LGBTQIA+ does not refer to a single, monolithic community. Instead, it is best considered an evolving umbrella term—an acronym for lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual, and more – used to describe a person’s sexual orientation or gender identity. It is also important to note that some people may be part of sexual or gender minorities but do not consider themselves part of the LGBTQIA+ community. While belonging to one or more LGBTQIA+ communities can be a source of strength and belonging, members often face higher rates of mental health and substance use issues, lower rates of insurance coverage, and limited access to appropriate health care services. Moreover, LGBTQIA+ people face several challenges when seeking mental and physical health care services.

NOTE: Understanding the role culture plays in health care is essential. Still, patients are individuals – each person’s preferences, practices, and health outcomes are shaped by many factors, a concept known as intersectionality. Advancing whole-person health empowers individuals to improve their health and well-being in multiple interconnected biological, behavioral, social, spiritual, and environmental areas.

LGBTQIA+ in Minnesota

The demographics of the LGBTQIA+ population vary across the U.S. Accurate demographic assessments can be challenging to establish because common measurements, such as the U.S. Census, currently ask questions that only indirectly reflect a narrow range of LGBTQIA+ in Minnesota, for example, while about four percent identify as LGBTQIA+, a 2022 Gallup Poll concluded that about seven percent of adult Americans identified as LGBT (up from 5.6% in 2020). A 2021 survey of LGBTQIA+ people in Minnesota indicated that 44% live in the Twin Cities itself, 18% live outside the Twin Cities but in the Twin Cities 7 county metro area. The remaining 38% live in Greater Minnesota. 40% of respondents are people of color, and 60% are white.

Language is continuously evolving, with various acronyms representing the diverse communities of lesbian, gay, bisexual, transgender, queer/questioning, intersex, and asexual people. This is not meant to be an all-encompassing list, and the acronyms used vary depending on whether the community is based on gender identity and/or sexual orientation.

Biological sex is the anatomy of an individual’s reproductive system and genetic differences. Assigned sex—female, intersex, male—is a label given at birth based on medical factors, primarily genitals, but potentially also including hormones and chromosomes.

Gender refers to a set of expectations, or roles, that society assigns to a person based on sex. The phrase “gender binary” refers to the idea that there are two, and only two, possible genders. These expectations or roles frequently vary from place to place and from time to time.

Gender expression refers to how a person represents themselves to the world. It can be through clothing choices, mannerisms, hairstyles, voice, body language, and pronouns. These and others are ways a person adheres–or not–to the roles or expectations society has placed on them based on their sex.

Gender identity is a person’s inner sense of being male, female, a blend of both, or neither. Transgender people have a gender identity that differs from the sex assigned at birth. Cisgender people have a gender identity that aligns with the sex they were assigned at birth. A person whose gender identity is neither wholly male nor wholly female is often referred to as “nonbinary.”

Sexual orientation is a person’s pattern of emotional and sexual attraction to other people. Gay, lesbian, bisexual, and heterosexual terms are primarily based on who a person is attracted to.

Queer is a complicated term in this context. For some, it is a welcome shorthand for the lengthy LGBTQIA+ acronym, encompassing all such communities. For others, “queer” refers primarily to sexual minorities, not gender minorities. For still others, particularly older LGBTQIA+ persons, the word “queer” remains associated with stigma and violence and is considered an undesirable label. It is best to follow a patient’s lead in learning whether this is a term they embrace or shun.

Understanding how someone defines themselves as an individual leads to better care. Ask patients what names and pronouns they use.

“You may see or hear people say ‘preferred pronouns,’ but we recommend not using the term ‘preferred.’ Gender isn’t a preference — it’s who we are. Pronouns reflect our identity to the world; thus, they aren’t a preference; they just are.”
— From A Short(ish) Guide to Pronouns and Honorifics

 

LGBTQIA+ Glossary of Terms

LGBTQIA+ people often experience health disparities related to their experiences as sexual or gender minorities in a society that has, historically, not often been accepting of them. Compared to heterosexual/cisgender people:

LGBTQIA+ individuals are at greater risk of suicide, mood disorders and anxiety, eating disorders, substance use disorder, and tobacco use. Men who have sex with men (MSM) are more likely to have an HIV infection. Statistically speaking, MSM, who are also people of color, have an even higher incidence rate. Some lesbian and bisexual women get less routine care than other women, including breast, colorectal, and cervical cancer screening tests. Lesbian and bisexual women are more likely to be overweight or obese. Transgender individuals have a high prevalence of HIV/STIs (particularly among transgender women of color), victimization, mental health disorders, and suicide. Older LGBTQIA+ individuals face additional barriers to health because of isolation and a lack of social services, support networks, and culturally responsive providers.

