LGBTQ+: Background

Approximately 3.5% of the population of the United States label themselves as part of the LGBTQ+ community, accounting for nearly 9 million Americans (Hafeez et al., 2017). Progression in LGBTQ+ human equality rights has drastically helped the LGBTQ+ community in acquiring the same legal opportunities as their heterosexual counterparts, such as same-sex marriage, and anti-discrimination policies (Bolderston & Ralph, 2016). Despite the advancements in society, stigmatization and discrimination are still widely prevalent in many areas of the country. Additionally, forty-two percent of those who identify as LGBTQ+ reported that they live in an unwelcome environment (Do Something, 2019). 

History of LGBTQ+ rights in the United States dates back to the 1920's, when Henry Gerber founded the first gay rights organization called the Society for Human Rights (CNN, 2020). In 1952, the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association listed 'homosexuality' as a 'sociopathic personality disturbance' (CNN, 2020). The fight for equal rights and decriminalization of "homosexuality" took place in the late 20th century, when the Stonewall raid and riots of 1969 in New York sparked the birth of the modern movement for LGBTQ+ rights (CNN, 2020). The LGBTQ+ movement gained a momentous victory in the medical realm, when the American Psychiatric Association removed "homosexuality" from its psychiatric disorders in 1973, marking progress towards de-stigmatization of the LGBTQ+ community (CNN, 2020). Another significant milestone was in 1974, when Kathy Kozachenko became the first openly LGBTQ+ elected official in any public office, when she won a seat on the Michigan City Council.

The first March on Washington for Lesbian and Gay Rights took place in October 14, 1979, which drew in an estimated 125,000 people, setting a precedent for future legislative action for the rights of the LGBTQ+ community (CNN, 2020). However, the "Don't Ask, Don't Tell" military policy, signed in 1993 by President Bill Clinton, prohibited openly gay and lesbian individuals from serving in the military, which caused a decline in progress towards equal rights for the LGBTQ+ population. This policy would not be repealed for another eighteen years by President Barack Obama (CNN, 2020). Ten years later, the U.S Supreme Court rejected the "homosexual conduct" law, an important win for the LGBTQ+ rights movement (CNN, 2020). In 2009, President Obama signed the Matthew Shepard Act, which expanded the prosecution of hate-crimes to those motivated by a victim's sexual orientation or gender identity (CNN, 2020). Finally, in 2015, the United States Supreme Court legalized same-sex marriage in all 50 states (CNN, 2020).

Though America has gone through significant societal advances in terms of LGBTQ+ rights, discrimination and stigma continue to be widely prevalent. In the last few years, critical laws such as Title IX, which protects transgender students from discrimination in government-funded educational programs, were repealed by the Trump administration, a major backslide for LGBTQ+ youth and their safety in school settings (GLSEN, 2019). In 2017, the Trump administration overturned an Obama-era law allowing transgender individuals to serve in the military, producing a cascade of negative effects for the LGBTQ+ community (CNN, 2020).


Common Challenges

Research exploring the everyday occupations of individuals who are marginalised by gender identity and/or sexual orientation continues to be very limited despite increased attention to occupational justice issues in recent years (Beagan, 2011).

Stigma, Discrimination, and  Poor Awareness

LGBTQ+ individuals face discrimination in healthcare which is linked to stigma, societal discrimination, and lack of awareness (Bonvicini, 2017). They often encounter substantial obstacles to health care opportunities that may drastically impair their overall health and well-being (Bolderston & Ralph, 2016). 

Stigma happens on three different levels: individual, social, and structural (Bolderston & Ralph, 2016). Homophobia and shame can occur on a personal level if societal stigma has forced LGBTQ+ individuals to internalize the prejudice and question their worth (Lee & Kanji, 2017). Those who have reaffirming and inclusive interactions with healthcare professionals can positively affect individuals who identify as LGBTQ+, and trust can be established (Lee & Kanji, 2017). However, negative interactions cause the opposite, leading LGBTQ+ patients to internalize self-hatred and homophobia. Stigma at the social level can come in different forms- subtly such as microaggressions, or direct like hate crimes and vile remarks (Bolderston & Ralph, 2016). Microaggressions are unintentional remarks or and indirect actions that target minority groups such as the LGBTQ+ community. Assumptions made by healthcare providers are an example of a microaggression (Lee & Kanji, 2017). These assumptions are evident in the heteronormativity of the surrounding environment. For example, a healthcare facility may utilize language that is only specific to a heterosexual individual and is not inclusive to the LGBTQ+ population (Lee & Kanji, 2017). Other examples include pamphlets and brochures that may depict visuals that only cater to heterosexual and cisgender individuals (Lee & Kanji, 2017). Structural stigma can be defined at the institutional and federal levels. Examples may include repeals of necessary laws pertaining to the LGBTQ+ community, and anti-discrimination laws that are not inclusive (Bolderston & Ralph, 2016).

