, it is worth bearing in
mind that stigma is neither xed nor insurmountable. Rather, it is malleable and
intervenable: it has changed and will continue to change with time. Signs of change
are visible everywhere. Laws that protect the civil rights of LGBTQ people are
becoming more numerous. In 2017, there were 63 countries with laws designed to
protect LGBTQ from various forms of discrimination (e.g., bans on blood donation,
protection against bullying), 22 countries that recognized same-sex marriage, and
26 countries that recognized the rights of same-sex parents to adopt children (Carroll
& Mendos, 2017). Pride, a movement that celebrates LGBTQ people, commemo-
rates past historic traumatic assaults and civil rights victories (i.e., 1969 Stonewall
police raid and riots), and protests ongoing civil rights inequities, gains momentum
every year as it spreads to new cities around the world and more people attend. As
2 LGBTQ Stigma
35
this change in stigma slowly occurs, LGBTQ people are building community, and
providing and receiving support, to build resilience and protect LGBTQ individuals
from the effects of stigma. The Trevor Project, which provides crisis intervention
and suicide prevention services in the United States, represents an example of the
response from the LGBTQ community to address suicidality among LGBTQ youth
(The Trevor Project, 2019). Public health researchers, practitioners, policymakers,
and other stakeholders have key roles to play in supporting these efforts and advo-
cating for continued change in LGBTQ stigma worldwide.
2.6 Case Study: Tackling LGBTQ Stigma inLebanon
LGBTQ visibility and activism in Lebanon have been steadily increasing over the
past few decades. Multiple, diverse LGBTQ organizations have formed, the local
LGBTQ community has mobilized to advocate against police violence and crimi-
nalization of same-sex sexual practices, and Beirut has become one of the most
socially progressive cities in the region, holding its rst LGBTQ Pride event in 2017
(OutRight, 2018; McCormick, 2011; Healy, 2009).
Despite this progress, LGBTQ people face pervasive stigma at multiple socio-
ecological levels, including the interpersonal, community/institutional, and struc-
tural levels (Wagner etal., 2013; Nasr & Zeidan, 2015). Many Lebanese citizens
remain opposed to the acceptance of LGBTQ people into society, viewing LGBTQ
people as psychologically or medically defective and as a threat to traditional heter-
opatriarchal values. Harassment and discrimination against LGBTQ individuals are
common, even in healthcare facilities (OutRight, 2018). Pride 2018 was canceled
after the organizer was arrested and threatened with criminal prosecution for pro-
moting debauchery (Homsi, 2018). A law passed in 1942 criminalizing same-sex
sexual practices continues to be implemented to arrest LGBTQ people, and such
arrests have steadily increased in recent years (OutRight, 2018; Tohme etal., 2016).
Prior research across the globe has consistently demonstrated that social and
structural stigma impacts the sexual health of sexual and gender minorities
(Fitzgerald-Husek etal., 2017; Hatzenbuehler, 2016; Link & Hatzenbuehler, 2016).
Stigma has been linked to high-risk sexual behaviors and low uptake of sexual
healthcare services (Fitzgerald-Husek etal., 2017). Although, in general, research
on LGBTQ populations in Lebanon is limited, a similar link has been demonstrated
with cisgender sexual minority men in Beirut, with social and structural stigma
being related to condomless anal intercourse with partners of unknown HIV status
(Wagner etal., 2015). This occurs in a population where HIV is likely concentrated,
where condomless anal intercourse is already common, and where HIV-related
knowledge and perceived risk for HIV acquisition are low (Mumtaz etal., 2011,
2019; Wagner etal., 2014; Mahfoud etal., 2010).
The stigma experienced by LGBTQ people in Lebanon has ties to the country’s
history, culture, and religious environment. The structural stigma seen in the
Lebanese penal code stems from a 1942 law ratied under French colonial rule
2 LGBTQ Stigma
36
(OutRight, 2018). In addition, Lebanon has a history of sectarian conict, and over
90% of the population identies as Muslim or Christian (Haddad, 2002). A legacy
of colonialism and sectarian conict, the ongoing use of colonial law to arrest
LGBTQ people, and the social values and practices of dominant religious institu-
tions have no doubt played, and continue to play, a role in shaping sociocultural
conditions, attitudes, and norms with regard to sexuality and gender, essentially
underpinning the stigmatization of LGBTQ people.
Several local LGBTQ organizations have been integral in addressing much of
this stigma and its associated sequelae. Three organizations of note are Helem, the
Lebanese Medical Association for Sexual Health, (LebMASH), and Marsa Sexual
Health Center, all of which are located in Beirut. The work of these three organiza-
tions provides a blueprint for multilevel stigma mitigation interventions in Lebanon
that tackle both the source and effects of stigma. Helem intervenes at the policy
level, targeting one of the primary drivers of stigma, and also at the community
level, providing safe spaces for LGBTQ people to gather. Marsa and LebMASH
both intervene across the community and institutional levels. Marsa provides
stigma-free sexual healthcare services to LGBTQ people, while LebMASH engages
in LGBTQ-related scholarship and education.
Since its formulation, Helem, a non-prot organization, has devoted its efforts to
addressing structural issues that target LGBTQ people, particularly the law crimi-
nalizing same-sex sexual practices. Helem has spent years advocating for decrimi-
nalizing same-sex sexual behavior, and a series of court rulings over the past 10
years indicate movement toward that end. The rst came in 2009, when a judge
refused to apply the law to two cisgender men, reasoning that the law criminalizing
same-sex behavior was no longer consistent with social change. Five years later, a
judge refused to apply the law in a case involving a transgender woman and a cis-
gender man, reasoning that the individual’s gender identity should be accepted, ren-
dering the application of the law null and void. In 2017, a judge again refused to
apply the law, reasoning that sexual minorities have a right to the same intimate
relationships as everyone else, which was later upheld on appeal. Relatedly, Helem
has used targeted media campaigns to advocate for a ban on forced anal examina-
tions, which were commonly employed to prove one’s homosexuality; in 2012, the
Minister of Justice called for an end to the practice. Aside from policy advocacy,
Helem also provides a safe physical space for LGBTQ people to gather and holds
various events for local LGBTQ people, helping to foster a much-needed sense of
community (OutRight, 2018; Mutchler etal., 2018).
LebMASH, a nonprot, nongovernmental organization, is comprised of health-
care professionals and strives to achieve health equity for sexual and gender minori-
ties. In 2013, LebMASH collaborated with the Lebanese Psychological Association
and the Lebanese Psychiatric Society to issue public statements that homosexuality
is not a mental illness and that it is not amenable to conversion therapy. LebMASH
created a video series to debunk myths regarding homosexuality and holds an annual
medical conference entitled National LGBT Health Week to share research and
encourage scholarship in the eld of LGBTQ sexual health (OutRight, 2018;
LebMASH, 2017; Abdessamad & Fattal, 2014).
V. A. Earnshaw et al.
37
Marsa Sexual Health Center is a nongovernmental organization that provides
condential, anonymous sexual healthcare services to sexual and gender minorities,
as well as other vulnerable, marginalized groups. Their services include free HIV
testing and counseling and several subsidized services, including testing for sexu-
ally transmitted infections and psychosocial counseling, among others. Marsa
explicitly markets its facility as a stigma- and discrimination-free space. Marsa has
also developed LGBTQ sexual health education materials for universities and for
the general public, as well as general educational materials, to increase the public’s
understanding of gender minorities (Marsa, 2019; OutRight, 2018).
Sustained by such organizations, LGBTQ people in Lebanon and their allies
remain steadfast in their commitment to topple homophobia and bring about a soci-
ety free of stigma, where social progress and equality ourish (Harb, 2019).
Acknowledgments We are grateful to John Mark Wiginton for his contribution to the case study
on Lebanon accompanying this chapter and to Carly Hill for her assistance with the chapter.
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V. A. Earnshaw et al.
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Chapter 3
Global LGBTQ Mental Health
RichardBränström, TondaL.Hughes, andJohnE.Pachankis
3.1 Differences inMental Health Between LGBTQ
Individuals andCisgender Heterosexual Individuals
Research studies from many parts of the world, including countries in Europe,
North and South America, Asia, Africa, and Oceania, have demonstrated signi-
cantly elevated risk of poor mental health among lesbian, gay, bisexual, transgender,
and queer (LGBTQ) individuals as compared to cisgender and heterosexual indi-
viduals (Blondeel etal., 2016; Mendoza-Perez & Ortiz-Hernandez, 2019; Meyer,
2003a; Mueller etal., 2017; Mueller & Hughes, 2016; Ploderl & Tremblay, 2015;
Valentine & Shipherd, 2018). Earlier reports tended to come from small studies that
used nonrepresentative samples and self-report measures of mental health concerns.
More recent studies, including from the Netherlands, New Zealand, Sweden, the
United Kingdom, and the United States, that used stronger research designs and
representative samples have conrmed these ndings and increased our knowledge
about sexual orientation and gender identity-related mental health disparities
(Bränström, 2017; Bränström etal., 2018; Bränström & Pachankis, 2019; Cochran
etal., 2003; Sandfort etal., 2014; Semlyen etal., 2016; Spittlehouse etal., 2019).
R. Bränström (*)
Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
e-mail: richard.branstrom@ki.se
T. L. Hughes
Department of Psychiatry, School of Nursing, Columbia University, New York, NY, USA
e-mail: th2696@cumc.columbia.edu
J. E. Pachankis
Department of Social and Behavioral Sciences, School of Public Health, Yale University,
New Haven, CT, USA
e-mail: john.pachankis@yale.edu
© The Author(s) 2024
S. J. Hwahng, M. R. Kaufman (eds.), Global LGBTQ Health, Global LGBTQ
Health, https://doi.org/10.1007/978-3-031-36204-0_3
46
3.1.1 Types ofMental Health Problems
Depression, anxiety, suicidality, general distress, and substance use show the largest
disparities by sexual orientation and gender identity based on a variety of studies
from the United States, Latin America and the Caribbean, Australia, Southern
Africa, the United Kingdom, and New Zealand (Bostwick etal., 2010; Caceres
etal., 2019; Hughes etal., 2010; Mueller etal., 2017; Ploderl & Tremblay, 2015;
Semlyen etal., 2016; Spittlehouse etal., 2019; Valentine & Shipherd, 2018). The
results of representative surveys in Sweden and New Zealand show that compared
with heterosexual and cisgender people, LGBTQ people are about two to three
times as likely to experience depression, anxiety, and substance abuse (Bränström,
2017; Bränström etal., 2018; Lucassen et al., 2017). A considerable number of
studies from across the globe have also found substantially elevated risk of suicidal
thoughts and suicidal behavior among LGBTQ people, with the majority of studies
coming from North America and Europe (di Giacomo etal., 2018; Haas etal., 2010;
Hottes etal., 2016; Ploderl etal., 2013; Ploderl & Tremblay, 2015; Salway etal.,
2019; Valentine & Shipherd, 2018). Substance use, another area of health disparities
affecting LGBTQ individuals, is described in greater detail in Chap. 8.
3.1.2 Cultural Differences inUnderstanding Mental Health
Understanding of mental health and mental disorders differs by cultural settings.
The manifestations of mental illness vary across cultures, with culture-specic
expressions of psychological distress and suffering. This variation makes it harder
to uniformly assess symptoms, develop and implement effective mental health treat-
ments, and conduct cross-cultural mental health research globally.
There is also a growing body of research on cross-cultural, transcultural, and
global psychiatry spearheaded by organizations such as the World Association of
Cultural Psychiatry and the Society for the Study of Psychiatry and Culture, which,
respectively, publish the peer-reviewed journals World Cultural Psychiatry Research
Review and Transcultural Psychiatry (Society for the Study of Psychiatry and
Culture, 2020; World Association of Cultural Psychiatry, 2020). This body of
research often emphasizes Global South contexts and mental health constructs, such
as culture-bound syndromes, collectivistic coping, interdependent self-construal,
and decolonial interventions and service delivery (Crozier, 2018; Hickling, 2019;
Joe etal., 2017; Mascayano etal., 2019; Prakash etal., 2018; Roldán-Chicano etal.,
2017; Yeh & Kwong, 2008).
It is important to note, however, that much of the existing LGBTQ mental health
research and treatment development work to date has been conducted in the Global
North. Consequently, there is currently limited research contextualizing LGBTQ
populations within Global South mental health constructs in various parts of the
world. In this chapter, we focus on available scientic information about LGBTQ
R. Bränström et al.
47
mental health and its determinants. Because of the relative dearth of research con-
ducted in the Global South, all references will refer to Global North countries/con-
texts unless otherwise specied.
3.2 Differences inMental Health Across Diverse Populations
ofLGBTQ Individuals
Because the LGBTQ population reects the demographic diversity of the global
population, it is of great importance to understand how various sociodemographic
characteristics affect the health and lives of LGBTQ people, how such characteris-
tics interact with sexual orientation and gender identity, and which LGBTQ sub-
populations are most vulnerable to negative mental health outcomes. An
intersectional perspective can help address this. The section below describes
sociodemographic characteristics that intersect with LGBTQ identities that are
commonly investigated in global LGBTQ mental health research.
3.2.1 Age andSex
The increased risk of poor mental health among LGBTQ people begins early in life
(Irish etal., 2019) and often persists across the life course (Fredriksen-Goldsen
etal., 2013, 2015; Yarns etal., 2016). For instance, a study comparing mental health
disparities in sexual minorities and heterosexuals across age groups in the United
Kingdom found disparities among both younger (age <35) and older (age 55+) sex-
ual minority individuals (Semlyen etal., 2016). In contrast, a large multi-site study
of women enrolled in a US interagency HIV study found no differences in mental
health disparities between sexual minority and heterosexual women at mid-age or
older (Pyra etal., 2014). Similarly, a community-based study of sexual minority
women found that self-perceived mental health was signicantly better among older
(age 55+) sexual minority women than among their younger age counterparts
(Veldhuis etal., 2017). Studies of suicidality have shown that the sexual orientation
disparity in this particular mental health risk peaks for LGBTQ individuals around
adolescence and young adulthood (Fish etal., 2018; Irish etal., 2019).
3.2.2 Sexual Identity andGender Identity
Many studies of sexual minority mental health do not disaggregate gay/lesbian and
bisexual individuals when analyzing data and presenting results, but there is grow-
ing evidence of substantial variability across sexual minority subgroups. For
3 Global LGBTQ Mental Health
48
example, a number of studies have found higher rates of depression, anxiety, and
suicidality among bisexuals compared to gay men and lesbian women (Bostwick
etal., 2010; Bränström, 2017; Bränström etal., 2018; Huang etal., 2018a; Hughes
etal., 2010; Ross etal., 2018; Salway etal., 2019). There are indications that this
heightened risk is particularly strong for bisexual women (Salway etal., 2019). It is
not completely clear why the mental health status of bisexuals differs from that of
gay men and lesbian women, although possible explanations include experiences of
bisexuality-specic discrimination, bisexual invisibility/erasure, and lack of
bisexual- afrmative support (Colledge et al., 2015; Hughes et al., 2014; Ross
etal., 2018).
Although the large majority of studies on LGBTQ mental health has focused on
sexual minorities, an increasing number of studies indicate that transgender indi-
viduals are at even greater risk of mental health problems, such as depression, anxi-
ety, suicidality and self-harm, and eating disorders as compared to both non-LGBTQ
individuals and sexual minority cisgender people (Calzo etal., 2017; Connolly
etal., 2016; Jones et al., 2016; McNeil etal., 2017; Millet et al., 2017; Mueller
etal., 2017). Transgender people may be at risk for gender dysphoria, which is sig-
nicant psychological distress arising from an incongruence between the assigned
birth sex and gender identity (American Psychiatric Association, 2021).
3.2.3 Socioeconomic Status
There is currently strong scientic evidence linking lower socioeconomic status
(SES), often dened based on income and level of education, with mental and
physical health (Adler etal., 1994; Link & Phelan, 1995). In research concerning
the health of LGBTQ people, socioeconomic factors tend only to be used as con-
trol variables so as to isolate the effects of LGBTQ status and associated determi-
nants as predictors of mental health disparity by LGBTQ status (McGarrity,
2014). There are, however, reasons to investigate the specic effects that socio-
economic status (e.g., income, education) might have on LGBTQ people’s experi-
ence of social stress and their ability to cope with such stress. For example,
McGarrity (2014) found that openness about one’s sexual orientation was associ-
ated with positive physical health among gay/bisexual men with higher socioeco-
nomic status in the United States, but the opposite appeared to be true for gay/
bisexual men with lower socioeconomic status. Although certain subgroups within
the LGBTQ population have been shown to have higher levels of education, par-
ticularly gay men (Bränström & Pachankis, 2018; Conron etal., 2018), higher
levels of education do not necessarily translate to higher levels of income. Sexual
minority women are typically burdened with the gender disadvantage facing
women in general, which becomes compounded in same-sex female couples
(Badgett, 2009). The ability of SES to both be eroded by LGBTQ-related
R. Bränström et al.
49
discrimination and to moderate the ability of LGBTQ people to cope with such
stigma is an important area for future research.
3.2.4 Race/Ethnicity
A good deal of research into the intersection of ethnic minority status and LGBTQ
identity has been conducted in the United States, with a focus on the consequences
of possessing a double minority status as both a person of color and an LGBTQ
individual (Toomey etal., 2017; Trygg etal., 2019). Studies have shown that racial/
ethnic minority LGBTQ people may experience stigma and discrimination due to
their LGBTQ identity, skin color, and racial/ethnic identity (Toomey etal., 2017; Vu
etal., 2019; Wade & Harper, 2017) and that these associated stressors can come
both from their racial/ethnic minority communities as well as from white LGBTQ
people (Balsam etal., 2011). Studies examining mental health prevalence among
ethnic minority LGBTQ individuals compared to ethnic majority LGBTQ individu-
als present varied results (Rodriguez-Seijas etal., 2019; Toomey etal., 2017). Some
studies have found higher levels of mental illness among ethnic minority LGBTQ
people (Hwahng & Nuttbrock, 2014; O’Donnell etal., 2011), whereas others have
found lower levels of mental illness among this group or no difference (Bostwick
etal., 2014; Rodriguez-Seijas etal., 2019; Toomey etal., 2017). Globally, the role
of race/ethnicity in mental health varies greatly depending on the country, world
region, and migration pattern (Arndt & Hewat, 2009; Toomey etal., 2017; Wade &
Harper, 2017). There is a great need for additional research to understand the mental
health implications of multiple minority statuses more fully.
3.2.5 Migration Status
Given the wide regional variation in stigmatizing environments and cultural norms
globally, LGBTQ people might be particularly likely to migrate in order to escape
persecution or to seek freedoms not available to LGBTQ people living in high-
stigma global regions. Of course, LGBTQ people are also part of the substantial
general global population that migrates across national borders within any given
year (Luibhéid, 2008). The mental health of LGBTQ migrants remains relatively
unstudied, although the LGBTQ- and migrant-specic support available in LGBTQ
migrants’ sending and receiving countries appears to be an important determinant
of this population’s health (Pachankis etal., 2017). Other factors shaping LGBTQ
migrants’ mental health include violence and acculturation (Alessi et al., 2016,
2017; Alessi & Kahn, 2017; Piwowarczyk etal., 2017).
3 Global LGBTQ Mental Health
50
3.2.6 Geographic Variations inLGBTQ Mental Health
3.2.6.1 Central andSouth America
Although there have been few representative studies of LGBTQ mental health con-
ducted in Central and South America, one study from Mexico among high school
students showed a higher risk of mental health problems among sexual minority
individuals compared to heterosexuals, conrming the global pattern (Mendoza-
Perez & Ortiz-Hernandez, 2019). The disparity was strongest among sexual minor-
ity men and was mediated by exposure to violence. In addition, several non-probability
studies from Central and South America (e.g., Brazil and Jamaica) suggest a high
prevalence of mental health problems among sexual minority individuals in these
regions (Caceres etal., 2019; Ghorayeb & Dalgalarrondo, 2011; Teixeira & Rondini,
2012; White etal., 2010). Similar elevations in mental health morbidity have been
found among transgender women in Argentina, Brazil, and the Dominican Republic
(Budhwani etal., 2018; Lobato etal., 2008; Marshall etal., 2016).
3.2.6.2 Middle East/North Africa
Information about the prevalence of mental health problems among LGBTQ indi-
viduals living in the Middle East and North African region is very limited. Some
studies using non-probability samples from Israel and Lebanon have shown
increased risk of mental health problems (i.e., depression and suicidality) among
sexual minority men compared to matched heterosexual controls (Shenkman etal.,
2019; Shenkman & Shmotkin, 2011; Wagner etal., 2018). Further, a few studies of
transgender individuals receiving gender-afrming surgical treatment in Iran and
Lebanon have found elevated prevalence of mental health problems (e.g., anxiety,
post-traumatic stress symptoms, and suicidality) among this population both before
and after surgery (Gorjian etal., 2017; Havar etal., 2015; Ibrahim et al., 2016;
Kaplan etal., 2016). Some of these studies suggest that mental health problems are
more common among male-to-female transgender individuals compared to female-
to- male transgender individuals, possibly as a result of cultural gender roles and
status (Havar etal., 2015; Ibrahim etal., 2016).
3.2.6.3 Sub-Saharan Africa
Few studies using representative samples have been conducted in sub-Saharan
Africa. However, several non-probability studies from this region, mostly with men
who have sex with men (MSM), have been reported. For example, high levels of
depression symptoms have been reported among MSM in Tanzania and South Africa
(Ahaneku etal., 2016; Mgopa etal., 2017; Stoloff etal., 2013); high prevalence of
psychological distress among gay men, lesbian women, and bisexual women and
men in Botswana (Ehlers etal., 2001); and lower quality of life among gay, lesbian,
and bisexual students compared to their heterosexual peers in Nigeria (Boladale
R. Bränström et al.
51
etal., 2015). Studies have also found a high prevalence of suicidal ideation among
MSM living in the Gambia, Burkina Faso, Togo, and South Africa (Stahlman etal.,
2016; Stoloff etal., 2013). One study using a heterosexual comparison group found
almost three times higher prevalence of depression among gay male university stu-
dents in Nigeria compared to heterosexual students (Oginni etal., 2018). A review
of the literature on the health of sexual minority women in Africa (Mueller &
Hughes, 2016) highlighted the impact of heteronormativity and social exclusion on
mental health, particularly related to psychological distress and elevated rates of
depression. In this study, experiences of hate speech, sexual violence, and religion-
based stigma and discrimination were associated with mental distress and suicidal
ideation among sexual minority women. In the only published study of lesbian and
bisexual women’s health in Rwanda, Moreland and colleagues (Moreland et al.,
2019) found high levels of interpersonal trauma and minority stressors.
3.2.6.4 South, East, andSoutheast Asia
Although there are few studies of LGBTQ mental health reported from South, East,
and Southeast Asia using representative samples, a few population-based studies of
Chinese sexual minorities have shown an increased risk of suicidality compared to
Chinese heterosexuals (Huang etal., 2018a; Lian etal., 2015). Additionally, a large
number of non-probability studies have been conducted with sexual and gender
minorities, mostly MSM and transgender individuals, from South, East, and
Southeast Asia. For example, recent studies have reported high levels of depression
symptoms among MSM and transgender women (hijra) living in India (Chakrapani
etal., 2017a, b; Logie etal., 2012; Parikh-Chopra, 2019; Sivasubramanian etal.,
2011; Tomori etal., 2016). There are reports of elevated depression and suicidality
among MSM and transgender individuals living in Nepal (Deuba et al., 2013;
Kohlbrenner etal., 2016), gay/bisexual men in Japan (Hidaka & Operario, 2006),
and gay/lesbian and bisexual youth in India (Singh & Srivastava, 2018). High risk
of suicidality has been identied among transgender individuals in China (Chen
etal., 2019); lesbian/bisexual women in Taiwan (Kuang etal., 2003); and gay men,
lesbian women, and MSM in South Korea (Cho & Sohn, 2016; Kim & Yang, 2015).
A lower degree of psychological well-being has been reported among transgender
men (toms) and transgender women (kathoeys) in Thailand (Gooren etal., 2015);
elevated risk of suicidality among sexual minority women in Taiwan (Kuang etal.,
2003) and among LGBTQ Filipinos (Reyes etal., 2017); and high levels of depres-
sion among transgender women in Cambodia (Yi etal., 2018).
3.2.6.5 Oceania andthePacic Islands
Few representative studies have been reported from Oceania and the Pacic Islands,
but one national population-based study among young women in Australia reported
increased risk of depression and anxiety among sexual minority women, especially
women who identied as bisexual or mostly heterosexual, compared to exclusively
3 Global LGBTQ Mental Health
52
heterosexual women (Hughes etal., 2010). Non-probability studies from Australia
and New Zealand similarly report higher rates of mental health problems (e.g.,
depression and suicidality) among sexual minorities (Cantor & Neulinger, 2000;
Lucassen etal., 2015; Mathy, 2002; Skerrett etal., 2014, 2015).
3.2.6.6 Europe
Because of the existence of national health registries in many Northern European
countries, some of the earliest population-based studies of LGBTQ mental health
came from that region (Sandfort et al., 2001). Europe continues to produce
population- based insights into LGBTQ mental health largely not available else-
where, including studies from the Netherlands, Sweden, and the United Kingdom
(De Graaf etal., 2006; King etal., 2003; La Roi etal., 2016; Meads etal., 2007;
Sandfort et al., 2001, 2006, 2014). These studies support ndings from earlier
European research and more recent population-based studies from North America
of higher rates of mental health problems such as depression, anxiety, substance
use, and suicidality (Bränström, 2017; Bränström et al., 2018; Bränström &
Pachankis, 2019; King et al., 2008; Sandfort etal., 2001, 2014; Semlyen etal.,
2016; Wang etal., 2012).
Recent European studies have also taken advantage of the wide diversity of
social acceptance of LGBTQ people to predict variations in mental health. Indeed,
LGBTQ legal rights and protection (e.g., same-sex marriage rights and inclusion of
LGBTQ status in hate crime legislation) and population attitudes and acceptance of
LGBTQ individuals vary greatly across European countries (Bränström & van der
Star, 2013). Studies have shown a clear link between a European country’s stigma-
tizing legislation and attitudes and the life satisfaction of LGBTQ individuals living
in that country (Bränström etal., 2021; Pachankis & Bränström, 2018). Preliminary
evidence suggests that this association exists due to LGBTQ individuals living in
high-stigma countries perceiving a need to conceal their sexual identity to avoid
discrimination and victimization.
3.2.6.7 North America
As mentioned above, the majority of studies on LGBTQ mental health, especially
earlier studies (i.e., those published in the 1990s and early 2000s) were conducted
in North America. These earlier studies typically used small, nonrepresentative
samples and self-report measures of mental health. The results pointed to greater
risk of psychiatric morbidity among sexual minorities than among heterosexuals;
the mental health of transgender populations was rarely examined (Cohen-Kettenis
& Van Goozen, 1997). However, more recent studies from North America employ
representative samples and stronger methodologies and have largely conrmed
these early ndings (Bostwick etal., 2010; Cochran etal., 2003, 2007; Cochran &
Mays, 2000, 2009; Hottes etal., 2016; Meyer, 2003b; Pakula etal., 2016; Pakula &
R. Bränström et al.
53
Shoveller, 2013). There has also been increasing attention to transgender mental
health (Cogan etal., 2021; McGuire etal., 2021; Nuttbrock etal., 2010; Samrock
etal., 2021). Recent population-based studies show that LGBTQ people in North
America have between two- and three-times greater risk of depression, anxiety, and
substance abuse problems compared to heterosexual, cisgender individuals (Cochran
& Mays, 2009; Meyer, 2003b; U.S.Institute of Medicine, 2011). LGBTQ people in
North America also have a severely heightened risk of suicidal thoughts and suicidal
behavior (di Giacomo etal., 2018; Fish etal., 2018; Hottes et al., 2016; Salway
etal., 2019).
3.3 Determinants ofLGBTQ Mental Health
Increasing evidence from around the world suggests that the elevated mental health
risk among LGBTQ people can be attributed to, at least in part, the greater stigma-
related stress that LGBTQ people are exposed to compared with heterosexual and
cisgender individuals (see Stigma chapter, Chap. 2). Stigma-related stress among
LGBTQ people is described in minority stress theory, originally developed to
explain differences in mental health based on sexual orientation (Meyer, 2003a), but
in recent years expanded to facilitate understanding of the increased risk of mental
health problems among transgender people as well (Operario etal., 2014; White
Hughto etal., 2015). According to minority stress theory, LGBTQ people experi-
ence specic stressors (e.g., discrimination, violence, threats, social isolation, and
identity concealment) that are unique and linked to their sexual or gender identity.
Exposure to these stressors across the life course compounds the burden of general
life stress to generate higher rates of stress-related mental health concerns (Meyer,
2003a). In the sections below, we review evidence for the cross-cultural relevance
of minority stress theory (Sect. 3.1) and possible culturally distinct factors that
might extend or challenge the relevance of minority stress theory to certain cultural
contexts (Sect. 3.2), barriers to LGBTQ people’s societal integration across coun-
tries (Sect. 3.3), and the potential impact of LGBTQ conversion therapy on sexual
and gender minority individuals’ mental health (Sect. 3.4).
3.3.1 The Cross-Cultural Relevance ofMinority Stress Theory
Because the majority of research linking minority stress exposure to increased risk
of mental health among LGBTQ individuals comes from North America and
Europe, and the fact that “minority stress” is a construct originating from the Global
North, it is not completely clear how applicable these ndings might be to non-
Western countries and countries in the Global South. However, during the past sev-
eral years, an increasing number of studies have explored the cultural relevance of
minority stress theory to LGBTQ mental health in different parts of the world,
3 Global LGBTQ Mental Health
54
including Central and South America (e.g., Budhwani etal., 2018; Dunn et al.,
2014); Middle East/North Africa (e.g., Kaplan etal., 2016); sub-Saharan Africa
(e.g., Mgopa etal., 2017; Polders etal., 2008; Stahlman etal., 2015); as well as
South, East, and Southeast Asia (e.g., Hu etal., 2016; Sattler & Lemke, 2019).
Studies conducted in those global regions have found support for the generalizabil-
ity of factors proposed by minority stress theory as predictors of mental health prob-
lems among LGBTQ individuals. This section reviews those experiences, including
victimization, discrimination, concealment/openness with LGBTQ status, lack of
social support, and internalized stigma.
Victimization and discrimination, when measured generally, have been found to
predict higher risk of mental health problems across countries (Albuquerque etal.,
2018; Budhwani etal., 2018; Lyons etal., 2019; Parikh-Chopra, 2019). However,
the particular expression and frequency of victimization and discrimination can
vary greatly across countries. Examples include the corrective rape experiences of
lesbian women in South Africa (Anguita, 2012), exposure to torture and murder
attempts of transgender women in the Dominican Republic (Budhwani etal., 2018),
and family and school violence among gay and lesbian youths in Mexico (Ortiz-
Hernandez & Valencia-Valero, 2015).
In the global literature, the mental health consequences of concealment and
openness about LGBTQ identity show signicant cross-cultural variation. For
instance, in high-stigma settings, being open about one’s LGBTQ status has been
found to increase the risk of discrimination and victimization, which in turn
increases the risk of poor mental health (Bränström etal., 2021; Dunn etal., 2014;
Pachankis & Bränström, 2018; Sattler & Lemke, 2019). Therefore, in high-stigma
countries where all or most LGBTQ people are unable to be open about any aspect
of their sexual orientation, concealment of LGBTQ status serves a protective func-
tion and has been found to ameliorate the negative impact of stigma-related stress
exposure on mental health problems (Pachankis & Bränström, 2018). For example,
a study among sexual minority men and women in Jamaica found a more than ve-
fold increased risk of current Axis I mental disorders (such as anxiety, mood, and
eating disorders) among those who were open about their sexual orientation com-
pared to those who were not (White etal., 2010). However, in lower-stigma coun-
tries (i.e., those containing protective legislation and acceptance of LGBTQ
individuals) where LGBTQ individuals have the possibility of choosing when and
to whom to disclose their sexual orientation, not being open with one’s LGBTQ
identity appears to increase the stress of making decisions around concealment as
well as increase associated social isolation and psychological strain (Lawrenz &
Habigzang, 2019). At the same time, protective effects of disclosing one’s sexual
orientation have been found even in some high-stigma settings such as China and
South Africa (Liu etal., 2018; McAdams-Mahmoud etal., 2014), and more research
is needed to disentangle the complex relationship between openness/concealment
of LGBTQ status and mental health in various cultural contexts.
Social support has been found to buffer the effect of stigma-based stress expo-
sure in numerous studies globally (Huang etal., 2018b; Kaplan etal., 2016; Shilo &
Savaya, 2011; Wagner et al., 2018). For instance, the negative effect of
R. Bränström et al.
55
victimization on suicidality among sexual minority youth in Chinese schools
(Huang etal., 2018b), transgender women in Lebanon (Kaplan etal., 2016), and
young middle eastern MSM (Wagner etal., 2018) has been found to be moderated
by supportive interpersonal peer and family connections.
Internalized stigma (e.g., internalized homophobia and transphobia), has been
less explored outside of the Global North. However, internalized homonegativity
has been found to predict depressive symptoms among sexual minority men in
Brazil (Dunn etal., 2014) and Nigeria (Oginni etal., 2018), as well as suicidality
among sexual minority men in Chile (Pinto-Cortez et al., 2018). Internalized
homophobia has also been shown to vary widely across European countries, with
gay and bisexual men living in more LGBTQ-supportive countries showing lower
endorsement of internalized homophobia than those living in more stigmatizing
countries (Berg etal., 2013).
Additional support for the cross-cultural relevance of minority stress as a predic-
tor of LGBTQ mental health comes from a cross-country study conducted online in
Western Europe, Eastern Europe, India, the Philippines, and Thailand. This study,
limited to gay and bisexual men, specically found evidence for the cross-cultural
relevance of the factors described in minority stress theory (e.g., victimization,
internalized homophobia, concealment) as predictors of life satisfaction across
these groups (Sattler & Lemke, 2019).
3.3.2 Cross-Country Variation inStructural Stigma
Despite major changes in societal attitudes, laws, and policies affecting LGBTQ
people in several countries in recent years, LGBTQ people still face discriminatory
legislation and limitations in the fulllment of fundamental human rights in many
parts of the world (International Lesbian Gay Bisexual Trans and Intersex
Association, 2019). The legal climate inuencing the lives of LGBTQ individuals
varies from the criminalization of consensual same-sex sexual acts in some coun-
tries to protecting against discrimination based on LGBTQ status in others. Studies
have shown that stigmatizing legislation seems to go hand-in-hand with stigmatiz-
ing population attitudes (Flores & Park, 2018; Hooghe & Meeusen, 2013). Stigma
at a societal level is referred to as structural stigma (Hatzenbuehler, 2014). Research
on structural stigma demonstrates that LGBTQ individuals’ mental health is strongly
inuenced by where they live. For example, in US states with more discriminatory
laws and policies and fewer equal protections for sexual minorities, the disparity in
poor mental health based on LGBTQ status has been found to be greater than in
more supportive structural contexts (Hatzenbuehler etal., 2010). LGBTQ youth liv-
ing in municipalities without protective school policies and support have been found
to be at greater risk of suicidality than those who live in more supportive contexts
(Hatzenbuehler, 2011). Variation in structural stigma also predicts LGBTQ mental
health across countries. For instance, life-satisfaction among LGBTQ individuals
varies greatly across European countries largely as a function of structural stigma
3 Global LGBTQ Mental Health
56
and associated demands to conceal one’s sexual identity to avoid discrimination and
victimization (Bränström etal., 2021; Pachankis & Bränström, 2018). See the chap-
ter on Stigma, Chap. 2, for a more detailed discussion of the impact on the lives of
LGBTQ individuals and communities.
3.3.3 Barriers toSocietal Integration Across Countries
Although the stigma-based psychosocial stressors described above are most fre-
quently explored as determinants of LGBTQ mental health, some studies have tried
to identify less-examined sociological factors that contribute to sexual and gender
minority mental health disparities. These studies have been guided by the assump-
tion that a person’s lack of integration within society and a lack of societal attach-
ments and commitments can increase their risk of mental health problems. The
section below reviews those experiences, including the mental health impact of
societal trust and participation, unemployment, lack of stable housing, living with-
out children, and religious afliation.
A number of studies from the Global South have recently found support for the
importance of societal integration in reducing mental health disparities affecting
LGBTQ populations. For example, a study from Lebanon found that barriers to
societal integration, in the form of unemployment and lack of legal resident status,
predicted poor metal health in a sample of young MSM in Beirut (Wagner etal.,
2018). In another study, lack of access to stable housing among transgender indi-
viduals in Argentina was linked to increased suicidality (Marshall etal., 2016). A
study of MSM in three West African countries (i.e., the Gambia, Burkina Faso, and
Togo) reported that lower degree of social participation with the broader community
was associated with higher likelihood of suicidal ideation (Stahlman etal., 2016). In
one study from Kenya, being married to an opposite-sex partner was found to be
protective against depression among MSM, possibly by both providing a source of
social support and facilitating the concealment of sexual orientation (Secor
etal., 2015).
In one of the few studies applying this perspective in the Global North, a study
from Sweden found elevated risk of suicidality among sexual minority women and
men, which was partially explained by this group’s greater lack of societal integra-
tion, including being unmarried or living without a partner, not having children,
being unemployed, and experiencing low societal trust, compared to heterosexuals
(Bränström etal., 2023). In line with these results, a study among Israeli gay fathers
found elevated levels of both subjective well-being and meaning in life compared to
gay men without children (Shenkman & Shmotkin, 2014). This indicates that rais-
ing children may allow for greater integration within Israeli society.
In some cultural contexts, such as the United States, religious afliation func-
tions as a facilitator of societal integration among people (Lim & Putnam, 2010; for
more information see the Community and Social Support chapter, Chap. 6).
However, there are several studies showing that religiosity contributes to
R. Bränström et al.
57
detrimental coping and poor mental health among LGBTQ individuals. For exam-
ple, one study showed an increased negative impact of stigma-based violence on
depression among gay men in Tanzania who perceived religion to be important
(Ross & Anderson, 2014). The authors conclude that living in a context of reli-
giously motivated anti-gay religious beliefs can have a detrimental effect on coping
with stigma-based violence among religious gay men. Similar reports of religiosity
as an enhancer of stigma- based stress among religious sexual minority men have
been reported among Polish Roman Catholics (Zarzycka etal., 2017) and religious
US young adults (Lytle etal., 2018). In a study of sexual minority women in the
United States, researchers found that the impact of religiosity and spirituality on
depression and substance use differed by race/ethnicity (Drabble etal., 2018). Also
in the United States, personal religiosity has been shown to exacerbate suicidality
risk among sexual minorities, but not for heterosexuals (Lytle etal., 2018), suggest-
ing that this common global indicator of societal integration can be harmful to sex-
ual and gender minorities in at least some contexts.
3.3.4 LGBTQ Conversion Therapy
Conversion therapy has predominately been practiced in the United States and other
parts of the Global North (Haldeman, 2002a) but is gaining increasing prominence
in other global regions such as China (Beijing LGBT Center, 2014). Conversion
therapy refers to any kind of treatment with the intention to change an LGBTQ
sexual orientation or gender identity to a heterosexual orientation and/or cisgender
identity (Drescher et al., 2016; Substance Abuse Mental Health Services
Administration, 2015). There is not only a lack of evidence that conversion therapy
treatments can be effective in changing sexual or gender identity (Adelson & Child,
2012; American Psychiatric Association, 2000), but substantial research has shown
that it harms the mental health of LGBTQ individuals (Beckstead, 2012; Haldeman,
2002a, b; Shidlo & Schroeder, 2002). The spread and reach of conversion therapy
globally are hard to assess, and the overall impact of conversion therapy on the
mental health of LGBTQ populations from a global perspective is largely unknown
and warrants further research, given its potential for signicant harm.
3.4 Interventions toImprove LGBTQ Mental Health
3.4.1 Interventions toReduce LGBTQ Stigma
As noted above, the degree to which LGBTQ individuals around the world are
exposed to stigma-related stress is highly dependent on structural factors at national,
regional, or state/provincial levels, such as discriminatory laws and policies and
negative societal attitudes (Hatzenbuehler etal., 2009, 2012; 2018). In many parts
3 Global LGBTQ Mental Health
58
of the world, societies’ views of LGBTQ individuals have changed a great deal over
a relatively short period (Flores & Park, 2018). For example, in Europe, a number
of countries have passed same-sex marriage legislation, which has been found to go
hand-in-hand with improvements in population attitudes toward LGBTQ people
(Hatzenbuehler etal., 2012; Hooghe & Meeusen, 2013). In India, the recent deci-
sion to decriminalize homosexuality is expected to be followed by an improvement
in societal attitudes and a greater acceptance of same-sex relationships.
In addition to country- or state/provincial-level interventions, a number of inter-
ventions targeting the school environment (Hatzenbuehler & Keyes, 2013; Mayberry
etal., 2013) and work environment (Button, 2001) have shown promising results in
reducing the mental health burden of LGBTQ individuals. These results suggest that
community action and other efforts to reduce stigmatizing national laws, policies,
and attitudes in cultural settings where LGBTQ individuals have limited legal rights
can be expected to yield improvements in LGBTQ individuals’ mental health.
3.4.2 Interventions toPromote Coping withStigma
There is a clear need for evidence-based prevention and treatments specically tai-
lored to LGBTQ people. However, few such programs exist partly due to insuf-
cient research on the efcacy of such interventions (Fisher & Mustanski, 2014).
Sexual orientation and gender identity are typically not monitored in research evalu-
ating the efcacy of mental health treatments (Heck etal., 2017), and few mental
health intervention studies have been conducted with LGBTQ people. It is therefore
unknown if mainstream treatments currently offered are effective in reducing
LGBTQ individuals’ mental health problems, although existing evidence suggests a
mixed pattern (Pachankis, 2018).
There is a small but growing literature focusing on mechanisms underlying
LGBTQ people’s increased risk of mental illness, with implications for interven-
tions with this population (Hatzenbuehler & Pachankis, 2016; Meyer, 2003b). Some
of the factors believed to contribute to higher rates of poor mental health among
LGBTQ people are elevated experiences of universal risks for psychopathology,
such as poor emotion regulation, social isolation, and maladaptive cognitive pro-
cesses. Such factors are believed to be more common among LGBTQ people than
among heterosexual and cisgender people (Hatzenbuehler & Pachankis, 2016). For
several of these more general risk factors, effective evidence-based psychological
treatments exist, including cognitive behavioral therapy and emotion-focused
approaches (Elliott et al., 2004; Farchione et al., 2012). Other mechanisms that
underlie the heightened risk of poor mental health outcomes are specic to LGBTQ
people, such as stress related to sexual or gender identity non-disclosure, expecta-
tions of rejection, and internalization of society’s negative attitudes (Pachankis,
2015). Because these risk factors are specic to LGBTQ people, they are likely to
require tailored treatment strategies to be optimally effective.
R. Bränström et al.
59
Research into effective psychological treatments to reduce mental illness among
LGBTQ people remains limited (Chaudoir etal., 2017; Public Health Agency of
Sweden, 2018). In fact, two recent literature reviews identied only one evidence-
based mental health treatment specically developed for LGBTQ people in the
United States that had been tested in a randomized controlled trial. This treatment
was specically designed to afrm gay and bisexual men’s sexual identities and
help them cope with minority stress (Pachankis etal., 2015). In this trial, the inter-
vention showed initial promise for improving gay and bisexual men’s mental and
sexual health. This treatment focuses on building LGBTQ individuals’ capacity to
cope with minority stress through strategies such as normalizing the negative impact
of minority stress; facilitating emotional awareness and acceptance; reducing avoid-
ance; building self-afrming communication styles; restructuring thoughts relating
to minority stress; afrming unique strengths; and encouraging a healthy, rewarding
expression of sexuality (Pachankis, 2014). A recent extension of this research shows
its preliminary efcacy for sexual minority women as well (Pachankis etal., 2020).
Several other studies have examined LGBTQ-afrmative treatments based on these
general LGBTQ-afrmative principles but have lacked a comparison group and
have included relatively brief monitoring periods (Chaudoir et al., 2017; Public
Health Agency of Sweden, 2018).
3.5 Future Directions
3.5.1 Improved Research Methodologies forGlobal LGBTQ
Mental Health
As mentioned above, the majority of studies on global LGBTQ mental health have
been conducted using non-probability samples. Although such samples have
allowed researchers to recruit large numbers of otherwise hard-to-reach LGBTQ
individuals, such as those living in high-stigma settings, there are clear limitations
to this approach. First, non-probability samples yield nonrepresentative results and
prohibit population estimates of mental health prevalence. Second, individuals
recruited using non-probability methods are more likely to be open about their
LGBTQ identity, tend to be younger, and otherwise might not represent the full
spectrum of diversity within the LGBTQ population (Hottes etal., 2016; Kuyper
etal., 2016). Additionally, a disproportionately high number of studies have focused
on the mental health of MSM (possibly due to funding streams that favor addressing
HIV), and the great majority of studies have been conducted in the Global North. To
better understand the mental health of LGBTQ individuals, higher-quality studies
are needed that use representative samples of the full spectrum of LGBTQ popula-
tions from different parts of the world, including sexual minority women and trans-
gender individuals.
3 Global LGBTQ Mental Health
60
3.5.2 Comparative Research toIdentify Cultural Variation
inLGBTQ Mental Health
The best way to explore geographical and cultural differences in LGBTQ mental
health is to conduct studies using identical research methodologies across countries.
Because the structural climate surrounding LGBTQ individuals varies widely across
the globe, and recent studies have demonstrated that variations in structural stigma
are likely associated with variations in mental health (Hatzenbuehler etal., 2011;
Pachankis & Bränström, 2018), more extensive cross-country research is warranted.
The few current studies that have been replicated across countries have produced
important information. One such study demonstrated the cross-cultural relevance of
factors described in minority stress theory in understanding the determinants of
LGBTQ mental health (Sattler & Lemke, 2019). Another cross-European study
demonstrated the impact of country-level variations in discriminatory legislation
and societal acceptance on life satisfaction among LGBTQ people (Pachankis &
Bränström, 2018). Compelling arguments have been made against hegemonizing
the sexual and gender minority experience worldwide (Massad, 2002), while at the
same time, country-specic variation in experiences of those identities has been
argued to vary around common themes (Sullivan, 2001). A recent systematic review
of global mental health also emphasized learning from and supporting mental health
in Global South countries (Rajabzadeh etal., 2021). To the extent these arguments
also apply to the mental health experience of sexual and gender minority individu-
als, they suggest the need to further understand the shared and distinct experiences
of identity and mental health in cross-cultural studies while striving to privilege
local understandings.
3.5.3 Dissemination ofLGBTQ-Afrmative Mental
Health Interventions
Future research is needed to develop efcient means of distributing LGBTQ-
afrmative treatment to LGBTQ populations that most need them. One strategy that
has shown initial promise involves training mental health providers to deliver
LGBTQ-afrmative mental health treatment in high-stigma, low-resource global
settings. For instance, after participating in a 2-day training in LGBTQ-afrmative
mental healthcare, 110 mental health professionals in Romania reported signicant
reductions in stigmatizing beliefs and signicant increases in LGBTQ-afrmative
clinical skills (Lelutiu-Weinberger & Pachankis, 2017). That half of the trainees
participated in the training online and did not differ from the half who attended in-
person suggests that delivering remote training and supervision in LGBTQ-
afrmative mental healthcare represents an efcient means to provide needed
mental health support to a large segment of the global LGBTQ population. In addi-
tion, a recent systematic review and meta-analyses found digital interventions to be
R. Bränström et al.
61
effective in Global South countries (Fu etal., 2020). Remote delivery of LGBTQ-
afrmative mental health services directly to LGBTQ people living in high-need
global regions thus represents a potentially efcient means for reaching these popu-
lation groups (Leluțiu-Weinberger etal., 2018). Finally, psychosocial interventions,
including social capital interventions (such as community engagement and educa-
tion programs, cognitive processing therapy, sociotherapy, and neighborhood proj-
ects), have been effective in both Global South and Global North countries (Barbui
etal., 2020; Flores etal., 2018) and could be adapted for LGBTQ populations.
3.5.4 Aging-Related Dementia andCognitive Decline
The situation for middle-aged and older LGBTQ populations and the unique aging-
related stressors they face is an understudied area and a growing global public health
priority. Given the increasing concerns about aging-related dementia and cognitive
decline in the general population, more knowledge about the specic needs and
concerns of LGBTQ people is warranted (Barrett etal., 2015; McGovern, 2014;
Witten, 2014). The current small body of literature on aging-related concerns among
LGBTQ people has also been conducted in cohorts who have lived much of their
lives before the start of the global LGBTQ rights movement (McGovern, 2014).
This research needs to consider the great regional variation in legal rights and popu-
lation acceptance of LGBTQ people globally, as well as the rapidly changing social
realities in some global regions.
3.6 Conclusion
As is apparent based on the amount of research included in this chapter, the mental
health of LGBTQ individuals is being studied in some places in the world but not in
others. There are clear disparities in mental health for LGBTQ people, especially
when disaggregating the data by sexual orientation and/or gender identity.
Additionally, when examining mental health through the intersections of sexual ori-
entation, gender identity, race, socioeconomic status, and more, it becomes notable
that this disproportionate burden of mental health challenges that LGBTQ people
face. Globally, minority stress and social integration barriers greatly impact LGBTQ
people and their ability to cope with their mental health, although the interaction
between the two is widely unknown. While some geographic areas have more
research, large gaps still exist in other areas, especially when studying LGBTQ
subpopulations in non-Western countries. Evidence is also missing on the impact of
interventions that go beyond the traditional Western ideas of therapy and counseling
to include other cultural factors within the Global South and low- and middle-
income countries. More in-depth studies of intervention dissemination are also nec-
essary to begin to address the extreme disparities that exist and allow LGBTQ
people to both survive and thrive in the world.
3 Global LGBTQ Mental Health
63
3.7 Case Study: LGBTQ Mental Health inSweden
The burden of mental illness for the LGBTQ population in Sweden is high, with
young LGBTQ people having approximately twice the risk of depression, anxiety,
and substance abuse problems as young heterosexual people (Bränström, 2017).
Additionally, transgender individuals who seek mental health treatment and have a
diagnosis of gender dysphoria are up to six times more likely than cisgender people
to be treated for depression and anxiety (Bränström & Pachankis, 2019). The out-
look for the mental health of LGBTQ people seems bleak; however, over the past
several decades there has been a push to improve LGBTQ mental health through
several initiatives. For instance, LGBTQ people are included in the Swedish Mental
Health Strategy and the global Sustainable Development Goals. Policymakers are
making an effort to utilize legislative changes, and continued pressure comes from
key nongovernmental organizations focused on equality for LGBTQ people.
A number of studies have examined the mental healthcare of LGBTQ individuals
in Sweden (Bränström, 2017; Bränström & Pachankis, 2019; Tholin & Broström,
2018; Zeluf et al., 2016). One longitudinal, prospective, population-based study
found that LGBTQ people were at signicantly higher risk than heterosexual people
for mental health disorders, with especially high risk identied for bisexual women,
gay men, and young lesbian women (Bränström, 2017). The study also found that
LGBTQ individuals, because of their increased rates of mental disorders, had an
elevated rate of mental healthcare usage (Bränström, 2017). This utilization differ-
ence is important to note because, according to another study, transgender individu-
als had elevated rates of mental illness compared to cisgender individuals (Tholin &
Broström, 2018). Transgender individuals also believed that healthcare practitioners
lacked competency around treating transgender patients (Tholin & Broström, 2018),
which needs to be addressed.
Over the past 25years, Sweden has worked to deinstitutionalize their mental
healthcare system and transition to community-based care in order to better serve
the people utilizing mental health services. Several major policy changes were
adopted between 1995 and 2012 toward this goal (Bergmark etal., 2017). However,
most recently, the government’s National Mental Health Strategy for 2016–2020
identied, as one of their ve foci for 5years, an area of attention on vulnerable
populations that includes LGBTQ people (EuroHealthNet Magazine, 2017;
Nationell samordnare, 2016), as they are at disproportionate risk of mental illness in
their lifetimes (Bränström, 2017; Bränström & Pachankis, 2019). Additionally, the
global Sustainable Development Goals (SDGs), which apply to Sweden and which
Swedish organizations have subsequently strived toward, were created in 2015
(Weitz etal., 2015). The SDGs focus on the principle “leave no one behind,” which
is repeated throughout. This includes sexual and gender minorities, who are some of
the most marginalized and vulnerable people throughout the world. Certain SDGs,
like number three, “Ensure healthy lives and promote well-being for all at all ages,”
would necessarily include LGBTQ people (Weitz et al., 2015). If Sweden is to
address this goal, and others, there need to be strategies that aim to combat the
3 Global LGBTQ Mental Health
64
discrimination, violence, and other minority stress that negatively impact LGBTQ
people in Sweden and across the world.
Not only has Sweden worked to improve mental health and protect people who
have a mental illness, but they have also broadly defended the rights of LGBTQ
people through a series of legislation that addresses discrimination in employment,
hate speech, and marriage rights (Swedish Code of Statutes, 1999, 2003, 2009).
Many initiatives similar to those advanced in the United States that have shown
positive effects on the mental health of LGBTQ people (Bufe, 2011; Hatzenbuehler
etal., 2009, 2010; Riggle etal., 2010; Rostosky etal., 2009) have also been intro-
duced in Sweden. One study using data from 23,000 respondents to population-
health surveys from 2005, 2010, and 2015 found that decreases in Sweden’s
structural stigma were associated with lower levels of psychological distress for gay
men and lesbian women. However, mental health disparities still persist in the levels
of psychological distress experienced by gay men and lesbian women as compared
to heterosexuals (Hatzenbuehler etal., 2018).
Along with the structural and governmental changes that have helped improve
mental health outcomes for LGBTQ people, one nongovernmental organization has
helped to inuence several decades of policy and legislative changes that protect
LGBTQ rights and improve the accessibility of community-based mental health
services. This organization is called Riksförbundet för homosexuellas, bisexuellas,
transpersoners och queeras (RFSL) or the National Organization for Lesbian, Gay,
Bisexual, and Transgender Rights (in English), and its goal is for LGBTQ people to
have the same rights as everyone else—locally, nationally, and internationally
(RFSL, 2018). The RFSL published an analysis of the mental health action plans for
the various regions and municipalities of Sweden, including whether LGBTQ peo-
ple were explicitly included. They found that out of the 21 regions of Sweden, only
11 explicitly included LGBTQ people in the programmatic analysis, and only 1
region, Stockholm, explicitly included LGBTQ people in their action plan (RFSL,
2016). Additionally, the report incorporated recommended strategies to ensure that
future action plans involve LGBTQ people and their mental health needs (RFSL,
2016). The RFSL has a dedicated website and resources for transgender Swedes,
and their webpage includes a variety of information on the unique mental health
needs of this population (RFSL Ungdom, 2019).
Although signicant disparities still exist, through the work of this organization
as well as the sustained efforts of legislators and other activists in Sweden, the men-
tal health outlook for LGBTQ people is improving. As research has demonstrated,
structural change and support for LGBTQ rights have an extremely important effect
on making LGBTQ people feel accepted and valued in society. Work needs to con-
tinue in this direction to create the best possible future for this population.
