Psychiatric Annals

CME Article 

Facing Stigma and Discrimination as Both a Racial and a Sexual Minority Member of the LGBTQ+ Community

Lenore Arlee, LCSW, LADC; Robyn Cowperthwaite, MD; Britta K. Ostermeyer, MD, MBA, FAPA

Abstract

Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) sexual minority people who are also racial minorities (people of color) face significantly more complex life stressors than their white counterparts, likely due to more stigma and discrimination. This article outlines some of the disparities in this double-minority population that contribute to trends in (1) higher rates of mental health disorders; (2) higher percentages of medical illnesses in general, including higher rates of HIV; (3) higher rates of substance use disorders; and (4) increased rates of violence. Much of the existing research literature pertains to either LGBTQ+ populations or racial/ethnic minority populations, and there has been little research addressing this double-minority population to date. Further research is warranted to better understand the effect of stigma, prejudice, and discrimination in double-minority populations and how to better address their social, health, and mental health disparities. [Psychiatr Ann. 2019;49(10):441–445.]

Abstract

Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) sexual minority people who are also racial minorities (people of color) face significantly more complex life stressors than their white counterparts, likely due to more stigma and discrimination. This article outlines some of the disparities in this double-minority population that contribute to trends in (1) higher rates of mental health disorders; (2) higher percentages of medical illnesses in general, including higher rates of HIV; (3) higher rates of substance use disorders; and (4) increased rates of violence. Much of the existing research literature pertains to either LGBTQ+ populations or racial/ethnic minority populations, and there has been little research addressing this double-minority population to date. Further research is warranted to better understand the effect of stigma, prejudice, and discrimination in double-minority populations and how to better address their social, health, and mental health disparities. [Psychiatr Ann. 2019;49(10):441–445.]

Sexual minorities face significant challenges of discrimination, higher rates of violence, and institutionalized and internalized prejudice perpetrated by society far more than their cisgender heterosexual counterparts.1 Sexual minorities who are also racial minorities (people of color) are subjected to an additional level of prejudice. This article refers to them as “double” minorities because this population is subjected to actual and/or perceived discrimination due to sexual and to racial status.

The complexities of double-minority status contribute to a significant disparity in access to health services.1 In this predominantly white cisgender heterosexual world, the double-minority group receives less social and emotional support from their own racial minority community and fewer resources than their white LGBTQ+ counterparts. As a result, double minorities are more isolated, more prone to sexually transmitted infections, have higher rates of depression, higher rates of violence, and are less likely to receive adequate health care services compared to their white counterparts.2 Consequently, this population has higher rates of morbidity and mortality due to multiple mitigating factors. This article summarizes current research literature about double minorities to raise awareness for clinicians and educators who serve this unique population.

Racial and Cultural Findings

The underrepresentation of research on double-minority populations is well documented.3 Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) sexual minority populations are challenged by a dominant cisgender heterosexual society who may disagree with their different sexual orientation and lifestyle. Double minorities experience everyday life stressors and additionally must struggle with societal heterosexist prejudice toward sexual minorities, including differential treatment, derogation, rejection, harassment, victimization, expectations of stigma, anticipation of encountering cisgender heterosexist discrimination (and the vigilance this requires), as well as internalized negative attitudes toward people who are sexual minorities.4 They experience increased rates of violence perpetrated against them, greater severity of illnesses, poor social support, poor self-esteem, and hopelessness, and a potentially shorter life-span than their white counterparts.5 The hypothesis is that the level of prejudice and societal cisgender heterosexism is exponentially greater for LGBTQ+ racial and ethnic minorities in comparison to their white sexual minority peers.