The personal beliefs of healthcare professionals, especially those rooted in stigma, may interfere with unbiased patient care. Healthcare clinicians may express bias towards heterosexual patients both directly and indirectly. Patient-centered care may only be directed towards patients who are heterosexual due to the lack of education on how to treat patients who are of sexual minority and therefore inadvertently obstruct patient-centered care (Bolderston & Ralph, 2016; Pellegrini et al., 2015). In turn, LGBTQ+ patients may hesitate to provide accurate health information that can impede quality care (Bolderston & Ralph, 2016). 

Due to a fear of being judged based on their sexual orientation and gender, LGBTQ+ individuals often face a difficult dilemma on whether or not they should "come out"(Hafeez et al., 2017). The term for the disclosure of sexual identity is "coming out of the closet", or "coming out". When individuals in the LGBTQ+ community do come out, they are often faced with less than positive experiences, such as ignorance and inequality during healthcare treatment (Bonvicini, 2017). In a research study conducted on discrimination of LGBTQ+ individuals in the healthcare field, same-sex partners of the patients often introduce themselves as friends or roommates in order to avoid conflict or unfair treatment from the healthcare professional (Lee & Kanji, 2017). According to the National LGBT Health Education Center, LGBTQ+ individuals report looking for "signs" whether the healthcare facility is inclusive or by noticing how they are greeted by staff members, non-discrimination policies posted, or gender-neutral bathrooms (n.d). The level of openness or withholding of accurate medical information by the LGBTQ+ patient is directly determined by the healthcare professionals' attitude about the topic of LGBTQ+ individuals (Bristol et al., 2018). Past experiences of discrimination, whether in healthcare or other parts of their lives, can also affect the individual's perception at a healthcare facility (Bolderston & Ralph, 2016). In addition, the anticipation of a negative reaction can negatively affect the LGBTQ+ patient, adding more stress to an already unpleasant situation (Bolderston & Ralph, 2016).

Transgender individuals within the LGBTQ+ community face significant obstacles to equality, especially within the healthcare field. Stigma is particularly present for transgender individuals, who are more likely to be discriminated against (Hughto et al., 2015). Heterosexual individuals have been found to possess stronger negative feelings for transgender individuals than those who identify as lesbian, gay, or bisexual (Copti et al., 2016). Those who identify as transgender have also reported postponing and canceling medical appointments due to a fear of discrimination brought on by past negative experiences (Bristol et al., 2018). Studies show that transgender individuals seeking medical care are repeatedly denied and transferred to other healthcare providers due to a lack of education regarding the treatment of transgender patients (Beagan et al., 2013). Discrimination may be intentional, such as a healthcare provider's personal beliefs of stigma towards transgender patients, or unintentionally, such as incorrect use of pronouns (Beagan et al., 2013). 

Health Disparities 

Research suggests LGBTQ+ individuals face health disparities linked to societal stigma, discrimination, and denial of their civil and human rights (Healthy People, n.d.). LGBTQ+ individuals are at a higher risk of mental health issues such as anxiety, depression, suicide/suicidal thoughts, and substance abuse disorders (Jaime et al., 2011). Discrimination and stigma negatively influence how LGBTQ+ individuals access healthcare. This may lead to less filled prescriptions, possible delay of emergency care, and refusal of healthcare services (Operario et al., 2015). 

A study conducted in 2015 revealed that sexual minority men experienced having fifteen or more poor mental health days in the last month compared to their heterosexual counterparts (Operario et al., 2015). The same study concluded that compared to heterosexual women, sexual minority females had a greater chance of lifetime heavy alcohol use (Operario et al., 2015).  LGBTQ+ older adults face an increased risk of negative behavioral health issues due to a lifetime of discrimination and stigma that causes higher levels of stress (Goldhammer, Krinsky, Keuroghlian, 2019). LGBTQ+ aging adults face "double-whammy discrimination" due to age and sexual orientation (American Psychological Association, n.d). 

In general, LGBTQ+ individuals are at a higher risk of mental health issues such as anxiety, depression, suicide/suicidal thoughts, and substance abuse disorders (Healthy People, n.d; National Alliance on Mental Illness, 2019). According to the National Alliance on Mental Illness (2019), LGBTQ+ individuals are three times more likely to experience a mental health condition, such as major depression and a variety of anxiety disorders (National Alliance on Mental Illness, 2019). The above information implies that LGBTQ+ clients require mental health attention that is more unique to this population. 