Acknowledgments We are grateful to Alicia T.Bazell for contributing to the case study on the
mental health of LGBTQ people in Sweden accompanying this chapter and to Arjan van der Star
for assisting with the literature searches.
R. Bränström et al.
65
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Chapter 4
If YouDon’t Ask, YouDon’t Count:
Elements toConsider inUnderstanding
Global Sexual andGender Minority Data
onNoncommunicable Diseases
JaneA.McElroy andBennettJ.Gosiker
4.1 Introduction
Globalization, often narrowly dened as the increasing integration of the world’s
economies, has aspects beyond economic factors, including technological, political,
social, scientic, and cultural phenomena (Huynen etal., 2005). The sociocultural
dimension is particularly germane to the discussion of noncommunicable diseases
(NCDs or physical chronic conditions) among sexual and gender minorities (SGMs)
that will be discussed in the next chapter. In the twentieth century, scholars in sexu-
ality and nationalism presented alternatives to the beliefs that sexuality is “private,”
apolitical, sinful (according to religious authorities), or deviant (according to mental
health experts) (Foucault, 1984; Rosario etal., 2002).
One alternative perspective uses the concept of sexual scripts to understand the
three interrelated categories of human sexuality: attraction, behavior, and identity
(i.e., orientation) (Seidman, 2003). This idea can also be extended to gender scripts,
such as ones related to gender as binary, linked to anatomical features, and xed at
birth. This perspective argues that sexual and gender scripts that people use are
rooted within each nation’s establishments, such as churches, schools, and laws, and
are implemented by socializing agents, such as religious leaders, peers, and the
media (Stambolis-Ruhstorfer, 2017). SGMs living in places or within racial/ethnic
groups where the scripts associated with SGM identity, behaviors, and/or attraction
are nonexistent, associated with allegations of not being legitimate, or depicted as
an inherent erotic, racially centric characteristic have ramications on
J. A. McElroy (*)
Department of Family & Community Medicine, School of Medicine, University of Missouri,
Columbia, MO, USA
e-mail: mcelroyja@umsystem.edu
B. J. Gosiker
Kaiser Permanente Bernard J.Tyson School of Medicine, Pasadena, CA, USA
e-mail: bgosiker@gmail.com
© The Author(s) 2024
S. J. Hwahng, M. R. Kaufman (eds.), Global LGBTQ Health, Global LGBTQ
Health, https://doi.org/10.1007/978-3-031-36204-0_4
80
characterizing the health of SGM people (Carrillo & Fontdevila, 2014; Decena,
2011; Epstein & Carrillo, 2014; Provencher, 2016). Specically, these scripts reduce
the likelihood of describing NCD outcomes for these populations due to receiving
low or no priority in scientic and medical research.
Not only is globalization a multidimensional phenomenon, but contemporary
global health issues have moved from an emphasis on the health burden tied to
infectious disease to that of NCDs. In the twenty-rst century, cardiovascular dis-
ease, cancer, diabetes mellitus, and chronic respiratory diseases are associated with
71% of all premature deaths worldwide. Among those aged 30–69years, over 85%
of premature deaths linked to these health conditions occur in low- and middle-
income countries (Adeyi etal., 2007; Lopez etal., 2006; World Health Organization,
2005, 2018). Extensive evaluation and modeling of mortality patterns by the Global
Burden of Disease Study demonstrated that some NCDs topping the list as leading
regional contributors of years of lost life (YLLs: a standard metric for mortality
studies) also showed considerable intraregional differences based on a composite
sociodemographic index as well as between subpopulations; this index is comprised
of the geometric mean of income per capita, educational attainment, and total fertil-
ity rate in the current year (GBD 2017 Disease and Injury Incidence Prevalence
Collaborators, 2018). To illustrate, NCD burden in New Zealand (NZ) has signi-
cant variation between indigenous Polynesian people of NZ (i.e., Maori) compared
to non-Maori populations (GBD 2017 Disease and Injury Incidence Prevalence
Collaborators, 2018). This nding highlights the importance of recognizing that the
prevalence of NCDs by region or within countries in which SGM-specic data are
unavailable may not accurately represent SGM’s health status in those places.
A parallel metric to capture disease burden is disability-adjusted life year
(DALY), which adds both years of life lost (YLLs) and years lived with disability
(YLDs) (Murray etal., 2012). This metric was developed in the 1990s specically
to compare national health burden around the world, as it is an acceptable measure
of the effects of chronic illness on population health burden (Murray, 1994). As the
selected NCDs described in the next chapter contribute to premature death and/or
disability, especially in countries with limited health interventions, this metric is
particularly valuable. According to the Global Burden of Disease Study, which ana-
lyzed and modeled data to describe the burden of both communicable and noncom-
municable diseases in 195 countries and territories, NCDs contributed an estimated
54% of the DALYs in 2010, with 25.3% by the selected ve NCDs (i.e., cardiovas-
cular diseases(CVD), includingstrokes, at 11.8%, cancer at 7.6%, diabetes mellitus
at 1.9%, asthma at 0.9%, COPD at 3.1%) (Murray, 1994).
4.2 On theImpact ofCOVID-19
The COVID-19 pandemic links both infections from a severe acute respiratory syn-
drome coronavirus 2 (SARS-CoV-2) with NCDs. First detected in Wuhan, China in
December 2019, the World Health Organization declared COVID-19 a pandemic on
J. A. McElroy and B. J. Gosiker
81
March 11, 2020 (Neher et al., 2020; Zhou et al., 2020). A higher risk of severe
COVID-19 disease is experienced by two groups of people; adults aged 65years or
older and people with underlying medical conditions, such as those NCDs described
in the subsequent chapter (CVD, cancer, diabetes, asthma, and COPD) (Azarpazhooh
etal., 2020). Among younger patients diagnosed with COVID-19 (18–49years),
obesity, underlying chronic lung disease (primarily asthma), and diabetes are the
most prevalent chronic disorders (Stokes etal., 2020). According to Clark and col-
leagues, among the global population, countries with older populations, African
countries with high HIV/AIDS prevalence, and small island nations with high dia-
betes prevalence are estimated to be at the highest increased risk for severe
COVID-19 illness (Clark etal., 2020). No research has addressed the impact of the
COVID-19 pandemic on gender minority populations with NCDs. Some work has
been done to characterize reduced access to gender-afrming services, including
one study with a global sample of 849 transgender and non-binary people represent-
ing Europe (n= 382), Southeast Asia (n = 215), the Americas (n = 81), Eastern
Mediterranean (n=76), Western Pacic (n=40), and Africa (n=31). The authors
found reduced access to gender-afrming services as well as increased levels of
anxiety and depression among their sample (Restar etal., 2021). Unfortunately, at
the writing of this chapter, no studies have reported on SGM individuals’ risk for
severe COVID-19, though it is possible that multiple syndemic factors may increase
this population’s risk of exposure (Cahill etal., 2020).
4.3 Chronic Stress andImmune Dysregulation
Segerstrom and Miller evaluated over 300 studies and concluded that chronic stress
was associated with numerous measures of immune dysregulation, such as inam-
matory engagement and poor antibody responses (Segerstrom & Miller, 2004).
However, inconsistent results using biological markers of stress, such as cortisol or
C-reactive protein levels, comparing SGM and non-SGM participants have been
published with virtually all of these data from developed countries (Austin etal.,
2016; Cohen etal., 2017; DuBois etal., 2017; Huebner & Davis, 2005; Juster etal.,
2013, 2015). As noted by Segerstrom and Miller, many studies suffer from method-
ological limitations in sampling with a variety of biomarkers used to signal stress
which adds uncertainty to understanding the stress response (Segerstrom &
Miller, 2004).
4.4 Factors Contributing toChronic Illnesses
Since the major causes and/or signicant risk factors of the leading NCDs are known,
approximately 60% of these deaths are preventable. For example, the Oxford Health
Alliance (OHS) developed a conceptual model called “4four60” to support effective
4 If You Don’t Ask, You Don’t Count: Elements to Consider in Understanding Global…
82
communication on the prevention of NCDs. They link four risk factors (poor diet,
physical inactivity, tobacco use, and excess alcohol consumption) known to be asso-
ciated with four leading NCDs (cardiovascular disease, cancer, diabetes, and chronic
lung disease) to the contribution of 60% of all global premature deaths (Colagiuri
etal., 2007). Both poor diet and physical inactivity in association with these NCDs
are often associated with high body mass index (BMI). As a sidenote, BMI is often
used as a standardized and convenient method to classify people into weight catego-
ries, though numerous limitations have been reported in using this metric (Nuttall,
2015). In a systematic review comparing BMI, waist circumference, and waist-to-
height ratio (WHtR) measurements to visceral adipose tissue (VAT) measurement,
waist circumference and WHtR were better predictors of VAT than BMI (Browning
etal., 2010). Using indexes that account for body fat distribution such as waist-to-hip
or WHtR ratio, intra-abdominal fat depot volume, or waist-to-height ratio provides a
more accurate means of risk assessment associated with obesity.
Regarding dietary choices, a signicant downstream effect of globalization is the
unprecedented increase in the global food trade, which has been dominated by large
transnational companies (Pang & Guindon, 2004). Global brand names and aggres-
sive marketing strategies have adapted to local environments such that recognition
of brand names of popular beverages and fast foods has been especially rapid
(Chopra etal., 2002). This situation has contributed to the global epidemic of obe-
sity by replacing traditional diets with fat- and calorie-rich foods (Gakidou etal.,
2017). The results from the Global Burden of Disease study on high BMI found
12% of the adult population (603.7 million adults; 95% uncertainty interval: 592.9
to 615.6) were obese worldwide with a consistently higher prevalence of obesity
among women. In 2015, high BMI contributed to deaths from any cause worldwide
at 7.1% (95% uncertainty interval: 4.9 to 9.6) with obesity-related cardiovascular
disease and diabetes as leading causes of these mortality statistics (Afshin etal.,
2017). Beyond mere statistics, the threats to population health in many LMICs are
occurring on two fronts simultaneously: “In the slums of today’s megacities, we are
seeing NCDs caused by unhealthy diets and habits, side by side with undernutri-
tion” according to former Director-General of World Health Organization, Dr. Gro
Harlem Brundtland (World Health Organization, 2002, p. x).
Although considerable data have been compiled with recent excellent work by
the Global Burden of Disease study (Benziger etal., 2016), sparse data are available
to address the question of the burden of NCDs among sexual and gender minority
(SGM) populations. SGMs in some parts of the world, where data are available,
have a higher prevalence of known risk factors (as detailed by the aforementioned
“4for60” model) associated with leading NCDs. For example, in a systematic review
of literature, Eliason and colleagues reported that lesbian and bisexual women had
a higher prevalence of a BMI over 30 compared to heterosexual women (Eliason
etal., 2015); however, of the 20 studies included, only two (Australia and Great
Britain) were outside of the USA, thus limiting the global picture. Similarly, some
studies in the USA have suggested a higher prevalence of overweight but not obese
status among transmasculine individuals compared to cisgender women (Caceres
etal., 2019; Reisner etal., 2013).
J. A. McElroy and B. J. Gosiker
83
A fundamental question that remains largely unanswered is whether factors
related to SGM status, and perhaps the synergistic or syndemic effects between
SGM status and health-related behaviors (e.g., unhealthy weight, smoking, exces-
sive alcohol consumption), are associated with an increased prevalence of NCDs
among SGMs (Coulter etal., 2015). For example, in Western countries, the minority
stress model is often used to help explain health disparities experienced by SGMs,
with similar stressors identied in other counties (Bowling et al., 2018; Kontos
etal., 2011; Laćan, 2015; Lobato etal., 2019; Mahdavi, 2019).
To understand this issue, extramural funding and/or intramural funding priorities
are critical. Perhaps a systematic bias in selecting grant proposals worthy of funding
or considering SGM issues beyond HIV/AIDS research is due to (unconscious)
bias. Historically,bias in US National Institutes of Health (NIH) funding (Kaiser,
2011) culminated in NIH mandating justication for studies if women and minority
groups (race/ethnicity) were not included. It is not unreasonable to consider bias as
a factor in funding focused on SGM issues. The catch-22 of rejections in grant
applications, particularly in the USA and other countries in which extramural fund-
ing is expected of researchers, is that young researchers will either move on to more
fundable opportunities with a non-SGM focus, since successful funding is neces-
sary for tenure and promotion or move out of the research arena entirely.
4.5 Health Disparity Theories
A recent study in Sweden tested another related hypothesis to explain health dis-
parities faced by SGMs, called the fundamental cause theory (Branstrom et al.,
2016). In a comparison of advantaged (heterosexuals) and disadvantaged (SGMs)
groups, they found the prevalence of high-preventable diseases—ones that could be
prevented or effectively treated—was signicantly higher among SGMs. They posit
that for preventable diseases, disadvantaged groups cannot leverage the resources
necessary (i.e., knowledge, prestige, power, or supportive social connections) to
achieve healthy outcomes. To bolster this theory, analysis of low-preventable dis-
eases—ones that cannot be effectively prevented or cured—had similar outcomes
between the two groups (Branstrom etal., 2016). Although this study provides evi-
dence that a true health disparity for NCDs may exist for the SGM population that
cannot be explained by an increased prevalence of established risk factors linked to
these NCDs, we are still left with a very difcult construct to assess and compare
across countries. Further, the validity of the construct has not been tested, although
tangential information partially supports the fundamental cause theory (Branstrom
et al., 2016). For example, in Niger, general population patients were typically
viewed as passive or without a “voice” by their local nurse, and therefore obtaining
services beyond the local health centers rarely occurred. One could extrapolate this
characteristic to SGM individuals in which presumably their lower prestige and/or
power could limit optimizing their health-seeking behavior (Bossyns & Van
Lerberghe, 2004).
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84
National legislation and political rhetoric can also have the effect of reduced
privilege and/or power for SGM citizens (see Stigma chapter, Chap. 2), which can
create dissonance between one’s personal self and one’s national self and likely
engenders a sense of powerlessness. Alternatively, some countries, such as Canada,
Spain, and the Netherlands, embrace SGM rights as a key characteristic of national
belonging (Stambolis-Ruhstorfer, 2017). However, the intersection of SGM identity
and nationalism ideology can also create discordance (“Muslim and gay: seeking
identity coherence in New Zealand,” 2016). For SGMs who also identify with other
ethnicities, such as a Muslim with family from Iran (known for its extreme anti-gay
laws), national rhetoric from any country that supports SGM rights may require its
citizens to reject or renounce their ethnic communities in order to gain acceptance;
thus, these individuals may experience one aspect of their identity being pitted
against another aspect of their identity. These situations could have a negative inu-
ence on their health either from a stigmatizing position (i.e., minority stress theory
(Meyer, 2003)) or an inability to leverage necessary resources to optimize health
(i.e., fundamental cause theory). Regardless of the source of such disparities, it is
critical to characterize potential sources that create dissonance so that the health of
SGM populations can be better understood and disparities addressed across various
healthcare delivery systems.
Two theories have been suggested regarding aging, health disparity, and NCD
prevalence. Compression of morbidity theory for health disparities posits that with
increasing years lived, the disparity gap narrows since only the hardiest individuals
survive (Beckett, 2000; House etal., 2005). On a global scale, countries rst need
to achieve a more equal comparison of three domains before the hardiest individuals
would have the opportunity to survive. One domain is for countries to transition
more fully from health outcomes based on injury/violence, infection, and maternal/
perinatal/nutritional issues to NCDs, known as the epidemiological transition
(Omran, 2005). To illustrate, sub-Saharan Africa (of 48 countries) has the highest
under-ve mortality rate (1in 13 births) and modest life expectancy of 61 years
(range: 52years in the Central African Republic to 74years in Mauritius) versus
Australia and New Zealand with the lowest mortality rate (1in 263 births) and a life
expectancy of 82years (World Bank Group, 2019; United Nations Inter-agency
Group for Child Mortality Estimation, 2018). A second domain is achieving a rela-
tively equable performance of the country’s health system to treat medical condi-
tions including NCDs, thereby supporting the potential for an aging population
(Gordon-Larsen etal., 2000; Schutte etal., 2018). The third domain encompasses
similar NCD risk-attributable burden (i.e., tobacco use, excessive alcohol consump-
tion, obesity, and inactivity) at the population level among the countries (GBD 2017
Disease and Injury Incidence Prevalence Collaborators, 2018). For example, world-
wide, the age-standardized prevalence of daily smoking was 25% (95% uncertainty
interval 24.2–25.7) for men and 5.4% (5.1–5.7) for women. However, wide vari-
ability exists globally, with half the population smoking in Greenland (women at
44% and men at 43%) compared to rare smoking behavior in Sudan (women at
0.4% and men at 1.3%) (Reitsma etal., 2017).
J. A. McElroy and B. J. Gosiker
85
The second theory, the cumulative disadvantage hypothesis, advocates the oppo-
site—a widening of the health disparity gap due to the accumulation of burden over
time (Dupre, 2007; Kim & Durden, 2007; Lauderdale, 2001). The concept of
chronic stress experienced by SGM individuals over a lifetime translates into the
wearing down of biological coping systems and thereby results in an increased prev-
alence of NCDs per this hypothesis (Schneiderman etal., 2005). As with the rst
theory, applying this hypothesis on a global scale requires more equable treatment
of SGM populations worldwide. As explored in the Stigma chapter (Chap. 2), there
is considerable variability in how the people and institutions within any country
accept and embrace SGM citizens. Establishing the prevalence of NCDs over the
life course among sexual and gender minorities compared to heterosexual groups
can provide support for one of these theories within individual countries. From a
global perspective, further narrowing of differences among countries on aforemen-
tioned health domains as well as capturing data on SGM populations will provide
evidence regarding the health of SGMs worldwide.
4.6 Methodological Considerations
Regardless of a potential mechanism(s) underpinning differences in NCD preva-
lence, systems have to be in place to detect such a potential difference. Much of
health research is guided by opportunities either directly through funding initia-
tives or through agency/organization’s priorities, and a critical component in
being selected as a research priority lies in the generalizability of results. Two
critical components of the generalizability of results are determined from a suf-
cient sample size and the use of probability-based sampling of participants. Sexual
minorities (SM) comprise 6–14% of the global population (Rahman etal., 2020).
The visible (“out”) number of SM individuals comprises a sufciently large group
to warrant inclusion on national NCD surveillance surveys with the caveat that up
to 83% of SM individuals, globally, may conceal their identity from most or all
others (Pachankis & Branstrom, 2019). This concealment means their perspec-
tives may not be represented in NCD prevalence and incidence statistics and
therefore reduces the generalizability of the study results. Alternatively, estimates
of the global prevalence of transgender identity range from 0.3 to 0.5% (Gender
Identity in US Surveillance (GenIUSS) Group, 2014; Reisner etal., 2016) and
vary depending on how transgender identity is dened (Collin etal., 2016; Reisner
etal., 2016). According to Collin and colleagues, the prevalence estimates vary by
degree of medical intervention with surgical or gender-afrming hormonal ther-
apy (GAHT: i.e., estrogen and testosterone supplementation) or transgender-
related diagnoses versus self-reported transgender identity (Collin etal., 2016).
For the former, estimates range from 1 to 30 per 100,000 (0.001–0.03%) persons,
and the latter is 100–700 per 100,000 (0.1–0.7%) (Collin etal., 2016; Peitzmeier,
2013). Although transgender identity prevalence seems to be increasing over time
(Ahmadzad-Asl et al., 2010; Blosnich et al., 2013; Eklund etal., 1988; Kauth
4 If You Don’t Ask, You Don’t Count: Elements to Consider in Understanding Global…
86
etal., 2014; Meier & Labuski, 2013), one limitation in understanding NCD issues
among transgender populations is the relatively small sample size that would be
captured on any national surveillance study. Unless intentional over-sampling of
the transgender population is implemented, a small sample size will limit report-
ing outcomes among this population in large surveillance studies. Finally, for both
the SM and transgender populations, participation in research is voluntary.
Therefore, until it is safe and acceptable for individuals to disclose their SGM
status, it is unlikely that estimates of NCD prevalence will capture the true state
of health among these populations.
A second strong element in the generalizability of study results is the use of
probability-based sampling as opposed to convenience sampling. A mantra often
used by SGM researchers advocating inclusion of sexual orientation/gender identity
(SOGI) questions on surveillance surveys is, “If you don’t ask, you don’t count.”
Probability-based sampling requires a list of all eligible participants from which a
random sample is selected. Unless these identities are collected in a similar manner
as other commonly acquired demographics such as age, marital status, race/ethnic-
ity/nationality, and educational attainment, researchers will be hampered in design-
ing studies that accurately reect the state of SGM health. For NCD research, these
two components are critical for credible research ndings. One objective down-
stream effect of these elements of scientic rigor determines which countries con-
tribute to the SGM research agenda as described in the next chapter.
Another important aspect of SGM research associated with the prevalence of
NCDs is age. For transgender healthresearch, virtually no NCD research has been
done to explore the health impact of age of medical afrming interventions, GAHT
use, and experience of gender dysphoria. Among those who have medical afrming
interventions, these three characteristics are likely to vary with age. For example, in
a small cohort of transfeminine patients aged 19–66years who were undergoing
gender-afrming surgery in Germany, the reported age of gender dysphoria was
between 4 and 63years. Age of GAHT use for this cohort was not provided for
individual participants but was between 18 and 63years (Zavlin et al., 2019). In
general, most NCD ndings have been reported without details on these three char-
acteristics (Goodman & Nash, 2018). For SM individuals, status is more uid across
the lifespan without clear patterns of stability at any age cohort (Morgan, 2013). For
example, about two-thirds of participants aged 36–50 (n=762) reported a shift in
sexual orientation labels over time (Kinnish etal., 2005), and very little is known
about the health impact of changing sexual orientation labels as one ages. In a sys-
tematic review of national, international, state, and regional health surveillance data
sources that capture SOGI information, Patterson etal. (2017) reported substantial
gaps in the SM measurement of older adults. As most NCDs selected for the study
are age-dependent, this age discrepancy limits the quality of health surveillance
results since extrapolation of younger SM health may not reect older SM health
(Patterson etal., 2017).
J. A. McElroy and B. J. Gosiker
87
4.7 Conclusion
The forces shaping the mere ability to acknowledge, enumerate, and engage SGM
populations across the globe are ever-changing and heavily inuenced by country-
specic cultural norms. Further, a lack of security is felt by many SGMs locally due
to structural stigma, outright violence, and discrimination, as well as local laws and
political rhetoric, which lends itself to the SGM population remaining difcult to
identify. With the pressures of globalization weighing strongly on the burden of
NCDs across the globe, it is critical to accurately capture the SGM population’s
similarity or divergence from regional NCD patterns. The path forward is fraught
with competing tensions that make the gold standards of universal acceptance of
this population as well as data collection currently unattainable. In the interim, it
behooves researchers across the globe to proactively include SGM populations in
their research agenda. The rst step is to consistently incorporate answer options to
the question on gender that includes gender options beyond male/female as well as
asking specically about sexual orientation (Brown & Herman, 2020; Gender
Identity in US Surveillance (GenIUSS) Group, 2014; Sexual Minority Assessment
Research Team (SMART), 2009). Ultimately, we return to a concluding point: “If
you don’t ask, you don’t count” and a hope that, in the near future, the SGM popula-
tion will be counted in assessing the health of each nation.
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93© The Author(s) 2024
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Health, https://doi.org/10.1007/978-3-031-36204-0_5
Chapter 5
Sexual andGender Minority Population’s
Health Burden ofFive Noncommunicable
Diseases: Cardiovascular Disease, Cancer,
Diabetes, Asthma, Chronic Obstructive
Pulmonary Disease
JaneA.McElroyandBennettJ.Gosiker
5.1 Introduction
As advances are made in precision medicine, life expectancies move steadily toward
the century mark, andthere is a growing expectation of living healthy lives into
advanced age, there is value in comparing the health status between the sexual and
gender minority (SGM) populations and heterosexual/cisgender populations. In the
realm of noncommunicable diseases (NCDs), incidence and prevalence are markers
of the health of a population. Evaluating these statistics between populations allows
for the discovery of disparities and subsequent targeted interventions to close health
gaps. Globally, factors ranging from overt discrimination, economic deprivation,
and lack of access to healthcare resources may drive potential differences in NCD
prevalence among SGM populations. With the intention to describe the health of
SGMpopulations across the globe, a thorough literature review was undertaken to
capture peer-reviewed manuscripts that reported on NCDs prevalence or incidence
in the SGM population.
Among the 169 selected articles garnered from the literature review that
addressed the ve selected noncommunicable diseases (NCDs), most did not report
on prevalence or incidence among SGM individuals, but rather risk factors only or
as a review of studies on NCDs. Nevertheless, among these, 71% (n=119) studied
the USpopulation, with the next top ve countries for the number of studies being
J. A. McElroy (*)
Department of Family & Community Medicine, School of Medicine, University of Missouri,
Columbia, MO, USA
e-mail: mcelroyja@health.missouri.edu
B. J. Gosiker
Kaiser Permanente Bernard J.Tyson School of Medicine, Pasadena, CA, USA
e-mail: bgosiker@gmail.com
94
the Netherlands (n=10), Australia (n=8), England/United Kingdom (n=5each),
and Italy/Canada (n=3each). Data reported here represent 22 countries. The geo-
graphic distribution was striking, with sexual minority original research almost
exclusively provided by a few “mature” countries (n=9), and only one study on
CVD from Guam, a “developing” county. In contrast, studies of cancer among
transgender populations are almost exclusively case studies or case series (n=48)
and span the globe. For sexual minority results, except for Australia, North America,
and Western European countries, limited generalizations can be made for other
regions given sparse data. For studies of transgender populations, only 11 provided
evidence for the population as opposed to unique aspects of individual patients as
reported in the casestudies and case series.
Beyond the obvious sparse data available to assess the global burden of NCDs,
another important factor is the supporting role of the medical system. An in-depth
discussion of this system-level factor in NCD morbidity is beyond the scope of this
chapter. Briey, however, the Economist Intelligence Unit created a healthcare
index that used data from 60 countries of various income levels (The Economist
Intelligence Unit, 2019). In this analysis, three categories were developed to describe
the region’s ability to provide appropriate health services. African and Middle
Eastern countries generally scored as “emerging.” In Africa, the major challenge is
addressing infectious diseases, NCDs, and traumatic injuries with workforce short-
ages (Azevedo, 2017). In contrast, Middle Eastern countries struggle to address the
increased incidence of NCDs as well as considerable variability in health service
inequities due to the effects of social determinants of health (Kauth etal., 2017).
For the next group, Asia-Pacic nations and most countries in Latin America
scored “developed.” The challenges in these regions are divided into disparities
between wealthier countries, such as Japan and Australia, and less wealthy coun-
tries, such as Afghanistan and Bolivia. In wealthier countries, the challenge is pro-
viding adequate care for historically marginalized populations, such as the Maori of
New Zealand (Ellison-Loschmann & Pearce, 2006). Among the poorer countries, a
challenge is delivering healthcare services to their population living on remote
islands or in rural areas. Numerous studies examining healthcare access in devel-
oped countries have reported multiple barriers at both the individual and structural
levels (Baptiste-Roberts etal., 2017), whereas disentangling sexual politics from
healthcare to allow for safe access continues to be challenging in emerging and
developed countries (Kelly-Hanku etal., 2020; Mahdavi, 2019).
The third category comprised of Europe and North America scored “mature.”
Although these regions, in general, provide high-quality care, there are large dis-
parities in affordability and access to care within some countries. Compared to
European countries, the United States has recently witnessed a widening of health
inequalities (Mackenbach etal., 2018). Using a different metric, the Global Burden
of Disease Study 2016 also described healthcare access and quality for each country
in the world with similar but more nuanced ndings (G.B. D.Healthcare Access
and Quality Collaborators, 2018). A logical correlation between access to care and
quality of care for NCDs will inuence the trajectory of disease management. This
trajectory can be negatively exacerbated among SGM populations.
J. A. McElroy and B. J. Gosiker
95
Each section of this chapter will begin with a brief overview of the global burden
of the specic NCD followed by a description of the burden in sexual minority and
transgender populations, respectively. We recognize the wide diversity in both sex-
ual orientation and gender identity across the globe. For the purposes of this chapter,
we will address groups identifying as lesbian, gay, or bisexual for sections concern-
ing sexual orientation. While we recognize that gender is not a binary construct, the
existing literature broadly focuses on people identifying as transfeminine, transmas-
culine, and non-binary. As such, those are the groupings we will use in discussing
the literature. This method of organization inherently leaves out individuals not
identifying in these groups but who are still considered sexual or gender minorities.
5.2 Cardiovascular Disease (CVD)
CVD is a group of medical conditions that affect the heart and blood vessels.
Diseases include coronary artery diseases (CADs) such as myocardial infarction
(aka “heart attack”), stroke, and peripheral artery disease. Although not covered in
this section, hypertension (HTN; aka high blood pressure) is also considered a
CVD. HTN is often called a “silent killer” as there are rarely signs and symptoms
thereby leading to substantial underreporting of this condition. Several medical con-
ditions can lead to secondary HTN, including kidney disease, obstructive sleep
apnea, thyroid problems, and adrenal gland tumors (Puar etal., 2016). Numerous
concerns limit the ability to compare primary/secondary hypertension around the
world that led to the decision to not report these ndings since the interpretation of
study results would be country-specic and more importantly year-specic.
CVD continues to be the leading cause of death in the world for both men and
women (Clark, 2013). However, incidence rates for CVD vary by gender among
younger cohorts. Specically, CVD tends to develop 7–10 years later in women
compared to men (Maas & Appelman, 2010). Afterward, the incidence rates are
similar between men and women (Kazis etal., 2012). Among countries with greater
than 15% of the population aged 65 and older (i.e., Japan and some European coun-
tries) or a projected growing aging population by 2050 (except Pakistan, Afghanistan,
Yemen, Iraq, Papua New Guinea, and sub-Saharan Africa (except for Botswana)),
CVD burden can be expected to persist or increase (Population Reference
Bureau, 2018).
The impact of CVD on each nation’s population remains high. Globally,
disability- adjusted life years (DALY) for ischemic heart disease was ranked third
in 1990 and almost 20years later in 2019 remains at the same level of prevalence
among 25–49-year-olds. In 2019, stroke ranked ninth for this age group. For
those 50 and older, ischemic heart disease is ranked rst and stroke second as
aleading cause of DALY (G.B. D.Diseases and Injuries Collaborators, 2020)
over the 30-year period.
5 Sexual and Gender Minority Population’s Health Burden of Five Noncommunicable…
96
5.2.1 Epidemiology ofCVD inSexual Minority Populations
According to our literature review, over 30 studies have been published on CVD
incidence and/or risk comparing sexual minority (SM) populations to heterosexual
populations. All of these studies on CVD prevalence described US residents, with a
small number of studies on CVD risk from other mature countries (e.g., Sweden
(Branstrom et al., 2016), Canada (Steele et al., 2009; Veenstra, 2013), and
Switzerland (Wang etal., 2007)). Three systematic reviews have been completed,
with one evaluating CVD prevalence among SMs using studies published from
1985 to 2015 (Caceres et al., 2017). The second included a meta-analysis and
reported the prevalence of three NCDs—diabetes mellitus and cardiovascular and
respiratory conditions in SM women using studies published from 2010 to 2016
(Meads etal., 2018). The third systematic review evaluated the prevalence of NCDs,
including the ve selected for this chapter, among SM women using studies pub-
lished from 2009 to 2013 (Simoni etal., 2017). Finally, two critical reviews of the
CVD prevalence literature for the SM population were completed (Caceres etal.,
2017; McElroy & Brown, 2018).
Among the numerous studies, a few reported a signicant increased prevalence
of CVD among SMs compared to heterosexual populations. In a study comparing
SM women and men to heterosexuals, Fredriksen-Goldsen and colleagues reported
only lesbians and bisexual women aged 50years and older (range 50–94years for
females) had increased CVD prevalence, dened as physician-diagnosed heart
attack, angina, or stroke diagnosis (Fredriksen-Goldsen etal., 2013b). One small
study completed by the Los Angeles County Health Department in California
reported increased CVD prevalence for lesbians and bisexual women compared to
heterosexual women (Diamant & Wold, 2003; Diamant etal., 2000).
Some studies found bisexuals at higher risk, with one study nding bisexual
men, but not gay men, lesbians, or bisexual women had a higher CVD prevalence
(Blosnich etal., 2014). Another study found that bisexual women had higher stroke
prevalence compared to heterosexual women (Caceres etal., 2019b). With regard to
age differences, Boehmer and colleagues found increased CVD prevalence among
only young male and female SMs (<40years old) compared to heterosexuals but no
difference among older age groups: 40–59 years or >59 years for either sex
(Boehmer etal., 2014).
Comparing race/ethnicities using the 2013–2015 US National Health Interview
Survey (NHIS) data, white and Black SM women were more likely to report stroke
but not heart disease compared to white and Black heterosexual women, respec-
tively. However, in this same study, Hispanic/Latina SM women were less likely to
report heart disease compared to white heterosexual women (Trinh etal., 2017).
In contrast to these handful of studies, many more studies found no difference in
or even reduced CVD prevalence between SMs compared to heterosexual popula-
tions (Andersen et al., 2014; Blosnich & Silenzio, 2013; Caceres et al., 2019b;
Cochran & Mays, 2007; Conron et al., 2010; Diamant & Wold, 2003; Diamant
etal., 2000; Garland-Forshee etal., 2014; Matthews & Lee, 2014; Mays etal., 2002;
J. A. McElroy and B. J. Gosiker
97
Patterson & Jabson, 2018; Stupplebeen et al., 2019; Swartz, 2015; Trinh et al.,
2017; Valanis etal., 2000; Wallace etal., 2011; Ward etal., 2015). These null nd-
ings were supported by Meads and colleagues’ meta-analysis of data from 15 CVD
prevalence studies in which no difference was found between male or female SMs
and their respective heterosexual counterparts for CVD prevalence (Meads
etal., 2018).
Several limitations of these studies reduce the generalizability of the ndings.
The most striking limitation is the lack of peer-reviewed publications from any
other country aside from the United States on CVD prevalence by SM status.
Among the US studies, comparability was difcult due to differences in measures
of CVD (e.g., self-reported, chart extraction), inclusion criteria for CVD medical
conditions, and established (and adjustment for) CVD risk factors, such as alcohol
consumption, smoking, and obesity. For example, in the systematic review (Caceres
etal., 2017), only 7 out of 24 studies that included smoking status used a standard-
ized measure, and only 2 included all nicotine products (Blosnich et al., 2014).
Virtually all analyses used self-reported data on CVD risk factors, with less than a
quarter of the studies using clinically obtained data to establish the presence of
CVD (Caceres etal., 2016). Another limitation in the majority of the studies was the
younger age of the SM participants compared to heterosexual participants, although
some, but not all, used age-adjusted models. In addition, most studies had a median
or mean age of 38–44years for the SM participants, which is a couple of decades
younger than the average age of one type of CVD, heart attack (63years for men
and 73years for women in the United States; 62.1years for men and 69.3years for
women globally) (Fuster & Kelly, 2010).
5.2.2 Epidemiology ofCVD inTransgender
andNon-binary Populations
About the same number of studies as have been done for the SM population have
also been completed with transgender populations (n=30). 22 studies were located
in eight countries: Belgium, China, Germany, Italy, the Netherlands, Spain,
Thailand, and the United States. They characterized changes in biological markers
of CVD risk (e.g., total cholesterol, weight, endothelin levels, etc.) following
gender- afrming hormone therapy (GAHT) initiation (Bunck etal., 2006; Chandra
etal., 2010; Deutsch etal., 2015; Emi etal., 2008; Fisher etal., 2016; Giltay etal.,
2004; Jacobeit etal., 2007, 2009; Mueller et al., 2006, 2007; Pelusi et al., 2014).
Studies comparing the incidence or risk of CVD between transgender and cisgender
populations (n= 8) described populations in four countries: Germany, Guam, the
Netherlands, and the United States. The ve studies not conducted in the United
States focused on transgender populations initiating GAHT (Asscheman et al.,
1989; Bazarra-Castro etal., 2012; Ott etal., 2010; van Kesteren etal., 1997; Wierckx
et al., 2013), whereas US-based studies largely did not account for this
5 Sexual and Gender Minority Population’s Health Burden of Five Noncommunicable…
98
characteristic (Alzahrani etal., 2019; Meyer etal., 2017; Nokoff etal., 2018). Two
Europe- based cohorts (Sweden and the Netherlands) assessed CVD-related mortal-
ity among transfeminine populations (Asscheman etal., 2011; Dhejne etal., 2011).
One US-based study explored CVD among gender non-binary individuals, com-
prised of both those assigned female at birth (AFAB) as well as those assigned male
at birth (AMAB) (Nokoff etal., 2018).
Five reviews have been published to synthesize the evidence concerning CVD
among transgender populations (Gooren etal., 2014; Irwig, 2018; Maraka et al.,
2017; Streed etal., 2017; Velho etal., 2017). Two scoping reviews of publications
from 1989–2011 and 1997–2017 stratied by GAHT use and CVD health outcomes
or risk factors (Gooren etal., 2014; Irwig, 2017). Streed etal. conducted a narrative
review of literature published 1989–2016 focused on CVD health events among
transmasculine and transfeminine populations receiving GAHT and focused dis-
tinctly on clinical guidelines for GAHT regimes (Streed etal., 2017). Maraka etal.
conducted the only meta-analysis to quantify changes in lipid prole, venous throm-
boembolism, CVD health events, and mortality among transgender adults receiving
GAHT from studies published in 1989–2016 (Maraka etal., 2017). Finally, Velho
etal. conducted a systematic review of studies published in 2004–2016 and focused
on changes in BMI, blood pressure, and routine blood test results (such as lipid
panels) of transmasculine populations following testosterone therapy (Velho etal.,
2017). The length of follow-up of these studies ranged from 4months to 2 years
after GAHT initiation.
A number of studies focused on characterizing CVD risk factor changes after
initiation of GAHT among transgender populations. The underlying assumption
seems to be that the hormonal milieu specic to sex is linked to CVD risk given that
among similarly aged men and women, men experience more CVD events; after
menopause, more women experience CVD events; and hyperandrogenism in women
confers a higher CVD risk (Kannel, 2002; Liu et al., 2001; Wild et al., 2000).
However, current thinking explores the multifactorial understanding of CVD risk
beyond the hormonal milieu, including genomic and nongenomic effects (Vitale
etal., 2010). Findings from these and additional studies will be discussed below.
5.2.2.1 Transfeminine Population
5.2.2.1.1 CVD Risk Factors
Among transfeminine individuals, CVD risk factor changes included increases in
weight (Elbers etal., 2003; Giltay et al., 1998, 1999; Gooren etal., 2014; Quiros
etal., 2015), body mass index (Klaver etal., 2020; Suppakitjanusant etal., 2020),
total body fat (Elbers etal., 2003; Gooren & Giltay, 2014), visceral fat (Giltay etal.,
1998), triglycerides (Giltay et al., 1998, 1999; Klaver etal., 2020), brinolysis
(Elbers etal., 2003; Giltay etal., 1998), and endothelin levels (Polderman etal.,
1993). Mixed results among transfeminine individuals were seen for changes in
low-density lipoprotein (LDL) cholesterol (Elbers etal., 2003; Gooren & Giltay,
J. A. McElroy and B. J. Gosiker
99
2014; Klaver etal., 2020; Kulprachakarn etal., 2020), blood pressure (Elbers etal.,
2003; Giltay etal., 1999; Klaver etal., 2020; Kulprachakarn et al., 2020; Quiros
etal., 2015), and markers of inammation (measured by IL-4, IFN-γ, and C-reactive
protein (CRC)) (Giltay etal., 2003; Gooren & Giltay, 2014; Kulprachakarn etal.,
2020). No effects among transfeminine individuals were seen in total cholesterol
(Elbers etal., 2003; Giltay etal., 1999; Gooren & Giltay, 2014; Klaver etal., 2020;
Kulprachakarn etal., 2020), very low-density lipoprotein (VLDL) (Elbers etal.,
2003), heart rate (Giltay etal., 1999), or arterial stiffness (measured by distensibility
and compliance coefcients of the carotid, femoral, and brachial arteries) (Giltay
etal., 1999). Two studies noted an increase in high-density lipoprotein (HDL) cho-
lesterol (Elbers etal., 2003; Gooren etal., 2014). A meta-analysis by Maraka etal.
found statistically signicant changes only for triglycerides after ≥24 months of
follow-up subsequent to GAHT initiation. In this meta-analysis, other lipid mea-
sures assessed (i.e., LDL, HDL, and total cholesterol) had no statistically signicant
change after GAHT initiation (Maraka etal., 2017) (see Table5.1).
One known risk factor for dangerous clot formation that can lead to CVD events
in cisgender women is exogenous estrogen supplementation (Laliberte etal., 2011;
Vinogradova etal., 2019). A similar nding of pulmonary embolism and venous
thromboembolism was also described in four cohort studies among transfeminine
individuals (Asscheman etal., 1989; Getahun etal., 2018; Goodman & Nash, 2019;
van Kesteren etal., 1997). One narrative review considered evidence of the associa-
tion between specic GAHT regimens and venous thromboembolism and pulmo-
nary embolism and suggested that clinicians should favor “low-dose transdermal
estrogen and oral bioidentical estrogens (such as 17β-estradiol, estrone, and estriol)
and limiting the use of high-dose oral ethinyl estradiol” (Streed etal., 2017, p.261).
Outside of analyses reporting results, this is one of the only sources to suggest spe-
cic clinical guidance based on the limited evidence available.
5.2.2.1.2 CVD Prevalence
Mixed results are seen for CVD prevalence when comparing transfeminine indi-
viduals with cisgender men across an array of events and conditions including myo-
cardial infarction, congestive heart disease, and stroke (Alzahrani et al., 2019;
Bazarra-Castro etal., 2012; Getahun etal., 2018; Nokoff etal., 2018). The largest
studies to assess CVD among transfeminine persons compared to cisgender men
(n=3477 and n=4394) found equivalent incidence of myocardial infarctions and
increased incidence of stroke (Goodman & Nash, 2019). Two other studies found no
difference in incidence rate (Getahun etal., 2018) or prevalence (Wierckx et al.,
2013) of myocardial infarction when comparing transfeminine individuals using
GAHT to cisgender men.
Much of the literature focuses on CVD events (stroke, myocardial infarction,
venous thromboembolism, and pulmonary embolism) with less attention paid to
CVD conditions that lead up to those events such as hyperlipidemia, hypercholes-
terolemia, and hypertension. One of the larger studies to assess CVD health did not
5 Sexual and Gender Minority Population’s Health Burden of Five Noncommunicable…
100
Table 5.1 CVD risk prole changes in transfeminine individuals following GAHT initiation
CVD risk factor
Change after
GAHTinitiation
CVD risk
prole
status References
Weight Increase Increase Gooren et al. (2014), Elbers etal. (2003),
Giltay etal. (1998, 1999) andQuiros etal.
(2015)
Total body fat Increase Increase Elbers etal. (2003) and Gooren and
Giltay (2014)
Visceral fat Increase Increase Giltay etal. (1998)
Triglycerides Increase Increase Giltay etal. (1998, 1999), Kulprachakarn
etal. (2020) and Klaver etal. (2020)
Fibrinolysis Increase Increase Elbers etal. (2003) and Giltay etal.
(1998)
Endothelin levels Increase Increase Polderman etal. (1993)
LDL (low-density
lipoprotein)
cholesterol
Mixedevidence NA Elbers etal. (2003), Gooren and Giltay
(2014), Kulprachakarn etal. (2020) and
Klaver etal. (2020)
Blood pressure Mixedevidence NA Elbers etal. (2003), Giltay etal. (1999),
Quiros et al (2015), Kulprachakarn etal.
(2020) and Klaver etal. (2020)
Inammatory
markers (CRP,
IFN-γ, IL-4)
Mixedevidence NA Gooren and Giltay (2014), Kulprachakarn
etal. (2020) and Giltay etal. (2003)
Total cholesterol Mixedevidence NA Elbers etal. (2003), Giltay etal. (1999),
Gooren and Giltray (2014),
Kulprachakarn etal. (2020) and Klaver
etal. (2020)
Very low-density
lipoproteins
No changes Null Elbers etal. (2003)
Heart rate No changes Null Giltay etal. (1999)
Arterial stiffness No changes Null Giltay etal. (1999)
HDL (high-density
lipoprotein)
cholesterol
Mixedevidence NA Gooren et al. (2014), Elbers etal. (2003),
Kulprachakarn etal. (2020) and Klaver
etal. (2020)
Heart rate No changes Null Kulprachakarn etal. (2020)
Ankle-brachial index
(ABI)
Decrease Increase Kulprachakarn etal. (2020)
Pulse wave velocity No changes Null Kulprachakarn etal. (2020)
Cardio-ankle
vascular index
(CAVI)
No changes Null Kulprachakarn etal. (2020)
Carotid intima-
media thickness
(CIMT)
No changes Null Kulprachakarn etal. (2020)
Fasting plasma
glucose
No changes Null Kulprachakarn etal. (2020) and Klaver
etal. (2020)
Body mass index
(BMI)
Increase Increase Suppakitjanusant etal. (2020) and Klaver
etal. (2020)
J. A. McElroy and B. J. Gosiker
101
stratify by GAHT use and found no difference in adjusted odds of hypertension
when comparing transfeminine individuals (n=369) to cisgender men (n=60,009)
or cisgender women (n=78,548) (Nokoff etal., 2018).
Many of the studies accounting for GAHT are limited by their short duration of
post-GAHT follow-up. One may expect that extended use of GAHT among trans-
feminine individuals may change the hormonal prole-attributable aspects of car-
diovascular risk. Without extensive follow-up, this dynamic cannot be understood.
Even among individuals using GAHT, which presumably mimics the female hor-
monal milieu, the CVD risk prole of transfeminine individuals may be closer to
that of cisgender men, who share their sex assigned at birth, than that of cisgender
women. Additional research is needed to deepen our understanding of genomic and
non-genomic factors associated with CVD risk.
5.2.2.2 Transmasculine Populations
5.2.2.2.1 CVD Risk Factors
Among transmasculine individuals initiating GAHT, decreases in HDL cholesterol
were observed (Chandra etal., 2010; Deutsch etal., 2015; Giltay etal., 1998, 1999;
Klaver etal., 2020; Mueller etal., 2007, 2010). Increases were seen for triglycerides
(Emi etal., 2008; Giltay etal., 1998; Klaver etal., 2020; Quiros etal., 2015) and
weight (Giltay etal., 1998, 1999, 2004; Gooren & Giltay, 2014). Mixed changes
were observed in blood pressure (Elbers etal., 2003; Emi etal., 2008; Giltay etal.,
2003; Gooren & Giltay, 2014; Klaver etal., 2020). No effect was seen on arterial
stiffness (Giltay et al., 1999), brinolysis (Giltay et al., 1998), total cholesterol
(Elbers et al., 2003; Gooren & Giltay, 2014; Gooren et al., 2014; Klaver et al.,
2020), or BMI (Klaver etal., 2020; Suppakitjanusant etal., 2020). Comparing trans-
masculine individuals receiving GAHT to cisgender women in routine blood test
results for CVD risk factors (such as cholesterol) did not nd any difference
(Asscheman et al., 1989, 2011; Bazarra-Castro etal., 2012; van Kesteren et al.,
1997; Wierckx etal., 2013) (see Table5.2).
5.2.2.2.2 CVD Prevalence
The largest analysis of transmasculine individuals to date (n=2893) was a US-based
cohort that found no difference in venous thromboembolism, myocardial infarction,
or stroke when compared to cisgender women (n= 63,855) (Goodman & Nash,
2019). With the exception of one US-based study that did not account for GAHT
usage (Alzahrani etal., 2019), the current evidence does not support an elevated
CVD morbidity among transmasculine populations for myocardial infarction,
stroke, venous thromboembolism, pulmonary embolism, or hypertension
(Asscheman etal., 1989, 2011; Getahun etal., 2018; Goodman & Nash, 2019; van
5 Sexual and Gender Minority Population’s Health Burden of Five Noncommunicable…
102
Table 5.2 CVD risk prole changes in transmasculine individuals following GAHT initiation
CVD risk factor
Change after
GAHT
initiation
CVD risk
prole
status References
HDL (high-density
lipoprotein)
cholesterol
Decrease Increase Chandra etal. (2010), Deutsch etal.
(2015), Giltay etal. (1998, 1999), Mueller
etal. (2007, 2010), Emi etal. (2008) and
Klaver etal. (2020)
LDL (low-density
lipoprotein)
Increase Increase Klaver etal. (2020)
Triglycerides Increase Increase Giltay etal. (1998), Emi etal. (2008),
Quiros etal. (2015) and Klaver etal.
(2020)
Weight Increase Increase Giltay etal. (1998, 1999, 2004) and
Gooren and Giltay (2014)
Blood pressure Mixed evidence NA Emi etal. (2008), Gooren and Giltay
(2014), Elbers etal. (2003), Giltay etal.
(2003) and Klaver etal. (2020)
Arterial stiffness No changes Null Gitay etal. (1999)
Fibrinolysis No changes Null Giltay etal. (1998)
Total cholesterol Mixedevidence NA Gooren and Giltay (2014), Elbers etal.
(2003), Gooren and Wierckx (2014) and
Klaver etal. (2020)
Body mass index
(BMI)
Mixedevidence NA Suppakitjanusant (2020) and Klaver etal.
(2020)
Kesteren etal., 1997; Wierckx etal., 2013).This assessment is greatly limited by
the younger average age of transgender populations in these studies.
5.2.2.3 Gender Non-binary Populations
One general US population-based study accounted for gender non-binary individu-
als in their analyses (Behavioral Risk Factor Surveillance Study: BRFSS). BRFSS
is an annual national study with probabilistic sampling for each state to provide data
on health-related risk factors, health outcomes, and healthcare utilization for indi-
vidual states. Each state had the option of including the Centers for Disease Control
and Prevention’s approved question on sexual orientation and gender identity
(SOGI) beginning in 2014. However, some states included their own version of a
SOGI question as early as 2001 (Baker & Hughes, 2017). Comparison groups were
selected based on natal sex. In adjusted analyses of non-binary individuals (AFAB,
n=61), no differences were found in odds of obesity, overweight status, myocardial
infarction, angina/CHD, or stroke when compared to cisgender females (n=78,548).
Among non-binary individuals (AMAB, n=68), no differences were seen for myo-
cardial infarction or angina/CHD when compared to cisgender males (n=60,009).
Non-binary individuals with male natal sex were found to have higher odds of obe-
sity/overweight status and lower odds of stroke (Nokoff etal., 2018).
J. A. McElroy and B. J. Gosiker
103
The generalizability of the existing data is limited due to a narrow geographic
scope and small sample size. Differences in comparison groups for transgender
populations also make comparison of study results challenging. While some smaller
studies from the Netherlands indicated specic GAHT regimens, few large-scale
studies noted GAHT regimen or duration. This lack of information presents an
interpretation challenge when trying to assess the effect that GAHT may have on
CVD prevalence. It is also of note that recommended GAHT formulations have
changed over the years with potential concomitant health effects. In addition, there
is likely a cohort effect due to this change that would need to be considered in com-
paring studies. Another challenge is that many samples of transgender individuals
skew younger, notably in some of the early studies with smaller sample sizes.
Younger samples make it more difcult to draw conclusions about CVD outcomes,
which have strong relationships with age. Additionally, the mean age reported by a
study may not reect the distribution of the data. Analytically, if a sample has a low
number of older transgender individuals and is not a random sample, then selection
bias may be introduced, and simply applying statistical adjustments for age may not
be a sufcient analytic approach. Among the larger cohort studies represented, the
median age was usually in the 40–50-year age bracket (Caceres et al., 2019a;
Getahun etal., 2018; Meyer etal., 2017; Nokoff etal., 2018). This is an important
context for any discussion of NCDs where age is strongly related, particularly CVD.
5.3 Cancer
Approximately 5% of the world’s population are cancer survivors (43.8million),
with 20% and 16% of men and women, respectively. In 2018, there were an esti-
mated 18.1million new cancer cases and 9.6million cancer deaths. India, China,
and other East and Central Asian countries make up approximately half of new
cancer cases (American Cancer Society, 2019). Lung, female breast, and colorectal
cancers dominate worldwide, together comprising one-third of the cancer burden
(Bray etal., 2018). The global picture of cancer incidence shows a mosaic of 23
individual cancer sites that describe 90% of the cancer incidence burden (Bray
etal., 2018). By 2040, these numbers are expected to double due to growth and
aging populations as well as changes in the prevalence of established cancer-related
risk factors such as overweight/obesity, unhealthy diet, physical inactivity, tobacco
use, alcohol use, and air pollution (World Health Organization, 2018). The increased
prevalence is also expected to be the most pronounced in emerging and developing
countries due to an expected shift from cancers related to poverty and infections to
cancers associated with lifestyles more typical of mature countries (International
Agency for Research on Cancer, 2018; Omran, 2005).
Cancer burden can be described in three ways: incidence, prevalence, and mor-
tality. For this chapter, both incidence and prevalence will be described. Incidence
data means the number of all new cancer cases, either overall or for a specic
5 Sexual and Gender Minority Population’s Health Burden of Five Noncommunicable…
104
cancer, typically dened over a year period for the population at risk for that cancer,
whereas prevalence includes both newly diagnosed and survivors of cancer.
A frequent statistic used is that 4in 10 cancer diagnoses are preventable since
many cancers are strongly or causally linked to modiable lifestyle behaviors or
treatable/avoidable exposures. The top risk factors are cigarette smoking; second-
hand smoke exposure; excess body weight; drinking alcohol; eating red and pro-
cessed meat; diets low in fruits and vegetables, dietary ber, and dietary calcium;
physical inactivity; ultraviolet (UV) radiation from the sun or indoor tanning; and
cancer-associated viruses, including helicobacter pylori, hepatitis B virus (HBV),
hepatitis C virus (HPC), human herpes virus type 8 (HHV8), human immunode-
ciency virus (HIV), and human papillomavirus (HPV) (Islami etal., 2018). The
majority of studies that address cancer burden among the SM population inevitably
suggest a disparity in many of the aforementioned established risk factors compared
to heterosexual populations (Boehmer & Elk, 2015; Mansh etal., 2015; Meads &
Moore, 2013; van der Zee etal., 2013; Ward etal., 2014). However, little is known
about the prevalence of most of these risk factors by SM status for the majority of
the world’s population.
5.3.1 Epidemiology ofCancer inSexual Minority Populations
The preponderance of studies that describe cancer in SM populations assesses can-
cer risk with established cancer-related risk factor data and possibly cancer screen-
ing behavior. Most of these studies report an increased cancer risk for SMs compared
to heterosexualpopulations. Because of the lack of SM identity in established data
systems, such as cancer registry data, a handful of studies have used geography to
evaluate cancer risk. For example, San Francisco, California in the United States is
known to have a large SM population. Using this knowledge, compared to the state
of California’s age-adjusted anal cancer incidence rates, San Francisco county had
higher rates, attributed to the higher proportion of men who have sex with men
(Cress & Holly, 2003).
