Health and Access to Care and Coverage for Lesbian, Gay, Bisexual, and Transgender Individuals in the U.S.
The LGBT Community
While there is no single definition of the “LGBT community” – indeed, it is a diverse and multidimensional group of individuals with unique identities and experiences, and variations by race/ethnicity, income, and other characteristics – LGBT individuals share the common experience of often being stigmatized due to their sexual orientation, gender identity, and/or gender expression.1 In its landmark 2011 report, The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding, the Institute of Medicine defines sexual orientation as “an enduring pattern of or disposition to experience sexual or romantic desires for, and relationships with, people of one’s same sex, the other sex, or both sexes.”2 This definition incorporates elements of attraction, behavior, and identity. It is important to note that for some individuals, their sexual identity does not necessarily fall into any specific category but, rather, exists along a spectrum. In addition, not all persons who engage in same-sex behavior or experience same-sex attraction identify as lesbian, gay, or bisexual.
Gender Identity refers to “an individual’s internal sense of being male, female, or something else. Since gender identity is internal, one’s gender identity is not necessarily visible to others.”3 Additionally, gender expression and gender role conformity further describe the extent to which a person does or does not adhere to expected gender norms and roles. Transgender refers to individuals whose sex at birth is different from their identity as male, female, or elsewhere along the gender spectrum. People who identify as transgender may live their lives as the opposite gender, and may seek prescription pharmacologic therapy and/or surgical transformation. Transgender people may identify as heterosexual, lesbian, gay, or bisexual, or somewhere else along the spectrum of sexual identity.
Lastly, while sexual orientation and gender identity are important aspects of an individual’s identity, they interact with many other factors, including sex, race/ethnicity, and class. The intersection of these characteristics helps to shape an individual’s health, access to care, and experience with the health care system.
Assessing the health needs and barriers to care of the LGBT population has been challenging due to the historical lack of data collection on sexual orientation and gender identity. While some health surveys have asked about sexual orientation, it has not been routine to collect and analyze data on sexual orientation and gender identity in many major health surveys, particularly nationally representative ones, meaning that much of the data available to date have been from smaller, non-representative studies and convenience samples. Where data have been collected, they have mostly focused on same-sex couples using data systems that collect information on relationship status.4 In addition, where data are available for individuals, there is more information about lesbian, gay, and bisexual persons than transgender individuals. There has been growing recognition of the need for research focused on the LGBT community, and the ACA has new data collection requirements on disparities, which include sexual orientation and gender identity (described below). The National Health Interview Survey (NHIS), the principal source of information on the health of the U.S. population, began including a question on sexual orientation in its 2013 survey and findings were released in July 2014.
Many data sources are used to make inferences about the LGBT population and estimates on the size of the LGBT population vary:
- Data on the size of the LGBT population in the United States range. The latest data from the National Health Interview Survey (NHIS), a nationally representative survey of the U.S. population on health issues which now includes questions on sexual orientation, indicate that 2.3% of adults ages 18 and older in the U.S. identify as lesbian, gay, or bisexual, equating to more than 5.2 million people.5 Gallup poll data have found that between 3.4% and 3.6% of Americans ages 18 and older identify as LGBT, or about 9 million people.6,7,8,9 Estimates may vary due to differing methodologies for data collection. Most of these surveys include only those who self-identify as LGB10 and do not include those who may have engaged in same-sex behavior or have same-sex attraction but do not identify as gay, lesbian, or bisexual. Other studies have looked beyond self-identification, to include behavior and attraction, and obtained higher estimates, including one that found that 10% of adults reported experience with same-sex partners.11 In addition, a recent analysis indicates that standard survey measures appear to significantly underestimate non-heterosexual identity and same-sex sexual experiences.12
- Data on those who identify as transgender are limited but a recent study found that an estimated 0.3% of the U.S. population is transgender, equating to approximately 700,000 people.13
- Estimates of self-identified LGBT individuals also vary by state. According to a 2012 Gallup poll, the share of adults who identify as LGBT ranges from a low of 1.7% in North Dakota to a high of 10% in the District of Columbia.14 This range could reflect local policies and societal attitudes regarding LGBT equality, which may be correlated with an individual’s willingness to self-identify as LGBT or live in a certain locale.
- Racial and ethnic minorities, young people, and women are more likely than their counterparts to identify as LGBT (Figure 1).15
- One in five (20%) LGBT individuals indicate they are married, and an additional 18% are in a domestic partnership or living with a partner (some of whom could be in heterosexual marriages or domestic partnerships).16
- According to the 2012 American Community Survey, a smaller share of same-sex couples is raising children compared to both married and unmarried heterosexual couples.17 Just over 40% of married and unmarried heterosexual couples are raising children, compared to 18% of same-sex couples, 11% of male same-sex couples and 24% of female same-sex couples.
- Compared to the general population, sexual and gender minorities are disproportionately poor overall, but there is variation between subgroups. A recent Pew Research poll of LGBT individuals found that about 4 in 10 (39%) earned $30,000 or less per year, compared to 28% of the U.S. population overall.18 Poverty rates on average are higher among lesbian and bisexual women, young people, and African Americans.19 According to an analysis of the 2006-2010 National Survey of Family Growth, more than one-quarter (28%) of lesbian and bisexual women are poor, compared with 21% of heterosexual women. Just over 1 in 5 gay and bisexual men (23%) are poor, compared to 15% of heterosexual men. However, when comparing couples, lesbian couples have the highest poverty rates, followed by heterosexual couples and male same-sex couples. Further, a recent survey of more than 6,400 transgender people from across the U.S. found that the transgender population is approximately 4 times as likely as the non-transgender population to have an annual income of less than $10,000.20