LGBTQ+ individuals also face more physical health issues. Those in the LGBTQ+ community are more prone to health risks, including certain cancers, sexually transmitted infections, and eating disorders (Copti et al., 2016). Lesbian and bisexual women may have an increased chance of cervical cancer, while gay and bisexual men are at a higher risk for anal cancer. LGBTQ+ individuals, especially gay and bisexual men, have an increased risk of contracting HIV/AIDS (National LGBT Cancer Network, 2013). Individuals who identify as transgender also face increased risks of cardiovascular issues, deep vein thromboses, diabetes, and osteoporosis due to hormone therapy (Copti et al., 2016). 

Housing  

LGBTQ+ people are more likely to experience homelessness than their heterosexual peers (Conron et al., 2010; Kruks & Gray, 2010; Van Leeuwen et al., 2006). Thirty-two percent of the total homeless population is made up of unaccompanied young people who are between 18 and 24 years old (Hild et al., 2019). Of these individuals, 42% of them identify as LGBTQ+. It is common for many of these individuals to be forced to leave their familial homes at a young age. With a lack of guidance and support during these formative years, many individuals fail to develop the necessary independent living skills and adult roles necessary for residential stability. (Hild et al., 2019). They are also at higher risk for 

Many elderly LGBTQ+ couples face challenges with finding affordable and safe housing as well. LGBTQ+ individuals are less likely than their heterosexual peers to have children who may be capable of providing them support in late life (Brennan-Ing et al., 2011; Grigorovich, 2016; Hash, 2006). This indicates a higher likelihood that LGBTQ+ seniors will require the assistance of a senior residential facility of some sort for support. In a 2014 report, the Equal Rights Center, which is a housing advocacy group, along with the Services and Advocacy for LGBT older adults (SAGE) reported that 48 percent of older same-sex couples experienced discrimination when they applied for senior housing (The Equal Rights Center, 2014). SAGE also conducted a survey for transgendered older adults and discovered that 25% of individuals reported they had experienced discrimination while seeking housing (SAGE, 2014). Discrimination includes, but is not limited to, using improper pronouns, offering different amenities than others, delays or refusal to make housing repairs, and outright refusal to house them due to being part of the LGBTQ+ community (Johnston & Meyer, 2017). Individuals who are transgender have also reportedly been placed in rooms with roommates who are incongruent with their gender identity (Johnston & Meyer, 2017). LGBTQ+ couples seeking housing together may encounter staff that refuses to acknowledge their partnership, staff that insists on showing them two-bedroom options even at the request to see one-bedroom options, and being pushed into areas within the facility where the staff has clustered LGBTQ+ individuals together (Johnston & Meyer, 2017). Many also fear that their same-sex partners will not be acknowledged as life partners by nursing home staff leading to a lack of input for the care process (Furlotte et al., 2016; Hash & Netting, 2007; Hughes, 2009; McFarland & Sanders, 2003; Sharek et al., 2015). 

Identity

As a result of the stigma and discrimination often experienced by the LGBTQ+ community, many individuals choose occupations that are more traditionally aligned with their expected behaviors and/or outward appearances in an effort to hide their sexual orientation or gender identity (Beagen et al., 2013). Choosing occupations that are not personally meaningful can result in a loss of identity leading to poorer quality of life, well-being, and life satisfaction. Outness has been associated with improved well-being, lower depression, and higher self-esteem, however; it is also associated with higher victimization (Kosciw et al, 2015). Higher levels of victimization may indicate a need for self-advocacy skills. 

Older LGBTQ+ individuals living in assisted livings facilities or skilled nursing facilities often hide their true identity for fear of their well-being and health poorly impacted as a result of being mistreatment by staff and other residents (Johnston & Meyer, 2017). Examples of mistreatment include physical and emotional abuse, commonly being fed last, and staff refusing or delaying to change their bedpans or soiled linens (Johnston & Meyer, 2017).  

ADLS / IADLS

As mentioned prior, LGBTQ+ individuals are less likely to have children than their heterosexual peers (de Vries & Gutman, 2016; Family Caregiver Alliance, 2020). Without familial support, aging in place may be disproportionally difficult. LGBTQ+ individuals often create a family of choice consisting of close friends who they consider family even though there is no biological or legal relation. The challenge with this is that the friends are often of similar age and, therefore; results in older adults relying on other older adults for the entirety of their available support (de Vries, 2016; Family Caregiver Alliance, 2009). Tasks such as driving, grocery shopping, bathing, grooming, and home and money management may be equally challenging for the individual and the individuals within their support group.

