lgbtqia research

Advertisement

LGBTQI+ Youth and Mental Health: A Systematic Review of Qualitative Research

• Systematic Review
• Open access
• Published: 21 May 2019
• Volume 5 , pages 187–211, ( 2020 )

Cite this article

You have full access to this open access article

• Clare Wilson 1 &
• Laura A. Cariola 1  

128k Accesses

93 Citations

95 Altmetric

10 Mentions

Explore all metrics

Due to increased levels of stigma, discrimination and victimization Lesbian, Gay, Bisexual, Transgender, Queer, Questioning or Intersex (LGBTQI+) youth face particular challenges in society. With the intention of better understanding the challenges and issues that LGBTQI+ youth are experiencing, this systematic review explored qualitative studies with a focus on mental health services and the requisite social support service policies and programs for LGBTQI+ youth. Qualitative research systematically examines the expressed thoughts and feelings of the research participants, and through reflective analysis of the themes and links discussed, can provide rich and nuanced understanding. A synthesis of the included studies identified five core themes: (1) Isolation, rejection, phobia, need for support; (2) Marginalization; (3) Depression, self-harm and suicidality; (4) Policy and environment; and (5) Connectedness. Key results suggest that community, school, and family resources to support resilience will optimize LGBTQI+ mental health. This systematic review of qualitative research provides a source of rich information to inform the provision of services and policies that will address the disparity into mental health statistics for the LGBTQI+ population.

Similar content being viewed by others

The Role of Social Sciences in Understanding Mental Health and LGBTIQA+ People

Psychosocial Interventions for Mental Illness among LGBTQIA Youth: A PRISMA-Based Systematic Review

Avoid common mistakes on your manuscript.

Introduction

Young people experience many challenges in adolescence. Anxiety, depression and suicide are reported as causes of youth morbidity and mortality across the world (Adelson et al. 2016 ). Empirical studies suggest that youth who identify as Lesbian, Gay, Bisexual, Transgender, Queer, Questioning or Intersex (LGBTQI+) can find themselves faced with greater challenges, compared to youth of heterosexual orientation, as they navigate the heteronormative educational and societal institutions where children and youth spend much of their early lives (Almeida et al. 2009 ; Fergusson et al. 1999 ; Hafeez et al. 2017 ; Russell and Fish 2016 ). Online and community services, such as RainbowYOUTH (RainbowYOUTH 2018 ) and InsideOUT (InsideOUT 2018 ) in New Zealand and their international equivalents, are available to youth, but the provision of a positive school climate where LGBTQI+ youth can feel physically, emotionally and socially safe is vital for them to thrive during their adolescence and early adulthood. Research into mental health disparities and challenges for LGBTQI+ youth to date has a predominantly quantitative focus, and several systematic reviews provide an overview of quantitative data available on issues faced by Sexual and Gender Minority Youth (SGMY) (e.g. Brown et al. 2016 ; McDonald 2018 ). Surprisingly, there are fewer qualitative studies that contribute to an in-depth understanding of the challenges and issues that LGBTQI+ youth are facing by exploring the views and opinions of those affected. This systematic review aims to identify and obtain a comprehensive overview of qualitative studies by appraising, critically reviewing and synthesizing qualitatively derived evidence-based results and main emergent themes sourced from current literature. Special attention is given to the provision of mental health services and the requisite social support service policies and programs for LGBTQI+ youth.

LGBTQI+ Mental Health

LGBTQI+ youth are one of the most vulnerable groups in society due to their increased risk of mental health problems. Statistics for the LGBTQI+ population estimate that New Zealand has 8% non-heterosexual youth (Clark et al. 2013 ), the U.S. has 7-8% LGB youth (lesbian, gay or bisexual) (Wilson et al. 2014 ), and the U.K. has 4.1% of LGB young people aged 16–24 (Office for National Statistics 2016 ). Although LGBTQI+ represents only a small proportion of the total youth population, they are at increased risk, compared to heterosexual youth, of experiencing hostile environments at home and in wider society, and are subject to direct and indirect discrimination, harassment, disadvantage and inequality with detrimental consequences for mental health (Hudson-Sharp and Metcalf 2016 ).

In fact, the 2012 survey completed as part of the Youth 2000 Survey Series, Young People Attracted to the Same Sex or Both Sexes Report (Lucassen et al. 2014 ), stated that sexual and gender minority youth were more than three times as likely to express symptoms of depression and more than twice as likely to have self-harmed than their heterosexual peers. One in five had attempted suicide, with almost half of the respondents having thought about a suicide attempt. 41% of sexual and gender minority youth had been to see a professional for emotional support in the last 12 months, compared to 16.6% of their non-LGBTQI+ peers. The Youth 2000 Survey (Lucassen et al. 2014 ) also identifies a greater risk of alcohol or drug use in LGBTQI+ youth. During the same period, in Scotland, 40% of LGBT youth considered themselves to have a mental health condition in comparison to 25% of non-sexual and gender minority youth, and bullying was identified as a key factor in distress among respondents (Mental Health Foundation 2016 ).

In particular, evidence suggests that sexual and gender minority youth have different risk factors and markers (Silenzio et al. 2007 ) and that these unique risks combined with general life stressors have the phenomenological outcome of higher levels of self-harm, suicidality and impulsivity (Liu and Mustanski 2012 ). These risk factors extend over the lifespan, with four times greater risk of suicide for SGM men, and both men and women being 1.5 times more likely to suffer from anxiety, depression and substance misuse (King et al. 2008 ). Evidence from Mental health of the non - heterosexual population of England, a 2011 study (Chakraborty et al. 2011 ) concludes that gay men and lesbian women have higher levels of psychological distress than heterosexuals and that discrimination may be a significant factor affecting mental health for the LGBTQI+ population.

Minority stress theory (Meyer 2003 ) suggests that the increased prevalence of mental health issues experienced by LGBTQI+ youth is due to the increased level of social stress, including stigma, discrimination, prejudice and victimization. Adolescence is a critical neurological development stage, with heightened effects of stress on mental health, important memory system development and a time of increased sensitivity to drug use (Fuhrmann et al. 2015 ). At this crucial time, feeling discriminated against by educational, medical or religious institutions, or internalizing feelings of victimization due to homophobia, transphobia or biphobia can result in significant psychological challenges for sexual and gender minority youth (Russell and Fish 2016 ). Evidence has consistently identified that issues such as marginalization, isolation, exclusion and bullying create social stress for sexual and gender minority youth (Grossman et al. 2009 ; Hafeez et al. 2017 ). Additionally, lack of access to understanding adults, safe places and change room facilities creates a psychological burden. However, as Bryan and Maycock ( 2017 ) point out, this can create a pathologizing phenomenon, which paradoxically may stigmatize well-adjusted and happy LGBTQI+ youth who are managing their lives in psychological comfort.

Particularly, stigma and shame create personal barriers for at-risk youth, preventing those affected from accessing services (Brown et al. 2016 ). McDermott ( 2015 ) suggests that embarrassment, shame and fear of stigmatization are reasons for sexual and gender minority youth to avoid seeking support from mental health services. Young LGBTQI+ people who are homeless, rural, or who are substance-users face additional barriers to seeking help (Brown et al. 2016 ). If support from adults or professionals is inaccessible, an alternative is for LGBTQI+ youth to find peer support and information on internet-based forums (McDermott et al. 2015 ; McDermott et al. 2008 ).

Family acceptance also has been identified as a salient influence on the mental health of sexual and gender minority youth (Sitkin and Murota 2017 ). Parental attachment, as described by Mohr and Fassinger ( 2003 ), is characterized by sensitivity and responsiveness to a young person’s needs. If sexual and gender minority youth feel accepted and valued as individuals, there is an increased likelihood to disclose non-heteronormative status to family, and “come out,” or “be out,” the colloquial terms for being able to openly express LGBTQI+ orientation (Ryan et al. 2010 ). However, there is a disproportionate number of homeless LGBTQI+ youth, signifying that familial rejection is a significant factor for compromised mental health (Russell and Fish 2016 ). Durso and Gates ( 2012 , p. 4) published results of a national USA online survey and found that “nearly seven in ten (68%) of their LGBT homeless clients have experienced family rejection and more than half of clients (54%) had experienced abuse in their family.”

Adolescence is a developmental time frame within which youth explore their sexuality and for LGBTQI+ youth it will often be the time when they develop understanding of their own sexual and gender orientation. Within the realm of early family relational psychology, Bowlby ( 1962 /1982) discusses changing attachments during the time of adolescence, with a subsequent shift in attachment to peers and social groups other than the family, and to institutions such as school, universities, religious or political groups. Acceptance by these alternative attachment groups is a strong protective factor for sexual and gender minority youth (Higa et al. 2014 ). The wider ecology of LGBTQI+ youth has a significant effect on their mental health and well-being and feelings of social connectedness to adults gives sexual and gender minority youth resilience in the face of adversity, particularly at the vulnerable developmental stage when they are establishing their sense of personal identity (Difulvio 2011 ).

Key Themes in Quantitative Research

The vast majority of quantitative literature on LGBTQI+ focuses on the impact of isolation, marginalization and discrimination against sexual and gender minority youth in relation to mental health outcomes, and the identification of risk and protective factors. For example, there is a robust pattern of results that demonstrated sexual and gender minority youth experience significantly higher levels of suicidality, depression, and substance misuse than heterosexual youth, which highlights the severity and prevalence of differences between sexual and gender minority youth and heterosexual youth (King et al. 2008 ; Lucassen et al. 2017 ). These results also identified higher rates of violence and victimization associated with higher levels of hopelessness and attempted suicide in sexual and gender minority youth, and also a greater potential for psychosocial problems (e.g. drug and alcohol use or abuse, risky sexual behaviors, eating disorders, and mood disorders) than reported by their heterosexual or cisgender peers. The relationship between peer victimization and sexual orientation, gender identity or expression associated with poor mental health outcomes (e.g. depression, traumatic stress, and suicidality, as well as alcohol and substance abuse) and educational outcomes (e.g. diminished school belonging, disruptions in educational trajectories) has been also confirmed in another systematic review (Collier et al. 2013 ). In particular, bisexual individuals have been shown to experience more psychological distress, compared to homosexual and heterosexual peers due to experiences of victimization, peer judgments and family rejection (King et al. 2008 ; Pompili et al. 2014 ).

Quantitative research has also focused on identifying risk and protective factors for mental health in LGBTQI+ youth, which has resulted in setting directions for prevention, intervention and treatment, as well as influencing laws and policies, and making advances in fostering improved mental health (Russell and Fish 2016 ). For example, the role of family acceptance as a protective factor in LGBTQI+ youth and young adults has been shown to be a predictor for positive mental health outcomes (e.g. greater self-esteem, social support, general health) and a protector against depression, substance abuse and suicidality (Bouris et al. 2010 ; Ryan et al. 2010 ). As such, family programs that motivate and empower parents, caregivers and other family members, have been recognized as a promising framework for community interventions that emphasize a strengths-based approach concentrating on the effects of positive parent–child relationships, rather than focusing on negative parent–child relationships and influences where a child’s sexual orientation and gender identity may be seen as a “deficit.” Further supporting these findings are those of a recent systematic review of literature (McDonald 2018 ), who identified that higher levels of social support were associated with positive self-esteem whereas lack of social support was associated with higher levels of depression, anxiety, shame and self-esteem, alcohol and drug misuse, as well as risky sexual behavior. In particular family or significant adults providing support for young LGBTQI+ is a protective factor. Family and caregiver acceptance and a sense of belonging to a peer group were identified as moderators of resilience, and thus, suggests McDonald, can be utilized in communities to support mental health outcomes.

In relation to accessing and engaging with mental health care, Brown and colleagues’ systematic review ( 2016 ) identified barriers and facilitators among youth from different minority groups, including but not exclusively LGBTQI+ , who had distinct needs that must be recognized by mental health services in order to improve their experiences with mental health care. In particular, findings demonstrated that barriers to access are more often identified (e.g. lack of awareness of services, stigma and shame around seeking help, issues around confidentiality, trust and anonymity), however, facilitators to support engagement with providers (e.g. community and educational programs to increase awareness of services and attitudes toward mental health services) have remained widely underexplored, and thus require further attention in future research. With regards to educational programs aimed at increasing LGBTQI+ wellbeing, safe school interventions and supportive environments such as “gay-straight alliances,” sometimes referred to as the “gender and sexuality alliances,” (GSAs) have been shown to have a positive effect in reduction of stigma in schools, with significantly better psychological outcomes (e.g. improvement in academic performance, feeling more comfortable in their sexual identity and empowerment), social outcomes (e.g. positive sexual diversity climates, greater sense of connectedness to their school), and also physical outcomes (e.g. lower levels of youths’ self-reports of homophobic victimization, fear of safety, and hearing homophobic remarks) (Black et al. 2012 ; Marx and Kettrey 2016 ). This study also showed that the empowering of youth to be activists and to form their own peer supports may mediate the negative effects of marginalization and the poor mental health outcomes, including depression and suicidality.

The Current Study

The existing quantitative studies provide a rich picture of trends based on statistical indications of sexual and gender minority youth who experience adverse outcomes in a heteronormative society. In contrast to quantitative studies, qualitative approaches to the analysis of data represent an important perspective for advancing the literature by obtaining an in-depth awareness of LGBTQI+ youth and their experiences of engaging in mental health and social support services and programs. As such, qualitative research provides insight into the thoughts and feelings of the research participants, and through reflective analysis by the researcher of the themes and links discussed, can provide meaning and understanding (Sutton and Austin 2015 ). One of the reasons participants may voluntarily engage in this type of research is the implicit chance that the evidence will inform change by giving them a voice, hence both personal and political empowerment (Clark 2010 ). The key aim is to provide a comprehensive understanding of nuances of human experience through analysis and interpretation of texts and images (McLeod 2010 ).

Qualitative research has also been traditionally excluded from systematic reviews but it has been recognized that qualitative research provides valuable insight to inform policies and practice (Thomas and Harden 2008 ). In particular, with the current focus on public and individual opportunity to be involved in the development and provision of LGBT services (Gillespie et al. 2002 ; Ministry of Youth Development 2015 ; Stonewall Scotland 2018 ), there is international recognition of the importance of client-centered, consultative and inclusive policy development informed by the voices of services users and consumers of services. The inclusion of service user voices draws on the notion of being given the power in respect to “having a voice,” and conversely, the notion of “silence” sometimes associated with feminism but equally ascribable to any marginalized or minority population (Hadfield and Haw 2001 ). Notably, experiences of youth are also often marginalized or they are spoken for by the parents or carers, and youth, if they do speak out, often assume that their voices will not be heard or respected as valid contributions in decision-making processes. There should be specific efforts to include youth in meaningful ways to voice their opinion in relation to matters that are of concern to them, without resulting in further inequalities. A Canadian paper, Promoting LGBT health and wellbeing through inclusive policy development , which also draws on literature from Australia, the UK and the USA, asserts that the marginalized LGBTQI+ community must be “explicitly included in policy development for a more inclusive form of health promotion” (Mulé et al. 2009 , p. 2). Because youth have authentic, legitimate experiences of the problems they encounter, qualitative research involving them will improve policies and future research (McLaughlin 2015 ). Hence, having the voice of young LGBTQI+ people available through qualitative research is imperative if we are to address the ecological, social, and pedagogical issues and ultimately the human rights of this marginalized group (Mockler and Groundwater-Smith 2015 ; UNICEF 1990 ).

The focus of this systematic review is to provide a comprehensive overview by collating and critically appraising the existing evidence-base of qualitative research studies of the last ten years (2008–2018), a decade that has seen a global increase in acceptance towards LGBT (Flores and Park 2018 ), which sought to provide a youth voice in regards to mental health challenges and experiences for LGBTQI+ people. This 10-year period has seen international changes in same-sex marriage laws, gay parenting rights, and gender reassignment as a protected characteristic (Stonewall Scotland 2018 ). In particular, this review aimed to identify and map themes from across the different types of qualitative research being undertaken, as well as identifying gaps in knowledge, to inform community-based LGBTQI+ service provision with a focus on ecological measures needed to support young LGBTQI+ people.

Search Strategy and Eligibility Criteria

For this literature search, several clinical psychology databases were identified to best represent the diverse fields of study relevant to this review, including ASSIA, CINAHL Plus, EMBASE, IBSS, MEDLINE and PsycINFO. With focus on qualitative studies published in the last decade characterized with marked changes of LGBTQI+ legislation, all database searches were limited to articles written in the English language, and published between January 2008 and April 2018. The search focused on international research articles appearing in peer-reviewed journals. Following the initial database search, a Google search and a manual back literature search were conducted in June 2018. The search strategy aimed to identify qualitative research literature on LGBTQI+ youth with particular attention to mental health issues, using Boolean operators and variations of the following keywords: qualitative, LGBT*, youth, young people, adolescent, teenager and mental health.

To identify relevant articles for this systematic review, inclusion and exclusion criteria were applied. Identified journal articles had to fulfill further inclusion criteria: (1) published between 2008 and 2018, (2) published in English language peer-reviewed journals, (3) focus on mental health of LGBTQI+ , (4) participants aged 12 to 24 years (using the New Zealand Government definition of youth age range being 12 to 24 years inclusively (Ministry of Youth Affairs 2002 ), (5) use of a qualitative methodology to the analysis of data. Journal articles were excluded if: (1) the study focus was on a specific, non-generalizable intervention or socio-economic population demographic, (2) the study had a medical perspective or focus on sexual health or practices, (3) the methodology did not include a qualitative methodology. All studies were evaluated according to these inclusion and exclusion criteria, and only studies that met the criteria were included in this systematic review. Studies that did not meet these inclusion criteria were discarded.

To identify relevant studies for this review, the inclusion and exclusion criteria were applied using a three-stage selection process (Meade and Richardson 1997 ): (a) looking only at the title, (b) looking at the abstract to identify its relevance to the research question and methodology, and (c) looking at the whole article. In cases where the researcher was not sure whether the paper was relevant and met inclusion criteria, the item was retained for the next screening stage.

Based on the outlined literature search strategy, 873 studies were initially identified. At this stage an additional manual search of Google using the same search terms and a manual back literature search of the articles included to date identified a further 21 articles. After duplicate removal and a title review of these studies, 676 were excluded and 52 were determined to meet inclusion criteria. Following another exclusion process, a total of 34 research articles were selected as having satisfied the eligibility criteria. A detailed overview of the search stages can be seen in the PRISMA Flow Diagram (see Fig.  1 ). The 34 articles include seven mixed methods studies where the results of the qualitative thematic analysis was deemed to add valuable data.

PRISMA flow chart

Data Extraction

Data of the included studies were extracted using a standardized format for systematic reviews of qualitative studies (NICE 2012a ). Characteristics identified from each of the 34 studies included research questions, methods, sample size and quality assessment. The extracted data were aggregated clearly and structured in a data extraction table (see Tables  1 , 2 , 3 , 4 and 5 ). To synthesize the findings of the studies, findings were extracted from the studies and grouped into thematic categories. Subsequently, patterns were sought across the findings to provide a more comprehensive understanding of the issues of concern to LGBTQI+ population using mental health services addressed in the studies.

Quality Assessment

Quality assessment of the retrieved journal articles was performed using the NICE guidelines quality appraisal checklist for qualitative studies (NICE 2012b ). Following these guidelines, assessment identifies the research question and the robustness of the methodology in relation to key findings and a valid conclusion. Six main domains are assessed: theoretical approach, study design, data collection, trustworthiness, analysis and ethics. A seventh overall assessment looks at the relevance of the study and grants an overall rating; “++” where all or most of the checklist criteria have been fulfilled, and where they have not, conclusions are highly unlikely to alter; “+” where some of the checklist criteria have been fulfilled, and conclusions are unlikely to alter; or a rating of “-” where few or no criteria are fulfilled. The seven mixed methods studies included in this systematic review had quality assessment performed only on the qualitative data methodology results of the research. In relation to the qualitative assessment of this systematic review, one reviewer initially assessed the quality of the included studies and subsequently, the quality assessment was verified by another reviewer.

The search identified 97 abstracts which were screened for relevance to qualitative research into mental health of LGBTQI+ youth. The full texts of 52 articles were assessed and 34 were identified as providing data pertaining to the aim of this systematic review. The 34 reviews were organized into five groups based on the research settings: (1) Internet search studies (see Table  1 ), (2) University student studies (see Table  2 ), (3) School or community group studies (see Table  3 ), (4) Studies focusing on Transgender (see Table  4 ), (5) Intervention studies (see Table  5 ). The results were compiled tables, and sorted into groups.

Included Study Characteristics

Population samples.

Of the 34 studies included in the systematic review, 19 studies (55.88%) focused on school or community populations, 9 studies (26.47%) were online- or Internet-based of which 3 studies were conducted using Internet-sourced data and 3 studies (8.8%) used university student populations, 3 studies (8.8 s %) focused on transgender subjects, and further 3 studies (8.88%) were related to the assessment of an intervention. The population numbers showed great variability from the smallest sample numbers (n = 10) (Diamond et al. 2011 ; Saltzburg and Davis 2010 ) to the largest study population (n = > 3700), taken from an online study (Peter et al. 2016 ).

Geographical Information

Of the studies included in this systematic review, 16 were done in the USA (47.06%), with 7 studies from the UK being the next highest geographical location (20.59%), followed by four in Australia (11.76%) and three in New Zealand (8.82%), and one in Canada (2.94%). Also included were international collaboration studies between the USA and Canada (Porta et al. 2017 ), Ireland, the USA and Canada (Catalpa and McGuire 2018 ) and the Universities of York, Leicester and Oslo (McDermott et al. 2013 ).

Of the identified studies for this systematic review, 23 studies were of high quality (67.65%) and 11 studies were of medium quality (32.35%). Of the 19 school and community population studies, 11 studies (57.89%) being of high quality and 8 (42.11%) of medium quality. The online Internet studies were assessed as having four (66.6%) high quality studies, and the university student population articles had two high quality studies (66.6%). The transgender and intervention study research groups both had all (100%) high quality studies.

Qualitative Methods

The most common methodology overall was thematic analysis, with 13 studies (38.23%), followed in frequency by four grounded theory (11.11%). Ethnographic and phenomenological approaches were used by three studies each (8.33% respectively). The remaining 11 studies (33%) used a variety of qualitative approaches, including one Foucauldian Discourse Analysis (McDermott 2015 ), one Life Story approach (Difulvio 2011 ), and a Go-Along Interviewing technique (Porta et al. 2017 ). There are three identified intervention studies in this systematic review. Porta et al. ( 2017 ) used an exploratory study to get a qualitative perspective from LGBTQI+ students (n = 25) about bathroom facilities, Lucassen and Burford ( 2015 ) evaluated a school-based workshop offered to students (n = 229), and a computerized e-resource aimed at sexual and gender minority youth with depression (n = 25) was also evaluated (Lucassen et al. 2015 ).

Synthesis of Themes

An analysis of the studies’ findings identified five core themes: (1) Isolation, rejection, phobia, need for support, ( 2) Marginalization, (3) Depression, self-harm and suicidality, (4) Policy and environment and (5) Connectedness. A diagram provides a visual outline of identified themes (see Fig.  2 ). The greatest proportion of studies (19) were categorized as School and Community services, and commonly identified all 5 themes, as did the Online/internet studies. The University studies concentrated on themes 1 to 4, the transgender studies identified all but the third theme, of suicidality, self-harm and depression, whereas the predominant theme of the three intervention studies was connectedness (see Fig.  2 ).

Diagram of identified themes

Isolation, Rejection, Phobia, Need for Support

Online studies, school and community based studies and transgender studies discussed themes of rejection and isolation, bullying and phobic behavior and the need for both more support and information to be made accessible to LGBTQI+ youth. Thematic narrative analysis of interviews and focus groups by Steinke et al. ( 2017 ) provided evidence of isolation as a reason that sexual and gender minority youth seek out Internet-based support channels, and further, the study by Wolff et al. ( 2014 ) of online-sourced media of completed suicides perceives isolation as both a precursor to suicidality and a warning sign of mental distress. Rejection from social, family and peer groups was a key trigger for distress in LGBTQI+ youth (Jones and Hillier 2013 ), and Higa et al. ( 2014 ) who identified negative and positive factors in a school-based sample, stated that the risk of rejection is potentially greater for those who are also at risk of racist or sexist bias, for example young women of color. Homophobia and transphobia towards sexual and gender minority youth was identified across several studies (Formby 2013 ; McDermott et al. 2017 ; McDermott et al. 2008 ). In McDermott et al. ( 2017 ), a high quality mixed-methods study involving thematic analysis of both online and face-to-face interviews, victimization through phobic behavior and attitudes of others towards sexual and gender minority youth was described as one of the five social determinants leading to suicidality, with 70.8% of their respondents having reported experiences of homophobia, transphobia or biphobia. These concepts of discrimination are re-framed as heterosexism by Nadal et al. ( 2011 ) and Roffee and Waling ( 2016 ), where the result of such discrimination and microaggressions contributes to negative effects on self-esteem and subsequent feelings of rejection and isolation.

The need for support in school and social environments for LGBTQI+ was put forward as an important factor for mental health, and in particular the availability of peer groups such as Gay Straight Alliance (GSA) groups and safe, inclusive community gathering places and events like RainbowYOUTH meetings. GSAs were specifically described as a source of safety and advocacy for youth (Porta et al. 2017 ; Russell et al. 2009 ). In particular, Steinke et al. ( 2017 ) suggest that a lack of any such supportive community for some sexual and gender minority youth is a valid driver of the need for online LGBTQI+ community groups, which is further supported by Higa et al. ( 2014 ) by pointing out that connecting via online interventions would be especially beneficial for those sexual and gender minority youth who are geographically isolated or who are either not “out” or who are not supported by their families to attend LGBTQI+ groups. The Internet, school GSA-type groups and community groups, such as RainbowYOUTH, were all found to be sources of information pertaining to gender or sexual minority identity as well as mental health support (Steinke et al. 2017 ; Waling and Roffee 2018 ). In a secondary inductive analysis of Concept Mapping Needs Assessments at two GLBT-focused youth centers in the U.S., Davis et al. ( 2009 ) argue that as well as material resources and information, having a person to talk to was a priority for sexual and gender minority youth who access these services, stating: “In fact, needing someone to talk to was the most important idea across groups for meeting youths’ emotional needs” (p. 1037).

Marginalization

Closely associated to “Isolation” is the concept of “Marginalization,” which can be defined as “Treatment of a person, group, or concept as insignificant or peripheral” (Oxford Dictionaries 2018 ). Both concepts, however can be differentiated to the extent that isolation refers to an individual experience, whereas marginalization describes the socio-political status of a population sub-group such as LGBT experiencing diminished community acceptance and systemic discrimination. The research articles identified in this systematic review put forward that marginalization for the LGBTQI+ community was a significant factor for mental health. For example, Alessi et al. ( 2017 ) conducted a grounded theory of focus groups to understand the role of minority stress and identified a continuum of marginalization experienced by first-year experience of LGBQ emerging adults attending a university in the Northeastern part of the United States. In a thematic analysis of qualitative interviews, Pallotta-Chiarolli and Martin ( 2009 , p. 200) also talk of young bi-sexual people “feeling like marginal X-files,” and the socio-political marginalization of sexual and gender minority youth makes it particularly critical that young bi-sexual people have a collective voice in order to be empowered to challenge the status quo (Russell et al. 2009 ). In a New Zealand ethnographic study, McGlashan and Fitzpatrick ( 2017 ) found that heteronormative environments, such as schools, create a culture where sexual and gender minority youth are more likely to be marginalized due to the dominant discourse of heterosexuality being positioned as “normal.” McDermott et al. ( 2008 ) and Scourfield et al. ( 2008 ) posit that despite increasing social acceptance of same-sex partnerships, marginalization is still prevalent for sexual and gender minority youth in the UK, and that until recently, sexual or gender orientation has not been recognized as a significant mental health risk factor, referring to the Preventing Suicide in England report (Department of Health 2012 ).

Depression, Self-harm and Suicidality

The previously identified themes of marginalization, isolation, rejection and being victims of phobic behavior are linked to poor mental health outcomes such as depression, self-harm and suicidality (Catalpa and McGuire 2018 ; Diamond et al. 2011 ; Difulvio 2011 ). In particular, self-harm was identified in the transgender population as an expression of dissatisfaction with the natal anatomy and physiology which was experienced to be erroneous or undesirable (McDermott et al. 2015 ). Jones and Hillier ( 2013 ) state in their mixed-methodology study findings that almost half of young trans-spectrum people have self-harmed. Scourfield et al. ( 2008 ), having used interviews and focus groups in their high quality study, discuss the ways in which this self-harm can manifest, from cutting to risky behaviors, and the question of whether sexual and gender minority youth identity has direct causality to these phenomena, or whether it is one factor among many in the lives of LGBTQI+ youth which may lead to self-destructive behaviors. Bullying and victimization by homophobic, transphobic or biphobic behavior was found to be a key component in self-harm behaviors (Formby 2013 ; Lucassen and Burford 2015 ; McDermott et al. 2017 ; Scourfield et al. 2008 ; Wolff et al. 2014 ). The inability to disclose sexual or gender orientation, or fear of “coming out” and negative experiences following disclosure were also found to be a strong predictor of depression and suicidality (Grafsky et al. 2018 ; Jones and Hillier 2013 ; McDermott et al. 2017 ).

Out of the 34 articles identified, 13 specifically dealt with the topic of suicide, and one online-based study by Wolff et al. ( 2014 ) was a frame analysis of completed suicides by sexual and gender minority youth in the USA, as reported in the media. The research was undertaken after a number of news reports, including six high-profile media stories involving young males aged 13 to 19 years who took their own lives in September 2010, linked the reported suicides to bullying and shame. Peter et al. ( 2016 ) also undertook research following a well-publicized youth suicide a year later in Canada, subsequent to reports of victimization, depression and self-harm for much of the victim’s life, and as with Wolff et al. ( 2014 ) there was a strong link between the suicide and a hostile school and community climate.

Policy and Environment

The “ Preventing Suicide in England ” report outlines how many LGBT pupils who are victims of bullying experience further negative academic, social and mental health outcomes, with the impact possibly persisting into adult life (Community Mental Health and 7 Day Services 2017 ). Hence, it is imperative that schools are safe, inclusive environments where pupils are able to learn and fulfill their potential. Developing and establishing inclusive policies that address bullying and homophobic, transphobic or biphobic behavior was a consistent theme from all groups of the identified studies. Several studies had school policy as a focus (Grossman et al. 2009 ; Peter et al. 2016 ), whereas others looked at the wider ecology of community and agency or government level policy (Harper et al. 2012 ; Pallotta-Chiarolli and Martin 2009 ; Scourfield et al. 2008 ). Curriculum inclusion of LGBTQI+ relevant topics was identified as an additional way to recognize diversity, particularly in the subject areas of health, humanities and the social sciences such as history (Formby 2013 ; Snapp et al. 2015 ). However, Formby’s ( 2013 ) high quality study of interviews and focus groups involving teachers, youth service workers and youth found that there was a disparity between the “visibility” of gay youth among their peers and the taboo nature of homosexuality within the school curriculum.

Formalized diversity programs and safe meeting spaces at educational institutions as well as community-based social groups such as RainbowYOUTH were strongly recommended for supporting the mental health of sexual and gender minority youth. The GLSEN report (Kosciw et al. 2014 , p. 68) states that: “Students who attended schools with a GSA were much more likely to report that their classmates were accepting of LGBT people.” Using phenomenological analysis of interviews conducted with undergraduate students who identify as LGBTIQ + attending a large Australian university, Waling and Roffee ( 2018 ) focus on diversity and inclusion programs in higher education facilities, whereas Lucassen and Burford ( 2015 ) evaluated the potential of an intervention involving a sexuality diversity workshop that was delivered in a high school setting in New Zealand. Having facilities such as bathrooms and changing rooms, which are gender neutral, therefore inclusive, was a recommendation from research conducted in Canada and the US (Porta et al. 2017 ) and Australia (Waling and Roffee 2018 ). In New Zealand a guide produced for schools (Ministry of Education 2015 ), directs that schools not only challenge bullying and marginalization of students, but also delivers a mandate to engender diversity through gender-neutral uniform policies and consideration of such things as inclusive sports and extracurricular events, and allowing same-sex partners for school dances, which address the needs of sexual and gender minority youth throughout the wider school community, rather than solely through the curriculum (McGlashan and Fitzpatrick 2017 ).

An important consideration for educators and professionals working with youth is continuing education on LGBTQI+ issues, as Wolff ( 2014 ) asserts that appropriate support for LGBTQI+ youth from educators and mental health professionals can mitigate the stress of “coming out” and navigating a heteronormative environment. Sherriff et al. ( 2011 ) and Jones and Hillier ( 2013 ) suggest that the needs of sexual and gender minority youth are not being met by community and educational services and that training for service providers is imperative, with opportunities provided to hear the voice of young LGBTQI+ as part of such training, so that subjective experiences of sexual and gender minority youth are heard and understood by professionals. The findings of Scourfield et al. ( 2008 ) evince “the need for sexual cultural competence in practitioners.” Likewise Snapp et al. ( 2015 ) advocate staff training policies on LGBTQI+ issues.

