LGBT Individuals Not Getting Equal Attention in Research

More and better research is needed to understand and address disparities in the health of lesbian, gay, bisexual, and transgender (LGBT) people, concluded an Institute of Medicine report issued March 31.

The request for the study came from the Office of the Director at the National Institutes of Health. The report covered mental and physical health issues, as well as research insufficiencies in the field.

The panel was chaired by Robert Graham, M.D., a professor and chair of the Department of Family Medicine at the University of Cincinnati School of Medicine. No psychiatrists were appointed to the panel.

"The committee was chosen to balance various aspects of the project—lesbians, gay men, bisexual people, transgender people, as well as comprehensive health concerns over the life course and research methodology issues," IOM media relations officer Christine Stencel told Psychiatric News. "While there may not have been a psychiatrist on the committee, the committee examined mental health issues for these populations, and its findings are reflected in the report."

The IOM report covered both substantive and methodological questions in examining the state of research on LGBT health issues.

Much of the existing research on the younger LGBT population has focused on mental health, the report noted, although data are lacking that could fill in many of the gaps in understanding LGBT-related health issues and how to treat them.

At any age, LGBT people are "typically well adjusted and mentally healthy," the report's authors pointed out.

However, much existing research among young people deals with depression and suicidality, which do appear at higher rates in this population (Psychiatric News, May 6). Some of the added risk is probably due to the factors common to all adolescents, but antigay victimization, stigma, gender nonconformance, and family rejection appear to increase risk, studies have shown.

Research does point to a disproportionate risk of suicidality among LGBT youth with pre-existing mental illness, said Marshall Forstein, M.D., an associate professor of psychiatry at Harvard Medical School and director of adult psychiatry residency training at Cambridge Hospital.

Some psychiatric symptoms may be caused by stress induced by minority status, explained Forstein in an interview with Psychiatric News. "Being a sexual minority and feeling outcast predisposes a young person to symptomatology."

Each adolescent's social setting can increase or reduce his or her risk for depression or suicide, Forstein added.

Adolescents who identify early as gay are more vulnerable to belonging to a stigmatized peer group and often more isolated from their families of origin than those who so identify at a later age, said Forstein.

In contrast to other minorities in which the adolescent has the same minority status as his or her parents, the LGBT adolescent may also have to deal with parents who reject their offspring because of the child's sexual orientation.

"Kids who ‘come out’ later have a stronger sense of self and identify more with the mainstream," he said. A crucial question "is how to help kids identify sooner and to feel better about themselves without putting them at increased risk."

The report also noted that a childhood diagnosis of gender identity disorder is controversial.

"[This psychiatric diagnosis] identifies gender-variant identity and expression as pathological, even though many gender-variant children do not report emotional distress; rather, distress may be related to the reaction of the social environment to the child's gender variance," said the report. Furthermore, "most children [with] gender-variant expression do not develop an adolescent or adult transgender identity."

The diagnosis is being revised for DSM-5 and will cover children, adolescents, and adults, said William Narrow, M.D., M.P.H., associate director of APA's Division of Research. The current proposed term is "gender incongruence," but a more recent proposal posted on the DSM-5 Web site on May 4 (www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=192) suggested a change to "gender dysphoria," implying that it is not the difference but the individual's unhappiness with the difference that requires a diagnosis. Retaining a diagnostic term would make it easier for some individuals to obtain insurance payment for mental health care, said Narrow.

Frequent Bias, Stigma Take Toll

Once they reach adulthood, LGBT people are typically as mentally healthy as the general population, although the chronic stress of stigma and discrimination can have significant negative effects on them, the report pointed out.

Their LGBT status has varying effects as they age, according to the report. They may feel more self-reliant and resilient and have support from a circle of friends. But they also fear discrimination on the basis of both age and identity, and feel vulnerable when interacting with health care providers.

Health Barriers Inadequately Studied

Collecting reliable data from sufficiently large samples of LGBT individuals has challenged researchers trying to assess demographic factors in this population, the report noted. It called for more research across the life cycle, more study of the barriers to equitable health care for LGBT individuals, and more research into the interventions to address their health inequities.

The IOM panel's report also called for more study of the social influences that impact the lives of LGBT people and the role of those influences in supporting their mental health. Finally, the report said that more must be learned about the specific needs of transgendered persons and of dual minorities, that is, LGBT individuals who are also members of racial or ethnic minority groups.

People with dual-minority status are likely to be doubly marginalized. Aside from a call for more research, the report made little mention of people who fit this category.

These dual-minority individuals "are ostracized from the white gay community and don't fit into their own ethnic minority group of origin," said Forstein. Apportioning risk to each element of identity is not easy, so it's hard to generalize about the needs or characteristics of this subpopulation, he said.

Part of the problem in researching LGBT health issues has to do with definition. The IOM panel included sexual attraction, behavior, and identity under the heading of sexual orientation, which it defined as a construct covering "an enduring pattern of or disposition to experience sexual or romantic desires for, and relationships with, people of one's own sex, the other sex, or both sexes."

This report may lead to better research, said Forstein, noting that there is little agreed-upon terminology across most existing studies.

For instance, he said, when studying the epidemiology of HIV infection, there was an important difference between sexual self-identity versus sexual behavior as a research criterion.

Sampling problems may have to be overcome with special statistical techniques to gain explanatory power from a small population that may be hesitant to identify its sexual-orientation status, especially in telephone surveys.

As welcome as more research might be, accumulation of additional data is outweighed by an immediate need to improve access to health care for LGBT people, laws to support them and counter discrimination, and better education for physicians and other health care providers to understand and treat sexual minorities, said Forstein.

"We've known about this for 25 or 30 years," he emphasized. "The government is good at research and not as good at providing resources."

A summary of and purchase information for "The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding" are posted at <www.iom.edu/Reports/2011/The-Health-of-Lesbian-Gay-Bisexual-and-Transgender-People.aspx>.