Furthermore, transgendered individuals living in skilled nursing facilities have reportedly experienced staff that refuses to permit them to dress in clothing of their choice, assist in personal grooming activities, and restrict gender expression inline with their identity (Johnston & Meyer, 2017). Similar issues can also arise while in the hospital, in outpatient care, and at community centers. Refusal from staff to assist in a client-centered and accepting manner means an even greater loss of autonomy for those who require assistance. A restriction in daily activities can also place individuals at greater risk for other mental and physical health complications. For example, restricting or limiting bathing and grooming activities can lead to compromises in skin integrity and increased risk for infections.

For some individuals within the LGBTQ+ community, they will require less assistance with relearning or adapting their daily livings skills and more assistance with learning new skills that they were never initially taught. For example, clients who are transgender and in the midst of transitioning or recently transitioned may encounter self-care needs (Beagan, 2011). Self-care could include skills such as dressing, grooming, and medication management needs. Moreover, a study by Hild et al. (2019) found the needs of young LGBTQ+ individuals residing in a transitional living facility include needing assistance with health and self-management skills, pre-vocational and employment skills, and financial and home management skills. They also require assistance with navigating environmental barriers to occupational participation and developing healthy habits. Trauma-informed care which is specific to the population's needs and occupation-based intervention has been identified as necessary and beneficial for this population (Hild et al., 2019).

Education

For LGBTQ+ youth, their school can become a dangerous and hostile place due to present prejudice and intolerance (Kosciw et al., 2012). In fact, six out of 10 students who identify as LGBTQ+ state that they feel unsafe and isolated at school due to their sexual orientation (Do Something, 2019). Victimization within school leads to poor self-esteem and lower academic outcomes (Kosciw et al., 2015).

Research suggests that LGBTQ+ youth also experience disparate disciplinary treatment within their school (Snapp et al., 2014). For example, they are punished more frequently and more harshly for violating gender norms and public displays of affection when compared to their heterosexual, cisgender peers (Snapp et al., 2014). It has also been found that school administrators are three times more likely to elicit harsh disciplinary treatment to gender-nonconforming girls when compared to their non-LGBTQ+ peers (Mitchum & Moodie-Mills, 2014). Strict disciplinary school systems, along with homelessness and family exile, facilitate entry into the school-to-prison pipeline (Snapp et al., 2014).

LGBTQ+ individuals who are transitioning into college may demonstrate an increased level of occupational disparities in ADLs, IADLS, work, and social participation in comparison to their heterosexual, cis-gendered peers (San & Breen-Franklin, 2019). It is during this time that many LGBTQ+ individuals are working toward a positive role and identity fulfillment. Environmental and contextual barriers to this process can lead to occupational deprivation, increased risk for psychological and physical abuse, low self-esteem, and maladaptive performance patters in relation to work, school, and social participation (Bergan-Gander & von Kurthy, 2006; Romijnders et al., 2017; Russell & Fish, 2016; San & Breen-Franklin, 2019).

Relationships / Sexual Participation 

Most LGBTQ+ youth desire to be in relationships like their heterosexual and cisgender peers (D'Augelli et al., 2008; DeHaan et al., 2013). Existing school-based sexual education programs are not adequately addressing the needs of this population, especially as it relates to STIs/HIV (Pingel et al., 2013). There are also gaps in education regarding dating violence and sexual health among the LGBTQ+ population (Greene et al, 2015). Young LGBTQ+ couples may have their long-term emotional, social, physical health threatened by the unique challenges they face such as the absence of LGBTQ+ relationship norms and sexual minority stress (Greene et al, 2015). The LGBTQ+ youth population is not being adequately served due to the inequalities present in the availability of evidence-based community- and school-based programs and services which limits their accessibility of health resources (Greene et al., 2015).

Transgendered individuals who have undergone gender-affirming surgery often experience improved body satisfaction and a decrease in gender dysphoria (Holmberg et al., 2019). Despite these benefits, the surgery can also be associated with postsurgical pain, physical constraints of their new genitals, psychological difficulties with accepting their new body, and the social ramifications of having changed gender (Holmberg et al., 2019). A need for assistance with managing disclosure and relationships has been an identified need within the transgender population (Beagan, 2011). Overall, support for sexuality and sexual function should be considered for transgender individuals throughout their lives in order to improve their quality of life (Holmberg et al., 2019).