Connectedness

Sexual and gender minority youth connectedness to others was identified in the context of smaller groups such as GSAs, which then become part of a wider network that grants empowerment to marginalized LGBTQI+ youth (Russell et al. 2009 ). As such, the sense of solidarity and friendship in the face of isolation and a physical place such as GSA or community group, where sexual and gender minority youth can be physically and mentally safe while forging connections with peers, was found to be a vital protective factor for LGBTQI+ youth (Davis et al. 2009 ; Russell et al. 2009 ; Saltzburg and Davis 2010 ; Steinke et al. 2017 ). In the absence of these physical spaces an online support forum is an acceptable alternative (McDermott et al. 2015 ; Steinke et al. 2017 ). McDermott ( 2015 ) discusses the problems facing young LGBTQI+ in a heteronormative society and the difficulties they face in finding support and information, resulting in peer group interaction online being a strategy used to cope with emotional distress.

Parental and family acceptance for sexual and gender minority youth and the potential for disconnect was identified as a significant mental health factor (Diamond et al. 2011 ; Grafsky et al. 2018 ; Scourfield et al. 2008 ; Wolff et al. 2014 ). Parental acceptance versus rejection was signified in the transgender studies as key to resilience for transgender youth (Catalpa and McGuire 2018 ; McGuire et al. 2010 ). Capous-Desyllas and Barron ( 2017 ) discuss the concept of loss for parents of gender-variant children and learning to love and accept their child unconditionally, as well as issues of transgender youth acceptance by other ecological groups such as medical providers and religious communities. Having one caring adult providing connection and understanding, who is both confidante and advocate, is an invaluable resource for young LGBTQI+ people in their navigation of the heteronormative institutions of their early life ecology (Porta et al. 2017 ).

Each of the five themes identified in this systematic review of qualitative research intersect and overlap. The key overarching findings from the qualitative studies into mental health of LGBTQI+ youth are summed up succinctly by Higa ( 2014 ) stating that there is a need to address the persistent prejudice that can be experienced by LGBTQ[I+] youth in their community institutions and ecology.

Qualitative research into mental health issues experienced by LGBTQI+ youth, while not commonly undertaken, is essential to the provision of understanding and insight for community service providers, health professionals and for the youth themselves. Without a LGBTQI+ youth voice to influence policy and practice it is challenging to provide support within their ecosystem where the needs of these youth can be met. For this population much of their time is spent in their family, school or community environment, where acceptance and the ability to express their authentic self is paramount to mental well-being. To this end, this systematic review aimed to identify studies using qualitative research methods of enquiry into mental health in young LBGTQI+ people. Findings revealed consistent themes across the research methods and populations studied. 34 articles of high and medium quality with diverse content and focus were identified as relevant to the aim of this review. A subsequent synthesis identified five groups that characterize the focus and settings of the studies: online or internet based, school and community populations, university setting, focus on transgender, and intervention programs. These five characteristics of populations and setting further revealed five core themes relating to the mental health challenges faced by sexual and gender minority youth including (1) Isolation, rejection, phobia and need for support, (2) Marginalization, (3) Depression, self-harm and suicidality, (4) Policy and environment and (5) Connectedness.

In relation to the first core theme, isolation, rejection, phobia and need for support, this review identified that the internet is one means of addressing this isolation and need for support. Online websites, forums, chat groups and information services were identified as a valuable resource for sexual and gender minority youth, especially those who had limited access to other ecological supports (Capous-Desyllas and Barron 2017 ; Higa et al. 2014 ; Steinke et al. 2017 ). Paradoxically, online forums are perceived as a safe and accessible means for LGBTQI+ to access information, regardless of disclosure status, and to make meaningful connections with supportive peers (Hillier et al. 2012 ). For example, the GLSEN study (GLSEN CiPHR and CCRC 2013 ) found that two-thirds (62%) of sexual and gender minority youth had connected with other LGBTQI+ youth via the internet in the previous year, and sexual and gender minority youth were five times more likely to have looked online for information pertaining to their sexuality (62%) than their non-sexual and gender minority youth peers (12%), and for information regarding health (81% sexual and gender minority youth versus 46% non-sexual and gender minority youth).

In addition, the mental health risk factors of rejection and need for a supportive network can be addressed via access to school and community cultures and services where sexual and gender minority youth feel welcomed, accepted and valued. In relation to educational and social environments, government agencies have consistently acknowledged that having safe and supportive social environments in which to live and learn is a strong protective factor for the mental health of LGBTQI+ youth (Government Equalities Office 2018 ; Ministry of Youth Development 2015 ; U.S. Department of Health and Human Services 2017 ). Availability of support groups in the community and schools, such as RainbowYOUTH or GSAs provide connections for marginalized sexual and gender minority youth to interact with peers, access information and find a collective voice (Poteat et al. 2016 ). In particular, having such a collective voice in the face of bullying, victimization, stigmatization, homophobic, transphobic or biphobic behavior can lead to activism and civic engagement (Poteat et al. 2018 ; Russell et al. 2009 ). Social activism can act as a resilience factor for transgender youth and also ascribe the self-affirming value of being a role model for others (Singh et al. 2011 ).

By examining the findings of qualitative research reported in the last decade, it is clear that discrimination, marginalization and victimization cause much of the distress experienced by sexual and gender minority youth (King et al. 2008 ; Liu and Mustanski 2012 ). In relation to the second core theme, the socio-political marginalization of sexual and gender minority youth is responsible for feelings of systemic discrimination. This holds particular importance in predominantly heteronormative institutions such as schools, where straight cisgender individuals are “normal” and therefore sexual and gender minority youth are “not normal” (McGlashan and Fitzpatrick 2017 ). While acknowledging the marginalized status of LGBTQI+ youth, attention must be also paid to avoid pathologizing sexual and gender minority youth, either in their gender expression or sexual orientation, or in respect to having mental health issues (Drescher 2015 ; Lerner and Robles 2017 ; McDermott et al. 2015 ). Harper et al. ( 2012 ) describe adolescence as a time of developing one’s unique identity and acknowledge that research to date into mental health challenges for sexual and gender minority youth is crucial. At the same time, however, Harper et al. ( 2012 ) posit that many young LGBTQI+ are resilient and well-adjusted and that future research might benefit from a strengths-based focus.

Of particular relevance to the third core theme “depression, self-harm and suicidality,” resilience-focused research may grant insight into these poor mental health outcomes for sexual and gender minority youth. If almost half of trans-spectrum youth have self-harmed (Jones and Hillier 2013 ) and the link between suicide and mental distress due to sexual and gender minority youth status is established (Peter et al. 2016 , Wolff et al. 2014 ), then it is imperative to find ways of addressing these statistics and finding interventions that support and moderate the levels of depression and self-destructive coping mechanisms. This systematic review also identified a recommendation for service providers such as teachers, community workers and medical staff to have access to education on issues including suicide prevention, bullying interventions and sensitivity training (Pallotta-Chiarolli and Martin 2009 ; Scourfield et al. 2008 ; Sherriff et al. 2011 )). It was not until 1987 that homosexuality was removed from the Diagnostic and Statistical Manual (DSM-III-R) (American Psychiatric Association 1987 ) and in 1990 removed from the International Classification of Diseases (ICD-10) (World Health Organisation 1990 ) as a diagnostic category of psychopathology. Despite gains in civil rights, there is persistent discrimination against LGBTQI+ people (Dessel and Rodenborg 2017 ; Drescher 2015 ). Although attitudes are changing, societal misperceptions and discomfort about homosexual behavior and identity are persistent even among health care personnel (Dessel and Rodenborg 2017 ; Mayer et al. 2008 ; Scourfield et al. 2008 ). Changing attitudes and developing cultural competence is an ongoing socio-political process. To this end, Youth Scotland (LGBT Youth Scotland 2018 ) sets gold standards for achievement at LGBTQI+ inclusivity in the LGBT Charter program to which educational institutions can strive. This was achieved through consultation with LGBT service providers and their users and has provided a framework for organizations to develop their own LGBT policies and practices. Hence, this type of LGBTQI+ Charter community initiative, and the provision of ongoing training for professionals who work with youth, will increase efficacy and cultural competence for service providers and support emotional safety for sexual and gender minority youth (Kull et al. 2017 ; Swanson and Gettinger 2016 ).

In relation to policy and environment, the fourth key theme identified in this review, many western countries are fostering inclusive and non-discriminatory legislation and services, such as the Youth Scotland initiative. Most western nations have, at least in urban areas or online, support organizations such as RainbowYouth in New Zealand or MINUS18 in Australia. However, in the global context of LGBTQI+ mental health, it is notable that in more than 70 countries it is still illegal to be homosexual (United Nations 2011 ). The United Nations Committee on the Rights of the Child ( 2003 ) states that: “parties have the obligation to ensure that all human beings below 18 enjoy all the rights set forth in the Convention without discrimination, including with regard to ‘race, color, sex, language, religion, political or other opinion, national, ethnic or social origin, property, disability, birth or other status.’ These grounds also cover adolescents’ sexual orientation and health status.” There is still much to be done in the international arena at the very basic level of human rights before all sexual and gender minority youth are accepted and need not face discrimination.

Connectedness, the final core theme, is key at a societal level, where finding a group of peers fosters not only well-being but also opportunities for empowerment, solidarity and networking (Russell et al. 2009 ). Possibly the most important ecological environment within which connectedness engenders good mental health is that of the family, where attachment to parents or caregivers and acceptance by siblings and other family members leads to resilience in the face of more hostile community or societal institutions (Catalpa and McGuire 2018 , Ryan et al. 2010 ). Young people who identify as sexual or gender minority are a high-risk group who are developmentally vulnerable (Liu and Mustanski 2012 ) and the family environment has been identified as an important protective factor against stressors and mental health problems in LGBTQI+ youth. For example, in Growing up LGBT in America , a national survey of LGBTQI+ youth in the USA (Human Rights Campaign 2012 ) the most important factor identified as a problem in their lives was non-acceptance by families (26%). A lack of family connectedness or acceptance compounds the issues that sexual and gender minority youth have at school, further hindering their learning (Mallory et al. 2017 ), and suicidality in youth has been shown to be related to family connectedness, identified as the most protective factor against suicidal ideation and attempt (Stone et al. 2015 ).

From a resilience perspective, in The Health of LGBTQ Youth: Risk and Protective Factors , a Canadian report (Buote et al. 2012 ), family support for sexual and gender minority youth resulted in prevention of suicide, more positive levels of mental health, less substance use, better coping skills and more openness about their sexual or gender identity. Evidence supports these findings that family acceptance is protective for negative health outcomes such as depression, substance abuse, and suicidality (Ryan et al. 2010 ; Stone et al. 2015 ). This evidence underpins connectedness to and acceptance by family members of sexual and gender minority youth as a crucial factor for their mental health and well-being.

Limitations and Future Directions

Although this systematic review provides an important overview into the qualitative research that is being carried out, it has some limitations. Variations in the terminology used in LGBTQI+ literature and resources are extensive, and at least 23 variations on gender or sexual minority descriptors are in common use (Trans Student Educational Resources 2018 ). For this systematic review the general key term “LGBT*” was used in the search criteria, which may have excluded some articles that used terms such as non-binary, or non-cisgender. As such, the results obtained in this systematic review cannot make any valid and generalized statements about mental health needs and resources of specific groups that are represented under the LGBTQI+ label. To increase the population represented under the LGBTQI+ umbrella and to increase the level of specificity of the results, future systematic reviews should comprise a wider range of key terms that would provide a broader insight and overview of mental health and well-being in LGBTQI+ youth.

Such a relatively inclusive and broad use of key terms needs to be aligned with a set of equally broad research aims and questions. In this regard, to produce more valid results in relation to the various LGBTQI+ groups, future systematic reviews should narrow their search terms to increase the level of specificity, and thus be able to provide applicable and valid recommendations to improve mental health supports to the specific LGBTQI+ groups. Whereas characteristics of the identified studies varied greatly in respect to aim, sample size, methodology, population base and focus, which further impinges on the generalizability of the results, future systematic reviews could focus more specifically on certain criteria. Thus, systematic reviews should define from the onset the scope of the review and its desired level of generalizability to inform appropriate key term selection, methodological characteristics and research aims questions.

Deriving evidence to identify the mental health needs of LGBTQI+ groups is of great societal importance, as for example, transgender adolescents are particularly vulnerable as they navigate the cisgender world and manage the challenges of a changing body in which they do not feel they belong (Perez-Brumer et al. 2017 ; Peterson et al. 2017 ). However, there are noticeable limitations in gaining access to rich, experiential, qualitative data from transgender youth, their families and peers, which restricts understanding of mental health resource priorities for transgender youth. This gap in qualitative research relates to the issues and problems faced by families when adjusting to a child who wishes to change their gender expression, the complex nature of acceptance and coping in this situation, their possible resistance and the dynamic relationship between families and their access to services (Tishelman et al. 2015 ). Thus, systematic reviews are only able to synthesize existing data, and it becomes apparent that qualitative studies that explore lived experiences of LGBTQI+ youth within their family context are widely under represented. Here future empirical research needs to invest greater resources to produce more high quality studies that can be then included in systematic reviews.

The majority of the studies included in this systematic review (58.3%), identified their study population through school and community groups. These studies pointed out the difficulties in recruiting populations for research into LGBTQI+ youth and the effects this has on obtaining robust empirical evidence. In this sense, unknown numbers of youth who have not disclosed their sexual identity or who have barriers to accessing community support are not represented in any empirical research as to their mental health status or needs. The complexities of recruitment challenges and data collection are further confounded by the hidden nature of those who feel they cannot disclose due to cultural and ethnicity-based considerations of individual ecologies. Some of the research is Internet-based and thus only sexual and gender minority youth with access to the World Wide Web and computers or digital devices can be involved. Thus, the question remains largely unanswered of how many youth struggle with mental health issues because they feel different from heteronormative societal models but find no avenue to gain support, a sense of belonging or resources. This highlights wider patterns where voices of youth are marginalized in society and efforts to include youth in research, as outlined by the UN Convention on the Rights of the Child (1990), often results in further inequalities as youth of advantaged backgrounds have more opportunities for inclusion compared to disadvantaged youth. This leads then into a self-perpetuating cycle of exclusion. Here social science research needs to find ways to include youth across the social spectrum so that their voices are heard.

It is also important to mention that this study did not examine cultural, ethnic and faith-based differences in acceptance of LGBTQI+ youth. Religious beliefs and cultural homophobia, transphobia and bi-phobia are existing ecological factors in the lives of young sexual and gender minority youth that affect the level of societal and familial inclusion or exclusion experienced. The lack of data across cultures, genders, orientations and ethnicities is especially challenging for researchers, with some minority ethnic groups particularly underrepresented (Collier et al. 2013 ). Here, future research needs to be more rigorous to explore the relationship between culture, ethnicity and religion to obtain a better understanding of the wider socio-cultural influence on levels of experienced societal acceptance or exclusion of LGBTQI+ youth.

The review was also based on peer-reviewed journals that were published in empirical research over the last ten years, and hence literature selection was time limited and not exhaustive. As such future research could explore a wider range of available empirical research (e.g. book chapters and Ph.D. dissertations) and grey literature (e.g. government reports and policy statements), that extends beyond the 10-year time span of the present systematic report, to provide a more comprehensive insight into the topic. This would be of particular importance when tracing, comparing and mapping out existing debates and narratives, and their evolution over time, to derive a better understanding of mental health and wellbeing in LGBTQI+ youth.

Implications for Research and Practice

This is the first systematic review of qualitative research into the mental health of LGBTQI+ youth. Qualitative research provides a voice for the research participants to offer authentic experiential and perceptual evidence that can be used to inform and influence policy and mental health service provision from an evidence-based perspective. This systematic review provides a reference of qualitatively derived evidence-based knowledge by mapping out the themes and findings of qualitative research into LGBTQI+ mental health over the last decade.

The first implication for practice relates to the recognized and mandated provision of safe spaces and places in educational institutions and in the community with an emphasis on client-centered policy and in community planning at micro and macro levels of civil and state governance. For example, school and community level GSA-type services provide support within the micro-ecology of the young person whereas international law preventing discrimination on the grounds of sexual or gender minority status legislates at a global level. The provision of collective social opportunities facilitates a collaborative and united voice and empowerment to gain socio-political influence and thus to drive change for LGBTQI+ youth. As such a unified resistance to victimization and stigmatization challenges the pervasive heteronormative discourse, where, in particular, institutional policies must address bullying and marginalization of sexual and gender minority youth while demanding a cultural environment of inclusivity and acceptance.

A second implication for practice is the targeted education of service providers in all social, educational and health agencies and continuing efforts to address transphobia, biphobia and homophobia. To address disparities in well-being of sexual and gender minority youth, it is of vital importance to ensure that services for LGBTQI+ youth, such as drug and alcohol support, mental health services and sexual health clinics, adhere to a welcoming and inclusive ethos. Within these services, the provision of support must be provided by key adults with whom sexual and gender minority youth can make connections and feel valued in their identity choices.

This systematic review also identified directions for future research. For example, the Minority Stress Theory (Meyer 2003 ), with a focus on increased prevalence of mental health problems experienced by LGTBQI+ youth due to increased levels of social stress, (e.g., stigma, discrimination, prejudice and victimization), might provide a framework for further research to fill gaps in the knowledge to date. It is also vital that future research focuses on continued exploration of effective platforms for internet-based services, such as online forums, as a critical information resource, both for researchers to obtain an in-depth understanding of LGBTQI+ youth and their experiences relevant to mental health, and for the sexual and gender minority youth themselves. Thus these forums provide sexual and gender minority youth a means of access to help and advice online, and the experience of social networking, acceptance and connectedness. Further research is also needed within the realm of online e-therapy interventions such as Rainbow SPARX (Lucassen et al. 2015 ) that can be used as a treatment option for any LGBTQI+ youth that are experiencing emotional distress regardless of access to community services and disclosure status.

Transgender youth in particular are vulnerable to social isolation in the face of rejection by family and other ecological supports, and studies demonstrate the significantly greater number of homeless LGBTQI+ youth (Crossley 2015 ; Matthews et al. 2018 ; Oakley and Bletsas 2018 ). Thus it is of great importance that research investigates specific risk factors and markers for marginalized youth with a focus on the disparities in suicide and self-harm rates for sexual and gender minority youth. Similarly, there is a need for qualitative research to support quantitative evidence as well as interventions through social policy (Durso and Gates 2012 ; Kidd et al. 2017 ; McDonald 2018 ; Prock and Kennedy 2017 ). More strengths-based enquiries are needed into resilience and protective factors for sexual and gender minority youth and the ecological, psychosocial and cognitive characteristics of young LGBTQI+ people who are leading happy, well-adjusted lives within their microsystems and macrosystems. By having access to these rich qualitative data that can be evinced from analysis of nuanced lived experiences of marginalized but adaptive members of their communities, further support mechanisms can be devised and implemented with sexual and gender minority youth who are less resilient. Also, as suggested by Collier et al. ( 2013 ), there is a need for more longitudinal studies to provide data into the long-term outcomes, especially considering the developmental differences across adolescence.

Although quantitative investigations into sexual and gender minority youth have revealed poor mental health outcomes, and identified risk and protective factors, there are gaps in our understanding of how these effects arise. To address this we performed a systematic review of qualitative investigations into the experiences of LGBTQI+ youth. The results identified five core themes: isolation, rejection, phobia and need for support; marginalization; depression, self-harm and suicidality; policy and environment; and connectedness. These five themes became apparent across the differing methodologies and population samples, providing rich information. The implications for policy, practice and future research are clear from this synthesis of research findings. The voices of LGBTQI+ youth call for inclusive environments, acceptance and support from service providers and family members, and a community to which they can belong, either in their own geographical ecology or internet-based. Addressing these key needs provides resilience in the face of marginalization, isolation, and victimization. Safe environments and anti-discrimination policy alleviate the stressors which make the challenges faced by sexual and gender minority youth greater than those of their peers. These results provide a source of rich information to inform the provision of services and policies that will address the disparity into mental health statistics for the sexual and gender minority youth population.

*Denotes study included in systematic review

Adelson, S. L., Stroeh, O. M., & Ng, Y. K. W. (2016). Development and mental health of lesbian, gay, bisexual, or transgender youth in pediatric practice. Pediatric Clinics of North America, 63 (6), 971–983. https://doi.org/10.1016/j.pcl.2016.07.002 .

Article   PubMed   Google Scholar  

* Alessi, E. J., Sapiro, B., Kahn, S., & Craig, S. L. (2017). The first-year university experience for sexual minority students: A grounded theory exploration. Journal of LGBT Youth, 14 (1), 71–92. https://doi.org/10.1080/19361653.2016.1256013 .

Article   Google Scholar  

Almeida, J., Johnson, R. M., Corliss, H. L., Molnar, B. E., & Azrael, D. (2009). Emotional distress among LGBT youth: the influence of perceived discrimination based on sexual orientation. Journal of Youth and Adolescence, 38 (7), 1001–1014. https://doi.org/10.1007/s10964-009-9397-9 .

Article   PubMed   PubMed Central   Google Scholar  

American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders. DSM–III–R (3rd ed.). Washington, DC: American Psychiatric Press.

Google Scholar  

Black, W. W., Fedewa, A. L., & Gonzales, K. A. (2012). Effects of “safe school” programs and policies on the social climate for sexual-minority youth: A review of the literature. Journal of LGBT Youth, 9, 321–339.

Bowlby, J. (1969/1982). Attachment and Loss. Volume I. Attachment (2nd ed.). New York, NY: Basic Books. Retrieved from http://www.abebe.org.br/wp-content/uploads/John-Bowlby-Attachment-Second-Edition-Attachment-and-Loss-Series-Vol-1-1983.pdf .

Brown, A., Rice, S., Rickwood, D., & Parker, A. G. (2016). Systematic review of barriers and facilitators to accessing and engaging with mental health care among at-risk young people. Asia-Pacific Psychiatry, 8, 3–22. https://doi.org/10.1111/appy.12199 .

Bouris, A., Guilamo-Ramos, V., Pickard, A., Shiu, C., Loosier, P. S., Dittus, P., et al. (2010). A systematic review of parental influences on the health and well-being of lesbian, gay, and bisexual youth: Time for a new public health research and practice agenda. Journal of Primary Prevention, 31, 273–309.

Bryan, A., & Mayock, P. (2017). Supporting LGBT lives? Complicating the suicide consensus in LGBT mental health research. Sexualities, 20 (1–2), 65–85. https://doi.org/10.1177/1363460716648099 .

Buote, D., Darwich, L., Hymel, S., Waterhouse, T., & Danbrook, M. (2012). The health of LGBTQ youth: Risk and protective factors . Health Canada. Retrieved from http://arboreducational.com/wp-content/uploads/2013/11/GLBTQ-Youth__May-2012__HC.pdf .

* Capous-Desyllas, M., & Barron, C. (2017). Identifying and navigating social and institutional challenges of transgender children and families. Child and Adolescent Social Work Journal, 34, 527–542. https://doi.org/10.1007/s10560-017-0491-7 .

* Catalpa, J. M., & McGuire, J. K. (2018). Family boundary ambiguity among transgender youth. Family Relations, 67 (1), 88–103. https://doi.org/10.1111/fare.12304 .

Chakraborty, A., McManus, S., Brugha, T. S., Bebbington, P., & King, M. (2011). Mental health of the non-heterosexual population of England. The British Journal of Psychiatry, 198, 143–148. https://doi.org/10.1192/bjp.bp.110.082271 .

Clark, T. (2010). On ‘being researched’: Why do people engage with qualitative research? Qualitative Research, 104, 399–419. https://doi.org/10.1177/1468794110366796 .

Clark, T. C., Fleming, T., Bullen, P., Denny, S., Crengle, S., Dyson, S., et al. (2013). Youth’12 Overview: The health and wellbeing of New Zealand secondary school students in 2012 . Auckland: The University of Auckland.

Collier, K., van Beusekom, G., Bos, H., & Sandfort, T. (2013). Sexual orientation and gender identity/expression related peer victimization in adolescence: A systematic review of associated psychosocial and health outcomes. Journal of Sex Research, 50 (3–4), 299–317.

Community Mental Health and 7 Day Services. (2017). Preventing suicide in England: Third progress report of the cross - government outcomes strategy to save lives . London: Ministry of Health. Retrieved from www.nationalarchives.gov.uk/doc/open-government-licence/ .

Crossley, S. (2015). Come out come out wherever you are: A content analysis of homeless transgender youth in social service literature. PSU McNair Scholars Online Journal, 9 (1), 4.

* Davis, T. S., Saltzburg, S., & Locke, C. R. (2009). Supporting the emotional and psychological well being of sexual minority youth: Youth ideas for action. Children and Youth Services Review, 31, 1030–1041. https://doi.org/10.1016/j.childyouth.2009.05.003 .

Department of Health. (2012). Preventing suicide in England: A cross-government outcomes strategy to save lives . London: Ministry of Health.

Dessel, A. B., & Rodenborg, N. (2017). Social workers and LGBT policies: Attitude predictors and cultural competence course outcomes. Sexuality Research & Social Policy, 14 (1), 17–31. https://doi.org/10.1007/s13178-016-0231-3 .

* Diamond, G. M., Shilo, G., Jurgensen, E., D’Augelli, A., Samarova, V., & White, K. (2011). How depressed and suicidal sexual minority adolescents understand the causes of their distress. Journal of Gay & Lesbian Mental Health, 15 (2), 130–151. https://doi.org/10.1080/19359705.2010.532668 .

* Difulvio, G. T. (2011). Sexual minority youth, social connection and resilience: From personal struggle to collective identity. Social Science & Medicine Journal, 72, 1611–1617. https://doi.org/10.1016/j.socscimed.2011.02.045 .

Drescher, J. (2015). Out of DSM: Depathologizing homosexuality. Behavioural Science, 5, 565–575. https://doi.org/10.3390/bs5040565 .

Durso, L. E., & Gates, G. J. (2012). Serving our youth: Findings from a national survey of services providers working with lesbian, gay, bisexual and transgender youth who are homeless or at risk of becoming homeless . Los Angeles, CA: The Williams Institute with True Colors Fund and The Palette Fund. Retrieved from www.TrueColorsFund.org .

Fergusson, D. M., Horwood, L. J., & Beautrais, A. L. (1999). Is sexual orientation related to mental health problems and suicidality in young people? Archives of General Psychiatry, 56 (10), 876–880. https://doi.org/10.1001/archpsyc.56.10.876 .

Flores, A. R., & Park, A. (2018). Polarized progress. Social acceptance of LGBT people in 141 countries, 1981 to 2014 . The Williams Institute, UCLA School of Law. Retrieved from https://williamsinstitute.law.ucla.edu/wp-content/uploads/Polarized-Progress-April-2018.pdf .

* Formby, E. (2013). Understanding and responding to homophobia and bullying: Contrasting staff and young people’s views within community settings in England. Sexuality Research and Social Policy, 10, 302–316. https://doi.org/10.1007/s13178-013-0135-4 .

Fuhrmann, D., Knoll, L. J., & Blakemore, S.-J. (2015). Adolescence as a sensitive period of brain development. Trends in Cognitive Sciences, 19 (10), 556–558. https://doi.org/10.1016/j.tics.2015.07.008 .

Gillespie, R., Florin, D., & Gillam, S. (2002). Changing relationships: Findings from the patient involvement project. London: King’s Fund. Retrieved from https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/changing-relationships-findings-patient-involvement-project-rosemary-gillespie-dominique-florin-steve-gillam-kings-fund-1-October-2002.pdf .

GLSEN CiPHR & CCRC. (2013). Out online. The experiences of lesbian, gay, bisexual and transgender youth on the Internet. New York, NY: GLSEN. Retrieved https://www.glsen.org/sites/default/files/Out%20Online%20FINAL.pdf .

Government Equalities Office. (2018). LGBT action plan. Improving the lives of lesbian, gay and transgender people. London: Government Equalities Office. Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/721367/GEO-LGBT-Action-Plan.pdf .

* Grafsky, E. L., Hickey, K., Nguyen, H. N., & Wall, J. D. (2018). Youth disclosure of sexual orientation to siblings and extended family. Family Relations, 67 (1), 147–160. https://doi.org/10.1111/fare.12299 .

* Grossman, A. H., Haney, A. P., Edwards, P., Alessi, E. J., Ardon, M., & Jarrett Howell, T. (2009). Lesbian, gay, bisexual and transgender youth talk about experiencing and coping with school violence: A qualitative study. Journal of LGBT Youth, 6 (1), 24–46. https://doi.org/10.1080/19361650802379748 .

Hadfield, M., & Haw, K. (2001). ‘Voice’, young people and action research. Educational Action Research, 9 (3), 485–502. https://doi.org/10.1080/09650790100200165 .

Hafeez, H., Zeshan, M., Tahir, M. A., Jahan, N., & Naveed, S. (2017). Health care disparities among lesbian, gay, bisexual, and transgender youth: A literature review. Cureus, 9 (4), e1184. https://doi.org/10.7759/cureus.1184 .

* Harper, G. W., Brodsky, A., & Bruce, D. (2012). What’s good about being gay? Perspectives from youth. Journal of LGBT Youth, 9 (1), 22–41. https://doi.org/10.1080/19361653.2012.628230 .

* Higa, D., Hoppe, M. J., Lindhorst, T., Mincer, S., Beadnell, B., Morrison, D. M., et al. (2014). Negative and positive factors associated with the well-being of lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) youth. Youth and Society, 46 (5), 663–687. https://doi.org/10.1177/0044118X12449630 .

Hillier, L., Mitchell, K. J., & Ybarra, M. L. (2012). The internet as a safety net: Findings from a series of online focus groups with LGB and non-LGB young -people in the United States. Journal of LGBT Youth, 9 (3), 225–246. https://doi.org/10.1080/19361653.2012.684642 .

Hudson-Sharp, N., & Metcalf, H. (2016). Inequality among lesbian, gay, bisexual and transgender groups in the UK: a review of evidence. Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/539682/160719_REPORT_LGBT_evidence_review_NIESR_FINALPDF.pdf .

Human Rights Campaign. (2012). Growing up LGBT in America. HRC youth survey Report key findings . Washington, DC: Human Rights Campaign. Retrieved from https://assets2.hrc.org/files/assets/resources/Growing-Up-LGBT-in-America_Report.pdf .

InsideOUT. (2018). InsideOUT. Kōaro – Tatū ki roto, tatū ki waho. Retrieved from http://insideout.org.nz/ .

* Jones, T., & Hillier, L. (2013). Comparing trans-spectrum and same-sex-attracted youth in Australia: Increased risks, increased activisms. Journal of LGBT Youth, 10 (4), 287–307. https://doi.org/10.1080/19361653.2013.825197 .

Kidd, S. A., Gaetz, S., & O’Grady, B. (2017). The 2015 national Canadian homeless youth survey: Mental health and addiction findings. Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie, 62 (7), 493–500. https://doi.org/10.1177/0706743717702076 .

King, M., Semlyen, J., Tai, S. S., Killaspy, H., Osborn, D., Popelyuk, D., et al. (2008). A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry, 8, 70. https://doi.org/10.1186/1471-244X-8-70 .

Kosciw, J., Greytak, E., Palmer, N., & Boesen, M. (2014). The 2013 national school climate survey. The experiences of lesbian, gay, bisexual and transgender youth in our nation’s schools . New York: GLSEN. Retrieved from www.glsen.org/research .

Kull, R. M., Kosciw, J. G., & Greytak, E. A. (2017). Preparing school counselors to support LGBT youth: The roles of graduate education and professional development. Professional School Counseling, 20 (1a), 13–20. https://doi.org/10.5330/1096-2409-20.1a.13 .

Lerner, J. E., & Robles, G. (2017). Perceived barriers and facilitators to health care utilization in the United States for transgender people: A review of recent literature. Journal of Health Care for the Poor and Underserved, 28 (1), 127–152. https://doi.org/10.1353/hpu.2017.0014 .

LGBT Youth Scotland (2018). LGBT charter. LGBT Youth Scotland. Retrieved from https://www.lgbtyouth.org.uk/lgbt-charter/lgbt-charter/ .

Liu, R. T., & Mustanski, B. (2012). Suicidal ideation and self-harm in lesbian, gay, bisexual, and transgender youth. American Journal of Preventive Medicine, 42 (3), 221–228. https://doi.org/10.1016/j.amepre.2011.10.023 .

* Lucassen, M., Clark, T., Moselen, E., Robinson, E., & The Adolescent Health Research Group. (2014). Youth’12 the health and wellbeing of secondary school students in New Zealand: Results for young people attracted to the same sex or both sexes . Auckland, New Zealand: The University of Auckland. Retrieved from www.youthresearch.auckland.ac.nz .

* Lucassen, M. F., & Burford, J. (2015). Educating for diversity: an evaluation of a sexuality diversity workshop to address secondary school bullying. Australasian Psychiatry, 23 (5), 544–549. https://doi.org/10.1177/1039856215592324 .

Lucassen, M. F. G., Hatcher, S., Fleming, T. M., Stasiak, K., Shepherd, M. J., Merry, S., et al. (2015). A qualitative study of sexual minority young people’s experiences of computerised therapy for depression. Australasian Psychiatry, 23 (3), 268–273. https://doi.org/10.1177/1039856215579542 .

Lucassen, M. F. G., Stasiak, K., Samra, R., Frampton, C. M. A., & Merry, S. N. (2017). Sexual minority youth and depressive symptoms or depressive disorder: A systematic review and meta-analysis of population-based studies. Australian and New Zealand Journal of Psychiatry, 51, 774–787.

