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Discrimination in the United States: Experiences of lesbian, gay, bisexual, transgender, and queer Americans

Discrimination in the United States: Experiences of lesbian, gay, bisexual, transgender, and... Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts Objective: To examine reported experiences of discrimination against lesbian, gay, Department of Epidemiology, Harvard bisexual, transgender, and queer (LGBTQ) adults in the United States, which broadly T.H. Chan School of Public Health, Boston, Massachusetts contribute to poor health outcomes. Research, Evaluation, and Learning Data Source and Study Design: Data came from a national, probability-based tel- Unit, Robert Wood Johnson Foundation, ephone survey of US adults, including 489 LGBTQ adults (282 non-Hispanic whites Princeton, New Jersey and 201 racial/ethnic minorities), conducted January-April 2017. Correspondence Methods: We calculated the percentages of LGBTQ adults reporting experiences of John M. Benson, MA, Department of Health Policy and Management, Harvard T.H. Chan discrimination in health care and several other domains related to their sexual orien- School of Public Health, 677 Huntington th tation and, for transgender adults, gender identity. We report these results overall, Avenue, Kresge 4 Floor, Boston, MA 02115, USA. by race/ethnicity, and among transgender adults only. We used multivariable models Email: jmbenson@hsph.harvard.edu to estimate adjusted odds of discrimination between racial/ethnic minority and white Funding information LGBTQ respondents. Robert Wood Johnson Foundation, Grant/ Principal Findings: Experiences of interpersonal discrimination were common for Award Number: 73713 LGBTQ adults, including slurs (57 percent), microaggressions (53 percent), sexual har- assment (51 percent), violence (51 percent), and harassment regarding bathroom use (34 percent). More than one in six LGBTQ adults also reported avoiding health care due to anticipated discrimination (18 percent), including 22 percent of transgender adults, while 16 percent of LGBTQ adults reported discrimination in health care encounters. LGBTQ racial/ethnic minorities had statistically significantly higher odds than whites in reporting discrimination based on their LGBTQ identity when applying for jobs, when trying to vote or participate in politics, and interacting with the legal system. Conclusions: Discrimination is widely experienced by LGBTQ adults across health care and other domains, especially among racial/ethnic minorities. Policy and pro- grammatic efforts are needed to reduce these negative experiences and their health impact on sexual and/or gender minority adults, particularly those who experience compounded forms of discrimination. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2019 The Authors. Health Services Research published by Wiley Periodicals, Inc. on behalf of Health Research and Educational Trust 1454     wileyonlinelibrary.com/journal/hesr Health Serv Res. 2019;54:1454–1466. CASEY Et Al .       1455 Health Services Research K E Y WO R D S discrimination, gender identity, Lesbian, gay, bisexual, trangender, queer (LGBTQ) health, Racial/ethnic differences in health and health care, sexual orientation, Social determinants of health, Survey research 1  |   I NTR O D U C TI O N Further, these negative consequences for health are likely to be compounded for individuals from multiple minority backgrounds, 18,25-30 Lesbian, gay, bisexual, transgender, and queer (LGBTQ) people in such as LGBTQ racial/ethnic minorities or LGBTQ women. the United States have experienced a long history of discrimina- Transgender people, with their unique health concerns, may also tion, including criminalization and classifications as mentally ill, at- face special health-related vulnerabilities as a result of discrimi- tempts to forcibly change LGBTQ people's sexual orientation and/ nation, including social and economic vulnerabilities that increase 31,32 or gender identity, hate crimes and violence, and exclusion from health risks. These effects are particularly alarming given that 1-3 employment, housing, public spaces, and social institutions. And LGBTQ people are significantly less likely than non-LGBTQ people 31,33 yet, despite this history and despite research examining beliefs to have health insurance and therefore may have less access to about discrimination generally and the consequences of experienc- medical care that could mitigate the adverse health consequences ing discrimination (discussed below), relatively few national efforts of discrimination. have been made to systematically study LGBTQ people's reported Few surveys have documented LGBTQ people's personal expe- 3-5 personal experiences of discrimination. While such efforts are riences of discrimination using national data and/or across multiple hindered by the inherent challenge of surveying a small, dispersed, domains of life. The landmark Institute of Medicine report on LGBT 6-8 difficult-to-define, and internally diverse population, it is none- health in 2011 identified the need for research to overcome some of theless critically important to study experiences of discrimination the methodological challenges that arise in studying LGBTQ popu- because of the established impact of discrimination on health and lation health, such as noninclusion of items to assess sexual orienta- well-being. tion and/or gender identity in federal surveys, small population size, Research demonstrates that experiencing discrimination or stigma, discrimination, privacy, and dispersion in sampling, among 8,34,35 harassment has significant and negative consequences for both others. Although some progress has been made, large national 9,10 physical and mental health. This field of research shows that probability studies of discrimination across multiple domains among experiences of enacted stigma, discrimination, and/or harass- LGBTQ adults remain the exception, rather than the rule. Particularly ment induce psychological, behavioral, and physiological stress needed are studies that allow comparisons by race/ethnicity within 3-6,8 responses in the body and that the impacts of these