To our knowledge no country in the world systematically collects SM demo-
graphic data as part of the patient’s medical record and/or for a cancer registry data
element. The consequence of this omission is that incidence data cannot be ascer-
tained reliably for any country or for comparison among countries or regions. For
example, the Behavioral Risk Factor Surveillance Study (BRFSS), a national survey
in the United States, does not include SOGI data from all 50 states, which results in
an “incomplete picture” of both the nationwide health needs and cancer disparities
among LGBTQ+ people (National LGBT Cancer Network, 2021, p.1).
Less than a dozen unique studies have been published on cancer comparing SM
populations to heterosexual populations with the caveat that studies focusing on
HIV/AIDS were excluded (see Chap. 7). Studies that compare overall cancer preva-
lence include three from the United States and one from England (which also
described individual cancers) (Blosnich et al., 2016; Patterson & Jabson, 2018;
J. A. McElroy and B. J. Gosiker
105
Saunders et al., 2017; Trinh et al., 2017). Incidence data calculated among SM
cohorts of a longitudinal study were described in one Australian study for any can-
cer; one Danish study for both overall and individual cancer incidence; and one US
study of SM female participants (Brown etal., 2015; Frisch et al., 2003; Valanis
etal., 2000). Two more studies from the United States evaluated individual cancers
of the skin and breast among SMs (Cochran etal., 2001; Mansh etal., 2015).
The preponderance of aforementioned studies described no statistical difference
in overall cancer prevalence or incidence between SM males/females and hetero-
sexuals (Blosnich etal., 2016; Brown etal., 2015; Frisch etal., 2003; Patterson &
Jabson, 2018; Saunders et al., 2017; Valanis etal., 2000). The one exception for
overall cancer was the US National Health Interview Survey (NHIS). This national
surveillance survey, conducted yearly, included a sexual orientation question since
2013. Pooled data (2013–2015) stratied by race/ethnicity and using direct stan-
dardization for age reported an increased cancer prevalence for white SM women
but not Latina, whereas Black SM women were at a reduced cancer prevalence
compared to white heterosexuals. Among SM men, only white SM men were at an
increased cancer prevalence compared to white heterosexuals (Trinh etal., 2017). In
the second NHIS study using pooled data (2013–2016) and adjusting for demo-
graphic and socioeconomic factors, gay men and bisexual women had a higher
prevalence of any cancer than their respective heterosexual counterparts. This nd-
ing was more pronounced among those aged 65 years and older (Gonzales &
Zinone, 2018).
Machalek and colleagues’ systematic review reported on anal HPV infection and
cancer among men who have sex with men (Machalek etal., 2012). They stratied
studies by HIV status (Chaturvedi et al., 2009; D’Souza et al., 2008; Dal Maso
etal., 2009; Franceschi & De Vuyst, 2009; Frisch etal., 2003; Koblin etal., 1996;
Piketty etal., 2008; Silverberg etal., 2009; van Leeuwen etal., 2009). Neither of the
two studies of HIV-negative men who have sex with men reported an increased anal
cancer incidence (D’Souza etal., 2008; Koblin etal., 1996). In Machalek’s meta-
analysis of these studies, the incidence of anal cancer was signicantly higher in
HIV-positive men compared to HIV-negative men (Machalek etal., 2012). Van der
Zee and colleagues also reported similar ndings of a signicantly increased stan-
dardized incidence ratio for anal cancer in HIV-positive men who have sex with
men (van der Zee etal., 2013). Similarly, other studies have shown no increased
cancer prevalence among HIV-negative gay men (Frisch etal., 2003; Lyter etal.,
1995). It is noteworthy to mention that neither of the NHIS studies described above
that reported an overall increased cancer prevalence for gay men and bisexual
women adjusted for HIV/AIDS infection (Gonzales & Zinone, 2018; Trinh
etal., 2017).
Evaluating the literature on participants living with HIV and/or HPV and cancer
is beyond the scope of this chapter. However, a brief comment is warranted. Six
cancers have been identied with strong evidence of a causal cancerrelationship
with HPV: cervix, penis, vulva, vagina, anus, and oropharynx (IARC Working
Group on the Evaluation of Carcinogenic Risks to Humans, 2012). Similarly, an
International Agency for Research on Cancer (IARC) working group indicated a
5 Sexual and Gender Minority Population’s Health Burden of Five Noncommunicable…
106
causal role of HIV infection for Kaposi sarcoma, non-Hodgkin’s lymphoma,
Hodgkin’s lymphoma, as well as cancer of the cervix, anus, and conjunctiva (IARC
Working Group on the Evaluation of Carcinogenic Risks to Humans, 2012;
International Agency for Research on Cancer). Some of these HIV-related cancers
are the most prevalent in several African counties. From a global perspective, HPV
and HIV-related cancer may be less associated with SM status in many countries
where the transmission route is predominantly among heterosexual contacts, such
as sub-Saharan Africa (Forman etal., 2012; Gayle & Hill, 2001; Williamson, 2015).
In the two studies in which individual cancer incidence was described, SM men
were over-represented among men with Kaposi’s sarcoma, penile cancer, anal can-
cer, and/or non-Hodgkin’s lymphoma (Frisch etal., 2003; Saunders etal., 2017). In
one of these two studies, SM women were over-represented among women with
oropharyngeal cancer (Saunders etal., 2017).
The most striking limitation to understanding the global burden of cancer among
SM populations is no peer-reviewed publication on national cancer incidence for
the SM population exists. Data to evaluate cancer prevalence or incidence (from
longitudinal studies) were also limited to four countries—all mature countries.
Until SM status is systematically collected, it will be difcult to denitely deter-
mine whether or not SM populations are at increased cancer risk.
5.3.2 Epidemiology ofCancer Among Transgender Populations
Population-level data does not exist with respect to cancer incidence or prevalence
for transgender populations. Broadly, the literature falls into the categories of case
studies (n= 48) and incidence and prevalence measures of cancers in cohorts of
transgender patients (n=8).
Case studies form the majority of literature and chronicle a single or up to ve
patients with a given cancer. The case studies have the most geographic variation
compared to cohort studies with 17 countries represented: Australia (n=2), Belgium
(n=1), Brazil (n = 1), Canada (n = 1), Czech Republic (n=2), France (n= 1),
Germany (n=3), Italy (n=2), Japan (n=1), the Netherlands (n=5), Serbia (n=1),
Singapore (n=1), Spain (n=3), Switzerland (n=2), Thailand (n=1), the United
Kingdom (n= 8), and the United States (n = 15). Among the 48 publications, 59
cases were detailed, as some publications described more than one case. Among the
59 case reports, transfeminine individuals comprised 71% (n=42). Cancer inci-
dence and prevalence studies (n=9) using cohorts comprised less geographic diver-
sity, including populations from Belgium, the Netherlands, and the United States.
5.3.2.1 Case Studies
Among transfeminine individuals, case studies were found describing testicular
(Chandhoke etal., 2018), anal (Caricato etal., 2009), neovaginal (Fernandes etal.,
2014; Harder etal., 2002), prostate (Dorff etal., 2007; Markland, 1975; Miksad
J. A. McElroy and B. J. Gosiker
107
etal., 2006; Nguyen & O’Leary, 2018; Thurston, 1994; Turo etal., 2013; van Haarst
et al., 1998), and breast cancers (Chotai etal., 2019; Dhand & Dhaliwal, 2010;
Ganly & Taylor, 1995; Gooren etal., 2015; Grabellus etal., 2005; Maglione etal.,
2014; Pattison & McLaren, 2013; Pritchard etal., 1988; Sattari, 2015; Symmers,
1968; Teoh etal., 2015), as well as meningiomas (Bergoglio etal., 2013; Cebula
etal., 2010; Deipolyi etal., 2010; Gazzeri etal., 2007) and prolactinomas (Bunck
etal., 2009; Cunha etal., 2015; Garcia-Malpartida etal., 2010; Gooren etal., 1988;
Kovacs etal., 1994; Mueller & Gooren, 2008). For transmasculine individuals, case
studies were found for uterine (Urban etal., 2011), breast (Burcombe etal., 2003;
Nikolic etal., 2018; Shao etal., 2011), cervical (Dizon etal., 2006), ovarian (Dizon
etal., 2006; Hage etal., 2000), and endometrial cancers (Urban etal., 2011). Most
of the case studies identied individual cases associated with reproductive organs
(testicular, uterine, cervical, ovarian, endometrium), breast cancer, hormone-
associated masses (prolactinomas and meningiomas), as well as prostate and anal
cancers. The majority of cases were among individuals who had initiated
GAHT.Little information was provided on sexual behavior. Although these case
studies are important for exploring pathophysiology, treatment, and prognosis, they
do not appropriately characterize population-level cancer burden (see Appendix).
5.3.2.2 Transgender Cohort Studies
In total, eight cohort studies were found that assessed cancer among transgender
populations (see Table5.3). One of the larger cohorts of transgender persons
(1578 transfeminine individuals and 3557 transmasculine individuals) was from
a US-based cohort of military veterans. The mean age of transfeminine and trans-
masculine individuals in the study was 56years. This study found a decreased
incidence of breast cancer and an increased incidence of prostate cancer among
transfeminine individuals compared to the group of cisgender male and female
individuals combined (10,671 cisgender men and 4734 cisgender women), after
adjusting for established risk factors (Brown & Jones, 2016). Another large
US-based cohort found an elevated risk of endocrine gland cancers (i.e., thyroid,
adrenal, pituitary, and pineal gland cancers) and reduced risk of prostate cancers
when comparing transfeminine individuals (n = 2793) to cisgender males
(n=63,813) who were enrolled in a private health insurance plan over 8years of
follow-up and were age-matched for analyses (Goodman & Nash, 2019). In this
sample of transfeminine individuals, 47% were ≥36 years, and 14% were
>55years. The same study also found the equivalent risk of intestinal, lymphatic,
smoking-related (i.e., lung/bronchus, trachea, esophagus, larynx, cervix, stom-
ach, pancreas, urinary bladder, kidney, and renal pelvis), and viral infection-
induced (i.e., anus, base of tongue/tonsil, oropharynx, nasopharynx, pharynx,
liver, Kaposi sarcoma, non-Hodgkin’s lymphoma, and Hodgkin’s lymphoma)
cancers comparing the two populations. In the same cohort, no differences were
noted between transmasculine participants (n = 2099) and cisgender women
(n=63,855) for incidence of breast, cervical, smoking-related, or viral infection-
induced cancers over 8years of follow-up (Goodman & Nash, 2019). In this
5 Sexual and Gender Minority Population’s Health Burden of Five Noncommunicable…
Table 5.3 Cohort studies assessing cancer among transgender populations
Study
Transgender
Population
Comparison
Group Elevated Equivalent Lower
Study
Measure
Cohort
Description Country
Brown, 2016 5135 (1578
TF, 3557
TM)
15405 (4734
CW, 10671 CM)
Prostate – Breast Odds ratio US military
veterans
United
States
Braun, 2016 354
transgender
individuals
CM, number not
specied
Anal, breast, Kaposi
sarcoma, non-Hodgkin’s
lymphoma
Tongue, pharynx,
colorectal, kidney,
liver, lung, pituitary,
bladder
Melanoma Proportional
incidence
ratio
US National
Cancer Institute’s
Surveillance,
Epidemiology, and
End Results
(SEER) database
United
States
CW, number not
specied
Anal, Kaposi sarcoma,
liver, lung, non-
Hodgkin’s lymphoma,
bladder
Colorectal, kidney,
pituitary
Breast,
melanoma
De Blok,
2019
2260 TF
individuals
using GAHT
2260 age-
matched CM
Invasive breast and
noninvasive breast
cancers
– – Standardized
incidence
ratio
VU University
Medical Centre in
Amsterdam
patients matched
with the
Nationwide
Network and
Registry of
Histopathology
and Cytopathology
in the Netherlands
(PALGA)
Netherlands
2260 age-
matched CM
– – Invasive
breast and
noninvasive
breast
cancers
1229 TM
individuals
using GAHT
1229 age-
matched CM
Invasive breast cancer – –
1229 age-
matched CW
– – Invasive
breast cancer
Study
Transgender
Population
Comparison
Group Elevated Equivalent Lower
Study
Measure
Cohort
Description Country
Nash, 2018 805
transgender
individuals
10,928,591 CW Anal, tongue, colorectal,
esophageal,
hematopoietic,
Hodgkin’s lymphoma,
Kaposi sarcoma,
laryngeal, liver, lung,
non-Hodgkin’s
lymphoma, bladder, and
vaginal cancers
Brain, kidney,
melanoma, ovarian,
pancreatic, pituitary,
stomach, and thyroid
cancers
Breast,
cervical, and
endometrial
cancers
Proportional
incidence
ratio
North American
Association of
Central Cancer
Registries
(NAACCR)
database
United
States
10,896,000 CM Anal, breast, Kaposi
sarcoma, and non-
Hodgkin’s lymphoma
cancers
Tongue, brain,
colorectal,
esophageal,
hematopoietic,
Hodgkin’s
lymphoma, kidney,
laryngeal, liver, lung,
pancreatic, pituitary,
stomach, thyroid, and
bladder cancers
Melanoma,
prostate, and
testicular
cancers
(continued)
Study
Transgender
Population
Comparison
Group Elevated Equivalent Lower
Study
Measure
Cohort
Description Country
Goodman,
2019
2793 TF 63183 CW Lymphatic and
hematopoietic cancers
Endocrine gland
cancersa, intestinal,
melanoma of the
skin, smoking-related
cancerb, colorectum,
viral-infection
inducedd
– Adjusted
hazard ratio
Commercially
insured patients
under Kaiser
Permanente
United
States
63855 CM Endocrine gland cancersaIntestinal, melanoma
of the skin,
lymphatic, smoking-
related cancerb,
colorectum,
viral-infection
inducedd
Prostate
cancer,
screening-
detectable
cancersc
2099 TM 63855 CM Breast, smoking-relatedb,
screening-detectable
cancersc viral-infection
inducedd
– –
63183 CW – Breast, cervical,
smoking-relatedb,
screening-detectable
cancersc viral-
infection inducedd
–
4266 TF 42660 CM – Colorectal, lung,
melanoma of the
skin, liver, kidney,
bladder cancers
Prostate
cancer
US military
veterans
42660 CW – Colorectal, lung,
melanoma of the
skin, liver, kidney,
bladder cancers
–
Table 5.3 (continued)
Study
Transgender
Population
Comparison
Group Elevated Equivalent Lower
Study
Measure
Cohort
Description Country
Wierkx,
2013
214 TF 640 age-
matched CM
– Any cancer – Prevalence Patients at the
Center for
Sexology and
Gender Problems
at the Ghent
University
Hospital
Belgium
619 age-
matched CW
– Any cancer –
138 TM 414 age-
matched CM
– Any cancer –
414 age-
matched CW
Any cancer – –
Brown, 2015 138
transgender
individuals
188 cisgender
individuals
– Prostate and breast
cancer
– Odds ratio US military
veterans
United
States
Brown, 2015 1579 TF 10671 CM Breast cancer – – Standardized
incidence
ratio
US military
veterans
United
States
4734 CW – Breast cancer –
3566 TM 10671 CM Breast cancer – –
4734 CW – Breast cancer –
Abbreviations: TM transmasculine, TF transfeminine, CM cisgender men, CW cisgender women
aIncludes cancers of the thyroid gland, adrenal gland, pituitary gland, and pineal gland
bIncludes cancers of the lung/bronchus, trachea, esophagus, larynx and other head/neck, cervix, stomach, pancreas, urinary bladder, kidney, and renal pelvis
cIncludes cancers of the colorectum, melanoma of the skin, and prostate; the analyses are natal-sex specic. 6 Includes cancers of the cervix, breast, colorectum, and
melanoma of the skin; the analyses are natal-sex specic
dIncludes cancers of the anus, base of tongue/tonsil, oropharynx, nasopharynx, pharynx, liver, and Kaposi sarcoma, non-Hodgkin’s lymphoma, and Hodgkin’s lym-
phoma. 6 Includes cancers of the cervix, breast, colorectum, and melanoma of the skin; the analyses are natal-sex specic
eAll cancers of the cervix
112
sample of transmasculine individuals, 24%were ≥36years and only 4.2%were
>55years. Another US-based cohort of transfeminine veterans (n=4394) found
a reduced risk of prostate cancer when compared to cisgender males (n=14,431)
and an equivalent risk of colorectal, lung, skin (melanoma), liver, kidney, and
bladder cancers over 17years of follow-up with a median study population age
of 46–55years (Goodman & Nash, 2019).
There is some evidence of an increased risk of breast cancer among transfemi-
nine individuals as compared to cisgender men (Braun etal., 2017; de Blok etal.,
2019; Gooren etal., 2013). Other studies among transfeminine individuals com-
pared to cisgender male populations detected increased incidence of anal, Kaposi-
Sarcoma, non-Hodgkin’s lymphoma, prostate, and HPV-induced cancers after
adjusting for age at diagnosis (Braun etal., 2017; Brown & Jones, 2015; Nash etal.,
2018). Though statistically signicant differences in cancer incidence exist, the
relatively small number of cases (4–15) for any single cancer among transfeminine
participants does not allow for population-level inferences. Instances of decreased
cancer levels were isolated to invasive breast, noninvasive breast, prostate, and
colorectal cancers as well as melanoma of the skin comparing transfeminine indi-
viduals to cisgender men and invasive breast cancer when comparing transmascu-
line individuals to cisgender women (de Blok etal., 2019; Goodman & Nash, 2019;
Nash etal., 2018).
As described above, the eight cohort studies used different comparison groups
to calculate estimates including cisgender women, cisgender men, or combined
cisgender persons (both cisgender men and women together) for the transfemi-
nine group as well as for the transmasculine group. Consequently, comparing the
results from the nine cohort studies cannot be reasonably done given different
comparison groups. Another major issue in understanding cancer incidence
among transgender populations is the relatively small number of cases within
even the largest cohorts of transgender patients. Assessing cancer risk is compli-
cated further by a lack of data concerning medical gender afrmation treatments
for transgender individuals, preventing analyses from stratication on this basis.
GAHT in particular has raised concerns related to the risk of some cancers, as
has been the focus of case studies, especially given some cancers are hormone-
dependent, such as breast cancer (Wierckx etal., 2013). None of the largest stud-
ies of cancer among transgender populations accounted for GAHT use. As
mentioned in the SM section, HIV- positive status is associated with certain can-
cers. In the United States among transgender populations, the estimate of the
prevalence of HIV is 14% (Becasen etal., 2019). HIV status is another factor not
considered in the studies that estimated cancer incidence. Of note is that some of
the top global cancers (lung and colorectal) are sparsely mentioned in the litera-
ture for transgender populations. This distinction is particularly germane for
hormone-dependent cancers, where multiple comparison groups (i.e., cisgender
women and cisgender men separately) may be needed to most appropriately draw
conclusions.
J. A. McElroy and B. J. Gosiker
113
5.4 Diabetes Mellitus
Diabetes mellitus (DM) is a medical condition in which glucose (i.e., blood sugar)
levels are abnormally high because the body is not properly using or does not make
the hormone insulin. Insulin is made in the pancreas and allows the body to use
glucose from consumed foods or to store glucose for future use. Insulin helps keep
glucose levels from getting too high or too low (Palicka, 2002).
Approximately 7–12% of DM cases in mature countries are Type 1 (formerly
known as juvenile or insulin-sensitive DM in which the body does not produce
(enough) insulin) (International Diabetes Federation, 2019; Olokoba etal., 2012).
The majority of cases, where data are available, are attributed to Type 2 diabetes
(formally known as non-insulin dependent, insulin-insensitive, or adult-onset DM,
which indicates that the cells in the body do not respond well to insulin and there-
fore cannot use glucose for energy) (D’Adamo & Caprio, 2011; Gale, 2002; Klonoff,
2009; Motala etal., 2003; Olokoba etal., 2012). Signicant and alarming increases
in Type 2 diabetes among children and adolescents have been described in Europe,
New Zealand, Oceanic, and Asian countries (Pinhas-Hamiel & Zeitler, 2005).
Almost all surveillance studies about NCDs make no distinction between Type 1
and Type 2 DM. Consequently, if not specied, the term diabetes refers to the com-
bination of both Type 1 and Type 2.
Diabetes has emerged as a leading cause of disability globally, ranking as the
fourth leading cause of age-standardized years of life disabled (YLDs) in 2017 up
from a ninth position in 1990 (Institute for Health Metrics and Evaluation, 2018).
This increased burden was observed across all levels of economic development
(G.B. D.Risk Factor Collaborators, 2018).
5.4.1 Epidemiology ofDiabetes Mellitus inSexual
Minority Populations
As with surveillance data on DM globally for the general population, the prevalence
of DM reported in the studies with SM populations does not differentiate between
Type 1 and Type 2. Consequently, it is assumed that prevalence data reect a com-
bination of both types. Over 30 studies, virtually all completed by US respondents,
reported DM prevalence or adjusted odds ratios comparing SM populations to het-
erosexual populations. The data consistently demonstrate no difference in DM
between lesbians or gay men and their heterosexual counterparts (Beach et al.,
2018; Blosnich etal., 2016; Boehmer etal., 2014; Conron etal., 2010; Diamant &
Wold, 2003; Dilley etal., 2010; Jackson etal., 2016; Newlin Lew etal., 2018a, b;
Patterson & Jabson, 2018; Wallace etal., 2011; Wang etal., 2007).
For bisexual males and females, among the 13 studies that reported bisexual
female statistics, all but three (Diamant etal., 2000; Dilley etal., 2010; Newlin Lew
etal., 2018b) reported no difference in DM prevalence (Beach etal., 2018; Boehmer
5 Sexual and Gender Minority Population’s Health Burden of Five Noncommunicable…
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etal., 2014; Clark etal., 2015; Conron etal., 2010; Diamant & Wold, 2003; Jackson
etal., 2016; Patterson & Jabson, 2018; Wallace etal., 2011; Ward etal., 2015) com-
pared to heterosexual females. Among the three studies, two showed increased and
one decreased DM prevalence. The increased DM prevalence was among studies of
specic places in the United States: Los Angeles, California (data collected in
1997), and Washington state (data collected in 2003–2006). For bisexual men, half
of the studies indicated signicantly increased DM prevalence (Beach etal., 2018;
Dilley etal., 2010; Farmer et al., 2013; Newlin Lew etal., 2018a; Wallace et al.,
2011), and the other half indicated no difference (Boehmer etal., 2014; Clark etal.,
2015; Conron etal., 2010; Jackson etal., 2016; Patterson & Jabson, 2018; Ward
etal., 2015) compared to heterosexual men. It is not clear what unique risk factors
support the nding of a possible increased risk of diabetes for bisexual men. Nor is
it clear why half of the studies found bisexual men at no increased risk but the other
half identied an increased risk.
Among the US studies, one-third used BRFSS.Of the 10 BRFSS studies explor-
ing DM, 4 focused on older age or age groups, and all found no difference between
SM and heterosexual populations (Boehmer etal., 2014; Fredriksen-Goldsen etal.,
2013a; Garland-Forshee etal., 2014; Matthews & Lee, 2014).
Two studies carefully considered weight status (i.e., underweight-healthy weight
(<25.0 body mass index (BMI)) as a reference category, and three increasing weight
categories) and diabetes (Eliason etal., 2017; Stupplebeen etal., 2019). Each over-
weight category compared to a reference weight category demonstrated an increased
likelihood of DM among SM men and women and heterosexual men and women
independently. However, for both SM men and women, the increased likelihood of
DM was much stronger compared to their heterosexual counterparts (Eliason etal.,
2017; Stupplebeen et al., 2019). Further, a strong positive DM trend was also
reported with increasing weight. Corliss and colleagues support this nding (Corliss
etal., 2018). The implication of this remains to be determined, but current work
explores inammation pathways in obesity, diabetes prevention, and diabetes man-
agement (Monteiro & Azevedo, 2010; Tsalamandris etal., 2019).
A severe limitation to understanding the global burden of DM, or lack thereof,
among SM populations is virtually nonexistent data on this topic, globally. Evidence
exists for only the US Patterns of DM prevalence or risk cannot be generalized
beyond US borders. Even within the United States, the literature on DM typically
mixes Type 1 and Type 2. With the increase in Type 2 DM among children and ado-
lescents globally, disentangling information from participants on the type of DM
will become increasingly important.
5.4.2 Epidemiology ofDiabetes Mellitus inTransgender
andNon-binary Populations
The studies (n=11) assessing DM among transgender populations are represented
by Belgium (Defreyne etal., 2017), the Netherlands (Elbers et al., 2003; Giltay
etal., 1999; Nokoff etal., 2018; Polderman etal., 1993; Wierckx etal., 2013), and
J. A. McElroy and B. J. Gosiker
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the United States (Alzahrani etal., 2019; Caceres etal., 2019a; Dragon etal., 2017;
Herman et al., 2017; Nokoff et al., 2018). Three studies from the Netherlands
assessed changes in biomarkers for DM risk following the initiation of GAHT
among small cohorts of transgender individuals (Elbers etal., 2003). Five studies
compared the prevalence of DMamong transgender populations to cisgender popu-
lations (Alzahrani etal., 2019; Caceres etal., 2019a; Dragon etal., 2017; Herman
etal., 2017; Wierckx etal., 2013), four of which were general population samples.
The fth study specically compared transgenderpopulations that were elderly (age
over 65years) or experiencing disability to their cisgender counterparts (Dragon
etal., 2017). One study assessed the prevalence of DM in a cohort of transgender
individuals but did not have a comparison group (Defreyne etal., 2017). Another
general US population study (using BRFSS data) compared the odds of DM status
among transmasculine, transfeminine, and non-binary populations to cisgender
comparator groups (Nokoff etal., 2018). Only one of the studies on DM stratied
estimates by GAHT use (Defreyne etal., 2017). Unlike DM studies among sexual
minority populations, two studies among the transgender population differentiated
between Type 1 and Type 2 DM (Defreyne etal., 2017; Wierckx etal., 2013).
The three studies assessing biomarkers for diabetes before and after GAHT ini-
tiation were relatively small with 12–20 transfeminine individuals and 12–17 trans-
masculine individuals (Elbers etal., 2003; Giltay et al., 1999; Polderman etal.,
1993). One study found reduced insulin sensitivity among transfeminine individuals
and no change among transmasculine individuals following GAHT (Elbers etal.,
2003). The second study found decreased endothelin levels among transfeminine
individuals and increased endothelin levels among transmasculine individuals fol-
lowing GAHT initiation (Polderman etal., 1993). The third study noted no change
in insulin levels among transmasculine individuals and an increase among trans-
feminine individuals following GAHT initiation (Giltay etal., 1999).Notably, these
studies were published over two decades ago and standard GAHT formulations
have changed in the interim.
The largest general population surveillance study to date on DM used data from
a US state-based study with BRFSS data. This study contained 829 transmasculine
individuals, 1373 transfeminine individuals, and 570 gender non-binary persons
compared separately to cisgender women (n = 368,220) and cisgender men
(n=291,911) (Caceres etal., 2019a). The breakdown of birth-assigned sex for the
gender non-binary individuals in the study was not provided. No statistically signi-
cant difference was seen in adjusted DM prevalence when comparing transmascu-
line, transfeminine, or gender non-binary persons to cisgender men or among
transmasculine or gender non-binary individuals compared to cisgender women.
Transfeminine individuals were found to have a higher adjusted DM prevalence
when compared to cisgender women. Analyses were adjusted for the state of resi-
dence, age, survey year, race/ethnicity, income, education, marital status, employ-
ment status, self-rated health, healthcare coverage, delayed care, routine checkup,
current tobacco use, heavy drinking, and exercise but not obesity status.
Another large cohort study using BRFSS data found no differences in the preva-
lence of DM comparing transfeminine individuals (n= 1788) or transmasculine
individuals (n = 1267) separately to cisgender men (n = 306,046) or cisgender
5 Sexual and Gender Minority Population’s Health Burden of Five Noncommunicable…
116
women (n=410,828). These were unadjusted analyses, with each group having a
similar average age (Alzahrani etal., 2019). A smaller study (n=369 transfeminine
individuals, n=239 transmasculine individuals, n=78,548 cisgender women, and
n=60,009 cisgender men) using BRFSS data had similar ndings comparing trans-
feminine and transmasculine individuals to cisgender women and men. The only
comparison to note a difference was lower adjusted odds of DM comparing trans-
masculine individuals to cisgender women (Nokoff etal., 2018). Adjusted odds of
DM were not statistically signicantly different when comparing gender non-binary
(AFAB) (n=61) to cisgender women or gender non-binary (AMAB) (n = 68) to
cisgender men.
A study analyzing the prevalence of Type 2 DM among transfeminine individu-
als (n=214) and transmasculine individuals (n=138) in Belgium used age-matched
control groups. The transfeminine cohort was compared, separately, to age-matched
cisgender men (n=640) and cisgender women (n=619). Similarly, the age-matched
comparator groups for transmasculine individuals had cisgender men (n=414) and
cisgender women (n=414) (Wierckx etal., 2013). Higher prevalence of DM was
found when comparing transfeminine individuals to cisgender men and to cisgender
women. Similarly, a higher prevalence of Type 2 DM was found when comparing
transmasculine individuals to cisgender women. Transmasculine individuals did not
have a statistically signicant difference in Type 2 DM prevalence when compared
to cisgender men (Wierckx etal., 2013).
Four studies used general population samples and showed mixed evidence of
DM among transfeminine, transmasculine, and gender non-binary individuals in the
United States and Belgium compared to cisgender men and cisgender women
(Alzahrani etal., 2019; Herman etal., 2017; Wierckx etal., 2013). Two high-quality
studies noted higher prevalence of DM among transgender women compared to
cisgender women, and one found a higher prevalence compared to cisgender men
(Alzahrani etal., 2019; Caceres etal., 2019a; Wierckx etal., 2013). All other studies
noted no difference in DM prevalence compared to either cisgender men or women.
Among transmasculine patients, one study noted a higher prevalence when com-
pared to cisgender women and men separately, but all other studies found no differ-
ence (Wierckx etal., 2013). Studies assessing changes in DM risk prole following
GAHT initiation among transfeminine individuals had mixed results, with two stud-
ies noting increases in DM risk prole (based on insulin sensitivity and insulin
levels) and one noting a reduced risk prole (by endothelin levels). Among trans-
masculine individuals, one study found an elevated DM risk prole (based on endo-
thelin) following GAHT initiation, and two others found no signicant changes.
Notably, the samples for these studies were relatively small (less than 30) (Elbers
etal., 2003; Giltay etal., 1999; Polderman etal., 1993).
There does not seem to be substantial evidence to suggest a difference in DM
comparing transmasculine individuals to cisgender men or women. With mixed
evidence concerning transfeminine individuals, more high-quality research is
needed to make a conclusion on DM risk compared to cisgender populations. Too
few high- quality studies have been conducted stratifying by GAHT status to make
meaningful recommendations. A single study with a small sample size explored
J. A. McElroy and B. J. Gosiker
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DM among gender non-binary individuals, so no conclusions can be drawn here
either. No studies address DM among transgender populations outside of the
United States, Belgium, and the Netherlands, and similarly they do not incorporate
consideration of diabetes risk factors. Some studies controlled for age, while others
relied on similarly distributed age or did not account for it in their analysis, pre-
senting challenges with drawing population-level conclusion given DM’s strong
association with age.
5.5 Asthma
Among chronic respiratory diseases, asthma is the most common. Asthma is some-
times reported as a “lifetime” diagnosis; in other words, ever diagnosed with asthma.
“Lifetime” diagnosis includes childhood asthma, which is “outgrown” by adulthood
in more than two-thirds of patients (Sears etal., 2003). In other studies, current
asthma includes both adult-onset asthma and unresolved childhood asthma (de Nijs
et al., 2013). For international studies, the accepted gold standard question is
“wheezing in the last 12 months” as the response to determine the prevalence of
asthma or diagnosed by physicians (Masoli et al., 2004; Pearce et al., 2000).
However, there is no single test or clinical feature that denes the presence or
absence of asthma. As a result, the prevalence of current asthma symptoms is not
equivalent to the prevalence of clinically diagnosed asthma.
Worldwide, approximately 339million people have asthma (Marks etal., 2018).
Globally, asthma is ranked 16th among the leading causes of years lived with dis-
ability and 23rd among the leading causes of burden of disease, as measured by
disability-adjusted life years (DALYs) in 2015 (G. B. D. Chronic Respiratory
Disease Collaborators, 2017). Established risk factors for asthma include smoking
and chemical irritants in the workplace, whereas other strongly suspected exposures
include indoor pollutants, outdoor allergens such as pollens and molds, and air pol-
lution (G.B. D. Chronic Respiratory Disease Collaborators, 2017; World Health
Organization, 2019). Sparse surveillance data are available on older and elderly
populations globally. Overall, a U-shaped pattern exists between asthma prevalence
and country income, with emerging and mature countries bothfacing the greatest
asthma burden (Sembajwe etal., 2010).
5.5.1 Epidemiology ofAsthma inSexual Minority Populations
About two dozen studies describe asthma prevalence in SM, with only three stud-
ies restricted to current asthma diagnosis only. Among the studies that separated
lesbians and bisexual females, the majority reported an increased asthma preva-
lence for both populations compared to heterosexual populations (Blosnich etal.,
2014; Boehmer etal., 2014; Conron etal., 2010; Dilley etal., 2010). Similarly, in
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a meta- analysis of nine studies, Meads and colleagues reported an increased
asthma risk for lesbians and bisexual women compared to heterosexual women
(Meads etal., 2018). However, the only study conducted outside of the United
States in Australia reported asthma prevalence among their four groups of partici-
pants: exclusively heterosexual, mainly heterosexual, bisexual, and lesbian.
Among these four groups, bisexual and mainly heterosexual females had a statis-
tically increased asthma prevalence. When the model controlled for current smok-
ing, the difference was found to be nonsignicant for current smokers but remained
signicant for those who had never smoked or were former smokers by sexual
identity (McNair etal., 2011).
Studies comparing gay or bisexual men to their heterosexual counterparts gener-
ally found similar asthma prevalence between the two groups (Blosnich etal., 2014,
2016; Boehmer etal., 2014; Cochran & Mays, 2007; Conron etal., 2010; Dilley
et al., 2010; Kim & Fredriksen-Goldsen, 2012; Stupplebeen etal., 2019). In the
BRFSS studies described under the diabetes section that focused on older popula-
tions, asthma was similar between SM men and women compared to their respec-
tive heterosexual groups (Boehmer etal., 2014; Fredriksen-Goldsen etal., 2013b,
2017; Matthews & Lee, 2014).
To evaluate the heterogeneity in the published literature regarding the role of
obesity in asthma incidence, Beuther and colleagues completed a meta-analysis that
included seven studies (sexual orientation was not noted) (Beuther & Sutherland,
2007). A dose-response effect of elevated BMI on asthma incidence was observed
in both men and women (Beuther & Sutherland, 2007). Obesity status and asthma
were evaluated in three studies (Blosnich et al., 2013; Eliason et al., 2017;
Stupplebeen etal., 2019). For example, in Blosnich and colleagues’ study, over-
weight/obese status was a signicant predictor of both current and lifetime asthma
diagnosis among same-sex partners as well as opposite-sex partners for women but
not for men. Some risk factors for asthma, such as smoking and obesity, were much
higher among lesbians compared to heterosexual females (Garland-Forshee
etal., 2014).
Smoking is also considered a risk factor for adult onset of asthma. In a
Finnish case-control study, both workplace and total environmental tobacco
exposures (combining both workplace and home exposure) during a 12-month
period were signicantly related to general population adult-onset asthma diag-
nosis (Jaakkola etal., 2003). As higher smoking rates have been consistently
noted for SM populations compared to heterosexual populations, this is an
important component in understanding asthma risk among SMs. See Chap. 6
(Substance Use) for more details on smoking among the SM populations. Most
of the studies controlled for smoking by adding this variable to the models to
assess asthma risk. However, the denition of smoking varied (current versus
ever), and none considered environmental tobacco exposure, thereby limiting
the comparability among studies.
Similar to diabetes, virtually no studies have been published on asthma risk for
the SM population beyond the United States. This dearth of information limits the
generalizability of ndings. It also does not provide an assessment of the global
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burden of asthma in other places where triggers and links to asthma may be consid-
erably different than in the United States.
5.5.2 Epidemiology ofAsthma inTransgender
andNon-binary Populations
A limited number of studies (n=5) have assessed the prevalence of asthma in trans-
gender populations, all of which were based in the United States. Three of the stud-
ies were national samples (Dai & Hao, 2019; Downing & Przedworski, 2018;
Dragon etal., 2017), while the fourth (Herman etal., 2017) was limited to the state
of California. Each used varying comparison groups for transfeminine and trans-
masculine individuals. One study that accounted for non-binary individuals did not
conduct comparative analyses (Dai & Hao, 2019).
Data from the 2014 BRFSS survey found no statistically signicant differences
in the prevalence of asthma comparing 206 transmasculine individuals to 60,485
cisgender men and 351 transfeminine individuals to 85,739 cisgender women after
adjusting for age, race, ethnicity, education, income, employment status, and depres-
sion. The study calculated the prevalence for the 112 gender-nonconforming per-
sons but did not conduct analyses comparing them to cisgender populations (Dai &
Hao, 2019). The proportion of participants aged 45 years and older was similar
across the groups, ranging from 59% among transfeminine individuals to 51%
among gender non-binary individuals (Dai & Hao, 2019). The breakdown of sex
assigned at birth for individuals identifying as gender non-binary was not included
in the study. Another study of 85 transgender persons in California showed a similar
prevalence of asthma to a sample of 32,142 cisgender individuals at 8% (Herman
etal., 2017). This estimate is nearly identical to CDC estimates for the prevalence
of asthma in the general population in the United States (Asthma and Allergy
Foundation of America, 2019).
Data from the 2014 to 2016 BRFSS surveys analyzed 1073 transfeminine indi-
viduals, 699 transmasculine individuals, and 449 non-binary individuals. The
breakdown of sex assigned at birth for individuals identifying as gender non-binary
was not included in the study. Each of these groups was compared independently to
samples of 297,810 cisgender women and 218,021 cisgender men. Transfeminine
individuals in the study had a lower adjusted odds ratio (aOR) of having asthma as
compared to cisgender females after adjustment for age, race/ethnicity, relationship
status, educational attainment, health insurance coverage, and state of residence. All
other comparisons were not statistically signicantly different (Downing &
Przedworski, 2018).
In contrast, two studies reported an increased prevalence of asthma among
transgender populations. The rst study focused on two mutually exclusive
groups: US residents aged 65 or older (age-entitled Medicare beneciaries) and
disability- entitled Medicare beneciaries using a large claims database from a
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120
government- funded health plan (Dragon et al., 2017). All of the analyses pre-
sented were unadjusted for relevant covariates, such as age. This is particularly
relevant for the disability-entitled Medicare beneciaries, where the transgender
population was statistically signicantly younger. The age distribution in the three
groups (18–44, 45–54, and 55–64years) are almost exact opposites with about
50% of transgender individuals in the youngest age group and 50% of cisgender
individuals in the oldest age group. The study found higher prevalence estimates
of asthma among 2133 transgender individuals (transfeminine and transmasculine
combined) as compared to 32,588,061 combined cisgender individuals (cisgender
women and men combined) who were age-entitled Medicare beneciaries and for
the 5321 transgender disability-entitled Medicare recipients compared to
6,548,168 combined cisgender disability-entitled Medicare recipients (mean age
44.9 and 51.3, respectively). In unadjusted estimates, a prevalence of 20.9% was
found among transgender age- entitled Medicare beneciaries compared to 12.7%
among cisgender age-entitled Medicare beneciaries. Among the disability-enti-
tled Medicare beneciaries, the unadjusted prevalence was 33.2% among trans-
gender individuals and 18.0% among cisgender individuals (Dragon etal., 2017).
However, this analysis did not adjust for any risk factors, such as smoking status,
indoor air pollution, or family history of asthma due to the limitation of these data
and included only individuals who have this health plan. The second study was a
quantitative needs assessment among transmasculine individuals (n=73) in the
United States and also reported elevated age-standardized asthma prevalence of
33.3% compared to the CDC-reported age- standardized estimate for all US males
of 11.0% (Reisner etal., 2013).
In summary, the one probabilistic-based study reported no difference in
asthma prevalence when comparing transgender populations to their cisgender
counterparts (Herman etal., 2017). None of the studies indicated whether they
inquired specically about lifetime, adult-onset, or current asthma. Conating
these would have direct implications, as many people have asthma during child-
hood that does not persist into adulthood. Given evidence only existing for US
populations, limited generalizations can be made as to the burden of asthma in
transgender populations globally. Finally, studies that do not evaluate transfemi-
nine and transmasculine populations separately have limited value in under-
standing their asthma burden since these groups have unique asthma-related risk
factors (Naeem & Silveyra, 2019). Additionally, disability status is highly cor-
related with NCDs, and assessment of disability status has received focused
attention recently. As indicated in the Dragon et al.’ (2017) study described
above, disability may disproportionally affect the transgender population and
therefore warrants further investigation. The Washington Group on Disability
Statistics has validated a six-item question in all regions of the world that pro-
vides a standardized instrument to characterize disability status (Groce &
Mont, 2017).
J. A. McElroy and B. J. Gosiker
121
5.6 Chronic Obstructive Pulmonary Disease (COPD)
Chronic obstructive pulmonary disease (COPD) is a medical condition character-
ized by incompletely reversible chronic obstruction of lung airow that interferes
with normal breathing (Viegi etal., 2007). This occurs as a response to inamma-
tion. COPD has been associated with inhalation of toxins from cigarette smoke,
combustion of biomass for cooking and heating, and environmental pollution
(Global Initiative for Chronic Obstructive Lung Disease, 2018). A population-based
US study estimated that the fraction of COPD attributable to workplace exposure
was 19.2% in smokers and 31.1% in nonsmokers (Hnizdo etal., 2002). Household
air pollution from exposure to smoke from the combustion of solid or biomass fuels
is a frequently reported COPD risk factor in nonsmoking populations (Gnatiuc &
Caramori, 2014; Gordon et al., 2014; Mortimer et al., 2012; Salvi et al., 2012).
Other COPD risk factors include age, genetics, socioeconomic status, and lung
growth and development (Chinai etal., 2019).
Unlike the term asthma that has been used for over 3000years, the term COPD
has only been used since the mid-twentieth century. Prior to the adoption of the term
COPD, American physicians used the term ‘emphysema,’ whereas British physi-
cians used the term “chronic bronchitis” for the same condition (Petty, 2006).
Describing the global burden of COPD is hampered for several methodological rea-
sons (Salvi etal., 2012; Soriano & Lamprecht, 2012) as well as 72–92% of COPD
cases being underdiagnosed (Casas Herrera etal., 2016).
Globally, COPD is projected to rank seventh in 2030, up from the 11th position
in 2002, in DALYs (Mathers & Loncar, 2006). This translates into approximately
168 million men and 160 million women worldwide (Vos etal., 2012). COPD
accounted for 5% of all deaths worldwide in 2015, with more than 90% of COPD
deaths occurring in emerging and developed countries (World Health Organization,
2017). The prevalence of COPD is around 10%, but considerable variation in preva-
lence by country exists (Buist etal., 2007; Halbert etal., 2006; Menezes etal., 2005).
5.6.1 Epidemiology ofChronic Obstructive Pulmonary Disease
inSexual Minority Populations
Given the methodological issues in ascertaining the global burden of COPD, it is
not surprising that very limited studies are available to describe the global burden of
COPD among the SM population (Salvi etal., 2012; Soriano & Lamprecht, 2012).
The Geneva Gay Men’s Study indicated that gay men were much more likely to be
treated for bronchitis in the previous 12months than heterosexual men (Wang etal.,
2007). Similarly, Patterson and colleagues also found an increased risk for chronic
bronchitis in the United States among gay men but not bisexual men or heterosexu-
als who have a history of opposite-sex sexual behavior (Patterson & Jabson, 2018).
In contrast, two other US-based studies did not nd an increased risk for
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122
emphysema or COPD, respectively, for SM men (Blosnich et al., 2016; Ward
etal., 2015).
The two studies that reported on COPD for SM women produced mixed results.
One study reported no difference in COPD prevalence between lesbians and bisex-
ual women compared to heterosexual women (Ward etal., 2015). The second study
only reported an increased risk for chronic bronchitis among lesbians but not bisex-
uals, lifetime lesbians or bisexual females, or those self-identied as SM with or
without same-sex sexual behavior (Patterson & Jabson, 2018).
Smoking is the most common risk factor for COPD (Global Initiative for Chronic
Obstructive Lung Disease, 2018). A family history of asthma is another signicant
risk factor (Silva etal., 2004; Vonk etal., 2003). SMs have an increased smoking
prevalence, and SM women may also have an increased asthma prevalence. (See
Chap. 6 (Substance Use) on smoking prevalence among SMs.) No studies have been
published that evaluate the additional risk factors associated with COPD for the SM
population.
5.6.2 Epidemiology ofChronic Obstructive Pulmonary Disease
inTransgender andNon-binary Populations
COPD is a growing cause of morbidity and mortality in countries at all levels of
economic development (Buist etal., 2008; Mannino & Buist, 2007). Similar to the
SM section on COPD, sparse data are available for the transgender population. This
may reect a global issue of the younger age of participants who provide data,
whereas COPD is considered a disease of the elderly (Holm etal., 2014). Only two
studies were found that explored the prevalence of COPD among transgender popu-
lations, both of which focused on US-based cohorts. One study focused on trans-
gender individuals with government-provided health insurance noted in the prior
section on asthma also explored COPD prevalence (Dragon etal., 2017). In unad-
justed analyses, the prevalence of COPD was higher among transgender individuals
among both age-entitled and disability-entitled Medicare beneciaries compared to
similarly dened cisgender beneciaries. The unadjusted prevalence of COPD among
patients older than 65 was 30.4% in transgender patients (transmasculine and trans-
feminine patients combined) as compared to 20.7% in cisgender beneciaries (cisgen-
der women and men combined). Among disability-entitled Medicare beneciaries, the
unadjusted prevalence of COPD was 26.1% among transgender patients as compared
to 21% among cisgender patients.No adjusted analyses were presented.
Similarly, in the 2014 BRFSS study also described in the asthma section, no dif-
ferences in unadjusted COPD prevalence were found when comparing transmascu-
line individuals to cisgender women, transfeminine individuals to cisgender men,
and gender non-conforming individuals to both cisgender men and women (Dai &
Hao, 2019). Adjusted analyses comparing COPD prevalence among the three afore-
mentioned transgender populations to gay cisgender men also showed no
differences.
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123
With only two studies, both in the United States, exploring COPD among
transgender populations and one of these two studies not evaluating the preva-
lence separately for transfeminine and transmasculine participants, generaliza-
tions cannot be drawn as to the global burden of COPD in transgender populations.
However, given that smoking is the leading cause of COPD, and smoking preva-
lence among transgender populations has been reported at higher rates than either
the SM or cisgender heterosexual populations (Buchting etal., 2017; McElroy
etal., 2011; Tamí-Maury etal., 2020), the prevalence of COPD would be expected
to be much higher in transgender populations. This higher prevalence would be
particularly noticeable in countries with high tobacco smoking prevalence
(Reitsma etal., 2017).
5.7 Conclusion
In the scoping review of SGMs and the top ve NCDs, 11% of the countries in the
world were represented. A note of caution should be at the forefront when consider-
ing the global burden of NCDs represented in this chapter given the clear over-
representation of data from one country. Specically, the United States contributed
almost three-quarters of research articles. Further, ndings from only a few and
mostly mature countries as described in this chapter limits the generalizability given
the lack of representation of many countries and regions of the world. With that
being said for the SM population, the literature suggests an increased burden only
for asthma among lesbians and bisexual women. Little evidence exists of an
increased burden among SMs for cancer, COPD, diabetes mellitus, or CVD. This is
in stark contrast to established risk factors for NCDs, such as increased weight (SM
women), smoking, excess alcohol consumption, and minority stress (see Chap. 2 on
Stigma and Chap. 6 on Substance Use for a more in-depth exploration of these
factors).
There is minimal evidence of any differential burden of cancer, COPD, diabe-
tes mellitus, or asthma among transgender populations. Too few studies exist to
draw conclusions specic to GAHT use for these NCDs. Among transfeminine
populations, there is some evidence of elevated CVD risk, with notable increases
in venous thromboembolism and pulmonary embolism across multiple studies
associated with GAHT use (Getahun et al., 2018; van Kesteren etal., 1997;
Wierckx etal., 2013). Large-scale studies centered on transgender populations
infrequently accounted for GAHT use, regimen, or duration. The lack of these
data drastically inhibits conclusions that may be drawn concerning NCDs among
transgender populations given the diversity of various medical and physical gen-
der afrmation processes that individuals may pursue. Smaller studies tended to
focus explicitly on NCDs among transgender persons using GAHT, often exclud-
ing those who may choose not to pursue GAHT and limiting conclusions that
may be drawn.
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A very limited understanding of the inuence of multiple identities that each
person embodies beyond gender is reected in this research. For example, racial/
ethnic minority populations within the SGM community are rarely captured. In
Thailand, one such population is the SGM Malay Muslims (Minority Rights Group
International, 2018), whereas in the United States, SGM Native Americans com-
prise another such population. In addition, socio-cultural characteristics such as
marriage/co-habitation among same-sex couples or economic position are not com-
monly considered in these studies. This lack of consideration of important charac-
teristics also restricts the generalizability of ndings to the SGM population within
any one country and across countries.
Another characteristic reected in the SGM population is the uidity of identi-
cation over one’s life course. This uidity can be experienced by both sexual minor-
ity individuals as well as transgender individuals and is not uncommon (Dickson
etal., 2013; Katz-Wise etal., 2014, 2016). The practical implications of this uidity
are unclear. A parallel construct is marital status. At any moment in time, marital
status may change but is considered a core socio-demographic characteristic cap-
tured in medical records, health-related surveys, and countries’ censuses. A rich and
deep level of research continues to explore this social behavior, and, going forward,
a similar depth and breadth of research is warranted to understand sexual and gen-
der uidity.
A notable limitation to drawing conclusions concerning NCD incidence and
prevalence among SGM populations is that the average age in many studies skews
younger. This is most noteworthy in studies with transgender populations, where
many have average ages under 50. Some studies dealt with this dilemma by generat-
ing estimates adjusting for age or using age-matched samples. Many studies did not
account for differences in age structure. This gap in study recruitment prevents
strong conclusions given the strong associations between age and disease onset for
CVD, cancer, DM, and COPD. Unlike the other NCDs discussed in this chapter, age
is not strongly associated with asthma (American Lung Association, 2020; Centers
for Disease Control and Prevention, 2021).
In conclusion, the limited data representing a global perspective hint at the pos-
sibility of a similar burden for CVD, cancer (excluding HIV/AIDS-related can-
cers), diabetes mellitus, COPD, and asthma (among SM men and transgender
populations) compared to heterosexual and/or cisgender populations with some
evidence of an increased asthma risk among SM women and elevated CVD risk
among transfeminine populations. Research on long-term use of GAHT is needed
since little is known about the inuence of these exogenous hormones on the bio-
logical system.
The exponential increase in publications over the last two decades on SGM
health concerns, albeit with the United States dominating the eld, illustrates a
promising trend. Increasing research from the 21 other countries who have already
contributed to the literature as well as other countries joining this research agenda
will undoubtedly provide valuable evidence-based insight into the inuence of
SGM status on the global burden of NCDs. For this to happen, adding SGM identity
questions to national surveillance studies as well as capturing these identities within
J. A. McElroy and B. J. Gosiker
125
healthcare records and in cohort studies would signicantly improve our ability to
evaluate NCDs as well as other health outcomes among the SGM population.
5.8 Case Study: Noncommunicable Diseases Among Men
Who Have Sex withMen andTransgender Women
inIndia
The research on cancer and other noncommunicable diseases (NCDs) among sexual
and gender minorities (SGM) in India is limited. The one comprehensive literature
review of research on SGM people in India identies one of the major gaps in
research as the topic of noncommunicable diseases (Chakrapani etal., 2023). This
dearth of research is likely due to multiple factors including the lack of some legal
rights and anti-discrimination protections for SGMs in the country. Fear of stigma-
tization from healthcare providers and other communities can also play a role, pre-
venting SGMs from seeking the routine and appropriate medical care they need and
hindering the ability of epidemiologists to track their chronic illness patterns (Patel
etal., 2012). Of the research on SGM in India on all topics related to health, there
is virtually no research on lesbian women and transmasculine people, with just 4%
and 2% of the research, respectively, focusing on these identity groups (Chakrapani
etal., 2023). However, there are some studies that allow insight into NCDs among
transgender people and illnesses related to HIV-positive status and high-risk human
papilloma virus (HPV) infection among men who have sex with men (MSM)
in India.
5.8.1 NCDs Among Transgender Populations
The research on the risk and prevalence of NCDs among SGMs in India is scarce;
however, there is an emerging body of research exploring risk and disease preva-
lence for transgender people. One study analyzed data on 200 transgender people,
the vast majority of whom were transfeminine, from Puducherry, India, and found
that their prevalence of risk factors, such as high blood pressure, obesity, physical
inactivity, and unhealthy dietary practices, were signicantly higher than the gen-
eral population (Madhavan etal., 2020). Another study found that among transgen-
der people surveyed in Mumbai, two-thirds suffered from NCDs including diabetes
(40%), hypertension (11%), and other musculoskeletal disorders like arthritis
(Gupta & Sivakami, 2016).
Transgender women often receive GAHT as part of their gender afrmation jour-
ney, and research shows that such transgender women in India are at an increased
risk of developing breast cancer when compared to cisgender men (Majumder etal.,
5 Sexual and Gender Minority Population’s Health Burden of Five Noncommunicable…
127
2020). Additionally, the presence of estrogen receptors in prostate tissue raises con-
cern for prostate cancer among transgender women (Majumder et al., 2020).
Although prevalence estimates for India are not available for these cancers in trans-
gender women, data collected outside of India showing the increased risk of breast
cancer during a relatively short duration of hormone treatment can be extrapolated
to this population (Majumder etal., 2020).
5.8.2 HIV-Related Cancers Among MSM
When examining the risk for other NCDs, it becomes apparent that MSM are at
increased risk of cancer if they areliving with HIV due to the way HIV compro-
mises their immune systems. Globally, HIV status contributes to the risk of certain
cancers, specically called AIDS-dening malignancies, as well as non-AIDS-
dening cancers such asthose of the anus and oral cavity/pharynx (National Cancer
Institute, 2017). One study examined malignancies in over 2500 people with HIV in
India in an antiretroviral clinic, of which almost 70% were males (Sharma etal.,
2015). With MSM prevalence of HIV higher among MSM,it is likely that some or
many of these participants were MSM.Results of a retrospective analysis of patients
registered at this clinic found that the frequency of malignancies was higher in the
study group than in the general population, suggesting an important connection
between their HIV status and these malignancies (Sharma etal., 2015).