Mallory, C., Brown, T. N. T., Russell, S., & Sears, B. (2017). The impact of stigma and discrimination against LGBT people in Texas . Los Angeles, LA: The Williams Institute, UCLA School of Law. Retrieved from http://williamsinstitute.law.ucla.edu/wp-content/uploads/Texas-Impact-of-Stigma-and-Discrimination-Report-April-2017.pdf .

Marx, R. A., & Kettrey, H. H. (2016). Gay-straight alliances are associated with lower levels of school-based victimization of LGBTQ + youth: A systematic review and meta-analysis. Journal of Youth and Adolescence, 45 (7), 1269–1282. https://doi.org/10.1007/s10964-016-0501-7 .

Matthews, P., Poyner, C., & Kjellgren, R. (2018). Lesbian, gay, bisexual, transgender and queer experiences of homelessness and identity: insecurity and home(o)normativity. International Journal of Housing Policy . https://doi.org/10.1080/19491247.2018.1519341 .

Mayer, K. H., Bradford, J. B., Makadon, H. J., Stall, R., Goldhammer, H., & Landers, S. (2008). Sexual and gender minority health: What we know and what needs to be done. American Journal of Public Health, 98 (6), 989–995. https://doi.org/10.2105/AJPH.2007.127811 .

* McDermott, E. (2015). Asking for help online: Lesbian, gay, bisexual and trans youth, self-harm and articulating the “failed” self. Health, 19 (6), 561–577. https://doi.org/10.1177/1363459314557967 .

* McDermott, E., Hughes, E., & Rawlings, V. (2017). The social determinants of lesbian, gay, bisexual and transgender youth suicidality in England: a mixed methods study. Journal of Public Health, 40 (3), e244–e251.

Article   PubMed Central   Google Scholar  

* McDermott, E., Roen, K., & Piela, A. (2013). Hard-to-reach youth online: methodological advances in self-harm research. Sexuality Research and Social Policy, 10, 125–134. https://doi.org/10.1007/s13178-012-0108-z .

* McDermott, E., Roen, K., & Piela, A. (2015). Explaining self-harm: Youth cybertalk and marginalized sexualities and genders. Youth & Society, 47 (6), 873–889. https://doi.org/10.1177/0044118X13489142 .

* McDermott, E., Roen, K., & Scourfield, J. (2008). Avoiding shame: Young LGBT people, homophobia and self-destructive behaviours. Culture, Health & Sexuality, 10 (8), 815–829. https://doi.org/10.1080/13691050802380974 .

McDonald, K. (2018). Issues in mental health nursing social support and mental health in LGBTQ adolescents: A review of the literature social support and mental health in LGBTQ adolescents: A review of the literature. Issues in Mental Health Nursing, 39 (1), 16–29. https://doi.org/10.1080/01612840.2017.1398283 .

* McGlashan, H., & Fitzpatrick, K. (2017). LGBTQ youth activism and school: Challenging sexuality and gender norms. Health Education, 117 (5), 485–497. https://doi.org/10.1108/HE-10-2016-0053 .

* McGuire, J. K., Anderson, C. R., Toomey, R. B., & Russell, S. T. (2010). School climate for transgender youth: A mixed method investigation of student experiences and school responses. Journal of Youth and Adolescence, 39, 1175–1188. https://doi.org/10.1007/s10964-010-9540-7 .

McLaughlin, H. (2015). Involving children and young people in policy, practice and research: An introduction. In H. McLaughlin (Ed.), Involving children and young people in policy, practice and research (pp. 5–13). London: NCB.

McLeod, J. (2010). Process research: Using qualitative methods to explore therapeutic practice around issues of fear and sadness. In D. Langdridge, M. Barker, & A. Vossler (Eds.), Understanding counselling and psychotherapy (pp. 307–326). Milton Keynes: Open University Press.

Meade, M. O., & Richardson, W. S. (1997). Selecting and appraising studies for a systematic review. Annals of Internal Medicine, 127 (7), 531–537. https://doi.org/10.7326/0003-4819-127-7-199710010-00005 .

Mental Health Foundation. (2016). Mental health in Scotland: fundamental facts . Retrieved from www.mentalhealth.org.uk .

Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129 (5), 674–697. https://doi.org/10.1037/0033-2909.129.5.674 .

Ministry of Education. (2015). Sexuality education: A guide for principals, boards of trustees, and teachers . Wellington: Ministry of Education.

Ministry of Youth Affairs. (2002). Youth development strategy Aotearoa. Action for child and youth development . Wellington New Zealand: Ministry of Youth Affairs. Retrieved from http://www.youthpolicy.org/national/New_Zealand_2002_Youth_Development_Strategy.pdf .

Ministry of Youth Development. (2015). Supporting LGBTI young people in New Zealand . Wellington, New Zealand: Ministry of Youth Development. Retrieved from http://www.msd.govt.nz/documents/about-msd-and-our-work/newsroom/lgbti-release-ministry-of-youth-development.pdf .

Mockler, N., & Groundwater-Smith, S. (2015). Engaging with student voice in research, education and community. Beyond Legitimisation and Guardianship . Ourimbah and Sydney: Springer.

Mohr, J. J., & Fassinger, R. E. (2003). Self-acceptance and self-disclosure of sexual orientation in lesbian, gay, and bisexual adults: An attachment perspective. Journal of Counseling Psychology, 50 (4), 482–495. https://doi.org/10.1037/0022-0167.50.4.482 .

Mulé, N. J., Ross, L. E., Deeprose, B., Jackson, B. E., Daley, A., Travers, A., et al. (2009). Promoting LGBT health and wellbeing through inclusive policy development. International Journal for Equity in Health, 8, 18. https://doi.org/10.1186/1475-9276-8-18 .

* Nadal, K. L., Issa, M.-A., Leon, J., Meterko, V., Wideman, M., & Wong, Y. (2011). Sexual orientation microaggressions: “Death by a thousand cuts” for lesbian, gay, and bisexual youth. Journal of LGBT Youth, 8, 234–259. https://doi.org/10.1080/19361653.2011.584204 .

NICE. (2012a). Appendix H. Examples of evidence tables. Retrieved from https://www.nice.org.uk/process/pmg10/resources/appendix-h-examples-of-evidence-tables-pdf-4476228445 .

NICE. (2012b). Appendix H Quality appraisal checklist – qualitative studies. Retrieved from https://www.nice.org.uk/process/pmg4/chapter/appendix-h-quality-appraisal-checklist-qualitative-studies .

Oakley, S., & Bletsas, A. (2018). The experiences of being a young LGBTIQ and homeless in Australia: Re-thinking policy and practice. Journal of Sociology, 54 (3), 381–395. https://doi.org/10.1177/1440783317726373 .

Office for National Statistics. (2016). Sexual identity, UK: 2016. Retrieved from http://doi.wiley.com/10.1002/9781119085621.wbefs073 .

Oxford Dictionaries. (2018). Definition of marginalization. Retrieved https://en.oxforddictionaries.com/definition/marginalization .

* Pallotta-Chiarolli, M., & Martin, E. (2009). “Which sexuality? Which service?” Bisexual young people’s experiences with youth, queer and mental health services in Australia. Journal of LGBT Youth, 6 (2–3), 199–222. https://doi.org/10.1080/19361650902927719 .

Perez-Brumer, A., Day, J. K., Russell, S. T., & Hatzenbuehler, M. L. (2017). Prevalence and correlates of suicidal ideation among transgender youth in California: Findings from a representative, population-based sample of high school students. Journal of the American Academy of Child & Adolescent Psychiatry, 56 (9), 739–746. https://doi.org/10.1016/j.jaac.2017.06.010 .

* Peter, T., Taylor, C., & Campbell, C. (2016). “You can’t break…when you’re already broken”: The importance of school climate to suicidality among LGBTQ youth. Journal of Gay & Lesbian Mental Health, 20 (3), 195–213.

Peterson, C. M., Matthews, A., Copps-Smith, E., & Conard, L. A. (2017). Suicidality, self-harm, and body dissatisfaction in transgender adolescents and emerging adults with gender dysphoria. Suicide and Life-Threatening Behavior, 47 (4), 475–482. https://doi.org/10.1111/sltb.12289 .

Pompili, M., Lester, D., Forte, A., Seretti, M. E., Erbuto, D., Lamis, D. A., et al. (2014). Bisexuality and suicide: A systematic review of the current literature. Journal of Sexual Medicine, 11, 1903–1913.

* Porta, C. M., Gower, A. L., Mehus, C. J., Yu, X., Saewyc, E. M., & Eisenberg, M. E. (2017). “Kicked out”: LGBTQ youths’ bathroom experiences and preferences. Journal of Adolescence, 56, 107–112. https://doi.org/10.1016/j.adolescence.2017.02.005 .

Poteat, V. P., Calzo, J. P., & Yoshikawa, H. (2016). Promoting youth agency through dimensions of gay-straight alliance involvement and conditions that maximize associations. Journal of Youth and Adolescence, 45 (7), 1438–1451. https://doi.org/10.1007/s10964-016-0421-6 .

Poteat, V. P., Calzo, J. P., & Yoshikawa, H. (2018). Gay-straight alliance involvement and youths’ participation in civic engagement, advocacy, and awareness-raising. Journal of Applied Developmental Psychology, 56, 13–20. https://doi.org/10.1016/j.appdev.2018.01.001 .

Prock, K. A., & Kennedy, A. C. (2017). Federally-funded transitional living programs and services for LGBTQ-identified homeless youth: A profile in unmet need. Children and Youth Services Review, 83, 17–24. https://doi.org/10.1016/j.childyouth.2017.10.023 .

RainbowYOUTH. (2018). RainbowYOUTH |Aotearoa. Retrieved from https://www.ry.org.nz/ .

* Roffee, J. A., & Waling, A. (2016). Rethinking microaggressions and anti-social behaviour against LGBTIQ + youth. Safer Communities, 15 (4), 190–201.

Russell, S. T., & Fish, J. N. (2016). Mental health in lesbian, gay, bisexual, and transgender (LGBT) Youth. Annual Review of Clinical Psychology, 12, 465–487. https://doi.org/10.1146/annurev-clinpsy-021815-093153 .

* Russell, S. T., Muraco, A., Subramaniam, A., & Laub, C. (2009). Youth empowerment and high school gay-straight alliances. Journal of Youth and Adolescence, 38 (7), 891–903. https://doi.org/10.1007/s10964-008-9382-8 .

Ryan, C., Russell, S. T., Huebner, D., Diaz, R., & Sanchez, J. (2010). Family acceptance in adolescence and the health of LGBT young adults. Journal of Child and Adolescent Psychiatric Nursing, 23 (4), 205–213. https://doi.org/10.1111/j.1744-6171.2010.00246.x .

* Saltzburg, S., & Davis, T. (2010). Co-authoring gender-queer youth identities: Discursive tellings and retellings. Journal of Ethnic & Cultural Diversity in Social Work, 19 (2), 87–108. https://doi.org/10.1080/15313200903124028 .

* Scourfield, J., Roen, K., & McDermott, L. (2008). Lesbian, gay, bisexual and transgender young people’s experiences of distress: Resilience, ambivalence and self-destructive behaviour. Health and Social Care in the Community, 16 (3), 329–336. https://doi.org/10.1111/j.1365-2524.2008.00769.x .

* Sherriff, N. S., Hamilton, W. E., Wigmore, S., & Giambrone, B. L. B. (2011). “What do you say to them?” Investigating and supporting the needs of lesbian, gay, bisexual, trans, and questioning (LGBTQ) young people. Journal of Community Psychology, 39 (8), 939–955. https://doi.org/10.1002/jcop.20479 .

Silenzio, V. M. B., Pena, J. B., Duberstein, P. R., Cerel, J., & Knox, K. L. (2007). Sexual orientation and risk factors for suicidal ideation and suicide attempts among adolescents and young adults. American Journal of Public Health, 97 (11), 2017–2019. https://doi.org/10.2105/AJPH.2006.095943 .

Singh, A. A., Hays, D. G., & Watson, L. S. (2011). Strength in the face of adversity: Resilience strategies of transgender individuals. Journal of Counseling and Development, 89, 20–27.

Sitkin, N. A., & Murota, D. (2017). Moving beyond the basics of the binary: Addressing mental health needs and suicidality among transgender youth. Journal of the American Academy of Child & Adolescent Psychiatry, 56 (9), 725–726. https://doi.org/10.1016/j.jaac.2017.07.005 .

* Snapp, S., Burdge, H., Licona, A. C., Moody, R. L., & Russell, S. T. (2015). Students’ perspectives on LGBTQ-inclusive curriculum. Equity & Excellence in Education, 48 (2), 249–265.

* Steinke, J., Root-Bowman, M., Estabrook, S., Levine, D. S. W., & Kantor, L. M. (2017). Meeting the needs of sexual and gender minority youth: Formative research on potential digital health interventions. Journal of Adolescent Health, 60, 541–548. https://doi.org/10.1016/j.jadohealth.2016.11.023 .

Stone, D. M., Luo, F., Lippy, C., & McIntosh, W. L. (2015). The role of social connectedness and sexual orientation in the prevention of youth suicide ideation and attempts among sexually active adolescents. Suicide and Life-Threatening Behavior, 45 (4), 415–430. https://doi.org/10.1111/sltb.12139 .

Stonewall Scotland. (2018). Engaging LGBT people in your work . Retrieved from https://www.equality-network.org/wp-content/uploads/2013/02/Community-Connections-1.-Engaging-LGBT-People.pdf .

Sutton, J., & Austin, Z. (2015). Qualitative research: Data collection, analysis, and management. The Canadian Journal of Hospital Pharmacy, 68 (3), 226–231.

Swanson, K., & Gettinger, M. (2016). Teachers’ knowledge, attitudes, and supportive behaviors toward LGBT students: Relationship to Gay-Straight Alliances, antibullying policy, and teacher training. ERIC, 13 (4), 326–351. https://doi.org/10.1080/19361653.2016.1185765org/10.1080/19361653.2016.1185765 .

Thomas, J., & Harden, A. (2008). Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Medical Research Methodology , 8 , 45. https://doi.org/10.1186/1471-2288-8-45 .

Tishelman, A. C., Kaufman, R., Edwards-Leeper, L., Mandel, F. H., Shumer, D. E., & Spack, N. P. (2015). Serving transgender youth: Challenges, dilemmas and clinical examples. Professional Psychology, Research and Practice, 46 (1), 37–45.

Trans Student Educational Resources (2018). LGBTQ +  definitions. Retrieved from http://www.transstudent.org/definitions/ .

U.S. Department of Health and Human Services. (2017). LGBTQ youth. Retrieved from https://www.stopbullying.gov/at-risk/groups/lgbt/index.html .

United Nations Human Rights Office. (2011). Tackling discrimination on grounds of sexual orientation and gender identity. Retrieved from https://www.ohchr.org/Documents/Issues/Discrimination/LGBT_discrimination_A4.pdf .

UN Committee on the Rights of the Child. (2003). General comment No. 4 (2003): Adolescent Health and Development in the Context of the Convention on the Rights of the Child. Retrieved from https://www.refworld.org/docid/4538834f0.html .

UNICEF. (1990). The United Nations convention on the rights of the child. Retrieved from https://downloads.unicef.org.uk/wp-content/uploads/2010/05/UNCRC_united_nations_convention_on_the_rights_of_the_child.pdf?_ga=2.90812051.804002699.1531716962-59161298.1531716962 .

* Waling, A., & Roffee, J. A. (2018). Supporting LGBTIQ + students in higher education in Australia: Diversity, inclusion and visibility. Health Education Journal . https://doi.org/10.1177/0017896918762233 .

Wilson, B. D. M., Cooper, K., Kastanis, A., & Nezhad, S. (2014). Sexual and gender minority youth in foster care: Assessing disproportionality and disparities in los angeles. Los Angeles, CA: The William Institute. Retrieved from: http://williamsinstitute.law.ucla.edu/wp-content/uploads/LAFYS_report_final-aug-2014.pdf .

* Wolff, J. R., Allen, K. D., Himes, H. L., Fish, A. E., & Losardo, J. R. (2014). A Retrospective examination of completed sexual and gender minority youth suicides in the United States: What can be learned from written online media? Journal of Gay & Lesbian Mental Health, 18 (1), 3–30. https://doi.org/10.1080/19359705.2013.827607 .

World Health Organisation. (1990). ICD - 10: International statistical classification of diseases and related health problems: Tenth Revision. Retrieved from https://www.who.int/classifications/icd/en/ .

Download references

Acknowledgements

The authors would like to thank the researchers of the included articles for their diligence in applying qualitative research methods to exploring LGBTQI+ youth and mental health.

Author information

Authors and affiliations.

Clinical Psychology, Old Medical School, University of Edinburgh, Teviot Place, Doorway 6, Edinburgh, EH8 9AG, UK

Clare Wilson & Laura A. Cariola

You can also search for this author in PubMed   Google Scholar

Contributions

CW conceived of, designed and conducted the systematic review, analyzed the data and drafted the manuscript; LAC supervised the study, guiding the analysis of the data and contributing to the writing and editing of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Clare Wilson .

Ethics declarations

Conflict of interest.

The authors declare that they have no conflict of interest.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Reprints and permissions

About this article

Wilson, C., Cariola, L.A. LGBTQI+ Youth and Mental Health: A Systematic Review of Qualitative Research. Adolescent Res Rev 5 , 187–211 (2020). https://doi.org/10.1007/s40894-019-00118-w

Download citation

Received : 26 September 2018

Accepted : 07 May 2019

Published : 21 May 2019

Issue Date : June 2020

DOI : https://doi.org/10.1007/s40894-019-00118-w

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Mental health
• Systematic review
• Qualitative research
• Find a journal
• Publish with us
• Track your research

WashU Libraries

A guide to lgbtqia+ research.

• Starting Out
• How to Find Things
• Local History
• Primary Sources
• Journals & Articles
• Public Scholarship
• Local & National Organizations
• Healthcare This link opens in a new window
• Finding OA Articles
• Off-Campus Access (Proxy & VPN) This link opens in a new window
• COVID-19 Access

This guide is an entry point for research on LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, Intersex, Asexual, Aromantic, and adjacent experiences) people, stories, and concerns. This is a constantly expanding field that is often highly affected by contemporary politics. As a result, such a guide will never be comprehensive and the terminology will vary widely. Resources are provided here for the purposes of research and should not be used to invalidate anyone's lived experiences or expressions.

For example- these dictionaries and terminology guides may support general learning, however language use and understanding may not be consistent on an individual level.

• An Ally's Guide to Terminology: Talking About LGBT People & Equality (GLAAD and MAP)
• The Trans Language Primer

• Next: Starting Out >>
• Last Updated: Jun 10, 2024 2:52 PM
• URL: https://libguides.wustl.edu/lgbtqiaresearch

• Library of Congress
• Research Guides
• Newspapers & Current Periodicals

LGBTQIA+ Studies: A Resource Guide

Introduction.

• Main Reading Room Reference Materials
• The Daughters of Bilitis
• The Mattachine Society
• 1969: The Stonewall Uprising
• Activism After Stonewall
• Native American and Indigenous Peoples
• Drag and Gender Performance
• HIV and AIDS
• LGBTQ+ Youth
• Psychology & Conversion Therapy
• Sports and Recreation
• LGBTQ+ Government Workers
• Transgender & Gender Non-Conforming
• Archived Websites
• Audio/Visual + Oral Histories
• Bibliographies & Indexes
• Manuscript Collections of Distinction
• Microform Collections
• Periodicals & Newspapers
• Subscription Databases
• LGBTQ+ Events at the Library
• External Websites

Author: Meg Metcalf, Women's, Gender, & LGBTQ+ Studies Librarian, General and International Collections

Created: June 1, 2019

Last Updated: July 14, 2022

Welcome to the LGBTQIA+ Studies Resource Guide. This guide offers an introduction to the LGBTQIA+ collections of the Library of Congress. The Library collects at the research level in the area of Lesbian, Gay, Bisexual, Transgender, Queer, Intersex and Asexual (LGBTQIA+) studies. Library holdings are particularly strong in LGBTQIA+ politics, history, literature and the performing arts. This guide is organized by subject, format, and time period. Have a question? Submit your query to the Library of Congress Ask a Librarian Service , and our LGBTQIA+ Studies Librarian will assist you.

For a video introduction to LGBTQIA+ collections and research at the Library, watch:

We are everywhere! 1979. Library of Congress Prints and Photographs Division.

Audre Lorde . Between 1970-1978. Library of Congress Prints and Photographs Division.

Juan Carlos y Nestor.. Gay is angry, gay revolution networker. 1971. Library of Congress Prints and Photographs Division.

• Next: Main Reading Room Reference Materials >>
• Last Updated: Mar 7, 2024 10:38 AM
• URL: https://guides.loc.gov/lgbtq-studies

Contact the Office

Apa lgbtq resources and publications.

APA has made a significant contribution to the understanding of lesbian, gay, bisexual, transgender and intersex people since first dedicating staff time to these populations in 1987. Over the years, APA has produced many resources to educate the public, support the work of psychologists and inform public policy about LGBTQ people and their lives and health needs. This page provides many of those resources, organized by the primary audiences for which they are intended.

Addressing bias and discrimination

Avoiding Heterosexual Bias in Language   Reprint: Committee on Lesbian and Gay Concerns. (1991). Avoiding heterosexual bias in language.  American Psychologist ® , 46,  973-974.

Avoiding Heterosexist Bias in Psychological Research   Reprint: Herek, G.M., Kimmel, D.C., Amaro, H., & Melton, G.B. (1991). Avoiding heterosexist bias in psychological research.  American Psychologist , 46 (9), 957-963.

Education and research

Students of psychology.

APAGS Committee on Sexual Orientation and Gender Diversity The APAGS Committee on Sexual Orientation and Gender Diversity (APAGS-CSOGD) works on behalf of the community of lesbian, gay, bisexual and transgender graduate students in psychology and their allies nationwide. The committee provides education, advocacy and personal and professional development opportunities to ensure the successful graduate experience of LGBTQ and allied students. The committee aspires to build, strengthen, and empower its members through the use of innovative technologies, collaborative advocacy, and inclusive practice.

Graduate Students in Psychology A selection of tools, resources, and scholarship and grant opportunities for graduate students in psychology.

Making a Doctoral Program Lesbian & Bisexual Friendly/Welcoming These suggestions create an open and supportive environment for all students, both LGBTQ and heterosexual.

Research Support and Awards   APA and non-APA opportunities.

Just the Facts About Sexual Orientation and Youth: A Primer for Principals, Educators and School Personnel ( Español ) The information in this booklet has been developed by a coalition of education, health, mental health and religious organizations that share a concern for the health and education of all students in schools, including lesbian, gay, and bisexual students, and believe that all students should have an opportunity to learn and develop in a safe and supportive environment.

Facing the school dropout dilemma   APA has a longstanding commitment to school dropout prevention as is evident from its 1996 resolution on the topic. This article seeks to complement and supplement the resolution with data from more recent research on child development, early childhood education, and social and emotional learning that helps to define the school dropout dilemma.

College guide for LGBTQ Students Each year, Campus Pride  provides a comprehensive listing of the most LGBTQ-friendly colleges in the nation and hosts a college fair specifically geared toward LGBTQ youths and their families.

LGBTQ Scholarships for College Students Scholarships established for LGBTQ college students are available from several public and private organizations, as well as individual donors.

Transgender College Students: A Guide to Finding a Supportive School This guide is designed to support trans students in learning about their rights, help them find colleges that affirm their value, and empower them to fully embrace their gender identity.

General audience resources

This Day In June This uplifting and upbeat book shares the experience of attending an LGBTQ pride festival. A Note to Parents and Caregivers provides information on how to talk to children about sexual orientation and gender identity in age-appropriate ways. Children's book (May 2014).

10 factors to consider when searching for a gender-competent therapist for your child A resource for helping parents and guardians make informed decisions when seeking psychological support services for their children who are working through gender identity issues.

Understanding Bisexuality   Information about APA resources pertaining to bisexuality, organizations that focus on bisexuality, and additional related resources.

Reducing Sexual Prejudice: The Role of Coming Out Psychological research has concluded that active sharing by LGBTQ people of what their lives are like with people they know—whether in their families, communities or workplaces and schools—is very likely to reduce others' prejudice against LGBTQ people and increase their support for social and political equality.

Report by the Task Force on Gender Identity and Gender Variance A 6 member task force reviewed the scientific literature and APA policies regarding transgender issues, then developed recommendations for education, professional training, and further research into transgenderism, and proposed how APA can best meet the needs of psychologists and students who identify as transgender or gender-variant.

Lesbian, Gay, Bisexual, and Transgender Health Information and resources from both government agencies and the non-profit health care community to address a range of LGBTQ health related topics.

Lesbian, Gay, Bisexual, and Transgender Aging Resources to address the unique disparities facing a growing population of older LGBTQ adults.

Fact Sheet: Lesbian, Gay, Bisexual and Transgender Persons & Socioeconomic Status Why individuals who identify as lesbian, gay, bisexual, or transgender are especially susceptible to being placed at a socioeconomic disadvantage.

LGBTQ Concerns and International Psychology Resources for international LGBTQ human rights advocacy, including civil societies and the International Network on Lesbian, Gay and Bisexual Concerns and Transgender Issues in Psychology.

History of Lesbian, Gay, Bisexual, and Transgender Social Movements Essay written as an appendix for a lesson plan for high school psychology teachers.

Lesbian, Gay, Bisexual and Transgender History Month Resources on LGBTQ history and LGBTQ people.

Marriage and families

Lesbian and Gay Parenting    Includes a summary of research findings on lesbian mothers, gay fathers, and their children; an annotated bibliography of the published psychological literature; and additional resources relevant to lesbian and gay parenting.

Marriage and Family Issues for LGBTQ People    APA resources, resolutions, and amicus briefs addressing parenting and family issues for LGBTQ people.

Policy and Advocacy

Lesbian, Gay, Bisexual, and Transgender Issues, Federal   Activity updates and resources provided by the APA Public Interest Government Relations Office.

Resources for Grassroots and State-Level Advocacy on LGBTQ+ Issues Learn more about policy issues affecting the LGBTQ community. Includes talking points and references for more information on each topic.

APA Expresses Opposition To State Bills Targeting LGBTQ Citizens APA statement in response to a proliferation of state level legislation in 2016 unfavorable to LGBTQ people, and in support for the federal Equality Act to provide protections nationwide for LGBTQ people against such unfair and harmful treatment.

APA Policy Statements on Lesbian, Gay, and Bisexual Concerns Text and references of APA policy resolutions on lesbian, gay and bisexual concerns adopted by the American Psychological Association Council of Representatives.

Amicus Briefs List of all Amicus Briefs filed by APA in support of lesbian, gay, and bisexual issues.

Psychological Practice

Guidelines for psychological practice with transgender and gender nonconforming people.

Arabic (PDF, 1.0MB)

English (PDF, 616KB) APA council adopted new guidelines, Aug. 5–7, 2015.

Georgian (PDF, 1.4MB)

Portuguese (PDF, 816KB)

Spanish (PDF, 774KB)

Turkish (PDF, 7.7MB)

Applying the APA Guidelines for Psychological Practice for Transgender and Gender Nonconforming People in Everyday Practice The March 29, 2018, webinar presented by Sand Chang, PhD, describes the rationale for the guidelines, lists applications of the guidelines and discusses how to utilize related clinical skills. Webinar recording | Presentation (PDF, 1MB)

Guidelines for Psychological Practice with Sexual Minority Persons

English Approved as APA Policy by the Council of Representatives, February 26–28, 2021.

Chinese (PDF, 1.6MB)

Georgian (PDF, 6.2MB)

Polish (PDF, 1.2MB)

Spanish (PDF, 538KB)

Report of the APA Task Force on Appropriate Therapeutic Responses to Sexual Orientation

English A six-member task force conducted a systematic review of the peer-reviewed journal literature on sexual orientation change efforts (SOCE). They concluded that such efforts are unlikely to be successful and involve some risk of harm, contrary to claims of SOCE practitioners and advocates.

More for Practitioners

Practitioner Resources and Publications A selection of tools and resources of particular interest to providers of psychological services.

Issues in Psychotherapy with Lesbians and Gay Men: A Survey of Psychologists Reprint: Garnets, L., Hancock, K.A., Cochran, S. D., Goodchilds, J., and Peplau, L.A. (1991). Issues in psychotherapy with lesbians and gay men: A survey of psychologists. American Psychologist , 46, 964-972.

Promoting Good Practices for Mental Health Facilities in Working with LGBTQ Clients with Serious Mental Illnesses Personnel who serve people with serious mental illness face important challenges in addressing the needs of LGBTQ clients.

Psychological and Neuropsychological Assessment with Transgender and Gender Nonbinary Adults Key points to consider when administering or conducting an assessment with transgender, gender nonbinary, or gender diverse adults.

LGBTQ Asylum Seekers: How Clinicians Can Help (PDF, 534KB) This resource considers the ways in which psychologists can help asylum seekers cope with trauma and navigate systems, and distinguishes between assessment vs. therapeutic and advocacy roles.

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• NATURE CAREERS PODCAST
• 03 March 2021

Science diversified: Queer perspectives on research

• Dom Byrne 0

Dom Byrne is a freelance radio and podcast producer based in Brighton, UK.

You can also search for this author in PubMed   Google Scholar

Credit: Getty

Tom Welton and Blair Hamilton describe how queer perspectives drive scientific research.

Two LGBTQ+ scientists describe how sexual and gender identities can help to drive research by offering perspectives that others in a lab group or collaboration might not have considered.

Collection: Diversity and scientific careers

What role, for example, did gay scientists have in developing the direction of research into HIV and AIDS in the early 1980s, when the condition was erroneously seen as something that only affected homosexual men?

And how are transgender researchers helping to shape investigations into the physiology of transitioning women undergoing oestrogen therapy to underpin fairness in sport?

This episode is part of Science diversified, a seven-part podcast series exploring how having a more diverse range of researchers ultimately benefits not only the scientific enterprise, but also the wider world.

Never miss an episode: Subscribe to the Working Scientist podcast on Apple Podcasts , Google Podcasts , Spotify or your favourite podcast app.

doi: https://doi.org/10.1038/d41586-021-00166-0

Paid content: International Science Council (ISC)

The ISC is exploring diversity in science, and this episode is on representation and visibility. We hear how important it is to be able to express the whole of your identity in a safe and welcoming environment, where you can see allies and other people who are like you.

Marine biogeographer Huw Griffiths talks about initiatives for LGBTQ+ and allies working in polar science. And chemical engineer Abhijit Majumder discusses the role of science organizations in fostering welcoming spaces, including through explicit statements of support. Please note that this ISC episode, first published on 3 March 2021, has since been edited for clarity.

Find out more about this type of paid content

David Payne: 00:04

Hello, I'm David Payne, careers editor at Nature. And this is Working Scientist, a Nature Careers podcast.

In this seven-part series, Science diversified, we're exploring how the scientific enterprise truly benefits when you have a team of researchers from a broad range of backgrounds, disciplines and skillsets.

Each episode ends with a 10 minute sponsored slot from the International Science Council, about its work on diversity.

In this fourth episode, we turn our attention to sexual identity. We meet a gay chemist and a transgender sports scientist who are changing the world of science in their own unique ways.

Tom Welton: 00:43

So hello, I'm Tom Welton, and I'm professor of sustainable chemistry at Imperial College London. And I'm currently president of the Royal Society of Chemistry.

Diversity of sexuality is undoubtedly a positive for science, just as all diversity is a positive for science.

And it operates in two different kinds of ways. And so the first you can kind of think about, the culture of the laboratory, the culture of science, where having people from different backgrounds with different interests gives different points of views.

And so even in those areas of science which are seemingly the furthest away from humans and humanity, you know, just looking at that experiment with different eyes can sometimes mean that you see something that somebody else doesn't.

And that has a general positive effect that is probably quite subtle. You wouldn't necessarily be able to point it out and say, “Oh, that observation was made because that person was LGBT+ or whatever they were. But it does have a general positive effect having a diversity of views.

Blair Hamilton: 02:11

My name is Blair Hamilton. I am the lead researcher on the Tavistock transgender athletes study at the University of Brighton, in England.

So a trans women is someone who was born male, and transitions, legally and socially, to female, but obviously will still keep an XY chromosome. There's things that during the transition that a trans woman probably will never lose, for example, you know, stature, longer bones, that sort of thing. However, obviously testosterone suppression is obviously when a transgender female (so a trans woman) takes medication to chemically reduce their testosterone levels before they have surgery.

So basically, it chemically reduces their testosterone to probably about castrate levels.

I am a transgender athlete in football. I grew up on the west coast of Scotland just outside a place called Kilmarnock. I didn't exactly know, but I knew something was up from an early age, from probably about the age of four. Didn't understand it, until you know, I was maybe about 16 or 17 that's when the feelings really clicked for me.

And then I kind of, you know, because of social things. And obviously, the west coast of Scotland is not exactly the most, you know, forgiving place. So I tended to kind of suppress those feelings.

And I suppressed those feelings up until 2017, and 2017 on 1 January 2017 I decided I couldn't no longer, you know, put everyone else first. I put myself first.

So that's when the medical transition started on 26 January that year. Yes, so 26 when that happened. And then I play, I play football at quite a high level at that point. I played with the University of Aberdeen.

I played on the first team and the third team, which is odd because being a goalkeeper you kind of moved about, where you were needed.

Basically, at one point, it was in my last year, my fourth year of university they got the opportunity to switch after a year of my medication.