reactions ac- the LGBTQ population. This study attempts to expand on prior cumulate over time, leading to a wide range of negative health telephone polling methods by examining LGBTQ adults' experiences outcomes and health-related behaviors. Even the anticipation of across many areas of life, drawn from a large national sample of US or mental preparation for discrimination, whether discrimination adults. actually occurs (ie, felt stigma), has significantly harmful effects This study, alongside complementary articles in this issue of 12-14 on health. Health Services Research, brings a public health perspective to While much related research has focused on the effects of rac- the complexity and pervasiveness of discrimination in the United 10,15,16 16,17 ism and sexism on health, these same effects have also States today. It was conducted as part of a larger survey fielded been observed in the context of discrimination, harassment, and in 2017 in response to a growing national debate about discrim- 18-21 36 assault against nonrepresentative samples of LGBTQ people. ination in the United States today, to understand experiences In some cases, these effects persist even after basic protection of discrimination against several different groups in America, in- policies have been implemented. Experiencing discrimination cluding blacks, Latinos, Asians, Native Americans, women, and 23,24 persistently leads to negative health ef fects for LGBTQ people, LGBTQ people. This particular study has four main purposes: (a) and it limits their opportunities and access to critical resources in to examine the prevalence of discrimination, harassment, and vi- 21,22 areas such as health care, employment, and public safety. It olence against LGBTQ adults specifically because of their sexual also leads to avoidance of care, further amplifying these negative orientation and, for transgender adults and gender nonconform- health consequences. For example, transgender people who ing adults, their gender identity; (b) to examine such experiences have experienced discrimination in health care are more likely than across multiple domains of life raised as areas of concern among those who have not experienced discrimination to subsequently experts, including health care, education, employment, housing, avoid both preventative and urgent health care services, including political participation, police, and the criminal justice system, as needed care due to illness or injury. This leads to worse health well as interpersonal areas including slurs, microaggressions, ha- outcomes, including higher likelihood of depression and suicidal rassment, and violence; (c) to examine variation in experiences ideation or attempts. of discrimination within LGBTQ adults by race/ethnicity, as prior CASEY Et Al . 1456       Health Services Research research illustrates that racial/ethnic minority LGBTQ adults may survey were similar demographically to LGB adults in other na- be at particular risk for experiencing discrimination; and (d) to ex- tional, population-based samples obtaining higher response rates amine experiences of discrimination and harassment among a sub- (General Social Survey and National Health Interview Survey), sample of transgender adults (including those who identified as though federal surveys are also subject to the limitations noted genderqueer or gender nonconforming), who are also at particular above. We expect these results to be generalizable to the US adult risk for experiencing discrimination. population within a margin of error of ±6.6 percentage points at the 95% confidence interval, while noting the potential for un- derreporting among the US adult LGBTQ population. See Benson, 2  |  M E T H O DS Ben-Porath, and Casey (2019) for a further description of the sur- vey methodology. 2.1 | Study design and sample Data were obtained from a nationally representative, probability- 2.2 | Survey instrument based telephone (cell and landline) survey of US adults, conducted from January 26 to April 9, 2017. The survey was jointly designed by In this poll, we analyzed 25 questions about lifetime experiences of Harvard TH Chan School of Public Health, the Robert Wood Johnson discrimination, including adults' personal experiences of discrimina- Foundation, and National Public Radio. SSRS, an independent firm, tion and perceptions of discrimination in the nation. The objective administered the survey. Because Harvard researchers were not of this study was to examine the extent of discrimination experi- directly involved in data collection and de-identified datasets were enced by LGBTQ adults in America, building on question modules in used for analysis, the study was deemed “not human subjects re- this field adapted from prior surveys on racial and LGBTQ discrimi- 3-5,42,43 search” by the Harvard TH Chan School of Public Health Office of nation. We conceptualized discrimination as differential or Human Research Administration. unfair treatment of individuals based on their LGBTQ identity, and The full sample included 3453 US adults aged 18 years and older, we include discrimination that is “institutional” (based in laws, poli- including nationally representative samples of blacks, Latinos, Asian cies, institutions, and related behavior of individuals who work in Americans, Native Americans, whites, men, women, and LGBTQ or control these laws, policies, or institutions) and “interpersonal” 8,43,44,a  adults. This paper examines the subsample of 489 LGBTQ adults, (based in individuals' beliefs, words, and behavior). including 282 whites and 201 racial/ethnic minorities and an over- For this study, we analyzed questions about personal expe- sample of 86 transgender adults. Screening questions regarding riences, covering six institutional and seven interpersonal areas sexual orientation and gender identity were asked at the beginning of discrimination (full questions and wording in Appendix S1). of the survey, so that LGBTQ respondents could be identified and Institutional areas included employment, education, health care, asked relevant questions (see Appendix S1). For sexual orienta- housing, political par ticipation, and police and cour t s. Interpersonal