When examining sexual behaviors in Indian menliving with HIV in relation to
cancer risk and incidence, another study screened 126 male patientsliving with HIV
who were accessing antiretroviraltherapy. Although 91% were married to female
partners, almost 40% of those gave a positive history of anal sex with other men
(Gautam etal., 2018). Researchers found that 60% of patients screened had a vari-
ety of cytological abnormalities, all of which were precursors to anal cancer
(Gautam etal., 2018). Risk factors for these lesions included a history of anal inter-
course (Gautam etal., 2018). Finally, one study compared the prevalence of abnor-
mal anal cytology in Indian MSM living with and without HIV. Researchers
established that MSMliving with HIV had higher rates of abnormal anal cytology
than HIV-negative MSM (Arora etal., 2014).
5.8.3 HPV-Related Cancers Among MSM
While there is no national prevalence data on HPV infection in MSM in India,
researchers who examined it within West Bengal, an eastern province in India,
found that the prevalence of HPV infection among MSM was almost 70% in that
region (Ghosh etal., 2012), as compared to 26%in men overall (Bruni etal., 2019).
While HPV itself is not cancer, there is overwhelming evidence that certain high-
risk strains of HPV cause cancer (Frisch etal., 1997; Hoots etal., 2009). In one
5 Sexual and Gender Minority Population’s Health Burden of Five Noncommunicable…
128
systematic review, high-risk strains of HPV were found in 71% of invasive anal
cancer cases (Hoots etal., 2009). Globally, nearly 90% of anal cancers can be attrib-
uted to HPV infection, occurring more frequently in males in lower-income coun-
tries such as India (de Martel etal., 2017). In one study in India, HPV-attributable
cases of penile cancer were almost as frequent as anal cancer in males, which sug-
gests a higher burden of disease for MSM who are at higher risk of contracting HPV
(de Martel etal., 2017).
5.8.4 Health Advocacy forSGM Populations inIndia
There are multiple organizations in India that are working to both advocate for bet-
ter health services and change stigmatizing social beliefs about LGBTQ+ people.
One of these organizations is Naz, which has an initiative dedicated to ghting for
LGBTQIA+ individuals (Naz India, 2020). They empower LGBTQIA+ people to
access their rights, including medical care, safer sex information, and HIV testing
(Naz India, 2020). Earlier access to appropriate medical care can decrease the risk
of cancer going undetected and untreated (World Health Organization, 2020).
Additionally, LGBTQ+ people’s ability to receive information regarding safer sex
and regular HIV testing as well as preventative screening and treatment for illnesses
like diabetes and heart disease can reduce the risk for SGM and allow them to get
the appropriate treatment should they need it.
Another organization that is ghting for the rights of LGBTQ+ people in India is
the Humsafar Trust. This organization has been doing outreach to LGBTQ+ people
within the Mumbai metropolitan and surrounding areas for over 25years (Humsafar
Trust, 2020a). Their health-related projects include three targeted interventions
among MSM and transfeminine/koti/hijra communities surrounding Mumbai:
reduce transmission of HIV, promote access to healthcare for the community, and
reduce stigma against these individuals (Humsafar Trust, 2020b). The Humsafar
Trust also does research about the LGBTQ+ community in India (Humsafar Trust,
2020c). Their focus is on behavioral health research, which is necessary as mental
and behavioral health are inextricably intertwined with chronic illness and physical
health outcomes. One example of a research study they are currently conducting is
regarding the impact of stigma on depression and sexual risk behavior of MSM and
transgender women in India (Humsafar Trust, 2020c). Findings will be able to
inform interventions to reduce stigma and discrimination, both of which are associ-
ated with physical and sexual health outcomes related to HIV prevention for these
populations (Humsafar Trust, 2020c).
Finally, there is an advocacy organization called Swatantra whose mission is to
advocate for transgender working-class Indians (Global Human Rights, 2018).
They advocate for more inclusive laws and policies on all levels of the Indian gov-
ernment, conduct research on issues impacting the transgender community, and lead
community outreach campaigns to support transgender people (Global Human
Rights, 2018). All these actions can support the legal protections for and
J. A. McElroy and B. J. Gosiker
129
destigmatization of transgender people in India, ultimately supporting their access
to and utilization of healthcare to improve their health outcomes.
The lack of research on the burden of NCDs among SGMs in India is striking
and needs to be remedied. While research on HIV- and HPV-related cancer among
this population can be connected to inferences about cancer, and there is some
research on general health outcomes for transgender people, without research
focused on specic conditions such as cancers,CVD, or diabetes, it is not possible
to fully understand the scope of the problem. It is necessary to have an epidemio-
logical understanding of NCDs among these populations to feasibly allocate fund-
ing for intervention or prevention work. The three organizations described above,
Raz, the Humsafar Trust, and Swatantra, are key starting places for further explora-
tion of NCDs among SGM.
Acknowledgments We are grateful to Alicia T.Bazell for her contribution to the case study on
chronic disease in MSM and transgender women in India accompanying this chapter.
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S. J. Hwahng, M. R. Kaufman (eds.), Global LGBTQ Health, Global LGBTQ
Health, https://doi.org/10.1007/978-3-031-36204-0_6
Chapter 6
Community andSocial Support
ChichunLin andSelJ.Hwahng
6.1 Introduction
In a study of 741 men who have sex with men (MSM) living in NewYork City,
Meyer (1995) found that the men experienced internalized homophobia, societal
rejection and discrimination, and direct or indirect stress. Meyer (1995, 2003) called
these experiences minority stress, which is dened as chronic feelings of stress on
members of marginalized and stigmatized groups. Minority stress can lead to a
heightened risk of physical health problems as well as mental health challenges.
Studies in the United States have revealed the impact of minority stress associated
with negative physical health outcomes (Flentje etal., 2020) and increased levels of
depression, anxiety, loneliness, and diminished self-esteem (see Stigma and Mental
Health chapters, Chaps. 2 and 3; Bowen etal., 2007; McDougall etal., 2001; Meyer,
2003). Minority stress has also been examined globally in lesbian, gay, bisexual, trans-
gender, and queer (LGBTQ) populations, with relevance among populations in
Taiwan (Chan etal., 2022) and South Africa (McAdams-Mahmoud etal., 2014).
This chapter aims to introduce the benets of a sense of community and social
support among LGBTQ populations as an antidote to minority stress. We describe
the consequences of a lack of community and social support. We also attempt to
highlight and explore the experiences of LGBTQ individuals living in low- and
middle-income countries (LMICs) in the Global South. This population tends to
experience greater levels of minority stress because of the high levels of homophobia,
biphobia, and transphobia in many countries, including the outright illegality of
C. Lin (*)
Master of Marriage and Family Therapy Program, Faculty of Education,
The University of Winnipeg, Winnipeg, Manitoba, Canada
e-mail: ch.lin@uwinnipeg.ca
S. J. Hwahng
Department of Women’s and Gender Studies, Towson University, Towson, MD, USA
e-mail: shwahng@towson.edu
148
same-sex relationships in some settings; moreover, the poverty-related issues,
such as inadequate access to physical and mental health services, limited nancial
support, low levels of education, and limited capacity of their governments to solve
the societal oppression might enlarge the minority stress of LGBTQ people
(Detenber etal., 2014;Wang etal., 2009; Williams, 2009; Wong & Tang, 2003).
In other words, LGBTQ individuals globally, but particularly in LMICs, tend to
experience various health-related challenges that may be mitigated with sufcient
social support.
Social support can buffer the negative effects of minority stress on an individual
and allow someone to feel cared for, loved, esteemed, valued, and as belonging to a
network of mutual obligations. House (1981), a social psychologist in the United
States, described four types of social support, including (a) emotional (e.g., love,
trust, caring, and listening); (b) appraisal (e.g., validation and positive feedback); (c)
instrumental (e.g., money, time, labor, and resources); and (d) informational support
(e.g., suggestion and advice). House (1987) also mentioned three aspects of social
relationships, which are often referred to as social support, including (a) their exis-
tence or quantity (i.e., how many persons exist in the social group); (b) their struc-
ture (i.e., how the social group is formed); and (c) their function or behavior (i.e.,
what the members of the social group do). The members of communities to which
an individual belongs are often the main sources of social support. According to
Cohen etal. (2000), social support can be provided in a variety of ways through a
network of two or more people. This chapter presents a general overview of com-
munity and social support research, networks, and organizations for LGBTQ indi-
viduals globally.
6.2 Support inFamilies
6.2.1 Parental Support
Unlike other stigmatized groups (e.g., racial minorities), LGBTQ individuals usu-
ally do not share their stigmatized identity with their parents; therefore, they may
face numerous oppressions alone (Pachankis & Hatzenbuehler, 2013; Rothblum &
Factor, 2001). Moreover, parental rejection can lead to additional challenges, espe-
cially in the Global South or for individuals migrating from the Global South. For
example, a survey of 340 self-identied Filipino gay and lesbian adolescents found
that parental rejection was a major risk factor leading to their suicidal ideation
(Reyes etal., 2015). A qualitative study with female-to-male (FtM) transgender
individuals of Asian and Pacic Islander descent in the United States suggested that
parental rejections were rooted in a lack of knowledge about transgender and gender
variant identities (Mar, 2011).
On the other hand, parental support can promote the well-being of LGBTQ
children and improve their mental health (Goldfried & Goldfried, 2001; Needham
& Austin, 2010; Pearson & Wilkinson, 2013; Ryan etal., 2009). For instance, a
C. Lin and S. J. Hwahng
149
survey of 277 self-identied Chinese LGB young adults found that perceived paren-
tal support in regard to their sexual orientation was associated with positive psycho-
logical adjustment (Shao etal., 2018).
6.2.2 Sibling Support
Sibling support also matters. Studies in the United States found that biological and
heterosexual siblings’ attitudes toward LGBTQ populations were associated with
their LGBTQ siblings’ suicidal ideation/attempts, self-injurious behavior, use of
psychotherapy, and general well-being (Balsam etal., 2005; Hilton & Szymanski,
2011; Toomey & Richardson, 2009). The authors summarized the biological and
heterosexual siblings’ potential reactions after their LGBTQ siblings came out to
them (Hilton & Szymanski, 2011). First, they felt shocked, confused, happy, and/or
accepting. Second, they rethought or challenged their own stereotypes toward
LGBTQ issues. Third, their sibling relationships started changing, and the biologi-
cal and heterosexual siblings may have gained more awareness and knowledge
about LGBTQ issues. Fourth, if the biological and heterosexual siblings fully
accepted their LGBTQ siblings, they became allies to the siblings and provided
assistance when the LGBTQ siblings came out to their parents. Fifth, they may have
attended LGBTQ pride events with their siblings; moreover, they may have chal-
lenged the homophobia, biphobia, and transphobia existing in society.
LGBTQ individuals sometimes choose to come out to their siblings as a rst step
before sharing their identity with other family members. For example, in a case
study, a Muslim lesbian living in Scotland reported that although she experienced
many challenges because of her religion compared to other lesbians, she stressed
that coming out to her siblings would still be easier and safer than to her parents and
other relatives (Siraj, 2011). Similarly, an unpublished doctoral dissertation in
which 16 siblings of LGBTQ individuals in Taiwan were interviewed found they
were more likely to disclose their sexual and gender identity to their siblings before
coming out to their parents; moreover, they connected with their siblings through
LGBTQ-only Facebook accounts (in Taiwan, most LGBTQ individuals have two
Facebook accounts, one for LGBTQ friends and one for family and straight friends)
and shared the LGBTQ-related events with their siblings (Brainer, 2014). These two
examples imply that disclosing one’s sexual and/or gender minority identity with
siblings may be an important step before sharing with one’s parents.
6.3 Support inSchools
In addition to the impact of family relationships, school peers and teachers also play
key roles in LGBTQ students’ mental health. LGBTQ students in the US report greater
loneliness and depression than their heterosexual peers (Davies & Kessel, 2017;
6 Community andSocial Support
150
Westefeld etal., 2001). Allen (2020) found that heterosexual teachers in the United
States often ignore homophobia that exists in the classroom or respond to it ineffectu-
ally; moreover, some heterosexual teachers perpetuate homophobia and heterosexism
in the process of teaching. In a US study, Bradley etal. (2019) argued that teachers are
in an ideal position to prevent the micro-aggressions or bullying of LGBTQ students,
but most of them do not have adequate training. In a study with 732 LGBT high school
and college students in China, students reported that most teachers lack training and
awareness about LGBT issues, which led the students fearing coming out to the teach-
ers (Wei & Liu, 2019). Another qualitative study in South Africa involved interviews
with schoolteachers about their attitudes toward providing sexual education, especially
about LGBTQ issues (Francis, 2012). The interviews revealed that teachers did not
know how to teach because of their limited knowledge about LGBTQ individuals or
because they were against teaching it due to their religious beliefs. However, some
teachers were open to teaching LGBTQ+ topics but only to discuss it when students
asked the relevant questions.
In another study of bisexual students in South Africa, Francis (2017) strongly
recommended that school leaders, managers, and teachers be obligated to develop
school support systems to protect sexual minority (SM) students. Glikman and
Elkayam (2019) reported that LGBT students in Israel continue to experience alien-
ation and opposition in the school environment, and these students strongly believe
teachers should oppose and prevent homophobic behaviors in school through
receiving relevant training.
A South African study with 35 adolescents who identied as MSM, transgen-
der female, and drag queen adolescents living with HIV in South Africa stated
that the participants experienced discrimination, homophobia, and abuse from
both peers and teachers (Daniels etal., 2019). Participants reported that these
experiences resulted in disengagement from school and limited their willingness
to stay connected with education. Moreover, these experiences led them to adopt
unhealthy coping behaviors, such as smoking, drinking alcohol, skipping school,
and eventually dropping out of school (Daniels etal., 2019). However, the partici-
pants expressed their desires to continue education because they aspired to gain
social and economic power through educational attainment, especially when their
sexual and/or gender identity may have resulted in victimization. In a South
African study with 35 adolescents who identied as MSM, transgender, and drag
queen and were living with HIV, participants reported experiencing discrimina-
tion, homophobia, and abuse from both peers and teachers in schools (Daniels
etal., 2019). Those experiences resulted in disengagement from school and lim-
ited their willingness to stay connected with education; moreover, the adolescents
adopted unhealthy coping approaches, such as smoking, drinking alcohol, skip-
ping school, and eventually dropping out of school (Daniels etal., 2019). In spite
of these, the adolescents still expressed their desire to continue education because
they could gain social and economic power and change their lives through educa-
tion (Daniels etal., 2019).
C. Lin and S. J. Hwahng
151
6.4 Support inOther Relationships
6.4.1 Intimate Partners
Besides parent, sibling, peer, and teacher support, intimacy plays an inuential role
in one’s health and well-being. Johnson etal. (1993) found that a romantic partner’s
support behavior affected the other partner’s happiness in an intimate relationship.
A study among sexual minority women in Mumbai, India revealed that intimate
partners comprised a fundamental aspect of their closest social support connections
(Bowling etal., 2018). Those who had intimate partners described the constant
source of support from these relationships. A stable, loving primary partner who
could serve as a condante was the ideal, but single women often had to deal with
social stigma, lack of parental acceptance, and nancial instability that interfered
with meeting and forming long-term relationships with women.
According to Reczek and Umberson (2012), “health behavior work” includes
activities that promote a partner’s positive health behaviors. These researchers
found that in lesbian and gay couples both partners were more likely to mutually
take care of each other’s health, termed “cooperative health behavior work,” com-
pared to heterosexual couples. Despite this mutuality, in a majority of lesbian and
gay couples (73% and 80%, respectively), one partner performed work to enhance
the other partner’s health behavior, usually due to the latter partner engaging in
unhealthy behavior that was perceived as needing intervention.
In a systematic review of sexual minority female cancer survivors in the United
States, the United Kingdom, and Canada, intimate partners provided important
forms of social support, such as emotional, instrumental (e.g., personal and medical
care, transportation, meal preparation, and childcare), decision-making, post-
treatment adjustment, and medical advocacy (Thompson etal., 2020). Intimate part-
ners were also important for survivors to create pleasurable and fullling lives as
cancer survivors. In a study among SGM cancer survivors, sexual minority women,
compared to sexual minority men, were more likely to have an intimate partner in
the room when they learned of their cancer diagnosis (Kamen et al., 2015). In
another study, the association between having an intimate partner and a better physi-
cal quality of life was stronger for sexual minority women compared to heterosex-
ual women (Boehmer et al., 2005). Sexual orientation disclosure has also been
found to affect the level of intimate partner support SMW cancer survivors receive
(Boehmer etal., 2005; Fish etal., 2019).
For older sexual minorities (SMs), losing an intimate partner can be particularly
devastating. Some SMs experience “disenfranchised grief” (Hughes etal., 2014,
p.323) in which their losses are not openly acknowledged, publicly mourned, or
socially supported due to homophobic stigma and exclusion. The loss of an intimate
partner can also trigger re-experiencing previous losses that may have incurred dur-
ing a coming-out process earlier in the life course. And the passing of an intimate
partner may also signify the breaking of a bond that had been established upon a
shared experience of social marginalization, in which the psychological burden
6 Community andSocial Support
152
from social marginalization and exclusion had been alleviated by the relationship.
Thus, SMs are particularly vulnerable to experiencing psychological distress and
depression due to the passing of an intimate partner (Hughes etal., 2014).
In the Midwestern region of the United States, a bereavement support group
specically tailored for older SMs was developed that received a positive reception
from group members (Hughes et al., 2014). The six-week curriculum included
understanding the grief process (including experiences and stages of grief), emo-
tional coping, stress management, managing difcult emotions, dealing with holi-
days, and returning to life after a person one loves has died. Hughes and colleagues
also provide several recommendations for tailoring the support group curriculum,
interfacing with other community and bereavement providers, and advertising and
integrating the support group within the LGBT community (Hughes etal., 2014).
Intimate partner violence (IPV) also plays a crucial role in contributing to nega-
tive mental and physical health outcomes (Buller etal., 2014). Walters etal. (2013)
found that the lifetime prevalence of rape, physical violence, and/or stalking by an
intimate partner was 43.8% for lesbian women, 61.1% for bisexual women, 35% for
heterosexual women, 26% for gay men, 37.3% for bisexual men, and 29% for het-
erosexual men. The rate of IPV in LGB individuals was similar to the rate of IPV in
heterosexual individuals. In a study with 99 LGBT individuals in Latin America,
Swan etal. (2021) found that 60.61% reported at least one IPV event in their life,
with psychological aggression being the most common type. Thus, the reduction of
IPV events within LGBTQ couples is a crucial way to improve their well-being.
6.4.2 Parenting andFamily-Building
It is a well-known fact that a number of positive mental and physical health out-
comes result from people who live in stable families (International Federation for
Family Development, 2022). Historically, however, there have been a number of
systematic factors that have prevented LGBTQ people from parenting and family-
building. Simon and Farr (2021) developed a Conceptual Future Parent Grief Scale
for LGBTQ+ people to measure the “ambiguous loss” of an idealized future self-
involving parenthood as a result of systematic factors that prevent LGBTQ people
from pursuing parenthood. They found that LGBTQ+ identity authenticity (i.e.,
having a positive attitude toward their LGBTQ+ identity) could be protective
against ambiguous loss and thus reduce barriers for LGBTQ+ people pursuing
future parenthood. In addition, LGBTQ people often experience a myriad of nancial,
legal, and medical obstacles to starting and building families (Kreines etal., 2018).
Social support available in health care can greatly facilitate LGBTQ parenting, yet
many countries do not even provide the most basic access for LGBTQ people to
build families. For example, many countries limit LGBTQ adoption and restrict in-
vitro fertilization, insemination, or other assisted reproductive technologies for
LGBTQ people. In the United States, LGBTQ people are less likely to have both
personal health insurance coverage as well as family-building health insurance
C. Lin and S. J. Hwahng
153
(Kreines etal., 2018). An analysis of 100 US-based websites on LGBTQ family-
building revealed poor reliability (according to criteria such as user feedback, pri-
vacy, purpose, identity, content updating, and content development) and a lack of
inclusivity among many of the websites (Kreines etal., 2018).
Despite these barriers, a focus on what resources are available for LGBTQ
family- building and parenthood can identify ways to augment these resources. A
qualitative study among LGBTQ parents in Finland found several factors that con-
tributed to parental empowerment with regard to maternity and child health care
(Kerppola etal., 2019). These factors fell into three main categories—recognition
and acknowledgment, cooperation and interaction, and equitable care. Recognition
and acknowledgment included LGBTQ parents dening their own gender within
the health care sector, dening their family constellation and the roles of various
members of the family, and being welcomed and acknowledged within health care
practice and communication. Cooperation and interaction included health profes-
sionals actively listening and inviting parents to speak, providing individualized
information, respecting parents’ authority and decision-making, and granting non-
legal parents equal rights and responsibilities for health care involvement. Equitable
care included health professionals providing a sense of security and condentiality
as well as being approachable, non-judgmental, and fair. It was important for
LGBTQ parents in this study to experience being treated the same as heterosexual
families, including receiving the same services (Kerppola etal., 2019).
In another qualitative study on reproductive health care in Sweden (Klittmark
etal., 2019), some LGBTQ participants had experienced disempowering treatment
by health care providers such as being assigned incorrect genders for their newborns
and themselves, ascribed heteronormative stereotypes with regard to femininity and
masculinity, and being questioned or excluded as LGBTQ people. Participants
coped in various ways with the inadequate treatment, including using humor, overtly
questioning and educating health care providers, and seeking out information and
support through the Internet, social media, and social networks.
Through family, friends, and LGBTQ networks, participants in the aforemen-
tioned study were also able to seek out pregnancy and birthing clinics that were
known to be LGBTQ-competent, and many of these clinics also provided LGBTQ-
specic parent education groups (Klittmark etal., 2019). Participants who were able
to receive care from LGBTQ-competent clinics or health care providers expressed
satisfaction with this quality of care. This competence included providers being
knowledgeable about LGBTQ rights and supporting participants to navigate the
health care system as LGBTQ people, problematizing cisgender and heterosexual
norms, using gender-neutral terms unless otherwise directed, acknowledging the
entire family constellation, and being open and inclusive. If health care providers
themselves also identied as LGBTQ and/or did not adhere to gender norms,
divulging this information to participants also fostered a sense of connection
(Klittmark etal., 2019).
LGBTQ+ people in studies in North America also emphasize the need for inclusive
and educated health care practitioners as part of culturally competent reproductive
and obstetrical environments during the prenatal/antenatal, intrapartum, and
6 Community andSocial Support
154
postpartum care periods. This practice of care would include the following: (1) pro-
viding “queer-friendly” medical intake forms, sexual history conversations, pictures
and posters decorating the facilities, and pornography for sperm donation; (2)
providing gender-neutral bathrooms near ultrasound rooms and andrology laborato-
ries to include trans and non-binary gendered people who were pursuing pregnancy
or freezing sperm; (3) adopting non-cisgender and non-heteronormative terminol-
ogy to refer to all patients, family members, and friends, including pregnant and
non- pregnant partners; (4) understanding the varying combinations of conception
modes, egg origin, and sperm origin; (5) knowledgeable about co-parenting arrange-
ments and considerations, including co-nursing; (6) awareness of health-related risk
factors that disproportionately affect LGBTQ+ people; and (7) cognizant of legal
issues, such as second parent adoption, that LGBTQ+ parent families may have to
navigate (Bushe & Romero, 2017; Gregg, 2018; Juntereal etal., 2020; Ross etal.,
2014; Scheib etal., 2020).
The Human Rights Campaign regularly evaluates more than 2200 hospitals and
other health care facilities in the United States through a Healthcare Equality Index,
which measures how much a given facility has met the national benchmarks to pro-
mote LGBTQ equity and inclusion (Human Rights Campaign Foundation, 2022a).
This tool may be particularly useful for LGBTQ people interested in accessing the
best possible and most inclusive health care for a current or anticipated pregnancy.
A small body of literature exists specically on sexual minority mothers in same-
sex female relationships with regard to pregnancy and health care. In a study of
lesbian mothers in South Africa, some participants expressed that their partner was
a main source of emotional as well as other types of support in raising children (Van
Ewyk & Kruger, 2017). This study also emphasized the importance of bonding
between lesbian parents as well as between parent and child. Participants reported
that children who were birthed by one woman in a couple often bonded equally with
both the biological and non-biological parents. For those parents who adopted, chil-
dren often loved both adoptive parents equally. The authors emphasized that a bond-
ing relationship with a child was often premised on the attention and care a child
received, not from a biological tie (Van Ewyk & Kruger, 2017).
In addition, lesbian mothers in South Africa often participated in equitable co-
parenting arrangements so that one parent was not overly burdened with most of the
childcare responsibilities. There was often no traditional gendered role division
with respect to household chores and childcare in these lesbian-parented families,
and a exible and pragmatic approach was often endorsed for undertaking these
tasks (Van Ewyk & Kruger, 2017. This study postulated that these equitable and
exible conditions may have been protective against the birthing mothers experi-
encing postpartum depression in their study.
In the same study, although some South African lesbian mothers experienced
postpartum decreases in sexual activity with their partners, they viewed these
decreases as temporary. Socializing with friends also became more difcult, which
was viewed as a necessary sacrice for family-building. Thus, lesbian mothers in
South Africa were subversive by contesting the association of motherhood with
biology given that both birthing and non-birthing partners identied as mothers.
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155
However, some “traditional” motherhood tropes were still observed, such as that of
the self-sacricing mother (Van Ewyk & Kruger, 2017).
In the United States, many sexual minority female mothers experience
heteronormative- based care or homophobia that diminishes their health care experi-
ences (Bushe & Romero, 2017; Gregg, 2018; Juntereal etal., 2020). In fact, some
same-sex couples resort to “crusading” to demand afrming treatment from health
care providers (Hayman etal., 2015). Mothers in same-sex female relationships in
Australia and the United States often use assisted reproductive technologies such as
home or medical intrauterine insemination or in-vitro fertilization for conception,
although some mothers also choose vaginal insemination (Bushe & Romero, 2017;
Gregg, 2018; Juntereal et al., 2020; Power et al., 2020). Sexual minority female
mothers in the United States have been found to often have to educate their health
care practitioners on practices such as “co-nursing” through induced lactation, in
which both the birthing and non-birthing partners nurse the infant (Juntereal etal.,
2020). Co-nursing was found to provide a range of mental, physical, and emotional
benets and profound bonding between the mothers and children.
To date, most countries have not legalized same-sex marriage, so adoption or sur-
rogacy for same-sex couples is still very difcult to pursue. Thus, studies about rela-
tionships between gay or lesbian parents with their own children are few. The relevant
studies mainly seek to answer the question, “Does parental sexual orientation affect
child development?” Stacey and Biblarz (2001) compared development among chil-
dren of divorced lesbian mothers with development among children of divorced het-
erosexual mothers and found few signicant differences. Patterson (2006) also found
that children of lesbian couples and children of heterosexual couples showed no dif-
ference among levels of social competence, behavior problems, and adaption to a new
environment. Wainright and Patterson (2006) reported there were no signicant dif-
ferences between teenagers living with same-sex parents and those living with other-
sex parents on self-esteem, anxiety, school performance, and family relationships. A
study with 93 Chinese girls adopted by single mothers, heterosexual couples, and
lesbian couples (31 girls in each type of family) showed that girls from the three types
of families were not statistically different in behavioral adjustment (Tan & Baggerly,
2009). In this study, the only difference occurred for preschool-aged girls from lesbian
couples who had more somatic complaints than those from single-parent households.
Also, school-aged girls from lesbian couples had more aggressive behaviors than
those from single-parent households (Tan & Baggerly, 2009). Tan and Baggerly
(2009) suggested that the difference might be rooted in the socio-cultural environment
(e.g., children from lesbian couples might experience more prejudice).
6.4.3 Colleague Support
LGB employees tend to experience more challenges in the workplace than hetero-
sexual employees as a result of their sexual identity. First of all, heterosexual
employees do not need to worry about whether and how they disclose their sexual
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156
orientation in the workplace as do LGB employees (Benozzo etal., 2015). There are
three strategies for sexual identity management, including counterfeiting a false
heterosexual identity; avoiding discussing any issues related to sexuality; and
openly acknowledging and advocating for their LGB identity (Button, 2004). First,
a sexual minority individual might apply a different strategy in different workplaces
based on various factors (e.g., the individual’s position in the workplace, the
workplace’s attitude toward LGB issues, the cost and effect of coming out in the
workplace, and the individual’s current mental and nancial status) (Croteau etal.,
2008). Second, LGB employees may worry about their physical and psychological
safety in the workplace (Baker & Lucas, 2017). Third, LGB employees may worry
about their relationships with co-workers and supervisors, such as whether their co-
workers will discover their sexual identity through interactions or tell others in the
workplace (Periard etal., 2018). Usually, a supervisor plays a more important role
in creating an LGB-friendly environment than a co-worker (Periard etal., 2018).
Supervisor support is dened as a type of social support that provides both work-
related instrumental and emotional assistance to employees. In addition, employees
value supervisor over co-worker support because supervisors are perceived as
offering more stability, skill, and experience to employees (Periard etal., 2018).
The ability to be one’s authentic self in the workplace could inuence an
LGBTQ employee’s career success. For instance, a study which is phenomeno-
logical and qualitative in design with 13 MSM interviewees living in South Africa
revealed that the existing prejudices toward MSM in the workplace restricted their
freedom and career development (Soeker etal., 2015). In particular, those MSM
employees working in lower-level positions or those who had less power in their
companies experienced more challenges and had more fear of being transparent in
the workplace (Soeker etal., 2015). However, the same study found that those
participants who disclosed their identity to colleagues and felt accepted and sup-
ported felt free and comfortable in the workplace and were able to fully engage in
their job duties.
In India, workplace attitudes toward employees’ sexual orientation or gender
identity have typically followed a “don’t ask, don’t tell” pattern (Banerji etal.,
2012). However, over the last two decades, India has emerged as one of the most
rapidly developing economies, and thus, numerous multinational companies have
entered the country (Banerji etal., 2012). Those international companies high-
lighted LGBT issues within the workplace. Therefore, managers of companies in
India began to work on creating LGBT-friendly environments, including (1)
ensuring equal opportunity policies for all employees; (2) prohibiting discrimina-
tion based on sexual and gender identity; (3) providing diversity training to
employees and supervisors; (4) establishing and supporting an LGBTQ network
in the workplace; and (5) offering counseling services for any employee, espe-
cially for those who experience harassment in the workplace due to their sexual
and gender identity (Banerji etal., 2012). These changes might lead not only to
safer workplace environments but ones that provide ample social support for
LGBTQ employees.
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157
6.4.4 LGBTQ Elders
A US study dened loneliness as an individual’s subjective experience with a lack
of engagement in human relationships and a lack of physical and emotional support
(Greysen etal., 2013). Loneliness has been found to be associated with an increased
risk of depression, smoking, alcohol consumption, hospitalization, morbidity, and
with a poor level of health-related quality of life and physical and mental health
more broadly (Elovainio etal., 2017; Finlay & Kobayashi, 2018; Greene etal.,
2018; Savikko etal., 2005). It is not surprising that LGBT elders experience more
loneliness than someone who is either not a SM or not an elder (Harley etal., 2016;
Wilkens, 2015). A study in the Philippines with 10 older and single MSM (61years
old and above) found that aging was associated with more discrimination, oppres-
sion, and experiences of abuse (de Guzman etal., 2017). In addition, loneliness
forced them to overcome life challenges by themselves, and they desired to seek
acceptance and belongingness (de Guzman etal., 2017).
In the United States there are several LGBTQ-friendly and LGBTQ-focused
senior retirement communities in cities such as Palmetto (Florida), Palm Springs
(California), Gresham (Oregon), Pecos (New Mexico), and Boone (North Carolina)
(Feltman, 2021). These types of senior housing may not only help combat loneli-
ness for LGBTQ+ older adults but may also provide much-needed material and
social support resources. Examples may include information and access to afford-
able food, health, community, and social activity resources. Studies from several
global regions found that social support was associated with positive physical health
outcomes among older adults (Dai etal., 2016; Smith etal., 2017). Thus, social sup-
port may be especially important for older adults who may be encountering a myr-
iad of health issues due to the aging process.
There is also LGBTQ-friendly senior housing for those who are at risk for home-
lessness and/or living with HIV/AIDS in Hollywood (California) and Chicago
(Illinois) in the United States (Larson, 2016; Wehoville.com, 2021). These types of
senior housing may be especially important for vulnerable LGBTQ+ older adults to
receive material and social support for their housing and health care, as well as their
other needs.
6.5 LGBTQ Communities
6.5.1 Same-Sex Male Communities
In the past, a same-sex male community usually meant a gay village, enclave, or
ghetto within a geographical area containing gay bars, restaurants, or bookstores as
well as gay residents. Examples of such communities are in Chelsea in NewYork
City, USA; Castro in San Francisco, USA; and Davie Street in Vancouver, Canada.
Wow Travel (2021) listed the following cities as the most gay-friendly cities in the
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158
world: Toronto, Canada; São Paulo, Brazil; London, UK; Madrid, Spain; Miami,
USA; Amsterdam, Netherlands; Barcelona, Spain; San Francisco, USA; NewYork
City, USA; Berlin, Germany; and Tel Aviv, Israel. It should be noted that only 2 out
of 11 cities were outside of the Global North. Due to the longer history of develop-
ment and wealth, Global North countries are generally more accepting of LGBTQ
people compared to many Global South countries. Ironically, however, it is the colo-
nization by Global North countries that often introduced homo- and transphobic
laws and norms in many Global South countries (see Victimization and Intentional
Injury chapter, Chap. 9). It is also important to observe that gay cis-gender men are
usually the population that is most visible and active in these gay-friendly cities.
There are gay-friendly places in the Global South, but these might not be as vis-
ible compared to those in the Global North. For example, Rio de Janeiro, São Paulo,
Recife, Salvador, Porto Alegre, Florianópolis, and Brasília are the most LGBTQ-
friendly cities in Brazil (Alface, 2018). Chapinero, Bogotá is a popular and inclu-
sive place in Colombia for local and international LGBTQ tourists to visit its bars,
clubs, and bathhouses (Lifeafar, 2019). The most LGBTQ-friendly district in Cuba
is the tangle of streets around the Malecón, Av de Infanta, and La Rampa on the
cusp of Centro Habana and Vedado (Lonely Planet, 2021). Cape Town, South
Africa, is the undisputed queer capital of Africa with an inclusive culture and com-
munity that grows stronger each year (Matador Network, 2020). Silom Soi 4 and
Silom Soi 2 are the major gay areas in Bangkok, Thailand, which is one of the most
popular gay destinations in Asia (Nomadic Boys, 2021a, b).
In the Chinese gay communities, such as those in Taiwan, Hong Kong, mainland
China, Malaysia, and Singapore, due to the severe level of societal homophobia,
Chinese gay men tend to engage with their own gay groups in order to obtain a sense
of acceptance and belongingness and to buffer the rejections and prejudices from
their families, schools, or workplaces (Lin, 2016). However, the Chinese gay com-
munity is not always cohesive; instead, it is divided into different categories: gay
bear (heavy, hairy, and masculine), gay wolf or hamadryad (muscular, t, and
hypermasculine), and gay twink (who is also called gay monkey in the Chinese
societies and has an effeminate manner, thin build, and no bodily or facial hair, all
of which contributes to a youthful look) (Lin, 2014, 2018). Research has shown that
Chinese gay men sometimes feel secondarily excluded from the gay community
because they might not meet the physical standards of the gay groups they wish to
engage in (Lin, 2016). This causes some men to feel excluded from heterosexual
society because of their sexual orientation and gay society because of their physical
appearance (Lin, 2016). Moreover, Chinese gay men living with HIV, mental or
physical disabilities, and aging issues tend to experience more exclusions than those
without these additional challenges (Lin, 2016).
Although there exist hierarchies and prejudices for men in this example of a
singly ethnic gay community (e.g., the Chinese gay community), gay men living in
ethnically diverse gay communities may also experience challenges. For example,
in Canada, gay Black Canadian men not only experience racism in the greater
Canadian society but also in the gay Canadian community (George etal., 2012). In
one study, some gay Canadian men directly stated “No Asians” in their dating
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159
proles or email responses when they were seeking potential dating partners
(Nakamura etal., 2013). In sum, gay communities may provide belongingness and
support to gay men but, sadly, can also create challenges through various types of
exclusions of certain groups of gay men.
6.5.2 Same-Sex Female Communities
Compared to the gay male community, the lesbian community may be less visible
globally. For example, lesbians in the United States experience higher rates of pov-
erty compared to gay cis-gendered men (17.9% vs. 12.1%, respectively, Badgett
etal., 2019). It also appears to be more of a trend over the last few decades for
younger people in the LGBTQ spectrum who are assigned female at birth (AFAB)
in the United States to take on other types of sexual and gender identities instead of
the identity of lesbian (Schmidt, 2021). Thus, the lesbian community may be dimin-
ishing in numbers since younger AFAB people may not be identifying as lesbian in
equal or higher rates compared to older lesbians passing away.
Jones (2020) mentioned that lesbian groups have historically been marginalized
from women’s and gay men’s movements as well as were excluded from LGBTQ
spaces. In South Korea, although gay and lesbian organizations collaboratively
hosted the rst pride parade in 1999, the lesbians had much fewer physical spaces
for gatherings, especially outside Seoul and outside college campuses (Jones, 2020).
In South Korea, the oldest LGBTQ neighborhood is located in the Jongno District
of Seoul but only provides services for cisgender gay men; also, the second oldest
LGBTQ neighborhood, located in the Yongsan District of Seoul, mainly hosts cis-
gender gay men through the provision of several gay male establishments.
Conversely, only two lesbian-only bars exist in this district (Jones, 2020). Lesbian
bars were a common meeting ground for South Korean sexual minority women to
congregate and build community. The owners of lesbian bars therefore developed
multiple strategies to protect their lesbian patrons. First, the lesbian bar signboards
were often rendered in English to avoid garnering attention from the South Korean
public. Second, while the gay men’s bars were often located on the rst oor, the
lesbian bars were more commonly located on the basement or top oor of a building
to avoid attention. Some lesbian bars coordinated their schedules to remain open
until public transportation resumed in the morning for security reasons (Jones,
2020). It thus appears that owners and employees from different lesbian bars worked
together to ensure the safety of their women patrons from potential harassment and
victimization by cisgender men.
Thailand has a long history of sexual and gender diversity including female spirit
mediums who would adopt masculine identities or make explicit claims to mascu-
linity (Morgan, 1999; Sinnott, 2004). Another tradition is toms and dees, who tradi-
tionally enter into same-sex female romantic relationships with each other. Toms are
transmasculine individuals who do not identity as either women or men, whereas
dees are their feminine partners who do identify as “normal” women (Sinnott, 2004).
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Because heteronormative Thai society does not consider sexual activity between
two anatomically female-bodied people as actual sex, toms have traditionally been
“utilized” to safeguard the virginity of dees. That is, within mainstream Thai cul-
ture, young dees may be encouraged to partner with young toms until the dees reach
marriageable age. The dees are then “released” by the toms so that the dees can
enter into “proper” marriage and sexual unions with cisgendered men (Sinnott,
2004). The dees are considered virgins until marriage because tom/dee unions are
considered asexual, even if these unions include female same-sex activity.
Tom/dee communities are most prevalent in large cities like Bangkok but can
also be found in more rural areas as well. These communities have been found
among various social classes including factory workers, students, urban profession-
als, and even media celebrities (Sinnott, 2004). Anjaree was established in 1986 and
was the oldest advocacy and activist organization for toms, dees, lesbians, and other
sexual minority women. This organization launched a public information campaign,
sponsored workshops and seminars to educate academics and the public on sexual
rights, held social events, and promoted the terms “women who love women” and
“same-sex love” in Thailand (Sinnott, 2004).
Lesla was established in 2000 and seems to be currently still viable focusing on
urban middle-class female-bodied people and, in particular, on young toms and
dees. It was rst founded as an online club but also organizes parties at bars and
discos in Bangkok. The focus of this organization is social and does not sponsor
educational or political events or initiatives. When Anjaree was still viable, many
people were members of both Anjaree and Lesla and both organizations provided
open forums on the gender roles of toms and dees (Sinnott, 2004). There have also
been nationwide social events, such as Mr. Tom Act, which was a talent show that
attracted tom participants—and their dee admirers—across the country (Coconuts,
2015). It is probable that the gender forums that Anjaree and Lesla provided allowed
for members to explore departures from and derivations of the traditional tom/dee
gender roles. New roles and identities such as one-way, two-way, tom gay, les king,
and les queen are currently in use among sexual and gender minority anatomically-
female communities in Thailand (Coconuts, 2015).
Mitini Nepal (2021) is a Nepalese NGO focused on women with lesbian, bisex-
ual, and transgender identities. According to Mitini Nepal (2021), several programs
and services are offered including lobbying and advocacy, awareness and sensitiza-
tion, provision of skill development and income-generating training, leadership
development and human rights training, and psychological and legal counseling.
Some of these initiatives focus on various sectors of Nepalese society such as utiliz-
ing street dramas, cultural programs, posters, and pamphlets to educate the public as
well as impacting institutions such as schools, colleges, government stakeholders,
and police. Increasing awareness in schools and colleges, among governmental of-
cials, and throughout the general public could greatly augment access to resources
and support for sexual minority women and transgender people throughout various
sectors of Nepalese society.
In the United States, a study of butch/femme lesbian participants suggested that
femme lesbians might be afraid of not being desired by women and not being
C. Lin and S. J. Hwahng
161
recognized as lesbians, whereas butch lesbians might be afraid of being rejected by
potential partners and mistaken for males (Hiestand & Levitt, 2005). Butch/femme
identities have a relatively long history in the United States and can be traced from
the early twentieth century (Kennedy& Davis, 1993; Faderman, 1992). In one piv-
otal study based on 45 oral histories, the evolution of a working-class community of
both Black and White butch/femme lesbians in upstate NewYork in the United
States was examined from the 1930s to the 1960s (Kennedy& Davis, 1993). In
these more politically repressive times in the United States, these lesbians had to
develop several ways to resist various forms of hostility and oppression, including
sometimes getting involved in physical altercations with cisgendered men. These
women were nancially independent, working at their own jobs (instead of being
nancially dependent on cisgendered men). These lesbians often met other lesbians
in bars, and lesbian bar culture was thus prominent during these decades. The public
spaces of bars, however, could not be taken for granted, and these lesbians often had
to assertively claim and maintain these public spaces for the continual existence of
these meeting grounds. Women in this community also supported and encouraged
each other to actively resist heteronormative coercive forces. It is thus believed that
this community was one of the roots of the more recent US gay and lesbian libera-
tion social movement (Kennedy& Davis, 1993).
In one US-based sexual minority women’s online magazine, Kim (2019) listed
the best lesbian-friendly cities. The cities were evaluated based on the Municipal
Equality Index, calculated from the quality of non-discrimination laws, services,
and leadership, and the LGBTQ population density, based on the Gallup survey.
What can be inferred is that a mixture of equality laws, ample service provision, and
prominent LGBTQ+ communities can comprise a supportive matrix in which lesbi-
ans can thrive. The highest-ranked cities included the following: Austin, Texas; New
Orleans, Louisiana; Portland, Oregon; Tampa, Florida; Louisville, Kentucky;
Columbus, Ohio; Atlanta, Georgia; and Denver, Colorado.
Senior retirement communities also exist for older sexual minority women,
including lesbians. Discovery Bay Resort in Washington State is a recreational vehi-
cle (RV) community located on the North Olympic Peninsula (Feltman, 2021). The
Resort in Fort Myers, Florida, encompasses 50 acres with over 250 homes and RV
lots and offers many activities for its residents (Covelloin, 2021). As noted above, it
is important for older adults, including older sexual minority women, to access cru-
cial material and social support resources. Access to these resources may become
even more dire due to the health effects of aging. These retirement communities
may thus provide a “safety net” for older sexual minority women by providing
companionship, information, and access to resources.
6.5.3 Bisexual Communities
Bisexual groups include those who identify as bisexual, men who have sex with
men and women (MSMW), women who have sex with men and women (WSMW),
pansexual, omnisexual, biromantic, polysexual, and sexually uid. Bisexuals seem
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to be divided into two groups—those who are “out” with regard to being bisexual
and those who are not.
Numerous “out” bisexual communities exist globally, including many that orga-
nize communities online. For example, Bi-Sides (2021) hosts a cyberspace for
bisexual people in Brazil and is actively working against biphobia in the Brazilian
society. Toronto Bi+ Network (2021) offers peer support, social networks, informa-
tion, and resources to support the community of bisexuals, pansexuals, omnisexual,
two-spirit, uid, and people questioning their sexuality and is committed to operat-
ing within an anti-oppression framework, such as biphobia, transphobia, homopho-
bia, ableism, racism. There also exist some bisexual groups on social media such as
the Bi Collective Delhi (2021) on Twitter for Indian bisexual people and BiQuPan
(2021) on Facebook for Swedish bisexual people.
In contrast, men who are not “out” about their bisexual activities are often termed
“non-disclosing” in research studies. Arena and Jones (2017) explained that bisex-
ual persons were less likely to disclose their sexual orientation publicly as compared
to gay and lesbian persons because of the potential negative views toward bisexual-
ity from heterosexual, gay, and lesbian groups. Non-disclosing bisexual MSM are
often characterized as a hard-to-reach population with no discernable SGM com-
munity afliations. Some of these men will identify as heterosexual or will have no
sexual orientation identication and have been identied as a potentially high-risk
HIV population (Millett etal., 2005; Siegel etal., 2008; Siegel & Meunier, 2019).
6.5.4 Transgender andNon-binary Gender Communities
Although in the Global North, it may appear that trans and non-binary gender com-
munities are relatively new, there are several cultures in Mexico, Thailand, India,
South Africa, the Middle East, and Polynesia in which trans and non-binary gender
identities have existed for hundreds or even thousands of years (Gannon, 2007;
Gibson, 2002; Herdt, 2020; Mirandé, 2017; Morris, 1994; Mujtaba et al., 1997;
Reddy, 2005). In some countries and regions such as Thailand, South Africa,
Mexico, and North America, both transfeminine and transmasculine people existed
as part of the historical traditional cultures (Gibson, 2002; Gosling & Osborne,
2000; Lang, 1998; Morris, 1994; Roscoe, 1998). These identities that come from
historical traditions in the Global South often have non-binary gender characteris-
tics and these identities are often considered a third or fourth sex rather than transi-
tioning from one side of a gender binary to the other (Herdt, 2020; Hwahng, 2011;
Morris, 1994; Sinnott, 2004). Despite this history, transfeminine communities in the
Global South, in particular, are highly marginalized, and a large number of trans-
feminine people live in poverty and engage in survival sex work (Gannon, 2007;
Kulick, 1998; La Fountain-Stokes, 1998; Nuttbrock, 2018).
One exception to the extreme forms of marginalization and coerced sex work
that many transfeminine people encounter in the Global South is the transfeminine
muxes in the Oaxaca district of Mexico (Finkler, 2008; Gosling & Osborne, 2000;
C. Lin and S. J. Hwahng
163
Mirandé, 2017). Muxes are considered part of traditional indigenous Mexican soci-
ety but do not have to engage in survival sex work because of their relatively higher
societal acceptance and integration into the larger Zapotec society. They are thus
able to engage in other types of occupations within the legal work economy includ-
ing working as beauty salon owners, NGO staff, local politicians, and lawyers.
Muxes also host large traditional festivals (velas) that are well attended by the gen-
eral community and consecrated by the local Catholic church as well as engaging in
muxe-specic support groups (Mirandé, 2017).
There is also an active global transgender or “trans*” community presence
online. For example, TransWorldView is comprised of blog posts written by Kayley
Whalen, a transfemale activist who actively travels in Asia and writes about the
diversity of transgender communities she encounters (Whalen, 2021). She was also
selected in 2020 to represent Miss USA in the Miss International Queen pageant in
Thailand, which is the world’s most prestigious transgender beauty pageant. In gen-
eral, transfeminine communities appear to be more visible globally compared to
transmasculine communities. Although speculative, it is interesting to note that
there may be some parallels between the greater visibility of gay men among the
cis-gendered sexual minority communities and the greater visibility of transfemi-
nine people among the gender minority communities. Over the last few decades,
there has been a marked increase in trans visibility, resulting in legislative changes,
marches, and media visibility (Flores & Sutterman, 2020).
6.5.5 Biphobia andTransphobia inLesbian/Gay Communities
Socially and politically, LGBTQ groups work together to protest anti-LGBTQ poli-
cies and confront anti-LGBTQ groups. However, bisexual and transgender/gender
non-binary individuals are usually marginalized in the merged community com-
posed of all sexual and gender minorities. Moreover, studies related to the bisexual
and transgender/gender non-binary communities are lacking. A study with 69 cis-
gender bisexual men and 21 cisgender bisexual women in France reported the exis-
tence of biphobia in either gay or lesbian communities; moreover, the bisexual
participants reported they were stereotyped as disloyal partners in same-sex rela-
tionships because they have interest in more than one gender (Welzer-Lang &
Tomolillo, 2008). The lack of inclusion of MSM and non-cisgender individuals in
gay communities has also been documented in Taiwan, Hong Kong, mainland
China, Malaysia, and Singapore (Lin, 2016). A study with 112 male-to-female
(MtF) individuals in Thailand found that the participants were excluded from the
heterosexual society and lesbian/gay groups because of their job types (most were
sex workers) and the high rate of HIV within the transgender population in Thailand
(Nemoto etal., 2012). A US study with six cisgender gay males and ve cisgender
lesbian female participants found that the inexperience of some gay and lesbian
participants led them to feel uncomfortable being around transgender people
because of the lack of familiarity (Nagoshi etal., 2017).
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6.5.6 Intersex Communities
Compared to other sexual and gender minority groups, the intersex community is much
less invisible and has less access to relevant information and resources. Organization
Intersex International (2021) is a decentralized global network of intersex organizations
from various countries and regions of the world. For instance, Organization Intersex
International Austria (2021) provides counseling services for intersex people in Austria
and training for people who work for this population, and Organization Intersex
International Chinese (2021) advocates for human rights for intersex people in Taiwan
and promotes education to raise awareness about this population. There are also some
cyberspaces for intersex people in the Philippines (OII InterSex Philippines Inc, 2021)
and Latin America (Organización Internacional Intersexual– Hispanoparlante, 2021).
Intersex Asia (2021) on Facebook is the rst regional network established by Asian
intersex activists and organizations advocating intersex human rights.
6.5.7 Asexual/Aromantic Communities
Asexual (ace) and aromantic (aro; and derivations including greysexual/romantic and
demisexual/romantic) communities are the most recently visible communities within
the LGBTQ spectrum (Aces and Aros, 2021). There is still debate whether ace/aro
communities should be included in the LGBTQ spectrum (Kelsey, 2017). A good
introduction to ace and aro identities is provided by the Asexual Visibility and
Education Network’s website (2020), which hosts the world’s largest online asexual
community as well as an archive of asexuality and aromantic resources. An interna-
tional network of asexuality organizers has also been organizing “Ace Week” since
2010 as an awareness campaign to encourage LGBTQ orgs to support the ace com-
munity (Ace Week, 2021). One major campaign run by this network is to change the
Diagnostic and Statistical Manual so that asexual and aromantic identities are com-
pletely depathologized. This group was able to advocate for partial depathologization
in the DSM-5, however, this group is still advocating for complete depathologization.
The Ace Week site also lists community events from Australia, India, and various
regions of the US Indian Aces (2021) is a collective of, for, and by ace and aspec
(asexual spectrum) people from/in India. This organization offers a series of work-
shops and events on gender and sexual diversity including asexuality and LGBTQIA+
identities. The collective is also involved in research and advocacy.
6.5.8 Online Communities andSocial Media
In most LGBTQ communities within LMICs, members tend to hide their sexual and
gender identity in public and, thus, would tend not to live in an LGBTQ village,
enclave, or ghetto. Instead, LGBTQ online communities offer opportunities for
C. Lin and S. J. Hwahng
165
connection and social support, such as those on Facebook, Twitter, and Instagram as
well as dating apps (e.g., Grindr (for gay men), Scruff (for gay men), GROWLr (for
gay men, especially bears), Her (for lesbians), Bumble (for lesbians), TS Dates (for
transgender individuals)). These online communities allow LGBTQ individuals to
meet their interpersonal, intimate, and sexual needs quickly and conveniently.
In general, there do not seem to be active online lesbian communities in the
Global South that are separate from larger LGBTQ organizations and communities
tied to specic geographic locations. One network that stands out is the
Eurocentralasian Lesbian Community (ELC) (2021), which is an NGO advocating
for lesbian rights in Europe and Central Asia. In early 2021, ELC disseminated a
survey about the impact of COVID-19 on lesbians in Europe and Central Asia as a
way to assess the state of these lesbian communities in these specic regions of the
world. ELC also offers emergency grants for lesbian-led and focused groups and
promotes lesbian politicians.
A recent study also found a fairly large and fast-growing gay Mandarin-language
cybercommunity on Facebook in Asia (Lin, 2018). For some LGBTQ individuals,
however, having an online presence requires them to mask their true identity in one
prole and to be “out” in another prole. This approach was documented in a study
of Taiwanese gay men (Lin, 2018).
6.5.9 Religious andSpiritual Groups
Religious and spiritual groups can also offer support to LGBTQ individuals. For
example, the Reformation Project is a Bible-based ecumenical organization inclu-
sive of Protestant, Catholic, and Orthodox Christians. Its mission is to advance
LGBTQ inclusion in the Church (The Reformation Project, 2022). Another example
is the Good Hope Metropolitan Community Church (GHMCC) in South Africa,
which stands in solidarity with LGBTQ individuals to ght for human rights and be
a voice for social justice (Potgieter & Reygan, 2011). Comunidad San Elredo is a
gay Catholic youth group started in Mexico in 2007 to support such youth (Agren,
2007). The conservative Christian denomination Seventh Day Adventists (SDAs)
are considered the most racially diverse religious group in the United States (Lipka,
2015). Although ofcially the SDA Church does not accept LGBTQ+ behaviors and
lifestyles, there is an international network of current and former SDAs who have
organized as Seventh-Day Adventist Kinship International (2021). This organiza-
tion has branches in South America, Europe, and other international sites and offers
alternative faith-based programming and resources that are inclusive of and sup-
portive to LGBTQ+ people (Seventh-Day Adventist, 2021).
In Judaism, the Reform Movement (the largest Jewish denomination in the
United States) has been leading the inclusiveness of LGBTQ individuals in syna-
gogues and Jewish communities more broadly, including the acceptance of LGBTQ-
identifying rabbis and acknowledgment of same-sex Jewish marriages (Human
Rights Campaign Foundation, 2022b). Keshet is an LGBTQ Jewish organization
6 Community andSocial Support
166
based in the United States that works for the full equality of all LGBTQ Jews and
families in Jewish life (Keshet, 2022).
While many religions enact rules about sexual behavior, Buddhist attitudes
toward LGBTQ people are often a reection of culture rather than Buddhist phi-
losophy, and Buddhism is generally socially liberal and welcoming to LGBTQ
members (Atwood, 2019). For example, Ven. Shih Chao-Hwei, a Taiwanese
Buddhist master, was awarded the 38th Niwano Peace Prize in 2021 and has been a
vocal supporter of same-sex marriage and ofciated the rst Buddhist same-sex
wedding for a lesbian couple in Taiwan in 2012 (Lewis, 2021; Lieblich, 2020).