And then I started playing with the Aberdeen university women's team and then I started playing with Stonehaven ladies, moving on to Grampian ladies, and then I now play with Montpellier Villa and University of Brighton.

So I've been around, it's a little bit of a journey, but I'm happy where I am.

So obviously I take a testosterone suppressing injection once every three months, which again reduces my testosterone levels but I am also supplementing that with oestrogen patches.

The research is a unique collaboration between a gender identity clinic in London called the Tavistock Portman trust. And obviously the University of Brighton. So what we are looking at is testosterone suppression, in obviously transgender women, and the effects of their relative transitions on sport and performance.

The common sense approach right now is that transgender women are thought to have an advantage due to going through male puberty.

And what we are trying to elucidate, and actually try and highlight, is, does that really matter in terms of sport and performance?

So for example, you're looking at in terms of running times between elite male and female runners is 10%.

And in terms of "does testosterone suppression in trans women, you know,with oestrogen administered as well, does that bring that 10% down into cisgender female levels?"

So we're basically trying to see what the advantage is retained or not?

World rugby policy, just to let people know, has basically banned trans women from playing elite international rugby, based on a hypothetical model.

And I don't believe that that should be the case. It should be on evidence. So that's what we're trying to do. So again, in terms of sports we're studying, we're looking into case studies, we've got five trans women lined up for our rugby study. And the same for football. The same for hockey as well. So we’ve got case studies going on as well.

Tom Welton: 06:51

And then, of course, there are very specific ways. And one good example is the emergence of HIV and AIDS in the 1980s.

The interest in, there's something happening, the realization that there's something happened, this is an important thing. And what was causing this dreadful disease, was, the discussions were very much led by gay men, whom it affected directly.

And of course, at that time, less was known about actually, it can and does affect everybody.

And those discussions of the science itself, and people choosing to do research to discover what was causing this dreadful disease, but also, the translation of that science, as the knowledge started to come into the broader community was very much led by gay men, who were using people like myself, (I did this myself), who were using their knowledge of science and their understanding of how science works.

And even though I was an inorganic chemist, and not a biologist, and certainly not a virologist, I was able to talk to people about what we knew, and what we didn't know.

What was a piece of scientific information? What was the difference between saying, "We do not know that, it is not known," and saying that, you know, this was A or B. And so therefore, your response to it should be C or D. And being able to explain that, and that activity was was, as I say, very much led by gay men.

And so it is a huge positive, that those diversities of experience are brought to bear on these big problems.

So one of the things which makes me very proud of the Royal Society of Chemistry community is, you know, the first time there was a planned election of its president, they elected a well-known out gay man.

And, in many ways, if you look back into, you know, back into when I was starting my career as a scientist in the 1980s, that would have been unimaginable.

And so I'm hugely proud of the community for doing that. Now, of course, that does have some consequences.

And, you know, presidents have their themes. And one of the big discussions we had was about, you know, the theme of diversity, which we already had in place, very much led by Leslie Yellowlees when she was president.

And it was sort of sort of realized that actually, just by being me, then diversity remains a really, really important theme.

It is a really important thing for the society anyway, and it would have carried on had I been a, you know, a heterosexual male, you know that it was not going to go away.

But having a president who comes from one of those backgrounds really does kind of keep the show on the road.

And so it was kind of, we don't need to, in a way, make it a theme, because it already is one.

And it's one in which we are doing very well. And so the job is not inventing it, the job is sustaining it and making it move forward. And so that's kind of the way that I view diversity within my presidency and my presidency within diversity.

Blair Hamilton: 10:53

So the reason why all my work is important in sport, is that sport should be inherently fair. There is some unfairness inherent to sport. I mean, there's going to be athletes, for example, let's look at Usain Bolt for an example. There’s going to be athletes that are racing against him that are not going to beat him but they'll try their hardest. That's an inherent fairness or unfairness in sport.

However, we don't believe in sport there should be an advantage due to obviously, you know, male physiology from like this kept beyond their transition.

And so we want to make sure that we're also being inclusive, to make sure that we are, you know, incorporating transgender athletes and, and, you know, trying to be fair at the same time.

Again, we don't want to make it “not inclusion, but being unfair”, its inclusion, but being fair to everyone as well.

David Payne 11:59

Now, that's all for this section of our Working Scientist podcast. We now have a slot sponsored by the International Science Council, which looks at why diversity is so critical to advancing science and the steps we can take to improve it. I'm David Payne, careers editor at Nature. Thanks for listening.

Huw Griffiths: 12:20

When we think of diversity in science, or in academia in general, even if there is no, just for the argument's sake, there is no measurable outcome. Still, I think it is our duty to make sure that this world is a safe, habitable place for everyone. No one should feel threatened.

Marnie Chesterton: 12: 47

Welcome to this podcast series from the International Science Council, where we're exploring diversity in science. I'm Mani Chesterton, and in this episode, we'll be looking at representation and visibility, we'll be hearing how important it is to be able to express the whole of your identity in a safe and welcoming environment, where you can see allies and other people who are like you. And we'll look at the role of organizations in fostering these spaces in science, including through explicit statements of support, which really can make a difference. We're starting by going to Antarctica.

Huw Griffiths: 13:27

I can spend two or three months on a ship, living amongst the icebergs looking at what lives at the bottom of the sea. And one of the really exciting things is being able to discover new species. So probably about 10 to 20% of what we find is brand new to science.

Marnie Chesterton: 13: 42

This is Dr. Hugh Griffiths from the British Antarctic Survey.

Huw Griffiths: 13:45

I work in mostly the polar regions of marine biogeography. Someone who looks at where animals live, and why they live there. So why they're distributed in some places and maybe not found in other places. For example....

Marnie Chesterton: 13:59

Huw is also involved with the Scientific Committee on Antarctic research, or SCA, which is a thematic organization of the International Science Council.

Huw Griffiths: 14:02

So the Scientific Committee on Antarctic Research, or SCA, as it's called, which sounds like a bond villain's kind of name, actually has been sort of a huge part of my career.

So early on, I was involved with scientific projects that were led by other people within SCA, and today, I am the co-chair of one of the biology programs within the organization. But also I'm on all sorts of other committees and things as well. So, for me, it's a brilliant way of networking with international colleagues.

And because Antarctica is such a huge place where no one country could do all the research, you do need to connect up with other nationalities and that's kind of an ideal way of both meeting new friends and colleagues and for helping to get brand new collaborations that help answer some really big questions.

Marnie Chesterton: 14.54

According to Huw, this need for collaboration within Polar Research means it's home to have that very diverse community of scientists.

Huw Griffiths: 15:02

In all senses of the word, all sciences are covered in Antarctica. We've got engineering, we've got biology, we've got atmospheric sciences, we've got all these different things.

And so it's a melting pot for different types of science as well as different types of people.

And because it's so International, you've already got to deal with lots of different cultural backgrounds anyway.

So it's not a huge step for us to move on to include things like sexuality, gender, or disability, for example,

Marnie Chesterton: 15.30

Indeed, on 18 November, the International Day of LGBTQIA, plus people in STEM, the Polar Research community got together for the first polar pride day.

Huw Griffiths: 15.42

We put out a load of things on social media and thought it will be a few pretty pictures and people you know, with rainbows and penguins, and things. But actually, there were some really heartfelt comments in some of the things that came back to us, like people saying that the fact that we've given out pins and badges to senior members of staff to wear that showed that they were allies meant that there were people staying within polar research because they finally found a place where they felt welcome and safe.

Marnie Chesterton: 16.08

Something as simple as a badge can go a long way to making people feel secure, that science workplaces or conferences are a safe space where they're welcomed and accepted. The importance of creating environments like this within science can't be overstated.

Abhijit Majumder: 16.26

Unless any person feels safe, feels welcome, how do we expect that we will get the best out of those people? So, I think it is very important, whether it is a lab it is an institute, it is any organization, we need to make the place safe.

And in this particular context, just making it a safe place is not enough, because there are you know, lots of taboos that is associated with it.

So that's why it is very important to explicitly mention that we don't care what sexuality what gender expression you are, we are open to you. So this explicit statement is important in this context.

Marnie Chesterton: 17.14

That's Abhijit Majumder, associate professor in the department of chemical engineering at the Indian Institute of Technology in Bombay, and part of the global Young Academy, an affiliate member of the ISC.

Abhijit Majumder: 17.27

The purpose of the Global Young Academy is to make the voice of young academicians hope, both in terms of improving the quality of the life of the researchers, quality of science, as well as interaction between science and society. We look into how as investigators we can contribute towards the society.

Marnie Chesterton: 17.51

Within the GYA, Abhijit is co-leading an initiative that works towards creating a safe space for people to discuss discrimination faced by LGBTQIA plus, and other minority groups within academia.

I was inducted to the GYA in 2018, and then at the annual meeting, we found that there is no group or no incubator, no working group addressing this issue of gender expression and sexuality.

Our first goal is just to let the new people, new members know that this is a safe place, and they can express themselves, their gender expression and their sexuality and will not be judged rather, it will be embraced.

And we are trying to at least to make this mark in the Global Young Academy that it's okay, it's a safe place.

Marnie Chesterton: 18.57

That included adding new language to the academy's public statements on diversity.

That statement says how globally an academy is open to all various different kinds of race, color, etc, etc, gender, etc.

But however, the explicit mention of sexuality and gender expression, these were not present in that diversity statement.

So then we kind of brought up this topic and it was again, very heartily accepted. And then now it is part of our diversity statement.

Marnie Chesterton: 19.31

Statements on diversity by international organizations such as the IRC and the GYA have an important role to play ensuring support, breaking down barriers and ultimately sowing the seeds for change.

Do you need to increase the earnings First of all, but also to get actively involved with the National Academies? And to ask them, get them into the discussion table and Funding whether the government will follow that or not, that is obviously a very different question. But at least if the National Science academies they put pressure on their respective government to act least to start with to ask least legalize the gender expression and various forms of sexualities, I think that will be a great start.

Marnie Chesterton: 17.46

Having an explicit statement on openness and diversity can be a useful starting point. One of the five key missions of the ISC is to defend the free and responsible practice of science. This principle is reflected in all of the IRC is policies and operational guidelines, and they have a dedicated committee to oversee this. commitments like this are particularly important for scientists who need to travel and collaborate in different settings, which may be less accessible than their usual places of work, or even unsafe.

Abhijit Majumder: 21.00

Sometimes you just need some guidelines and help from people who've been through these experiences or who are disadvantaged, to help set up different ways of working. For example, we the new ways of working in the pandemic have really helped us to show that disabled people can attend conferences or work remotely on field work and things because we've had to set up different ways of communicating. And we should bring them forward with us, even when hopefully Coronavirus is long behind us to show that we can actually change the way we work. So that we don't stop doing things in countries where it may be illegal to be gay, but that we allow people to attend or participate in events there where they feel safe, whether it's through safe spaces, or actually just remote attendance, for example. But it is hugely impactful on people's careers. That is something where if conference organizers and these are made aware, then that can all be fed into guidelines, and make people within science a lot more comfortable. And even just knowing that somebody thought about it, even if the solution is not perfect, will make you feel as if you're part of a community where things are at least being considered and they're doing their best for you.

Marnie Chesterton: 22:04

For organizations like the IRC, the freedom to participate in science is something that needs to be reasserted continually in the face of barriers.

And that also means recognizing that people may experience different types of discrimination that intersect.

Huw Griffiths: 22.19

It is really important that we recognize things like intersectionality, or developing nations or countries where people don't have the same rights and freedoms as we do.

And we learn from each other's experiences, because I'm a cisgendered, white male.

So my experience as a gay man in science is very different to a black female LGBT person, for example, I don't have a whole bunch of other barriers, I have quite a bit of privilege. So although I can recognize where I may be disadvantaged, actually, I can't speak for everybody in the community.

Marnie Chesterton: 22.55

Diversity and Inclusion is about making science accessible for each and every person. And by doing that, all of science stands to gain,

Huw Griffiths: 23.05

It's very important that we open the doors to everybody to have a voice.

And if those voices are heard, then it will be better for everybody if you make a nicer working environment or a more friendly place to be everybody benefits.

So it's not a pie where if I have my slice, you'll get a smaller slice. It's something where if I'm happier than other people don't have to put up with me being miserable. So it's a win win.

Marnie Chesterton: 23.29

The ISC Committee for Freedom and Rresponsibility in Science is currently reexamining and re articulating what scientific freedom and responsibility means for the 21st century, including when it comes to equal access to the scientific endeavor, and its benefits for all more information about this work, and about the IRC members and networks mentioned in this podcast is available online at council dot science.

Next week, we'll be talking to two early career researchers about the importance of democratizing knowledge and access to tools data and infrastructure, and how as well as securing basic human dignity. It can also support different routes into science for people from diverse backgrounds.

Related Articles

Hiring discrimination laid bare by mountain of data

Endowed Chair in Macular Degeneration Research

Dallas, Texas (US)

The University of Texas Southwestern Medical Center (UT Southwestern Medical Center)

Postdoctoral Fellow

Postdoc positions on ERC projects – cellular stress responses, proteostasis and autophagy

Frankfurt am Main, Hessen (DE)

Goethe University (GU) Frankfurt am Main - Institute of Molecular Systems Medicine

ZJU 100 Young Professor

Promising young scholars who can independently establish and develop a research direction.

Hangzhou, Zhejiang, China

Zhejiang University

Qiushi Chair Professor

Distinguished scholars with notable achievements and extensive international influence.

Research Postdoctoral Fellow - MD

Houston, Texas (US)

Baylor College of Medicine (BCM)

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

Numbers, Facts and Trends Shaping Your World

Read our research on:

Full Topic List

Regions & Countries

Publications

• Our Methods
• Short Reads
• Tools & Resources

Read Our Research On:

Gender & LGBTQ

Women and political leadership ahead of the 2024 election.

For the most part, Americans don’t think a woman president would do better or worse than a man when it comes to key leadership traits or the handling of various policy areas. At the same time, the public sees differences in the way men and women running for higher office are treated by the media.

Women have gained ground in the nation’s highest-paying occupations, but still lag behind men

Public has mixed views on the modern american family, about 8 in 10 women in opposite-sex marriages say they took their husband’s last name, sign up for our weekly newsletter.

Fresh data delivered Saturday mornings

Featured Publications

The enduring grip of the gender pay gap.

The difference between the earnings of men and women has barely closed in the United States in the past two decades. This gap persists even as women today are more likely than men to have graduated from college, suggesting other factors are at play such as parenthood and other family needs.

About six-in-ten Americans say legalization of same-sex marriage is good for society

37% of Americans have a negative view of the impact of same-sex marriage being legal, with 19% saying it is very bad for society.

More Than Twice as Many Americans Support Than Oppose the #MeToo Movement

Most say that, compared with five years ago, those who commit sexual harassment or assault at work are more likely to be held responsible and those who report it are more likely to be believed.

The Experiences, Challenges and Hopes of Transgender and Nonbinary U.S. Adults

A new Pew Research Center survey finds that 1.6% of U.S. adults are transgender or nonbinary – that is, their gender is different from the sex they were assigned at birth.

Cultural Issues and the 2024 Election

Voters who support Biden and Trump have starkly different opinions on many issues, and these two groups are divided internally as well.

Half of Latinas Say Hispanic Women’s Situation Has Improved in the Past Decade and Expect More Gains

Government data shows gains in education, employment and earnings for Hispanic women, but gaps with other groups remain.

A Majority of Latinas Feel Pressure To Support Their Families or To Succeed at Work

Many juggle cultural expectations and gender roles from both Latin America and the U.S., like doing housework and succeeding at work.

Majority of U.S. Catholics Express Favorable View of Pope Francis

Most say Francis represents change in the church. And many say the church should allow priests to marry and let Catholics use birth control.

Changing Partisan Coalitions in a Politically Divided Nation

Amid shifts in demographics and partisan allegiances, registered voters are now evenly split between the Democratic Party and the GOP.

Few East Asian adults believe women have an obligation to society to have children

Two-thirds or more in Hong Kong, Japan, South Korea, Taiwan and Vietnam say that women should decide for themselves whether to bear children.

Among parents with young adult children, some dads feel less connected to their kids than moms do

Majorities of both moms and dads with a young adult child age 18 to 34 say they’re as involved in their child’s day-to-day life as they’d like to be.

Many in East Asia say men and women make equally good leaders, despite few female heads of government

When Taiwanese President Tsai Ing-wen’s term ends in May, only one woman will serve as head of government anywhere in Asia, excluding the Pacific Islands.

For Women’s History Month, a look at gender gains – and gaps – in the U.S.

Women made up 47% of the U.S. civilian labor force in 2023, up from 30% in 1950 – but growth has stagnated.

Race and LGBTQ Issues in K-12 Schools

We asked public K-12 teachers, teens and U.S. adults how they see topics related to race and LGBTQ issues playing out in the classroom.

REFINE YOUR SELECTION

Research teams.

1615 L St. NW, Suite 800 Washington, DC 20036 USA (+1) 202-419-4300 | Main (+1) 202-857-8562 | Fax (+1) 202-419-4372 |  Media Inquiries

Research Topics

• Email Newsletters

ABOUT PEW RESEARCH CENTER  Pew Research Center is a nonpartisan fact tank that informs the public about the issues, attitudes and trends shaping the world. It conducts public opinion polling, demographic research, media content analysis and other empirical social science research. Pew Research Center does not take policy positions. It is a subsidiary of  The Pew Charitable Trusts .

© 2024 Pew Research Center

• Northeastern University Library
• Research Subject Guides
• LGBTQIA Studies
• Research and topic suggestions
• Get Started
• Personal narratives
• Nonfiction-- society and culture
• LGBTQIA History
• Coming-out books
• Trans/nonbinary/genderqueer
• Other supportive resources

LGBTQIA Studies : Research and topic suggestions

Arts & culture.

• queer performance art
• LGBTQIA+ writers
• bullying in schools; opposition to anti-bullying efforts by those who want to maintain traditional gender roles and stereotypes
• gender nonconforming children in schools
• how people who identify as non-binary navigate a world that sees gender in binary terms
• how nonbinary and transgender identities are similar and different
• legal rights of transgender people
• transgender visibility and "passing"
• how sexual orientation (who you're attracted to) differs from gender identity (who you are)
• LGBTQIA+ marches and political movements
• LGBTQIA+ pioneers and activists
• transgender history-- e.g., search transgender history in San Francisco
• lesbian and gay history-- at what point did sexual behavior come to be seen as an identity?
• history of bisexuality-- at what point was it recognized as an identity?
• the influence of cultural norms and attitudes of a specific century or decade, and how/why people hid their feelings of same-sex attraction
• was there a time period and location in which the social climate was more accepting of same-sex attraction and desire?
• biography of a specific person in history whose trans identity or same-sex attraction was known or documented
• Important Legislation for LGBTQIA+ people

International

• contrast how LGBTQIA+ people experience life in other countries outside of the United States
• compare and contrast laws and culture within the Asian continent
• which countries are the most and least accepting of LGBTQIA+ people
• LGBTQIA+ couples of differing nationalities-- can they live in the same country?
• LGBTQIA+ rights worldwide (focusing on the "LGBTQIA+ climate" in a specific country or region)
• how are transgender people transforming the medical establishment?
• sexual orientation-- what does biological research tell us about it?
• LGBTQIA+ mental health; research shows LGBTQIA+ people have higher overall rates of depression, anxiety, and substance abuse disorders
• the diagnosis of "gender dysphoria" and how it has been reframed and is no longer a pathology
• parenting as a trans, nonbinary or gender fluid person
• lesbian and gay parenting and adoption
• new reproductive technologies for LGBTQIA+ people
• the history of how LGBTQIA+ people have or have not been integrated into the priesthood of a particular faith
• what new elements have LGBTQIA+ people brought to a particular faith
• LGBTQIA+ themes in the Bible;
• use of the Bible to justify mistreatment of LGBTQIA people
• What it's like to be gay and Muslim
• Gay and Lesbian - Does God Love you?
• 10 Reasons God Loves Gay Christians

Sexual Orientation

• bisexuality and issues that are unique to bisexual people
• asexuality-- what is means, how it is often misunderstood;
• new efforts at asexual visibility coming out stories/ coming out process;
• challenges to the concept of "coming out"

Society & Politics

• recent backlash against LGBTQIA+ people
• gender identity and America's (or another nation's) changing cultural norms
• opposition to gay rights
• discrimination and treatment in the workplace (search also phrases such as "openly gay teachers")
• violence and bullying of LGBTQIA+ people
• marriage of LGBTQIA+ people to heterosexuals in order to "pass" (especially in traditional cultures)
• queer film festivals as a step toward visibility
• same-sex marriage -- who supports it, who opposes it, and which countries have legalized it
• Rainbow capitalism

Article Databases

Scholarly and nonscholarly articles on LGBTQ topics can be found in the following sources (accessible to current Northeastern affiliates)

For cultural studies, current events, political aspects, and all interdisciplinary topics:

For psychological aspects:, for sociological aspects:, for health aspects:, additional databases.

It Gets Better

• << Previous: Get Started
• Next: Find Books and Ebooks >>
• Ask a Librarian
• Last Updated: Apr 30, 2024 4:20 PM
• URL: https://subjectguides.lib.neu.edu/LGBT

Article Definition

Written content on a narrow subject and published in a periodical or website. In some contexts, academics may use article as a shortened form of journal article.

• Green Paper
• Grey Literature

Bibliography Definition

A detailed list of resources cited in an article, book, or other publication. Also called a List of References.

Call Number Definition

A label of letters and/or numbers that tell you where the resource can be found in the library. Call numbers are displayed on print books and physical resources and correspond with a topic or subject area.

LGBTQIA Research & Education

• Databases, Journals, Scholarly Articles
• Books, Theses, and Dissertations
• Recommended Books & Film
• Campus Resources
• Professional and Community Organizations

• Gender Studies Database This link opens in a new window Combines NISC's popular Women's Studies International and Men's Studies databases with the coverage of sexual diversity issues. Includes professional journals, conference papers, books, book chapters, government reports, working papers, dissertations and more.
• JSTOR This link opens in a new window JSTOR provides access to the highest-quality academic journals, books, and primary sources in the humanities, social sciences, and sciences.
• ACLS Humanities Ebook This link opens in a new window Searchable collection of humanities books organized by the American Council of Learned Societies.
• Academic Search Complete This link opens in a new window Designed for academic institutions, this database provides complete coverage of multidisciplinary academic journals.
• PsycINFO This link opens in a new window Psychology journal coverage from 1887 to the present, including more than 1,700 periodicals in 35 languages

Film Databases

• LGBT Studies in Video - United States This link opens in a new window LGBT Studies in Video is a cinematic survey of the lives of lesbian, gay, bisexual, and transgender people as well as the cultural and political evolution of the LGBT community.
• Academic Video Online (AVON) This link opens in a new window Academic Video Online is the most comprehensive video subscription available to libraries. It delivers more than 62,000 multidisciplinary video titles including 17,000 exclusive to Alexander Street.
• Inclusion in Video This link opens in a new window Over 1,400 videos covering the topic of Inclusion.
• Kanopy Streaming - TTU Women's Studies Dept. Collection Kanopy is a streaming service to find movies, documentaries, foreign films, classic cinema, independent films and educational videos that inspire, enrich and entertain.

LGBTQIA Journals

• GLQ: A Journal of Lesbian and Gay Studies Providing a much-needed forum for interdisciplinary discussion, GLQ publishes scholarship, criticism, and commentary in areas as diverse as law, science studies, religion, political science, and literary studies. Its aim is to offer queer perspectives on all issues touching on sex and sexuality.
• Sexualities Sexualities is an established international journal and an invaluable resource, publishing articles, reviews and scholarly comment on the shifting nature of human sexualities. The journal adopts a broad, interdisciplinary perspective covering the whole of the social sciences, cultural history, cultural anthropology and social geography, as well as feminism, gender studies, cultural studies and lesbian and gay studies.
• Transgender Health The journal dedicated to delivering authoritative, peer-reviewed research and clinical studies focused exclusively on meeting the healthcare needs of transgender individuals throughout their lifespan.
• Gender & Society Gender & Society, the official journal of Sociologists for Women in Society, is a top-ranked journal in sociology and women's studies and publishes less than 10% of all papers submitted to it. Articles analyze gender and gendered processes in interactions, organizations, societies, and global and transnational spaces.
• Sexuality Research & Social Policy Sexuality Research and Social Policy is a peer-reviewed academic journal and an official journal of the National Sexuality Resource Center, published by Springer Science+Business Media.
• Journal of Lesbian Studies

Encyclopedias & Reference

• The SAGE Encyclopedia of LGBTQ Studies This far-reaching and contemporary new Encyclopedia examines and explores the lives and experiences of Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ) individuals, focusing on the contexts and forces that shape their lives. The work focuses on LGBTQ issues and identity primarily through the lenses of psychology, human development and sociology, emphasizing queer, feminist and ecological perspectives on the topic, and addresses questions such as: What are the key theories used to understand variations in sexual orientation and gender identity? • How do Gay-Straight Alliances (GSA) affect LGBTQ youth? • How do LGBTQ people experience the transition to parenthood? • How does sexual orientation intersect with other key social locations, such as race, to shape experience and identity?
• The SAGE Handbook of Global Sexualities This two-volume Handbook provides a major thematic overview of global sexualities, spanning each of the continents, and its study, which is both reflective and prospective, and includes traditional approaches and emerging themes. The Handbook offers a robust theoretical underpinning and critical outlook on current global, glocal, and 'new' sexualities and practices, whilst offering an extensive reflection on current challenges and future directions of the field.
• The SAGE Encyclopedia of Psychology and Gender The SAGE Encyclopedia of Psychology & Gender is an innovative exploration of the intersection of gender and psychology--topics that resonate across disciplines and inform our everyday lives. This Encyclopedia looks at issues of gender, identity, and psychological processes at the individual as well as the societal level, exploring topics such as how gender intersects with developmental processes both in infancy and childhood as well as throughout later life stages; the evolution of feminism and the men’s movement; the ways in which gender can affect psychological outcomes and influence behavior; and more.
• Next: Books, Theses, and Dissertations >>
• Last Updated: Apr 30, 2024 1:18 PM
• URL: https://guides.library.ttu.edu/lgbtqia

ICYMI: New & Notable Articles (24 June 2024)

Each week, we collect the articles that we posted in the last week and put them all in one place, right here on the blog. So no worries if you missed an article we posted to Facebook , X/Twitter , Mastodon , Threads , Bluesky , Instagram and/or LinkedIn . 

Here they are, I n C ase Y ou M issed I t: 

Hansberry Offstage: The playwright's lesbian writings

Alec pollak, the yale review volume 111, number 3, fall 2023.

Lorraine Hansberry’s renaissance has affirmed her work in the 20th century pantheon, but critics are only beginning to reckon with her queerness

Alec Pollak explores Hansberry’s lesbian writings in The Yale Review , free on Project Muse thru 30 June  

Chasing Fae: The Watermelon Woman and Black Lesbian Possibility

Laura l. sullivan, callaloo volume 23, number 1, winter 2000.

In a vintage piece for Callaloo, Laura L. Sullivan considers Cheryl Dunye’s film The Watermelon Woman, which offers a unique, groundbreaking exploration of the cinematic representation of Black lesbian women, inviting the viewer into the critique 

Read free thru 30 June  

Alison Bechdel's Fun Home : Queer Futurity and the Metamodernist Memoir

Meghan c. fox, mfs modern fiction studies volume 65, number 3, fall 2019.

Alison Bechdel's classic graphic novel memoir Fun Home uses modernist allusions to supplant patriarchal genealogies with queer kinship structures, posits Meghan C. Fox in a 2019 article for MFS Modern Fiction Studies

Read free thru June 30  

Otherwise Charisma: James Baldwin and the Black Queer Archive of Civil Rights Historiography

Sarah winstein-hibbs, american quarterly volume 74, number 2, june 2022.

James Baldwin’s oeuvre strategically rethinks black charismatic leadership & queers the historiography of the civil rights era into an alternative usable past that has been taken up in the activism of the Black Lives Matter era

Read free in American Quarterly thru 30 June  

Langston Hughes on the DL

Andrew donnelly, college literature volume 44, number 1, winter 2017.

Modern scholars are tempted to pull Langston Hughes out of the closet, argues Andrew Donnelly , but part of the appeal of his poetry is its denial of stable sexual identity, content to remain on the “down-low”

Read free in College Literature thru 30 June   

Neuter-Bound/Neuter-Freed: Queer Gender and Resistance to Slavery

Christopher s. lewis, african american review volume 52, number 4, winter 2019.

In African American Review , Christopher S. Lewis examines queer sexuality and gender expression in antebellum slave narratives, expanding our understanding of liberation and resistance to slavery

Read free thru 30 June   

The Most Generous, Disinterested, and Philanthropic Motives: Race and the 1826 Maryland Jew Bill

Eric eisner, american jewish history volume 107, number 4, october 2023.

In the new issue of American Jewish History , Eric Eisner examines the history of the legislative struggle that led to the 1876 law that finally allowed Jewish men to hold political office in Maryland 

Read free in American Jewish History thru 30 June  

A Critical Conversation on Agency

Stephanie olsen , kristine alexander , susan miller , ville vuolanto , simon sleight , mischa honeck , sarah emily duff , and karen vallgårda, journal of the history of childhood and youth volume 17, number 2, spring 2024.

Historians of childhood suggest the conventional formulation of “agency” has limited usefulness for understanding change, and may need redefinition

In the new “Children in Crisis” special issue of The Journal of the History of Childhood and Youth , eight scholars hold “ A Critical Conversation on Agency ”

Free to read thru 30 June  

Southeast Asian Refugee Resettlement in Philadelphia Through the Shifting Frames of Racialization

Jacinda s. tran, journal of asian american studies volume 27, number 1, february 2024.

Jacinda S. Tran investigates the optics and racialization of Southeast Asian refugees settling in Philadelphia in the 1980s and 1990s, teetering between victimization and criminalization in the aftermath of the Vietnam War 

Read free in Journal of Asian American Studies thru 30 June  

From the Archives: An LGBTQIA+ Reading List

The journals of Hopkins Press offer a real bounty of art, research, and thinking about LGBTQIA people and culture around the world. This month, we've collected a cross section of 35 articles spanning 28 of our journals, including: 

African American Review , American Quarter ly , ariel: A Review of International English Literature , ASAP/Journal, Bookbird: A Journal of International Children's Literature , Callaloo , College Literature , CUSP: Late Nineteenth and Early Twentieth Century Cultures , Diacritics , ELH , The Emily Dickinson Journal , The Hopkins Review , J19: The Journal of Nineteenth-Century Americanists, Journal of Asian American Studies , Journal of College Student Development , Journal of Democracy , Journal of Health Care for the Poor and Underserved , Leviathan , MFS Modern Fiction Studies , Poe Studies , Postmodern Culture , Progress in Community Health Partnerships: Research, Education, and Action , The Review of Higher Education , Reviews in American History , Studies in the Novel , Theatre Topics , Victorian Review, and The Yale Review . 

We've made all of these articles freely accessible through 30 June 2024

HOPKINS PRESS PODCAST: Helene Hedian on Building Patient-Centered Trans Health Care

On this month's Hopkins Press Podcast , we talk with Helene Hedian , MD,  Director of Clinical Education, Center for Transgender and Gender Expansive Health, discussing data in a new study published in the February 2024 edition of Journal of Health Care for the Poor and Underserved ," What Patients Want in a Transgender Center:Building a Patient-Centered Program ."

Dr. Helene Hedian is an Assistant Professor of Medicine at the Johns Hopkins University School of Medicine, the Director of Clinical Education at the Johns Hopkins Center for Transgender and Gender Expansive Health, and the Assistant Vice Chair for LGBTQ+ Equity and Education in the Department of Medicine. Her academic interests include internal medicine, medical education, and the specific health needs of LGBTQ patients. 

For further reading, see “ What Patients Want in a Transgender Center:Building a Patient-Centered Program ” for free in Journal of Health Care for the Poor and Underserved   through 30 June 2024  

What Patients Want in a Transgender Center: Building a Patient-Centered Program

Helene f. hedian , md , paula m. neira , msn, jd, rn, cen , devin coon , md, mse , joshua schwarz , phd , joseph cofrancesco jr, md, mph , and brandyn d. lau , mph  , journal of health care for the poor and underserved volume 35, number 1, february 2024.

As featured in the Hopkins Press Podcast, Helene Hedian and her colleagues discuss the findings of a 2016 study that shares how Johns Hopkins Center for Transgender and Gender Expansive Health assessed patients' perceptions of health care organizations that provide gender-affirming care.

Read free in Journal of Health Care for the Poor and Underserved thru 30 June  

Transgender Men and Non-Binary Students Managing Their Identities to Pay for College

Alex c. lange, review of higher education ahead of print, 2024.

Compared to previous generations, U.S. college students must increasingly rely on non-government sources of money to pay for college. Yet, paying for college looks markedly different for students from marginalized communities, given historical exclusion and inequitable access to financial capital. 

Using data from a longitudinal study of transgender men and non-binary students, this study argues that identity management is a key tactic these students use to pay for college and navigate competing financial priorities. Ultimately, this study can help researchers and policymakers better address issues of affordability, while more clearly understanding the unique nature of identity management for transgender students.

Read free in Review of Higher Education thru 30 June  

MLN Forum: Translators Reimagine Literary Citizenship in the Academy

Eleni theodoropoulos and bradley harmon, mln volume 138, number 5, december 2023.