tion, respondents were classified as LGBQ if they identified as gay areas included anti-LGBTQ slurs, microaggressions, other people's or lesbian, bisexual, or another sexual orientation specified by the fear of LGBTQ adults, sexual harassment, being threatened or non- respondent that was not heterosexual or straight. For gender iden- sexually harassed, being harassed or questioned regarding bath- tity, respondents were classified as transgender if they identified as room use, and experiencing violence, among other experiences. transgender male, transgender female, genderqueer or gender non- We also examined two areas where individuals might avoid seeking conforming, or another gender identity specified by the respondent help or services due to anticipation or fear of being discriminated that was not male or female. against: seeking medical care or the services of police or other au- The completion rate for this survey was 74 percent among thority figures. We examined these numerous domains in order to respondents who answered initial demographic screening ques- capture a wide range of possible discriminator y experiences across tions, with a 10 percent overall response rate, calculated based on adults' lives. the American Association for Public Opinion Research's (A APOR) Questions were only asked among a random half-sample of RR3 formula. Because data from this study were drawn from respondents to maximize the number of questions while limiting a probability sample and used the best available sampling and respondent burden (half-sample A = 259, half-sample B = 230). weighting practices in polling methods (eg, 68 percent of inter- Questions were only asked of relevant subgroups (eg, college-re- views were conducted by cell phone, and 32 percent were con- lated questions only asked among adults who had ever applied to ducted via landline), they are expected to provide accurate results or attended college). Questions about harassment (sexual and non- 38,39 consistent with sur veys with higher response rates. Sur veying sexual), violence, and avoiding institutions for fear of discrimination LGBTQ populations faces major challenges in constructing ade- were asked about yourself or friends or family members who are also quate sampling frames and sample sizes, as well as a stigmatized LGBTQ, because of the sensitive nature of the questions and prior respondent population, underreporting, and variations in ques- literature demonstrating that vicariously experiencing stress (eg, 6-8,34,35 tion wording on sexual orientation and/or gender identity. through discrimination experienced by family members) can directly While federal benchmark data are limited, respondents for this and adversely affect individuals. CASEY Et Al .       1457 Health Services Research and all tests accounted for the variance introduced by weighted 2.3 | Statistical analyses data. We first calculated the prevalence of all LGBTQ people who re- ported they had ever experienced discrimination because of their 3  |   RE S U LT S sexual orientation and/or gender identity in each of the afore- mentioned domains. Second, we generated bivariate statistics to 3.1 | Characteristics of the LGBTQ study sample assess whether experiencing discrimination because of LGBTQ identity was associated with race. Because of the sample size, Demographic and socioeconomic characteristics of US LGBTQ particularly with split-sampled questions, responses of nonwhite adults are displayed in Table 1; percentages of LGBTQ adults who racial/ethnic minorities were pooled together, and we compared have experienced discrimination because of their sexual orientation whites to racial/ethnic minorities. Six people were included in and/or gender identity are shown in Table 2; adjusted odds ratios of overall analyses but excluded from racial/ethnic comparisons be- reporting discrimination are shown in Table 3; descriptive analysis cause of insufficient race/ethnicity data. Using pairwise t tests of of transgender adults is shown in Table 4. All estimates display data differences in proportions, we made uncontrolled comparisons of weighted using survey weights. the weighted percentage of adults reporting discrimination be- Table 1 shows that a majority of the LGBTQ sample were cis- tween racial/ethnic minority and white adults, to examine where gender (77 percent), with 23 percent identifying as transgender or race/ethnicity affects LGBTQ adults' experiences of discrimina- genderqueer or gender nonconforming. A majority were also white tion, irrespective of cause. For all analyses, statistical significance (61 percent), while 39 percent identified as racial and/or ethnic mi- was determined at P < .05. norities. LGBTQ racial/ethnic minorities were significantly less likely We then conducted logistic regression models to assess than LGBTQ whites to have a college degree (23 percent vs 38 per- whether identifying as a racial/ethnic minority remained statisti- cent, P < .01) and to make $25 000 or more per year (46 percent vs cally significantly associated with discrimination after controlling 66 percent, P < .04). LGBTQ racial/ethnic minorities were also sig- for the following covariates and possible confounders: self-iden- nificantly more likely (23 percent) than LGBTQ whites (10 percent) tified gender (male or female, excluding genderqueer or gender to be without health insurance (P < .02). nonconforming due to insufficient sample size, n = 28); age in years (18-29 or 30+); self-reported household income (<$25 000 3.2 | Discrimination attributed to or $25 000+); and education (less than college degree or college sexual orientation and/or gender identity graduate). We also examined whether each of these sociodemo- graphic variables was significantly associated with experiencing Table 2 shows the weighted percent of LGBTQ adults, both in ag- discrimination across domains. Metropolitan status, region, and gregate and by race/ethnicity, who reported personally experiencing health insurance status were omitted from these models for par- various forms of discrimination because of their sexual orientation b  simony, due to the sample size. Odds ratios (OR) and 95% confi- and/or gender identity. The majority of LGBTQ adults