There is a fundamental assumption that racial and ethnic minority communities, including black, Asian, and Latinx populations, in the United States hold more negative views about homosexuality, bisexuality, and people who are sexual minorities.5 Although several explanations for this have been offered, adherence to traditional gender roles and to religious beliefs as well as endorsement of collectivistic racial minority population values, such as filial piety (respecting traditional beliefs of elders), may be the most important.6 In addition, scholars have contended that racial and ethnic minority communities may associate homosexuality and bisexuality with white/European American culture and an abandonment of their own racial/ethnic community and culture.6 Regardless of its cause, the presumed greater heterosexism in racial and ethnic minority communities subject double minorities in those communities to more negative experiences and much greater distress. Consequently, there are significant group differences for sexual minority status disclosure and concealment; people who are double minorities are less likely to disclose and more likely to conceal their sexual minority status to reduce their exposure to oppression in their own racial/ethnic minority community.7,8

Scholars have cautioned that the uncritical assumption that racial and ethnic minority communities are more cisgender heterosexist may perpetuate stereotypes and over-pathologize people who are a double minority.8 Of course, such over-pathologizing is then followed by greater distress experienced by this population who are given even less family and community support and resources for their sexual minority status. Racial and ethnic minorities also experience unique factors that affect their reaction to stressors, such as lack of social support in general, discrimination, harassment, and mistreatment.9 More research, as well as more general public education, on sexual minority LGBTQ+ issues is warranted in racial and ethnic communities, in particular.

An examination of specific ethnic subgroups and trends shows particular areas of elevated risks. For example, Latinx (14%) high school students report a higher percentage of suicide attempts than their white (9.9%) or black peers (7.7%).10 Disparate suicide rates have consistently emerged based on sexual orientation and gender identity.11 LGBTQ+ people have higher rates of attempted suicide compared to their heterosexual (2%) and cisgendered counterparts (5% to 32%).9 This is another area where more research is needed to explore explanations for the increased suicide risk and/or suicide attempts in this double-minority population.

Health Concerns for Sexual Minorities

Multiple health care disparities persist that place double minorities within the LGBTQ+ community at greater health risk.12 Many variables must be considered when providing medical and mental health care. As discussed earlier, this particularly vulnerable population faces persistent and cumulative discrimination. Due to these persistent and cumulative barriers, this population often has fewer social supports, lower income, decreased educational attainment, and limited access to health care as compared to their cisgender heterosexual and white sexual minority peers.13 Historically, limited access to health care appears related to a lack of employer-sponsored health insurance and of cultural health care awareness, as well as to a dearth of access to high-quality health care providers who understand single minority or double-minority needs.2,12 This lack of health care can lead to delays in preventive medical screenings, starting necessary treatment, and obtaining prescription medications, as well as significant problems in finding and establishing a reliable and consistent source for basic health care needs.2 As a reminder, only in more recent years has the government begun to legally recognize the spouse and family status of children and partners of sexual minority employees, thereby allowing them equal access to employer-sponsored health coverage available to cisgender heterosexual counterparts.

The Center for American Progress outlined several health discrepancies among double sexual minorities.2 Statistics obtained from the California Health Interview Study, a large survey on health care data on sexual orientation,2 described health disparities and differences in social, economic, and environmental arenas. This health survey only obtained data for lesbian, gay, and bisexual individuals and did not include the transgendered population. Overall, racial disparities in health care outcome are even greater for sexual minority populations. For example, only 64% of lesbian, gay, and bisexual (LGB) Latinx adults have health insurance versus 77% of all LGB adults and 82% of cisgender heterosexual adults.14 LGB Latino adults suffer alcohol abuse at a rate of 60% compared to 33% of their cisgender heterosexual Latinx peers. Only 35% of LGB black women obtained age-appropriate mammography in a 2-year period in comparison to 57% of LGB women of all races and 62% of all heterosexual women.14 LGB black adults are 2.5 times more likely to have diabetes than the general population of black people, and 4 times more likely to have diabetes then white LGB counterparts or heterosexual peers.14 Black transgender women have the highest rates of HIV diagnoses with 29% as compared to all other racial or ethnic groups.14 These preventable differences in health care outcomes are likely related to difficulties obtaining consistent, reliable, and competent medical care.12

Some specific health disparities were demonstrated by Molina et al.15 at the University of Washington. In an Internet-based survey of 1,029 lesbian and bisexual women participants supported by the Centers for Disease Control and Prevention (CDC), they found the following discrepancies: (1) black lesbian and bisexual women were much more likely than white lesbian or bisexual participants to report both low fruit/vegetable intake and lower physical activity; (2) body mass index was considerably higher for black women; and (3) black lesbian and bisexual women were 4 times more likely to have diabetes and almost twice as likely to be diagnosed with hypertension than white lesbian or bisexual women.15 The authors reported that this discrepancy may be explained, in part, by black women living in more low income, segregated neighborhoods with fewer opportunities for exercise.15 Lower socioeconomic status and limited access to health care may also be contributing factors.