How and when will translation receive recognition for its crucial role in the academic ecosystem? 

Spanning the Hopkins Press blog & 9 articles in a new special issue of MLN , it's a lively and thoughtful 10-scholar forum, open access for a year thru March 2025  

Cirights: Quantifying Respect for All Human Rights

Skip mark , mikhail filippov , and david cingranelli, human rights quarterly volume 46, number 2, may 2024.

Using data from the CIRIGHTS Data Project to discover global patterns in government respect for human ri ghts, a new study in Human Rights Quarterly discusses implications of patterns in worker rights, protection from torture, physical integrity rights and more

Content Warnings and Censorship

Kristin antelman, portal: libraries and the academy, volume 23, number 3, july 2023.

Kristin Antelman ’s “ Content Warnings and Censorship ” won the 2024 Johns Hopkins University Press Award for the Best Article in portal: Libraries and the Academy

The article is free to read through 30 June 

Explore Kristin Antelman’s award-winning “Content Warnings and Censorship” more in depth in this new video interview with Antelman (UC Santa Barbara Library) and portal’s Carmen Cole (Penn State University Libraries)   

Meat, Flesh, Skin: The Carnality Of The Secret Agent

Ivan kreilkamp, studies in the novel, volume 56, number 1, spring 2024.

In Studies in the Novel , Ivan Kreilkamp compares Joseph Conrad’s The Secret Agent to Upton Sinclair’s The Jungle, drawing out an overlap between the direct violence of terrorism and the violence of meat production

Emily in Paris : Nostalgia, Nationalism and Sepia Cinema in an American Fish-Out-Of-Water Dramedy

Nathan brown, the french review, volume 97, number 3, march 2024.

“Emily in Paris” highlights the intersection of “sepia cinema” and “Francofascination,” phenomena from the early 2000s that contribute to implications for America’s self-fashioning, says Nathan Brown in The French Review

The Madness of Mold: Ecogothic in Nathaniel Hawthorne’s The House of the Seven Gables

Joshua myers, studies in american fiction, volume 50, issue 1-2, spring-fall 2023.

Hawthorne’s depictions of decay in The House of the Seven Gables underscore human anxiety about the environment, posits Joshua Myers — part of a series of articles exploring the “ecogothic” in a new special 50th anniversary issue of Studies in American Fiction

Recently Released

Joseph Michael Sommers, Central Michigan University

Andrew Bone and Gülberk Koç Maclean

Grigore Pop-Eleches  Executive Editor : Emily W. Babson

Princeton University

Penny A. Pasque, The Ohio State University; Thomas F. Nelson Laird, Indiana University, Bloomington

Jeremy A. Greene, M.D., Ph.D., Johns Hopkins University; Alisha Rankin, Ph.D., Tufts University; Gabriela Soto Laveaga, Ph.D., Harvard University

Greg Barnhisel, Duquesne University; Beth le Roux, University of Pretoria; and Yuri Cowan, Norwegian University of Science and Technology​

Chrysogonus Siddha Malilang, Malmö University, Sweden

Stephen J. Shoemaker, University of Oregon

Elizabeth Ho, University of Hong Kong

Skip to content

Equity, Diversity, and Inclusion

Our Office of Equity, Diversity, and Inclusion works to create an inclusive environment that values diversity in academic medicine.

Education and Training

Columbia Psychiatry is teaching the next generation of clinicians and researchers through our residency, fellowship, and training programs.

Research Areas

Clinical trials and research studies.

Would you like to help support our research? Learn about how to participate in clinical trials or research studies here at Columbia Psychiatry.

• Patient Care

Read about the world of psychiatric research, education, and patient care—and see what's happening here at Columbia Pyschiatry.

A Family-Friendly Guide to Support, Affirm & Celebrate LGBTQIA+ Youth

Share this page.

• Share on Facebook
• Share on X (formerly Twitter)
• Share on LinkedIn
• Share by email

In honor of Pride Month, celebrated throughout June and culminating in festivals, parades, and calls to action centering queer joy and unity, the Columbia Gender & Sexuality Program (CGSP) offers a family-friendly guide to support LGBTQIA+ youth and caregivers and to events taking place across the city.

NYC’s Pride 2024 theme is “Reflect. Empower. Unite.” Events throughout June highlight the unique contributions of LGBTQIA+ people, serving as both a celebration and an opportunity to center queer liberation and authentic self-expression.

Check Out These Events for Youth and Families

• Queer Teen Night: June 14th, Whitney Museum of American Art, 4-7 pm.
• Youth Pride Fest: June 15th, Pier 76, 2-5 pm.
• Cathedral Pride Sunday: June 23rd, Cathedral Church of Saint John the Divine, noon-5 pm.
• Youth Pride: June 29th, Pier 17, noon-6 pm.
• The Center: Programs for youth ages 13-22, featuring special Pride events.
• Children’s Museum of Manhattan: Month-long Pride celebration with special programming.
• NYC Pride March: Sunday, June 30. Columbia Pride invites all LGBTQIA+ Columbians and allies to join in the annual tradition of marching in the event. Don't miss this amazing opportunity to connect with the community and show your pride!

The Importance of Family and Peer Support

Kareen M. Matouk, PhD

Social support from family and peers is vital for queer and trans youth. Research consistently shows that parental acceptance, support, and advocacy lead to positive mental health outcomes for LGBTQIA+ children and adolescents, while the absence of such support is associated with increased distress. The role of caregivers and family support in fostering a positive environment cannot be overstated.

Creating a Supportive Environment

Visibility: Bringing LGBTQIA+ pride and visibility into the home helps create a safe and supportive environment for gender-diverse youth. This can be achieved by engaging with books and TV shows featuring LGBTQIA+ characters, participating in community activities with other LGBTQIA+ families, and discussing positive stories about LGBTQIA+ individuals in the media. Some youth might prefer to express pride by putting up a Transgender Pride Flag in their room. It's crucial to affirm their identity by supporting their authentic self-expression and respecting their choices about sharing their identity.

Dialogue: Open discussions about sexuality and gender are essential. Initiate these conversations, but also respect your child's wishes if they do not want to talk about their identity. Letting your child lead and directing you in how to be most supportive can improve your relationship and their sense of comfort and trust.

Pronouns: Introduce yourself with your name and pronouns to model allyship and invite other family members to do the same. However, avoid pressuring your child to out themselves, especially in potentially hostile environments. Simply using your pronouns signals allyship and support.

Building Community and Support Networks

Ani Fredman, PhD

Community Involvement: Creating a safe and supportive community involves attending LGBTQIA+ affirming events and supporting youth in connecting with LGBTQIA+ communities. This can include online or in-person support groups or drop-in spaces.

Advocacy: Advocate for LGBTQIA+ rights in your community, which signals allyship and acceptance. Support your LGBTQIA+ youth by advocating for gender- and sexuality-affirming support at their school, introducing them to LGBTQIA+ friendly social spaces and encouraging connections. Gender and Sexuality Alliances (GSAs) provide safe environments for LGBTQIA+ youth, significantly reducing the risk of depression and increasing well-being.

Supportive Peers: Seek opportunities to introduce yourself and your children to other LGBTQIA+ and gender-diverse adults who are thriving. Educate yourself on the diverse history of trans-rights activism, especially from your cultural background.

Respect and Encourage Self-Exploration

Encouragement: Encourage your child to explore new forms of expression without judgment and with unconditional positive regard. Support their gender-affirming presentation choices, even if you don’t fully agree. Youth who experience gender-affirming interpersonal interactions build self-esteem and improve their overall quality of life.

Boundaries: Respect your youth’s boundaries regarding information sharing and disclosure. Pressuring them to explain themselves can lead to frustration and withdrawal. Reflect on whether your questions might feel too personal or difficult to answer. Model that it’s okay not to know or to be in the process of discovery.

Communication: Ask your child how they feel about sharing their name and pronouns with family and friends. Respect their wishes and let them guide you in how to be most supportive, which can improve your relationship.

Cultivating Caregiver Self-Compassion

Self-Exploration: Explore your own history and experiences with sexuality and gender identity. This self-awareness can help you better support your child. Reflect on your earliest memories related to these aspects and how they have evolved over time.

Community Support: Identify sources of support for yourself, such as affirming friends, family members, teachers, mental health professionals, and support spaces. Building your resilience includes seeking support and having reliable resources.

Self-Care: Prioritize your self-care and resilience. Show your children what self-love looks like by celebrating your uniqueness and practicing self-compassion. By fostering a supportive environment, building community, and engaging in self-care, caregivers can play a vital role in affirming and celebrating their LGBTQIA+ youth.

Additional Resources for Parents

• PFLAG: The largest organization connecting family, friends, and allies with the LGBTQ+ community, offering local chapters and support resources.
• Human Rights Campaign: Strives to end discrimination and achieve equality for LGBTQ+ people.
• Gender Spectrum: Provides support for creating a gender-inclusive world.
• GLSEN: Ensures safe learning environments and offers inclusive LGBTQ+ training.
• Family Equality: Advances legal and lived equality for LGBTQ+ families.

The Columbia Gender & Sexuality Program offers gender-affirming services, including therapy for LGBTQ+ children and their families. We provide inclusive care through a cultural lens, emphasizing intersectionality. For more information, please visit our website .

Written by Ani Fredman, PhD [any (they/she/he)] , Postdoctoral Fellow, Gender & Sexuality Program Department of Psychiatry, and Kareen M. Matouk, PhD (she/her) , Clinical Psychologist, Assistant Professor in Medical Psychology (in Psychiatry), and Assistant Program Director, Gender & Sexuality Program, Department of Psychiatry, Columbia University Irving Medical Center.

Healing Trauma in LGBTQIA+ Adults

• Share to Facebook
• Share to Twitter
• Share to LinkedIn
• Share on Email

Trauma is a term that covers a wide range of painful past experiences that are still emotionally active in the present -day lives of people. These experiences may originate in childhood or adolescence at the hands of parents, schoolmates or strangers. They can be physical, sexual or emotional, and they tend to leave their mark on the adult psyche.  

Weill Cornell Medicine’s LGBTQIA+ Trauma Treatmen t Program is housed at the institution’s Center for Trauma and Addiction .  The Center treats members of the general population —including veterans— for post-traumatic stress disorder (PTSD) , substance use disorder and related conditions, while the LGBTQIA+ Trauma Treatment Program is focused on addressing these issues among members of the queer community.  

Why is there a separate trauma treatment program for LGBTQIA+ individuals?  

LGBTQIA+ individuals are more likely than others to have endured mistreatment by peers and family during childhood, and they’re at greater risk for violence and discrimination as adults.   

But there’s hope. Our clients can overcome the traumatic events of the past with the help of mental health professionals trained to provide treatments that are evidence-based, compassionate and highly effective.  

What is psychological trauma?  

Psychological t rauma may be defined as a shattering past event, or series of events, that overwhelms the sufferer’s ability to digest it emotionally , says Erik Orozco, a social worker, counselor and member of the LGBTQIA+Trauma Treatment Program’s team. It deeply affects a person's feeling of safety and leaves them feeling helpless.  

A past traumatic event may have a “haunting” effect. Showing up in a memory or a dream, i t may trigger an outsize emotional reaction .  

Says Erik’s colleague Tom Lorio, m embers of the LGBTQIA+ community may have been traumatized by a parent’s rejection or neglect ; severe bullying at school or in their neighborhood ; or a random assault on the street.   

Thankfully, “there are ways to leave the past in the past,” Tom says. That’s where Weill Cornell’s LGBTQIA+ Trauma Treatment Program comes in.  

Treatment options  

“All of our clinicians are trained in EMDR,” says Tom. (EMDR stands for e ye movement desensitization and reprocessing .) “It’s an evidence-based technique that has proven high effective in treating people who were traumatized as children.  

“EMDR became a respected modality in the mental health field during the early 2000s,” he continues, “with advances in neuroscience and imaging technologies. We can see differences in brain scans taken before and after EMDR therapy.”  

In addition to EMDR, Erik says, the team offers other modalities , including:  

• Sensorimotor Psychotherapy  
• Gestalt therapy  
• Clinical hypnosis  
• Internal family systems (IFS) therapy  

What all of these have in common is a body-based approach. Instead of persuading a client to give up negative beliefs about themselves, for example, the psychotherapist taps into the way the body holds on to such beliefs and fosters the process of releasing them.  

Is the program expensive?  

The LGBTQIA+ Trauma Treatment Program accepts Blue Cross/Blue Shield  and Aetna, making its services affordable for people living in New York City who have these insurances.  

Age requirement  

“Our clients must be at least 21 years of age ,” Erik says.  

Does the program have a “mission”?  

The program aims to take care of vulnerable groups. Mental health services provided by the program’s caring staff are delivered with unfailing empathy and acceptance.  

Learn more about Weill Cornell Medicine’s LGBTQIA+ Trauma Treatment Program or make an appointment with a counselor by visiting the program’s website here . 

Related Links

Back to News

In This Article

Clinical service.

Warning: The NCBI web site requires JavaScript to function. more...

An official website of the United States government

The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• Browse Titles

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington (DC): National Academies Press (US); 2011.

The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding.

• Hardcopy Version at National Academies Press

3 Conducting Research on the Health Status of LGBT Populations

As background for the review of existing research on sexual- and gender-minority health in Chapters 4 , 5 , and 6 , the present chapter reviews research challenges associated with the study of LGBT populations, the research methods and data sources used in studying these populations, and best-practice principles for conducting research on the health of LGBT people. The final section presents a summary of key findings and research opportunities.

• RESEARCH CHALLENGES

Three important challenges confront researchers attempting to gather valid and reliable data for describing LGBT populations and assessing their health: (1) operationally defining and measuring sexual orientation and gender identity, (2) overcoming the reluctance of some LGBT individuals to identify themselves to researchers, and (3) obtaining high-quality samples of relatively small populations. In addition, as emphasized in Chapter 1 , although the acronym “LGBT” is applied to lesbians, gay men, bisexual men and women, and transgender people, these groups are distinct, and they also comprise subgroups based on race, ethnicity, geographic location, socioeconomic status, age, and other factors. These variations have implications for health research, including the need to obtain sample sizes that are large enough to understand differences among subgroups.

Operationally Defining and Measuring Sexual Orientation and Gender Identity

Many social, cultural, and behavioral phenomena pose measurement challenges to researchers. For example, multiple operational definitions have been used to assess education ( Smith, 1995 ), political ideology ( Knight, 1999 ), religiosity and religious fundamentalism ( Hall et al., 2008 ; Kellstedt and Smidt, 1996 ), and race and ethnicity ( NRC, 2004 ; Stephan and Stephan, 2000 ). Similarly, researchers who study LGBT populations face the challenges of defining sexual orientation and gender identity and developing procedures for operationalizing these constructs.

As explained in Chapter 2 , sexual orientation is typically defined and measured in terms of three dimensions—behavior, attraction, and identity. Ideally, which of these dimensions is used in research is informed by a particular study's research goals. For example, a study of HIV risk in gay men would appropriately focus on sexual behavior, whereas a study of experiences with hate crimes or housing discrimination might focus on sexual orientation identity ( Herek et al., 2010 ). Although most adults exhibit consistency across the three dimensions (e.g., they are exclusively heterosexual or homosexual in their sexual behavior, attractions, and self-labeled identity), some do not. Whether a particular study categorizes the latter individuals as lesbian, gay, homosexual, bisexual, heterosexual, or something else will depend on which specific dimension of sexual orientation is measured in that study. In a study that measures sexual orientation in terms of same-sex attraction or sexual behavior with a same-sex partner, for example, the sample may include some participants who do not label themselves as lesbian, gay, or bisexual.

Not only do studies vary in which facet of sexual orientation they measure, but they also can differ in how they define each of the three dimensions operationally. The current lack of standardized measures contributes to the variability of population estimates and can make comparisons across studies difficult. For example, if two studies defined sexual orientation operationally in terms of sexual behavior but used different time frames for screening participants (e.g., if one study used the criterion of any same-sex sexual behavior during the past 12 months, whereas the other used any same-sex sexual behavior since age 18), they might reach different conclusions about the target population. Moreover, the samples obtained for both studies would exclude individuals who were not sexually active during the specified time period even if they experienced same-sex attractions or self-identified as lesbian, gay, or bisexual. This variability in the criteria for operationally defining sexual orientation may produce what appear to be inconsistent findings across studies. Although it may appear obvious, it is important to make the point that researchers should carefully evaluate the appropriateness of their operational definition(s) of sexual orientation in light of the research question their study addresses and clearly explain their measurement procedures when reporting their results.

Similar definitional and measurement variability can be observed across studies of transgender populations. No uniformly accepted best measures of gender variance and gender nonconformity currently exist. One common approach is simply to ask participants whether they are transgender (e.g., Almeida et al., 2009 ), and, in some studies, whether they further self-identify as female-to-male or male-to-female. This question often follows immediately a question about sexual orientation. However, Buchting and colleagues (2008) have proposed combining the two questions by asking respondents: “Do you consider yourself to be one or more of the following: (a) Straight, (b) Gay or Lesbian , (c) Bisexual , (d) Transgender .”

Because some gender-variant people do not use “transgender” to identify themselves, and some nontransgender individuals may not fully understand the term, simply asking individuals whether they are transgender may lead to underreporting and false positives ( SMART, 2009 ). To address these concerns, some studies have provided respondents with a definition of “transgender” to increase the validity of responses (e.g., Massachusetts Department of Public Health, 2007 ). Conron and colleagues (2008) report the results of cognitive interviewing with a small nonprobability sample (n = 30) that included transgender youth. Using a question that combined biological sex and gender—asking respondents whether they were “female,” “male,” “transgender, female-to-male,” “transgender, male-to-female,” or “transgender (not exclusively male or female)”—they found that most transgender youth were able to choose a response option they felt was appropriate. However, the authors recommend further testing with slight modifications to the question ( Conron et al., 2008 ). In addition, questions about gender transitioning have been included in several studies ( Grant et al., 2010 ; Nemoto et al., 2005 ; Xavier et al., 2007 ).

Measuring the sexual orientation of transgender people poses special challenges because some respondents may answer questions about sexual orientation in terms of birth sex (their own or their partner's), whereas others may respond in terms of gender identity, and still others may find it difficult to answer in terms of a male–female dichotomy (e.g., Austin et al., 2007 ; Garofalo et al., 2006 ). Some HIV studies have included questions about the respondent's sexual behavior with males, females, transgender men, and transgender women.

While a number of effective measures of sexual orientation and gender identity have been developed, there remains a need for methodological research to determine the best ways to identify lesbian, gay, bisexual, and transgender people in health research. And while the most appropriate measures of sexual orientation and gender identity vary according to a particular study's research goals, standardization of measures in federally funded surveys would help improve knowledge about LGBT health because it would allow for the comparison and combination of data across studies.

Overcoming the Reluctance to Identify as LGBT to Researchers

Researchers studying sensitive topics must deal routinely with the reluctance of some participants to disclose accurate information about themselves. A topic may be sensitive because respondents perceive it as intruding on their privacy, because it raises concerns about the possible repercussions of disclosure to others, or because it triggers social desirability concerns (i.e., the desire to “look good” to others). Examples of sensitive topics include income, illegal activities, sexual practices, and membership in a stigmatized group. When confronted with a question about a sensitive topic, respondents may decline to answer or may intentionally give an inaccurate response. In some cases, respondents may decide not to participate in the study at all, thereby reducing the overall response rate and possibly making the sample less representative of the larger population. All of these outcomes have important implications for data quality ( Lee, 1993 ; Tourangeau and Yan, 2007 ; Tourangeau et al., 2000 ).

Because they wish to avoid stigma and discrimination and are concerned about their privacy, some individuals are reluctant to disclose their membership in a sexual- or gender-minority group. McFarland and Caceres (2001) , for example, describing the factors that lead to underestimation of HIV infection and risk among men who have sex with men, note that stigma and discrimination result in marginalization of these men, which in turn engenders suspicion toward government institutions, researchers, and service providers. Consequently, they argue, many men who have sex with men are unwilling or reluctant to participate in research studies.

As with research on other sensitive topics, challenges include nonparticipation and item nonresponse (which occurs when a respondent provides some of the requested information, but certain questions are left unanswered, or certain responses are inadequate for use). Nonparticipation and nonresponse threaten the generalizability of research data to the extent that those who do not disclose their sexual orientation or transgender identity accurately, or decline to participate altogether, differ in relevant ways from those who do disclose and participate.

A primary strategy to foster disclosure and reduce nonresponse is for researchers to establish a bond of trust with members of the target population. As with other populations, sexual and gender minorities are more likely to entrust researchers with sensitive information about themselves to the extent that they perceive the researchers to be professional, competent, and sensitive to their concerns about privacy (see, generally, Dillman et al., 2009 ). In addition, sexual- and gender-minority participants are more likely to trust researchers who evidence knowledge and sensitivity about their community and culture, characteristics commonly understood to be components of cultural competence.

As an adjunct to cultural competence, a number of techniques have been used to improve response rates to questions relating to sensitive topics. Modes of data collection that foster participants' sense of confidentiality or anonymity may yield higher rates of disclosure. For example, research participants may be more willing to disclose same-sex behavior or attractions when they provide their responses via computer rather than in a face-to-face interview ( Villarroel et al., 2006 ; for a review, see Gribble et al., 1999 ). Collecting data in a private setting and taking steps to establish rapport before asking questions about sensitive topics may also increase respondents' willingness to disclose sensitive information. Variations in the wording and format of questions, as well as use of terminology that is familiar to the participant, have shown some success in eliciting responses ( Catania et al., 1996 ).

Respondents may be more willing to disclose sensitive information about themselves when their participation is anonymous. If anonymity is not possible, understanding that their responses are confidential may increase the extent of participants' self-disclosure. Although it would not be required, a certificate of confidentiality from the National Institutes of Health ( NIH ) could be helpful in this regard ( NIH, 2011 ).

Obtaining High-Quality Samples of Relatively Small Populations

As documented below and in subsequent chapters, numerous studies of sexual and gender minorities that have relied on nonprobability samples have yielded important information about and insights into LGBT life and health. If the goal of a study is to provide estimates that can be generalized with confidence to the entire LGBT population, however, the use of probability-based methods is necessary. Obtaining a probability sample of a relatively small population, such as a racial, ethnic, religious, sexual, or gender minority, requires considerably more resources than are required for sampling the population as a whole. This is the case because a large number of potential participants must be screened to obtain a sample of minority group members large enough for statistical analysis. Still more resources are required to collect samples that permit study of subpopulations within these groups, such as socioeconomic, age, and geographic groupings, and comparisons of respondents according to health-related characteristics.

Lacking such resources, relatively few studies designed specifically to examine LGBT individuals have been able to utilize large probability samples. There are, however, some exceptions. In the Urban Men's Health Study, Catania and colleagues (2001) used a complex, two-stage sampling procedure in New York, Los Angeles, San Francisco, and Chicago to obtain a probability sample of men who have sex with men (n = 2,881) (see also Blair, 1999 ). Herek and colleagues used the Knowledge Networks panel to obtain a national probability sample of self-identified lesbian, gay, and bisexual adults (n = 662) ( Herek, 2009 ; Herek et al., 2010 ). Knowledge Networks creates a panel using random-digit dialing to generate a national probability sample and administers an online survey to the panel. Internet access and the appropriate equipment are provided for those panel members who lack them.

Other researchers have conducted secondary analyses of health data collected from surveys of large national samples that included at least one question about respondents' sexual behavior (e.g., Cochran and Mays, 2000 ), sexual attraction (e.g., Consolacion et al., 2004 ), or sexual orientation identity (e.g., Cochran et al., 2003 , 2007 ; Hatzenbuehler et al., 2009 , 2010 ; Mays and Cochran, 2001 ; McLaughlin et al., 2010 ). The findings from many of these studies are discussed in later chapters of this report.

In addition to the data sets used in these secondary analyses, numerous other government and academic surveys routinely use large national probability samples to collect extensive data on the health of Americans. However, relatively few of these surveys have included measures of variables related to sexual orientation or gender identity. Consequently, many of the data sources widely used by health researchers do not yield insights into LGBT populations. As discussed later in this chapter, this situation can be remedied by routinely including measures of sexual orientation and gender identity in these surveys.

U.S. census data have also been used to obtain information about the LGBT population ( Black et al., 2000 ; Gates, 2007 ; Rosenfeld, 2010 ), but the available information is limited. Since 1990, the census has reported data for same-sex partners who live in the same household, provided that one of them is designated the householder and both report their gender and relationship status on the household roster. However, an unknown number of same-sex partners who do not meet these conditions are not identified. Moreover, because census respondents' sexual orientation is not ascertained, lesbians, gay men, and bisexual adults who are not cohabiting in a same-sex relationship remain invisible in the data. Nor can transgender people be identified in census data. It should be noted that adding content to the census requires the approval of the U.S. Office of Management and Budget and, ultimately, the Congress.

A third approach to obtaining a national probability sample with a sufficient number of sexual- and gender-minority respondents involves combining data across studies. For ongoing studies that recruit new probability samples on a regular basis, it can be possible to combine sexual- and gender-minority respondents across years to produce a sample that is sufficiently large for analysis, provided that the studies all include comparable measures of key variables. Combining data from eight waves of the General Social Survey with data from the National Health and Social Life Survey ( NHSLS ) and the Chicago Health and Social Life Survey, for example, Wienke and Hill (2009) compared the well-being of partnered gay men and lesbians (n = 282) with that of single gay men and lesbians (n = 59) and married, cohabiting, dating, and single heterosexuals (sample sizes ranged from 614 to 6,734).

Combining data from multiple samples can be helpful in researching groups (like sexual and gender minorities) that represent a small domain in part of a larger survey. Because the numbers of these small groups often are not sufficiently large for analysis, combining data from multiple samples allows researchers to generate more accurate estimates. However, this method poses a variety of analytical challenges, and statistical methods for improving the estimation and analysis of small domains continue to be developed ( Rao, 2003 ). These methods usually require assumptions about the statistical models employed and additional information related to the estimates the researcher wants to produce. For application to LGBT health research, these measures require the implementation and use of consistent measures to identify LGBT populations.

Raghunathan and colleagues (2007) provide an example that, although not involving LGBT populations, combines information from two data sets to improve the efficiency of county-level estimates. The authors use a statistical modeling approach—combining data from the Behavioral Risk Factor Surveillance System ( BRFSS ), a telephone survey conducted by state agencies, and the National Health Interview Survey ( NHIS ), an area probability sample surveyed through face-to-face interviews—to improve county-level prevalence rates of cancer risk factors that were developed from one survey alone. In a case study using data from the NHIS and the National Nursing Home Survey, Schenker and colleagues (2002) provide an example that illustrates the benefits of combining estimates from complementary surveys and discuss the analytic issues involved in doing so. Schenker and Raghunathan (2007) review four studies conducted by the National Center for Health Statistics that combine information from multiple surveys to improve various measures of health. In another example, Elliott and colleagues (2009) recognized that estimates of health care disparities in small racial/ethnic groups are often lacking in precision because of the small sample sizes involved. They developed an application of the Kalman filter (a recursive algorithm originally used in engineering applications; see Kalman, 1960 ) to use the available data more efficiently. By applying the Kalman filter to 8 years of data from the NHIS, they demonstrated how estimates for small populations could be improved by combining estimates from multiple years. In many cases, this method improved precision to an extent that would be similar to what would be achieved by doubling the sample size of the yearly data. When this method is used, the LGBT populations in the data sets that are statistically combined must be identified.

• RESEARCH METHODS

In all empirical research, each component of the study design must be based on consideration of specific characteristics of the population being studied if effective methods for data gathering are to be developed. For LGBT studies, researchers must identify and select the most effective methods to compensate for the unique research challenges discussed above. This section reviews sampling issues, including the utility of probability and nonprobability sampling for generating study populations for LGBT health research, and describes quantitative and qualitative analytic methods used in LGBT research.

Research studies are designed to describe population characteristics, explore unanswered questions, or test hypotheses in order to validate previous findings or investigate areas that have not been fully explored. The applicability of research findings is directly related to the study design and the ability of the research team to identify an adequate sample for analysis. The manner in which the data collection methodology, the measurement design, and sample selection methods and subject recruitment are assembled into a coherent study design determines the relevance and generalizability of the findings.

Internal and external validity are important considerations for evaluating the relevance of LGBT research findings. Internal validity means that the measures of all variables are reliable, there is justification for linkages of relationships between independent and dependent variables, and other extraneous variables that are not logically associated are ruled out. External validity denotes the generalizability of study results beyond the specific study setting. These issues are discussed throughout the chapter.

Sampling Challenges

Careful sampling requires a precise definition of the target population of the study. The target population is the set of elements about which information is wanted and parameter estimates are required ( OMB, 2001 ). For example, the target population could be all LGBT persons in the United States or in a state, community, or other geographic area. If members of the target population are selected into the sample by a random, unbiased mechanism such that every person in the target population has a known chance of being selected into the study, the resultant study sample can be used to draw inferences and generalize about the target population, and the sample thus generated is “representative” of the target population. After the desired target population for a study has been specified, selection of a sample requires identifying or developing a sampling frame or list of elements in the target population. The completeness of the sampling frame relative to the target population and the methods by which individual units are selected or identified for the study sample determine the limits of statistical inference and generalizability for the study results. Typically, researchers obtain study samples by selecting participants from a geographically defined population or a list of individuals who share a common characteristic, such as inclusion in a membership list of professionals. As discussed above, a variety of factors create challenges for generating samples that are representative of LGBT populations.

Recently, alternative models have been developed to identify a target population by starting with the community of interest and identifying samples that mirror characteristics of that community. A probability-based mechanism may or may not be used for selecting the study sample. For LGBT studies, both probability and nonprobability sampling methods have been used.

Probability Sampling

Probability sampling identifies a well-defined target population and sampling frame and uses a probabilistic method of selection to obtain a sample that is representative of the target population ( Kalton, 2009 ). Although probability sampling can be expensive and the statistical methods employed can be complicated, the ensuing data lead to findings that can be generalized to the target population. If the target population were the nation's LGBT populations, the sampling frame had characteristics such that it was possible to identify all LGBT people, and a probability mechanism were defined that gave everyone in the sampling frame an equal chance of being selected, then the findings could be generalized to LGBT populations in the United States—within the scope of the study measures and subject to limitations of sampling and nonsampling error. Probability-based sampling methods rely on the assumption that a list of all eligible units of the target population can be constructed and that all units will have a known probability of selection.

Many approaches to obtaining a probability-based sample of a population ensure that valid inferences can be drawn. Kalton (2009) describes a number of such approaches for obtaining valid samples for subpopulations. When an existing sampling frame can identify whether an individual is a member of a subpopulation, drawing a sample of a specified size can be accomplished in a straightforward way. On the other hand, in many applications, individuals cannot be identified prior to selection of the sample. In such cases, major challenges exist within the probability-based framework. The approaches Kalton describes can be costly, as several require extensive screening to identify the subpopulation(s) of interest or can rely on a number of assumptions to permit valid inferences.

A common practice is to draw a large sample of the general population and then screen potential participants for inclusion in the study based on criteria that define the study's target population. With populations such as LGBT individuals, ineligible participants must be identified and eliminated from the study during the data collection process. This process is often implemented with a series of screening questions administered at the time the interviewer first contacts the household person. For example, the previously mentioned Urban Men's Health Study used telephone screening, along with other techniques, to obtain a probability sample of men who were gay or bisexual or reported having sex with men and who resided in New York, Chicago, Los Angeles, and San Francisco ( Blair, 1999 ; Catania et al., 2001 ). To compare the yield of population-based methods for health needs assessments, Meyer and colleagues (2002) and Bowen and colleagues (2004) conducted paired surveys in Jamaica Plain, Massachusetts, using random-digit dialing and household area probability sampling in the same census tracts. Percentages of women who identified as sexual minorities were similar across the two sampling methods.

Another method, known as disproportionate stratification, can be effective for identifying small study populations. This method identifies areas where the target population is more highly concentrated and then samples a higher fraction of units within those areas. Disproportionate sampling may be an effective screening strategy for LGBT populations while ensuring that population estimates are possible. For example:

• Boehmer and colleagues (2010) used disproportionate sampling to select geographic units in census areas with a higher prevalence of lesbians and bisexual women.
• The 2003 California LGBT Tobacco Survey used disproportionate stratification in its random-digit dialing sampling design. The survey used areas identified by the 2000 decennial census as having a high proportion of unmarried same-sex partners and applied a weighting scheme to make the sample representative of the lesbian and gay population of California ( Carpenter and Gates, 2008 ).
• Sampling using multiple sampling frames takes advantage of more than one partial listing of the target population to create a probability sample; care must be taken to remove duplicate listings of individuals when using this method. Aaron and colleagues (2003) used capture recapture methods with multiple lists and elimination of duplicates to estimate the lesbian population in Allegheny County, Pennsylvania.
• Network or multiplicity sampling uses sampled persons as proxy respondents for persons who are “linked” to them in a specific way, for example, as a family member ( Sirken, 2004 ). An assumption required for this method is that all members of the linkage must know or be willing to report the rare population status of those linked to them ( Kalton, 2009 ).