reported dence intervals (95% CI) were estimated. personally experiencing interpersonal discrimination: 57 percent Finally, we conducted a subgroup descriptive analysis of said they have experienced slurs and 53 percent said they had ex- transgender adult s (n = 86), to assess their experiences separately perienced microaggressions related to their sexual orientation or from the larger LGBTQ population, given that we expected trans- gender identity. Similarly, the majority of LGBTQ adults reported gender experiences to be unique. We did not directly compare interpersonal discrimination either personally or in their immediate transgender adults to LGBQ adults because the groups are not friends or family: 57 percent said they or an LGBTQ friend or fam- mutually exclusive. Due to randomly assigned split sampling of ily member had been threatened or nonsexually harassed because the survey questionnaire, there were some questions that had of their LGBTQ identity, and 51 percent said they had experienced too few transgender respondents to report these percentages sexual harassment or violence because of their sexual orientation (half-sample A = 33, half-sample B = 55). Result s are only repor ted and/or gender identity. if n > 50. More than one-third (34 percent) of LGBTQ people said that they To compensate for known biases in telephone surveys (eg, or an LGBTQ friend or family member has personally been verbally nonresponse bias) and variations in probabilit y of selection within harassed while in a bathroom or been told or asked if they were in and across households, sample data were weighted by household the wrong bathroom. Another third (32 percent) said that they or size and composition, cell phone/landline use, and demograph- an LGBTQ friend/family member have been told or felt they would ics (gender, age, education, race/ethnicity, and census region) to be unwelcome in a neighborhood or place to live because they are reflect the true population distribution of adults in the country. LGBTQ. Other techniques, including random-digit dialing, replicate sub- In the context of institutional discrimination, 18 percent of LGBTQ samples, and random selection of a respondent within a house- adults reported they have avoided seeking health care for themselves hold, were used to ensure that the sample is representative. All or family members due to anticipated discrimination, while 16 per- analyses were conducted using STATA version 15.0 (StataCorp), cent reported discrimination in clinical encounters. One-fifth or more CASEY Et Al . 1458       Health Services Research T A B L E 1  Characteristics of LGBTQ adults in the study sample (N = 489) Racial/ethnic minority All LGBTQ adults N = 489 White LGBTQ adults N = 282 LGBTQ N = 201 Weighted percentage of respondents LGBQ (lesbian, gay, bisexual, and queer) 84 83 84 Cisgender 77 - - Transgender (including genderqueer and gender 23 25 20 nonconforming) Self-reported gender Male (cisgender and transgender) 38 35 43 Female (cisgender and transgender) 56 58 53 Genderqueer or gender nonconforming 6 6 5 Race White (non-Hispanic) 61 - - Nonwhite (racial/ethnic minority) 39 - - Age 18-29 y 41 39 45 30 + y 59 61 55 Education e * No college degree 68 62 77   College degree or more 32 38 23   Household income <$25 000 36 31 44 $25 000+ 55 61 46   Health insurance current status Uninsured 15 10 23   Insured, Medicaid 14 16 11 Insured, non-Medicaid 68 71 65 Area of residence Urban 30 26 3 Nonurban 64 67 61 Don't know/refused 6 7 4 US region of residence Northeast 23 22 26 Midwest 20 23 17 South 30 33 27 West 20 16 26 Don't know/refused 6 6 4 Percentage of US LGBTQ population estimated with survey weights to adjust for unequal probability of sampling. The sample size shown reflects the total number of respondents in each category. Percentages may not add up to 100% due to rounding and don't know/refused responses that are included in the total n but not reported in Table 1. LGBQ and transgender are not mutually exclusive. A person can identify as one or both. There were too few LGBTQ-identified racial/ethnic minority respondents to conduct independent analyses for each racial category (black, Latino, Asian American, Native American), particularly when questions are split-sampled. Including those with some college experience (including business, technical, or vocational school after high school) but no college degree, as well as those with a high school degree or GED certificate or less. Primary source of health insurance. Nonurban includes suburban and rural. Regions defined by US Census Bureau 4-region definition. *Different from whites, statistically significant at P < .05 (shown in bold). CASEY Et Al .       1459 Health Services Research T A B L E 2  Differences between white and racial/ethnic minority LGBTQ adults in reporting discrimination because of their LGBTQ identity Weighted Weighted percent of percent of all Weighted percent racial/ethnic minority b c c c Subject of discrimination N LGBTQ adults of white LGBTQ LGBTQ Belief in overall discrimination General belief that discrimination All LGBTQ adults (total 489 91 92 88 against lesbian, gay, and bisexual sample) people exists today in the United States General belief that discrimination All LGBTQ adults (total 489 91 93 88 against transgender people exists sample) today in the United States Experiences of institutional discrimination Employment Being paid equally or considered for You (half-sample A) 245 22 19 28 promotions Applying for jobs You (half-sample A) 245 20 13 32* Education Applying to or while attending You (half-sample B) 192 20 20 20 college Health care Going to a doctor or health clinic You (half-sample B) 230 16 20 9 Housing Trying to rent a room/apartment or You (half-sample B) 177 22 25 14 buy a house Political participation Trying to vote or participate in You (half-sample A) 255 11 7 16 politics Police and courts Interacting with police You (half-sample A) 258 16 11 24* Unfairly stopped or treated by the You or LGBTQ friend/family 259 26 26 26 police member (half-sample A) Unfairly treated by the courts You or LGBTQ friend/family 259 26 23 31 member (half-sample A) Experiences of interpersonal discrimination LGBTQ identity-based You (half-sample B) 230 53 64 35* microaggressions Racial identity-based You (half-sample B) 230 18 6 38* microaggressions LGBTQ identity-based slurs You (half-sample B) 230 57 65 41* Racial identity-based slurs You (half-sample B) 230 38 14 53* People acted afraid because of your You (half-sample B) 230 15 17 14 LGBTQ identity People acted afraid because of your You (half-sample B) 230 12 6 23* race/ethnicity Violence You or LGBTQ friend/family 259 51 57 42 member (half-sample A) Threatened or nonsexually harassed You or LGBTQ friend/family 259 57 60 52 member (half-sample A) Sexual harassment You or LGBTQ friend/family 259 51 57 43 member (half-sample A) (Continues) CASEY Et Al . 