Paganism was originally a polytheistic religion from ancient Europe that has
been adopted by many LGBTQ+ people globally in contemporary times. The con-
temporary form is sometimes viewed as modern/post-modern paganism, may
involve witchcraft, and has attracted people across the LGBTQ+ spectrum (Gay in
the CLE, 2021; “Gay Pagan Men,” 2021). Informed by paganism as well as New
Age spirituality, the Radical Faeries originated in the 1970s as a gay male move-
ment combining queer liberation and secular spirituality that has since grown into a
worldwide network encompassing a variety of genders and sexual identities. The
Radical Faeries often organize gatherings and environmentally sustainable rural-
based sanctuaries (Baume, 2021).
6.5.10 BDSM/Leather andPolyamory Communities
Finally, within the LGBTQ community exist subcultures that are considered the
radical fringe. One such subculture is the BDSM community, which stands for
bondage, discipline, and sado/masochism play. BDSM emphasizes power exchange
between consenting adults in which role-playing and physical and/or psychological
stimulation or manipulation is often involved (Ullmann, 2015). In 2013, the
American Psychiatric Association depathologized BDSM as a mental disorder in
the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (National
Coalition for Sexual Freedom, 2021). While individuals interested in BDSM come
from all genders and sexualities, many BDSM community members identify
as LGBTQ.
Despite its depathologization, organized BDSM communities seem to only exist
in the Global North. For example, there are annual International Ms./Mr. Leather
and International Ms./Mr. Bootblack contests held in the United States that have
attracted thousands of people, many of whom identify within the LGBTQ+ spec-
trum (IMSLBB, 2021; International Mr. Leather, 2021). Another organization is
Women of Drummer, which hosts several regional parties all over the United States
(Women of Drummer, 2021) as well as an annual camping weekend in Maryland,
USA.SISC is located on a farm in Denmark and hosts international BDSM weeks
for the LGBTQ+ community (SISC, 2021). One week is set aside specically for
queer, women, lesbian, trans, and intersex people, and a few weeks are reserved for
gay men.
C. Lin and S. J. Hwahng
167
Although there do not appear to be specic LGBTQ+ polyamory communities,
many polyamory communities include members who identify within the LGBTQ+
spectrum, BDSM/Leather communities, and/or have uid gender identities or sex-
ual orientations (The Polyamory Society, 2021). An annual retreat for members of
polyamory communities is held in the United States (Loving More, 2021).
6.5.11 Other Support Groups
Besides the other categories of social support delineated in this chapter, there are
also a variety of groups that offer support and resources for other types of LGBTQ
subpopulations such as those living with HIV, youth, seniors, and people with dis-
abilities. For an example regarding people living with HIV (PLWHIV), the Taiwan
Lourdes Association works on HIV prevention and human rights and quality of life
among PLWHIV, provides group and individual counseling services for PLWHIV,
and helps build up support groups for PLWHIV (Taiwan Lourdes Association,
2019). For an example about the youth group, CamASEAN Youth’s Future in
Cambodia aims to combat societal discrimination on LGBTQ youth and to build up
support groups for them (CamASEAN Youth’s Future, 2019). For an example
regarding LGBTQ seniors, Indiapink provides the customized and leisure travels
for LGBTQ seniors in India in order to improve their social interaction and well-
being (Indiapink, 2019). For an example about disabilities, the Disabled+Queer in
Taiwan works on the human rights and well-being of LGBTQ individuals living
with (Disabled+Queer, 2019).
6.5.12 LGBTQ-Related Organizations
LGBTQ-focused organizations also play important roles for LGBTQ individuals.
They aim to provide social support, hold local LGBTQ pride events, collect health-
related resources including counseling services and medical care, build up Parents,
Families and Friends of LGBTQ+ (PFLAG) groups, and improve the LGBTQ-
related policies (e.g., anti-discrimination, marriage equality, and gender change).
PFLAG was founded in 1973 and has over 400 chapters and 200,000 members in
both urban and rural areas of the United States (PFLAG, “About PFLAG,” 2021a).
Although the “ofcial” PFLAG is only afliated with the United States, also known
as “PFLAG National,” they have granted permission to some international organiza-
tions and activists to also utilize the PFLAG name. Thus, organizations in Australia,
Belgium, Canada, China, France, Israel, Italy, Japan, Jamaica, Mexico, New
Zealand, Portugal, South Africa, Spain, Switzerland, the United Kingdom, and
Vietnam also utilize the PFLAG moniker (PFLAG, “International Focus,” 2021b).
Human rights are a large focus of many global LGBTQ+ human rights organiza-
tions. The International Lesbian, Gay, Bisexual, Trans, and Intersex Association
6 Community andSocial Support
168
(ILGA) (2021) is a leading organization and global voice for the rights of those who
face discrimination on the grounds of sexual orientation, gender identity, gender
expression, and/or sex characteristics.
Outright Action International (OAI; formerly International Gay and Lesbian
Human Rights Commission) focuses on advocacy, movement resourcing, and
research. OAI has spearheaded a number of important international cases resulting
in legal and policy wins for LGBTQ+ rights around the world. OAI has also incu-
bated several LGBTQ+ organizations in the Global South as well as provides train-
ing and support to Global South and BIPOC activists. OAI has also produced
hundreds of reports and brieng papers, sponsored a webinar, video, and podcast
series, and in December 2020 hosted the OutSummit LGBTIQ human rights confer-
ence, bringing together 1600 people from 100+ countries (Outright Action
International, 2021).
Astraea: Lesbian Foundation for Justice is a public foundation based in NewYork
City in the United States that raises and distributes funds to programs and initia-
tives, prioritizing those led by lesbians, queer women, transgender and gender non-
conforming people, intersex people, and people of color. Aside from philanthropic
ventures, Astraea is also involved in media and communications awareness cam-
paigns, capacity building, and leadership development (Astraea, 2021).
There are also a variety of locally-focused LGBTQ organizations based in the
Global South: Nouakchott Solidarité Association in Mauritania (aims to improve
human rights for LGB communities, people living with HIV, and women); the
Iranian Lesbian and Transgender Network (aims to improve human rights for les-
bian and transgender people); and Bedayaa in the Nile Valley Area (works to pro-
mote the acceptance of homosexuality in Egypt and Sudan and helps LGBTQI
people to live a life free of discrimination or stigma) (The International Lesbian,
Gay, Bisexual, Trans and Intersex Association, 2021). Other Global South-based
organizations include Comunidad Homosexual Argentina (2021), ADESPROC
Libertad GLBT (2021) in Bolivia, Quality of Citizenship Jamaica (2021), Guyana
RainBow Foundation (2021), and AZAD LGBT (2021) in Azerbaijan. It is impor-
tant that local, regional, and global LGBTQ-focused organizations continue to
ourish to provide much-needed information, support, guidance, and resources to
LGBTQ+ people and communities throughout the world.
6.6 Conclusion
LGBTQ populations experience minority stress, especially those who live in LMICs
or the Global South. Their stress may be amplied by inadequate access to health
services, nancial challenges, few educational resources, and the limited capacity of
their governments to solve social problems. Therefore, it is important for LGBTQ
individuals to receive social support from their families (biological or chosen) and
communities. In this chapter, we discussed support from parents, siblings, teachers,
partners, and colleagues. We also discussed support provided during other life
C. Lin and S. J. Hwahng
169
stages, such as parenthood and elderhood, and by religious and spiritual connec-
tions. We explored worldwide LGBTQ+ communities, including those in physical
spaces and those online. We discussed the impact of biphobia and transphobia in
lesbian and gay communities. Lastly, we provided rich information about global,
regional, and local LGBTQ-related organizations throughout the world, including
organizations focused on specic LGBTQ subpopulations. As demonstrated in this
chapter, there is seemingly an abundance of LGBTQ community and social support
institutions, organizations, networks, and resources. The challenge is not only to
augment access to the already existing institutions, organizations, and resources, but
to continue building additional community and social support institutions, organiza-
tions, networks, and resources so that all sectors of the LGBTQ population can be
well-served.
6.7 Case Study: South African LGBTQ Communities
andSocial Supports
South Africa has been a democracy since the end of apartheid in 1994 and has con-
tinually worked on addressing the legal rights of lesbian, gay, and bisexual people
(Nel, 2014). Act No. 108 of 1996in the South African Constitution enshrines the
right to non-discrimination on the basis of sexual orientation. South Africa was the
rst country in the world to include this ban on discrimination based on sexual ori-
entation in their constitution (Outright International, 2022). Since then, South Africa
legalized same-sex marriage in 2006 (Brouard & Pieterse, 2012).
However, this progression in legislation has not eliminated the societal discrimi-
nation toward sexual and gender minority populations in the country. Lesbian, gay,
bisexual, transgender, and queer (LGBTQ) people in South Africa continue to expe-
rience high levels of violence, abuse, homophobia, and discrimination in their fami-
lies and certain public social spaces and challenges accessing basic services
including education, health care, and legal justice (Francis & Msibi, 2011; Haffejee
& Wiebesiek, 2021; Olney & Musabayana, 2016; Reygan & Lynette, 2014; Smuts,
2011; Van Zyl, 2015). For example, in a nationally representative study conducted
in 2015, 72% of those surveyed indicated they believed that same-sex relationships
are morally wrong, and only one in ten participants said they believed someone’s
sexual orientation was something they acquired from birth (Brouard etal., 2016).
Sexism and racism also often exist within LGBTQ communities in South Africa.
In 1995, gay identity in South Africa was used to refer almost exclusively to White
middle-class urban men (Gevisser & Cameron, 1995). Williams (2008) indicated
that racial segregation continued to exist in queer social spaces in Cape Town and
noted that the gay areas in the city were most frequented by White gay men, while
Black gay men and Black lesbian women were situated in the townships on the
periphery of central Cape Town. Also, gendered boundaries served to exclude
lesbian women from male-dominated gay social spaces, leading to the invisibility of
6 Community andSocial Support
171
Black lesbian women in queer social spaces in South Africa at large (Stephens &
Boonzaier, 2020). Interestingly, Black LGBTQ organizations were understood to
have political agendas that were rooted in their experiences of class and race oppres-
sion, while White LGBTQ organizations were described as having social agendas
rooted in classism and material privilege (Stephens & Boonzaier, 2020).
While White LGBTQ people may experience privilege compared to their Black
counterparts, they are still marginalized in South African society as a whole. As a
result of prejudice, stigma, and discrimination from both outside and within queer
spaces, LGBTQ people in South Africa experience a range of mental health chal-
lenges such as depression, anxiety, post-traumatic stress disorder, substance use
disorder, and suicidal ideation (Polders etal., 2008; Theuninck, 2000; Wells, 2006).
However, despite experiencing continued societal discrimination, resilience also
exists in LGBTQ populations (Haffejee & Wiebesiek, 2021). One example comes
from understanding that despite the challenges they face, the LGBTQ community in
South Africa continues to explore and welcome gender and sexual uidity. Fixed
gender roles are being challenged, and gender uidity is welcomed in the gay male
community (Henderson, 2018). Additionally, cisgender gay men also purportedly
have relationships and engage in sexual practices with transgender men as well as
intersex men, demonstrating their expanding understanding and celebration of vari-
ous gender identities (Henderson, 2018).
Because of the continued hardships LGBTQ people face in South Africa, as well
as to foster their resilience and build a sense of community, LGBTQ-focused social
support organizations have been created. Their overall goal, as in many countries, is
to support this population through education, service provision, health care,
strengths-building practices, and more. One example of such an organization is
Triangle Project. Triangle Project is one of the largest LGBTQI (“I” being intersex)
organizations in the country, offering a wide range of services to a diverse and grow-
ing community. Triangle Project provides mental health services, a medical clinic,
a mobile clinic, home-based care, solidarity spaces, and support groups. Triangle
Project seeks to foster community engagement and empowerment, explorations of
sex, attraction, and gender through solidarity and support groups, and political lead-
ership and activism, while addressing intimate partner violence, hate crimes, and
alcohol and drug use. Clientele includes people living with HIV, refugees, migrants,
LGBTQI youth and adults, and parents of LGBTQI children (Triangle Project, 2022).
Triangle Project has a long history of supporting LGBTQ communities in South
Africa. Its origins are in an organization called the Gay Association of South Africa
(GASA) 6010, which was established in 1981. GASA 6010 provided counseling
and medical services and a telephone hotline starting in 1982. It was one of the rst
organizations in South Africa to respond to the HIV/AIDS crisis, assisting with
prevention initiatives in gay bars and clubs in 1984. AIDS Support and Education
Trust (ASET) was established as part of GASA 6010in 1989, and ASET and the
counseling service became independent from the parent organization in 1994. In
1996, GASA 6010 changed its name to Triangle Project to reect the multi-faceted
nature of its services. Triangle Project then established the rst gay and lesbian
health project in a Black African township in Cape Town.
6 Community andSocial Support
172
Another organization doing important work to support the LGBTQ community
in South Africa is OUT LGBT Well-Being, the second-oldest LGBT organization in
the country (OUT LGBT Well-Being, 2022). It began in 1994 and is a professional
services organization and a member organization of the International Lesbian and
Gay Association (ILGA). OUT LGBT Well-Being’s work takes place on local,
provincial, national, continental, and international levels, and its focus areas are
direct health and mental health services, research, training, advocacy, and other
forms of support. Since 2006, OUT LGBT Well-Being has been particularly active
in advocacy, and past efforts include same-sex marriage, victim empowerment, hate
crimes mitigation, and advocating for the Sexual Offenses Act. Current advocacy
work by OUT LGBT Well-Being focuses on HIV and hate crime legislation. The
organization has played a major role in securing an LGBT Sector within the South
African National AIDS Council. As a member of African Men for Sexual Health
and Rights (AMSHeR), this organization actively promotes the interest of men who
have sex with men on the continent.
In summary, while South Africa has multiple legal protections for LGBTQ
people, there are still societal barriers to equality and equity for these populations.
Organizations like Triangle Project and OUT LGBT Well-Being work tirelessly to
improve the lives of LGBTQ people in South Africa. Support for these organiza-
tions and continued research into ways to encourage LGBTQ people to thrive are
key to continuing to positively impact LGBTQ people in South Africa.
Acknowledgments We are grateful to Chi-Chun Lin and Alicia T.Bazell for writing the case
study on South Africa.
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S. J. Hwahng, M. R. Kaufman (eds.), Global LGBTQ Health, Global LGBTQ
Health, https://doi.org/10.1007/978-3-031-36204-0_7
Chapter 7
HIV/AIDS Among Sexual andGender
Minority Communities Globally
S.WilsonBeckham, JenniferGlick, JowannaMalone, AshleighJ.Rich,
AndreaWirtz, andStefanBaral
7.1 Introduction
This chapter describes the impact HIV/AIDS has had on sexual and gender minority
(SGM) communities globally. Research challenges specic to SGM communities
related to HIV/AIDS are discussed, including research ethics; strategies for enu-
meration, recruitment, and sampling; and cross-cultural issues. We discuss the dis-
proportionate risks and vulnerabilities facing certain SGM groups, focusing on
intersecting structural, interpersonal, and individual-level risk factors, and high-
lighting some differences in regional contexts. We include promising HIV/AIDS
interventions for SGM populations at structural, interpersonal, and individual lev-
els. We also discuss chronic disease among SGM people living with HIV.Finally,
S. W. Beckham (*) · J. Glick
Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns
Hopkins University, Baltimore, MD, USA
e-mail: s.wilson.beckham@jhu.edu; jglick5@jhu.edu
J. Malone
Exponent, Inc., Washington, DC, USA
e-mail: Jmalon@whitman-walker.org
A. J. Rich
Center for Health Equity Research, University of North Carolina, Chapel Hill, NC, USA
e-mail: ajrich@med.unc.edu
A. Wirtz
Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University,
Baltimore, MD, USA
e-mail: awirtz1@jhu.edu
S. Baral
Department of Epidemiology, Division of Infectious Disease Epidemiology, Bloomberg
School of Public Health, Johns Hopkins University, Baltimore, MD, USA
e-mail: sbaral@jhu.edu
184
we point out major gaps in knowledge about SGM communities and explore future
directions for HIV research and practice for SGM people globally.
The key assumption underlying this chapter is that there are diverse sexual orien-
tations and gender identities among populations everywhere; there is no evidence of
regional or geographic absence of such diversity. We also know of no methodologi-
cally sound data that suggests that there are regional differences in why people
choose to have or not have consensual sex in terms of procreation, pleasure, and or
needs (e.g., transactional sex to meet material needs). However, there are regional
differences in the nomenclature used to describe SGM people as well as how sexual
orientations and gender identities are expressed outwardly (Reisner etal., 2016b).
Moreover, there are regional differences in the existence of punitive and protective
laws, general social acceptance, and celebration or condemnation of sexual and
gender diversity. Further, what does vary is the level of need, access to education
and commodities, and the prevalence of HIV or community viral load in sexual
networks. Taken together, drivers of HIV epidemics have little to do with individual
behaviors. That is, globally, individual sexual behaviors do not vastly vary, while
HIV incidence does; therefore, the differing HIV rates cannot be explained by indi-
vidual sexual behaviors alone. Rather, these health outcomes are the result of inter-
secting structural, social, and network-level determinants.
7.1.1 Subpopulations
When considering HIV among SGM people, the sub-populations with the highest
HIV risks are gay, bisexual, and other cisgender men who have sex with men
(MSM), and transgender women who have sex with cisgender men.1 In turn, most
available data are about those two groups, as is most of the discussion in this chap-
ter, but other SGM people are also at risk in certain circumstances.
7.1.1.1 Sexual Minority Men
Gay, bisexual, and other cisgender MSM (many of whom do not identify as gay or
bisexual) face substantial risk for HIV due to a variety of biological and socio-
structural factors. A meta-analysis from 2012 found pooled prevalence ranging
from 3.0% in the Middle East to 25% in the Caribbean, with vastly increased odds
of living with HIV compared to other men of reproductive age, even in countries
where the HIV prevalence is high in the general population (see Fig.7.1) (Beyrer
etal., 2012a). Subsequent meta-analyses demonstrated persistently high HIV inci-
dence among MSM (Beyrer etal., 2016).
1 Some transgender women only have sex with cisgender women, or are not sexually active at all,
and are thus at low risk for sexually transmitted infections, including HIV.Sexual orientation may
also be race-stratied, see Hwahng & Nuttbrock, 2007, for more information.
S. W. Beckham et al.
185
Fig. 7.1 Global HIV prevalence in MSM (2007–2011). (Beyrer etal. 2012a, b). (Reprinted from
The Lancet, Vol 380, Beyrer, C., Baral, S.D., van Griensven, F., Goodreau, S.M., Chariyalertsak,
S., Wirtz, A.L., and Brookmeyer, R.Global epidemiology of HIV infection in men who have sex
with men; Figure2, Page 370, Copyright 2012, with permission from Elsevier)
Fig. 7.2 Global prevalence of HIV in transgender women (2000–2011). (Baral etal. 2013a, b).
(Reprinted from Lancet Infectious Diseases, Vol 13, Issue 3; Baral, S.D., Poteat, T., Strömdahl, S.,
Wirtz, A.L., Guadamuz, T.E., Beyrer, C.Worldwide burden of HIV in transgender women: A sys-
tematic review and meta-analysis; Figure3, Page 219; Copyright 2013, with permission from
Elsevier)
7.1.1.2 Transgender Women andOther Transfeminine People
Transgender women and other transfeminine people (e.g., nonbinary and other people
who were assigned male at birth but do not identify as men) who have sex with men are
consistently more greatly affected by the HIV epidemic than any other population,
including cisgender MSM (Reisner etal., 2016b). In a 2013 meta- analysis, the pooled
prevalence of HIV among over 11,000 transgender women was 19.1% worldwide, and
17.7% in low- and middle-income countries (LMIC). Transgender women had 49
times higher odds of having HIV than the general population (see Fig.7.2) (Baral etal.,
7 HIV/AIDS Among Sexual andGender Minority Communities Globally
186
2013b). However, data were limited and restricted largely to the USA and Asia-Pacic
countries; few studies were in Latin America and Europe, and no studies in that review
were in Africa or the Middle East. A more recent global systematic review found HIV
prevalence varied by geography but reported a consistently higher prevalence among
transfeminine people worldwide, ranging from 4% to 40% (Poteat etal., 2016). Again,
there were geographic gaps in the systematic review, with no studies from sub-Saharan
Africa nor the Eastern Europe/Central Asian region. A more recent study that included
cross-sectional data from eight countries in Africa found a 25% HIV prevalence among
transgender women, which was a 2.2 times greater odds ratio in adjusted analysis com-
pared to their cisgender MSM counterparts (Poteat etal. 2017a, b).
7.1.1.3 Transgender Men andOther Transmasculine People
Other SGM people, such as transmasculine people and sexual minority women
(SMW) who have sex with cisgender men or transgender women,2 while not as
affected by the HIV epidemic as MSM and transgender women, can also face risk
of HIV, given structural factors such as violence, stigma, and discrimination. There
has been little attention to transgender men and other people on the transmasculine
spectrum (e.g., nonbinary and other people who were assigned female at birth and
do not identify as women), but transmasculine men who have sex with cisgender
men may be at risk for HIV.What little data there are (all from the United States and
Canada) show elevated rates of HIV and HIV-related risk behaviors (Appenroth
etal., 2021; Becasen etal., 2019; Poteat etal., 2017a; Reisner etal., 2016b; Scheim
etal., 2017). In the absence of data from other locations, trans and gender-diverse
advocates and activists from “Cape Town to Cologne” called for more funding and
attention to transgender people at risk for HIV (Appenroth etal., 2021). Outside of
North America, at the time of writing, a supplemental qualitative study of transgen-
der men’s health was recently completed in Uganda, and one was underway in India
(Mujugira, 2020; Scheim, 2021).
7.1.1.4 Sexual Minority Women
Sexual minority women (SMW, e.g., lesbians, bisexual, queer women) face
increased structural and interpersonal factors that can put them at risk of HIV, such
as stigma, homelessness, nancial insecurity, discrimination, substance use, and
violence (German & Latkin, 2015; Marshall etal., 2010; McCabe etal., 2009; Pyra
etal., 2014; Weber etal., 2004). In particular, SMW who engage in sex work and
transactional sex and/or inject drugs can be at increased risk for HIV and other
2 Note that transgender men and other transmasculine people, like transgender women, can have
any sexual orientation (gay, straight, bisexual, pansexual, asexual, etc.). Transmasculine people
can be at risk of HIV, depending on their sexual practices. Some sexual minority women (lesbians,
bisexuals, etc.) can also be at risk for HIV in certain circumstances.
S. W. Beckham et al.
187
negative health outcomes (Bell etal., 2006; German & Latkin, 2015; Glick etal.,
2020; Ompad etal., 2011; Pyra et al., 2014; Tat etal., 2015; Weber etal., 2004).
This speaks to the importance of examining behaviors (sexual minority women hav-
ing sex with men or transgender women) in addition to identity (e.g., lesbian), as
SMW are often not considered at risk and therefore overlooked in HIV interven-
tions (German & Latkin, 2015; Glick etal., 2020). In fact, some studies show that
WSW may actually be at higher HIV risk compared to heterosexual women (Bell
etal., 2006; Ompad et al., 2011). While much of these data are from the US and
Canada, the stigma and discrimination faced by SWM, like other SGM, is a global
phenomenon. Tat, etal., conducted a systematic review on the sexual health and
behaviors of SMW in low- and middle-income countries, nding HIV prevalence
ranging from 0 to 2.9% (East Asia, Latin America) to 7.7% to 9.6% (sub-Saharan
Africa).
7.2 Ethical andMethodological Challenges inGlobal HIV
Research Among SGM
There are particular challenges in conducting research about HIV/AIDS among
SGM populations globally. Challenges are ethical and methodological, and span the
research process from enumeration and recruitment to terminology used in survey
questions and how the data are presented and used. Historically, most health-related
funding for SGM populations has been HIV-focused; thus, many of the method-
ological challenges and innovations for SGM research were developed in the con-
text of HIV/AIDS research. Further, there are overlapping and synergistic stigmas
with SGM status and HIV.For example, breaches of data condentiality and privacy
can result in unintentional disclosure of sensitive information to others, including
but not limited to HIV status and sexual or gender identity, which can also lead to
social harms in certain contexts. SGM people and people living with HIV are under-
standably cautious about sharing private information with outsiders, which may
lead to research avoidance.
Importantly, too, is that the level of investment in SGM research around the
world has been very limited in comparison to that focused on household-based,
general population surveys. There are an increasing number of countries that regu-
larly conduct national integrated bio-behavioral surveys inclusive of MSM, and
some for transfeminine people as well, such as in Cambodia (Yi et al., 2017).
However, other SGM populations remain understudied. Consequently, knowledge
about SGM communities in most settings worldwide is limited, with limited invest-
ment in dedicated health services, which in turn results in limited interest in com-
pleting SGM-specic surveys. Thus, the cycle will continue until the global
community comes together to break the cycle and stop assuming that there are only
SGM people in some parts of the world and not others.
7 HIV/AIDS Among Sexual andGender Minority Communities Globally
188
7.2.1 Ethical Issues
There are ethical concerns to consider when conducting HIV research globally
among SGM groups, especially given the social stigma (AmfAR et al., 2015).
Furthermore, in 71 countries SGM identities and/or homosexual practices are illegal
(76 Crimes, 2021), and in several countries, homosexuality is even punishable by
death3 (76 Crimes, 2019 #1283). Researchers must take extra precautions in
researching in all settings, as the very act of participating in research may reveal
one’s SGM status, putting participants at social and/or legal risk (Baral et al.,
2014a), especially inlocations where SGM populations’ rights are violated by the
state (Amon etal., 2012); see the F&M Global Barometers (Dicklitch-Nelson etal.,
2021) and the International Lesbian, Gay, Bisexual, Trans and Intersex Association
(ILGA)’s reports (ILGA World, 2020) for information on specic countries. Thus,
in some cases, research may be ethically impossible, and efforts would be better put
toward providing safe, friendly health and social services.
Another challenge is the noted mistrust toward the medical research community,
as members of some SGM groups feel extensively over-approached to join research
studies, especially in urban areas. Additionally, if they join research, there is not
much benet from their participation afterward, as ndings from said research are
seldomly accessible to them, and subsequent programming is often not imple-
mented (Poteat etal., 2019; Reisner etal., 2019). For example, transgender women
have contributed to pre-exposure prophylaxis (PrEP) research, but still much less is
known about optimal provision, acceptability, and how to sustain long-term use in
this population.
Given that HIV is largely sexually transmitted, researching sexual practices and
behaviors is an element of HIV research. However, sexual behavior is not usually
something researchers can ethically observe. Thus, research about HIV-related sex-
ual behaviors is often reliant on self-report of participants, and therefore subject to
social desirability bias and recall bias, which can either over- or underestimate cer-
tain behaviors. This may be particularly exacerbated for SGM populations, particu-
larly inlocations where same-sex behavior is criminalized and stigmatized. Indeed,
in many places in low- and middle-income countries (LMIC; and even the high-
income countries), sexual and gender minorities may be so keen on repressing and/
or hiding their behaviors and identities that they lead seemingly cis-heteronormative
lives. That is, they compartmentalize their sexual and/or gender expressions, behav-
iors, and desires and live in socially acceptable, gender-conforming, opposite-sex
marriages, produce children, and express their SGM behaviors and desires in only
hidden, clandestine situations. These situations make them nearly invisible to
3 Countries with the death penalty for homosexual acts include Yemen, Iran, Brunei, Mauritania,
Nigeria, and Saudi Arabia. In Afghanistan, Somalia, Qatar, Sudan, the United Arab Emirates, and
Pakistan, the courts could interpret law to impose the death penalty ILGA World, Lucas Ramon
Mendos, Kellyn Botha, Rafael Carrano Lelis, Enrique López de la Peña, Ilia Savelev, and Daron
Tan (2020). State-Sponsored Homophobia 2020: Global Legislation Overview Update.
Geneva, ILGA.
S. W. Beckham et al.
189
researchers. In situations where researchers may be able to nd them—such as at
underground bars that cater to SGM people—they may be suspicious and too cau-
tious to engage. Every effort should be paid to understanding the full context of
these situations and not put any potential participant at risk of being outed in the
name of research.
7.2.2 Methodological Issues
Lack of enumeration of SGM communities arises as a key challenge to sampling
and recruitment, and thus, measuring HIV incidence and prevalence among them.
With no enumeration, there is no denominator; thus, the affected proportion is
unknown. When studying the overall population, strategies for enumeration include
using households, professional societies, and general health facilities to develop
sampling frames. With such sampling frames, population-level impacts of key inter-
ventions can be evaluated, and the coverage of key interventions can be determined.
Moreover, these sampling frames can provide opportunities for enrollment and
recruitment. In the absence of sampling frames, it is challenging to accurately enu-
merate populations, probability sampling cannot be conducted, and recruitment for
epidemiologic and interventional studies is also challenging. Accruing stable sam-
ple sizes for HIV research among SGM groups has thus been difcult.
7.2.2.1 Recruitment andEnrollment Issues
Given intersecting challenges, including multiple stigmas, SGM communities can
be particularly hard to enumerate, recruit, and enroll. Compared to other SGM
groups, there has been more success for MSM in achieving sufcient sample sizes
(e.g., iPrEx study which included cisgender men and transgender women in Peru,
Ecuador, South Africa, Brazil, Thailand, and the US (Grant etal., 2010)) and esti-
mating HIV prevalence (as seen in this review of data from multiple LMICs across
four continents) (Baral etal., 2014b). However, the ability to enroll populations is
related to differential economic and social marginalization, which means less data
on already-marginalized minority groups. In LMIC especially, population size esti-
mates have been difcult, but not impossible to estimate. Baral, etal., used social
media platforms, for example, to estimate MSM population sizes in 13 countries
(South Africa, Ghana, Nigeria, Senegal, Cote d’Ivoire, Mauritania, The Gambia,
Lebanon, Thailand, Malaysia, Brazil, Ukraine, and the United States) (Baral etal.,
2018). In regions such as sub-Saharan Africa, estimates in the past often only repre-
sented male sex workers but not the rest of the MSM population, leading to biased
estimates of HIV risk (Muraguri etal., 2012), though more recent work has shown
high HIV prevalence in the region (Poteat etal., 2017a).
7 HIV/AIDS Among Sexual andGender Minority Communities Globally
190
7.2.2.2 Sampling Issues
In the absence of sampling frames that permit probability sampling methods, three
primary non-probability sampling strategies have evolved to enroll SGM popula-
tions in HIV research. These can be classied as network-based, place-based, and
online strategies. Some hybrid approaches combine these strategies to maximize
reach. Network-based approaches leverage existing social networks to enroll others
generally using a chain-referral strategy. The level of complexity varies greatly from
ungoverned chain-referral such as snowball sampling to approaches such as peer-
referrals and respondent-driven sampling (RDS). An HIV study among transfemi-
nine people in South Africa, for example, used peer-referrals for recruitment (Poteat
etal., 2017a). RDS limits the number of enrollments at each wave of recruitment,
thus pushing recruitment further into networks and ultimately reducing bias associ-
ated with initial seeds. This method allows an approximation of population preva-
lence of key indicators, such as HIV infection (Heckathorn, 1997; Salganik &
Heckathorn, 2004).
Place-based approaches focus on building an understanding of different venues
from which SGM can be recruited. Specically, time-location or venue-day time
sampling includes building a universe of venues, days, and times of day as a de facto
sampling frame from which SGM can be recruited. This methodology is more
applicable to populations that may not be well networked, but who may frequent
venues, and has been used in HIV-related studies to recruit SGM in places as dispa-
rate as the US (Hwahng, 2018; Hwahng & Nuttbrock, 2007; Wei et al., 2012),
Guatemala (Paz-Bailey et al., 2014), Kenya (Geibel et al., 2012), and Thailand
(Toledo et al., 2010). However, in some places, the closure of such spaces may
impact the effectiveness of such approaches (Mattson, 2019).
Finally, online sampling is being increasingly used with recruitment from general
social media as well as mobile applications more specically focused on SGM.Unlike
RDS and time-location or venue-day time sampling, which approximate probability
samples, online recruitment methods more closely represent convenience samples.
They can be nevertheless useful for reaching SGM, but their limitations need to be
considered. There are selection biases associated with this method (Green et al.,
2015). In the United States and Europe, online samples tend to oversample people
who are white, younger, and have higher income, and marginalized groups may be
less able or willing to engage in online methods. Online methods have also been com-
bined with other recruitment and sampling methods in innovative ways, which come
with their own strategies and biases to consider (Grov etal., 2019, 2020). In the LITE
Study of transgender women in the U.S., online and site-based sampling were both
employed. The online sample reached people who were earlier in their transition, had
lower access to or use of gender-afrming services, and were more isolated than peo-
ple recruited at site-based locations (Wirtz etal., 2019). Online recruitment in lower-
income countries may not be as effective, depending on the context. For example,
internet access in some places is less common and nancially unobtainable, especially
outside of cities. Internet-based research done in such contexts should take into
account such biases and limits to generalizability.
S. W. Beckham et al.
191
Each of these sampling methods are associated with advantages and challenges
in terms of implementation and analyses (Magnani et al., 2005; Malekinejad
etal., 2008; Wei etal., 2012). Choosing the appropriate method necessitates char-
acterizing the specic question, such as what population or subpopulation you
want to be able to make statements about. For example, identifying if the research
question is about specic groups of SGM based on overall HIV rates in those
groups, or individual or network-level HIV risk behaviors. It also necessitates
knowing some characteristics of the target population, such as if they are well
networked, or if they are likely to be accessible in venues. Some methods that
work well in some settings may not work as well in others. RDS, for example, has
worked well for reaching MSM for HIV studies in many countries, but less effec-
tive in the United States, particularly for SGM youth and Black MSM, who tend
to be less well-networked to other SGMs (Wei etal., 2012; Wirtz etal., 2021).
Steps in the decision process include appropriate formative research, assessment
of the level of resources (time and nancial), and capacity of research partners
(Glick & Adrinopoulous, 2019).
7.2.2.3 Cultural Conceptualizations ofGender Identity
andSexual Orientation
Should the context be safe enough to conduct research among SGM populations in
a given locale, there are additional issues to consider. There are a variety of labels
used among sexual and gender minority groups even within one country and cul-
ture. There are culturally specic words for various behaviors and identities that
may mean slightly different things to people who use the labels to describe them-
selves. Additionally, these terms do not necessarily map on exactly to academic
categories of “homosexual” or “transgender” and can have different nuances and
historical meanings that may be lost in translation (Glick & Adrinopoulous, 2019;
Hwahng, 2009, 2011). These labels are also time-bound and sometimes rapidly
changing; words that were appropriate to describe SGM 20 or even 5years ago in
one context may become quickly dated and offensive but still considered appropri-
ate in another (likely including words used in this book).
Furthermore, while some communities take pains to separate gender identity and
sexual orientation as distinct concepts, many people and cultures conceptualize the
two in a variety of ways. Indeed, the categories of “homosexual” and “transgender”
are created and reied as social constructs (Singh etal., 2017; Valentine, 2007) and
are constantly being contested and changed. This is not to call these categories
unreal, but to point out that one society’s categories are not more or less “right” than
another’s, and to forcibly map Western categories onto other communities’ is inap-
propriate and counterproductive (Glick & Adrinopoulous, 2019). For example, a list
of gender identities in Thailand lists 18 genders, described as various combinations
of gender expressions and sexual attractions that cannot and should not be mapped
onto Western categories (Morris, 1994; Sinnott, 2004; Wilson, 2017). Effort should
7 HIV/AIDS Among Sexual andGender Minority Communities Globally
192
be made to understand and work within these local categories, rather than to colo-
nize them with Western concepts. Even in the United States, and especially in com-
munities of color, there are a variety of terms used. For example, people who might
be categorized as transgender for research purposes may not identify as such, and
many research studies have grouped transgender women with MSM, subsuming
their identities under their behaviors (e.g., receptive anal sex with men) (Baral etal.,
2011; Glick etal., 2018). Care should be taken to respect local conceptualizations,
labels, and meanings. All this can impact recruitment and validity of data (misclas-
sication bias) and using terms incorrectly may further stigmatize or offend the
populations being studied.
Researchers should be aware of these issues in order to thoughtfully conduct
HIV research in these populations, takings pains to be gender-afrming and
culturally competent (Glick & Adrinopoulous, 2019; Hwahng & Nuttbrock,
2007; Poteat etal., 2019; Reisner et al., 2016a). These challenges also mean that
there remain many gaps in understanding about HIV among SGM populations
across the globe. Not only are there gaps in the epidemiology of HIV in most
areas of the world, but also in the knowledge base about best practices for
implementing prevention and treatment programming. Furthermore, program-
ming that may be effective in one population (e.g., white MSM in the UK) can-
not be assumed to work well in other populations within that same country (e.g.,
Black MSM in the UK) nor in other locations (e.g., MSM in Russia, Vietnam, or
South Africa), let alone among different SGM groups (e.g., transgender women
of color in the United States, transgender men in Indonesia). Interventions
should be adapted or created to best address the needs of the SGM in their
respective local context. As an example of an appropriate adaptation, a team of
local and international researchers and implementers adapted a participatory
theater intervention to reduce stigma for SGM in Eswatini and Lesotho, given
the impact of stigma on the HIV epidemic. They rst conducted qualitative,
formative research to better understand local stigma dynamics, then worked
with a local SGM and theater groups to develop skits. They followed these skits
with focus group discussions with audience members (nursing students, health
care providers, educators, and general community members) to assess the reac-
tions (Logie etal., 2019).
7.3 Multi-level Factors andInterventions
Keeping in mind ethical and methodological challenges and funding gaps that
prevent a full global picture of HIV epidemiology, we now explore known factors
that drive and predict HIV risk, as well as interventions that mitigate those risks.
As a heuristic, we situate these factors and interventions into a modied social-
ecological model (mSEM) (Baral etal., 2013a). This model (see Fig.7.3), like
other SEMs, organizes elements into multiple levels (individual, social, commu-
nity, etc.) to aid understanding of an issue and focus interventions to at least one,
S. W. Beckham et al.
193
Fig. 7.3 Modied social-ecological model (Baral et al. 2013a, b). (Reprinted from Baral, S.,
Logie, C.H., Grosso, A. etal. (2013). Modied social ecological model: a tool to guide the assess-
ment of the risks and risk contexts of HIV epidemics. BMC Public Health. 13, 482, Figure3.
https://doi.org/10.1186/1471- 2458- 13- 482, licensed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0))
Legend: BME Black and minority ethnic populations, STI sexually transmitted infections
but preferably multiple, levels. Unlike other SEMs, this modied SEM speci-
cally acknowledges the importance of the HIV epidemic stage, that is, the preva-
lence and incidence of HIV in a given community, since this greatly impacts the
riskiness of individual condomless sexual encounters, for example. In this chap-
ter, we discuss factors and interventions at three levels: structural, interpersonal/
community, and individual.
7.3.1 Structural Level Factors
Globally, SGM communities face structural-level barriers that not only increase
their risks for HIV, but also constrain their abilities to access afrming, friendly
healthcare services and live fully actualized lives. These structural-level factors
include criminalization and pervasive stigma and discrimination, including cis-
and heteronormativity, homophobia, and transphobia, as well as intersecting stig-
mas such as classism, racism, nationalism, and ableism. This section focuses on
criminalization, stigma, and discrimination, while acknowledging that these other
factors are also at play, depending on the context.
7 HIV/AIDS Among Sexual andGender Minority Communities Globally
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7.3.1.1 Criminalization
One of the strongest structural forces driving risks and vulnerabilities for HIV
among sexual and gender minorities is criminalization of same-sex practices and the
legal and social policing of gender non-conformity.4 These forces, rather than stop
SGM people from existing, drive them underground. Criminalization reduces access
to HIV services and safer sex supplies such as condoms and water-based lubricants,
and increases stigma and discrimination, while ensuring victims have little or no
recourse to the justice system (Arreola etal., 2015; Beyrer, 2014). Criminalization
is variously enforced in different countries, ranging from no protection but no crimi-
nalization (e.g., India, Paraguay, China) to 10-year-to-life prison sentences
(Tanzania, Myanmar) to the death penalty (Sudan, Saudi Arabia) (Altman & Beyrer,
2014; ILGA World, 2020). (See Fig.7.4). Russia presents an alarming case of the
importance of state-sponsored structural violence against SGM people. Though
same-sex behavior was ofcially decriminalized in 1993 with the fall of the Soviet
Union, more recent draconian laws against “homosexual propaganda” led to
increases in violence against SGM people in Russia. This has led to apparent
increases in HIV transmission among MSM (Altman & Beyrer, 2014; Beyrer etal.,
2013) as well as worse mental health outcomes (Hylton etal., 2017). There are also
intersectional issues for SGM who are also ethnic minority groups and face xeno-
phobia but came to Russia because it was “safer” than being gay in the neighboring
countries where there were more severe penalties (Wirtz etal., 2014).
As of December 2021, there are 71 countries in the world that criminalize con-
senting same-sex behavior, particularly between males (76 Crimes, 2021), most of
them middle- and low-income countries. The most recent countries to decriminalize
homosexuality include Bhutan in Asia (February 2021) and Gabon in central Africa
(July 2020). Many of the 71 countries that criminalize homosexuality are former
British, French, and Portuguese colonies (76 Crimes, 2021). Indeed, it was the
British colonial structure which mapped Euro-Western “values” of same-sex crimi-
nality onto places that had tolerated or even accepted it previously. Many nations’
penal codes are retained from their colonial codes, copied from the British- era
Indian penal code, which criminalized “carnal knowledge against the order of
nature” and “gross indecency” (Altman & Beyrer, 2014; Beyrer, 2014).
In direct contravention to these anti-homosexuality laws are international human
rights covenants and bills, such as the International Bill of Human Rights, which
has been signed by 172 nations worldwide, including 95% of sub-Saharan African
4 Note that while this volume differentiates between sexual orientation and gender identity and
treats them as separate constructs, this differentiation is not commonly recognized worldwide.
Often, sexual orientation and gender identity are collapsed, and certain gender expressions are
sometimes interpreted as homosexuality, while some gay people may be seen as crossing society’s
gender boundaries. Thus, some countries that criminalize homosexuality might arrest a feminine-
presenting male or transgender woman with “gross indecency” and accuse the person of homo-
sexuality, regardless of actual sexual behavior. While sexual and gender minorities’ risks and needs
overlap in many ways, there are distinct issues that need addressing legally, socially, and culturally.
S. W. Beckham et al.
195
Fig. 7.4 Sexual orientation laws in the world– 2020 (ILGA World, 2020). (Reprinted from ILGA
World: Lucas Ramon Mendos, Kellyn Botha, Rafael Carrano Lelis, Enrique López de la Peña, Ilia
Savelev and Daron Tan. (2020 December). State-Sponsored Homophobia 2020: Global Legislation
Overview Update. https://ilga.org/maps- sexual- orientation- laws)
countries (Abara & Garba, 2015). The International Covenant on Civil and Political
Rights (ICCPR), signed in 1966, guarantees rights “without distinction of any kind,
such as race, color, sex…” (United Nations, 1966). In 1994, the Human Rights
Committee held that sexual orientation was a status protected from discrimination
under the ICCPR, with reference to “sex,” including “sexual orientation” (Baral
etal., 2011). In signing human rights conventions, countries commit to upholding
the principles therein, including non-discrimination. However, as Abara and Garba
(2015), stated, “it is evident that these rights are neither enforced nor protected
among MSM in SSA,” and this statement applies just as well to other SGM com-
munities and countries outside of SSA.
7.3.1.2 Stigma andDiscrimination
Even in countries that permit same-sex behavior, stigma, and discrimination remain
as barriers to HIV prevention and care. In South Africa, for example, where sexual
orientation is constitutionally protected, MSM were more likely to disclose their
sexual orientation than their counterparts in other southern African countries with-
out protections but were just as likely to report human rights abuses (Zahn etal.,
2016). Furthermore, in the United States, where SGM people have limited legal
7 HIV/AIDS Among Sexual andGender Minority Communities Globally
196
protections, MSM bear a disproportionate burden of HIV incidence and prevalence,
accounting for 67% of all new diagnoses (Centers for Disease Control and Prevention
(CDC), 2018). This burden is borne particularly by men of color, who are more
likely than non-Hispanic white MSM to face stigma, discrimination, lower socio-
economic status, and thus higher rates of STIs, lower rates of HIV testing, and
constrained access to treatment services. In some places, up to one in two Black
MSM is already living with HIV, making condomless sex within these networks
particularly risky (Latkin etal., 2012).
Like same-sex behavior, alternative gender expressions and gender identities are
not new nor Western, but are heavily stigmatized, resulting in many negative health
outcomes, including high prevalence of HIV (Reisner etal., 2016b; White Hughto
& Reisner, 2016). Cultures around the world have long traditions of recognizing
more than two genders, as seen in the variety of words to describe various gender
minorities, especially, but not limited to, male-to-female expressions. These include
terms such as kathoey, hijra, mahuvine, berdache, waria, mahu, bantut, nadleehi,
two-spirit, and xanith (Baral etal., 2011). While there is a lack of data on such SGM
identities throughout Africa and the Middle East, this is not to say they do not exist
there. Rather, the research is just beginning, and as trans-related research is moving
into those locations, ndings show increasing numbers of people who identify as
transgender (Reisner etal., 2016b).
Like same-sex behaviors, alternative expressions of gender are often policed by
the state and/or society and stigmatized. Transgender people and other gender non-
conforming people, particularly transfeminine people, are actively discriminated
against and their human rights violated in ways that reduce their access to services
and increase their risks for HIV.For example, lack of access to correct identication
and gender marker changes impacts access to employment, housing, and health
care, which in turn impact access to HIV testing, prevention, and treatment services
(Anderson & Kanters, 2015; Baral etal., 2011; Reisner etal., 2016b). In Thailand,
where various gender identities are socially recognized and accepted, and where
some of the leading surgeons for gender-afrming care are located, gender markers
on national identity documents cannot be legally changed. These identity docu-
ments also grant access to healthcare in Thailand, and thus create a stigmatizing
barrier for transgender people who are forced to access care under the wrong name
and gender marker (Samuel, 2021).
High rates of incarceration, homelessness, racism, and low socioeconomic status
also remain persistent in populations of transgender women, as many women are
isolated from the workforce due to their gender minority status (Reisner et al.,
2016b). Thus, transgender women who engage in sex work have much higher odds
of living with HIV (Poteat etal., 2016; Reisner etal., 2016b). Gender-related stigma
and discrimination in clinical settings have also hindered transgender women from
utilizing the healthcare system, creating a barrier for accessing HIV prevention
resources (testing, condoms, PrEP, treatment if already infected, etc.) (Poteat etal.,
2019; Reisner etal., 2016b).
S. W. Beckham et al.
197
7.3.2 Structural Interventions
Decriminalization of homosexuality and gender non-conformity, while worthwhile
and necessary for the safety, human rights, and dignity of all SGM people, also have
positive impacts on HIV prevention and treatment. Thus, anti-homosexuality laws
continue to be challenged in various countries, sometimes with an argument that it
serves an HIV prevention purpose. Recent countries to decriminalize homosexual-
ity span the globe and include Trinidad, India, and Angola. Not all challenges to the
law have been successful, however; in 2019, Kenya’s courts upheld an anti-gay law
(76 Crimes, 2019). Other countries, while not decriminalizing homosexuality, have
recognized the HIV prevention benet of allowing prevention efforts to reach SGM
communities without fear of legal or social repercussions.
International human rights principles can and have been interpreted to extend to
gender minorities, in language that calls for non-discrimination on the basis of sex,
the right to health, and the right to control one’s own body (Baral et al., 2011).
Courts have made legal judgments that protect gender minorities in several coun-
tries in Asia such as Pakistan, Nepal, Philippines, and Hong Kong (Baral et al.,
2011). Non-discrimination of transgender people is even written in Nepal’s consti-
tution as a “third type of gender identity” (Baral etal., 2011). As more countries
decriminalize, and we see more acceptance of SGM people globally, SGM com-
munities will be able to live more fully, without fear of legal repercussions.
Racial marginalization, racism, and xenophobia have also been documented as
structural factors for increased HIV risk. There is a small body of literature examin-
ing interventions addressing these structural oppressions among SGM people (see
Introduction to book).
7.3.3 Interpersonal andCommunity-Level Factors
Sexual and gender minorities face many community- and interpersonal-level chal-
lenges that increase HIV risk. These factors are exacerbated by intersectional identi-
ties (Bowleg, 2012) that may also be stigmatized, such as racial, ethnic, and religious
minorities in the United States (Hwahng & Nuttbrock, 2014; Nuttbrock & Hwahng,
2017, 2018), or other circumstances that increase vulnerabilities, such as poverty
(also see Stigma chapter, Chap. 2). It is also necessary to recognize the role of syn-
demics (multiple epidemics that co-occur) (Singer, 2009), such as substance use
(see Substance Use chapter, Chap. 8), violence victimization and abuse (see
Victimization and Intentional Injury chapter, Chap. 9), and poor mental health (see
Mental Health chapter, Chap. 3) in global HIV epidemics (Poteat etal., 2017b;
Reisner etal., 2016b). Additionally, SGM people globally experience higher rates
of physical and sexual assault, workplace discrimination, healthcare discrimination,
and family rejection (Patel etal., 2020; Sekoni etal., 2020; Yi etal., 2017).
7 HIV/AIDS Among Sexual andGender Minority Communities Globally
198
Network-level determinants have been shown to be profoundly important in
explaining the disproportionate burdens of HIV and STIs among MSM and trans-
gender women. The burden of HIV among MSM in North Africa and the Middle
East, for example, is attributed to high levels of risk behaviors among them, such as
having multiple partners, low condom use, high HSV-2 rates, male sex work, inter-
sections with drug use, and bisexual practices (Abara & Garba, 2015; Mumtaz
etal., 2010). However, do we know that there is more inherent HIV-related risk
among MSM, or that the biology of HIV and STIs, combined with sexual networks,
explains these disparities in outcomes? There are some key elements specic to
networks among MSM and transgender women, including the potential dual roles
of being both insertive and receptive partners during penile-anal sex, which differs
from that of cisgender women. Moreover, there tends to be higher density in these
networks than general heterosexual networks since the latter networks are much
bigger and not stigmatized in society. For example, the increased size and lower
density sexual networks among MSM have been linked to HIV in places as diverse
as Australia, China, and the United Kingdom (Beyrer etal., 2012a).
There are also those individuals, including those reporting transactional sex, that
create multiple points of contact within networks and have higher odds of HIV
infection compared to those who do not (Oldenburg etal., 2016). Stigma against
SGM can cause the size of sexual networks to increase, as individuals may have
multiple concurrent or serial, short-term encounters in order to keep them secret.
When there is acute infection within these networks, transmission may happen rap-
idly to all within the network in the absence of PrEP and early diagnosis and treat-
ment (see below). The nding that incidence occurs in these short blips (Lewis
et al., 2008) only reinforces the importance of networks in driving HIV among
MSM and transgender women.
Unlike MSM, sex workers (including cisgender and transgender men, transgender
women, and cisgender women who are sexual minorities) do not acquire or transmit
HIV from other sex workers. It is the male partners and clients who represent key
members of the sexual networks in driving risks among sex workers for transmission,
yet the cisgender male partners and clients of sex workers are very rarely the focus
of interventions. Moreover, sex workers have commonly reported tremendous chal-
lenges in effective condom negotiation with male clients in the absence of laws pro-
tecting sex workers either in the context of occupational health or criminal law (Baral
et al. 2013a). Consequently, the overlaps between structural stigmas, network-level
determinants, and individual risks become increasingly clear as fundamental drivers
of ongoing HIV epidemics (Baral etal., 2013a; Beyrer etal., 2012a).
7.3.4 Interpersonal/Community-Level Interventions
Given the critical role networks and other interpersonal and community-level fac-
tors play in HIV transmission, interventions that address these factors are essential.
That said, globally, network and community-level interventions are also
S. W. Beckham et al.
199
challenging, expensive, and less researched than individual-level interventions
(Poteat et al., 2017b). Nevertheless, we discuss some examples of interventions
here, though this is not an exhaustive list. For example, partner, family, and group
support are potentially powerful interventions at this level (Poteat et al., 2019),
especially given higher rates of family rejection and intimate-partner and non-part-
ner violence among SGM people, as evidenced by data from Peru (Murphy etal.,
2019), the United States (Brooks etal., 2021; Wirtz etal., 2020), and multiple other
high- and middle-income settings in a systematic review (Peitzmeier etal., 2020).
In the United States there have also been studies on couples-based intervention for
transgender women and their cisgender male partners, given that cisgender male
partners are often a major vector of HIV transmission to transgender women
(Gamarel etal., 2016, 2020a, b; Operarioo etal., 2017).
Culturally competent interventions grounded in the community and that employ
peer-based outreach, education, navigation, and community mobilization are prom-
ising. In all cases, community involvement or, better yet, community leadership, are
keys to success (Poteat etal., 2019). By employing existing social and sexual net-
work connections, peer-led, community-based interventions can also operate
in locations with high homophobia and transphobia, and even criminalization.
These can not only increase individual-level health promotion behaviors, but also
decrease stigma, encourage collective activism, and empower groups to demand
change that addresses their felt needs (Poteat etal., 2017b, 2019). The participatory
theater intervention in Eswatini and Lesotho, mentioned above, is one good exam-
ple (Logie etal., 2019). In Senegal, an integrated stigma mitigation intervention
showed reductions in stigma in SGM both living with and at risk of HIV (Lyons
etal., 2020). Multiple demonstration projects for transgender women of color that
involved peer-led community outreach, case management, and small group sessions
to improve HIV outcomes were conducted in the United States and may provide
lessons learned for similar projects in other locations (Reisner et al., 2016b).
Another study in a different region of the United States examined peer-led transgen-
der support groups that were part of harm reduction programs that also resulted in
improved health outcomes and decreased HIV risk for transgender women of color
(Hwahng etal., 2019, 2021).
Examples outside the United States are hard to nd (Poteat etal., 2017b), but one
is the pilot study TransPrEP in Peru (Poteat etal., 2017b). This was a social network-
based PrEP (see below) adherence intervention study for transgender women that
included individual counseling, group workshop, and social media-based network
interactions. Results showed a positive trend toward the intervention objectively
increasing adherence to PrEP, as evidenced by drug levels in blood and hair sam-
ples. The use of technology and social media such as this is a key component of
future interventions. SGM communities are already widely connected through pop-
ular apps such as Facebook and Twitter, as well as MSM-targeted apps such as
Hornet and Grindr. These networks can be leveraged as strategies to support com-
munity development, estimate population sizes, and disseminate information.
Healthcare that is gender-afrming and sensitive to the needs of all SGM com-
munities is essential not only for HIV prevention and care, but also for all health
7 HIV/AIDS Among Sexual andGender Minority Communities Globally
200
needs. Unfortunately, this is too rare globally. Healthcare providers need sensitivity
training and cultural and clinical competency in order to welcome and serve SGM
people (Poteat et al., 2019) and overcome understandable medical mistrust.