“Despite the progress we have made as a country toward granting equal rights to those who identify as LGBTQIA+, this community continues to experience worse health outcomes and reduced access to care when compared to their heterosexual and cisgender counterparts.”
— Brentton Lowery, PA-C, as quoted in “How to Identify and Help End 7 LGBTQIA+ Health Disparities”

LGBTQIA+ Health Disparities

Social determinants (or social drivers) of health are economic and social conditions that influence the health of people and communities. LGBTQIA+ people have a history of being discriminated against in housing, employment, legal status, and suffering from violence and bullying. Bias and discrimination in health care happen as well. Dealing with discrimination is associated with higher reported stress and poorer reported health, partly because many LGBTQIA+ people either do not share their identity with their provider, potentially leaving their provider unaware of critical information, or simply avoiding seeking care altogether.

  • U.S. Census data show significant economic disparities among the LGBTQIA+ community.
  • 7% of LGBTQIA+ Americans lacked health insurance in 2017, compared to 11.4% of the general population. Lack of health insurance may result in receiving less preventive care and health education.
  • 45% of the LGBTQIA+ respondents in a 2021 survey reported having experienced homelessness or housing insecurity at least once in their lives. LGBTQIA+ youth are more than twice as likely as their straight peers to experience homelessness, and rates of homelessness are significantly higher for those who identify as black or multiracial.
  • LGBTQIA+ people are among the most likely to be targets of hate crimes in America, respective to population size. LGBTQIA+ people of color and transgender people are disproportionally targeted.
  • Up to 46% of LGBTQIA+ employees say that they’ve experienced discrimination or physical, verbal, or sexual harassment at work at some point in their lives. Transgender employees were more than twice as likely to report that their gender identity led to discrimination (specifically, being fired or not hired) compared to their cisgender counterparts.
  • LGBTQIA+ teens were twice as likely to be bullied online and on school property and more than twice as likely to stay home from school to avoid violence they felt might befall them on the way there or on school grounds.
  • In 2021, nearly half of MN LGBTQIA+ adults reported experiencing unwanted physical or sexual activity at some point in their lives.

“According to the National Center for Transgender Equality, more than a quarter of transgender workers in California reported that in the past year, they were fired, passed over for promotions, or not hired because of their gender identity.”
— David Nahmias, Impact Fund Law Fellow

Social Determinant Disparities

As a result of a series of legislative efforts and court decisions, same-sex couples can marry nationwide, and states must extend all the rights and benefits of marriage to same-sex couples, including medical decision-making authority. About 63% of LGBTQ Millennials (aged 18-35) are considering expanding their families by becoming parents for the first time or having more children. Although society’s acceptance of differences in sexual orientation and gender identity has advanced:

  • 70% of the LGBTQ community says that discrimination increased significantly from 2020-2022. 54% of transgender and nonbinary people feel unsafe walking in their neighborhoods, compared to 36% of all LGBTQ adults, and being less safe in various environments, from work to social media or in a store.
  • Eight in 10 LGBTQ people strongly agree they wish there were more legislative action at the federal level to protect them. More Gen Z adults are out as LGBTQ than any previous generation. They also report higher levels of discrimination over the last two years (2020-2022) than all LGBTQ people. Only 19% of those who identify as bisexual say all or most of the important people in their lives are aware of their sexual orientation. In contrast, 75% of gay and lesbian adults say the same. About 59% of LGBTQIA+ people have “come out” (shared their LGBTQIA+ identity) to one or both of their parents and a majority say most of the important people know about this aspect of their life.
  • Older LGBTQIA+ are likelier to be “closeted” (not out). Social isolation is a concern for LGBTQIA+ older adults, who are twice as likely to live alone and twice as likely to be single. Isolation can mean a person’s health concerns may go unnoticed by others and worsen, and isolation can contribute to health concerns such as dementia. Compared to LGBTQIA+ persons under 30, those between 30 and 54 were at least 16 times more likely to be closeted, and those over 55 were 83 times more likely to be closeted.

Strong social networks are a source of resilience. LBGTQIA+ people estranged from their biological families may have a “family of choice” (friends, current and former partners, and others). These emotionally close groups function as a family, although not related by blood or legal ties. Being part of a supportive community fosters good health and can buffer against some disparities. Non-whites are more likely than Whites to say being LGBTQIA+ is extremely important to their overall identity (44% versus 34%). LBGTQIA+ people who are also racial/ethnic minorities are “multiply marginalized” and subject to microaggressions associated with racism and heterosexism.

LGBTQIA+ adults are less religious than the general public. Roughly half (48%) say they have no religious affiliation, compared with 20% of the public at large, in no small part because LGBTQIA+ adults describe many religions as being unfriendly toward people who are LGBTQIA+. It is worth noting that many faith communities are making strides to address their roles in these troubled relationships and actively welcome LGBTQIA+ individuals and families within their congregations.

