7.1: LGBTQ+ Health and Wellness - Overview

Introduction

The health and wellness of LGBTQ+ and other sexual minority people in the United States is influenced by many factors: access to health care and health insurance; ability for open self-disclosure with a queer-affirming health professional; knowledge about the unique health challenges of LGBTQ+ people, including disease prevention and health promotion; and a sense of self-efficacy about their health, or the confidence that they know how to live a healthy life, along with the intention, necessary knowledge, and resources to do so. According to the Institute of Medicine of the U.S. National Academy of Sciences, LGBTQ+ health can be understood through four lenses:

• Minority stress model—chronic stress that sexual and gender minorities routinely experience can contribute to physical and mental health problems.
• Life-course perspective—events at each stage of life influence subsequent stages, with LGBTQ+ people being particularly vulnerable in adolescence and young adulthood.
• Intersectionality perspective—an individual’s multiple identities and the ways they interact may compromise health so that gender and sexual identity may be complicated, for example, by racial or ethnic identity or economic status. Health disparities are already amplified among racial and ethnic minority populations, which queer sexual orientation is likely to intensify further.
• Social ecology—individuals are surrounded by spheres of influence and support, including families, friends, communities, and society, that shape self-efficacy and health.^[1]

In this chapter we keep in mind these four overlapping dimensions while exploring the following topics:

• LGBTQ+ people and the history and culture of medicine.
• Vulnerabilities of LGBTQ+ people across the lifespan and across intersectional identities (including race and ethnicity).
• Transgender people’s health.
• Guidelines for being a smart patient and health care consumer.

History and Culture of Medicine and LGBTQ+ People

LGBTQ+ people often have complicated relationships with medicine, and these relationships have histories that extend back to the 1800s. The philosopher Michel Foucault famously (and controversially) suggested that queer sexualities in the ancient and medieval worlds were judged in an exclusively legal or religious category but that in the 1800s sexualities became medicalized.^[2] From this perspective, in historical terms, LGBTQ+ people in Western society went from being criminal or immoral to being mentally ill.

Viewed as a pathology rather than just a moral failing or legal violation, queer sexuality became the object of medicine’s study: What is its cause, and if it is a pathology or disease, how might it be cured? This moment occurred in the second half of the 1800s when medical research and practice had absorbed enormous cultural power and authority through its first modern groundbreaking discoveries, including the development of germ theory, surgical antisepsis, and anesthesia. All things seemed possible to medicine.

Developing Terminology

The term homosexual appears to have been coined by the Austro-Hungarian journalist Karl-Maria Kertbeny (1824–1882) (figure 7.1) in an 1869 pamphlet criticizing a German anti-sodomy law.^[3] The term was taken up by the psychiatrist Richard von Krafft-Ebing (1840–1902) in his Psychopathia Sexualis [Mental illnesses related to sex] (1886).^[4] The term entered English through a translation of Krafft-Ebing’s work and through the advocacy writing of John Addington Symonds and Havelock Ellis in England. The term bisexual, in contrast, had been used in botany since the 1700s to denote plants with both male and female anatomy (also referred to as hermaphrodite), but was adapted in the late 1800s to denote a person with roughly equivalent attraction to men and women. The term intersex, used as a synonym for homosexual, was adapted in the early twentieth century from biology, where it indicated the possession of both female and male anatomical features, and it is now the term frequently used by people born with ambiguous genitalia.

Figure 7.1. Karl-Maria Kertbeny. (Public domain.)

Theories of Sexual Variation

These attempts to name this unique species of human beings and diagnose what they viewed as sexual pathology, or disease, led physicians, sexologists, and psychiatrists to a search for causality and treatment. David F. Greenberg identifies five explanatory categories that emerged over time: homosexuality as innate, degeneracy theory, Darwinian theory, psychoanalytic theory, and behaviorism.^[5]

Nineteenth-century advances in embryology and genetics may have influenced what had often been an assumption since Greco-Roman antiquity that sexuality was innate, leading to a theory of the third sex, which was also encouraged by movements for social tolerance and legal reform. In contrast, proponents of degeneracy theory viewed homosexuality and bisexuality as akin to criminality, alcoholism, and drug addiction. Degeneracy suggests that the gene pool had become exhausted as a result of modern life or personal vice and indulgence inherited from a previous generation. Similarly, the application of Darwinian theory evaluated people and behavior, characterizing homosexual and bisexual people as evolutionary throwbacks, akin to “primitive” peoples whom Europeans had colonized throughout the world and whose sexual mores were at odds with Western notions of morality.

Perhaps no theories of sexual identity have been more influential than psychoanalytic theory and behaviorism. Although various psychodynamic theories were espoused in the late 1800s and early 1900s, Sigmund Freud, often called the father of modern psychoanalysis, postulated that infants are “polymorphous perverse,” deriving pleasure from many parts of their body and regardless of gender. The function of society, for Freud, was to channel pleasure into an acceptable, productive heterosexuality. However, traumas or inner conflicts could arrest a child’s psychosexual development or cause a young adult to regress into homosexuality (for example, an overly attentive mother and distant father for boys). The role of psychotherapy was to expose the trauma or conflict and allow growth toward heterosexuality to resume. Nonetheless, Freud was less inclined to view homosexuality as a sickness than as a form of psychosexual immaturity. Behaviorism, in contrast, has been inclined to view sexual orientation generally as a learned behavior, which means that homosexuality can be unlearned.^[6] Whereas psychoanalytic theory prefers talk therapy, behaviorism has tended to employ rewards and punishments to “reprogram” sexual behavior, including electroshocks and hormone injections. So-called gay conversion therapy, the subject of increasing legal rejection by states today, has a decades-old history.