Furthermore, health recordkeeping systems, whether paper or electronic, should
allow for specifying and changing gender markers and chosen names, even if legal
changes are not allowed in a given country. Patients who cannot safely disclose their
sexual orientations and/or practices and their gender identities cannot access HIV
prevention and care that is appropriate to their needs. For transgender women, espe-
cially, care that does not also address housing and food insecurity, violence, racism,
misogyny, transphobia, etc., will fail at meeting their individual HIV prevention and
treatment needs. The Tangerine Clinic in Thailand is a great example of a community-
led organization that is responsive to the needs of the SGM people it serves (amfAR,
2017). For example, they include gender-afrming care such as hormone provision
as well as case management into their HIV programming. In Australia, the commu-
nity health organization, Acon, started as an HIV clinic, and has expanded to serve
all SGM for a variety of health needs in the HIV syndemic. This includes sexual
health, substance use, violence, mental health, etc. Acon also strives to be respon-
sive to the needs of Aboriginal and other minoritized communities (2021). Both
Tangerine and Acon are examples of locally led and developed interventions that are
contextually and culturally appropriate to meet the particular needs of their local
communities.
Condoms and water-based lubricants, when used consistently and correctly, are
highly effective at preventing HIV and a highly cost-effective intervention (Beyrer
etal., 2012b), and thus should be considered essential components of HIV preven-
tion programming. While often considered at the individual level, condoms are by
their nature an interpersonal intervention, requiring discussion and negotiation
between sexual partners. These negotiations often take place in contexts of power
imbalances between partners, while condom promotion interventions too often tar-
get those holding the least power in sexual encounters (transgender women, cisgen-
der, and transgender sex workers). There is a dearth of research and programming
targeting cisgender men who have sex with transgender women (Poteat etal., 2021),
though they are key transmission nodes in high-risk sexual networks. Condomless
receptive anal sex is an especially important driver in MSM and transgender women
who have sex with cisgender men, since HIV transmission through anal intercourse
is a more efcient means of infection compared to vaginal intercourse, as the rectal
tissue is more susceptible to tears and thus to the virus (Beyrer et al., 2012b).
However, access to condoms and especially water-based lubricants is poor in some
locations. In 2016in Tanzania, for example, the Magufuli administration banned
lubricants, ordered extant supplies to be destroyed, and closed drop-in-centers that
served “key populations” such as MSM and female sex workers (Tanzania Ministry
of Health, & Gender, Elderly and Children, 2017). Lubricants had been promoted as
an HIV prevention intervention for MSM in particular, and thus were seen as “pro-
moting homosexuality,” while homosexuality is criminalized in the country (ILGA
World, 2020).
S. W. Beckham et al.
201
7.3.5 Individual- andBiomedical-Level Factors
Major HIV-related risk factors SGM people face at the individual level include con-
domless sex, untreated STIs, substance use, and lack of HIV testing and knowing
one’s status. Broader structural and interpersonal factors play out at and inuence
the individual level, driving internalized stigma, for example, and increasing sub-
stance use as a maladaptive coping mechanism. Internalized stigma (homophobia,
transphobia) can increase individual risk behaviors among SGM individuals, such
as not seeking healthcare and/or not disclosing important information to providers;
substance use during sex; a higher number of partners; transactional sex; condom-
less sex, etc. However, as mentioned above, individual risk behaviors are insuf-
cient to explain disparities in HIV rates, and structural, community, interpersonal,
and network-level factors must be taken into account (Latkin etal., 2012).
Higher burdens of childhood trauma and ongoing minority stress have, in part,
resulted in higher burdens of injection and non-injecting substance use among SGM
people. In part, this substance use may be driven by undiagnosed and untreated
mental health stressors. Some substance use is recreational in nature, and there has
been an emergence of “chemsex,” which is the use of multiple amphetamine-like
substances during sex to heighten the experience (see Substance Use chapter, Chap.
8) (Bourne etal., 2015). Interventions in this space often end up being punitive or
risk- based in their framing. Peer-based substance use interventions likely represent
a critical path forward; a trial in Thailand and the United States showed reduction in
HIV-related drug use behaviors (sharing equipment) (Latkin etal., 2009).
7.3.6 Individual-Level andBiomedical Interventions
PrEP is a medication taken by HIV-negative people to prevent HIV acquisition. It is
recommended by the World Health Organization for anyone at substantial risk for
HIV (World Health Organization (WHO), 2017). The high efcacy of PrEP in pre-
venting HIV acquisition and transmission among MSM has been shown through
several studies. The rst, which was conducted in Peru, Ecuador, Brazil, Thailand,
the United States, and South Africa, showed a 44% reduction in the risk of HIV
acquisition (Grant etal., 2010). In 2015, intermittent PrEP use or “on demand” use
in which patients take PrEP only before and after sexual activity was shown to
reduce the incidence of HIV acquisition by 97% in the IPERGAY trial in MSM in
France and Canada (Molina etal., 2015, 2017). Other PrEP efcacy trials have been
conducted in MSM and transgender women, including in the US, Kenya, England
(Fonner et al., 2016) and Argentina, Brazil, Peru, Vietnam, Thailand, and South
Africa (Landovitz etal., 2021). For PrEP, effectiveness is highly correlated with
adherence (Fonner etal., 2016) so particular attention must be given to supporting
uptake and sustained, correct use to see the prevention benet. As of writing, there
were multiple formulations of PrEP in various stages of the research pipeline,
7 HIV/AIDS Among Sexual andGender Minority Communities Globally
202
including a bimonthly injectable form shown to be highly efcacious in multina-
tional trials among cisgender MSM, transgender women, and cisgender women
(HIV Prevention Trials Network (HPTN), 2020; Landovitz etal., 2021). There is
hope that longer-acting formulations will overcome some of the barriers to adher-
ence, thus ultimately reducing HIV acquisition.
Research gaps and concerns remain for PrEP for other at-risk SGM populations,
however, including transgender women and transgender men who have sex with
cisgender men (TMSM), as well as sexual minority women who sell sex and/or use
injection drugs. Most of the research on PrEP has been focused on cisgender MSM,
with the inclusion of a small minority of transgender women (Fonner etal., 2016).
The recent long-acting injectable PrEP study included 12.5% transgender women
(Landovitz etal., 2021). Few studies have specically examined PrEP use among
TMSM (Reisner etal., 2019, 2021), and none among SMW who are at risk, though
several were conducted among cisgender women (Fonner etal., 2016). One primary
concern for transgender people at risk is possible drug-drug interactions between
PrEP (and other ART) and gender-afrming hormones. While there is currently no
evidence that indicates clinically signicant drug-drug interactions (Radix etal.,
2016), there is evidence that some transgender women may avoid PrEP anyway
because of these fears (Hiransuthikul etal., 2019). Similar issues and fears may also
be present among TMSM, though there are limited data to date (and only from the
US) on TMSM taking PrEP and potential contraindications with masculinizing hor-
mones (testosterone), which many transgender men and other transmasculine indi-
viduals use (Reisner etal., 2019, 2021). As of writing, a small, exploratory study of
PrEP for Ugandan transgender men was recently completed, but results are pending
(Mujugira, 2020).
Special attention must be paid to the intersection of SMG status and various
racial, ethnic, religious, and other minoritized groups, including migrants and pris-
oners. For example, PrEP uptake and implementation has been low in Black and
Latinx communities in the US (Cahill etal., 2017; Eaton etal., 2015; Rolle etal.,
2017). As PrEP availability continues to expand beyond high-income countries,
careful attention must be paid to the most vulnerable sub-groups among SGM peo-
ple in various country contexts. In addition, SGM members of migrant, immigrant,
prison, and ethnic minority populations may be at heightened risk of being excluded
from HIV prevention services, and this is likely to be replicated in PrEP program-
ming if not given carefully tailored attention.
Another key biomedical intervention is the use of antiretroviral therapies (ART)
as both treatment and prevention. While ART cannot yet cure HIV completely, peo-
ple living with HIV can live long, healthy lives on treatment. Furthermore, multiple
studies have shown that sufcient treatment that leads to sustained viral suppression
(an undetectable viral load) stops transmission to their partners (untransmissible
virus), often called treatment-as-prevention (TasP) (Cohen, 2011; Rodger et al.,
2019). The US Centers for Disease Control and Prevention afrmed that “undetect-
able equals untransmissible” (“U=U”) after results of the PARTNER2 study in
which there was no transmission among male couples where one was living with
HIV and the other HIV-uninfected (Rodger etal., 2019).
S. W. Beckham et al.
203
Given the network-driven transmission dynamics among MSM and transgender
women with multiple partners, where HIV is transmitted often before people know
they are infected, TasP strategies are likely to be insufcient to control the epidem-
ics (Van Griensven etal., 2017). Taken together, though, PrEP and TasP (U=U) hold
signicant promise. This is especially hopeful given alternative formulations on the
horizon, such as long-acting forms of ART and PrEP, including injectables, implants,
patches, and suppositories, making the future of ART and PrEP look much like fam-
ily planning, with many choices for consumers to use what best ts their prefer-
ences. These have the potential to reduce some barriers to uptake and adherence
(Landovitz etal., 2016). Other biomedical interventions such as HIV vaccines and
broadly neutralizing antibodies to prevent HIV continue to be tested, and invest-
ment in these is essential.
However, for interventions like PrEP and U=U to reduce new HIV infections, it
remains important to tailor prevention and treatment support to the specic com-
munities at highest risk of both acquiring and transmitting HIV, including SGM
communities (Baral etal., 2019; Mishra & Baral, 2019). Universal treatment and
prevention programs that do not consider intersectional identities and stigmas will
reinforce pre-existing power dynamics, including cis- and heteronormativity,
misogyny, ableism, white supremacy, classism, etc., even within SGM communi-
ties, and further widen disparities in HIV outcomes. This reinforces the necessity of
multi-level interventions that situate the individual and biomedical interventions
within broader interventions that also address social, community, and struc-
tural levels.
7.4 Chronic Disease andSexual andGender Minorities
Living withHIV
HIV chronic comorbidities are an important concern for people living with HIV,
including SGM.Most of the literature on this topic, however, is from the Global
North, and further work needs to be conducted to understand the needs of SGM in
other locales. Though use of combination antiretroviral therapy has led to better
prognosis, improved survival, and reduced HIV-related illness and death for people
living with HIV (Hogg etal., 1998; Palella etal., 1998), non-HIV related comor-
bidities such as cardiovascular disease, non-AIDS-related cancers, and liver disease
are becoming more prevalent (Goulet etal., 2007; Wong etal., 2018). In the general
population, development of age-related chronic disease is associated with physio-
logical stress (Epel etal., 2004), while HIV disease processes and some antiretrovi-
ral therapy regimens are linked to chronic inammation and can exacerbate
age-related chronic conditions for people living with HIV (Drozd etal., 2017; Onen
& Turner Overton, 2011; Pathai et al., 2014). Minority stress (Brooks, 1981;
Hendricks & Testa, 2012; Meyer, 2003), stigma, and discrimination may also shape
chronic disease disparities for SGM (Hatzenbuehler etal., 2014), as is the case for
racialized minorities (Busse etal., 2017; Gallo etal., 2014; Jackson et al., 2010;
7 HIV/AIDS Among Sexual andGender Minority Communities Globally
204
Lucas etal., 2017). People living with HIV as well as SGM are also more likely to
engage in risk behaviors (i.e., smoking) (Akhtar-Khaleel etal., 2016; Gruskin etal.,
2007), and experience other socio-structural risk factors for chronic disease (see
Non-Communicable Diseases chapters, Chaps. 4 and 5).
Increased chronic disease risk for people living with HIV includes non-AIDS-
dening cancers, such as anal cancer. This elevated anal cancer burden is highest for
MSM, with one HIV and cancer registry-linked study of 447,953 people with HIV
in the United States estimating a 39-fold increased risk compared with the general
population (Colón-López etal., 2018). Evidence of other chronic illness disparities
for men who have sex with men living with HIV include diabetes and kidney dis-
ease, as well as higher likelihood of having multiple chronic conditions, compared
to men who have sex with men living without HIV (Althoff etal., 2014). For many
transgender people, gender-afrming hormone therapy is an important part of clini-
cal care, serving as a protective factor for HIV clinical outcomes-facilitating care
engagement, antiretroviral therapy adherence, and viral suppression (Wilson etal.,
2015). However, exogenous hormone use may also potentiate increased chronic
disease risk for transgender women in particular, both independently and through
potential drug-drug interactions with antiretrovirals. Exogenous hormones use has
been linked to elevated cardiovascular disease risk factors among transgender
adults, with excess cardiovascular disease incidence, prevalence, and mortality for
transgender women compared to cisgender counterparts, though not consistently for
transgender men (Gosiker etal., 2020; Streed etal., 2017). For SGM populations,
stress, antiretroviral therapy, and exogenous hormone use may also contribute to
heightened risk of other HIV co-morbidities, particularly inammation-related dis-
eases such as cancer, diabetes, and arthritis. These risks are likely exacerbated with
older age, racialization, and the multi-level determinants of health discussed else-
where in this chapter.
While the limited previous research in this area has demonstrated evidence of
HIV chronic comorbidity disparities for sexual and gender minorities, particularly
for men who have sex with men and transgender women, gaps remain in our under-
standing. A systematic review of the global literature on transgender health pub-
lished between 2008 and 2014 found less than 10% of included data comprised
general health—including chronic disease (Reisner etal., 2016b). A more recent
review of global transgender populations and their chronic disease burden showed a
persistent focus on mental health, demonstrating an evidence gap in chronic physi-
cal health morbidity, particularly around age-related conditions and inammation-
related disease (Rich etal., 2020). As noted for the larger HIV literature, research
gaps remain in understanding HIV chronic comorbidities, particularly for sexual
minority women. Much of the research in HIV and chronic illness among sexual
and gender minorities is from large administrative data studies in the US, and to
some extent Europe, leaving global sexual and gender minority populations largely
understudied. There is a need for high-quality evidence in this area. Particularly,
longitudinal research studies designed to look at the development of chronic condi-
tions over time is needed, as well as consistent measurement of sexual and gender
minority status and chronic conditions, validated measures of chronic disease for
these populations, and inclusion of appropriate comparison groups (Rich etal., 2020).
S. W. Beckham et al.
205
7.5 Conclusions
With the widespread criminalization, stigma, and discrimination to which SGM are
exposed around the world, the epidemiology of HIV among SGM communities, as
well as provision of culturally and clinically competent and afrming HIV preven-
tion and care, remains elusive in much of the world. Where state-sponsored
homophobia and transphobia exist, and where sexual and gender minorities face
multiple, intersecting stigmas, achieving HIV prevention and treatment goals, let
alone allowing people to live fully actualized lives with dignity, is challenging.
Nevertheless, there has been progress, especially in the past decade, in decriminal-
ization, reducing stigma, reaching vulnerable populations with HIV and other health
care needs, as well as in enumerating SGM populations and more accurately esti-
mating HIV across the globe.
In summary, while this chapter provides the most data on MSM, this is a reec-
tion of the research that has been conducted, and not a statement of importance of
one group over others. As shown above, it is transgender women who have sex with
cisgender men who face the greatest odds of becoming infected with HIV, followed
by men who have sex with men. Transgender men and sexual minority women who
have sex with cisgender men are a small minority, but nevertheless face HIV risks
and vulnerabilities as well. However, little research has been conducted among
these groups, so their HIV risks and prevalence are not well known. Additionally, it
is important to note that absence of data about HIV among SGM communities in
certain locales does not equate absence of risk or of SGM people, but rather may be
a reection of state-sponsored repression related to homophobia and transphobia.
7.6 Future Directions
While there is still a lot of work to do to eliminate HIV, the future holds promise. At
a basic level, we require more data about SGM people and HIV epidemiology
among them, globally. Data on sexual orientation/practices and gender identity
needs to be collected and disaggregated in national, demographic, and health sur-
veys and censuses (Poteat etal., 2017b) in order to implement data-driven, evidence-
based interventions tailored to SGM populations, and to implement them at scale
(Schwartz etal., 2019). We have interventions that we know work at multiple social-
ecological levels, including PrEP and U=U, community mobilization, and decrimi-
nalization and legal protections. These interventions need to be tailored to specic
SGM populations and locations, and implementation research needs to be con-
ducted to understand best practices. For the greatest impact, these interventions
must be concentrated on hyper-epidemics where most HIV transmission occurs rap-
idly (Tanser etal., 2014).
7 HIV/AIDS Among Sexual andGender Minority Communities Globally
207
7.7 Case Study: Thailand’s HIV Epidemic
The presence of HIV in Thailand was rst reported in 1984; the epidemic accelerated
rst among persons who inject drugs (PWID) and then among female sex workers
(FSW) (Siraprapasiri etal., 2016). The country experienced its highest rates of HIV
incidence in 1991 and 1992, around 150,000 new infections, and by 1993, there were
about 600,000–800,000 persons living with HIV (PLWH) in the country (Analysis
and Advocacy Project & Thai Working Group on HIV/AIDS Projections, 2008;
Siraprapasiri etal., 2016). According to UNAIDS, in 2020, about 500,000 individuals
in Thailand were living with HIV, and HIV incidence in adults per 1000 population
was 0.19. The HIV epidemic in Thailand is currently a generalized epidemic, with an
estimated 1% of the total population living with HIV/AIDS (UNAIDS, 2020).
Thailand has made a concerted and admirable effort to control its HIV epidemic.
Early prevention efforts, like the promotion of condom use, particularly in the context
of sex work, are credited with averting over two million new infections (Siraprapasiri
etal., 2016; Visrutaratna etal., 1995). Because of a focus on prevention of mother-to-
child transmission and providing free testing and anti-retroviral medications for HIV
treatment (ARTs), incidence of HIV among Thailand’s heterosexual populations has
signicantly declined (Seekaew etal., 2018; Siraprapasiri etal., 2016).
However, Thailand’s LGBTQ community bears the burden of its HIV epidemic.
In 2018, HIV prevalence among gay, bisexual, and other men who have sex with
men (MSM) was 11.9%, while HIV prevalence in transgender individuals was 11%
(UNAIDS, 2018). Currently, half of all new HIV infections occur in MSM, trans-
gender women (TGW), and male sex workers (Seekaew etal., 2019). HIV incidence
in MSM in Bangkok is particularly high at about 29% (Seekaew etal., 2018).
Consequently, these populations are priority populations for prevention interven-
tions in the country’s plan to end its HIV epidemic. In 2017, Thailand launched this
plan, with goals to drastically reduce HIV incidence, AIDS-related deaths, and HIV-
specic discrimination in healthcare settings by 2030 (UNAIDS, 2017). Furthermore,
this 13-year plan accelerates the country’s efforts to meet the international 90-90-90
targets– ensuring that 90% of PLWH know their status, 90% of those who know
their status are on ARTs, and 90% of those on ARTs are virally suppressed (UNAIDS,
2017). By 2018, Thailand had reached 94-75-73; however, that success is not equi-
tably distributed (Seekaew etal., 2019).
Indeed, knowledge of one’s status is at about 43% and 42% for MSM and TGW,
respectively (Seekaew etal., 2019). A recent sub-analysis of a prospective cohort of
MSM in Thailand found that 66% had a false perception of low HIV risk, and about
59% declined an offer for HIV testing and counseling because they had been tested in
the past 6months (47%), were not ready for testing (16%), or thought they were not
at risk (13%) (Khawcharoenporn etal., 2019). Furthermore, a sub-study of the MSM
and TGW-led Test and Treat study in Thailand found that about 49% of individuals
self-identied as having a low HIV risk, while about 81% of MSM and 82% of TGW
had what researchers asserted were “actual HIV-risk characteristics” (Seekaew etal.,
2019). Additional Thailand-specic barriers to HIV testing and care include a lack of
7 HIV/AIDS Among Sexual andGender Minority Communities Globally
208
awareness about HIV, the benets of HIV care, and where to access care; fear of unin-
tentional HIV status disclosure; and perceptions of antagonism from healthcare pro-
viders (Sapsirisavat etal., 2016; Tam etal., 2014; UNESCO, 2012; Zhang et al.,
2015). Stigma and discrimination against one’s HIV status, sexual orientation, or gen-
der identity, are also signicant barriers to testing and care (Anand etal., 2017).
In its “Operational Plan Accelerating Ending AIDS by 2030,” the government of
Thailand acknowledges that reducing inequality and addressing key populations,
including MSM and TGW, is vital to the plan’s success (Thailand National AIDS
Committee, 2014). The comprehensive plan implements, in collaboration with local
community and health service providers, a “reach, recruit, test, treat, and retain”
(RRTTR) strategy utilizing innovative methods, along with specialized services at
different levels of intensity for specic key populations. Reaching consists of using
social media and social networks for outreach, while recruiting involves the appro-
priate branding of services, peer-led interventions, and efforts to increase ease of
access. Rapid, culturally appropriate testing occurs at community-based organiza-
tions (CBOs), healthcare settings, and mobile sites, and innovations in treatment are
focused on the decentralization of care and the integration of services. Retention
utilizes mobile technology and community case management. Crucial aspects of
this plan are health systems strengthening, stigma and discrimination reduction, and
the empowerment of key populations to have ownership of and involvement in their
health, as well as building these communities’ capacity for HIV prevention and care
service delivery (Thailand National AIDS Committee, 2014).
The empowerment of key populations to deliver services in partnership with com-
munity-based organizations (CBOs) and healthcare organizations is referred to as the
Key Population-Led Health Services (KPLHS) model, which was developed by the
Thai Red Cross Research Centre (TRCARC), funded by the U.S Agency for
International Development (USAID) and the President’s Emergency Plan for AIDS
Relief (PEPFAR), and then locally adapted and tailored to key population’s needs
(Seekaew etal., 2018; TRCARC & FHI 360, 2018). The services were designed in
conjunction with the key populations that they serve, and as such are client-centered
(TRCARC & FHI 360, 2018).
CBOs doing this work with MSM and/or TGW are Service Workers in Group
Foundation (SWING), Rainbow Sky Association of Thailand (RSAT), Sisters,
Caremat, and Mplus (Seekaew et al., 2018; TRCARC & FHI 360, 2018). The
increased involvement of MSM and TGW in their own HIV prevention and care,
and their collaboration with Thai aid organizations, is changing the landscape of the
country’s HIV-related services. With this collaborative KPLHS model and its inno-
vative service delivery, implemented from January 2015 to January 2018, coverage
of these key populations increased by 319%, with referrals by peers increasing by
178% (TRCARC & FHI 360, 2018). These organizations have provided over 2000
individuals with access to PrEP, diagnosed over 3000 PLWH, and initiated almost
70% of those on ARTs (TRCARC & FHI 360, 2018). ART maintenance at these
CBOs was determined to be preferable (TRCARC & FHI 360, 2018).
Thailand’s prioritization of MSM and TGW in its plan to end its HIV epidemic,
and the centering of MSM and TGW in their own care and service delivery, directly
S. W. Beckham et al.
209
addresses these key populations’ substantial barriers to HIV prevention and care.
The strategies employed by TRCARC and local CBOs and healthcare settings have
the potential to signicantly impact these individuals’ rates of uptake and access to
these life-saving services, and they should be scaled up accordingly. Thus, these
approaches, coupled with efforts to decrease stigma and discrimination, are neces-
sary and vital for the future of Thailand’s HIV epidemic, as well as the general
health and well-being of its LGBTQ community. Thailand’s population-specic
efforts and deliberate integration of these populations into their own care is a model
that can and should be replicated and localized elsewhere.
Acknowledgments We are grateful to Sara Wallach for her contribution to the case study on
Thailand’s HIV epidemic accompanying this chapter.
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Chapter 8
Global Epidemiology andSocial-Ecological
Determinants ofSubstance Use Disparities,
Consequences ofUse, andTreatment
Options Among Sexual andGender
Minority Populations
MatthewJ.Mimiaga, LynnKlasko-Foster, ChristopherSantostefano,
HarryJin, TarynWyron, JackieWhiteHughto, andKatieBiello
8.1 Introduction
Substance use is entwined with individuals’ overall well-being, and with mental
health in particular. Comorbid mental health conditions are common among indi-
viduals who misuse substances. In the United States, 60% of adults with substance
use disorders (SUDs) also suffer from another mental illness; rates of mental illness
are similar among users of tobacco and alcohol (NIDA, 2018a, b). Sexual minority
stress in addition to substance use can negatively impact self-care, lead to
M. J. Mimiaga (*)
UCLA Center for LGBTQ+ Advocacy, Research & Health and Department of Epidemiology,
UCLA Fielding School of Public Health, Los Angeles, CA, USA
e-mail: mmimiaga@ph.ucla.edu
L. Klasko-Foster
Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown
University, Providence, RI, USA
e-mail: lynne_klasko-foster@brown.edu
C. Santostefano
Center for Gerontology and Healthcare Research, School of Public Health, Brown University,
Providence, RI, USA
e-mail: christopher_santostefano@brown.edu
H. Jin
Department of Epidemiology, School of Public Health, Brown University,
Providence, RI, USA
e-mail: Harryjin10@gmail.com
T. Wyron
Department of Behavioral and Social Sciences, School of Public Health, Brown University,
Providence, PA, USA
e-mail: twyron@reconstructingjudaism.org
© The Author(s) 2024
S. J. Hwahng, M. R. Kaufman (eds.), Global LGBTQ Health, Global LGBTQ
Health, https://doi.org/10.1007/978-3-031-36204-0_8
222
internalized stigma, and increase sexual risk behavior (Brown & Pantalone, 2011;
Johnson etal., 2008; Lehavot & Simoni, 2011; Scheer & Antebi-Gruszka, 2019;
Stall etal., 2003).
In order to understand the impact of substance use and misuse, health services
research, jointly funded by the US National Institutes of Health (NIH) and the US
Department of State, addresses a range of addiction service development questions
in low- and middle-income countries. Additionally, research on a variety of sub-
stance use disorders has been funded by the World Health Organization (WHO),
and the US Substance Abuse and Mental Health Services Administration (SAMHSA)
administers an annual survey of adolescents and adults in the United States with
respect to substance use and misuse and health. Each category of substances gener-
ates a particular cluster of effects of the drug on the central nervous system and
limbic system (NIDA, 2012). The long-term effects of misuse of the various catego-
ries of substances are outlined below.
Legal Substances Across the globe, many countries regulate the legal use of alco-
hol and tobacco by adults (ages vary by country). Effects of long-term alcohol use
can include heart and liver disease, as well as fetal damage for pregnant women
(NIDA, 2012). Tobacco use is associated with many cancers, along with lung and
cardiovascular disease (NIDA, 2012).
Cannabinoids The legal status of marijuana is mixed according to country-specic
and state laws, with patchwork legalization of medical marijuana use and recre-
ational use (NASEM, 2017). Among all drugs, marijuana is used most commonly;
20.6million people aged 12 or older in the United States used it in the past month
(SAMHSA, 2018). In clinical research, cannabis has been noted to have therapeutic
effects as a pain reliever but is also linked to cancers and respiratory disease (when
smoked) (NASEM, 2017).
Tranquilizers It is not uncommon for individuals to misuse prescribed tranquiliz-
ers such as benzodiazepines. In 2017, 1.7million people in the United States over
the age of 12 reported illicit tranquilizer use in the past month (SAMSHA, 2018).
These prescription sedatives work to calm or sedate a person by raising levels of the
neurotransmitter GABA found in the brain (NIDA, 2018c).
J. W. Hughto
Department of Epidemiology, School of Public Health, Brown University, Providence,
RI, USA
Department of Behavioral and Social Sciences, School of Public Health, Brown University,
Providence, RI, USA
e-mail: jaclyn_hughto@brown.edu
K. Biello
Department of Behavioral and Social Sciences, School of Public Health, Brown University,
Providence, RI, USA
e-mail: katie_biello@brown.edu
M. J. Mimiaga etal.
223
Narcotics The misuse of opioids, including prescription pain medication and illicit
heroin use, has reached large-scale crisis in the United States, with more than 100
deaths daily due to opioid overdose. According to the National Survey on Drug Use
and Health (NSDUH), “In 2017, an estimated 11.4 million people misused opioids
in the past year, including 11.1 million pain reliever misusers and 886,000 heroin
users” (SAMHSA, 2018, p.18). Because opioid intoxication affects the brain stem,
which controls heart rate, breathing, and sleeping, overdose carries a high risk of
lethality (NIDA, 2018b).
Stimulants Cocaine, amphetamines, and methamphetamines are highly addictive
and raise the risk of stroke, cardiac conditions, or seizures (NIDA, 2012). Over
time, cocaine use depletes the levels of dopamine D2 receptors in the brain, which
may affect users’ ability to exercise self-control (NIDA, 2018b).
Hallucinogens Lysergic acid diethylamide (LSD) is classied as a hallucinogen
(inducing altered states of sensory perception), while phencyclidine (PCP) and
Ketamine are identied primarily by their dissociative effects (causing users to feel
separate from their bodies and/or the surrounding environment) (NIDA, 2012).
Methylenedioxymethamphetamine (MDMA), more commonly known as ecstasy,
affects the body’s processing of the neurotransmitter serotonin, which induces
empathic feelings. It is classied as a club drug alongside Rohypnol and Gamma-
hydroxybutyrate (GHB), which have strong sedative effects (NIDA, 2012).
Anabolic-Androgenic-Steroids The misuse of anabolic-androgenic steroids by
adolescent boys and adult men with body image concerns—with higher rates of use
among gay and bisexual men—has been found to cause cardiovascular and endo-
crine damage over the long term (Blashill & Safren, 2014; NIDA, 2017).
This chapter identies current research ndings on substance use and misuse for
sexual and gender minority populations across the globe. It explicates some of the
multi-dimensional health and social consequences that follow from substance mis-
use and that must be considered in the development of effective treatment for sexual
and gender minority individuals (NIDA, 2018a). Given the members of sexual and
gender minority communities embody tremendous heterogeneity, it is not possible
to generalize all experiences of members of these varied groups. Rather, this sum-
mary will review current and emerging research trends focused on risk and protec-
tive factors for substance misuse and associated health concerns for sexual and
gender minority individuals, with specic attention to the “social discrimination,
personal and community social and behavioral risk factors, and certain unique med-
ical conditions” that may emerge from individuals’ specic gender identities or
sexual practices (Johnson etal., 2008, pp.214–215).
8.2 Epidemiology
In 2017, 5.5% of the world’s population (ages 15–64) engaged in some form of
substance use (UNODC, 2019). Estimates over the past 10years show increas-
ing use of opioids in Asia, Africa, Europe, and North America and increasing
8 Global Epidemiology and Social-Ecological Determinants of Substance Use…
224
use of cannabis in Asia, North America, and South America (UNODC, 2019).
While cannabis use is the most widespread (188 million people reported using
cannabis in 2017), global opioid use is rapidly increasing. In 2017, 53 million
people reported use of opioids, an increase of over 50% from 2016 data
(UNODC, 2019).
Sexual and gender minorities experience signicantly elevated rates of sub-
stance use and substance use disorders compared to cisgender heterosexuals
(Marshal etal., 2008; Schuler etal., 2018). Global research shows a pattern of
higher rates of alcohol-related problems, alcohol-use disorders, and marijuana
and illicit drug use among SMW compared to heterosexual women (Hughes
etal., 2020).
And global surveillance suggests that non-binary individuals and transgender
women (TGW) have greater odds of substance use than other gender groups
(Connolly etal., 2020). In the United States, national survey ndings show that
compared to heterosexuals, sexual and gender minority individuals are more
likely to be heavy tobacco smokers, smoke marijuana, use illicit drugs, and be
heavy drinkers (Cochran etal., 2013; Gonzales et al., 2016; Roxburgh etal.,
2016). There is also an indication that sexual minority individuals in the United
States are more likely to misuse opioids compared to heterosexuals (Anderson-
Carpenter & Rutledge, 2020; Capistrant & Nakash, 2019; Duncan etal., 2019;
Girouard, 2018; Morgan etal., 2020) and are prescribed opioids at higher rates
(Girouard etal., 2019; Robinson etal., 2020). This disparity in lifetime opioid
misuse is consistent across population subgroups including military veterans
(Anderson-Carpenter & Rutledge, 2020) and youth (Wilson et al., 2020).
However, these results are likely underestimated as some national data systems,
such as the NSDUH, have only begun collecting data on sexual orientation
within the last 5years. As increasing representativeness of data to include sex-
ual and gender minority Americans is a national priority, the scope of drug and
alcohol-related disparities will likely become clearer over the next decade.
There is generally a lack of sexual and gender minority population-level,
country- specic data on the prevalence of substance use and misuse.
Internationally, measurement issues exist in determining the incidence and
prevalence of substance use among LGBT-GNC populations, as 70 countries
criminalize same-sex behavior, which is a major deterrent to data capture
(ILGA, 2019). For transgender population health research, survey items are not
standardized and consistently operationalized, which limits both accurate sur-
veillance and generalizability (Reisner etal., 2016a). Additionally, much of the
focus of empirical research does not include sexual minority women (SMW),
and the majority of research on SMW and substance use has been conducted in
the United States (Hughes etal., 2020). In this section, we report on the epide-
miology of substance use across Africa, Asia, the Americas, and Europe. We
then provide an overview of the epidemiology of substance use and addiction by
sexual and gender minority groups.
M. J. Mimiaga etal.
225
8.2.1 Epidemiology ofSubstance Use Among Sexual
andGender Minorities: Africa andtheMiddle East
Substance use data among sexual and gender minorities in Africa are very limited,
with differences in availability of surveillance based on sexual orientation or gender
identity. For some countries, such as Nigeria and Mozambique, more data are avail-
able for urban areas. For example, in Lagos, 15.4% of men who have sex with men
(MSM) were reported to be current smokers (Odukoya et al. 2013). In terms of
alcohol consumption, 34.1% of MSM in Lagos were current drinkers, and half of
the current drinkers were described to have a drinking problem (Odukoya etal.,
2017). Furthermore, 43.8% of MSM in Maputo were classied as problem drinkers
(Sandfort etal., 2017). Cannabis use in the 12months preceding the survey was
reported by 11.8% of MSM in Maputo; less than 3% of MSM used other drugs
(Sandfort etal., 2017). There has been a rapid increase in the number of studies on
substance use as a risk factor for HIV/AIDS in sub-Saharan Africa; however, the
majority of these studies have focused on heterosexuals (Hahn et al., 2011;
Kalichman etal., 2007; Woolf-King & Maisto, 2011).
8.2.1.1 Sexual Minority Men
A systematic review of research focused on substance use and HIV among MSM in
Africa found that, compared to African heterosexual men, MSM report more fre-
quent alcohol consumption (Sandfort etal., 2017). The prevalence of alcohol use
varies greatly by country among MSM– 50% in South Africa (McAdams-Mahmoud
etal., 2014) to 100% in Kenya (King etal., 2013). Alcoholism is also prevalent in
certain African countries. For example, one study found that 44.4% of Black MSM
in South Africa were classied as hazardous drinkers based on the AUDIT scale
(Sandfort etal., 2015), a simple and effective method of screening for unhealthy
alcohol use, dened as risky or hazardous consumption or any alcohol use disorder.
Additionally, the proportion of MSM categorized as hazardous drinkers ranged
from 32.3% to 43.8% in Mozambique (Nala etal., 2015), and 22.7% of MSM in
Kenya are estimated to be alcohol dependent (Muraguri etal., 2015). Cannabis is
the most commonly used drug among MSM across the African continent (Sandfort
et al., 2017). Approximately 8.2% of MSM used cannabis in the past 12months
(Chapman et al., 2011), and 29% reported ever using cannabis (Nyoni & Ross,
2013). The review also identied a study conducted in a health clinic in South
Africa, which reported that 37% of their MSM patients reported having ever used
crystal methamphetamine (Sandfort etal., 2017). Injection drug use (IDU) is a pub-
lic health concern in certain African countries (Sandfort etal., 2017). The 3-month
prevalence of injection drug use ranged from 1.4% of MSM in Kenya (Sanders
etal., 2007) to 13.9% in Tanzania (Johnston etal., 2010).
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8.2.1.2 Sexual Minority Women
Studies in southern Africa also indicate high prevalence of drug and alcohol use
among SMW, but there is a lack of research focusing specically on substance use
among lesbian women compared to other groups (Muller & Hughes, 2016).
8.2.1.3 Transgender Populations
Studies enrolling gender minority participants in Middle Eastern countries had
small sample sizes and use non-probability sampling techniques. Additionally, gen-
der dysphoria diagnosis is often part of inclusion criteria; however, being transgen-
der is not a medical condition, and many transgender individuals do not experience
mental health distress associated with differences between their sex at birth and
gender identity. As such, ndings likely do not describe substance use among trans-
gender individuals across the region. One study in Iran that included both transmen
and transwomen with gender dysphoria (n= 97) recruited from outpatient sexual
health clinics reported lower rates of substance use than the general population
(Mazaheri Meybodi etal., 2014). A Turkish study similarly recruiting transgender
individuals with gender dysphoria from psychiatric clinics (n=94) indicated that
transmen were more likely than transwomen to use tobacco (35% vs. 5%) and alco-
hol (27% vs. 11%; Başar etal., 2016).
8.2.2 Epidemiology ofSubstance Use Among Sexual
andGender Minorities: Asia andAustralia
Alcohol and drug use is a serious problem in Asia and Australia among sexual and
gender minorities, and more efforts need to be made to address this issue. However,
for Asia, it is difcult to make country and city-specic comparisons when it comes
to alcohol and drug use due to a lack of population-level data and varying ways of
measuring data among sexual and gender minority populations. Data from
Melbourne, Australia, shows that 22.0% of sexual minorities reported drinking that
exceeds lifetime risk guidelines, and 38.0% reported drinking that exceeds single-
occasion risk guidelines (Tantirattanakulchai & Hounnaklang, 2021). Additionally,
16% of lesbian, gay, and bisexual individuals in Melbourne reported smoking
tobacco daily (Australian Institute of Health and Welfare, 2021). On average, the
prevalence of any substance use over the prior year in Melbourne among this popu-
lation is 40.0% (Tantirattanakulchai & Hounnaklang, 2021).
M. J. Mimiaga etal.
227
8.2.2.1 Sexual Minority Men
In terms of meeting diagnostic criteria for alcohol use disorder, the highest was seen
in the Philippines with a prevalence of 24.7% among MSM whereas gay and bisex-
ual men in the Philippines have a 71.3% prevalence of smoking (Manalastas, 2012).
The body of research describing substance use among MSM in Asia is also growing.
Illicit substances, particularly amphetamine-type stimulants (e.g., ecstasy, metham-
phetamine), have become more common in Asia and Southeast Asia (McKetin
etal., 2008). A study in Indonesia found that approximately 15% of MSM reported
using methamphetamine before having sex; however, the proportion of MSM who
have done so is higher in major cities, such as Jakarta (31%) and Medan (25%)
(Morineau etal., 2011). Similarly, a study in Thailand reported that of the 19.2% of
their sample who used illicit drugs, 32.0% used methamphetamine, 50.0% used
club drugs (e.g., ketamine, ecstasy), and 42.0% used sedatives/hypnotics in the past
3months (Newman etal., 2012). Studies conducted in China reported that 40–77%
of MSM used synthetic drugs (e.g., methamphetamine, mephedrone, poppers) (Luo
etal., 2018).
An online cross-sectional study of 10,861 MSM across Asia reported that 16.7%
of participants reported recreational drug use in the past 6months, with ecstasy
(8.1%) and Viagra (7.9%) being the most common recreational drugs (Wei etal.,
2012). Another study of MSM in China found that 28.0% of 3830 participants
reported recreational drug use in the past 6months (Xu etal., 2014a, b). The most
common recreational drug used was poppers, used by 26.5% of the sample in the
past 6months. Substance use among MSM in Japan is also common with approxi-
mately 65% self-reporting lifetime substance use (Hidaka etal., 2006). This study
also found that substance use primarily involves poppers, with 63.2% of their sam-
ple reporting lifetime use.
8.2.2.2 Sexual Minority Women
Lesbian and bisexual women in the Philippines have a startlingly high prevalence of
smoking, at 24.3%. This statistic is mirrored in Australian research, which has
found that among lesbian and bisexual women, 30% percent were current smokers,
including 48% of 16- to 24-year-olds (Deacon & Mooney-Somers, 2017). Also in
this setting, lesbian and bisexual women, are more likely to partake in high-risk
drinking and daily drinking, and to report ever having attended treatment than het-
erosexual women (Roxburgh etal., 2016). The Australian Longitudinal Study on
Women’s Health (ALSWH) further supports this nding (Hughes et al., 2010).
From these data, we see that there is a need to address the issue of smoking and
alcohol use among lesbian and bisexual women.
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8.2.2.3 Transgender Populations
There are limited data available among transgender individuals at the population
level. The data that are available reveal that 79.1% of transgender women and 75.1%
of transgender men in Bangkok, Thailand reported using alcohol in the previous
year (Wichaidit etal., 2021). In that same region, the data specic to smoking (i.e.,
using tobacco products) shows that 67.0% of transgender women and 56.9% of
transgender men report having smoked in the previous year (Hiransuthikul etal.,
2019). Specically among transgender women in this same region, the prevalence
of sexualized drug use was high, with 52.7% reporting this behavior in the prior
12months (Newland & Kelly-Hanku, 2021); with respect to specic drugs, mari-
juana prevalence was 6.2% (versus 2.9% among their cisgender peers), kratom was
4.9%, and 1.9% reported crystal methamphetamine use (Hyde etal., 2013).
8.2.3 Epidemiology ofSubstance Use Among Sexual
andGender Minorities: Central andSouth America
8.2.3.1 Sexual Minority Men
Among an online sample of MSM covering all Latin American countries, 16% per-
cent reported hazardous alcohol use, and 5.3% reported any hard drug use (e.g.,
methamphetamine, GHB, cocaine, etc.) in the past 30days (Mimiaga etal., 2008a,
b, c). In Chile, the prevalence of sexualized drug use is 24%, with cannabis, pop-
pers, and Viagra most often used (Donoso & Ávila, 2020). In Peru, 58% of MSM
reported problematic drinking in one study, which was signicantly associated with
risky sexual behavior (Deiss etal., 2013). Research conducted across Latin American
countries concludes that MSM with histories of childhood trauma are more likely to
engage in hazardous alcohol use (Wang etal., 2017),
8.2.3.2 Sexual Minority Women
SMW in Latin America and the Caribbean also report higher rates of tobacco and
alcohol use than heterosexual women (Caceres et al., 2019). SMW in Mexico
reported signicantly more alcohol and tobacco use and more experiences of dis-
crimination and violence than same-age heterosexual women, (Ortiz-Hernandez
etal., 2009). In another study only sampling sexual minority Mexican women, 21%
met the criteria for alcohol dependence (Ortiz-Hernández & García Torres, 2005).
In Colombia, sexual minority adolescent girls reported sixfold greater illicit drug
use compared to heterosexual youth (Díaz etal., 2005). Of 145 women recruited
during Pride activities in Sao Paulo, Brazil, 62% reported frequent use of alcohol,
50% reported frequent use of tobacco, and 77% reported past year drug use, with
45% of these women reporting marijuana use and 16% reporting cocaine use (Pinto
etal., 2005).
M. J. Mimiaga etal.
229
8.2.3.3 Transgender Populations
Findings from an online survey of over 200 Brazilian transgender youth indicated
that cannabis and pain medication are frequently used by this population (Fontanari
etal., 2019). A study assessing factors associated with viral suppression in 50 trans-
women living with HIV in Peru reported high rates of problematic alcohol and drug
use and associations between moderate to severe drug use and decreased likelihood
of viral suppression (Rich etal., 2018).
8.2.4 Epidemiology ofSubstance Use Among Sexual
andGender Minorities: North America
Across the Americas, research indicates that alcohol and drug use is prevalent
among gay, bisexual, and other MSM, and transgender women. According to Pakula
etal., 26.2% of gay, bisexual, and other MSM reported drinking alcohol at least
3days per week, and 10.6% were heavy drinkers. Meanwhile, marijuana was the
drug most likely to be used (across NewYork, Chicago, San Francisco, and Denver,
on average, 46.3% used), followed by 36.6% poppers (amyl nitrates), 24% halluci-
nogens, 19.3% cocaine and 12.9% crystal methamphetamine (Koblin etal., 2003).
In addition, 10% of these MSM had recent injection drug use. In terms of transgen-
der women, drug use did not vary much by US. city, with 11.2%, on average, having
alcohol dependence and 15.2%, on average, having substance use dependence
(Reisner etal., 2016b). Lastly, a study describing substance use among LGBTQ+
individuals in Mexico revealed that 94% reported current alcohol use, and 58%
reported tobacco use (Zavala-Arciniega etal., 2020; Hoetger etal., 2020).
8.2.4.1 Sexual Minority Men
Alcohol use and binge drinking among gay men is a serious public health concern
in both the United States and abroad (Bux, 1996; Irwin etal., 2006; Liu etal., 2016;
Mimiaga etal., 2011, 2015). In the United States, the National HIV Behavioral
Surveillance system, which recruits study participants from 20 US cities, estimates
that approximately 85% of MSM are current drinkers and 59% binge drank at least
once in the past month (Hess etal., 2015). Recent data from the National Health
Interview Survey shows that MSM had increased odds of binge drinking and smok-
ing tobacco compared to heterosexual men (Gonzales etal., 2016). A study con-
ducted among MSM in San Francisco found that 67% reported binge drinking at
least once in the past year compared to only 23.2% of heterosexual men (Center for
Disease Control & Prevention, 2012). In comparing within the MSM category, one
study found that bisexual men had higher rates of cigar use compared to gay men
(Schuler & Collins, 2020).
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230
8.2.4.2 Sexual Minority Women
Substance use among SMW does not closely resemble the behaviors of MSM since
illicit drug use is uncommon. Among lesbian communities, heavy alcohol and
tobacco use are the most pervasive health issues (Hughes, 2003). National Health
Interview Survey data from the United States shows that compared to heterosexual
women, sexual minority women have increased odds of heavy drinking (OR, 2.63;
95% CI, 1.54–4.50) and heavy smoking (OR, 2.29; 95% CI, 1.36–3.88) (Gonzales
etal., 2016). In a primarily Black and Latina sample in the United States, SMW
were more likely to have developed cocaine and/or crack dependency compared to
heterosexual women (Ompad etal., 2011). These results have been conrmed by
epidemiologic surveys at the state level (Aaron etal., 2001; Gruskin & Gordon,
2006). A meta-analysis of studies conducted in seven countries in North America,
Europe, and Australasia found that the risk of past-year alcohol and other drug
dependence was 4 times higher among SMW than heterosexual women for alcohol
dependence and 3.5 times higher for drug dependence (King etal., 2008).
One study examining illicit drug use among SMW found that marijuana was the
only commonly used illicit drug, with 33% of their sample having used marijuana
in the past year (Corliss etal., 2006). Study participants also reported using other
illicit drugs, such as stimulants (6.0%), methamphetamine (2.1%), tranquilizers
(11.6%), and sedatives/hypnotics (8.0%).
Bisexual women may be at greater risk for substance use and substance use dis-
orders compared to women who only have sex with women or who only have sex
with men (Ford & Jasinski, 2006; Halkitis & Palamar, 2008; Tucker etal., 2008;
Wilsnack etal., 2008), even when controlling for openness about sexual orientation
(Thiede etal., 2003). Bisexual women are more likely to be heavy drinkers and
smoke tobacco (Gonzales etal., 2016) and use illicit drugs (Paschen-Wolff etal.,
2019) compared to heterosexual women. Among sexual minorities, bisexual women
also had higher rates of substance use compared to lesbian/gay women (Schuler &
Collins, 2020). One possible explanation for these disparities is lack of social capi-
tal and minority stress, as bisexuals experience prejudice and discrimination from
homosexuals and heterosexuals (Balsam & Mohr, 2007; Fox, 2013).
8.2.4.3 Transgender Women
Although the body of research examining substance use disorders among transgen-
der communities is still limited (Flentje etal., 2015), existing studies report that
transgender women exhibit high rates of alcohol, marijuana, illicit drug, and non-
medical prescription drug use (Benotsch et al., 2013; Cochran & Cauce, 2006;
Garofalo etal., 2006; Hughes & Eliason, 2002; Peacock etal., 2015; Reisner &
Murchison, 2016; Santos etal., 2014). In the United States, the majority of studies
that focus on the health of transgender women have relied on convenience sampling
since national surveys only recently began including gender identity-related ques-
tions that allow respondents to indicate they are transgender (Flentje etal., 2015).
M. J. Mimiaga etal.
231
A prospective cohort study of transgender women in NewYork City reported
that 76.2% of their sample used any substances (e.g., alcohol, cannabis, cocaine,
heroin, amphetamines, methamphetamines, LSD, etc.) within 6 months prior to
enrolling in the study (Nuttbrock etal., 2014). When examining substance use at all
study assessments (6, 12, 24, and 36months), the range of period prevalence esti-
mates were high for any substance use (72.8–78.2%), heavy alcohol use
(48.4–60.4%), cannabis use (29.1–40.0%), and cocaine use (20.7–25.3%).
A respondent-driven sampling study examining the health of 314 transgender
women in San Francisco reported similarly elevated rates of substance use (Santos
etal., 2014). This study found that in the past 6 months, 58.0% of transwomen
drank alcohol. Additionally, they found that in the past 12months, 29.0% used
marijuana, 20.1% used methamphetamine, 13.4% used crack cocaine, and 13.1%
used club drugs (i.e., ecstasy, GHB, ketamine, poppers).
There is a lack on research of non-medical use of prescription drugs among
transgender women; however, one study found that 24% of 104 transgender women
sampled reported lifetime non-medical use of prescription drugs (i.e., analgesics,
anxiolytics, stimulants, and sedatives) (Benotsch etal., 2016).
Substance use among adolescents in the general population of the United States
has declined over the past decade; however, disparities with respect to substance use
are widening between sexual and gender minority youth and their cisgender hetero-
sexual counterparts (Homma etal., 2016; Hughes & Eliason, 2002). Transgender
youth are more likely to begin using substances earlier than cisgender youth (Day
etal., 2017), and there is growing evidence that transgender adolescents have greater
odds of using alcohol, marijuana, and other illicit drugs compared to cisgender
peers (Reisner etal., 2015). These results were consistent with other studies of ado-
lescent transgender populations. A study reported that US transgender students had
2.5 times the odds of using cocaine or methamphetamine during their lifetime and
more than 3 times the odds of using cigarettes at school compared to cisgender stu-
dents (De Pedro etal., 2017). Another study of ethnic minority MTF transgender
youth found that within the past year, 71% of their cohort used marijuana, 65% used
alcohol, 23% used ecstasy, and 21% used cocaine (Garofalo etal., 2006).
Despite many studies reporting high rates of substance use among transgender
women, there is a lack of evidence-based interventions and programming speci-
cally designed to meet the healthcare and welfare needs of this population, further
exacerbating the health disparities between the transgender and cisgender commu-
nities (Glynn & van den Berg, 2017).
8.2.4.4 Transgender Men
There has been a recent shift in the eld of public health to prioritize research to
better understand the health of transgender men and women; however, very few
empirical, peer-reviewed studies focusing on the health of transgender men have
been published (MacCarthy etal., 2015). One US-based study found that in the past
3months, approximately 10% of the sample of 468 transgender men engaged in
8 Global Epidemiology and Social-Ecological Determinants of Substance Use…
232
regular heavy alcohol use, 10% binge drank, 31% used marijuana, and 11.5% used
another illicit drug (Horvath etal., 2014). A study conducted among transgender
men who were patients at a community health center in Boston, Massachusetts also
found high rates of current substance use (Reisner, White, etal., 2014b). The authors
reported that 65.2% of their sample of 23 transgender men drank 5+ alcoholic bev-
erages a week, 17.4% were current marijuana users, 13.0% were current tobacco
smokers, and 69.6% used any substance.
8.2.4.5 Racial andEthnic Disparities
Social acceptability of drinking and drug use can be tied to both culture and gender,
impacting use patterns (Hughes etal., 2016). As such, in countries that value tradi-
tional gender roles, whereby it is more acceptable for men to drink alcohol than
women, alcohol use rates may diverge more for sexual minority women than men
(Talley etal., 2014). National Youth Survey data from Mexico reports greater alco-
hol use among sexual minority women as compared to heterosexual women, but no
difference between men based on sexual orientation (Ortiz-Hernández, 2005). An
analysis of BRFSS data in the US state of Washington shows similar patterns for
Hispanic sexual minority women compared to their Hispanic heterosexual counter-
parts (Kim & Fredriksen-Goldsen, 2012).
8.2.5 Epidemiology ofSubstance Use Among Sexual
andGender Minorities: Europe
Comparisons regarding alcohol and drug use across cities in Europe are challenging
because not every city has disaggregated data among sexual and gender minorities,
and the data that are measured and reported vary in terms of quantity, frequency, and
severity of use versus a diagnosis of substance use disorder. Data that were available
at the population level revealed that 35.4% of MSM in Dublin report current smok-
ing, and in Copenhagen, 1in 5 LGBT individuals smoke daily, and 25.0% of bisex-
ual women smoke cannabis in this setting (Barrett etal., 2019; Hansen etal., 2018).
In Glasgow and London, 15.0% of LGBT individuals report smoking every day;
whereas 43.1% of MSM in Paris report using cigarettes or e-cigarettes daily
(Bachmann & Gooch, 2018; Bridger etal., 2019; Park etal., 2018).
In Copenhagen, 16.0% of gay men exceed the high-risk limit (21units of alco-
hol/week), and 17% of transgender individuals drink more than 17.5units/week
(Hansen etal., 2018). Among LGBT individuals in London and Glasgow, 16% and
14% report daily drinking, respectively (Bachmann & Gooch, 2018; Bridger etal.,
2019). Among MSM in Dublin, 58% report binge-drinking in the last 12months,
whereas 46.7% of MSM in Paris report alcohol use (ve or more drinks in one sit-
ting) (Barrett etal., 2019; Park etal., 2018).
M. J. Mimiaga etal.
233
8.2.5.1 Sexual Minority Men
In terms of meeting diagnostic criteria for potential alcohol dependency, the highest
was seen in Kyiv with a prevalence of 30.6% among MSM, followed by Berlin
(22.1%), Vienna (21.8%), Brussels (18.0%), Lisbon (14.8%), Madrid (14.9%),
Prague (14.4%), Amsterdam (13.5%), Milan (10.8%), and Athens (10.1%). In a
study of over 1300 MSM in Moscow utilizing respondent- driven sampling, 32.4%
endorsed hazardous drinking, and 20.3% endorsed alcohol dependence (Wirtz etal.,
2016). Multivariate logistic regression analysis showed that the odds of inconsistent
condom use, selling or buying sex, and recreational drug use were twofold for haz-
ardous and dependent alcohol users relative to low- level drinkers. Alcohol depen-
dence was also associated with fourfold odds of injection drug use (Wirtz
etal., 2016).
While alcohol is among the most commonly used substances by MSM, illicit
stimulant drugs have become more ubiquitous in gay communities. Researchers in
England and Wales found that, compared to heterosexual men, gay and bisexual
men were three times more likely to have used an illicit drug in the past 12months
and seven times more likely to have used illicit stimulants drugs (e.g., cocaine and
ecstasy; Hunter etal., 2014). Among MSM in Paris and Dublin, 54.5% and 36.0%,
respectively, have a prevalence of any current illicit substance use (Barrett etal.,
2019; Park etal., 2018). Importantly, in terms of active use, 11% and 13% of LGBT
individuals (18–24years old) in Glasgow and London, respectively, report using
drugs at least once a month (Bachmann & Gooch, 2018; Bridger et al., 2019).