Other significant health concerns relate to the high HIV incidence in young black men who sleep with men (YBMSM). One study indicated that 11.8% of HIV-negative YBMSM seroconverted to HIV positive per year, demonstrating a community at much greater risk for HIV infection.16 The CDC reported that of the 38,739 new HIV diagnoses in the US and dependent territories in 2017, 10,070 (26%) were among black gay and bisexual men.17 Three of four black gay and bisexual men who received an HIV diagnosis were between the ages 13 and 34 years.17 Also, black gay and bisexual men had lower rates of viral suppression than other races/ethnic groups and a greater likelihood of having sexual partners of the same race than other ethnic groups.17 Also, CDC reported that YBMSM have a greater chance of coming in contact with HIV, and that stigma and homophobia may be preventing these men from seeking appropriate testing and treatment to reduce HIV viral load to negligible.17

Of note, we were unable to find any study to date that directly evaluated the potential negative effect of double-minority status on mental health and suicidality among a diverse group of sexual minority patients.1 In addition, research pertaining to adolescents who are a double minority is quite sparse, which limited our focus to adult populations.

Violence Against LGBTQ+ Sexual Minorities

Unfortunately, hate crimes and victimization directed toward people who are a sexual minority have a lengthy history. Assaults, torture, harassment, and even murder of LGBTQ+ people have been committed based on religious beliefs, political views, biases, and homophobic fear.18 People who are sexual minorities remain a likely target of hate crimes.19

In particular, transgender people are at high risk of discrimination, mistreatment, and violence.20 The 2015 US Transgender Survey, pooling data from 27,715 respondents, revealed high rates of “pervasive mistreatment and violence,” with most of these incidents occurring due to identified or perceived transgender status.20 An estimated 54% of this population were subjected to verbal harassment, 24% were physically attacked, and 13% were sexually assaulted. During the year prior to this survey, 46% reported being verbally harassed, 9% were physically attacked, 10% were sexually assaulted, and 30% were fired, denied promotion, or experienced some mistreatment in the workplace due to being transgender. Transgender respondents also reported a 39% incidence of serious psychological distress in the month prior to the survey compared to 4% in the general US population.20

Sexual minorities are also at increased risk for sexual victimization. Whereas 11% to 17% of women and 2% to 3% of men in the US reported that they have experienced sexual assault during their lifetimes,21 a review of population-based studies found that the reported lifetime prevalence of sexual assault is 15.6% to 85% for lesbian and bisexual women, 11.8% to 54% for gay and bisexual men,21 and nearly 47% in the transgender population.20

Relationship Violence in LGBTQ+ Communities

The term “domestic violence” is more closely associated with cisgender heterosexual relationships, whereas LGBTQ+ relationship violence may be referred to as “partner violence, relationship violence, or same-sex/same-gender domestic violence.”22 Although it is estimated that sexual minorities experience partner violence as often as or even more often than the general population, it has been difficult to estimate the prevalence of such violence as many large-scale domestic violence studies have not included LGBTQ+ members. Sexual minority victims often do not report the abuse due to possible fear about homophobic responses by authorities and concerns of betraying the LGBTQ+ community.22 It is also plausible that sexual minority victims of relationship violence may fear that their experience might be viewed as evidence that their sexual/gender identity is unhealthy. In addition, domestic violence services may not understand how to fully respond to same-sex partner violence, which may create the impression that these services are only for heterosexual persons. Women assaulted by other women may also not report these assaults because “rape” often implies penile penetration, and they may fear they will not be believed. People who are double minorities living in small, rural communities could be particularly vulnerable to violence due to increased isolation, lack of services and support, concern over homophobia, and increased presence of weapons.