“GLAAD’s annual Accelerating Acceptance study has measured Americans’ attitudes and comfortability towards LGBTQ Americans, highlighting the progress we’ve made and the challenges that still need to be addressed in pursuit of full acceptance for the LGBTQ community.”
— GLAAD Survey of American Acceptance and Attitudes Toward LGBTQ Americans

LGBTQIA+ Social Structure

High-quality care ensures that LGBTQIA+ patients feel accepted for who they are and are free to discuss all health issues and concerns with their doctors and others on their medical team. Too often, LGBTQIA+ people still experience mistreatment and poor-quality care. Only 52% of LGBTQIA+ Minnesotans are “out” to their doctor or primary care clinician, and 27% reported teaching their clinician about LGBTQIA+ people to receive appropriate care. Many health care professionals can better support their patients by adopting processes and behaviors that communicate to patients that it is safe to discuss their gender identity or sexual orientation. Opening the door to honest conversations about sexual orientation or gender identity allows health care professionals to ask well-informed questions to tailor care to address relevant health needs. Moreover, LGQBTQIA+ individuals have more difficulty accessing health insurance coverage, finding specialty care, and forgoing necessary prescription drugs.

Medical Care

Although the full range of LGBTQIA+ identities is not commonly included in large-scale studies of mental health, there is strong evidence from recent research that members of this community are at a higher risk for experiencing mental health conditions, especially depression and anxiety disorders, according to the National Alliance on Mental Illness (NAMI).

LGBTQIA+ individuals are twice as likely than others to experience a mental health condition such as major depression or generalized anxiety disorder. For transgender individuals, they are nearly four times as likely as cisgender individuals to experience a mental health condition.

About 42 percent of LGBTQ youth seriously considered suicide in the past year. Despite the mental crisis, there is still a gap when it comes to providing mental health services to them; since About 60 percent of LGBTQ youth who wanted mental health in the past year were not able to get it.

The fear of coming out and jeopardizing connections with family, friends, and community or being discriminated against because of one’s sexual orientation or gender identity can lead to depression, posttraumatic stress disorder, thoughts of suicide, and substance abuse. LGBTQIA+ people must confront stigma and prejudice based on their sexual orientation or gender identity while dealing with societal bias against mental health conditions. Some people report hiding their sexual orientation from those in the mental health system for fear of ridicule or rejection. In 2017, 29 percent of LGBTQIA+ people in Minnesota were experiencing severe mental distress, and an additional 46 percent were experiencing moderate mental distress.

“This study…highlights the pressing need for suicide prevention services that address the specific experiences and needs of lesbian, gay, and bisexual adults of different genders, ages, and race and ethnic groups.”
— Rajeev Ramchand, Ph.D., RAND Corporation

Mental Health

LGBTQIA+ individuals face unique challenges as they age. Because those in the current cohort of LGBTQIA+ older adults grew up in periods with less social acceptance and little understanding of intersectionality, they may have more significant fears of stigma and discrimination than younger people in these communities. As a result, they may be particularly hesitant to discuss their sexual orientation or gender identity, which can reinforce a sense of isolation while rendering even the best-intentioned health or social services a less good “fit” for the person’s needs.

Like other disadvantaged older adults, LGBTQIA+ elders experience more illness, disability, and premature death than their heterosexual and cisgender peers. They often are afraid to access services because of fear of discriminatory treatment.

“Health and well-being, economic security, and social connections are among the cornerstones for successful aging, yet these are areas in which many LGBTQ+ elders face substantial barriers—stemming from current discrimination as well as the accumulation of a lifetime of legal and structural discrimination, social stigma, and isolation.”
— From “Understanding Issues Facing LGBT Older Adults”

Aging and Caregiving

LGBTQIA+ older adults are more likely to be single, childless, and estranged from their biological family—relying on friends and community members as their chosen family. Only 20% of LGBTQIA+ older adults said they are comfortable being open about their sexual orientation with staff in long-term care facilities. Many people have concerns about abuse and/or neglect by staff, isolation from other residents, discrimination by residents, and discrimination by staff. Many transgender older adults are concerned that after death, unsupportive family members could place their bodies in coffins after dressing them in clothing inappropriate to their identity or burying them beneath headstones bearing their long-discarded birth name.

“Little is known about the knowledge and attitudes of hospice and palliative care professionals regarding LGBTQ patients beyond what is known anecdotally. Similarly, little is known about the care that LGBTQ patients receive.”
— Kimberly D. Acquaviva, PhD, MSW

End of Life

Other Populations in Minnesota

African American | American Indian | Asian Indian | Bhutanese | Cambodian | Deaf / Hard of Hearing | Ethiopian | European American | Latinx | Hmong | Iraqi | Karen | LGBTQ | Liberian | Poverty | Rural | Russian | Somali | Vietnamese

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