Among over 1500 sex workers in Amsterdam, MSM were more likely to use illicit
drugs, including cocaine, nitrites, and erectile performance drugs, only during sex
work compared to male sex workers with strictly female clients (40.5% of MSM
compared to 20.0% MSW; Drückler etal., 2020). The most cited reasons for drug
use during sex were “sex work becomes physically easier,” and “the client asked for
it” (Drückler etal., 2020, p.120).
8.2.5.2 Sexual Minority Women
There are no available studies that provide disaggregated data examining the sub-
stance use of sexual minority women in Europe nor comparing their substance use
to that of their heterosexual counterparts.
8.2.5.3 Transgender Populations
In the same study of drug use behavior among sex workers in Amsterdam, trans-
feminine sex workers were more likely to use drugs only during sex work compared
to men who only had sex with female clients (40.0% compared to 20.0%, Drückler
etal., 2020).
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8.3 Social-Ecological Determinants
The root causes of increased substance use and substance use disorders among sex-
ual and gender minorities are complex. As such, examination of factors beginning
at the individual level and extending to social and structural factors is important to
understanding the breadth of the problem and designing effective interventions to
increase health equity. Below, we compile evidence-based explanations for sexual
and gender minority substance use/abuse disparities, including minority stress and
related mental health issues; social, interpersonal, and cultural factors; and struc-
tural/environmental factors.
8.3.1 Sexual andGender Minority Stress Model: AFramework
forUnderstanding Disparities
The minority stress model posits that sexual and gender minority populations expe-
rience stressors unique to their sexual orientation or gender identity. These stressors
can be related to external experiences (e.g., discrimination), anticipated social
stigma (e.g., hiding identity), or internalized/enacted homophobia/transphobia.
Each of these experiences can create hostile and stressful social environments that
increase the risk of poor mental health outcomes (Meyer, 2003). Minority stress
compounded on top of stressors experienced by the general population is thought to
put minorities at elevated risk for poor health outcomes (McCabe etal., 2010).
Minority stress experienced by sexual and gender minority individuals is associated
with an increase in the risk of substance use (Amadio, 2006; McCabe etal., 2010),
which has been found to serve as a coping mechanism to mollify the effects of dis-
crimination (Goldbach etal., 2014; Green & Halkitis, 2006; Mereish etal., 2014).
8.3.2 Psychosocial Factors that Potentiate Substance Use
Sexual and gender minority populations are more likely than cisgender heterosexuals
to experience poor mental health (see Mental Health chapter, Chap. 3) (Lea etal.,
2014). A recent meta-analysis found that compared to cisgender heterosexuals, sex-
ual and gender minorities experienced more severe depressive symptoms, greater
likelihood of reporting a suicide attempt, and greater odds of substance use (Marshal
etal., 2008, 2011). Both mental health and substance use disparities between sexual
and gender minorities and cisgender heterosexuals emerge early in adolescence and
continue through adulthood (Bränström etal., 2016; Dermody etal., 2014; Marshal
etal., 2008). A national longitudinal study of substance use and mental health among
sexual minorities in the United States found that while these disparities manifest
early in life, evidence suggests the disparities do not increase over time (Needham,
M. J. Mimiaga etal.
235
2012). Other studies also suggest that the severity of mental health issues and sub-
stance use can be elevated by minority stress and often co-occur among sexual and
gender minorities (Pachankis, 2015; Pakula etal., 2016a; Rosario etal., 2009); how-
ever, research evaluating how substance use exacerbates mental health issues or vice
versa among sexual and gender minorities is limited.
A compelling body of global research shows that sexual and gender minorities
are more likely to experience victimization (see Victimization and Intentional Injury
chapter, Chap. 9; Balsam etal., 2005; D’Augelli, 2003; Hughes etal., 2007) and
substance use (Drabble etal., 2005; Omoto & Kurtzman, 2006) compared to cisgen-
der heterosexuals. There is also research suggesting that sexual and gender minority
populations who experience victimization are more likely to engage in substance
use, possibly to temporarily cope with negative feelings elicited by sexual and gen-
der minority-related victimization (Cooper etal., 1995; Holl etal., 2017; Mereish
etal., 2014).
8.3.3 Social, Interpersonal, andCultural Factors that Drive
Use Among Sexual andGender Minorities
It is hypothesized that the increased risk in substance use among sexual and gender
minorities is due in part to a combination of social, interpersonal, and cultural fac-
tors (Demant etal., 2018; Green & Halkitis, 2006; Mereish et al., 2014; Meyer,
2003). Across the globe, afliation with “gay culture” has been suggested to elevate
substance use among sexual and gender minority communities (Green & Feinstein,
2012). Countries in the Global South, including Brazil, South Africa, and Thailand,
have active cultural institutions for sexual and gender minorities, such as bars, sau-
nas, bathhouses, massage parlors, etc. (see Community and Social Support chapter,
Chap. 6; Shrestha etal., 2020; Hattingh & Bruwer, 2020). Researchers have hypoth-
esized that the increase in the number of gay bars in particular may have increased
substance use among sexual and gender minorities, especially gay men (Green &
Feinstein, 2012). Several studies have found that frequent attendance at gay social
venues (e.g., gay bars, bath houses) is associated with higher rates of substance use
(Halkitis & Parsons, 2002; Kipke etal., 2007).
8.3.4 The Role ofContextual, Environmental, andStructural
Factors inSubstance Use Among Sexual
andGender Minorities
There are several documented barriers to accessing treatment services by sexual and
gender minorities (Flentje etal., 2016). Sexual and gender minorities may encoun-
ter biases from providers within substance use programs that may result in poor
8 Global Epidemiology and Social-Ecological Determinants of Substance Use…
236
attendance or discontinuation of treatment (Cochran etal., 2007). Additionally, dis-
parities in health insurance coverage also exist between sexual and gender minori-
ties and cisgender heterosexuals, and as a result, sexual and gender minorities may
be less likely to be able to afford substance use treatment (Buchmueller & Carpenter,
2010). Despite these barriers, sexual and gender minorities are more likely to seek
substance use treatment compared to cisgender heterosexuals (McCabe etal., 2013).
8.4 Consequences ofUse
Over time, substance use can cause harm to mental and physical well-being, have
legal consequences, and injure or cause severance of social connections. These
effects, however, are not standard. While many people experience negative social or
health effects as a result of their substance use, some do not. The sequelae of sub-
stance misuse often further compound the effects of structural oppression, with
negative social consequences of substance use– ranging from stigma to incarcera-
tion- carrying a larger impact for individuals who experience marginalization on
multiple axes of identity (by both race and gender/sexual minority status, for
instance) (McCauley & Brinkley-Rubinstein, 2017).
8.4.1 HIV, Hepatitis C Virus, andOther Sexually
Transmitted Infections
Much of the literature on infectious disease within sexual and gender minority pop-
ulations addresses the risk for HIV and other sexually transmitted infections (STIs)
(see HIV chapter, Chap. 7), but no consensus exists on the specic causal link
between substance use and HIV/STI transmission (Abdulrahim etal., 2016). Both
non-injection and injection drug use (IDU) have been identied as factors that may
increase lifetime risk for acquiring HIV, due in part to the correlation between sub-
stance use and unprotected anal intercourse (UAI), more casual sex partners, and
other high-risk behaviors, such as transactional sex (Beyrer etal., 2007; Rosenberg
etal., 2011). Among gay and bisexual men and other MSM in the United States,
using multiple substances immediately before or during sex has demonstrated sig-
nicantly increased likelihood for UAI (Mimiaga, Mayer, etal., 2008a). In south-
east Asia, MSM who reported illicit drug use in the past 3months had almost six
times the odds of inconsistent condom use and nearly three times the odds of
exchanging sex with other men for money (Yi etal., 2015). For sexual and gender
minority people of color (POC) in the United States, recreational drug use in the
context of sex was shown to be correlated with serodiscordant UAI (Mimiaga etal.,
2010) and, in one epidemiological model, predictive of positive HIV serostatus
(Wilton, 2008). Although stimulant abuse is typically responsive to targeted
M. J. Mimiaga etal.
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psychosocial interventions, in the United States increased risk for HIV/STIs has
been observed with the use of hallucinogens and inhalants as well (Koblin etal.,
2003; Lambert etal., 2011; Ostrow etal., 2009). Excessive alcohol use is another
correlate of hard drug use and high-risk sexual activity among MSM in the United
States (Reisner etal., 2010), Latin America (Mimiaga etal., 2015), China (Liao
etal., 2014), India (Mimiaga etal., 2011), and Russia (Wirtz etal., 2016).
Substance use may also increase sexual risk-taking by other LGBT and gender
non-binary individuals. In the United States, illicit drug use in the past 3months was
identied as a statistically signicant mediator of the association between life stress
and sexual risk among transgender women (TGW), the majority of whom were
POC (Hotton etal., 2013). For Asian/Pacic Islander TGW in the United States,
recent use of alcohol or other recreational drugs was associated with greater odds of
engagement in transactional sex (Operario & Nemoto, 2005), and further analyses
among TGW have suggested that concurrent drug use during commercial sex work
may be predictive of HIV incidence (Hoffman, 2014). Because STIs are perceived
to be less commonly transmitted among SMW, this group often utilizes sexual
health prophylaxis and screening at lower rates, leading to potential missed diagno-
ses (Estrich etal., 2014). However, in a large sample of Asian Americans, lesbian
and bisexual women were about twice as likely as their heterosexual counterparts to
have had sex under the inuence or had more than one sex partner who may have
engaged in transactional sex or IDU in the past 6months, placing them at increased
risk for HIV and other STIs (Lee & Hahm, 2012). Similarly, a national survey in
Australia revealed that from 2004 to 2013, over half of SMW surveyed had been
exposed to hepatitis C (Iversen etal., 2015). Bisexual women in this study, followed
by lesbian women, had signicantly greater odds than heterosexual women of trans-
actional sex or needle sharing during IDU.
Several studies have identied women who have sex with women and men
(WSWM) who use drugs to be at high risk for HIV.Among drug users in NewYork,
one study found a higher prevalence of HIV in WSW, compared to both heterosex-
ual women and heterosexual men. However, they attributed higher HIV prevalence
to high-risk sexual behaviors rather than drug-using risk behaviors (Absalon etal.,
2006). Similarly, a study of young Latinx people who inject drugs in Harlem found
higher rates of HIV among WSW than heterosexual men (Diaz etal., 2001). A
population-based survey in Northern California also found that WSWM were more
likely to report high-risk sexual behavior, injection drug use, and serological mark-
ers for the hepatitis B and C viruses than women who had sex exclusively with men
(Scheer etal., 2002). Poor health outcomes, including increased HIV risk, among
drug-using WSWM are theorized to be the result of multiple marginalization due to
their gender, sexuality, race, class, and status as illicit drug users (Ompad etal.,
2011; Young etal., 2005). For example, compared to other young women, WSW
were found to be more likely to have been institutionalized or homeless (Friedman
etal., 2003; Ompad etal., 2011). WSW also report higher rates of violence victim-
ization and lower rates of health care utilization (Ompad etal., 2011). Research has
shown that many heroin-, crack-, and cocaine-using WSWM prefer women as their
relational and sexual partners, but often trade sex with men out of economic
8 Global Epidemiology and Social-Ecological Determinants of Substance Use…
238
necessity (Bell etal., 2006; Friedman etal., 2003; Ompad etal., 2011; Scheer etal.,
2002; Young etal., 2005).
In a qualitive interview study in the United States, many LGBT and gender non-
conforming (GNC) people living with HIV (PLWH) reported stimulant or opioid
use as a form of avoidance or self-medication to cope with the combined stigma of
their disease status with their sexual identity/gender expression (Gonzalez etal.,
2013; Semple etal., 2002). Those individuals who also used substances during sex
experienced impaired memory and judgment as well as schedule disruptions, lead-
ing to missed therapeutic antiretroviral doses and suboptimal treatment, increasing
potential HIV transmissibility to their sexual partners (Gonzalez etal., 2013; White
etal., 2014). Likewise, over half (60%) of PLWH who sought drug and alcohol sup-
port services at a community-based organization in the United Kingdom reported
decreased medication adherence while under the inuence, and nearly all (90%)
believed they had acquired HIV in a drug-using encounter (Stuart, 2013).
Co-infection of HIV with hepatitis C virus (HCV) is frequently seen in PWID,
although few studies specic to the LGBT community analyze the determinants of
HCV co-infection. Apparent correlates of increased infection risk include duration
of drug use, needle sharing, and lack of awareness (Abadie etal., 2017). Even in
more developed nations, knowledge and understanding of HCV, compared to other
STIs, is fairly low (De Ryck etal., 2011; Iversen etal., 2015), which further isolates
minority members. Australian individuals living with HCV described feeling mar-
ginalized from the LGBT community due to shared drug use but also ostracized
from the PWID community due to their sexual orientation/gender identity, leaving
them without support or resources (Deacon etal., 2013).
8.4.2 Chronic Disease
Variations in data collection and substance availability across countries create chal-
lenges in measuring the global burden of disease secondary to drug use; there is a
notable scarcity of evidence evaluating newer synthetic drugs and prescription med-
ication abuse. Conversely, non-illicit substances like tobacco and alcohol are known
to contribute signicantly to chronic disease prevalence, with health complications
ranging from liver cirrhosis to cardiovascular disease and cancer, especially in high-
income countries (see Non-Communicable Diseases chapters, Chaps. 4 and 5;
Degenhardt & Hall, 2012; Rehm etal., 2009). Excessive drinking in the United
States is more common in SMW and gay and bisexual men (GBM) than their het-
erosexual counterparts, with the highest rates observed among lesbian women
(Fredriksen-Goldsen et al., 2013). Similarly, elevated smoking rates have been
noted within the United States LGBT community (60–70% higher than national
averages), with the highest among self-identied gay men of color (Greenwood &
Gruskin, 2007; Tang etal., 2004) but with greater incidence and severity of lung
disease in women (Pinkerton etal., 2015).
M. J. Mimiaga etal.
239
Research in the United States has suggested that tobacco use within minority
communities may be due to an absence of cessation programs tailored to address
sexual and gender minority-specic barriers, such as minority stress and a lack of
engagement with health services (Gruskin etal., 2007; Matthews etal., 2013). This
places LGBT and GNC people at increased risk for respiratory diseases, including
lung cancer. Compared to other chronic conditions exacerbated by tobacco, the
odds for asthma among SMW and GBM appear to differ more strongly by socioeco-
nomic status than by sexuality (Dilley etal., 2010; Fredriksen-Goldsen etal., 2013),
and a review of data on the incidence of chronic obstructive pulmonary disease in
marginalized individuals was inconclusive (Clausen & Morris, 2017). Given that
smoking and alcohol abuse are reciprocal risk factors, there is also overlap in the
pathophysiology of their disease sequelae. Frequent tobacco and alcohol consump-
tion predispose users to cardiovascular disease regardless of sexual orientation or
gender identity, but there are noteworthy differences among minority subgroups:
multiple US studies have identied an above-average prevalence of obesity among
lesbian women, followed by bisexual and TGW (Boehmer etal., 2007; Fredriksen-
Goldsen etal., 2013; Lim et al., 2014; Roberts et al., 2003). As such, SMW who
drink heavily and smoke face increased odds for cardiac morbidity and early mor-
tality over other LGBT persons (Conron etal., 2010; Dilley etal., 2010).
Substance use by sexual and gender minority individuals also has the potential to
aggravate certain cancers. Most anal cancer tumors are secondary to human papil-
lomavirus, which is more widespread among MSM who engage in receptive anal
intercourse (Daling etal., 2004; Machalek et al., 2012). In an American Cancer
Society study, smoking was observed to increase the odds of anal cancer develop-
ment in MSM nearly fourfold (Daling etal., 2004); additionally, sexual risks under
the inuence, HIV co-infection (Frisch etal., 2003), and having multiple sex part-
ners (Lim etal., 2014) appear to be associated with anal cancer incidence. Data on
breast cancer in sexual minority women are inconclusive, but obesity and substance
abuse have been cited as precursors to breast cancer among SMW (Fredriksen-
Goldsen etal., 2013; Graham et al., 2011)– however, the risk for breast cancer
mortality does not appear to differ by sexuality (Cochran & Mays, 2012; Lim
etal., 2014).
Though there is a general lack of chronic health information focusing on bisex-
ual individuals of any gender, population-based surveys in the United States revealed
signicantly elevated substance-related risk behaviors, including binge drinking,
daily tobacco use, and recent illegal drug use among bisexual persons (Conron
etal., 2010). Such chronic drug abuse practices have been correlated with increased
odds for asthma, diabetes, and hypertension compared to exclusively lesbian women
or gay men (Dilley etal., 2010). Bisexual adults in North America also use statisti-
cally fewer protective and preventive health services, compounding their likelihood
of early mortality (Lim etal., 2014; Smalley etal., 2016). Along those lines, trans-
gender individuals in the United States are 1.5 times as likely as the general popula-
tion to smoke, even though nearly three-quarters of them want to quit (Grant etal.,
2010). The National Transgender Discrimination Survey report in the United States
estimated that, as of 2010, over a quarter (28%) of transgender persons avoided
8 Global Epidemiology and Social-Ecological Determinants of Substance Use…
240
medical care or rehabilitation due to experiences of discrimination, for which they
used alcohol and drugs to cope, creating a vicious cycle of health inequity with
“catastrophic consequences” (Grant etal., 2010; Lim etal., 2014).
8.4.3 Incarceration
Despite jail time serving as a punishment for illicit drug use, a 2007 European
review observed prisons to be risk environments where many individuals may con-
tinue to use or even take drugs for the rst time (Dolan etal., 2007). Additionally, in
the United States, incident HIV cases tend to be disproportionately clustered in
prisons where viral transmission is fostered by both drug-seeking and sexual-risk
behaviors (Wohl etal., 2006). The intersection of substance abuse and infectious
disease in the prison environment is particularly burdensome for LGBT and GNC
individuals, most notably POC, who already face disparate social and legal hurdles
placing them at greater lifetime risk for incarceration (McCauley & Brinkley-
Rubinstein, 2017). Although there is a general lack of applied inquiry in the eld of
justice involvement, the dearth of social services tailored toward sexual and gender
minority members with a substance use disorder may be a contributing factor to
their overrepresentation in the prison environment (Reisner etal., 2014a).
Stimulants, like methamphetamine and cocaine, (Rawstorne etal., 2007) and
IDU (Operario etal., 2011) are all correlates of unprotected sexual risk behaviors
that are also common within prisons and among individuals with a history of incar-
ceration for substance use (Cochran & Cauce, 2006). Past qualitative interviews
with MSM and TGW inmates have revealed that, aside from drug intoxication, an
absence of harm reduction resources (i.e., clean needles, condoms, counseling) in
United States jails is a primary contributor to continued “unsafe” behaviors (Harawa
etal., 2010). Meanwhile, countries such as Germany, Spain, and Switzerland have
piloted needle exchange programs for prisoners without observing any increase in
illicit drug use (Jürgens etal., 2009; Okie, 2007). Barriers to self-care and health
maintenance in jail can also be particularly disruptive for PLWH who rely on daily
antiretroviral therapy; in the absence of focused discharge planning and linkage to
care upon release, these people may be at risk for an increased viral load subsequent
to medication non-adherence and IDU dependence fostered during incarceration
(Jürgens etal., 2009; Khan etal., 2019; Palepu etal., 2004).
Few studies have explored the nature of legal consequences associated with
high-risk drug exchanges in sexual and gender minority populations. In 2018, a his-
tory of transactional sex, as a form of survival or to sustain an addiction in the
absence of supportive therapy, showed an independent correlation with incarcera-
tion among both MSM (Philbin etal., 2018) and TGW in the United States (Hughto
etal., 2018). Although data specic to transgender persons are fairly limited, in the
United States. tobacco use and polysubstance use have been identied as comor-
bidities of criminal justice involvement in addition to negative consequences like
sexual victimization while in jail and HIV infection (Brennan etal., 2012; Brown &
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241
Jones, 2015; Reisner etal., 2014a, b). LGBT and non-binary POC in the United
States are generally more likely to be imprisoned in relation to substance possession
or dependence, compared to white LGBTQ people. In a large sample of Black MSM
in the northeast United States, crack use during sex and IDU both increased the
probability of a prior incarceration lasting longer than 90days (Bland etal., 2012).
Among a primarily Black and Latina female sample in the United States, WSW
were more likely to have an illegal income source, sell drugs, trade sex for money
or drugs, and have a history of incarceration compared to heterosexual women
(Ompad etal., 2011). Another study demonstrated that the odds of incarceration
were greatest among Black TGW compared to MSM when controlling for alcohol
and drug use, which were both independently associated with jail time in the United
States (Brewer etal., 2014). The phenomenon in the United States where high num-
bers of Hispanic and African American LGBT youth with drug problems also report
criminal justice involvement is described as the “school-to-prison pipeline” (Knight
& Wilson, 2016; Snapp etal., 2015). In these instances, young adult POC are either
excessively disciplined for the outward expression of their sexuality/gender identity
or are punished for defending themselves against their own victimization. Once
introduced to the justice system at an early age, these adolescents face an increased
risk for both substance abuse and re-incarceration (Hughto etal., 2018; McCarthy
etal., 2016).
8.4.4 Social Isolation
A key consideration of substance use among sexual and gender minority individuals
is that many use recreational drugs without experiencing any negative social conse-
quences. This has fostered a communal culture in which illicit drug use may be
highly visible, accessible, and acceptable in certain contexts (Abdulrahim etal.,
2016; Bourne etal., 2014). Particularly among gay and bisexual males, “club drug”
stimulants and inhalants are sometimes perceived to enhance sociability (Fazio
etal., 2011; Race, 2015) and sexual pleasure (Hurley & Prestage, 2009; Palamar
etal., 2014; Van Hout & Brennan, 2011) as well as are used to alleviate pain and
fatigue (Semple etal., 2002). However, other individuals may nd that using such
drugs can take a serious toll not only physically but also on their interpersonal well-
being; and there are well-established associations between illicit drug use, cogni-
tion, and certain adverse psychosocial outcomes (Homer etal., 2008).
Substance use is often driven by a “desire for socialization,” but prolonged con-
sumption or injection can paradoxically lead to social isolation due to chemically
impaired judgment and decreased mood (Homer etal., 2008). Similarly, hazardous
drinking is both a precursor to and product of minority stress, particularly among
SMW (Lewis etal., 2016) and TGW (Arayasirikul etal., 2018). Social isolation
secondary to drug and alcohol abuse subsequently increases the risk for mental
health problems (Chou etal., 2011; Frederick, 2014), and for many marginalized
individuals this cycle is perpetuated by further experimentation with substances to
8 Global Epidemiology and Social-Ecological Determinants of Substance Use…
242
“numb the pain” (Weber, 2008). Alcohol and drugs are even hypothesized to deepen
the internalized homophobia that gay men and lesbian women struggle to dissociate
from in the public expression of their sexual orientation (Cabaj, 2000; Emslie etal.,
2017; McDermott etal., 2008).
As mentioned, injection and stimulant drug use often take place in shared settings
or in the context of sexual hook-ups (i.e., “Party and Play”). Although some LGBT
individuals partake in recreational substances to facilitate intimacy (Race, 2015),
others report feeling marginalized and increasingly unwelcome by both non- drug- using
friends and drug-using peers. In a small sample of MSM living with HIV in the
United States, nearly all (90%) said their relationships had been strained by their
abuse of crystal methamphetamine (Mimiaga, Fair, etal., 2008c). These ndings
were similar among female and transgender individuals in Australia who reported
facing a “loss of identity and chosen community” secondary to drug abuse (Deacon
etal., 2013). The experience of being ostracized, at its most extreme, has been con-
nected to high rates of suicidality within this population (Lea etal., 2014; Mereish
etal., 2014). However, the specic mediating role of substance abuse varies depend-
ing on the sexual/gender subpopulation in question (Lea etal., 2014): SMW, TGW,
and PLWH in particular tend to become most isolated and estranged, putting them
at risk for healthcare avoidance (i.e., addiction treatment) (Lyons etal., 2015) and
intimate partner violence (Andrasik etal., 2013; Lewis etal., 2012). Conversely,
evidence from analyses of LGBT adolescents in the United States who use sub-
stances have demonstrated the protective effect of parental connection and accep-
tance against the social derogation of drug addiction (Goldbach etal., 2014; Padilla
etal., 2010; Ryan etal., 2010). This suggests that sexual and gender minority adults
not raised in an accepting family environment or who lack a home support base may
be at greatest risk for the negative health sequelae of stress and depression.
8.5 Intervention andTreatment Options
While much of the research on the prevalence of substance use and misuse among
sexual and gender minority populations is nascent, particularly in the Global South,
some interventions have been tested with these populations with varying degrees of
success.
8.5.1 Alcohol Use
A systematic review of interventions to reduce problematic alcohol use among
MSM in the United States showed support for the use of motivational interviewing/
motivational enhancement-based interventions (MI) and hybrid MI and cognitive-
behavioral therapy (CBT) treatments for heavy drinking compared to no treatment
(Wray etal., 2016). The authors concluded the most important nding from this
M. J. Mimiaga etal.
243
review, however, is that rigorously designed efcacy trials of treatment interven-
tions guided by behavior change theories and specic to MSM and other sexual and
gender minority groups are scant.
8.5.2 Smoking
Community-based smoking cessation treatment programs culturally tailored for
LGBT smokers have yielded promising results. These programs are based on a
more generalized intervention, the American Lung Association’s Freedom from
Smoking (ALA-FFS) program but utilize LGBT-specic innovative activities and
smoking information (Eliason etal., 2012; Matthews etal., 2013). Compared to
traditional smoking cessation programs, an LGBT community-based program was
better at enrolling and retaining LGBT smokers, and quit rates were consistent with
outcomes associated with general population results from the ALA-FFS program
(Matthews etal., 2013). However, more rigorous testing through randomized clini-
cal trials is recommended to determine the efcacy of a culturally tailored ALA-
FFS program. In addition, evaluation of individual and group interventions,
cessation messaging, and policy is necessary to understand if outcomes are moder-
ated by sexual orientation and gender identity (Lee etal., 2014).
8.5.3 Stimulant Use Disorder
There is limited evidence to support the effectiveness of behavioral interventions for
reducing crystal meth use among MSM (Carrico etal., 2014, 2015; Ling etal.,
2014a; Phillips etal., 2014; Rajasingham etal., 2012). Cognitive behavioral therapy
(CBT) and contingency management (CM) have been studied the most (Ling etal.,
2014b; Phillips etal., 2014; Rajasingham etal., 2012) and co-occurring sexual risk-
taking (Carrico etal., 2014; Carrico etal., 2015), but the results have been mixed
(Hellem etal., 2015; Ling etal., 2014b; Rajasingham etal., 2012). While CM has
been found to produce short-term reductions in stimulant use (McDonell et al.,
2013; Phillips etal., 2014; Shoptaw etal., 2005), it does not appear to be consis-
tently maintained and dropout rates are high (Benishek etal., 2014; Ling et al.,
2014b; Nyamathi etal., 2015). Carrico etal. (2015) did not observe any benets of
CM on crystal meth use or sexual risk-taking at the 6-month follow-up assessment,
which has led to questioning the efcacy of CM as a long-term approach to treat-
ment for MSM.Additionally, ideological differences among providers and nancial
considerations may prevent the implementation of CM in substance use treatment
centers (Carroll, 2014). Therefore, more research needs to be done on developing
evidence-based behavioral interventions to reduce crystal meth use among gay,
bisexual, and other MSM.
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244
Pharmacotherapies for stimulants use disorders are under study, which are
designed to alter the effects of the drugs on the brain’s appetitive systems, including
assessments of antidepressants, antipsychotics, dopamine agonists, and anticonvul-
sants. Currently, there are no FDA-approved medications for the management of
stimulant craving and use reductions or withdrawal symptoms. Findings from clini-
cal trials evaluating the use of antidepressants, dopamine agonists, and antagonists
to reduce stimulant use have been mixed; thus, more research is needed to develop
effective pharmacotherapies for stimulant abuse in MSM.In a recent clinical trial to
determine the efcacy of mirtazapine for treatment of methamphetamine use disor-
der and reduction in HIV risk behaviors, mirtazapine reduced the use of metham-
phetamine over 24weeks of treatment and 12weeks of follow-up after treatment
was concluded. Mirtazapine also reduced several sexual HIV risk behaviors; both
ndings were consistent with a previous pilot study. As such, Mirtazapine is the rst
medication to demonstrate efcacy in treating methamphetamine use disorder, and
this has been documented in two independent randomized clinical trials (Cofn
etal., 2020).
Research has shown that gay, bisexual, and other MSM who use crystal meth
report a decrease in their capacity to enjoy activities that do not involve drug use
(Mimiaga etal., 2008a). This has led them to rely on crystal meth as the only source
of pleasure and enjoyment. Further, problematic crystal meth use is a complex and
difcult-to-treat issue. A likely reason for this may be that existing treatments lack
adequate attention to replacement activities or to the role of depressed mood/anhe-
donia relapse trigger (Mimiaga et al., 2008a). To address this, researchers have
developed Project IMPACT (Intervention with MSM to Prevent Acquisition of HIV
through Crystal methamphetamine Treatment). This intervention combines sexual
risk reduction counseling with behavioral activation, a cognitive behavior therapy
for improving mood by emphasizing the importance of goal-oriented activities. In a
pilot randomized controlled trial, participants who received the Project IMPACT
intervention reported fewer condomless anal sex acts with men who were HIV liv-
ing with HIV or of unknown HIV serostatus, as well as longer periods of continuous
abstinence from crystal meth compared to those in the control group (Mimiaga
etal., 2019). The efcacy of this promising intervention is currently being assessed
through a larger randomized controlled trial in the US (Mimiaga etal., 2018) among
adult gay, bisexual, and other MSM.This work is also being extended via a hybrid
type 2 effectiveness-implementation trial among sexually active young gay, bisex-
ual, and other men who have sex with men via the Adolescent Medicine Trials
Network for HIV Interventions (ATN170).
8.5.4 Opioid Use Disorder
As with all individuals suffering from opioid addiction, globally, medication-
assisted therapy (MAT), in combination with behavioral therapy, is the mainstay of
treatment for LGBT people with opioid use disorder. Medications, including
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245
buprenorphine (Suboxone®, Subutex®), methadone, and extended-release naltrex-
one (Vivitrol®), are effective for the treatment of opioid use disorders. However,
only licensed addiction-treatment programs (both ofce-based and inpatient treat-
ments) and physicians who have completed specialized training in the area of opioid
drugs and addiction medicine can administer opioids to treat opioid-use disorders.
In addition, CBT has been shown to improve treatment outcomes for patients receiv-
ing MAT for opioid use disorder (Moore etal., 2016). In Canada, Australia, and the
United Kingdom, MAT is available without a co-pay or at a subsidized price directly
from a pharmacist, decreasing barriers to treatment (Calcaterra etal., 2019).
8.5.5 Need forIntegrated Services
Substance use among sexual and gender minority individuals is of global concern
and access to substance abuse treatment services is limited (Flores etal., 2017). For
example, only 11% of a transcontinental survey of MSM reported high availability
of treatment programs and only 5% reported utilizing them (Flores etal., 2017).
Best practices for sexual and gender minority-afrming addiction treatment are
being promulgated by health institutions specic to this populations overall care
needs. Studies surveying LGBTQ+ alumni of substance use treatment have found
that patients value an LGBTQ+-afrming culture among staff and in clinical spaces,
as well as the absence of homophobia and transphobia (Lyons etal., 2015; Rowan
et al., 2013). In the general population, inclusion practices such as LGBTQ+-
afrming intake forms, restrooms, signs, and outreach materials can make a signi-
cant impact (Johnson etal., 2008). Institutions offering a specic sexual and gender
minority focus are vital in addressing the need for Individualized interventions that
uniquely address each person’s drug-related medical, mental health, and social
problems (NIDA, 2018b, p.24).
Research has demonstrated that sexual and gender minorities are more likely to
suffer from substance use disorders (SUDs) in combination with other mental health
issues, such as depression and anxiety, and co-occurring health problems, like
chronic pain. To effectively address the complexity of these cases, integrated mod-
els of behavioral health and primary care services must be developed. Integrated
care models range from simple coordination among different medical facilities to
fully merged practices. By utilizing these models, comprehensive programs can be
created to address addiction and its associated health issues.
Fenway Health is a renowned LGBTQ+-focused health center, research institute,
and advocacy organization located in Boston, Massachusetts. It offers a two-pronged
approach to treating opioid use disorder that integrates addiction treatment with
behavioral health and primary care services (Fenway Health, 2022). The Addictions
and Wellness Program is a key component of this approach, providing individual
and group therapy work that uses a minority stress framework. Additionally, the
program combines with the Behavioral Health Department’s Violence Recovery
Program to leverage LGBTQ+ community solidarity as a source of resilience and
8 Global Epidemiology and Social-Ecological Determinants of Substance Use…
246
self-efcacy for partaking in addiction treatment. Finally, the Addictions and
Wellness Program offers buprenorphine treatment in a weekly clinic staffed by a
psychiatrist, with group therapy specically for patients with trauma history and
active addiction (Fenway Health, 2022). Given this, Fenway Health exemplies an
innovative, comprehensive model for treating opioid use disorder.
The second part of Fenway’s model is conducted within Fenway’s Primary Care
Services. This program follows a harm-reduction model and is led by trained medi-
cal staff with years of experience; it requires few behavioral contingencies for ongo-
ing buprenorphine management. Hence, patients at Fenway may seek whichever of
the two buprenorphine treatment programs supports their sobriety from opioids the
best, while taking advantage of real integration of behavioral health services into
primary care. Notably, the integration of behavioral health services with primary
care for LGBTQ+ patients with stimulant and/or opioid use disorder and other
SUDs may offer many benets, including bolstering patient acceptability of care,
improving public health, and reducing costs to the patient and enhancing overall
economic prosperity.
8.6 Conclusion
This chapter has documented that sexual and gender minority populations experi-
ence disparities in substance use across all geographical contexts. Globally, these
disparities are exacerbated by sexual and gender minority-specic stressors (e.g.,
stigma, discrimination, harassment) at the individual, interpersonal, and environ-
mental levels that may heighten one’s vulnerability to substance use and substance
use disorders compared to individuals not experiencing these stressors (Demant
etal., 2016; McCabe etal., 2013; Medley etal., 2016). The chapter also details the
research showing a disproportionate burden of substance use and resultant disease
in sexual and gender minority individuals compared to both sexual majority groups
and the general populations across geographic areas. In addition, there are individ-
ual (e.g., mental health), interpersonal (e.g., intimate partner violence), and contex-
tual (e.g., health policy and the political climate) risk and protective factors that are
unique to sexual and gender minority groups and should be considered when devel-
oping intervention approaches to curb use among these groups. For sexual and gen-
der minority groups, treatment of substance use disorder must remain a priority
among health care providers. By reducing substance use, we can have an impact on
individual health outcomes, and subsequently reduce the burden of disease on a
population level. We must continue with research efforts that develop and test novel
strategies that are culturally tailored and address the specic factors driving their
use. Furthermore, among providers, it is critical that we continue to assess our sex-
ual and gender minority patients’ substance use. Even though there are few effective
treatments available for some substance use disorders, linkage to care should remain
an important focus in caring for this vulnerable population.
M. J. Mimiaga etal.
248
8.7 Case Study: Substance Use Among Men Who Have Sex
withMen inChina
In China, despite most studies being conducted in small regions or cities, literature
has consistently demonstrated a high rate of substance use among men who have
sex with men (MSM) compared to other population subgroups. Research on com-
mon substances used in China, such as alcohol and tobacco (Nehl etal., 2012; Yu
etal., 2013), and more modern psychoactive/recreational drugs such as poppers/
rush poppers, tryptamine, methamphetamine, and ecstasy (Li et al., 2021; Zhao
etal., 2017), has highlighted use among MSM.For a variety of reported time frames
(e.g., in the past 1month, in the past 12months), rates of alcohol use among Chinese
MSM range from 56% to 62% (Liu etal., 2016; Lu etal., 2013; Xu etal., 2019).
Nearly 44% of MSM in China report recent binge drinking (Xu etal., 2019), which
is much higher than the 32% prevalence found in the general male population
(Li etal., 2011). Young Chinese sexual minority males are signicantly more likely
to report moderate or heavy smoking when compared with general youth (Lian
etal., 2015). The reported use of recreational drugs among MSM ranges from 21.3%
to 31.2%, regardless of timeframe (during the past 3–12months) (Chen etal., 2015;
Wang etal., 2015; Xu etal., 2014a, b; Zhang etal., 2016).
8.7.1 Social andBehavioral Aspects ofSubstance Use
Previous research has documented how some MSM social environments and peer
networks promote substance use (Duan etal., 2017; Egan etal., 2011). Along with
the rapid economic development in China and the encouragement of social smoking
and drinking in Chinese cultural norms (Xu etal., 2020), gay bars and nightclubs
are expanding and rising in popularity in Chinese cities. While these venues allow
sexual minority individuals to socialize in a safe public space, they often facilitate
tobacco and alcohol use and may promote the emergence, use, and even popularity
of modern club drugs (Chen etal., 2015; Liu etal., 2016).
Methamphetamine is the most commonly used addictive stimulant drug among
MSM in China (Ding etal., 2013). Methamphetamines can increase sexual excite-
ment, enable individuals to engage in sex longer, and impair judgment resulting in
high-risk sexual practices (Anglin etal., 2000; Ding etal., 2013). Curiosity about
methamphetamines and a lack of understanding that they are potentially addictive
contribute to use initiation in China (Liu etal., 2018a).
Poppers, another fashionable recreational drug in China, has risen in popularity
and use among MSM in recent years (Chen etal., 2015; Xu etal., 2014a, b). Poppers
are cheap and easily accessible and, to date, are not dened as illicit or regulated by
the Chinese government. The relaxing effect of poppers often facilitates anal sex,
making them highly desirable among MSM in this context (Li etal., 2021; Xu etal.,
2014a, b).
M. J. Mimiaga etal.
249
Attitudes towards sexual minorities in China also play a role in the prevalence of
substance use; social attitudes toward homosexuality have become considerably
more open but cannot yet be described as tolerant, with same-sex marriage not
legally recognized. The prevalence of internalized homophobia among Chinese
sexual minority men is also high (Xu etal., 2017). The minority stress model theo-
rizes that substance use is sometimes used as a coping strategy for sexual minorities
in stressful social contexts (Meyer, 2003); substance users understand that the spe-
cic effects of certain drugs relieve distress. In line with this theory, Chinese MSM
who have sex with women out of perceived social obligations have been found to
also sometimes engage in frequent excessive alcohol and other illicit drug use (Liao
etal., 2011; Xu etal., 2019). This suggests substance use may be a coping response
to the internal conict between one’s public identity as a heterosexual and one’s
private desires for same-sex encounters and/or relationships.
8.7.2 Substance Use Intervention Programs
To our knowledge, there are currently no substance use services specically target-
ing MSM in China. The struggle to control the growing drug problem in this popu-
lation is further compounded by social stress that surrounds homosexuality in the
Chinese context. Such environments may lead MSM to hide their sexual orientation
and perhaps turn to substances to cope with the secrecy.
Despite the lack of intervention programs targeting the MSM community, in
2003 China piloted a national harm reduction program for illicit drug users in the
general population, which included methadone treatment for those using heroin.
This program has shown some benets, including for MSM, such as a signicant
decrease in injection drug use, overcoming addiction, and an increase in healthy
physical outcomes (Liu etal., 2018a). Furthermore, comprehensive psychological
and behavioral treatment interventions in conjunction with methadone maintenance
treatment (MMT), such as psychotherapy, counseling, and social and family sup-
port, have improved patient retention to address substance use dependence (Chen
etal., 2010; Pan etal., 2015; Zhang etal., 2009). In addition to MMT, buprenor-
phine, naloxone, and Chinese herbal medicines have also been applied in some
cases (Sun etal., 2014). All of these intervention efforts, despite having a universal
focus, have been benecial for MSM populations.
8.7.3 Substance Use Policy
On the policy side, laws and regulations have been enacted or modied to reduce the
supply and demand of drugs in China (Sun etal., 2014). While these policies are not
specic to MSM, they have resulted in reduced substance use in some MSM com-
munities as well as in the broader population (Duan etal., 2017; Liu etal., 2018a).
8 Global Epidemiology and Social-Ecological Determinants of Substance Use…
250
For instance, the Chinese government has made signicant advancements from an
old system of mandatory incarceration and punishment as treatment in recent years
(Li etal., 2010; Wu etal., 2007). Currently, compulsory isolation treatment is com-
monly used for drug abuse treatment in China. Chinese drug law mandates that
people with substance use disorders who refuse to receive community rehabilitation
or fail to maintain sobriety, or those found by police as having a severe addiction to
illicit drugs are sent for 2years of compulsory isolation treatment managed by jus-
tice departments (State Council of the People’s Republic of China, 2011). Treatments
in these settings include detoxication, physical medical care, behavioral and psy-
chological therapy, HIV treatment as indicated, and relapse prevention education
(Yang etal., 2018). Central and local governments have also organized a variety of
health education activities, especially for younger people, through manifold forms
including television, the internet, and community events.
To some extent, enactment and implementation of drug policy vary in different
regions in China. Despite a national law greatly expanding Chinese government
reach, many provinces and municipalities, such as Shanghai, Guangdong, and
Tianjin, have passed Smoking Control Regulation to create smoke-free public
places (Wan etal., 2013: Alcorn, 2013). Another example is Shenzhen, which in
recent years has carried out regulations on drug rehabilitation and cooperative drug
control interventions with Hong Kong. The strict policy resulted in a lower illicit
drug supply and use in Shenzhen. In terms of the connection between drug policy
and MSM’s substance use, researchers have found that, since the policy was passed,
12.7% of MSM in Shenzhen recently used at least one type of drug (Duan etal.,
2017), which is lower than the rates in other cities (Chen etal., 2015; Wang etal.,
2015; Xu etal., 2014a, b; Zhao etal., 2017). While none of the mentioned interven-
tions specically target MSM communities, they do seem to be having a benecial
impact by reducing substance use in that population.
In conclusion, research has highlighted signicant substance use among the
Chinese MSM community, especially the use of alcohol, methamphetamine, and
poppers. Although strategies and interventions for people who use drugs more
broadly have been successfully evaluated and applied in the Chinese context, a
national system for treatment, prevention, and intervention of substance use tar-
geted to high-risk drug user groups like MSM is also needed.
Acknowledgments We are grateful to Wenjian Xu, PhD, for contributing the case study on sub-
stance use among men who have sex with men in China accompanying this chapter.
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Chapter 9
Victimization andIntentional Injury
inGlobal LGBTQI Populations
CaseyD.XavierHall, G.NicRider, NovaBradford, EuniceM.Areba,
andKatyMiller
9.1 Victimization andIntentional Injury
inLGBTQI Populations
Individuals who are lesbian, gay, bisexual, transgender, queer, questioning, and/or
intersex (LGBTQI) historically and currently face signicant inequality, violence,
and discrimination based on sexual orientation, gender identity, and/or gender
expression globally (Jones, 2018; Tat et al., 2015; Tobin & Delaney, 2019; Yon
etal., 2017). LGBTQI individuals are often not afforded basic human rights and are
ill-treated, attacked, tortured, and/or criminalized for not conforming to rigid socio-
cultural gender and heteronormative ideals (Carrol & Mendos, 2019; Chiam etal.,
2016). Experiences of intentional injury and victimization include but are not lim-
ited to adverse childhood experiences, violence, homicide, suicide, and bias-
motivated harassment committed by a range of perpetrators such as families,
C. D. XavierHall (*)
College of Nursing, Florida State University, Tallahasee, FL, USA
e-mail: CXavierHall@fsu.edu
G. N. Rider
Department of Family Medicine and Community Health, University of Minnesota,
Minneapolis, MN, USA
e-mail: gnrider@umn.edu
N. Bradford
Health Policy, School of Medicine, Stanford University, Stanford, CA, USA
e-mail: bradf119@umn.edu
E. M. Areba
School of Nursing, University of Minnesota, Minneapolis, MN, USA
e-mail: areba002@umn.edu
K. Miller
Children’s Minnesota, Minneapolis, MN, USA
e-mail: mill8624@umn.edu
© The Author(s) 2024
S. J. Hwahng, M. R. Kaufman (eds.), Global LGBTQ Health, Global LGBTQ
Health, https://doi.org/10.1007/978-3-031-36204-0_9
272
intimate partners, other LGBTQI individuals, agents of the state, and colonial forces
(Carrol & Mendos, 2019; Chiam etal., 2016; Jones, 2018; Sotero, 2006; Tat etal.,
2015; Tobin & Delaney, 2019; Yon etal., 2017). While many forms of intentional
injury and victimization overlap with experiences of broader populations, elevated
levels of these detrimental experiences have been documented in LGBTQI popula-
tions relative to heterosexual, cisgender populations (Austin etal., 2016; Castro
et al., 2019; Peitzmeier et al., 2020; Sabidó et al., 2015; Walters et al., 2011).
Moreover, unique forms of victimization impact LGBTQI populations, including
hate-motivated violence and criminalization of LGBTQI identities (Carrol &
Mendos, 2019). While the bulk of this research has been conducted in the United
States and Europe, LGBTQI research and community advocacy is growing in the
Global South and spans every major region of the world. This chapter provides an
introduction to this growing literature, including relevant frameworks, types of
victimization, and interventions.
9.2 Frameworks forUnderstanding Intentional Injury
andVictimization inLGBTQI Populations
Scholars have employed various frameworks for understanding experiences of vic-
timization in LGBTQI populations. Some seek to address the etiology and multi-
level inuences on victimization (e.g., Syndemics and Minority Stress frameworks),
while others seek to situate victimization in socio-historical contexts (e.g., perspec-
tives on colonization and human rights). In either case, these frameworks highlight
that disparities in victimization are a product of complex psycho-social/structural
factors and are not inherent to LGBTQI populations. Here, we present an overview
of some of these frameworks.
9.2.1 Syndemics
The Syndemics framework posits that two or more health conditions may mutually
interface and exacerbate negative effects of one or more of the health conditions
(Singer et al., 2017). Thus, Syndemic Theory situates victimization with other
comorbidities including, but not limited to mental health, substance use, and HIV
(Chakrapani etal., 2019; Logie etal., 2019) in dynamic, mutually reinforcing rela-
tionships that exacerbate adverse outcomes of these co-morbidities. The framework
also suggests that syndemics are more likely to occur under conditions of structural
violence, inequity, stigma, stress, and poverty (Singer etal., 2017). One such appli-
cation examined mental health, intimate partner violence (IPV), binge drinking, and
childhood sexual abuse and their deleterious effects on HIV risk among LGBTQI
populations in Jamaica, nding that syndemics inuenced perceived HIV risk,
C. D. XavierHall et al.
273
number of sexual partners, and condom use self-efcacy (Logie et al., 2019).
Similarly, a study in India found evidence for syndemics among men who have sex
with men (MSM) and transgender women such that violent victimization, depres-
sion, and alcohol use were mutually associated, and experiencing multiple of these
conditions was associated with inconsistent condom use (Chakrapani etal., 2019).
9.2.2 Minority Stress andMultilevel Inuences
Virginia Brooks originally developed and applied the sexual minority stress frame-
work among lesbian women (Brooks, 1981; Rich etal., 2020), and Meyer (2013)
later popularized the framework. Since its development, the minority stress frame-
work has been used to address a variety of LGBTQI populations and outcomes such
as mental health, substance use, and violence (Balsam & Szymanski, 2005;
Goldbach etal., 2014; Meyer, 1995; Testa etal., 2015). The framework posits that
LGBTQI stigma (enacted, internalized, or anticipated) impacts cumulative stress
and ultimately health outcomes (further described in the chapter on Mental Health,
Chap. 3). The literature on minority stress has also been moving in the direction of
recognizing multiple overlapping and intersectional stigmas (e.g., racism, sexual
identity stigma, gender identity stigma, and HIV stigma) (for more on this see chap-
ter on Stigma, Chap. 2).
While some applications of minority stress have focused on addressing mental
health, the framework has also been used in relation to violence in global LGBTQI
populations. Published literature documents associations between minority stress
and perpetration and experience of violence. For example, Hershow etal. (2018)
reported that gay and bisexual men in Vietnam who experienced enacted stigma
were 3.5 times more likely to experience sexual violence. Stigma-motivated vio-
lence can also be conceptualized as enacted stigma and therefore a minority stressor.
In another example, researchers observed that gay and lesbian women in Brazil who
experienced enacted stigma (including community violence) were at higher risk for
depressive symptoms (Logie etal., 2012). Ultimately, the minority stress frame-
work has many potential applications across various types of violence and contexts.
9.2.3 Colonization, Intergenerational Trauma,
andHistorical Trauma
When considering LGBTQI experiences of violence, one would be remiss to neglect
the role of colonization and colonizers in promoting heterosexism (Gilley, 2006;
Hwahng & Nuttbrock, 2014; Ristock etal., 2019). Theories have sought to explain
the impacts of colonization through theoretical frameworks such as intergenera-
tional trauma and historical trauma. Intergenerational trauma, which was originally
9 Victimization andIntentional Injury inGlobal LGBTQI Populations
274
theorized to address trauma in families of holocaust survivors (Fossion etal., 2003;
Kellerman, 2001), posits that traumatic stress (e.g., from war, genocide, coloniza-
tion, slavery, or natural disasters) can be transmitted across multiple generations.
When descendants of trauma survivors experience symptoms of post-traumatic
stress, even though they may not have experienced a traumatic event rsthand, this
is known as intergenerational (or transgenerational) trauma, which has been linked
to a range of mental health symptoms in descendants of traumatized people
(Sangalang & Vang, 2017). Historical Trauma Theory similarly conceptualizes col-
onization as a collective traumatic event, which is further exacerbated by continued
collective traumatic exposures such as genocide, war, segregation, displacement,
psychological violence, economic destruction, and cultural dispossession (Sotero,
2006). The ongoing effects of colonization in a “post-colonial” world have long-
standing impact beyond the original act of colonization (Brave Heart, 2003; Brave
Heart etal., 2011).
Research extends the phenomenon of intergenerational trauma to many other
global communities, including: the experience of African American communities in
relation to slavery and racism (Gump, 2010); surviving families of Jewish people
who ed the Holocaust (Dashorst etal., 2019); Indigenous communities in Canada
in relation to settler-colonial genocide and racism (Bombay etal., 2014); the chil-
dren of refugees displaced from Southeast Asia due to war and genocide, including
Chinese, Cambodian, Loa/Mien, Vietnamese, and Hmong communities (Han, 2006;
Song etal., 2014; Spencer & Le, 2006); and children of those displaced by political
instability and armed conict in the Middle East, including Lebanon, Iraq, Syria,
Egypt, and Morocco (Daud etal., 2005, 2008).
Scholars have also linked colonization to the experiences of LGBTQI popula-
tions. Two-spirit is both a specic cultural identity and a label used to indicate sex-
ual and gender minority populations among many Indigenous peoples of North
America, including specic cultural understandings of sexual and gender variation
(Ristock etal., 2019). In one qualitative study of two-spirit peoples in Canada, par-
ticipants described how colonization damaged cultural understandings of sexual
and gender identity in their Indigenous communities, particularly through the inu-
ence of the Catholic Church (Ristock et al., 2019). Another study in the United
States found that two-spirit Indigenous people experienced more colonial trauma
compared to heterosexual Indigenous people from the same population (Balsam
etal., 2004). Scholars have argued that the context of colonialism is relevant to the
understanding of other forms of violence experienced by Indigenous populations
(Lindhorst & Tajima, 2008). Colonization may have also introduced homophobia
and transphobia, which were then transmitted inter-generationally through family
systems of Indigenous and other people of color (Gilley, 2006; Hwahng & Nuttbrock,
2014). Thus, colonization as a form of violence in itself impacts the ways that
LGBTQI identities are understood within cultural contexts, and it has been linked to
continued experiences of violence in Indigenous populations. Examples of these
will be discussed throughout the chapter.
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9.2.4 LGBTQI Rights asHuman Rights
LGBTQI movements have seen increasing global attention and growing acceptance
throughout the world (Kollman & Waites, 2009). Pressure for LGBTQI human
rights has mounted over time. In 2006, global LGBT activists released the
Declaration of Montreal and the Yogyakarta Principles (Kollman & Waites, 2009).
In 2008, Argentina presented a declaration to establish LGBTQI rights as human
rights among the United Nations (UN), and in 2010, South Africa presented a
similar proposal; however, these proposals initially languished without proper
support (including from Western nations; Langlois, 2020). Later, the UN set a goal
to support equal rights for LGBTQI populations globally, including a 2013 media
campaign titled, “Free and Equal,” and the appointment of an independent expert
for sexual and gender identity in 2016 (Langlois, 2020). This has clear implications
for state-sanctioned forms of violence such as the death penalty as well as prevalent
forms of stigma-motivated community violence. While there is increasing transna-
tional interest in advancing an LGBTQI rights agenda, the initiative is complicated
by varying cultural norms and practices (Kollman & Waites, 2009).
As the understanding of LGBTQI rights as human rights becomes more widely
accepted, criticism has arisen from some that LGBTQI rights and identities are
based on Western and colonial ideals being forced on the Global South (Kollman &
Waites, 2009). This ignores the unique cultural understanding of sexuality and
gender both in history and modernity, and the colonial inuence of anti-LGBTQI
legislation (discussed in the State-Sanctioned Violence section). A broad under-
standing of sexuality and gender exists across most major regions in the world. For
example, a number of identities and traditions have origins that predate colonization,
such as berdache and two-spirit in North America (Picq & Tikuna, 2019), Hijra
and Kothi in India (Dutta, 2012), and Ngochani in Zimbabwe (Epprecht, 2013;
Muparamoto & Moen, 2020). Some cultural understandings do not neatly align
with Western ideas of sexuality and gender as separate categories; instead, both
gender and sexuality may be considered as overlapping (Picq & Tikuna, 2019).
Despite attempts to homogenize these concepts with Western understandings, cul-
turally specic identities like Hijra and Kothi remain distinct (Dutta, 2012). This
highlights the complex interplay of local and transnational conceptualizations of
LGBTQI experiences as well as the undermining and erasure of identities that are
not rooted in a Western conceptualization of sexuality and gender.
While some may critique transnational human rights agendas as cultural imperi-
alism (Nuñez-Mietz & Iommi, 2017), it stands that many, if not most, statutes crimi-
nalizing LGBTQI identities are products of colonization (Carrol & Mendos, 2019;
Thapa, 2015) and continue to be upheld through relationships established during
colonization such as the global inuence of Western religious groups (Carrol &
Mendos, 2019; Thapa, 2015). Such is the case with Uganda, which is discussed in
more depth under the section Criminalization and the Death Penalty. Critiques are
further complicated by the presence of localized LGBTQI rights movements and
organizations that are also present across the globe (e.g., HELEM in Lebanon,
9 Victimization andIntentional Injury inGlobal LGBTQI Populations
276
Grupo Gay da Bahia in Brazil, Sexual Minorities Uganda, and Humsafar Trust in
India). For instance, in a qualitative study, local advocates in Namibia and South
Africa framed local LGBTQI advocacy as decolonization (Currier, 2011). To these
points, Waites (2019) has recently proposed a critical framework for understanding
global LGBTQI politics meant to articulate thematic elements for understanding
rights through a decolonizing perspective and highlighting the interplay between
local and national inuences and the implications of these power dynamics. Given
the complexity of historical and social contexts pertaining to LGBTQI populations,
an understanding of victimization within the context of colonial legacies and human
rights movements requires complex and interdisciplinary analysis.