1460       Health Services Research T A B L E 2  (Continued) Weighted Weighted percent of percent of all Weighted percent racial/ethnic minority b c c c Subject of discrimination N LGBTQ adults of white LGBTQ LGBTQ Harassed while using bathroom You or LGBTQ family mem- 259 34 32 36 ber (half-sample A) Been told or felt unwelcome because You or LGBTQ family mem- 489 32 34 31 of being LGBTQ ber (total sample) Actions based on concerns about discrimination Avoided doctor or health care be- You or LGBTQ family mem- 230 18 21 12 cause of concerns of discrimination/ ber (half-sample B) poor treatment Avoided calling the police because of You or LGBTQ family mem- 259 15 11 21 concerns of discrimination ber (half-sample A) Thought about moving to another You (total sample) 489 31 31 30 area because of personally experi- enced discrimination White and racial/ethnic minority LGBTQ adults aged 18+, excluding n = 6 adults with missing race/ethnicity that are included in the total sample. Most questions only asked among a randomized subsample of half of respondents. Don't know/refused responses included in the total for unad- justed estimates. Questions about you are personal experiences only; questions about you or friend/family member ask if items have happened to you or a friend/ family member because you or they are part of the LGBTQ community. Percent calculated using survey weights. Bolded and starred values show a statistically significant difference between white and nonwhite LGBTQ adults at P < .05 using a t test. Question asked as “Generally speaking, do you believe there is or is not discrimination against [lesbian, gay, and bisexual people OR transgender people] in America today?” Equal pay question only asked among respondents who have ever been employed for pay. Jobs question only asked among respondents who have ever applied for a job. College application/attendance was only asked among respondents who have ever applied for college or attended college for any amount of time. Housing question only asked among respondents who have ever tried to rent a room or apartment, or to apply for a mortgage or buy a home. Question wording: “Do you believe that you or a friend or family member who is also part of the LGBTQ community has [experienced/been _____] because you or they are part of the LGBTQ community, or not?” Question wording: “In your day-to-day life, have any of the following things ever happened to you, or not?” and respondent indicated they had expe- rienced this and believed this happened because your sexual orientation or gender identity. Slurs = someone referred to you or a group you belong to using a slur or other negative word; Microaggressions = someone made negative assumptions or insensitive or offensive comments about you; People acted afraid = people acted as if they were afraid of you. You or a friend/family member who is also part of the LGBTQ community has been told or felt you would be unwelcome in a neighborhood, building, or housing development you were interested in because you are part of the LGBTQ community. You have thought about moving to another area because you have experienced discrimination or unequal treatment where you were living. reported personally experiencing discrimination specifically because of reporting race-based microaggressions (38 percent vs 6 percent, of their LGBTQ identity across multiple domains of life: when seeking P < .01), slurs (53 percent vs 14 percent, P < .01), and racial fear (23 housing (22 percent), equal pay or promotions (22 percent), applying percent vs 6 percent, P < .01). for jobs (20 percent), and applying to or while attending college (20 percent). About one-quarter of LGBTQ adults said they or LGBTQ 3.3 | Adjusted odds of reporting personal friends or family members had also been unfairly treated by the courts experiences of discrimination in LGBTQ adults (26 percent) or unfairly stopped or treated by police (26 percent) be- cause of their LGBTQ identity. Table 3 reports odds ratios with 95% confidence intervals examin- Importantly, LGBTQ racial/ethnic minorities were more than ing whether race/ethnicity differences in reported experiences of twice as likely as LGBTQ whites to say they had personally experi- discrimination persist after controlling for pertinent demographic enced institutional discrimination because of their LGBTQ identity variables, including age, race, gender, education, and income. For when applying for jobs (32 percent vs 13 percent, P < .02) and when institutional discrimination, LGBTQ racial/ethnic minority adults interacting with police (24 percent vs 11 percent, P < .05). Compared had significantly higher odds than LGBTQ whites for reporting dis- to LGBTQ whites, LGBTQ racial/ethnic minorities reported lower crimination on the basis of being LGBTQ when applying for jobs, prevalence of some forms of interpersonal discrimination, specifi- voting or participating in politics, and being treated unfairly by the cally LGBTQ-based microaggressions (35 percent vs 64 percent, courts. LGBTQ racial/ethnic minorities had lower odds for reporting P < .01) and slurs (41 percent vs 65 percent, P < .02). However, LGBTQ-based discrimination when going to a doctor or health clinic LGBTQ racial/ethnic minorities had a higher prevalence than whites than LGBTQ whites. CASEY Et Al .       