Unfortunately, within Western society, there is a stereotypical and ageist misconception that older individuals have no interest in sex (Bauer et al., 2016). In part, healthcare staff, relatives, and other peers contribute to this misconception which may prevent individuals from freely expressing themselves as the sexual beings that they are (Elias & Ryan, 2011; Mahieu et al., 2011; Mahieu & Gastmans, 2015). Older LGBTQ+ individuals, such as those in a residential facility, are often at risk for dual discrimination due to this ageist assumption in addition to presumptions of heterosexism (Addis et al., 2009; Boggs et al., 2014, Hillman, 2017; Richardson & King, 2017; Wilson et al., 2018).

Ableist and heterosexual attitudes present as barriers to sexual expression of LGBTQ+ individuals with disabilities (Gallo-Silver et al., 2017; Hillman, 2017). Many individuals, even those who are attendant care-dependent (ACD), due to conditions such as cardiovascular accidents, spinal cord injury, Spina Bifida, muscular dystrophy, multiple sclerosis, and cerebral palsy consider sexual activity and expression as components of a meaningful life Gallo-Silver et al., 2017). Requiring assistance with toileting and bathing in addition to a lack of privacy are prominent barriers to an LGBTQ+ individual with ACD for participating in sexual activity (Gallo-Silver et al., 2017 ). Embarrassment and shame are common among these individuals wanting to explore their sexuality. Self-advocacy and problem skills are necessary for these individuals to reclaim their right to sexual experiences (Gallo-Silver et al., 2017).

Religion and Spirituality 

Mainstream faith traditions have traditionally condemned sexual and gender minorities and, therefore; inflicted considerable harm on the LGBTQ+ population (Beagan & Hattie, 2015a). A large body of compelling research has highlighted how incongruence with sexual/gender identity with religious teachings has caused significant damage to the psychological and emotional well-being of many LGBQ Christians (Barton, 2010; Dahl & Galliher, 2009, 2012; Garcia et al., 2008; Murr, 2013; Ream & Savin-Williams, 2005; Rodriguez, 2009; Rodriguez & Ouellette, 2000; Schuck & Liddle, 2001; Super & Jacobson, 2011). However, it is important to recognize that not all LGBTQ+ individuals have experienced conflict with religion (Beagan & Hattie, 2015).  Research on transgender Christians is not as prevalent at this time. Research is also scarce regarding LGBTQ individuals in faith traditions other than Christianity (Beagan & Hattie, 2015). 

The religious community has been found to affect LGBTQ+ individuals in a multitude of ways. For example, LGBTQ+ individuals are sometimes asked to leave their religious institutions upon "coming out" and report experiencing a tremendous loss in their social network and community connectedness (Beagan & Hattie, 2015). Others decide to leave their religious institutions by choice for various reasons including judgment, discrimination, lack of acceptance, and feeling misunderstood. A loss of specific religious occupational roles, rituals, and family connectedness has also been reported after leaving a religious institution (Beagan & Hattie, 2015b). For some individuals, religion can offer a sense of meaning to their life (Jimenez et al., 2020). Disaffiliating with their faith can result in questions about purpose and a loss in meaningful engagement. An individual's participation in sexual activity is also often postponed and/or is heavily weighted with shame (Beagan & Hattie, 2015). A denial of self, low self-esteem, poor body image, low self-worth, self-harm, internal conflict, fear of hell, and mental health challenges such as depression, anxiety, and substance abuse are commonly reported amongst this population in relation to religion. However, those who extensively studied their religion typically report less conflict with their sexual/gender identity and their religion with the conception that the condemnation of diverse sexual/gender identities has more to do with human error in interpretation than the Biblical teachings themselves (Beagan & Hattie, 2015).

Conclusion

The above findings imply the need for more health and wellness services for this population, alongside educational resources to aid in improved quality of life. Advocacy and self-advocacy need to be enacted in an effort to decrease victimization. There is also an increased need for LGBTQ+ preventative care, sexual education, and healthcare competency education. Assistance with ADL and IADL skills acquisition, adaption, and translation is also necessary for some individuals. LGBTQ+ individuals have a diverse range of experiences, but the many experience occupational adaptation, loss, and exploration in relation to their sexual/gender identity that may benefit from supportive care. 

Content Contributor

Kim Nguyen is an OT doctoral student at the University of St. Augustine for Health Sciences. She is completing her capstone project titled "Exploring the Needs of the LGBTQ+ Community and the Role of OT", which aims to address the health disparities of this marginalized group through LGBTQ+ specific needs through the broad scope of OT. Kim received her Bachelor's degree from the University of South Florida with a focus on social and behavioral sciences. Kim hopes her capstone project will help bring light to disparities in order to promote advocacy for underrepresented populations.