9.3 Types ofIntentional Injury andVictimization
Intentional injury and victimization among global LGBTQI populations have a
wide range of manifestations, which have both distinct and overlapping literatures.
Here we introduce a range of forms of victimization with varying actors in different
global contexts that affect LGBTQI populations (See Fig.9.1). However, this chap-
ter is not exhaustive (for more on suicide see Mental Health chapter, Chap. 3).
9.3.1 State-Sanctioned Victimization
State-sanctioned victimization may take various forms. In the following section, we
emphasize the roles of governing bodies in victimization of LGBTQI people by
discussing criminalization of LGBTQI identities, police violence, forced genital
surgeries on infants with intersex variation, and victimization disparities among
asylum seekers.
Fig. 9.1 Multilevel framework showing forms of LGBTQI victimization, correlates, and inu-
ences discussed in chapter
C. D. XavierHall et al.
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9.3.1.1 Criminalization andtheDeath Penalty
Unfortunately, same-sex practices and diverse gender identities and expressions
remain criminalized in many parts of the globe. South Africa was the rst country
in the world to establish constitutional protections for LGBTQI individuals in 1996
(Carrol & Mendos, 2019), while most other countries, including many Western
nations, still have not established explicit constitutional protections for LGBTQI
individuals (Carrol & Mendos, 2019). As of the 2020 report by the International
Lesbian and Gay Association, sexual orientation had constitutional protection in 11
UN member states and broad protection in another 57 (Carrol & Mendos, 2019).
Legal gender recognition was available for transgender persons in at least 96 UN
member states, with 25 allowing for legal gender recognition without any prohibi-
tive requirements (Chiam etal., 2016). At the same time, same-sex sexual activity is
criminalized in 67 UN member states and punishable by death in nine (Carrol &
Mendos, 2019). Moreover, at least 13 UN member states criminalize transgender
persons or non-conforming gender expression in some way (e.g., anti- “cross-
dressing” laws), and few (only about 12 states) allow for non-binary gender markers
(Chiam etal., 2016). Criminalization policies and the lack of protections have grave
implications for the lives of LGBTQI populations through state-sanctioned violence
and death. These policies also create environments that may exacerbate other health
concerns including increasing social prejudice, increasing all forms of violence
against LGBTQI populations, and reducing access to critical services such as
healthcare (Nyato etal., 2018).
Even with growing movements toward repealing laws criminalizing LGBTQI
identities, there is often continued risk for violence. One such example is Uganda,
which received much international attention during the attempted repeal of the Anti-
Homosexuality Act in 2015 followed by continued attacks and public murders of
LGBTQI individuals through “mob violence” (Thapa, 2015, p.3). Uganda is also an
example of the inuence of colonial forces on the development and codication of
anti-LGBTQI hate in previously colonized countries. In Uganda, same-sex sexual
acts were criminalized under British Colonial rule in Section 145 of Penal Code Act
of 1950 (Thapa, 2015). External inuence on these policies did not stop after
Uganda’s independence, as Human Rights Campaign notes that specic conserva-
tive American Christian groups as well as Muslim religious leaders continue to
advocate for anti-LGBTQI policies, which is mirrored in other parts of the world
(Thapa, 2015). For many countries, criminalization of LGBTQI identities and
expression is the most wide-reaching form of victimization layered on top of other
forms of victimization and intentional injury.
9.3.1.2 Police Violence andHarassment
Police violence has a long history in LGBTQI communities, particularly among
transgender and Black, Indigenous, and/or People of Color populations. Famous
examples of police violence include the Queen Boat incident in Egypt, where gay
9 Victimization andIntentional Injury inGlobal LGBTQI Populations
278
and bisexual men were subject to torture at the hands of police (Pratt, 2007). These
dynamics have also been vividly documented in the lm, Call Me Kuchu, which
portrays the life and work of LGBT activists in Uganda, including the murder of
David Kato (Wright & Zouhali-Worral, 2012). Police violence is widespread and
not relegated to the past or specic geographic boundaries. In some ways, this form
of victimization may be amplied by the legal status of LGBTQI communities. In
one study of police violence trends in Nigeria from 2014 to 2019, police violations
against LGBTQI populations increased 214% following the passage of the Same-
Sex Marriage Prohibition Act (Giwa etal., 2020). Moreover, a study in Kenya found
that an estimated 20% of MSM experienced police violence in the preceding six
months (National AIDS and STI Control Programme, 2017).
Police violence is sometimes in response to LGBTQI rights activism. For exam-
ple, Ana-Maurine Lara (2018) documented accounts of police violence against pro-
testers and LGBTQI activists in the Dominican Republic. Police sometimes neglect
complaints, and in some cases, actively participate in community violence against
LGBTQI individuals (Blake & Dayle, 2013) or even murders, such as in one report
to Human Rights Watch in 2004 where police participated in the public murder of a
gay Jamaican man (Schleifer, 2004).
Police-perpetrated violence against individuals in need of state support is a com-
mon theme across multiple studies in multiple regions and may dampen LGBTQI
interest in seeking support in instances of other forms of violence. For example, in
a qualitative study in Tajikistan, gay and bisexual men described police raids,
harassment, police violence, sexual coercion, and sexual assault by police ofcers,
which impacted their ability to report experiences of same-sex intimate partner vio-
lence as well as access to health and social services (Hall etal., 2020; Ibragimov &
Wong, 2018). This means not only may LGBTQI populations be more at risk for
intimate partner violence, but they may also face arbitrary arrests or additional vio-
lence if seeking support from police.
Police violence is widespread in contexts that are characterized by disparities in
access to opportunities based on race, ethnicity, ancestry, and other identities ren-
dering multiple sub-groups among LGBTQI populations at higher risk for police
violence including racial minorities in multi-ethno racial contexts, transgender
women, and people engaged in sex work. In the United States, reports of abuse or
violence by police ofcers against non-incarcerated transgender individuals are as
high as 47% (Mitchell-Brody etal., 2010; Stotzer, 2014), with transgender women
of color being at higher risk relative to white transgender women (Mitchell-Brody
etal., 2010; Woods etal., 2013). Similar patterns are observed in the Global South,
such as in one study in Brazil, where 47.2% of transgender participants reported
experiences of police violence (Magno etal., 2018), and transgender individuals
recounted police violence in qualitative interviews from Brazil and India (Gomes de
Jesus etal., 2020).
Moreover, growing evidence shows that risk of violence is also widespread
among sex workers. For example, in a cross-sectional study in Jamaica, MSM who
also engaged in sex work in the past 12months had four times the odds of police
harassment, and transgender women who were engaged in sex work in the past
C. D. XavierHall et al.
279
12months had twice the odds of police harassment relative to those who were not
engaged in sex work (Logie etal., 2017). Similarly, in a qualitative study in India
and Kenya, police were named as perpetrators of sexual coercion, sexual assault,
harassment, arbitrary arrests, extortion, and physical violence against transgender
and MSM individuals engaged in sex work (Ganju & Saggurti, 2017). Thus,
LGBTQI sex workers may experience violence from clients and police.
9.3.1.3 Forced Surgeries onChildren withIntersex Variations
Intersex variation refers to a range of traits that differ from hegemonic denitions
of binary sex (e.g., male and female), including traits that may be imperceptible
without in-depth medical examination (e.g., Androgen Insensitivity Syndrome).
Also included are variations that may be immediately perceptible at birth, such as
genital variations not easily categorized by binary denitions of sex (Davis, 2015;
Reis, 2019). While there is a growing understanding of these traits as natural varia-
tions, they have been stigmatized and labeled as “disorders” in many contexts
throughout time (Reis, 2019). Throughout the world, genital surgeries are often
conducted on children with intersex variations to conform with normative ideas of
binary genitalia before they are able to consent. Until very recently, this has unfor-
tunately been the standard of care for children with intersex variations in the United
States (Reis, 2019). A relatively decentralized global movement has been growing
and spreading testimony from adults with intersex variations (Ammaturo, 2016;
Carpenter, 2016; Reis, 2019). Moreover, global research on intersex variations has
begun to diverge from medicalized accounts and move toward person-centered
research and human rights framings (Jones, 2018), which highlight these policies as
state-sanctioned violence against children with intersex variations. People with
intersex variations have recounted experiences of nonconsenting disclosure of their
variations and displaying their bodies for medical purposes (Jones, 2018). Yet only
a handful of countries address these concerns through bodily autonomy laws
(Ammaturo, 2016). In 2013, the Parliamentary Assembly of the Council of Europe
adopted a resolution protecting intersex children from genital surgeries; however, it
is not legally binding for member states (Ammaturo, 2016). Some countries in the
Global South have begun to collect data about people with intersex variations. For
instance, in 2017 Kenya’s National Commission on Human Rights (2018) formed a
Taskforce on Policy, Legal, Institutional and Administrative Reforms regarding
Intersex Persons in response to a mandate by the Kenyan Attorney General to com-
pile data about persons with intersex variations and to develop recommendations for
reforms to protect the interests of intersex people. Increasing intersex-focused
research is crucial, because without systematic, empirical examination of global
prevalence of genital surgeries on infants with intersex variations, the extent of their
impact on the well-being of people with intersex variation worldwide is difcult to
establish. However, mounting testimonies by people with intersex variations empha-
size the urgency of this issue (Reis, 2019).
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280
9.3.1.4 Forced Surgeries onGay andBisexual Adults
There is growing attention on forced genital surgeries on gay and bisexual men in
other contexts. An example that has attracted growing media attention is Iran, where
some surgeries are described as being intended to eradicate homosexuality (Carter,
2010; Hodge, 2020; Kyriacou, 2020). While homosexuality remains illegal in Iran,
gender-afrming surgery was legalized in 1987 (Hodge, 2020). As of 2020, Iran
reportedly carried out 4000 gender conrmation surgeries annually, and the govern-
ment subsidized most of them (Hodge, 2020). Reporting suggests that these surger-
ies are sometimes forced with the intention to change the gender of people with
same-sex attraction to eliminate homosexuality in Iran (e.g., a gay man “becoming”
a heterosexual woman through surgery) (Hodge, 2020). For example, gay men
report transitioning due to fear of being hanged (Hodge, 2020). There are also
reports of psychiatrists attempting to convince gay men they are, in fact, transgender
despite their rm identity as cisgender gay men (Terman, 2014). Sometimes in the
context of a same-sex couple, societal pressure, and fear of violence lead to the deci-
sion that one partner should undergo a gender transition (Terman, 2014). Surgery
does not eliminate stigma or ensure safety. Transgender people and people who are
forced to have genital surgeries face family rejection, unemployment, and threats of
community violence without continued medical or mental health support post-
operation (Hodge, 2020; Terman, 2014). Thus, the treatment of LGBTQ individuals
in Iran and forced genital surgeries in particular, remain a threat to the well-being of
LGBTQ Iranians.
9.3.1.5 LGBTQI Asylum Seekers
Due to state-sanctioned violence, in certain circumstances, LGBTQI individuals
may be eligible for asylum in some nations (e.g., South Africa and the United
States). Although asylum is available to various populations, disparities are observed
among LGBTQI asylum seekers relative to their heterosexual and cisgender peers.
Hopkinson etal. (2017) conducted a study where LGBTQI asylum seekers reported
more violence relative to non-LGBTQI asylum seekers (sexual assault: 66% vs.
24%, familial persecution: 37% vs. 0%, adverse childhood experiences: 63% vs.
37%) (Hopkinson etal., 2017). A similar qualitative study conducted by the UN
described child and adolescent abuse among LGBT refugees/asylum seekers and
found common themes of abuse by family members, caregivers, classmates, and
teachers beginning from a young age. Family rejection and lack of protection and
support at home were described by multiple participants, many of whom had high
levels of depression, anxiety, traumatic stress, and suicide attempts as adults (Alessi
etal., 2017).
The fact that LGBTQI asylum seekers are more likely to experience abuse by
family members is signicant in several ways. First, asylum seekers by denition
have experienced traumatic or life-threatening events that have led to forced migra-
tion (Bhagat, 2018; Siriwardhana & Stewart, 2013); by nature of this migration,
C. D. XavierHall et al.
281
they are at risk for experiencing symptoms of traumatic stress. However, asylum
seekers who migrate with the support of their families and communities can often
nd safety and solace with migrants from their country of origin (Schweitzer etal.,
2006). Because of embedded homophobic and transphobic beliefs in certain cul-
tures, countries, and religions, LGBTQI asylum seekers are often left without this
source of support (Hopkinson etal., 2017). Thus, in addition to likely experiencing
state-sanctioned violence and childhood victimization and abuse, they are less likely
to benet from the support structures that cisgender and heterosexual asylum seek-
ers may utilize, further compounding traumatic experiences of forced migration.
9.3.2 Community andOrganizational Victimization
Community and organizational victimization often exist in relation to community-
level stigma (see Stigma chapter, Chap. 2). In the next section, we discuss one rel-
evant form of community-level violence (stigma-motivated assault and homicide)
and one form of organizational victimization (employment discrimination and
workplace harassment).
9.3.2.1 Stigma-Motivated Assault andHomicide
Stigma-motivated community violence such as assault or homicide due to percep-
tions of sexual or gender identity has been documented throughout the world. In a
global systematic review from 2018, stigma-motivated experiences of violence
among sexual minorities were as high as 31% overall (36% among men, and 25%
among women; Blondeel etal., 2018). In other studies, an estimated 31% of MSM
in the Caribbean and 35% in Latin America were physically assaulted for their sex-
ual orientation (Beck et al., 2015), and 43.4% of LGBTQI individuals in Kenya
reported hate-motivated violence (Harper etal., 2021). Stigma-motivated victimiza-
tion can also include verbal assault, physical abuse, sexual abuse, and even torture
or so-called honor killings (United Nations General Assembly, 2011).
While all LGBTQI individuals are subject to high levels of physical abuse and
assault, multiple studies have demonstrated that transgender and gender-diverse
individuals are at further increased risk. In a global systematic review, up to 68% of
transgender people reported hate-motivated assaults (Blondeel etal., 2018). This
may be due in part to increased visibility of gender non-binary individuals, who
may be more easily identied as LGBTQI, which can lead to mob violence and
harassment in the street and community (Hunter-Gault, 2015; Zingsheim et al.
2017). Moreover, hate-motivated crimes against transgender individuals tend to be
extreme in their violence, and perpetrators often describe a great deal of stigma
toward transgender people (Kidd & Witten, 2008). In multiracial societies like the
United States, these murders are particularly elevated among Black, Latina/x trans-
gender women, and two-spirit people (Dinno, 2017; James etal., 2016; Ristock
9 Victimization andIntentional Injury inGlobal LGBTQI Populations
282
etal., 2019). For example, the odds of a young, Black transgender woman in the
United States being murdered is 1in 2600; the odds of murder in the general popu-
lation of comparable age are 1in 12,000 (Momen & Dilks, 2020). Transphobia,
racism, and hate crimes are inextricably linked, and stigma-related victimization
serves to strike fear in LGBTQI community members and uphold these social
systems.
9.3.2.2 Victimization Through Employment Discrimination
andWorkplace Harassment
Workplace discrimination of LGBTQI individuals presents challenges all over the
globe (see Stigma chapter, Chap. 2). Widespread job discrimination, stigma, and
harassment have been reported among LGBTQI individuals worldwide (Bilgehan
Ozturk, 2011; Perraudin, 2019; World Bank Group, 2018; Zurbrügg & Miner,
2016;), which can have devastating economic impact on those affected. Employment
discrimination is common, such as in India (Badgett, 2014), Indonesia (Badgett
etal., 2017), and in Thailand, where 77% of transgender, 52.6% of lesbian, and 49%
of gay male survey respondents reported employment discrimination (World Bank
Group, 2018). About 81 countries had workplace discrimination laws for LGBTQI
groups in 2020 (Carrol & Mendos, 2019); however, even in countries where there
are protections, harassment remains a problem. For example, 70% of LGBTQI peo-
ple experience workplace harassment in the UK (Perraudin, 2019). In the United
States, LGBTQI employees at the National Institutes of Health faced some of the
highest levels of harassment even though US federal employees enjoyed some of
the most stringent protections (Cech & Pham, 2017). Among a qualitative sample of
Two Spirit Indigenous people in Canada, stories of employment discrimination at
the intersection of LGBTQI stigma and race are salient (Ristock etal., 2019). In
South Africa, where sexual minority women are at the highest risk for workplace
incivility (Zurbrügg & Miner, 2016), LGBTQI victims of workplace harassment
fear retaliation and hold a lack of condence in legal mechanisms (Nath, 2011).
Employment discrimination and workplace harassment present a formidable barrier
to the advancement of LGBTQI populations globally.
9.3.3 Interpersonal Victimization Across theLife Course
From adverse childhood experiences (ACEs) to elder abuse, a growing literature
highlights experiences of interpersonal victimization in LGBTQI populations across
the life course. In this section, we address ACEs, intimate partner violence (IPV),
sexual violence, stigma-motivated sexual violence, and elder abuse.
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283
9.3.3.1 Adverse Childhood Experiences
The form of victimization that likely occurs the earliest in the life course of most
LGBTQI individuals is ACEs, which can take the form of physical, sexual, or emo-
tional violence and are often perpetrated by the family of origin (Schneeberger
etal., 2014). A systematic review incorporating studies from both Global North and
Global South countries indicates that LGBTQ people are at higher risk for ACEs
relative to their heterosexual, cisgender counterparts (Schneeberger etal., 2014).
One possible explanation for elevated ACEs is that LGBTQ children may be more
likely to have non-conforming gender expressions and that perpetrators may target
non-conforming gender expression (Roberts etal., 2012). It should be noted that
there is not a precise unifying denition for ACEs, and these experiences may vary
by cultural context (Schneeberger etal., 2014). Understandings of ACEs continue to
center on Western populations. In a global systematic review, only 5.5% of the stud-
ies captured originated from the Global South (Schneeberger etal., 2014). Ranges
of prevalence varied by sex, form of ACEs, and populations, with as many as 71%
of MSM and 68% of women who have sex with women (WSW) reporting ACEs
(Schneeberger etal., 2014).
Focusing on countries in the Global South (China, Brazil, Turkey, India, Jamaica,
and Mexico), estimates of ACEs were as high as 57% (Carballo-Diéguez et al.,
2012; Choudhry etal., 2018; Eskin etal., 2005; Guanzhi Chen etal., 2012; Logie
etal., 2019; Semple etal., 2017). Disparities relative to heterosexual populations
have been noted. For example, one study in Turkey showed that individuals who
reported same-sex experiences were more likely to report ACEs compared to those
who did not report same-sex sexual experiences (Eskin etal., 2005). Adult LGB
persons in the United States are between twice and three times more likely to report
ACEs than heterosexuals depending on the type of victimization (Austin etal., 2016).
Literature addressing ACEs in transgender populations is less common. In a
2019 systematic review of ACEs literature for transgender individuals, rates were as
high as 100% in the 14 articles that were identied; however, none of the articles
were from the Global South (Tobin & Delaney, 2019). One study in the United
States also found that Black and Latinx trans feminine people were signicantly
more likely to experience ACEs during adolescence, as well as perpetration of ACEs
by family members, compared to White trans feminine people (Hwahng &
Nuttbrock, 2014). Although articles addressing ACEs in the Global South do exist,
these articles may be left out due to the operationalization of ACEs in these reviews.
It also may be that in the global literature childhood experiences of abuse are not
always identied under the concept of ACEs, but rather as individual exposures. For
example, in a Jamaican sample, 34% of transgender women experienced childhood
sexual abuse (Logie etal., 2019), and in Brazil, 33% of transgender participants
reported being sexually assaulted by someone 4+ years older at their rst sexual
experience (Carballo-Diéguez etal., 2012). More research is needed to understand
the etiology and prevention of ACEs in LGBTQI populations worldwide.
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284
9.3.3.2 Intimate Partner Violence
Intimate Partner Violence (IPV) is one of the more established topics relative to
other forms of victimization in LGBTQI global literature and has been documented
in many countries. Estimates of IPV among MSM in the Global South are as high
as 55% (Castro etal., 2019; Harper etal., 2021; Logie etal., 2019; Ogunbajo etal.,
2020). IPV can span a range of behaviors, and prevalence is dependent on how IPV
is measured, such as in a sample of MSM in Nigeria who reported experiencing
emotional violence (45%), physical violence (31%), sexual violence (20%), moni-
toring behaviors (55%), and controlling behaviors (22%) (Ogunbajo etal., 2020).
Whether these behaviors are labeled as “abuse” in study instruments also may inu-
ence estimates of prevalence. According to a literature review of WSW in the Global
South, prevalence ranged from 9–52% when asked about “abusive relationships,”
and 12–73% when using behavioral measures (Badenes-Ribera etal., 2016).
Disparities by sexual identity have been observed. Recent studies out of the
United States have identied bisexual women as being at particular risk for IPV
relative to both lesbians and heterosexual women (Edwards et al., 2015; Walters
etal., 2011). Disparities have also been identied between MSM and heterosexual
men (Finneran & Stephenson, 2013). For example, in Brazil, 11.4% of MSM
reported IPV compared to 7.5% among heterosexual men (Castro et al., 2019).
Prevalence can also be higher in unique sub-populations such as MSM engaged in
sex work, as was the case in one study out of China (57% of MSM engaged in sex
work relative to 45% of MSM not in sex work) (Dunkle etal., 2013).
Transgender populations are also at higher risk for IPV.In a 2020 systematic
review, transgender individuals were 1.7 times more likely to experience IPV over-
all, 2.2 times more likely to experience physical IPV, and 2.5 times more likely to
experience sexual IPV relative to cisgender populations (Peitzmeier etal., 2020). Of
the 74 studies identied, 73% were conducted in the United States, but additional
studies were from the Global South (Peitzmeier etal., 2020). There is considerable
variation; for example, in a study examining HIV risk factors in a sample from
China, transgender women were nearly ve times more likely to experience IPV
(economic, physical, sexual, threats) compared to cisgender MSM (Zhang etal.,
2016). Unlike the literature on other forms of victimization, it is possible to draw
comparisons across various transgender identities. Studies included in the review
covered transgender women, transgender men, and non-binary gender identities, but
did not observe statistically signicant differences in IPV across these identities
(Peitzmeier etal., 2020).
9.3.3.3 Sexual Violence
Sexual violence has been observed among various LGBTQI populations and across
geographic contexts (Aho etal., 2014; Braun etal., 2009; Chakrapani etal., 2019;
Hall etal., 2020; Peitzmeier etal., 2015; Sabidó etal., 2015; Sleath & Bull, 2010;
Walters et al., 2011). In a 2018 systematic review, estimates of sexual violence
C. D. XavierHall et al.
285
victimization were as high as 17% for gay/bisexual men, 13% for lesbian/bisexual
women, and 49% for transgender people (Blondeel etal., 2018). Sexual violence
disparities have been observed, such as in one Brazilian study where gay men were
2.63 times more likely to experience sexual violence than heterosexual men (Sabidó
etal., 2015). Some research in the United States has begun to document disparities
among disaggregated identities such as bisexual populations relative to both gay/
lesbian and heterosexual populations (Ford & Soto-Marquez, 2016; Walters etal.,
2011). Disparities have also been observed for sex workers. For example, an India-
based study showed MSM who participated in sex work were more than twice as
likely to report sexual violence as compared to MSM not in sex work (Shaw
etal., 2012).
A unique form of stigma-motivated sexual assault is often referred to as “correc-
tive rape.” The notion of corrective rape has been conceptualized as when a sexual
assault is motivated by the desire to punish someone for their LGBTQ+ identity or
change the identity of the targeted victim (Hunter-Gault, 2015). While this has
received signicant press coverage, the nuances of “corrective rape” have often
been misunderstood. “Corrective rape” is portrayed as sexual assault that can only
happen to so-called butch (i.e., masculine presenting) women who are perceived as
a threat to traditional masculine gender norms and perpetrated by people assigned
male at birth (Human Rights Watch, 2011; Lock Swarr, 2012). While this is some-
times the case, Lock Swarr points out that this simplied narrative ignores the com-
plex gender and social norms that contribute to and minimize this type of
gender-based violence and crime. Bisexual and lesbian women are certainly victim-
ized in this manner, but transgender and gender non-binary individuals are similarly
victimized in an attempt to punish them for violating gender norms (Reisner &
Murchison, 2016). Since the root of “corrective rape” stems from a desire to punish
perceived violations of gender role and gender expression, this form of violence is
experienced not only by lesbian women but also by people who hold various
LGBTQI identities. Reports of “corrective rape” have been documented in coun-
tries across the world (e.g., South Africa, Jamaica, and India, to name a few)
(Bowling et al., 2016; Logie et al., 2018; Logie et al., 2020; Mampane, 2020;
Smith, 2018).
9.3.3.4 Elder Abuse
Despite as many as 83% of individuals not disclosing their LGBTQI identity world-
wide, there is an increasingly visible segment of the population that identies as
LGBT (Pachankis & Bränström, 2019). Another global trend is an aging global
population in all regions of the world that is set to increase from 9% to 16% before
2050 (World Health Organization [WHO], 2020). A growing area of concern among
LGBTQI populations is aging and more particularly elder abuse. While the bulk of
research on elder abuse remains in Europe and the Americas, a recent systemic
review documented elder abuse in at least 26 different countries across the major
regions of the world, with the highest meta-analytic prevalence in the Middle East
9 Victimization andIntentional Injury inGlobal LGBTQI Populations
286
and Asia (Yon etal., 2017). Yet, LGBTQI populations are only mentioned in the
review when addressing areas for further research.
LGBTQI elder abuse research is largely nascent and incomplete; however, esti-
mates from the United States document abuse in older adults with as much as 7%
abuse overall (9% among bisexual men, 14% among bisexual women, and 15%
among transgender elders) (Fredriksen-Goldsen, 2011). There is a passing reference
of LGBTQI elder abuse in South African published literature, with qualitative
research documenting neglect of LGBTQI elderly due to stigma and disempower-
ment by an unequal care dynamic based on LGBTQI status (Reygan & Henderson,
2019; Reygan & Khan, 2019). Indeed, researchers suggest that LGBTQI elder abuse
is entangled with systemic stigma and LGBTQI-specic abuse tactics (Cook-
Daniels, 2017). While the literature on LGBTQI elder abuse remains quite nascent,
with growing populations of LGBTQI elders, this is an area of research that may see
growth in the coming decades.
9.3.4 Polyvictimization
It should be noted that experiences of victimization for any given individual can
span across various actors and forms of violence (e.g., ACEs, IPV, elder abuse,
enacted stigmas, etc.). Experiencing multiple forms of victimization is sometimes
called polyvictimization, which can be measured as a simple count of types of vic-
timization (Sterzing etal., 2017) or as qualitatively different combinations of vic-
timization types (Xavier Hall etal., 2022). In a United States sample, researchers
observed polyvictimization as dened as having multiple experiences of violence
among cisgender MSM (prevalence: 33%), cisgender WSW (35%), transgender
men (48.9%), transgender women (63.4%), and gender queer populations (assigned
male at birth: 71.5%, assigned female at birth: 49.5%) (Sterzing etal., 2017). The
conceptualization of polyvictimization is important because experiencing multiple
forms of victimization can amplify adverse outcomes. Polyvictimization has been
linked to substance use (Xavier Hall etal., 2022) and adverse mental health out-
comes (Sterzing et al., 2017) in LGBTQI populations in the United States.
Polyvictimization has also been linked to adverse health outcomes in the Global
South, such as HIV risk behaviors among transgender women engaged in sex work
in Jamaica (Logie etal., 2020).
9.4 Risk Factors forVictimization
Observed risk factors for victimization among LGBTQI populations range from
structural, communal, and individual factors. Structural factors such as criminaliza-
tion and police violence put LGBTQI populations at risk for other forms of violence
with limited options for recourse (Logie etal., 2016). Reviews of the literature also
C. D. XavierHall et al.
287
highlight structural factors related to IPV among transgender populations such as
homelessness, immigration status, and incarceration (Peitzmeier etal., 2020). As
mentioned earlier, asylum or refugee status is also associated with various forms of
violence (Hopkinson et al., 2017). The deep stigma associated with being an
LGBTQI individual in countries where it is illegal and/or heavily penalized allows
sexual abuse, “corrective rape”, and victimization to continue unchecked (Alessi
etal., 2017).
Community factors such as stigma put LGBTQI populations at risk for a variety
of victimization experiences. For example, in Brazil, MSM who experienced dis-
crimination had 3.1 times the odds of experiencing sexual violence than those who
had not experienced discrimination (Sabidó etal., 2015). Stigma is also associated
with suicidal ideation (Stahlman etal., 2016), community violence (Blondeel etal.,
2018), elder abuse (Cook-Daniels, 2017), and IPV (Edwards & Sylaska, 2013) in
LGBTQI populations.
Individual-level factors are probably the most examined in the literature.
Examples of risk factors at the individual level include disability status, race, gender
identity, education, participation in sex work, sexual positioning, and substance use,
to name a few (Peitzmeier etal., 2020; Shaw etal., 2012). In many cases, a single
risk factor is associated across multiple forms of violence such as how participation
in sex work is associated with police violence (Stotzer, 2014), IPV (Dunkle etal.,
2013), and sexual violence (Shaw etal., 2012). Similarly, substance use is associ-
ated with IPV (Chong et al., 2013), suicidal ideation (Wolford-Clevenger etal.,
2018), and sexual violence (Chakrapani etal., 2019). Lastly, one form of victimiza-
tion can be a risk factor for others. For example, re-victimization has been a risk
factor for sexual violence among lesbian and bisexual women in the United States
such that those who experience sexual victimization in childhood were more likely
to experience sexual violence as an adult (Morris & Balsam, 2003).
9.5 Health Consequences ofVictimization
Victimization experiences can lead to a range of health consequences, including
negative mental health outcomes (Dame etal., 2020), HIV (Logie, Wang, etal.,
2020), further victimization (Morris & Balsam, 2003), substance use (Xavier Hall
etal., 2022), physical injury, and death (Momen & Dilks, 2020). While these out-
comes may be seen across LGBTQI populations, differences across individual iden-
tities are important to note. For instance, the risk of HIV acquisition may be less
obvious to cisgender women who identify as lesbian, gay, or queer because they
may not perceive themselves at risk of an infection thought to be transmitted through
penis- in- vagina sex. The need for testing and treatment of HIV may not be consid-
ered a priority for lesbian, gay, or queer women, and early opportunities for treat-
ment may be missed. Moreover, signicant barriers exist for accessing supportive
care among LGBTQI individuals who experience violence including stigma, police
violence, criminalization of LGBTQI identities, and criminalization of sex work
9 Victimization andIntentional Injury inGlobal LGBTQI Populations
288
(Chynoweth etal., 2020; Ibragimov & Wong, 2018; Logie etal., 2016). These bar-
riers may further exacerbate the effect of violence on the well-being of LGBTQI
individuals.
9.6 Prevention andInterventions
The growing evidence of violence experienced by global LGBTQI populations pre-
sented in this chapter highlights the dire need for prevention and intervention work.
Given the wide array of multi-level inuences of violence, these interventions may
be conceptualized at multiple levels of the social ecology such as structural and
policy interventions, organizational or community interventions, and individual-
level interventions. Given the breadth of this eld, it is impossible to address the full
array of possible interventions across all forms of violence in the present chapter;
however, we highlight examples of interventions at each level.
While there is no existing systematic review of interventions addressing all forms
of violence faced by LGBTQI individuals, most systematic reviews point to a rela-
tive dearth of rigorous evidence for violence interventions among LGBTQI popula-
tions. Recent systematic reviews of relevant literature replicate the nding of scant
to no evidence addressing interventions for LGBTQI victimization overall, but
more specically in the Global South (Coulter etal., 2019; Edwards etal., 2021;
Kiss etal., 2020; Mengtong Chen & Chan, 2015; Peitzmeier etal., 2020; Tat etal.,
2015). Thus, the need for rigorous LGBTQI violence prevention and intervention
research is underlined by this apparent dearth, particularly in the context of the
Global South.
9.6.1 Decolonization
An area of growing interest is decolonization in the study of global LGBTQI vic-
timization. Decolonization is fundamentally rooted in the promotion of Indigenous
sovereignty and the return of land to Indigenous peoples in settler colonial states
(Tuck & Yang, 2021). Scholars have extended post-colonial thought such as appli-
cations of Indigenous Postcolonial Theory (Battiste, 2000), in which power dynam-
ics between scholars and Indigenous communities are recognized and addressed
through centering Indigenous voices, knowledge, and well-being (Browne etal.,
2005). Integrating decolonialist and post-colonialist perspectives into LGBTQI
rights discourse emphasizes the roles of local LGBTQI communities and advocates
in dismantling anti-LGBTQI laws that were established by colonial powers even as
these local actors interact with global transnational LGBTQI rights movements
(Waites, 2019). This theoretical reorganization dispels myths that uphold Western
C. D. XavierHall et al.
289
societies as morally superior in the case of LGBTQI rights and recognizes the
Indigenous knowledge and movements of LGBTQI communities across the Global
South (Currier, 2011). This is demonstrated by qualitative work highlighting the
conceptualization of decolonization by local LGBTQI advocates in Namibia and
South Africa, who view their work as decolonization and see leaders’ decisions to
uphold anti-LGBTQI laws and rhetoric as a selective embrace of colonial inuence
(Currier, 2011). Decolonization of knowledge production (Connell, 2014) in public
health efforts to address LGBTQI victimization in the Global South is crucial, par-
ticularly in relation to developing interventions. Such efforts should center the per-
spectives of LGBTQI populations in relevant communities through strategic
academic-community partnerships that address inherent power structures that are in
part a colonial legacy (Browne etal., 2005).
9.6.2 Structural/Policy Interventions
Clear implications for policy exist, the rst being decriminalization of LGBTQI
identities (Carrol & Mendos, 2019; Chiam etal., 2016), as well as the decriminal-
ization of sex work, which is associated with as much as a 30% decrease in violence
against workers (Cunningham & Shah, 2018). Decriminalization is only the rst
step, as 68+ countries (e.g., South Africa, Angola, Australia, Mongolia, Bolivia, and
Mexico) have begun to adopt protections for LGBTQI populations such as institut-
ing employment protections, creating hate crime protections, banning incitement to
hatred, establishing constitutional protections, and banning conversion therapy (see
Mental Health chapter, Chap. 3; Carrol & Mendos, 2019). Other national policies
may include adopting a comprehensive violence response strategy as was done in
Kenya in relation to improving HIV prevention in key populations such as MSM
(Bhattacharjee et al., 2018). Kenya’s response included trainings for providers,
awareness campaigns, building networks between service sectors, improving docu-
mentation of violence, police trainings, and advocacy meetings. These changes
reached more than 60,000 MSM between 2013 and 2017 and resulted in a reduction
in reports of violence among MSM (Bhattacharjee et al., 2018). Given the clear
inuence of policy and government actors, policy interventions are a natural starting
point in preventing LGBTQI populations; however, transnational efforts should be
aware of potential backlash when decriminalization efforts are perceived as a threat
to the sovereignty of states that criminalize LGBTQI identities. One such example
is former US president Obama’s visit to Senegal in 2013, where he emphasized the
need to decriminalize LGBTQI identities. His comments were met with marked
criticism from some, including academics that highlighted the asymmetric power
differential in the dynamic between a Western nation, such as the United States, and
Global South countries (Bertolt & Masse, 2019) as well as criticism from President
Macky Sall of Senegal (Nossiter, 2013).
9 Victimization andIntentional Injury inGlobal LGBTQI Populations
290
9.6.3 Organizational or Community Interventions
Community-level interventions have been developed to address some forms of vio-
lence in broader populations. For instance, the OAK Foundation and the US Centers
for Disease Control and Prevention have released a review of the global literature
addressing childhood sexual abuse prevention efforts, which includes addressing
broader environments (laws, norms, etc.) and parent/caregiver support, economic
strengthening, and response/support services (Saul & Audage, 2007; Ligiero etal.,
2019). While some strategies have promising evidence or demonstration of effec-
tiveness such as community mobilization programs, these programs primarily target
cisgender girls without consideration for sexual identity and still have limited evi-
dence overall (Ligiero etal., 2019).
The case is similar regarding interventions that address stigma-related violence
or IPV. One US-based study examined a multi-pronged approach to improving
interventions for partner violence and stigma-motivated violence among lesbian
and bisexual women. The approach involved partnership with police to improve
responsiveness, a police liaison, the implementation of “soft reporting” where a
liaison would contact possible victims and connect them with appropriate resources,
partnering with social service organizations aimed at survivors of violence to
improve their approach to supporting lesbian and bisexual women, and advocating
for state-level hate crime legislation (Rose, 2003).
Other interventions have sought to assist with processing trauma through cre-
ative means. Saul (2013) identied the important role of storytelling in genocide
survivors, indicating that both open communication and collective narration may be
important components of collective healing. As such, opportunities for collective
narration of collective traumas may be an important facet of community healing and
resilience. Likewise, returning to cultural practices that have been lost through colo-
nization or displacement has been identied as essential aspect of healing from
historical trauma (Gone, 2013). Additionally, theater and performance art have been
identied as important healing interventions for intergenerational trauma. The genre
of gay theater became complexly intertwined with themes of HIV/AIDS, trauma,
and identity starting in the early 1980s, which can be understood as an organic pro-
cess of crafting and sharing a collective narrative (Gavrila, 2013).
9.6.4 Individual Interventions
Some evidence suggests a survivor-centered approach that is responsive to specic
experiences and needs of survivors may be more effective than generic clinical
interventions, such as in the case of survivors of ACEs (Qi etal., 2016). This may
be particularly true of individual interventions among LGBTQI individuals who
experience violence. For instance, an exploratory study examined why male refu-
gees from Myanmar, the Democratic Republic of the Congo, and South Sudan who
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experienced sexual violence did not seek support from existing services. The study
found that laws criminalizing LGBTQI identity and stigma in service providers
were major barriers to seeking one-on-one services (Chynoweth etal., 2020).
Some have looked to the development of electronic applications to promote
safety planning among populations that face violence (Campbell & Glass, 2009);
however, these tend to be in Western nations and for heterosexual women. That
being said, some preliminary data on feasibility, usability, and appropriateness for
an e-health intervention for WSW have been reported (Bloom et al., 2016). One
known e-health intervention addressed safety planning in low- and middle-income
countries, but it targeted heterosexual women in Kenya (Decker etal., 2020). Its
promising results suggest that similar electronic applications may be adapted for
LGBTQI populations. Researchers and practitioners may need to look to existing
violence interventions among general populations and existing interventions among
LGBTQI populations that address other outcomes such as stigma, HIV, or substance
use for inspiration, all while working closely with communities to ensure efca-
cious interventions are developed.
9.7 Conclusions andHighlighting Gaps intheLiterature
Overall, victimization among LGBTQI populations is widespread, prevalent, and
interrelated. In Fig.9.1, we depict the multi-level nature of LGBTQI victimization,
including known correlates and inuences. This gure highlights that LGBTQI vic-
timization does not occur in isolation, nor is it limited to individual occurrences of
interpersonal victimization. Rather, LGBTQI victimization is part of a broader net-
work of phenomena affecting the social and material worlds of LGBTQI popula-
tions globally, which notably include colonization and widespread stigma. Violence
is perpetrated by multi-level actors (intrapersonal, interpersonal, communal, soci-
etal, and international) and will require solutions at multiple levels of the social
ecology. Thus, an understanding of LGBTQI victimization requires complex frame-
works such as minority stress, syndemics, post-colonial, and human rights frame-
works. Researchers may need to adapt or integrate frameworks to understand
interrelated forms LGBTQI victimization and to create effective interventions at
multiple levels of the social ecology.
Victimization impacts a range of LGBTQI identities across the lifespan as well
as intersectional populations such as Indigenous groups, asylum seekers, and racial
minority populations. While research pertaining to LGBTQI victimization in the
Global South is growing, it remains nascent, particularly research regarding specic
sub-populations (e.g., transgender, non-binary, intersex, and bisexual populations)
as well as research regarding prevention and intervention development. Thus, this
chapter also serves as a call to action for researchers, practitioners, and community
advocates to build upon existing bodies of knowledge on LGBTQI victimization.
Researchers should emphasize addressing subpopulations such as transgender, non-
binary, bisexual, intersex, LGBTQI elders, and LGBTQI populations of color.
9 Victimization andIntentional Injury inGlobal LGBTQI Populations
292
Moreover, future research and intervention development should center perspectives
from the Global South and employ decolonial and post-colonial frameworks.
9.8 Case Study: Experiencing Violence andVictimization:
Transgender Women inBrazil
In many places worldwide, violence against transgender women is an epidemic, and
Brazil’s rate is among the highest. Over 375 transgender people were killed globally
in 2021, and over 40 percent were in Brazil (ANTRA & IBTE, 2022). Of the docu-
mented and veried murders of transgender people in Brazil in 2021, 96 percent of
them were transgender women, and suspects were identied in less than a quarter of
cases (ANTRA & IBTE, 2022). An analysis conducted by the Associação Nacional
De Travestis E Transexuais Do Brasil (ANTRA, The National Association of
Transsexuals of Brazil) reported that the murders disproportionately affected young
transgender women, with 58 percent of 2021 victims under the age of 30, with the
average age of victims at 29years old (ANTRA & IBTE, 2022).
The rates of violence against transgender women in Brazil directly connect to
their self-reported feelings and experiences of victimization. According to the US
National Center for Victims of a Crime, “the trauma of victimization is a direct reac-
tion to the aftermath of a crime” (National Center for Victims of a Crime, 2008).
Additionally, crime victims can “suffer a tremendous amount of physical and psy-
chological trauma,” with their primary injuries grouped into three categories: physi-
cal, nancial, and emotional (National Center for Victims of a Crime, 2008).
Transgender women in general, and especially in Brazil, have several risk factors
that increase their risk of being victimized, including lower educational attainment,
higher rates of homelessness or housing insecurity, and higher risk sexual behaviors
such as survival sex work (ANTRA & IBTE, 2022). Regarding education, ANTRA
& IBTE (2022) estimates that 56 percent of transgender women in Brazil have only
an elementary school level of education, while 27 percent of transgender women
have a high school degree. Additionally, the estimated age at which transgender
girls are forced to leave their homes and nd their own housing due to their gender
identity is 13years old (ANTRA & IBTE, 2022). The normalization of childhood
and adolescent neglect and victimization of young transgender girls and women
contributes to their involvement in sex work.
ANTRA & IBTE (2022) reports that around 90 percent of transgender women in
Brazil use sex work as a source of personal income. These activities directly relate
to their risk of victimization because 78 percent of transgender murder victims in
2021 were sex workers (ANTRA & IBTE, 2022). Transgender women also com-
monly experience other treatments that may lead to them feeling victimized.
Markers of violence can be subtle, such as not being allowed to use the restroom
corresponding to their gender identity, or more obvious, like being denied necessary
medical care because of their gender identity (ANTRA & IBTE, 2022). While there
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294
are no ofcial suicide statistics in Brazil, one organization called Grupo Gay da
Bahia estimates that approximately 100 gay and transgender people in Brazil com-
mitted suicide in 2018, which was almost four times the number in 2016 (Lopez,
2019). Suicidality and suicidal thoughts are directly related to feelings of victimiza-
tion, especially when there is fear of violence involving weapons (Bouris etal., 2016).
Remedying these extremely high rates of violence and victimization of transgen-
der women in Brazil is not a simple task. One way to begin the necessary social
change is through legal regulation of certain behaviors. The Maria da Penha Law on
Domestic and Family Violence, passed in 2006, was the rst federal law in Brazil to
regulate violence against women and punish offenders (Gattegno et al., 2016).
Although it does not specically name protections for sexual and gender minorities,
in 2015 this law was successfully used to defend violence against a transgender
woman that was perpetrated by her partner (Santos, 2015).
In the past two decades, several laws have been passed or adapted in Brazil more
specically to protect people based on their sexual orientation or gender identity,
including transgender women in their scope. While no constitutional amendment
prohibits discrimination based on sexual orientation or gender identity, several
states within Brazil have local laws that prohibit such discrimination (ILGA World,
2020). Regarding the specic prohibition of discrimination in employment, simi-
larly, no federal law protects people based on their sexual orientation or gender
identity. Nevertheless, approximately 70 percent of Brazil’s population lives in an
area that has a local law prohibiting employment discrimination (ILGA World,
2020). Protections against employment discrimination are important because if
transgender people are discriminated against, it could mean they turn to less safe
income pursuits such as survival sex work. However, protection against discrimina-
tion in employment does little to protect transgender women, as only approximately
four percent are in formalized career paths that would be covered under this law
(ANTRA & IBTE, 2022).
Theoretically, the laws that protect transgender women from general discrimina-
tion, discrimination in employment, and intimate partner violence should serve to
decrease their fears and feelings of victimization based on their gender identity.
However, the laws of the country and the practices of the citizens are incongruent.
Although these laws have been in place for several years, the murder rates of trans-
gender women in Brazil remain the highest in the world, and other types of serious
violence committed against these women are prevalent. In an important and promis-
ing move that has the potential to help protect transgender women, the Federal
Supreme Court ruled in June 2019 that Brazil’s Law No. 7,761 about crimes moti-
vated by racial prejudice encompasses crimes motivated by sexual orientation and
gender identity until a more specic law is drafted (ILGA World, 2020). This ruling
would theoretically lead to criminal liability for those offenses committed against
people based on their sexual orientation or gender identity, a potentially powerful
consequence that could decrease transgender women’s fear of victimization (ILGA
World, 2020). Following the ruling, ANTRA and Associação Brasileira de Lésbicas,
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295
Gays, Bissexuais, Travestis, Transexuais e Intersexos (ABGLT) published a guide
for LGBTQ people on how to use the new ruling to their benet to ght homopho-
bia and transphobia (ANTRA & ABGLT, 2020). However, since the ruling went
into effect over two years ago, there has been no public reporting on prosecution of
discrimination based on sexual orientation or gender identity. ANTRA and ABGLT
(2020) report that while the Supreme Court ruled in favor of protecting LGBTQ
people, the government is ultimately against them and has thus put no additional
measures into place to protect LGBTQ people after the ruling.
Many organizations in Brazil are working steadfastly to support transgender
women, track the rates of violence against them, and ght for justice for this popula-
tion. For example, Rede Trans Brasil, or the National Network of Brazilian Trans
People, founded in 2016, represents transgender people in Brazil and supports them
in their ght for equal human rights and ending discrimination (Rede Trans Brasil,
2019). They prioritize advocating for the implementation of policy measures to pro-
tect transgender people at all levels of government, as well as monitoring the enact-
ment of existing legislation (Rede Trans Brasil, 2019).
Another organization called the Associação Nacional De Travestis E Transexuais
Do Brasil (ANTRA, 2019) represents 127 different organizations that came together
for the purpose of advocating for transgender people in Brazil (ANTRA & IBTE,
2022). Their major areas of work are creating positive public portrayals of transgen-
der people; collaborating with other networks to advocate for transgender people’s
right to health, education, and public safety; supporting actions to improve quality
of life for transgender people and decrease rates of sexually transmitted infections;
and disseminating information about violence and victimization of transgender
people in Brazil (ANTRA, 2022). Finally, the Instituto Brasileiro Trans De Educacão
(IBTE, 2019), or the Brazilian Trans Education Institute, works to combat transpho-
bia in the educational environment. In teaching younger children about transphobia
and its consequences and working to improve the acceptance of transgender people
earlier in life, this organization seeks to decrease transgender women’s victimiza-
tion later in life (IBTE, 2019).
The work being done by these organizations, and others within Brazil and inter-
nationally, is extremely promising. However, there is much progress to be made to
protect transgender women in Brazil from being victimized at the current rates. The
situation for this marginalized group is dire, and it is, quite frankly, a question of life
and death for them, as the life expectancy for transgender women in Brazil is only
35years old (VMLY&R Brazil, 2019). Stronger public support and better enforce-
ment of laws protecting transgender women will lead to a wider social and cultural
shift toward acceptance of transgender individuals.
Acknowledgments We are grateful to Alicia T.Bazell for her contribution to the case study on
violence against and victimization of transgender women in Brazil accompanying this chapter.
9 Victimization andIntentional Injury inGlobal LGBTQI Populations
296
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A
Alternative lifestyles, 104
Anxiety, 29, 31, 46, 48, 50, 52–54, 62, 63, 81,
147, 155, 170, 245, 280
Asexuality, 164
Asthma, 8, 80, 81, 117–124, 239
C
Cancer, 8, 29, 80–82, 94, 103–112, 123–125,
127–129, 151, 203, 204, 222, 238, 239
Cardiovascular disease (CVD), 8, 94–103,
123, 124, 203, 204, 222, 238, 239
Chronic obstructive pulmonary disease
(COPD), 8, 121–124, 239
Chronic stress, 8, 81, 85
Colonization, 5, 9, 17, 158, 272–275,
290, 291
Communities, 5, 8–10, 16–18, 32–36, 49,
56–58, 61, 84, 124, 125, 128, 147–171,
183–208, 223, 230–233, 235, 238, 239,
242, 245, 249, 250, 272–275, 277, 278,
280–282, 287–291
Compression of morbidity theory, 8, 84
COVID-19, 4, 8, 80, 81, 165
Cultural and religious contexts, 25
Cumulative Disadvantage Hypothesis, 8, 85
D
Depression, 26, 29, 32, 46, 48, 50–53, 56, 57,
62, 63, 81, 119, 128, 147, 149, 152,
154, 157, 170, 242, 245, 273, 280
Diabetes mellitus (DM), 96, 113–117,
123, 124
Disparities, 4, 8, 16, 29, 45–48, 50, 56, 61, 62, 64,
83–85, 93, 94, 104, 198, 201, 203, 204,
221–250, 272, 276, 278, 280, 283–285
E
Elder support, 8, 157
F
Familial support, 148–149, 249
Family-building, 9, 152–155
Fundamental cause theory, 8, 83, 84
G
Gender and sexual minority, 183–208
Global health, 4, 8, 80
Global mental health, 60
H
History, 4–5, 18, 30, 32, 35, 120–122, 127,
154, 158, 159, 161, 162, 171, 228, 240,
241, 246, 275, 277
HIV/AIDS, 81, 83, 104, 105, 157, 171,
183–208, 225, 290
Human rights, 9, 20, 22, 26, 30, 55, 128, 154,
160, 164, 165, 167, 168, 194–197, 271,
272, 275–279, 285, 291, 295
I
Immune dysregulation, 81
Indigeneity, 6
Index
© The Editor(s) (if applicable) and The Author(s) 2024
S. J. Hwahng, M. R. Kaufman (eds.), Global LGBTQ Health, Global LGBTQ
Health, https://doi.org/10.1007/978-3-031-36204-0
308
Intentional injury, 9, 271–286
Intersectionality, 6–7, 19
Intersex, 9, 20, 24, 55, 164, 166–168, 170,
171, 188, 271, 276, 279, 291
Interventions, 5, 8–10, 29–35, 46, 58–62, 80,
85, 86, 93, 128, 129, 151, 183, 187,
189, 192–203, 205, 207, 231, 234, 237,
242–246, 249, 250, 272, 288–292
L
Lesbian, gay, bisexual, transgender, and queer
(LGBTQ), 45, 128, 147–150, 152–154,
156–171, 280, 283, 295
Lesbian, gay, bisexual, transgender, queer, and
intersex (LGBTQI), 168, 171, 271–295
LGBTQ health, 1–3, 5, 6, 19, 28, 33
LGBTQ-related organization, 9, 169
M
Marginalization, 5, 17, 19, 151, 152, 162, 189,
197, 236, 237
Mental health, 19, 30, 45, 79, 147–149, 152,
157, 170, 171, 272–274, 280, 286, 287
Methodological issues, 9, 121
Minority stress, 16, 25, 32, 53, 83, 123, 147,
148, 168, 273, 291
Minority stress theory, 16, 25, 32, 53–55, 60
N
Non-communicable diseases (NCDs), 8, 80,
84–86, 93–96, 103, 113, 120, 123–127,
129, 204, 238
R
Race and ethnicity, 83
Rejection, 24, 26, 27, 31, 59, 147, 148, 158,
197, 199, 280
Relationships, 7, 9, 27, 33, 36, 55, 58, 103,
105, 119, 148, 149, 151–157, 159, 163,
169, 170, 242, 249, 272, 275, 284
Religion and spirituality, 57, 165–166
S
School support, 149–150
Sexual and gender diverse, 277
Sexual and gender minorities (SGMs), 3, 8, 9,
35, 36, 51, 53, 56, 57, 60, 63, 79–87,
93, 125, 160, 163, 164, 169, 183–208,
221–250, 274, 294
Sexual minority (SM), 8, 9, 23, 30, 32, 33, 35,
36, 47, 48, 50–57, 59, 60, 85, 87,
94–97, 104–106, 113–115, 117–119,
121–122, 124, 150, 151, 154–156,
159–161, 163, 186, 187, 198, 202, 204,
205, 221, 224, 226, 228, 230, 232–234,
236, 239, 248, 249, 273, 276, 281, 282
Social exclusion, 51
Social support, 5, 8–9, 27, 54–57,
147–171, 235
Socio-ecological model (SEM), 192, 193
Stigma, 7–9, 16–36, 49, 51, 53–56, 58–60, 64,
84, 87, 123, 128, 147, 151, 168, 170,
186–188, 192–199, 201, 203, 205, 207,
208, 222, 234, 236, 238, 246, 272, 273,
280–282, 286, 287, 291
Substance use, 9, 23, 29, 46, 52, 57, 118, 122,
123, 170, 186, 197, 200, 201, 221–250,
272, 273, 286, 287, 291
Suicidality, 34, 46–48, 50–52, 55–57, 242, 294
Syndemics, 9, 81, 83, 197, 200, 272, 273, 291
T
Transgender, 17, 18, 20, 22–24, 26–29, 32, 35,
45, 81, 85, 86, 94, 148, 150, 160,
162–163, 165, 168, 271, 277, 278,
280–287, 291, 292, 294, 295
Transgender men (TM), 9, 51, 108, 110, 111,
116, 170, 186, 192, 198, 202, 204, 205,
228, 231, 232, 284, 286
Transgender women (TW), 1, 9, 20, 27, 29,
50, 51, 54, 55, 108, 110, 111, 116,
125–129, 184–190, 192, 196, 198–205,
207, 224, 228–231, 237, 273, 278, 281,
283, 284, 286, 292, 294, 295
V
Victimization, 5, 9, 10, 52, 54–56, 150,
158, 159, 197, 235, 237, 240,
241, 271–295
Violence, 9, 10, 18, 24, 26, 29, 30, 34, 49–51,
53, 54, 57, 63, 84, 87, 152, 169, 171,
186, 194, 197, 199, 200, 228, 237, 242,
245, 246, 271–292, 294, 295
W
Workplace support, 28, 155–156
Index