Probability sampling has seen limited use in the study of LGBT health. As explained above, the relatively small size of LGBT populations, the lack of research funding, and the sensitivity of questions relating to sexual behavior and gender expression have been barriers to effective probability sampling. Despite these challenges, some researchers have used probability samples for LGBT research. In addition to the examples cited earlier ( Catania et al., 2001 ; Herek et al., 2010 ), the NHSLS , described in the previous chapter ( Laumann et al., 1994 ), used multistage sampling to create a probability sample of U.S. households. Although sexual and gender minorities were not specifically targeted for the study, questions about sexual orientation were included in the survey instrument. Similarly, the federally sponsored National Survey of Family Growth ( NSFG ) does not specifically target LGBT people but does include questions about sexual orientation identity, behavior, and attraction ( Mosher et al., 2005 ). A further example is the National Survey of Sexual Health and Behavior ( Herbenick et al., 2010 ), which was based on data from an online survey using a cross-sectional sample of U.S. adolescents and adults participating in a Knowledge Networks panel and reported data on the sexual orientation and behavior of participants. Another study using a probability sample of self-identified lesbian, gay, and bisexual participants in the Knowledge Networks panel reported extensive data on demographic, psychological, and social commonalities and differences across sexual orientation subgroups ( Herek et al., 2010 ). Illustrative examples of the study designs and sexual orientation measures used in some of these studies are shown in Box 3-1 .

Examples of Probability Sample Studies with Sexual Orientation Measures. Personal interviews were conducted with the civilian noninstitutionalized population to collect data on factors influencing pregnancy and women's health in the United States. Sexual (more...)

Sexual orientation and gender identity measures have also been included in state-level health surveys of probability-based samples, allowing some comparisons with heterosexual counterparts. The Massachusetts Department of Public Health has incorporated these measures into its Behavioral Risk Factor Surveillance System surveys since 2001 (transgender identity question added in 2010). Conron and colleagues (2010) aggregated 2001–2008 data from the Massachusetts Behavioral Risk Factor Surveillance System surveys to examine patterns in self-reported health by sexual orientation identity. The California Health Interview Survey ( CHIS ), conducted every 2 years, is a population-based random-digit dialing telephone survey of a sample of more than 42,000 California adults. In 2001 and 2003, the CHIS included questions about sexual orientation identity and gender (male/female) of recent sex partners. Data from the CHIS have been used to examine LGBT health issues, including obesity and body weight ( Carpenter, 2003 ; Deputy and Boehmer, 2010 ) and smoking ( Tang et al., 2004 ). The California Quality of Life Survey, a population-based health survey of adult Californians conducted in 2004–2005 (n = 2,272 adults), employed a sampling frame that was created from a subset of adults first interviewed in the 2003 CHIS and included an oversample of sexual-minority adults. These data have been used to examine physical health status, psychological distress, and mental health status in different sexual orientation groups ( Cochran and Mays, 2007 , 2009 ). These studies and others make use of survey vehicles designed for the general population to capture information about sexual and gender minorities that has localized relevance for priority setting at the state and substate levels. Illustrative examples of the study designs and sexual orientation measures of state-level probability-based studies are shown in Box 3-2 .

Examples of State-Level Probability Sample Studies with LGBT Measures. The Centers for Disease Control and Prevention's (CDC) Behavioral Risk Factor Surveillance System requires all states to implement annual random-digit dialing surveys of community-residing (more...)

The ability of researchers to draw valid inferences with probability samples hinges on three key elements: proper item design (i.e., questions that elicit the desired information from respondents), acceptably high completion rates, 1 and sufficiently large samples. Thus, for example, the NHSLS was carefully designed to elicit information on sensitive issues, and the completion rate was close to 80 percent. The design team initially hoped to sample 20,000 individuals for the study, but, as noted in the previous chapter, received funding sufficient to complete a sample of only 3,432. The total number of women who reported nonheterosexual behavior, attraction, or identity was 150 (8.6 percent of the total), and the comparable number for men was 143 (10.1 percent). The consequence is that estimates for these key subpopulations are not precise; that is, they have relatively large margins of error. Thus, the sample is useful, but far from ideal, for the purpose of studying LGB populations, and it does not permit meaningful analysis of subgroups defined by race/ethnicity, age, and other sociodemographic characteristics. The study included no measure of gender identity.

Other studies have also examined subsets of sexual and gender minorities in LGBT populations using probability samples that were not designed to study those individuals. An example is the study of same-sex couples in the U.S. census. Questions were not designed for the purpose of learning about same-sex couples, but the data have well-known properties. The 2000 U.S. census long form (received by approximately one in every six households) is very large. Thus, inferences drawn have high internal validity for very specific population parameters and have high external validity for more general population parameters. See Box 3-3 for an example of an inference that can be drawn from U.S. census data.

Drawing an Inference from Census Data. Using data from the 2000 U.S. census, Black and colleagues (2007) were able to report on home ownership among cohabitating same-sex couples. They report that 60.4 percent of cohabiting male couples and 61.7 percent (more...)

Respondent-driven sampling. Respondent-driven sampling, a chain-referral method, attempts to create a sample based on the social networks of participants. It has been used to obtain samples of rare populations and is being used more frequently in LGBT research. Respondent-driven sampling is similar to snowball sampling, defined later in the chapter, in that a sample is developed by using referrals from initial recruiters (seeds) and existing participants, from which estimates can be made about the social patterns of the study population. Those estimates are then used in conjunction with data generated by the study to draw inferences about the population as a whole.

Respondent-driven sampling is limited in that it relies on a number of assumptions to enable those generalizable inferences ( Kalton, 2009 ). For example, a theory of respondent-driven sampling developed by Volz and Heckathorn (2008) assumes that respondents accurately report the number of people linked to them in their social network, that they recruit others at random, and that they have reciprocal relationships with those they recruit. Most probability sampling methods do not require such assumptions. As a result, respondent-driven sampling is applicable mainly in examining small domains where clear social networks exist ( Kalton, 2009 ).

Reisner and colleagues (2010) examined data generated by 74 original seeds from four Massachusetts studies conducted between 2006 and 2008 that used respondent-driven sampling to reach high-risk men who have sex with men. Thirty-four percent of seeds generated two or more subsequent participants. Analysis of the data indicated that the size of a participant's social network was not significantly associated with generating additional participants. Social network size is frequently considered in developing a respondent-driven sample of men who have sex with men, but this study suggests that social network size alone is insufficient to identify participants who will recruit other participants. Factors such as the strength of social network ties and the frequency of a study-specific health behavior may be important as well.

Time-location sampling. This sampling approach uses multiple stages of data collection to increase the likelihood of developing a representative sample of the target study population, focusing on key social and behavioral characteristics. With community involvement, personal interviews with community leaders and gatekeepers and focus groups are included in an ethnographic assessment to generate an exhaustive list of sites where members of the target population congregate. A sample of the sites is drawn randomly for data collection, and specific time intervals are established when attendees are recruited for study participation. This method, described as venue-based, time-space sampling , has been used for studies of gay men and is one of the two methods employed by geographic sites within Centers for Disease Control and Prevention's ( CDC 's) National HIV Behavioral Surveillance program ( Gallagher et al., 2007 ).

The strengths of this method include community participation that may result in a more comprehensive roster of potential sites than might otherwise be obtained and reduce suspicion among the study population. Its effectiveness depends on how well the ethnographic assessment is conducted, as well as the comprehensiveness and stability of sites in the initial roster (sampling frame). If probability-based methods are used at each stage of implementation, inferences about the target population are possible. The Community Intervention Trial for Youth relied on this method to evaluate the effects of a multicomponent, community-level intervention to promote safer sexual behavior among men aged 15–25 who reported having sex with other men. The researchers identified locations or venues attended by the target population and at what times (days and time periods). They selected venues and time periods randomly and then systematically sampled members of the target population at those venues during those time periods. The collection of data from these participants allowed the researchers to draw inferences about the target population ( Muhib et al., 2001 ).

Nonprobability Sampling

For a variety of reasons, including a historical lack of the resources needed to obtain probability samples of sexual and gender minorities, the majority of studies addressing topics relevant to LGBT health have been conducted using nonprobability samples ( Herek et al., 2010 ). A nonprobability sample is one in which all elements of the target population do not have a known, nonzero chance of being included. Consequently, in contrast to probability samples, the sampling error associated with population estimates derived from nonprobability samples cannot be computed, and the extent to which the sample represents the population from which it was drawn cannot be known. In the worst cases, nonprobability samples based on extremely biased assumptions about the population can lead to highly inaccurate conclusions, as when findings from studies of sexual minorities in prison and clinical samples were used during the early twentieth century to depict homosexuality as a pathological condition ( Herek, 2010 ; Meyer and Wilson, 2009 ). In recent years, however, investigators have used increasingly sophisticated methods for obtaining large and diverse community-based nonprobability samples that have provided numerous insights into the health of sexual and gender minorities ( Binson et al., 2007 ; Herek et al., 2010 ; Meyer and Wilson, 2009 ).

An array of strategies can be used to create nonprobability samples, the choice of which depends on the study's research question, data collection methods, and available resources. For example, venues such as bars and clubs, community events and organizations, Internet listservs, and social networks have often been used to recruit LGBT study participants ( Herek et al., 2010 ; Meyer and Wilson, 2009 ). The samples drawn from such venues are often referred to as convenience samples , although Meyer and Wilson (2009) observe that “for most nonprobability sampling procedures, ‘convenience’ is a misnomer; nonprobability sampling requires very careful consideration, design, and execution” (p. 26). Whereas some researchers distinguish convenience samples from other types of nonprobability samples, the term often is used to refer generally to any type of nonprobability sample ( Binson et al., 2007 ). Throughout this report, the committee attempts to characterize each study's sample using the terminology employed by the authors, with the consequence that convenience sample is used to refer to nonprobability samples obtained through a variety of techniques. Similarly, the terms community sample and community-based study are used in this report to refer to nonprobability samples that are obtained from a specific locale, such as a city or neighborhood. The various techniques for collecting nonprobability samples of LGBT populations, each of which can be understood as incorporating “some level of systematic exclusion and inclusion criteria” into the task of obtaining participants ( Binson et al., 2007 , p. 406), include purposive sampling, quota sampling , and snowball sampling .

Purposive sampling involves selecting specific sample elements because the researcher has reason to believe they are likely to provide the most useful information about the topic to be researched. For example, a study may select HIV -infected individuals to study behaviors that can lead to an increased risk of infection. Or researchers conducting a school-based study of LGBT adolescent health may include a particular high school in the sample because they believe it will yield especially valuable information. Diamond (1998) , for example, recruited 89 nonheterosexual women aged 16–23 to participate in a longitudinal study of sexual identity development among young women. Participants were recruited at lesbian, gay, and bisexual community events; at classes on gender and sexuality issues at a large private university; and from lesbian, gay, and bisexual student groups at various universities. Of the 89 original participants, 79 participated in successive follow-up interviews over a period of 10 years. Two-thirds of those participants changed their sexual identity labels, and half did so two or more times ( Diamond, 2008 ). This study made an important contribution to the discussion of sexual fluidity among women.

Quota sampling involves selecting a set number of participants to fill preestablished categories as a means of increasing the sample's variability or diversity ( Binson et al., 2007 ). The researcher may begin by identifying the target number of sample elements in each of several categories (based on, for example, demographic groupings such as gender, race, and ethnicity). The goal may be to have a final sample in which the proportions of various key groups resemble the population from which the elements were drawn or to oversample relatively uncommon groups. Participants are then recruited to fill the various “quotas.” Kennamer and colleagues (2000) used quota sampling to develop a sample of more than 700 Caucasian and African American men who have sex with men in order to conduct a statewide survey of HIV -related knowledge, behaviors, and attitudes in Virginia. The purpose of this study was to provide information for public health planning with respect to the HIV risks of men who have sex with men. As men who have sex with men were largely hidden, no population data were available from which to sample. Using population estimates from statewide and regional census information, the research team created target sizes for regional-level samples and used community and venue recruitment to identify participants. Additional efforts were made to recruit African American men who have sex with men, who tend to be underrepresented in surveys. The results assisted public health planners in determining regional allocations for HIV education and prevention programs. Although the study data would not be applicable to another state or geographic area, information about the methodology could be helpful to others considering such a study.

Snowball sampling relies on an initial core group of participants to recruit others into the study through their social networks; those individuals, in turn, may be asked to recruit additional participants from their networks, and so on ( Binson et al., 2007 ; Meyer and Wilson, 2009 ). Sample development begins when members of the target population are identified and selected as seeds who will distribute surveys to or identify others who meet the study's inclusion criteria. This method was used prominently in early studies of sexual and gender minorities and continues to be applied when previously unstudied population groups are engaged in research. Like respondent-driven sampling (discussed earlier in this chapter), snowball sampling is a chain-referral method. Unlike respondent-driven sampling, however, it does not involve the use of probabilistic procedures for sample selection.

Many studies of sexual and gender minorities with large nonprobability samples have used a combination of the above and related methods (e.g., Bell and Weinberg, 1978 ; Herek et al., 1999 ; Kennamer et al., 2000 ; Martin and Dean, 1990 ; Meyer et al., 2008 ; Morris and Rothblum, 1999 ). The National Lesbian Health Care Survey ( NLHCS ), for example, conducted in 1984–1985, developed a national study of self-identified lesbians across the United States ( Solarz, 1999 ). A community effort throughout, the NLHCS used snowball sampling strategies by organizing groups of women across the country to distribute questionnaires to other lesbians. Notices about the survey were posted across the country in bookstores and other locations frequented by lesbians, and a study phone number was provided for those with questions or concerns. Women who self-identified as lesbians were eligible to participate ( Bradford et al., 1993 ). Each questionnaire was numbered and coded to enable identification of the initial and secondary distributors, such that the researchers could track them from the original distribution location through a second and sometimes third handler. NLHCS data were the earliest to suggest that lesbians experienced higher-than-expected rates of sexual abuse and stress-related behaviors, such as alcohol use and mental health support. The extent to which lesbians were open about their sexual orientation was associated with greater availability of mental health services ( Bradford et al., 1993 ). At a time when lesbians were largely hidden, the study results provided a base of information from which successive studies employing more rigorous sampling methods could be developed.

Another creative use of sampling methods is demonstrated by studies that have recruited sexual- and gender-minority participants through various nonprobability methods and then asked sample members to recruit other participants who meet specific criteria. For example, Rothblum and Factor (2001) placed advertisements in local and national periodicals to recruit lesbians with at least one female sibling. Eligible women who responded to the ad were sent two copies of a questionnaire, one for them to complete and the other for their sister (the questionnaires did not indicate that the study focused on lesbians). Although the representativeness of the sample could not be known, the researchers were able to compare lesbians with heterosexual “controls” from highly similar backgrounds on multiple health variables. Similar sibling-control studies have been conducted with gay men and bisexuals ( Rothblum et al., 2004 ) and with same-sex couples ( Balsam et al., 2008 ).

The National Transgender Discrimination Survey ( NTDS ), conducted by the National Center for Transgender Equality and the National Gay and Lesbian Task Force, distributed online links to the survey site through a network of more than 800 transgender-serving and transgender-led advocacy and service organizations, support groups, listservs, and online social networks; 2,000 paper surveys were distributed to difficult-to-reach transgender and gender-nonconforming respondents, resulting in a total sample of 6,450 ( Grant et al., 2010 ). Characteristics of this sample closely resembled a convergence of findings from a growing number of convenience studies conducted across the country, primarily in urban centers or at the state level. NTDS results pointed to critical concerns regarding unemployment and economic insecurity; employment challenges; and barriers to health care, such as a lack of health insurance and culturally competent providers ( Grant et al., 2010 ).

Well-designed nonprobability studies have been useful for local and state-level health access initiatives. In 2004–2005, the Virginia Department of Health's HIV Prevention Community Planning Group drew on findings from existing nonprobability transgender health surveys to develop the Virginia Transgender Health Initiative Survey ( THIS ). This policy-oriented health assessment study used focus groups to determine constructs for a statewide survey of transgender people and to gather information about regional differences that could affect survey distribution methods. A questionnaire was developed and distributed through community outreach efforts at local and regional locations, including health care providers' offices, LGBT events, and balls and house parties. It was also made available on a protected website. At a time when few transgender studies had been conducted, and none at the state level, it was critical for community representatives, experienced scientists, and public health officials to craft an approach that would be useful and accepted in the context within which they were working ( Xavier et al., 2005 , 2007 ). Study results were used to increase awareness of transgender health needs, resulting in expanded services throughout the public health system.

Even though the extent to which their findings accurately characterize the entire LGBT population is unknown, studies based on nonprobability samples have yielded valuable information for expanding the field of LGBT research and addressing health service gaps (see Box 3-4 ). In addition to providing general descriptive data for LGBT populations and subgroups, they have served to demonstrate the existence of phenomena; to test experimentally the effectiveness of various behavioral and medical interventions; to assess relationships among study variables; to identify differences among groups; and in general, to provide insights into the health-related challenges faced by LGBT populations.

Examples of the Use of Nonprobability Sample Surveys to Address Transgender Health. The NTDS gathered data from self-identified transgender or gender-nonconforming individuals in the first national effort to document discrimination found in previous small (more...)

In addition, in the absence of data from probability samples, researchers often develop approximations of population patterns when the findings from multiple methodologically rigorous studies with different nonprobability samples converge. During the 1990s and 2000s, for example, multiple studies using nonprobability samples suggested that lesbians were considerably more likely than gay men to report that they were in a committed relationship at the time of data collection (e.g., Kurdek, 2004 ). Data from the U.S. census and a national probability sample confirmed this pattern ( Gates, 2009 ; Herek et al., 2010 ).

Data Collection: Quantitative and Qualitative Methods

In addition to selecting an appropriate sampling frame, a major methodological concern is choosing quantitative or qualitative data collection methods.

Quantitative Data Collection Methods

Quantitative data collection methods include traditional survey research, Internet/online surveys, randomized controlled trials (RCTs), longitudinal cohort studies, and use of patient-level data.

Survey research. Survey methods are commonly used in LGBT health studies and are particularly valuable for determining population demographic and sociocultural characteristics, assessing knowledge and opinions, assessing behavior and behavioral intentions, and gathering data to describe the distribution of health conditions among populations and subpopulations. When a survey is used to gather information about a target population, it is important to assess the quality of the survey data to determine how useful the data are for drawing inferences about that population. Defined sources of error can and do affect all studies involving data collection, and researchers must strive to minimize their impact on the study results. A classification of error sources in data collection systems provides a framework with which analysts can evaluate the limitations of their data.

Survey data are subject to (1) the error inherent in examining a portion of the population (as opposed to surveying every individual of that population) and (2) errors that occur as a result of data collection procedures. Theoretically, the quality of survey data can be assessed in terms of total survey error, which is a combination of those two general sources of error, known as sampling error (when probability sampling methods are used) and nonsampling error ( Biemer, 2010 ).

When a probability-based sample is used, sampling error refers to the error that occurs when the researcher draws a sample of a population using a probability-based mechanism rather than surveying every member of that population ( Biemer, 2010 ; OMB, 2001 ). The sampling error associated with an estimate is a measure of the estimate's precision. Sampling error occurs by chance and is based on the random selection scheme used. The amount of expected variance due to sampling decreases as the size of the sample increases.

Nonsampling error refers to error that originates in the limitations of the data collection methods and procedures used in a study. This type of error may occur through a number of data collection mechanisms and is not easily quantified. Nonsampling error can be divided into four major categories: coverage error, nonresponse error, measurement error , and processing error ( Biemer, 2010 ; OMB, 2001 ). See Table 3-1 for examples of these sources of error.

Sources of Nonsampling Error in Survey Research.

Coverage error occurs when members of the target population are excluded from the frame population, when members outside of the target population are included in the frame population, and when members of the target population are included in the sampling frame more than once ( OMB, 2001 ). In the case of random-digit dialing telephone surveys, for example, low-income individuals and those living in rural areas may be disproportionately excluded as they are more likely to live in a household without a telephone line ( Galesic et al., 2006 ). More recently, the exclusion of households without a land-line telephone has exacerbated the coverage error of random-digit dialing surveys and resulted in the need to include a cell phone sampling frame in addition to the land-line telephone sampling frame.

Nonresponse error takes two forms. Unit nonresponse refers to cases in which a particular sampling unit (e.g., household, person, business) fails to respond to all parts of a questionnaire. Item nonresponse occurs when a respondent provides some of the requested information but leaves certain questions unanswered or provides responses that are inadequate for use. Nonresponse errors can result in biased survey estimates if there are relevant differences between those who respond to a questionnaire (or a particular question) and those who do not. Item nonresponse can be a significant factor for questions that are sensitive in nature.

Measurement error relates to the processes involved in data collection. These processes include the questionnaire design, important for receiving an accurate response; question wording or survey instructions, which if ambiguous lead to incorrect responses; and the way the questionnaire is formatted. Data collection methods have been shown to influence responses; for example, in-person interviews may generate more accurate information than telephone interviews, while reporting on sensitive topics may be improved when the interview takes place over the telephone because of the anonymity of the interviewee. Interviewers vary in how they ask questions and administer the interview, affecting respondents' answers. Respondents can also be a source of error: they may differ in their comprehension of questions and in their memory of past events; they also may provide incorrect responses to questions, intentionally or unintentionally.

Processing error stems from inconsistencies or oversight during the handling and use of data generated through the data collection process ( OMB, 2001 ). Such errors may take place when survey-generated data are transformed into published statistical results; when responses to survey questions are recorded incorrectly; and during data entry, when collected data are transferred to an electronic medium. More complicated errors can arise in applying mathematical algorithms to survey data in order to account for other sources of error; imputation, for example, is sometimes used for generating values to replace missing or erroneous data to facilitate analysis ( Brick and Kalton, 1996 ; Kalton and Kasprzyk, 1986 ). Such errors can also occur in population-based studies in which probability-based sample designs apply sampling weights to account for frame coverage, nonresponse, and sampling probabilities. Errors can occur in modifying data in these ways and can affect the results of the study.

Internet/online surveys. Internet surveys have numerous advantages over traditional survey methods. Data collection and coding can be completed rapidly over a large geographic area at a relatively low cost per survey. Because they are computer-based, moreover, Internet surveys allow for many capabilities not readily available with paper questionnaires, such as complex skip patterns, branching, and the inclusion of video and audio (e.g., Dillman et al., 2009 ). And the anonymity and accessibility of the Internet make it a particularly good medium for conducting sexuality research among otherwise underrepresented populations ( Mustanski, 2001 ).

As a data collection mode, the Internet can be used with probability or nonprobability samples, depending on the existence of a sampling frame and the use of a probability-based method of sample selection ( Couper, 2000 ). In organizational settings where Internet access is provided, such as academic and health care institutions, a sampling frame of research participants may be generated using personnel records, and members of the sample may be asked to complete a questionnaire online. Other methods, such as random-digit dialing, can also be used to obtain a probability sample for an Internet study if Web access is ensured for all. For example, Knowledge Networks has used random-digit dialing techniques to recruit members of an ongoing panel; Internet access and equipment are provided to panel members who lack them.

Most Internet studies, however, rely on nonprobability samples recruited through a variety of means. Samples recruited from the Internet are subject to bias because those without Internet access are excluded. In addition, the characteristics of individuals more likely to respond to Internet surveys could differ from those of the general population ( Rosser et al., 2009 ). For instance, Internet survey participants may be more likely than respondents recruited in other venues to seek sexual partners online ( Bolding et al., 2007 ). On the other hand, given that survey data gathered online reflect only the individuals who complete the survey, the data obtained may not reflect the complete population of individuals using the Internet to seek sexual partners. Studies of Web surveys conducted among men who have sex with men in the United States and the United Kingdom also have found that certain variables were associated with higher rates of questionnaire noncompletion in online sexuality research; these variables include nonwhite ethnicity, less openness about sexual orientation, self-identifying as heterosexual or bisexual, and in some cases younger age ( Evans et al., 2008 ; Ross et al., 2004 ).

As with other nonprobability sampling methods, Internet-based research with samples of volunteers faces some special challenges related to the internal validity of the data. Verifying participants' identities can be difficult, raising concern about the honesty of responses and the possibility of multiple submissions from the same respondent. (It should be noted that similar problems arise in studies that distribute paper questionnaires throughout a community, such as in newspapers or magazines.) A number of solutions have been proposed for this problem, including directly asking participants not to respond more than once, collecting e-mails or Internet Protocol (IP) addresses, and placing tracking “cookies” (units of information stored by a user's Web browser) on the computers of individuals who have responded ( Reips, 2000 ). While these strategies offer partial solutions, the collection of e-mail and IP addresses and the use of cookies also raise other methodological and ethical concerns ( Mustanski, 2001 ; Riggle et al., 2005 ).

With the increasingly widespread use of Internet and mobile phone technology, it is worth noting that emerging technologies can play a role not only in recruitment of study participants but also in many other areas of research (e.g., surveillance, interventions, clinical trials). Technologies such as text messaging, e-mailing, web-based interventions, and geographic information systems are currently being used to identify and reach at-risk populations and offer promising opportunities for future studies (for example, see Bowen et al., 2008 ; Carpenter et al., 2010 ; Geanuracos et al., 2007 ).

Randomized controlled trials. Since the work of Fisher (1925) was published, it has been recognized that randomization lends credibility to estimates of causal relationships that cannot be matched by other research designs. RCTs measure an intervention's effect by randomly assigning individuals (or groups of individuals) to an intervention group or a control group. In health research, RCTs typically are used to assess the efficacy of a behavioral or clinical intervention, such as in a drug trial, or participation in a risk reduction program.

While RCTs, at their best, can have high internal validity, concerns invariably remain with regard to external validity. For example, a particular AIDS treatment that is found to be effective in an RCT conducted with middle-aged white men in the United States might be less effective for other subpopulations. An RCT of the efficacy of a behavioral intervention to prevent the acquisition of HIV among men who have sex with men in six U.S. cities over a period of 48 months, known colloquially as the EXPLORE study, used HIV infection as the primary efficacy outcome ( HIV Prevention Trials Network, 2011 ). In a sample of 4,295 participants, 39.7 percent reported having a history of childhood sexual abuse ( Mimiaga et al., 2009 ). In prior studies, rates of childhood sexual abuse reported by men who have sex with men ranged from 11 to 37 percent ( Brennan et al., 2007 ), while the rate of such abuse among the general population of men had been estimated at 5 to 10 percent ( Finkelhor, 1994 ). Analysis of data from EXPLORE showed that childhood sexual abuse was highly associated with HIV risk-taking behavior and infection among men who have sex with men who participated in the study.

Even when RCTs are impractical, their basic principles can be extended to other research. Suppose one wants to evaluate the effectiveness of a community-based training program designed to help LGBT high school dropouts transition to employment. Researchers clearly cannot establish credible estimates of a “treatment” (completion of the program) by comparing subsequent employment rates of program participants with those of nonparticipants. After all, youths with high motivation are more likely to stay with the program than youths with low motivation. Researchers might, however, credibly estimate the impact of the program by comparing employment rates of youths in neighborhoods where the program was made available (the “treatment” group) with those of youths in otherwise comparable neighborhoods that had no training program (the “control” group). Such credible program evaluations are important for understanding the treatment effects of social programs, and can be conducted even when the “treatment” choice (the neighborhood choice for the employment program) is not randomly assigned as in a proper RCT .

CDC 's Diffusion of Effective Behavioral Interventions ( DEBI ) program is an example of how RCTs are being used to determine the most effective of two or more community-level or population-specific interventions. DEBI is a national-level strategy to provide high-quality training and ongoing technical assistance to state and community HIV /sexually transmitted infection ( STI ) program staff for selected evidence-based prevention interventions that focus on HIV, other STIs, and viral hepatitis. Initiated in 1999, the program includes evidence-based behavioral interventions identified in the 2009 Compendium of Evidence-Based HIV Prevention Interventions , which were evaluated through a series of efficacy reviews, many of which involved RCTs ( CDC, 2009 ). Development of a model for adapting evidence-based prevention interventions to groups not initially studied was initiated in 2004 ( McKleroy et al., 2006 ). This effort supported increased funding for adapting and culturally tailoring evidence-based prevention interventions initially designed for gay men for use with other affected population groups.

Implementation of the DEBI program has been critically reviewed in the context of dissemination and technology transfer. Dworkin and colleagues (2008) emphasize the importance of adaptation and dissemination as a participatory process and conclude that additional strategies are needed to ensure that the experience and assistance of community stakeholders are effectively represented.

The view of RCTs as the gold standard for measuring an intervention's impact extends across many diverse fields of human inquiry, such as educaion, welfare and employment, medicine, and psychology. The impact of an intervention can be evaluated only for populations participating in these trials. A letter to the New England Journal of Medicine suggests that sexual minorities have, at times, been explicitly excluded from such trials ( Egleston et al., 2010 ). There is a need for peer-reviewed research to explore this topic further. The inclusion of LGBT participants in efficacy trials of treatment interventions would help ensure that the needs of these populations are reflected in such research.

Longitudinal cohort studies. Longitudinal studies are often used in psychology to study developmental trends across the life span, in education to assess the outcomes of education or training, in sociology to study life events throughout lifetimes or generations, or in economics to study behavioral and attitudinal data on social and economic issues ( Kasprzyk et al., 1989 ; Lynn, 2009 ). Unlike cross-sectional studies, longitudinal studies track the same analytic units, usually individuals, over time. Therefore, analyses of unit-level changes and analyses of the frequency, timing, or duration of specific events are of interest. The advantages of such studies are discussed by Lynn (2009) . By providing repeated measures on the same characteristics and following the same individuals, these studies can observe changes more accurately than other approaches and develop an extensive set of analytic variables. One of the challenges with longitudinal studies is recruitment. LGBT participants are members of small populations and not always easy to identify. Another challenge is retention of participants. Since studies span a number of years, participants may move, lose interest, or otherwise become unreachable by researchers. In medicine, the design is used to uncover predictors of certain diseases. Results from longitudinal cohort studies have made a significant contribution to the understanding of LGB health concerns. Longitudinal designs may be employed with probability as well as nonprobability samples, the data may be qualitative or quantitative, and data collection can utilize any of the methods discussed in this chapter. Some examples of longitudinal cohort studies are presented in Box 3-5 .

Examples of Longitudinal Cohort Studies. Cohort participation has been carefully maintained. Deaths, usually reported by kin or by postal authorities, have been followed up. Where possible and permitted, in cases suggestive of cardiovascular disease or (more...)

The Nurses' Health Study ( NHS ), initiated in 1976 by Dr. Frank Speizer, and the NHSII, initiated in 1989 by Dr. Walter Willett, are the most definitive long-term epidemiological studies conducted to date on older women's health. Married registered nurses who were aged 30–55 in 1976, who lived in the 11 most populous states, and whose nursing boards agreed to supply the researchers with their members' names and addresses were enrolled in the cohort if they responded to the baseline questionnaire. Approximately 122,000 nurses out of the 170,000 who received the questionnaire by mail responded. For the NHSII, the target population was women aged 25–42 in 1989. Over time, additional questions have been added, most notably a dietary assessment added to the original NHS in 1980. Sexual orientation was not assessed at study initiation but was added in 1995 in the NHSII ( Case et al., 2004 ).

Corliss and colleagues (2008) analyzed data on 13,450 youth who had been followed for 7 or more years in the Growing Up Today Study ( GUTS ), a community-based prospective cohort study of adolescent girls and boys living throughout the United States. The researchers recruited 16,882 study participants in 1996 by identifying NHSII participants who reported having at least one child aged 9–14. A mail survey was used to collect data.

Use of patient-level data. Coupled with national health care reform initiatives, the growing awareness of health disparities among LGBT people and concerns about barriers to their care have generated increased attention to the importance of identifying sexual and gender minorities within patient populations. Although the rationale for collecting these data may be increasingly clear, the best ways to do so have not yet been clarified. Organizations that focus on services for LGBT people typically utilize information about sexual orientation entered within the patient's record by the physician; the physician may not be required to check a category that will become part of the patient's enduring record. Thus, disclosure is kept between patient and provider, and it is up to the patient to determine whether to share this information.

Gathering data about patients' sexual orientation and/or transgender identity has been a subject of considerable interest for at least a decade. In 2001–2002, an urban federally qualified health center with a specific focus on serving the LGBT community conducted a pilot study in which patients were asked at intake to complete a voluntary one-page survey that included sexual orientation and gender identity questions ( Barrett et al., 2002 ). Respondent demographics closely matched those of the overall patient population. Information from this study was valuable for organizational management and development, leading to an ongoing discussion about the best way to gather this information on a routine basis without endangering the privacy of patients. With recent improvements in database design and the expectation that such data will be increasingly important for tracking services to this population, the health center has added sexual orientation measures to the standard patient-registration form. To identify transgender patients, the question “Do you identify as a transgender person?” was added 3 years ago, following the legal sex question with “male” or “female” options.

In 2010, the Joint Commission on Accreditation of Healthcare Organizations published the monograph Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals to help hospitals integrate the concepts of effective communication and patient-centered care into their organizations. This monograph contains several recommendations specific to LGBT populations and identifies best practices and processes that can assist hospitals in meeting the needs of their LGBT patients ( The Joint Commission, 2010 ). New accreditation requirements have been developed to assess hospital performance, including two that are specifically relevant to the care of LGBT people: the first addressing the patient's right to choose his or her support individuals; the second addressing prohibition of discrimination, encompassing that based on personal characteristics, including “sexual orientation and gender identity or expression.” These new requirements will count toward a hospital's accreditation decision beginning July 1, 2011 ( The Joint Commission, 2011 ).