1461 Health Services Research T A B L E 3  Adjusted odds of reporting personal experiences of discrimination across institutional and interpersonal domains among US LGBTQ adults Institutional discrimination Political Employment Education Health care Housing participation Police and courts Avoidance Unfairly Avoided Equal College ap Doctor or Trying to Trying to vote stopped or Unfairly Avoided calling the doctor due to Applying pay/pro plication/ health clinic rent or buy or participate Interacting treated by the treated by police due to dis discrimina b c d e,f for jobs motions attendance visits a house in politics with Police police the courts crimination concerns tion concerns N 214 213 167 189 151 219 222 221 223 223 193 Race/ethnicity White Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref * * * * Racial/ 3.16   1.57 0.83 (0.24, 0.31   (0.10, 0.31 (0.08, 3.13   (1.00, 1.75 (0.69, 0.90 (0.41, 2.80   1.25 (0.50, 3.13) 0.56 (0.19, ethnic (1.35, (0.66, 2.81) 0.97) 1.24) 9.73) 4.48) 1.96) (1.26, 1.64) minority 7.40) 3.75) 6.24) Self-identified gender Male Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref * * * * Female 0.39   0.34   2.12 (0.77, 1.40 (0.54, 0.87 (0.26, 0.28   (0.09, 0.36 (0.13, 1.14 (0.50, 0.40   0.89 (0.32, 2.53) 1.11 (0.42, (0.15, (0.14, 5.86) 3.66) 2.96) 0.86) 0.94) 2.64) (0.17, 2.91) 0.96) 0.82) 0.96) Education <College Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref * * College+ 1.12 0.92 0.46 (0.14, 1.26 (0.41, 0.24   (0.08, 1.33 (0.35, 1.46 (0.48, 2.28 (0.93, 1.72 (0.71, 1.55 (0.53,4.51) 3.35   (1.32, (0.44, (0.38, 1.48) 3.88) 0.74) 5.09) 4.45) 5.57) 4.17) 8.48) 2.87) 2.23) Income <25k Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref 25k+ 0.67 (0.29, 0.87 1.28 (0.35, 0.86 (0.24, 0.77 (0.21, 0.37 (0.11, 0.31   (0.10, 0.79 (0.32, 1.08 (0.46, 0.40 (0.14, 1.15) 0.72 (0.25, 1.56) (0.34, 4.76) 3.09) 2.86) 1.22) 0.96) 1.95) 2.56) 2.04) 2.23) Age 18-29 Ref Ref Ref Ref - Ref Ref Ref Ref Ref Ref * * 30+ 0.52 1.17 2.46 (0.53, 2.89 (0.69, - 0.86 (0.27, 0.35   (0.13, 0.84 (0.36, 1.06 (0.45, 0.41 (0.15, 1.13) 0.31   (0.11, (0.20, (0.43, 11.39) 12.12) 2.72) 0.93) 1.97) 2.50) 0.92) 1.33) 3.24) (Continues) CASEY Et Al . 1462       Health Services Research T A B L E 3  (Continued) Interpersonal discrimination LGBTQ iden Harassed Been told/felt un Thought about titybased LGBTQ identity‐ Threats or non while using the welcome because moving to another microaggressions based slurs Sexual harassment sexual harassment Violence bathroom you are LGBTQ area N 421 421 222 224 225 225 412 420 OR (95% CI) Race/ethnicity White Ref Ref Ref Ref Ref Ref Ref Ref Racial/ethnic 0.44   (0.21, 0.88) 0.51 (0.25, 1.02) 0.72 (0.33, 1.58) 0.79 (0.35, 1.76) 0.52 (0.23, 1.15) 1.43 (0.64, 3.22) 1.07 (0.59, 1.94) 0.95 (0.51, 1.77) minority Self-identified gender Male Ref Ref Ref Ref Ref Ref Ref Ref Female 1.11 (0.59, 2.05) 0.97 0.52, 1.82) 0.87 (0.41, 1.86) 0.68 (0.32, 1.45) 0.40   (0.19, 0.83) 1.28 (0.59, 2.75) 1.01 (0.57, 1.79) 1.28 (0.70, 2.34) Education <College Ref Ref Ref Ref Ref Ref Ref Ref College+ 1.06 (0.56, 2.00) 1.48 (0.79, 2.80) 1.94 (0.87, 4.32) 2.20 (0.96, 5.01) 1.29 (0.57, 2.88) 2.06 (0.89, 4.81) 1.20 (0.66, 2.17) 0.85 (0.45, 1.59) Income <25k Ref Ref Ref Ref Ref Ref Ref Ref 25k+ 1.46 (0.71, 2.99) 0.92 (0.44, 1.91) 1.04 (0.44, 2.43) 1.16 (0.49, 2.70) 0.82 (0.34, 1.99) 1.43 (0.58, 3.50) 1.22 (0.65, 2.31) 0.97 (0.50, 1.89) Age 18-29 Ref Ref Ref Ref Ref Ref Ref Ref 30+ 0.44   (0.21, 0.89) 0.88 (0.41, 1.89) 0.50 (0.22, 1.16) 0.50 (0.21, 1.20) 0.68 (0.29, 1.57) 0.72 (0.31, 1.66) 0.67 (0.36, 1.24) 0.89 (0.46, 1.73) Abbreviations: CI, confidence interval; OR, odds ratio. Individual questions only asked among a randomized half-sample of respondents. Don't know/refused responses coded as missing. Jobs question only asked among respondents who have ever applied for a job. Equal pay question only asked among respondents who have ever been employed for pay. College application/attendance only asked among respondents who have ever applied for college or attended college for any amount of time. Housing question only asked among respondents who have ever tried to rent a room or apartment, or to apply for a mortgage or buy a home. Age variable omitted in the housing model due to too few respondents aged 18-29 who had ever attempted to rent an apartment or buy a house or mortgage. White (non-Hispanic) or racial/ethnic minority (including African American/black, Hispanic/Latino, Asian, American Indian, Alaska Native, Native Hawaiian, Pacific Islander, and other nonwhite identities). *Significant at P < .05 (shown in bold). US LGBTQ adults aged 18+. CASEY Et Al .       1463 Health Services Research T A B L E 4  Prevalence of transgender adults reporting discrimination Weighted percent of b c Subject of discrimination N transgender adults Belief in overall discrimination General belief that discrimination against transgender All transgender adults (total sample) 86 84 people exists today in the United States Personal experiences of institutional discrimination Health care Going to a doctor or health clinic You (half-sample B) 55 10 Personal experiences of interpersonal discrimination Microaggressions You (half-sample B) 55 28 Slurs You (half-sample B) 55 38 People acted afraid You (half-sample B) 55 18 Been told or felt unwelcome because of being You or LGBTQ friend/family member (total 86 22 transgender sample) Actions based on concerns about discrimination Avoided doctor or health care because of concerns of You or LGBTQ family member (half-sample 55 22 discrimination/poor treatment B) Thought about moving to another area because of You (total sample) 86 27 personally experienced discrimination Transgender adults include transgender, genderqueer, and gender nonconforming adults aged 18+. Most individual questions only asked among a randomized subsample of half of respondents. Don't know/refused responses included in the total for unadjusted estimates. Questions about you are personal experiences only; questions about you or LGBTQ friend/family member ask if items have happened to you or a friend/family member because you or they are part of the LGBTQ community. Percent calculated using survey weights. Question asked as “Generally speaking, do you believe there is or is not discrimination against transgender people in America today?” Question wording: “In your day-to-day life, have any of the following things ever