Emerging Self-Care

Throughout the twentieth century the medical establishment in the United States generally considered queer sexualities as mental illnesses. However, early descriptive research by Alfred Kinsey and his colleagues disclosed both a surprising number of self-identified LGB persons and a fluid spectrum of human sexual response. What they called a “heterosexual-homosexual rating scale” identified a range from exclusively heterosexual (0) to equally heterosexual and homosexual (3), otherwise known as bisexual, to exclusively homosexual (6). This scale was applied to each individual according to the participants’ sexual behavior and psychic reactions—that is, thoughts, feelings, and fantasies.^[7]

It is no wonder, then, that by the 1960s and the emergence of the gay rights movement, many LGBTQ+ people had come to distrust the medical establishment. Health care providers often either exhibited hostility or acknowledged ignorance about the unique health concerns of LGBTQ+ people.^[8] Many gay men and lesbians in particular had come to reject the notion of their sexual orientation as a pathology and had begun to seek the rare health care providers who were affirming of their sexualities. Feminists and the women’s movement had shown how this might be done with health collectives, like the one in Boston that produced the book Our Bodies, Ourselves, part of a movement in the United States in the late 1960s and early 1970s for homegrown self-published self-help books.^[9] One groundbreaking book for queer people included chapters on alcohol safety, venereal diseases (now called sexually transmitted infections), and other health topics, many of which had been previously published in local queer newspapers and magazines.^[10] In major urban areas, health clinics for LGBTQ+ people formed to serve this vulnerable population.^[11]

When the first published reports of an infectious epidemic that would come to be called acquired immune deficiency syndrome (AIDS) appeared in 1981, queer communities were wary of uncertain medical explanations and advice, aware of the stigmatization of their sexualities that was now exacerbated by AIDS, but also more prepared for community organizing around health concerns. Grassroots organizations at least in large or midsize metropolitan areas—like New York’s GMHC (Gay Men’s Health Crisis) and Tidewater AIDS Crisis Taskforce of Norfolk, Virginia—advocated, educated, and cared for people infected with HIV. Chapters of the AIDS Coalition to Unleash Power (ACT UP) blossomed in cities, particularly New York and San Francisco, bringing direct-action demonstrations against government and medical inaction. AIDS activists changed the ways that the U.S. medical establishment conducted research and delivered care by insisting on the participation of people living with AIDS in decisions about drug approvals and treatment.^[12]

Read

The Wellcome Collection is a free museum and library that aims to challenge how we all think and feel about health. Its article “The Shocking ‘Treatment’ to Make Lesbians Straight” (https://wellcomecollection.org/artic...WjZhAAACUAOpV2) describes the efforts of two researchers to uncover whether and how women were treated for lesbianism in England in the 1960s and 1970s.

• What were some of the challenges that the authors faced in conducting their research?
• How did the beliefs of the health care community at the time affect the treatments designed to “cure” their patients?
• A former patient pointed out that “[lesbians] were being tested against heteronormative ideas of sexual attraction—a significant flaw!” What did she mean by this?

Check Your Knowledge

Contributed by Has Arakelyan, Rio Hondo College

Multiple-Choice Questions

1. According to the Institute of Medicine, which of the following is NOT one of the four lenses for understanding LGBTQ+ health?
A) Minority stress model
B) Life-course perspective
C) Intersectionality perspective
D) Economic productivity model

2. What does the minority stress model suggest about the health of sexual and gender minorities?
A) They experience better health due to strong communities.
B) Chronic stress from prejudice can contribute to physical and mental health problems.
C) They have no unique health challenges.
D) They are less likely to seek health care.

3. What is the main idea of the life-course perspective in LGBTQ+ health?
A) Only childhood events matter.
B) Health is only determined by genetics.
C) Events at each stage of life influence later stages, with particular vulnerability in adolescence and young adulthood.
D) Health is unrelated to life events.

4. What does the intersectionality perspective emphasize in LGBTQ+ health?
A) Multiple identities (such as race, gender, and economic status) interact and can intensify health disparities.
B) Only sexual identity matters.
C) Health is only affected by age.
D) Intersectionality is not relevant to health.

5. According to Michel Foucault, how did the perception of queer sexualities change in the 1800s?
A) They were always seen as healthy.
B) They shifted from being judged legally or religiously to being medicalized as mental illness.
C) They were celebrated in society.
D) They were ignored by the medical community.

Discussion Questions

1. How do the four lenses (minority stress, life-course, intersectionality, social ecology) help us understand the unique health challenges faced by LGBTQ+ people?
2. In what ways has the medicalization of queer sexualities shaped the relationship between LGBTQ+ communities and health care providers?
3. Why might adolescence and young adulthood be especially vulnerable periods for LGBTQ+ individuals in terms of health and wellness?
4. How can understanding intersectionality improve health care for LGBTQ+ people with multiple marginalized identities?
5. What steps can health care professionals take to build trust and provide affirming care for LGBTQ+ patients today?

Multiple-Choice Questions - Answers

1. D) Economic productivity model
2. B) Chronic stress from prejudice can contribute to physical and mental health problems.
3. C) Events at each stage of life influence later stages, with particular vulnerability in adolescence and young adulthood.
4. A) Multiple identities (such as race, gender, and economic status) interact and can intensify health disparities.
5. B) They shifted from being judged legally or religiously to being medicalized as mental illness.