As awareness of the health-related needs of LGBT people grows, it is reasonable to expect that opportunities for collecting patient-level data for these populations will continue to emerge. For example, the Agency for Healthcare Research and Quality's Practice Based Research Networks could be one way to collect, analyze, and disseminate data on LGBT health. It is also reasonable to expect that the inclusion of sexual- and gender-minority measures in databases will increase. Consistent with the overall thrust of this chapter, it will be important for standard measures to be developed and implemented according to procedures that have been tested and found effective for ensuring privacy and confidentiality at all levels of health care organizations, including education of patients and their support persons, as well as providers and administrators. The use of patient-level data holds great potential for yielding a better understanding of the health status and health-related needs of LGBT people and how these differ from those of other groups in the U.S. population.

Qualitative Methods

Qualitative research methods can bring unique strengths to efforts to understand LGBT health. Examples of qualitative research include one-on-one interviews, focus groups, and cognitive interviews. Qualitative studies cannot be used to assess the characteristics of an entire population, but they do allow for a more detailed account of individuals' experiences as members of LGBT populations ( Binson et al., 2007 ). These accounts can help a researcher identify hypotheses that could be tested in another study and lay the groundwork for future research. This type of perspective is ordinarily unavailable from sample survey based research. In addition, qualitative research can assist in developing quantitative instruments for studying LGBT populations. Qualitative methods are particularly well suited to

• explore understudied areas of inquiry, social settings, behaviors, or groups;
• build knowledge of key issues to refine elements of research designs for subsequent quantitative study;
• understand thought processes, experiences, or meanings of phenomena;
• describe and explain complexity and situational context in lived experience; and
• generate novel understandings and formulate explanations of patterns of human experience.

In studies of LGBT health, qualitative research is particularly relevant in exploring and explaining meanings of sexual- and gender-minority status in specific, local, and historical contexts of lived experience. Qualitative methods, both on their own and in conjunction with quantitative methods, are essential tools for understanding LGBT health.

One-on-one interviews. One-on-one interviews can vary from structured interviews typically used by survey researchers to less structured interviews that tend to be used by researchers who collect qualitative data ( Bates et al., 2008 ). In structured interviews, the interviewer follows scripted questions, with no deviations from a set order; in semistructured interviews, the interviewer initiates questions and probes in response to the participant's answers, and questions may be reordered; and unstructured interviews are like a free-flowing conversation, with no set order to any questions—the interviewer may answer questions and make clarifications and may add or delete questions between interviews. Qualitative interviews are a good choice when the research aims are to shed new light on puzzling questions, identify variables and frame hypotheses for future survey research, and unravel complex events and events that evolve over time. Jarama and colleagues (2007) used random-digit dialing to recruit a probability sample of black women to undergo personal interviews conducted by trained peers. The purpose of the interviews was to have participants describe in their own words their perceptions of HIV risks and how they were taught to think and behave about sexuality. Each of the interviews was guided by a common set of questions; while some interviews followed the questions in order, others took their own direction, circling back to cover questions that were not answered in order. Peer interviewers had been carefully trained to ensure that study data would be collected from each interview and in a manner that respected the flow of each participant's thought process and mode of expression.

Focus groups. Focus groups are often used as one component of a mixed-methods study in which the goal is to obtain quantitative data on a target population. During the first phase of the Virginia Transgender Health Initiative Study, for example, regional focus groups were conducted to inform the content of a phase two statewide survey of self-identified transgender residents. A team of facilitators including transgender researchers and community advocates was trained to conduct the interviews, which were developed in conjunction with a statewide task force created to guide and support the initiative. Results were disseminated to communities, and after feedback was received from community and professional audiences, the focus group findings were used in developing a conceptual framework and questions for the phase two statewide quantitative survey ( Xavier and Bradford, 2005 ; Xavier et al., 2007 ). In another example, the Census Bureau recently used 18 focus groups distributed over seven locations to help develop a better understanding of how gay and lesbian couples think about and report their relationship and marital status ( Bates et al., 2010 ).

Cognitive interviews. The cognitive interviewing approach to evaluating sources of response error in survey questionnaires was developed during the 1980s through an interdisciplinary effort involving survey methodologists and psychologists ( NRC, 1984 ). This approach has the following general features ( Willis, 2004 ):

• It focuses mainly on the questionnaire rather than on the entire survey administration process. That is, the focus is on survey questions, as opposed to administrative procedures such as computer-administered personal interviewing, mentioned earlier in this chapter.
• It focuses explicitly on the cognitive processes that respondents use to answer survey questions. Therefore, covert processes that are normally hidden, as well as overt, observable processes, are studied.
• For the conduct of the cognitive interview, volunteer subjects are recruited and are interviewed either in a laboratory environment or in some other private location. (In this application, the term “subject” refers to an individual who is tested through a cognitive interviewing procedure, and “respondent” defines someone who is interviewed in a fielded survey.)
• The recruitment of subjects targets persons with specific characteristics of interest (for example, the elderly, those who have used illicit drugs in the past 12 months, teenagers who have used chewing tobacco).

Clark and colleagues (2005) used cognitive interviews of a sample of 40 women to evaluate survey questions designed to measure sexual orientation and gender expression. Results of the interviews helped identify questions that may have been confusing to respondents and specific terms that needed additional clarification. Cognitive interviews are currently being used by the National Center for Health Statistics to develop and test measures for including LGBT questions on federal surveys.

• DATA SOURCES

The relative lack of population-based data presents the greatest challenge to describing the health status and health-related needs of LGBT people. Although recommendations have been made for some time about collecting data on sexual and gender minorities ( Westoff, 1973 ), only a limited number of publicly funded probability sample studies include measures of sexual orientation, and none measure gender identity. In 2000, Healthy People, the nation's health promotion and disease prevention program ( HHS, 2000 ), included people defined by sexual orientation as a population group experiencing health disparities. At that time, only two federally funded data sets (the National Health and Nutrition Examination Survey and the National Household Survey on Drug Abuse) included measures of sexual orientation. Secondary analysis of these data sets was prominent in calling attention to significant differences in reported rates of mental health and substance abuse between LGB people and heterosexuals ( Cochran and Mays, 2000 ; Cochran et al., 2000 , 2004 ). In the past decade, sexual orientation measures have been included in additional federally funded surveys. Recurring federally funded surveys that include LGB measures are listed and their properties described in Table 3-2 .

Recurring Federally Funded Surveys That Include LGB Measures.

Not surprisingly, the limited number of studies that have used probability samples and rigorous methods and focused on sexual and gender minorities has contributed to the lack of an extensive published literature on LGBT health. A Medline database review of literature published during 1980–1999 found that only 0.1 percent of articles over this 20-year period had focused on LGBT people or same-sex behavior or attraction ( Boehmer, 2002 ). This percentage is based on the contents of the entire Medline database; the study identified 3,777 articles that met its inclusion criteria. Most of these articles were focused on HIV / AIDS , substance abuse, and mental health to the exclusion of other topics ( Gay and Lesbian Medical Association and LGBT Health Experts, 2010 ). Since 2008, the Center for Population Research in LGBT Health has maintained a publicly accessible bibliography of published literature on LGBT health, including journal articles, books, and reports published since 1990 and indexed in PubMed. As of this writing, the programmed search has yielded 12,928 journal articles. A chart of the number of publications meeting search criteria suggests an increase in annual scholarly output in LGBT health research, particularly in the last decade; when charted as a ratio of all PubMed 2 journal articles, however, growth in scholarly output in LGBT health appears to have been slower and more uneven ( Figure 3-1 ).

Publications in LGBT health indexed in PubMed. SOURCE: Center for Population Research in LGBT Health (http://www.icpsr.umich.edu/icpsrweb/FENWAY/findings/index.jsp).

• BEST-PRACTICE PRINCIPLES ASSOCIATED WITH SAMPLE SURVEY AND RESEARCH STUDIES

Scientific and methodological challenges exist in the design and implementation of most sample surveys and research studies. This is particularly true of studies of relatively small populations on topics construed by the respondent to be of a sensitive nature. Health research studies of LGBT populations are often viewed in this way. Methodological challenges, however, can be overcome when careful attention is paid to scientific rigor and respectful involvement of individuals who represent the target population. Scientific rigor includes incorporating and monitoring culturally competent study designs, such as the use of appropriate measures to identify participants and implementation processes adapted to unique characteristics of the study population. Respectful involvement of the study population, in this case LGBT people, refers to the involvement of individuals and community representatives in the research process, from decisions about the study purpose and methods, to ongoing consultation and data gathering, to dissemination of results ( Minkler and Wallerstein, 2002 ).

The use of professionally accepted best practices that ensure scientific rigor in the design, conduct, and analysis of sample surveys and research studies is critical to the general acceptance of the results. As noted earlier in this report, the lack of demographic, economic, and health-related information on LGBT populations and their racial/ethnic subgroups makes it difficult to discuss health policy options intelligently. Identifying and adopting best practices for a sample survey or research study helps ensure that discussions about health policy do not become confounded with discussions about the nature of the data and the sample survey/study used to collect the data. Several textbooks concerned with methods for conducting sample surveys provide good examples of the issues a researcher must address to conduct such a survey with scientific rigor ( Biemer and Lyberg, 2003 ; Czaja and Blair, 1996 ; Groves et al., 2004 ). These sources describe the key elements of sample surveys and design and implementation issues, sources of error, and ways of minimizing and controlling error. The American Association for Public Opinion Research ( AAPOR ), an association of survey methodologists, statisticians, and social science researchers, has identified best practices for its members to follow on its website ( AAPOR, 2010 ). These practices, identified by a committee of survey methodologists, represent a valuable and thoughtful way to approach collecting information by means of a rigorous sample survey.

The principles relied upon to design and conduct scientifically rigorous sample surveys are critical as well to successful research studies, particularly community-based participatory research studies, in which scientific rigor and strong research community collaboration are critical. The contributions of such studies to research on LGBT and other minority and underserved populations have been acknowledged by numerous public agencies and private organizations ( Buchting et al., 2008 ; SMART, 2009 ), including institutes within NIH that have allocated funding for this type of study with certain populations, including those defined by sexual orientation. For example, reviewing approaches to HIV surveillance, McFarland and Caceres (2001) emphasize the importance of ongoing formative research and alliances with key organizations and actors in communities of men who have sex with men to develop study measures and guide appropriate use of data.

Listed below are some general principles related to best practices for sample surveys and research studies. The intent is not to identify individual design decisions, such as the data collection mode, the reference period, or an appropriate sample or study design, as “best” since individual study goals, circumstances, and available resources will vary.

• Identify specific goals for the study—for example, to develop estimates with which to describe a population or certain relationships, or to study the effects of experimental treatments. If a community-based study, develop partnerships and collaborate actively on the study goals with representatives of the study population within the community.
• Identify and describe the study's target population.
• Identify or develop a sampling frame from which to select members of the target population for the study.
• Determine and implement an appropriate method for drawing a probability-based sample to represent the target population or a recruitment strategy for the study population in a nonprobability design.
• If the study will analyze the effects of a program or intervention, identify and implement an appropriate experimental design.
• Determine a data collection mode consistent with the nature of the study.
• Identify and develop the concepts to be measured, and, as appropriate, use cognitive interviews, focus groups, or expert panels to review draft questionnaires; for community-based research, developing a thorough knowledge of the local community, its culture, and its health-related needs is particularly important.
• If appropriate for the study, identify sponsors, respected community leaders, or interested parties who support the study, and develop materials for the respondents that enable them to understand the reasons for the study, its potential benefits, and the need for their participation.
• Pretest questionnaires on a sample of the study population.
• If interviewers are being used to conduct the study, ensure that they receive sufficient training.
• Develop procedures to maximize the data collection response rate, subject to availability of funds.
• Develop and implement data processing and editing specifications to ensure that data are consistent and outlier data are minimized.
• Develop and implement appropriate statistical methods to weight the data (if a probability sample) and to calculate variances for sample estimates.
• Use statistical methods appropriate to the analysis.
• Provide sufficient documentation on the survey, data collection, and statistical methods used (including response rates) to permit an independent reviewer to assess the quality of the data collection and analysis.
• Ensure the privacy and confidentiality of survey responses.
• Disseminate the results of the survey or research study widely, and in the case of community-based research, do so through meetings and presentations to the community and through partnership communication channels.
• SUMMARY OF KEY FINDINGS AND RESEARCH OPPORTUNITIES

This chapter has addressed the challenges as well as the methodological issues associated with conducting research on LGBT populations and subpopulations. This discussion should provide a foundation for the review of the state of knowledge regarding LGBT health across the life course in the following chapters. Key findings presented in this chapter are listed below.

Research Challenges

A number of challenges are associated with conducting research on the health status of LGBT populations:

• The lack of standardized measures in federally funded surveys— Sexual orientation and gender nonconformity are multifaceted concepts, and a variety of methods have been used to identify them for research purposes.
• Small populations—Since LGBT populations represent a relatively small proportion of the U.S. population, creating a sufficiently large sample to provide reliable estimates of these populations requires considerable resources. A further challenge arises in obtaining a probability sample of LGBT participants that includes sufficient numbers of representatives of population subgroups, such as racial-and ethnic-minority individuals, to permit meaningful analyses.
• Barriers to identification as LGBT —Because of concerns about stigma and privacy, individuals may be reluctant to answer research questions about their same-sex sexual behavior or gender nonconformity.
• Probability sampling allows findings based on the data to be generalized to the study's target population with a known margin of error. Some methods make it possible to improve the precision of estimates for small populations by combining two or more data sets. Although probability sampling is not used frequently in the study of LGBT health, some studies have obtained probability samples of LGBT participants, while others (such as federal health surveys and the U.S. census) have examined subsets of sexual and gender minorities using probability samples not designed specifically to study those individuals.
• The majority of studies addressing topics relevant to LGBT health have been conducted using nonprobability samples. Even though the extent to which their findings accurately characterize the entirety of LGBT populations is unknown, studies based on nonprobability samples have yielded valuable information. In addition to providing general descriptive data for LGBT populations and subgroups, they have served to demonstrate the existence of certain phenomena, to test experimentally the effectiveness of various behavioral and medical interventions, to assess relationships among variables, to identify differences among groups, and in general, to provide insights into the health-related challenges faced by LGBT people. In addition, in the absence of data from probability samples, researchers often develop approximations of population patterns when the findings from multiple methodologically rigorous studies with different nonprobability samples converge.
• Quantitative data can be collected through a variety of methods, including survey research, RCTs, longitudinal cohort studies, and patient-level data. Of these methods, survey research is particularly common in LGBT health studies, especially as a way to generate demographic data. There are four main sources of error associated with survey research: coverage, nonresponse, measurement, and processing errors ( Table 3-1 ).
• RCTs measure an intervention's effects by randomly assigning individuals (or groups of individuals) to an intervention or control group. While these trials are considered the gold standard for measuring an intervention's impact, the results may not be generalizable to groups other than those who participated in the trials.
• Longitudinal cohort studies track individuals over time, allowing researchers to observe changes more accurately than is otherwise possible. The NHS and NHSII are examples of longitudinal cohort studies that have made significant contributions to understanding health.
• Research on LGBT populations using patient-level data is evolving, with discussion ongoing about how to collect sexual orientation and gender identity data in databases.
• Qualitative data can be collected through a variety of methods, including one-on-one interviews, focus groups, and cognitive interviews. These methods can be especially useful for generating hypotheses and laying the groundwork for future research.

Research Opportunities

A number of issues related to studying the health status of LGBT populations would benefit from additional research:

• Federally funded surveys do not measure sexual orientation or gender expression in a uniform and consistent way, limiting the ability to compare data across these surveys.
• The majority of LGBT literature relies exclusively on LGBT respondents, making it difficult to compare characteristics of LGBT populations with those of the entire U.S. population.
• Research into better methods for recruiting and retaining participants in longitudinal studies is needed.
• While valuable research has been conducted despite the limitations of available data sources, more national data must be collected if we are to fully understand the health needs of U.S. LGBT populations.
• Even if LGBT populations can be identified through national surveys, since these populations represent a relatively small proportion of the U.S. population, estimates will be relatively imprecise unless resources are available with which to collect large oversamples of LGBT individuals. Research is necessary on ways to improve the quality and understand the limitations of estimates obtained by combining independent data sets, or by combining direct sample-based estimates with model-based estimates derived from supplemental but related data.
• Guidelines need to be developed for maximizing the utility of available data through such mechanisms as aggregating data sets over time, adding supplemental samples or oversampling LGBT individuals for ongoing studies, and developing standards for recoding measures across multiple studies to achieve nationally representative data sets.
• AAPOR (American Association for Public Opinion Research). Best practices. 2010. [October 22, 2010]. https://www ​.aapor.org/Best_Practices.htm .
• Aaron DJ, Chang YF, Markovic N, LaPorte RE. Estimating the lesbian population: A capture-recapture approach. Journal of Epidemiology & Community Health. 2003; 57 (3):207–209. [ PMC free article : PMC1732397 ] [ PubMed : 12594197 ]
• Almeida J, Johnson RM, Corliss HL, Molnar BE, Azrael D. Emotional distress among LGBT youth: The influence of perceived discrimination based on sexual orientation. Journal of Youth & Adolescence. 2009; 38 (7):1001–1014. [ PMC free article : PMC3707280 ] [ PubMed : 19636742 ]
• Austin SB, Conron K, Patel A, Freedner N. Making sense of sexual orientation measures: Findings from a cognitive processing study with adolescents on health survey questions. Journal of LGBT Health Research. 2007; 3 (1):55–65. [ PubMed : 18029316 ]
• Balsam KF, Beauchaine TP, Rothblum ED, Solomon SE. Three-year follow-up of same-sex couples who had civil unions in Vermont, same-sex couples not in civil unions, and heterosexual married couples. Developmental Psychology. 2008; 44 (1):102–116. [ PubMed : 18194009 ]
• Barrett K, Bradford J, Ellis J. Using mapping to facilitate development of a health care infrastructure. Redlands, CA: ESRI Newsletter; 2002.
• Bates C, Droste C, Cuba L, Swingle J. One-on-one interviews: A qualitative assessment approach. Crawfordsville, IN: Center in Inquiry in the Liberal Arts at Wabash College; 2008.
• Bates N, Demaio TJ, Robins C, Hicks W. Classifying relationship and marital status among same-sex couples; Paper read at Proceedings of the Section on Survey Research Methods; July 31–August 10, 2010; Vancouver, British Columbia, Canada. 2010.
• Bell AP, Weinberg TS. Homosexualities: A study of diversity among men and women. New York: Simon and Schuster; 1978.
• Biemer PP. Overview of design issues: Total survey error, Handbook on survey research. 2. Mardsen PV, Wright JD, editors. Bingley, UK: Emerald Group Publishing Limited; 2010. pp. 27–57.
• Biemer PP, Lyberg L. Introduction to survey quality. Hoboken, NJ: Wiley & Sons, Inc.; 2003.
• Binson D, Blair J, Huebner DM, Woods WJ. Sampling in surveys of lesbian, gay, and bisexual people, The health of sexual minorities. Meyer IH, Northridge ME, editors. New York: Springer; 2007. pp. 375–418.
• Black DA, Gates G, Sanders SG, Taylor LJ. Demographics of the gay and lesbian population in the United States: Evidence from available systematic data sources. Demography. 2000; 37 (2):139–154. [ PubMed : 10836173 ]
• Black DA, Sanders SG, Taylor LJ. The economics of lesbian and gay families. The Journal of Economic Perspectives. 2007; 21 :53–70.
• Blair J. A probability sample of gay urban males: The use of two-phase adaptive sampling. Journal of Sex Research. 1999; 36 (1):39–44.
• Boehmer U. Twenty years of public health research: Inclusion of lesbian, gay, bisexual, and transgender populations. American Journal of Public Health. 2002; 92 (7):1125–1130. [ PMC free article : PMC1447202 ] [ PubMed : 12084696 ]
• Boehmer U, Clark M, Glickman M, Timm A, Sullivan M, Bradford J, Bowen DJ. Using cancer registry data for recruitment of sexual minority women: Successes and limitations. Journal of Women's Health. 2010; 19 (7):1289–1297. [ PubMed : 20575681 ]
• Bolding G, Davis M, Hart G, Sherr L, Elford J. Where young MSM meet their first sexual partner: The role of the Internet. AIDS & Behavior. 2007; 11 (4):522–526. [ PubMed : 17347876 ]
• Bowen AM, Williams ML, Daniel CM, Clayton S. Internet based HIV prevention research targeting rural MSM: Feasibility, acceptability, and preliminary efficacy. Journal of Behavioral Medicine. 2008; 31 (6):463–477. [ PMC free article : PMC2614302 ] [ PubMed : 18770021 ]
• Bowen DJ, Bradford JB, Powers D, McMorrow P, Linde R, Murphy BC, Han J, Ellis J. Comparing women of differing sexual orientations using population-based sampling. Women & Health. 2004; 40 (3):19–34. [ PubMed : 15829443 ]
• Bradford J, Ryan C, Rothblum ED. National Lesbian Health Care Survey: Implications for mental health care. Journal of Consulting & Clinical Psychology. 1993; 62 (2):228–242. [ PubMed : 8201059 ]
• Brennan DJ, Hellerstedt WL, Ross MW, Welles SL. History of childhood sexual abuse and HIV risk behaviors in homosexual and bisexual men. American Journal of Public Health. 2007; 97 (6):1107–1112. [ PMC free article : PMC1874190 ] [ PubMed : 17463386 ]
• Brick JM, Kalton G. Handling missing data in survey research. Statistical Methods in Medical Research. 1996; 5 (3):215–238. [ PubMed : 8931194 ]
• Buchting FO, Scout, Fagan P, Pien M, Rose A. Lesbians, gays, bisexuals, and transgenders of color sampling methodology. Scotts Valley, CA: ETR Associates; 2008.
• Carpenter C. Sexual orientation and body weight: Evidence from multiple surveys. Gender Issues. 2003; 21 (3):60–74.
• Carpenter C, Gates GJ. Gay and lesbian partnership: Evidence from California. Demography. 2008; 45 (3):573–590. [ PMC free article : PMC2831392 ] [ PubMed : 18939662 ]
• Carpenter K, Stoner S, Mikko A, Dhanak L, Parsons J. Efficacy of a web-based intervention to reduce sexual risk in men who have sex with men. AIDS and Behavior. 2010; 14 (3):549–557. [ PMC free article : PMC3128504 ] [ PubMed : 19499321 ]
• Case P, Austin SB, Hunter DJ, Manson JE, Malspeis S, Willett WC, Spiegelman D. Sexual orientation, health risk factors, and physical functioning in the Nurses' Health Study II. Journal of Women's Health. 2004; 13 (9):1033–1047. [ PubMed : 15665660 ]
• Catania JA, Binson D, Canchola J, Pollack LM, Hauck W, Coates TJ. Effects of interviewer gender, interviewer choice, and item wording on responses to questions concerning sexual behavior. Public Opinion Quarterly. 1996; 60 (3):345–375.
• Catania JA, Osmond D, Stall RD, Pollack L, Paul JP, Blower S, Binson D, Canchola JA, Mills TC, Fisher L, Choi KH, Porco T, Turner C, Blair J, Henne J, Bye LL, Coates TJ. The continuing HIV epidemic among men who have sex with men. American Journal of Public Health. 2001; 91 (6):907–914. [ PMC free article : PMC1446467 ] [ PubMed : 11392933 ]
• CDC (Centers for Disease Control and Prevention). 2009 compendium of evidence-based HIV prevention interventions. 2009. [October 27, 2010]. http://www ​.cdc.gov/hiv ​/topics/research/prs ​/evidence-based-interventions.htm .
• Channing Laboratory. Growing Up Today Study (GUTS). 2011. [March 7, 2011]. http://nhs2survey ​.org/gutsweb/?page_id=2 .
• Channing Laboratory. The Nurses' Health Study. 2011. [March 3, 2011]. http://www ​.channing.harvard.edu/nhs/
• Clark MA, Armstrong G, Bonacore L. Measuring sexual orientation and gender expression among middle-aged and older women in a cancer screening study. Journal of Cancer Education. 2005; 20 (2):108–112. [ PubMed : 16083375 ]
• Cochran SD, Mays VM. Lifetime prevalence of suicide symptoms and affective disorders among men reporting same-sex sexual partners: Results from NHANES III. American Journal of Public Health. 2000; 90 (4):573–578. [ PMC free article : PMC1446201 ] [ PubMed : 10754972 ]
• Cochran SD, Mays VM. Physical health complaints among lesbians, gay men, and bisexual and homosexually experienced heterosexual individuals: Results from the California Quality of Life Survey. American Journal of Public Health. 2007; 97 (11):2048–2055. [ PMC free article : PMC2040376 ] [ PubMed : 17463371 ]
• Cochran SD, Mays VM. Burden of psychiatric morbidity among lesbian, gay, and bisexual individuals in the California Quality of Life Survey. Journal of Abnormal Psychology. 2009; 118 (3):647–658. [ PMC free article : PMC2847425 ] [ PubMed : 19685960 ]
• Cochran SD, Keenan C, Schober C, Mays VM. Estimates of alcohol use and clinical treatment needs among homosexually active men and women in the U.S. population. Journal of Consulting and Clinical Psychology. 2000; 68 (6):1062–1071. [ PMC free article : PMC4197972 ] [ PubMed : 11142540 ]
• Cochran SD, Sullivan JG, Mays VM. Prevalence of mental disorders, psychological distress, and mental health services use among lesbian, gay, and bisexual adults in the United States. Journal of Consulting and Clinical Psychology. 2003; 71 (1):53–61. [ PMC free article : PMC4197971 ] [ PubMed : 12602425 ]
• Cochran SD, Ackerman D, Mays VM, Ross MW. Prevalence of non-medical drug use and dependence among homosexually active men and women in the US population. Addiction. 2004; 99 (8):989–998. [ PMC free article : PMC4190042 ] [ PubMed : 15265096 ]
• Cochran SD, Mays VM, Alegria M, Ortega AN, Takeuchi D. Mental health and substance use disorders among Latino and Asian American lesbian, gay, and bisexual adults. Journal of Consulting and Clinical Psychology. 2007; 75 (5):785–794. [ PMC free article : PMC2676845 ] [ PubMed : 17907860 ]
• Conron KJ, Scout, Austin SB. “Everyone has a right to, like, check their box:” Findings on a measure of gender identity from a cognitive testing study with adolescents. Journal of LGBT Health Research. 2008; 4 (1):1–9. [ PubMed : 19860014 ]
• Conron KJ, Mimiaga MJ, Landers SJ. A population-based study of sexual orientation identity and gender differences in adult health. American Journal of Public Health. 2010; 100 (10):1953–1960. [ PMC free article : PMC2936979 ] [ PubMed : 20516373 ]
• Consolacion TB, Russell ST, Sue S. Sex, race/ethnicity, and romantic attractions: Multiple minority status adolescents and mental health. Cultural Diversity & Ethnic Minority Psychology. 2004; 10 (3):200–214. [ PMC free article : PMC3559128 ] [ PubMed : 15311974 ]
• Corliss HL, Rosario M, Wypij D, Fisher LB, Austin SB. Sexual orientation disparities in longitudinal alcohol use patterns among adolescents: Findings from the Growing Up Today Study. Archives of Pediatrics & Adolescent Medicine. 2008; 162 (11):1071–1078. [ PMC free article : PMC3725748 ] [ PubMed : 18981356 ]
• Couper MP. Web surveys: A review of issues and approaches. Public Opinion Quarterly. 2000; 64 (4):464–494. [ PubMed : 11171027 ]
• Czaja R, Blair J, editors. Designing surveys: A guide to decisions and procedures. Thousand Oaks, CA: Pine Forge Press; 1996.
• Deputy NP, Boehmer U. Determinants of body weight among men of different sexual orientation. Preventive Medicine. 2010; 51 (2):129–131. [ PubMed : 20510272 ]
• Diamond LM. Development of sexual orientation among adolescent and young adult women. Developmental Psychology. 1998; 34 (5):1085. [ PubMed : 9779753 ]
• Diamond LM. Female bisexuality from adolescence to adulthood: Results from a 10-year longitudinal study. Developmental Psychology. 2008; 44 (1):5–14. [ PubMed : 18194000 ]
• Dillman DA, Smyth JD, Christian LM. Internet, mail, and mixed-mode surveys: The tailored design method. 3. Hoboken, NJ: John Wiley & Sons, Inc.; 2009.
• Dworkin SL, Pinto RM, Hunter J, Rapkin B, Remien RH. Keeping the spirit of community partnerships alive in the scale up of HIV/AIDS prevention: Critical reflections on the roll out of DEBI (Diffusion of Effective Behavioral Interventions). American Journal of Community Psychology. 2008; 42 (1–2):51–59. [ PMC free article : PMC2735211 ] [ PubMed : 18612809 ]
• Egleston BL, Dunbrack RL Jr, Hall MJ. Clinical trials that explicitly exclude gay and lesbian patients. New England Journal of Medicine. 2010; 362 (11):1054–1055. [ PMC free article : PMC2875120 ] [ PubMed : 20237357 ]
• Elliott MN, McCaffrey DF, Finch BK, Klein DJ, Orr N, Beckett MK, Lurie N. Improving disparity estimates for rare racial/ethnic groups with trend estimation and Kalman filtering: An application to the National Health Interview Survey. Health Services Research. 2009; 44 (5 Pt. 1):1622–1639. [ PMC free article : PMC2754551 ] [ PubMed : 19656232 ]
• Evans AR, Wiggins RD, Bolding G, Elford J. Characteristics of gay and bisexual men who drop out of a web survey of sexual behaviour in the UK. AIDS & Behavior. 2008; 12 (6):957–963. [ PubMed : 18481166 ]
• Finkelhor D. Current information on the scope and nature of child sexual abuse. Future Child. 1994; 4 (2):31–53. [ PubMed : 7804768 ]
• Fisher RA. Statistical methods for research workers. London: Oliver and Boyd; 1925.
• Galesic M, Tourangeau R, Casper M. Complementing random digit dial telephone surveys with other approaches to collecting data. American Journal of Preventive Medicine. 2006; 31 (5):437–443. [ PubMed : 17046416 ]
• Gallagher KM, Sullivan PS, Lansky A, Onorato IM. Behavioral surveillance among people at risk for HIV infection in the U.S.: The National HIV Behavioral Surveillance System. Public Health Reports. 2007; 122 (Suppl. 1):32–38. [ PMC free article : PMC1804113 ] [ PubMed : 17354525 ]
• Garofalo R, Deleon J, Osmer E, Doll M, Harper GW. Overlooked, misunderstood and at-risk: Exploring the lives and HIV risk of ethnic minority male-to-female transgender youth. Journal of Adolescent Health. 2006; 38 (3):230–236. [ PubMed : 16488820 ]
• Gates G. Geographic trends among same-sex couples in the U.S. Census and the American Community Survey. Los Angeles, CA: The Williams Institute; 2007.
• Gates G. Same-sex spouses and unmarried partners in the American Community Survey, 2008. Los Angeles, CA: The Williams Institute; 2009.
• Gay and Lesbian Medical Association and LGBT Health Experts. Healthy People 2010 companion document for lesbian, gay, bisexual, and transgender (LGBT) health. San Francisco, CA: Gay and Lesbian Medical Association; 2010.
• Geanuracos CG, Cunningham SD, Weiss G, Forte D, Reid LM, Ellen JM. Use of geographic information systems for planning HIV prevention interventions for high-risk youths. American Journal of Public Health. 2007; 97 (11):1974–1981. [ PMC free article : PMC2040351 ] [ PubMed : 17901452 ]
• Grant JM, Mottet LA, Tanis J, Min D, Herman JL, Harrison J, Keisling M. National Transgender Discrimination Survey Report on Health and Health Care. Washington, DC: National Center for Transgender Equality and the National Gay and Lesbian Task Force; 2010.
• Gribble JN, Miller HG, Rogers SM, Turner CF. Interview mode and measurement of sexual behaviors: Methodological issues. Journal of Sex Research. 1999; 36 (1):16–24. [ PMC free article : PMC3516293 ] [ PubMed : 23226876 ]
• Groves RM, Fowler FJ, Couper MP, Lepkowski JM, Singer E, Tourangeau R. Survey methodology. New York: John Wiley & Sons, Inc.; 2004.
• Hall D, Meador K, Koenig H. Measuring religiousness in health research: Review and critique. Journal of Religion and Health. 2008; 47 (2):134–163. [ PMC free article : PMC8823950 ] [ PubMed : 19105008 ]
• Hatzenbuehler ML, Keyes KM, Hasin DS. State-level policies and psychiatric morbidity in lesbian, gay, and bisexual populations. American Journal of Public Health. 2009; 99 (12):2275–2281. [ PMC free article : PMC2775762 ] [ PubMed : 19833997 ]
• Hatzenbuehler ML, McLaughlin KA, Keyes KM, Hasin DS. The impact of institutional discrimination on psychiatric disorders in lesbian, gay, and bisexual populations: A prospective study. American Journal of Public Health. 2010; 100 (3):452–459. [ PMC free article : PMC2820062 ] [ PubMed : 20075314 ]
• Herbenick D, Reece M, Schick V, Sanders SA, Dodge B, Fortenberry JD. Sexual behavior in the United States: Results from a national probability sample of men and women ages 14–94. The Journal of Sexual Medicine. 2010; 7 :255–265. [ PubMed : 21029383 ]
• Herek GM. Hate crimes and stigma-related experiences among sexual minority adults in the United States: Prevalence estimates from a national probability sample. Journal of Interpersonal Violence. 2009; 24 (1):54–74. [ PubMed : 18391058 ]
• Herek GM. Sexual orientation differences as deficits: Science and stigma in the history of American psychology. Perspectives on Psychological Science. 2010; 5 [ PubMed : 26161884 ]
• Herek GM, Gillis JR, Cogan JC. Psychological sequelae of hate-crime victimization among lesbian, gay, and bisexual adults. Journal of Consulting and Clinical Psychology. 1999; 67 (6):945–951. [ PubMed : 10596515 ]
• Herek GM, Norton A, Allen T, Sims C. Demographic, psychological, and social characteristics of self-identified lesbian, gay, and bisexual adults in a US probability sample. Sexuality Research and Social Policy. 2010; 7 (3):176–200. [ PMC free article : PMC2927737 ] [ PubMed : 20835383 ]
• HHS (U.S. Department of Health and Human Services). Healthy People 2010: Understanding and improving health. Washington, DC: HHS; 2000.
• HIV Prevention Trials Network. Explore: A randomized clinical trial of the efficacy of a behavioral intervention to prevent acquisition of HIV among men who have sex with men (MSM). 2011. [March 7, 2011]. http://www ​.hptn.org/research_studies ​/hivnet015.asp .
• Holbrook AL, Krosnick JA, Pfent A. The causes and consequences of response rates in surveys by the news media and government contractor survey research firms, Advances in telephone survey methodology. Lepkowski CTJ, Brick JM, de Leeuw E, Japec L, Lavrakas PJ, Link MW, Sangster RL, editors. New York: John Wiley & Sons, Inc.; 2008. pp. 499–528.
• Jarama SL, Belgrave FZ, Bradford J, Young M, Honnold JA. Family, cultural and gender role aspects in the context of HIV risk among African American women of unidentified HIV status: An exploratory qualitative study. AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV. 2007; 19 (3):307–317. [ PubMed : 17453563 ]
• The Joint Commission. Advancing effective communication, cultural competence, and patient- and family-centered care: A roadmap for hospitals. Oakbrook Terrace, IL: The Joint Commission; 2010.
• The Joint Commission. Joint Commission Perspectives. 3. Vol. 31. Oakbrook Terrace, IL: The Joint Commission; 2011.
• Kalman RE. A new approach to linear filtering and prediction problems. Transactions of the ASME—Journal of Basic Engineering. 1960; 82 (Series D):35–45.
• Kalton G. Methods for oversampling rare subpopulations in social surveys. Survey Methodology. 2009; 35 (2):125–141.
• Kalton G, Kasprzyk D. The treatment of missing survey data. Survey Methodology. 1986; 12 (1):1–16.
• Kasprzyk D, Duncan G, Kalton G, Singh MP, editors. Panel surveys. New York: John Wiley & Sons, Inc.; 1989.
• Keeter S, Miller C, Kohut A, Groves RM, Presser S. Consequences of reducing nonresponse in a national telephone survey. Public Opinion Quarterly. 2000; 64 (2):125–148. [ PubMed : 10984330 ]
• Kellstedt LA, Smidt CE. Measuring fundamentalism: An analysis of different operational strategies, Religion and the culture wars: Dispatches from the front. Green JC, Guth JL, Smidt CE, Kellstedt LA, editors. Lanham, MD: Rowman & Littlefield; 1996. pp. 193–218.
• Kennamer JD, Honnold J, Bradford J, Hendricks M. Differences in disclosure of sexuality among African American and white gay/bisexual men: Implications for HIV/ AIDS prevention. AIDS Education & Prevention. 2000; 12 (6):519–531. [ PubMed : 11220504 ]
• Knight K. Liberalism and conservatism, Measures of political attitudes. Robinson JP, Shaver PR, Wrightsman LS, editors. Vol. 2. San Diego, CA: Academic Press; 1999. pp. 59–158.
• Kurdek LA. Are gay and lesbian cohabiting couples really different from heterosexual married couples? Journal of Marriage and the Family. 2004; 66 (4):880–900.
• Laumann EO, Michael RT, Gagnon JH. A political history of the national sex survey of adults. Family Planning Perspectives. 1994; 26 (1):34–38. [ PubMed : 8174695 ]
• Lee RM. Doing research on sensitive topics. Thousand Oaks, CA: SAGE Publications; 1993.
• Lynn P. Methodology of longitudinal surveys. New York: John Wiley & Sons, Inc.; 2009.
• Martin JL, Dean L. Developing a community sample of gay men for an epidemiologic study of AIDS. American Behavioral Scientist. 1990; 33 (5):546–561.
• Massachusetts Department of Public Health. Behavioral Risk Factor Survey 2007 Questionnaire. Boston, MA: Massachusetts Department of Public Health; 2007.
• Mays VM, Cochran SD. Mental health correlates of perceived discrimination among lesbian, gay, and bisexual adults in the United States. American Journal of Public Health. 2001; 91 (11):1869–1876. [ PMC free article : PMC1446893 ] [ PubMed : 11684618 ]
• McFarland W, Caceres CF. HIV surveillance among men who have sex with men. AIDS. 2001; 15 (Suppl. 3):S23–S32. [ PubMed : 11421179 ]
• McKleroy VS, Galbraith JS, Cummings B, Jones P, Harshbarger C, Collins C, Gelaude D, Carey JW. Adapting evidence-based behavioral interventions for new settings and target populations. AIDS Education & Prevention. 2006; 18 :59–73. [ PubMed : 16987089 ]
• McLaughlin KA, Hatzenbuehler ML, Keyes KM. Responses to discrimination and psychiatric disorders among black, Hispanic, female, and lesbian, gay, and bisexual individuals. American Journal of Public Health. 2010; 100 (8):1477–1484. [ PMC free article : PMC2901295 ] [ PubMed : 20558791 ]
• Meyer IH, Wilson PA. Sampling lesbian, gay, and bisexual populations. Journal of Counseling Psychology. 2009; 56 (1):23–31.
• Meyer IH, Rossano L, Ellis JM, Bradford J. A brief telephone interview to identify lesbian and bisexual women in random digit dialing sampling. Journal of Sex Research. 2002; 39 (2):139–144. [ PubMed : 12476246 ]
• Meyer IH, Schwartz S, Frost DM. Social patterning of stress and coping: Does disadvantaged social statuses confer more stress and fewer coping resources? Social Science & Medicine. 2008; 67 (3):368–379. [ PMC free article : PMC2583128 ] [ PubMed : 18433961 ]
• Mimiaga MJ, Noonan E, Donnell D, Safren SA, Koenen KC, Gortmaker S, O'Cleirigh C, Chesney MA, Coates TJ, Koblin BA, Mayer KH. Childhood sexual abuse is highly associated with HIV risk-taking behavior and infection among MSM in the EXPLORE study. Journal of Acquired Immune Deficiency Syndromes: JAIDS. 2009; 51 (3):340–348. [ PMC free article : PMC3292283 ] [ PubMed : 19367173 ]
• Minkler M, Wallerstein N, editors. Community-based participatory research for health. New York: Jossey-Bass; 2002.
• Morris JF, Rothblum ED. Who fills out a “lesbian” questionnaire? The interrelationship of sexual orientation, years “out,” disclosure of sexual orientation, sexual experience with women, and participation in the lesbian community. Psychology of Women Quarterly. 1999; 23 (3):537–557.
• Mosher WD, Chandra A, Jones J. Sexual behavior and selected health measures: Men and women 15-44 years of age United States, 2002. Advanced Data. 2005;(362):1–55. [ PubMed : 16250464 ]
• Muhib FB, Lin LS, Stueve A, Miller RL, Ford WL, Johnson WD, Smith PJ. A venue-based method for sampling hard-to-reach populations. Public Health Reports. 2001; 116 (Suppl. 1):216–222. [ PMC free article : PMC1913675 ] [ PubMed : 11889287 ]
• Mustanski BS. Getting wired: Exploiting the Internet for the collection of valid sexuality data. Journal of Sex Research. 2001; 38 (4):292–301.
• Nemoto T, Operario D, Keatley J. Health and social services for male-to-female transgender persons of color in San Francisco, Transgender health and HIV prevention: Needs assessment studies from transgender communities across the United States. Bockting W, Avery E, editors. New York: The Haworth Medical Press; 2005. pp. 5–19.
• NIH (National Institutes of Health). Certificates of confidentiality: Background information. 2011. [February 9, 2011]. http://grants ​.nih.gov ​/grants/policy/coc/background.htm .
• NRC (National Research Council). Cognitive aspects of survey methodology: Building a bridge between disciplines. Washington, DC: National Academy Press; 1984.
• NRC. Understanding racial and ethnic differences in health in late life: A research agenda. Washington, DC: The National Academies Press; 2004. [ PubMed : 20669466 ]
• OMB (Office of Management and Budget). Statistical policy working paper 31: Measuring and reporting sources of error in surveys. Washington, DC: Federal Committee on Statistical Methodology; 2001.
• Raghuhathan TE, Xie D, Schenker N, Parsons VL, Davis WW, Dodd KW, Feuer EJ. Combining information from two surveys to estimate county-level prevalence rates of cancer risk factors and screening. Journal of the American Statistical Association. 2007; 102 (478):474–486.
• Rao JNK. Small area estimation. New York: John Wiley & Sons, Inc.; 2003.
• Reips U. The web experiment method: Advantages, disadvantages, and solutions, Psychological experiments on the Internet. Birnbaum MH, editor. San Diego, CA: Academic Press; 2000. pp. 89–117.
• Reisner SL, Mimiaga MJ, Johnson CV, Bland S, Case P, Safren SA, Mayer KH. What makes a respondent-driven sampling “seed” productive? Example of finding at-risk Massachusetts men who have sex with men. Journal of Urban Health. 2010; 87 (3):467–479. [ PMC free article : PMC2871093 ] [ PubMed : 20354911 ]
• Riggle ED, Rostosky SS, Reedy C. Online surveys for BGLT research: Issues and techniques. Journal of Homosexuality. 2005; 49 (2):1–21. [ PubMed : 16048891 ]
• Rosenfeld MJ. Nontraditional families and childhood progress through school. Demography. 2010; 47 (3):755–775. [ PMC free article : PMC3000058 ] [ PubMed : 20879687 ]
• Ross MW, Rosser BRS, Stanton J. Beliefs about cybersex and Internet-mediated sex of Latino men who have Internet sex with men: Relationships with sexual practices in cybersex and in real life. AIDS Care. 2004; 16 (8):1002–1011. [ PubMed : 15511732 ]
• Rosser BRS, Miner MH, Bockting WO, Ross MW, Konstan J, Gurak L, Stanton J, Edwards W, Jacoby S, Carballo-Dieguez A, Mazin R, Coleman E. HIV risk and the Internet: Results of the Men's Internet Sex (MINTS) Study. AIDS & Behavior. 2009; 13 (4):746–756. [ PMC free article : PMC2718057 ] [ PubMed : 18512143 ]
• Rothblum ED, Factor R. Lesbians and their sisters as a control group: Demographic and mental health factors. Psychological Science. 2001; 12 (1):63–69. [ PubMed : 11294230 ]
• Rothblum ED, Balsam KF, Mickey RM. Brothers and sisters of lesbians, gay men, and bisexuals as a demographic comparison group: An innovative research methodology to examine social change. Journal of Applied Behavioral Science. 2004; 40 (3):283–301.
• Schenker N, Raghunathan TE. Combining information from multiple surveys to enhance estimation of measures of health. Statistics in Medicine. 2007; 26 (8):1802–1811. [ PubMed : 17278184 ]
• Schenker N, Gentleman JF, Rose D, Hing E, Shimizu IM. Combining estimates from complementary surveys: A case study using prevalence estimates from national health surveys of households and nursing homes. Public Health Reports. 2002; 117 (4):393–407. [ PMC free article : PMC1497448 ] [ PubMed : 12477922 ]
• Sirken MG. Network sample surveys of rare and elusive populations. A historical review paper read at Symposium 2004: Innovative Methods for Surveying Difficult-to-Reach Populations. 2004.
• SMART (Self-Monitoring, Analysis, and Reporting Technology). Best practices for asking questions about sexual orientation on surveys. Los Angeles, CA: The Williams Institute; 2009.
• Smith TW. Some aspects of measuring education. Social Science Research. 1995; 24 (3):215–242.
• Solarz A. Lesbian health care issues. Exploring options for expanding research and delivering care. AWHONN Lifelines. 1999; 3 (5):13–14. [ PubMed : 10827577 ]
• Stephan CW, Stephan WG. The measurement of racial and ethnic identity. International Journal of Intercultural Relations. 2000; 24 (5):541–552.
• Tang H, Greenwood GL, Cowling DW, Lloyd JC, Roeseler AG, Bal DG. Cigarette smoking among lesbians, gays, and bisexuals: How serious a problem? (United States). Cancer Causes & Control. 2004; 15 (8):797–803. [ PubMed : 15456993 ]
• Tourangeau R, Yan T. Sensitive questions in surveys. Psychological Bulletin. 2007; 133 (5):859–883. [ PubMed : 17723033 ]
• Tourangeau R, Rips LJ, Rasinski KA. The psychology of survey response. Cambridge, England: Cambridge University Press; 2000.
• Villarroel MA, Turner CF, Eggleston E, Al-Tayyib A, Rogers SM, Roman AM, Cooley PC, Gordek H. Same-gender sex in the United States: Impact of T-ACASI on prevalence estimates. Public Opinion Quarterly. 2006; 70 (2):166–196. [ PMC free article : PMC3191197 ] [ PubMed : 21998488 ]
• Volz E, Heckathorn D. Probability based estimation theory for respondent driven sampling. Journal of Official Statistics. 2008; 24 (1):79–97.
• Westoff CF. The commission on population growth and the American future: Its origins, operations, and aftermath. Population Index. 1973; 39 (4):491–507. [ PubMed : 12257905 ]
• Wienke C, Hill GJ. Does the “marriage benefit” extend to partners in gay and lesbian relationships? Evidence from a random sample of sexually active adults. Journal of Family Issues. 2009; 30 (2):259–289.
• Willis GB. Cognitive interviewing revisited: A useful technique, in theory? Methods for testing and evaluating survey questionnaires. Hoboken, NJ: John Wiley & Sons, Inc.; 2004.
• Xavier JM, Bradford J. Transgender health access in Virginia: Focus group report. Richmond, VA: Virginia Department of Health; 2005.
• Xavier JM, Bobbin M, Singer B, Budd E. A needs assessment of transgendered people of color living in Washington, DC. International Journal of Transgenderism. 2005; 8 (2/3):31–47.
• Xavier JM, Bradford J, Honnold J. The health, health-related needs, and life-course experiences of transgender Virginians. Richmond, VA: Virginia Department of Health; 2007.