Considerable misconception also exists about domestic violence in LGBTQ+ relationships. These myths include beliefs that violence in same-sex relationships is not as bad as in heterosexual relationships as it would represent more “mutual battering” of physically, equally strong partners.23 However, LGBTQ+ violence has many of the same forms as heterosexual violence, including emotional abuse of threats, humiliation, coercion, control, as well as physical and sexual abuse.22 Sexual abuse also includes forcing someone to have sex or raping someone with an object or weapon. It may also be assumed that in cisgender heterosexual relationships the “masculine” partner is the abuser and the “feminine” partner is the victim. However, physical appearance cannot be used to determine who the abuser is nor can gender binaries be assumed to operate within the LGBTQ+ relationship.22 However, bidirectional violence in which both partners perpetrate and receive acts of violence may be common in sexual minority people in same-sex relationships.24 Internalized homophobia, degree of “outness,” stigma consciousness, and experiences of discrimination based on sexual orientation are all related to intimate partner violence.24

There are abusive tactics that are specific to LGBTQ+ relationship violence related to homophobia, biphobia, and transphobia, and heterosexism.22 These behaviors may include threats to reveal the partner's sexual or gender identity to family, employer, and/or landlord. Intimidations may also include threats of reports to authorities to jeopardize the partner's child custody arrangements or immigration status. Survivors can experience a great deal of self-blame and shame, and both survivors and perpetrators may become ostracized by the LGBTQ+ community. This loss of support for survivors may impede recovery.22 The abusive partner may also tell the victim repeatedly that he or she is unattractive or—in case of transgender—is not a real women/man and that nobody else would want them.25 Abusive partners may not only threaten to reveal HIV/AIDS positive status to others but may also threaten to withhold medications. Victims who are HIV positive often perceive themselves as “damaged goods” and may remain in an abusive relationship as they believe that nobody else would want them.22

Domestic Violence in Double-Minority Communities

When two sexual minority people in a relationship are from the same cultural background, they may perceive to be the only support each other has in a given community or country. In such relationships, perpetrators may threaten and control their partner more easily and the victims may feel that they must endure the abuse and not turn on their partners. Also, an abusive partner may use their partner's immigration status, limited language skills, and lack of knowledge of the legal system against them by threatening deportation or incarceration.22,25

Conclusion

People who are both racial and sexual minorities experience more complex stressors and distress due to this status. The myth that racial/ethnic minority communities have fewer sexual minority LGBTQ+ people presents an additional stressor as double minorities are less likely to disclose their sexual identities. As a result, this population may suffer increased distress and significantly greater negative consequences than their cisgender heterosexual white peers, including less social support and a lack of consistent, quality health care access with poor medical outcomes. Although significant strides have been made in recent years to address issues and concerns in this population, an urgent need remains for additional research and public education on LGBTQ+ sexual minority issues in racial/ethnic minority communities.

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Authors

Lenore Arlee, LCSW, LADC, is an Instructor. Robyn Cowperthwaite, MD, is an Assistant Professor and the Chief of Child and Adolescent Psychiatry. Britta K. Ostermeyer, MD, MBA, FAPA, is a Practicing Board-Certified Forensic Psychiatrist; the Paul and Ruth Jonas Chair in Mental Health; a Professor and the Chairman; and the Chief of Psychiatry for OU Medicine and the Mental Health Authority of the Oklahoma County Detention Center. All authors are affiliated with the Department of Psychiatry and Behavioral Sciences at the University of Oklahoma College of Medicine and the University of Oklahoma Health Sciences Center.

Address correspondence to Britta K. Ostermeyer, MD, MBA, FAPA, Department of Psychiatry and Behavioral Sciences, University of Oklahoma Health Sciences Center, P.O. Box 26901, WP3470, 920 Stanton L. Young Boulevard, Oklahoma City, OK 73126-0901; email: Britta-Ostermeyer@ouhsc.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20190910-02

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