happened to you, or not?” and respondent indicated they had ex- perienced this and believed this happened because your sexual orientation or gender identity. Slurs = someone referred to you or a group you belong to using a slur or other negative word; Microaggressions = someone made negative assumptions or insensitive or offensive comments about you; People acted afraid = people acted as if they were afraid of you. You or a friend/family member who is also part of the LGBTQ community has been told or felt you would be unwelcome in a neighborhood, building, or housing development you were interested in because you are part of the LGBTQ community. You have thought about moving to another area because you have experienced discrimination or unequal treatment where you were living. Gender also had statistically significant associations in modeling 3.4 | Subsample of transgender adults institutional discrimination. Here, LGBTQ females (transgender-in- clusive) had lower odds than LGBTQ males of reporting institutional Table 4 presents the unadjusted percent of transgender adults, discrimination when applying for jobs, seeking equal pay or promo- where sample size allowed, reporting various experiences of tions, when trying to vote or participate in politics, and in unfair discrimination because of their gender identity and/or sexual treatment by the courts. Models did not meaningfully change in sen- orientation. In the context of interpersonal forms of discrimina- sitivity analyses excluding transgender adults. tion, 38 percent of transgender adults say they have personally Education was also influential: LGBTQ adults with a college degree experienced slurs, and 28 percent have experienced microaggres- had significantly higher odds than those without a college degree of sions specifically related to their gender identity and/or sexual reporting they had avoided seeking medical care out of concern they orientation. Due to split sampling, there were too few transgen- would be discriminated against or treated poorly. LGBTQ adults with a der respondents to analyze the question regarding bathroom college degree had lower odds of reporting discrimination when seek- harassment. ing housing, compared to those without a college degree. When it comes to health care, 10 percent of transgender peo- For interpersonal forms of discrimination, LGBTQ racial/ethnic ple said they have personally experienced discrimination because minorities were less likely than LGBTQ whites to report experiencing of their gender identit y when going to a doctor or health clinic, and LGBTQ-based microaggressions. LGBTQ adults aged 30 and older also more than one in five (22 percent) said they have avoided seeking had lower odds of reporting microaggressions, compared to those health care due to anticipation of discrimination or poor treat- aged 18-29. Finally, females were less likely than males to report ex- ment. With regard to the domain of housing, nearly one-quarter periencing LGBTQ-related violence. No other demographic variables (22 percent) of transgender people reported that they have been were statistically significant in models of interpersonal discrimination. told or felt they would be unwelcome in a neighborhood, building, CASEY Et Al . 1464       Health Services Research or housing development because they were transgender, while research using electronic health record data is a promising approach to over one-quarter (27 percent) said they have thought about mov- further study LGBTQ persons and other small populations, while mo- ing to another area to live because of the discrimination they have bile device or computer apps and other novel methods for data capture already experienced. may also improve research on the unique experiences of discrimination 8,46 among LGBTQ persons within the health care system. At a minimum, improving medical and administrative staff training on cultural compe- 4  |  D I S CU S S I O N tency for serving LGBTQ people, as well as improving data collection on sexual orientation and gender identity in health care, is needed. In this national US study of reported discrimination among LGBTQ adults, four key findings emerge. First, study results extend prior 4.1 | Limitations findings that LGBTQ adults in the United States experience perva- 3-6,18-21,24,27,28 sive discrimination across many areas of life. In par- The findings should be viewed with several limitations in mind. First, ticular, we found widespread interpersonal manifestations, including although we examined a broad range of domains of life, this study slurs, harassment, and violence. covers only a subset of types of discrimination and harassment that Second, institutional discrimination is also clearly present in LGBTQ people may experience. Second, we asked whether LGBTQ health care. Prior research has reported perceived mistreatment people had experienced these types of discrimination at any point 6,18,32 in health care settings among LGB and transgender adults. In in their life, without regard to timing or severity. This limits the abil- this study, more than one in six LGBTQ adults say they have avoided ity to estimate current levels of discrimination and harassment and health care due to anticipated discrimination and experienced dis- instead focuses on lifetime experiences. crimination in health care encounters. Among transgender adults, Third, the prevalence of many sensitive topics, including sexual ha- these estimates are even higher. This is particularly worrisome and rassment and violence, is often underreported—particularly on surveys merits further education and antidiscriminatory policies and train- administered by an interviewer, such as this study—and therefore, ing in health care, as avoiding health care can further exacerbate the “true” prevalence of LGBTQ people's experiences of discrimina- 6,14,22 health disparities between LGBTQ and non-LGBTQ adults. tion is likely higher than reported herein. Perceptions of various kinds Third, LGBTQ racial and ethnic minorities are significantly more of discrimination (eg, race-based and sexuality-based) are also signifi- 26,29,30 likely to report many forms of discrimination, even when controlling cantly