Response rates for survey research in the United States have generally declined in recent decades. At the same time, some research suggests that, compared with studies with higher response rates, the data from studies with lower response rates are not necessarily of lower quality. Thus, in noting the desirability of a high response rate, the committee recognizes that the association between response rate and data quality is complex (see, e.g., Holbrook et al., 2008 ; Keeter et al., 2000 ).

These patterns may not reflect all published scientific research on sexual- and gender-minority populations insofar as PubMed and Medline do not index all social and behavioral science journals.

• Cite this Page Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington (DC): National Academies Press (US); 2011. 3, Conducting Research on the Health Status of LGBT Populations.
• PDF version of this title (2.6M)
• Disable Glossary Links

In this Page

Other titles in this collection.

• The National Academies Collection: Reports funded by National Institutes of Health

Related information

• PMC PubMed Central citations
• PubMed Links to PubMed

Recent Activity

• Conducting Research on the Health Status of LGBT Populations - The Health of Les... Conducting Research on the Health Status of LGBT Populations - The Health of Lesbian, Gay, Bisexual, and Transgender People

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Connect with NLM

National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894

Web Policies FOIA HHS Vulnerability Disclosure

Help Accessibility Careers

• Download PDF
• Share X Facebook Email LinkedIn
• Permissions

Transitioning From SIRS to Phoenix With the Updated Pediatric Sepsis Criteria—The Difficult Task of Simplifying the Complex

• 1 Department of Women, Children, and Adolescents, Faculty of Medicine, National University of the Northeast, Corrientes, Argentina
• 2 Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
• 3 Departments of Emergency Medicine and Pediatrics, UC Davis School of Medicine and UC Davis Health, Sacramento, California
• 4 Departamento de Pediatría y Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
• Editorial Context and Implications of the New Pediatric Sepsis Criteria Erin F. Carlton, MD, MSc; Mallory A. Perry-Eaddy, PhD, RN; Hallie C. Prescott, MD, MSc JAMA
• Original Investigation Development and Validation of the Phoenix Criteria for Pediatric Sepsis and Septic Shock L. Nelson Sanchez-Pinto, MD, MBI; Tellen D. Bennett, MD, MS; Peter E. DeWitt, PhD; Seth Russell, MS; Margaret N. Rebull, MA; Blake Martin, MD; Samuel Akech, MBChB, MMED; David J. Albers, PhD; Elizabeth R. Alpern, MD, MSCE; Fran Balamuth, MD, PhD, MSCE; Melania Bembea, MD, MPH, PhD; Mohammod Jobayer Chisti, MBBS, MMed, PhD; Idris Evans, MD, MSc; Christopher M. Horvat, MD, MHA; Juan Camilo Jaramillo-Bustamante, MD; Niranjan Kissoon, MD; Kusum Menon, MD, MSc; Halden F. Scott, MD, MSCS; Scott L. Weiss, MD; Matthew O. Wiens, PharmD, PhD; Jerry J. Zimmerman, MD, PhD; Andrew C. Argent, MD, MBBCh, MMed; Lauren R. Sorce, PhD, RN, CPNP-AC/PC; Luregn J. Schlapbach, MD, PhD; R. Scott Watson, MD, MPH; Society of Critical Care Medicine Pediatric Sepsis Definition Task Force; Paolo Biban, MD; Enitan Carrol, MD, MBChB; Kathleen Chiotos, MD; Claudio Flauzino De Oliveira, MD, PhD; Mark W. Hall, MD; David Inwald, MB, MB BChir, PhD; Paul Ishimine, MD; Michael Levin, MD, PhD; Rakesh Lodha, MD; Simon Nadel, MBBS; Satoshi Nakagawa, MD; Mark J. Peters, PhD; Adrienne G. Randolph, MD, MS; Suchitra Ranjit, MD; Daniela Carla Souza, MD; Pierre Tissieres, MD, DSc; James L. Wynn, MD JAMA
• Original Investigation International Consensus Criteria for Pediatric Sepsis and Septic Shock Luregn J. Schlapbach, MD, PhD; R. Scott Watson, MD, MPH; Lauren R. Sorce, PhD, RN; Andrew C. Argent, MD, MBBCh, MMed; Kusum Menon, MD, MSc; Mark W. Hall, MD; Samuel Akech, MBChB, MMED, PhD; David J. Albers, PhD; Elizabeth R. Alpern, MD, MSCE; Fran Balamuth, MD, PhD, MSCE; Melania Bembea, MD, PhD; Paolo Biban, MD; Enitan D. Carrol, MBChB, MD; Kathleen Chiotos, MD; Mohammod Jobayer Chisti, MBBS, MMed, PhD; Peter E. DeWitt, PhD; Idris Evans, MD, MSc; Cláudio  Flauzino de Oliveira, MD, PhD; Christopher M. Horvat, MD, MHA; David Inwald, MB, PhD; Paul Ishimine, MD; Juan Camilo Jaramillo-Bustamante, MD; Michael Levin, MD, PhD; Rakesh Lodha, MD; Blake Martin, MD; Simon Nadel, MBBS; Satoshi Nakagawa, MD; Mark J. Peters, PhD; Adrienne G. Randolph, MD, MS; Suchitra Ranjit, MD; Margaret N. Rebull, MA; Seth Russell, MS; Halden F. Scott, MD; Daniela Carla de Souza, MD, PhD; Pierre Tissieres, MD, DSc; Scott L. Weiss, MD, MSCE; Matthew O. Wiens, PharmD, PhD; James L. Wynn, MD; Niranjan Kissoon, MD; Jerry J. Zimmerman, MD, PhD; L. Nelson Sanchez-Pinto, MD; Tellen D. Bennett, MD, MS; Society of Critical Care Medicine Pediatric Sepsis Definition Task Force; Juliane Bubeck Wardenburg JAMA

Everyone must acknowledge the difficulty of distinguishing diseases…whoever denies this may as well deny that there is such a thing as medical art. William Cullen 1

The art of making a diagnosis is essential to high-quality medical practice and is arguably the most valuable skill of a clinician. Diagnosis serves as the articulation of the language of medical science, guiding medical practice at every clinical encounter and through health policy. 1 Developing medical knowledge entails a social construct rooted in the prevailing medical framework, ethical perspectives, and the socialization of these ideas among physicians. For medical knowledge to evolve, there must be an interaction between a condition’s definition and its scientific identification. This framework is shaped by how these elements interact and how the definition of a condition is configured. 2

• Editorial Context and Implications of the New Pediatric Sepsis Criteria JAMA

Read More About

Jabornisky R , Kuppermann N , González-Dambrauskas S. Transitioning From SIRS to Phoenix With the Updated Pediatric Sepsis Criteria—The Difficult Task of Simplifying the Complex. JAMA. 2024;331(8):650–651. doi:10.1001/jama.2023.27988

Manage citations:

© 2024

Artificial Intelligence Resource Center

Cardiology in JAMA : Read the Latest

Browse and subscribe to JAMA Network podcasts!

Others Also Liked

Select your interests.

Customize your JAMA Network experience by selecting one or more topics from the list below.

• Academic Medicine
• Acid Base, Electrolytes, Fluids
• Allergy and Clinical Immunology
• American Indian or Alaska Natives
• Anesthesiology
• Anticoagulation
• Art and Images in Psychiatry
• Artificial Intelligence
• Assisted Reproduction
• Bleeding and Transfusion
• Caring for the Critically Ill Patient
• Challenges in Clinical Electrocardiography
• Climate and Health
• Climate Change
• Clinical Challenge
• Clinical Decision Support
• Clinical Implications of Basic Neuroscience
• Clinical Pharmacy and Pharmacology
• Complementary and Alternative Medicine
• Consensus Statements
• Coronavirus (COVID-19)
• Critical Care Medicine
• Cultural Competency
• Dental Medicine
• Dermatology
• Diabetes and Endocrinology
• Diagnostic Test Interpretation
• Drug Development
• Electronic Health Records
• Emergency Medicine
• End of Life, Hospice, Palliative Care
• Environmental Health
• Equity, Diversity, and Inclusion
• Facial Plastic Surgery
• Gastroenterology and Hepatology
• Genetics and Genomics
• Genomics and Precision Health
• Global Health
• Guide to Statistics and Methods
• Hair Disorders
• Health Care Delivery Models
• Health Care Economics, Insurance, Payment
• Health Care Quality
• Health Care Reform
• Health Care Safety
• Health Care Workforce
• Health Disparities
• Health Inequities
• Health Policy
• Health Systems Science
• History of Medicine
• Hypertension
• Images in Neurology
• Implementation Science
• Infectious Diseases
• Innovations in Health Care Delivery
• JAMA Infographic
• Law and Medicine
• Leading Change
• Less is More
• LGBTQIA Medicine
• Lifestyle Behaviors
• Medical Coding
• Medical Devices and Equipment
• Medical Education
• Medical Education and Training
• Medical Journals and Publishing
• Mobile Health and Telemedicine
• Narrative Medicine
• Neuroscience and Psychiatry
• Notable Notes
• Nutrition, Obesity, Exercise
• Obstetrics and Gynecology
• Occupational Health
• Ophthalmology
• Orthopedics
• Otolaryngology
• Pain Medicine
• Palliative Care
• Pathology and Laboratory Medicine
• Patient Care
• Patient Information
• Performance Improvement
• Performance Measures
• Perioperative Care and Consultation
• Pharmacoeconomics
• Pharmacoepidemiology
• Pharmacogenetics
• Pharmacy and Clinical Pharmacology
• Physical Medicine and Rehabilitation
• Physical Therapy
• Physician Leadership
• Population Health
• Primary Care
• Professional Well-being
• Professionalism
• Psychiatry and Behavioral Health
• Public Health
• Pulmonary Medicine
• Regulatory Agencies
• Reproductive Health
• Research, Methods, Statistics
• Resuscitation
• Rheumatology
• Risk Management
• Scientific Discovery and the Future of Medicine
• Shared Decision Making and Communication
• Sleep Medicine
• Sports Medicine
• Stem Cell Transplantation
• Substance Use and Addiction Medicine
• Surgical Innovation
• Surgical Pearls
• Teachable Moment
• Technology and Finance
• The Art of JAMA
• The Arts and Medicine
• The Rational Clinical Examination
• Tobacco and e-Cigarettes
• Translational Medicine
• Trauma and Injury
• Treatment Adherence
• Ultrasonography
• Users' Guide to the Medical Literature
• Vaccination
• Venous Thromboembolism
• Veterans Health
• Women's Health
• Workflow and Process
• Wound Care, Infection, Healing
• Register for email alerts with links to free full-text articles
• Access PDFs of free articles
• Manage your interests
• Save searches and receive search alerts

• Members' Area

• Competitions
• Press releases
• Spokespeople
• Share your story
• Vegan insight panel
• Plant milk market
• Meat alternative market
• Definition of veganism
• Go vegan for animals
• Go vegan for the environment
• Go vegan for your health
• How many animals would I save?
• The honey industry
• Meal planning
• Take the Vegan Pledge
• VeGuide App - Go Vegan the Easy Way
• Become a Member
• Donate Today
• Leaving A Gift In Your Will
• Giving in Loving Memory
• Run for The Vegan Society
• Walk for The Vegan Society
• Collection tins
• Fundraising ideas
• Vegan and Thriving 77 Challenge
• Volunteer Profiles
• Volunteer Roles
• Community Network
• Join our newsletter
• Our Manifesto for Veganism
• Planting Value in the Food System
• How We Influence Policy
• COP27 Policy Briefing
• Climate Crisis
• Research News
• Research Advisory Committee
• Researcher Network
• On the Pulse Webinars
• Publications
• Research Day 2022
• About the IRN
• What rights do vegans have?
• Veganism in the workplace
• Currently experiencing problems?
• International Rights Conference 2020
• Veganise your town
• Discount list
• Wholesale opportunities
• Offer a competition
• World Vegan Month
• Nutrition overview
• Life stages
• Bone health
• Vegan Supplementation
• Medications
• Allergen labelling
• Fuelling an active lifestyle
• Vegan and Thriving
• Vegan shoes
• Vegan tattoos
• Sandwich and wrap fillings
• Vegan-friendly options in UK chains
• Vegan on a budget
• Trademark search
• Lists of vegan items in UK supermarkets
• The Vegan magazine
• The Vegan Pod
• General FAQs
• Vegan Trademark
• VEG 1 Vegan Supplements
• Gifts & Accessories

Vegan LGBTQIA+ influencers to watch in 2024

You are here, lola méndez shares her list of top lgbtqia+ vegan influencers to support during pride month – and all year round..

The underlying connection between being LGBTQIA+ and vegan is undeniable . Both socio-political issues share many pillars, the most important being collective liberation. While veganism is a choice, sexuality and gender are not.

Veganism at its core value is about reducing harm for all living beings and this must encompass LGBTQIA+ people. Queer people (a multifaceted term for those who identify their sexuality in any way other than heterosexual) in most corners of the globe still face injustice, violence and even murder simply for existing. Meanwhile, billions of non-human animals endure commodification and captivity. Non-human animals are brutalized by humans whether the animals are raised as livestock for human consumption in factory farms, used for testing in labs or for human entertainment in circuses and zoos. So, it’s no surprise that many queer people are also vegan and centre liberation.

While members of neither community can be described through monolithic language, many LGBTQIA+ and vegans long to remove violence and suffering from the world for all living creatures. Both communities are fighting oppression. This parallel is apparent at vegan cafes I’ve visited around the world. More often than not, they’re usually the only place with a rainbow pride flag on display.

I’ve been plant-based for half my life. I stopped eating meat when I was 17 and although I knew at the time that I was also queer, I didn’t have the courage to come out until I was 30. While coming out and going vegan aren’t the same, both require deviation from societal norms. Going vegan doesn’t have the same potentially life-threatening repercussions as coming out. To come out as LGBTQIA+ you must self-reflect deeply on who you are. While building greater self-awareness many folks feel greater empathy for other suppressed beings, including captive animals.

My veganism and my queerness go hand-in-hand and are key aspects of who I am and what I stand for. Anecdotally I’ve experienced the homosexual herbivore correlation tenfold. My first girlfriend was vegan and the majority of the LGBTQIA+ community I’ve built around the world has mostly been with vegans. Don’t just rely on my experience — many beloved vegan celebrities are queer including Billie Ellish, Laverne Cox, Sia, Alan Cummings, Ellen DeGeneres, Elliot Page, Ruby Rose and Jane Lynch.

Here are some LGBTQIA+ vegan influencers to support during Pride month – and all year round.

Gal Shomron

Gal Shomron is a social media influencer and writer. They’re a vegan non-binary lesbian with “just another queer vegan” as their bio on their Instagram page, @_fuxkingfalafel . They’ve been vegan for nearly a decade and use their Instagram page to share delicious vegan eats they’ve tried worldwide from Amsterdam to London, and from their kitchen. You can recreate their vegan plates at home, such as these comfort food burgers , and vegan cheese-stuffed flatbreads.

Paul and Jason

Paul and Jason are the married influencer duo behind @thoseveganguys on Instagram. The gay couple have been together since 1997 and have been vegan for over a decade. They are vegan and animal rights activists. On their Instagram you’ll find their home-cooked vegan meals, vegan grocery store guides and more.

You may recognise Paul by his drag persona — Gemini Andro, who is part of the vegan drag mother-and-daughter duo, The Vegan Queens . On their YouTube channel they share ‘news, reviews and views’ about veganism and the LGBTQIA+ community. Their content advocates for equality, acceptance, and justice for marginalised communities and non-human animals, with a humorous edge.

Jasmin Singer

Jasmin Singer is a vegan lesbian and the author of Always Too Much and Never Enough , a poignant reflection of her journey to finding herself through veganism and queer love. She also wrote Fabulous Vegan for VegNews, a 30-day guide to going vegan. Singer is also the host of the award-winning Our Hen House weekly podcast, which is about changing the world for animals, and hosts the “Environmental Connections” show on PBS. On her Instagram, @jasminesingerauthor , she shares snippets from her life including her spouse More, who is also vegan, their four dogs and a cat.

Calen Otto is a non-binary pansexual vegan writer and content creator sharing their budget travels around the globe on their Instagram, @unruly_traveller . On Instagram and their blog , Otto shares insights into what it’s like to traverse the world while adhering to a vegan diet, tips on where to eat everywhere from Mexico to Costa Rica and a pinned post detailing why travellers should consider going vegan . For more in-depth travel guides they’ve written eBooks covering UK road trips and budget travel.

Kelsey is a queer vegan content creator who goes by @lilveganpickle on Instagram. They use their platform to share their “fakeaway” meals recreating delicious meals at home. They're earnest about the vegan home-cook process — such as trying foods for the first time that they never ate pre-vegan, such as blue cheese and their deeply relatable truffle obsession. Kelsey is transparent about her eating disorder recovery and is flourishing after a year in recovery.

Destiny DeJesus

Destiny DeJesus is the queer vegan content creator behind @eatyodestiny . She shares her tried-and-true tips for making affordable vegan dishes with budget-friendly ingredients. Her “The grass I be eating as a vegan” series highlights how varied and flavorful vegan cuisine can be from spring rolls, milkshakes, lasagna, mac ‘n’ cheese, and more. DeJesus launched the Texas Eats Green initiative aimed to reduce animal suffering by encouraging restaurants across The Lone Star State to add more vegan dishes to their menus, especially in predominantly BIPOC communities.

Billie Lee is a trans* vegan comedian, author and content creator. You may recognise her from her appearance on the reality TV show, Vanderpump Rules , where she was the first transgender person in the long-running series. She went plant-based for health reasons and never looked back. On her Instagram, @itsmebillielee , you’ll find posts highlighting her comedy which intersects veganism and her trans* identity. Her vegan empire continues to expand and now includes She’s So Vegan vegan-friendly gear including hoodies and tote bags.

Zacchary Bird

Zacchary Bird is the bisexual vegan author of “ The Vegan Butcher ” which highlights drool-worthy vegan meat alternatives. He’s also published two other cookbooks — “Vegan Junk Food: A Down & Dirty Cookbook” and “The Vegan Baker”. Bird is also an Instagram influencer, sharing a look at his queer vegan life on his namesake profile @zaccharybird .

He’s known for his hilarious content, such as the “ day in the life of an average vegan “ where he mocks vegan stereotypes including surviving off of nooch, that centres his queer identity and veganism. The content is super relatable — like the reality that vegans are likely to look at a restaurant’s menu in advance to determine if there’s anything they can eat.

By Lola Méndez

Lola Méndez is a Uruguayan-American freelance pansexual journalist. She writes about veganism, sustainability, travel, culture, and wellness for many print and digital publications such as CNN, USA Today, InStyle, and Refinery29. In addition to her responsible travel blog, you can follow her on Instagram , Facebook and Twitter @LolaAnnaMendez. 

• emma_parrott's blog

The views expressed by our bloggers are not necessarily the views of The Vegan Society.

Sign-up for our newsletter

Join our newsletter to receive monthly competitions, offers and information on all things vegan.