associated with each other, and it is not always possible for other factors. LGBTQ racial and ethnic minority adults had a to disentangle these experiences from each other, so asking specifi- significantly lower odds of reporting LGBTQ identity-based micro- cally about LGBTQ-based discrimination may lead to underreporting aggressions relative to whites, though they were more likely than of overall discrimination experienced by some respondents. Questions LGBTQ whites to report experiencing racially based microaggres- about discrimination based on race/ethnicity and gender (among fe- sions (not adjusted for demographic characteristics). These results males only) are examined separately in other articles in this issue. are largely consistent with prior research finding higher reported Fourth, our low response rate is a notable limitation, though ev- racial discrimination among racial/ethnic sexual minorities relative idence suggests that low response rates do not bias results if the 38,39 to white sexual minorities in public settings, accompanied by both survey sample is representative of the study population. Recent sexual orientation and gender discrimination. Our findings also research has shown that such surveys, when based on probability support other studies demonstrating that racial/ethnic identity com- samples and weighted using US Census parameters, yield accurate es- pounds experiences of discrimination in addition to LGBTQ identity timates in most cases when compared with both objective measures 25-27,29,30 38,39,48,49 in many areas of life. and higher-response surveys. For instance, a recent study While it is beyond the scope of our results to promote specific showed that across 14 different demographic and personal charac- policies or practices to end discrimination in the United States, these teristics, the average difference between government estimates from findings indicate both top-down (eg, policy) and bottom-up (eg, com- high-response rate surveys and a Pew Research Center poll with a re- munity organizations or local initiatives) efforts need to take steps sponse rate similar to this poll was 3 percentage points. However, it to address this widespread discrimination, on both institutional and is still possible that some selection bias may remain that is related to (especially) interpersonal levels. For transgender people, housing the experiences being measured, particularly given the challenges of 6-8,34-45 and health care appear to be major areas of concern, while LGBTQ surveying the LGBTQ population noted earlier. racial/ethnic minorities face significant obstacles with employment Fifth, transgender people are often discriminated against due and the legal system. Multisector partnerships are urgently needed to their presumed gender or gender identity. Given that trans peo- to implement interventions, propel policy efforts, and create social ple may be of any sexual orientation, they may also be discriminated change to protect LGBTQ people across different systems, including against because of their sexual orientation. Furthermore, some people employment, health care, housing, and legal systems. may not know the difference between sexual orientation and gender In addition, more research is needed that includes both new meth- identity, so they may discriminate against someone because of their ods and novel data sources to improve the study of LGBTQ popula- gender but using language about sexual orientation (or vice versa). 6-8,34,35 tions, given the current methodological limitations. In particular, Therefore, it should be expected that transgender people report CASEY Et Al .       1465 Health Services Research There were no statistically significant differences between LGBTQ men experiences of discrimination related to both their gender identity and women in their unadjusted reported experiences of anti-LGBTQ and sexual orientation, and so we report these experiences together, discrimination. and this study was unable to distinguish between these experiences. 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Discrimination in the United States: Experiences of lesbian, gay, bisexual, transgender, and queer Americans

Health Services Research , Volume 54 (Suppl 2) – Oct 28, 2019

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© 2019 The Authors. Health Services Research published by Wiley Periodicals, Inc. on behalf of Health Research and Educational Trust
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10.1111/1475-6773.13229
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Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts Objective: To examine reported experiences of discrimination against lesbian, gay, Department of Epidemiology, Harvard bisexual, transgender, and queer (LGBTQ) adults in the United States, which broadly T.H. Chan School of Public Health, Boston, Massachusetts contribute to poor health outcomes. Research, Evaluation, and Learning Data Source and Study Design: Data came from a national, probability-based tel- Unit, Robert Wood Johnson Foundation, ephone survey of US adults, including 489 LGBTQ adults (282 non-Hispanic whites Princeton, New Jersey and 201 racial/ethnic minorities), conducted January-April 2017. Correspondence Methods: We calculated the percentages of LGBTQ adults reporting experiences of John M. Benson, MA, Department of Health Policy and Management, Harvard T.H. Chan discrimination in health care and several other domains related to their sexual orien- School of Public Health, 677 Huntington th tation and, for transgender adults, gender identity. We report these results overall, Avenue, Kresge 4 Floor, Boston, MA 02115, USA. by race/ethnicity, and among transgender adults only. We used multivariable models Email: jmbenson@hsph.harvard.edu to estimate adjusted odds of discrimination between racial/ethnic minority and white Funding information LGBTQ respondents. Robert Wood Johnson Foundation, Grant/ Principal Findings: Experiences of interpersonal discrimination were common for Award Number: 73713 LGBTQ adults, including slurs (57 percent), microaggressions (53 percent), sexual har- assment (51 percent), violence (51 percent), and harassment regarding bathroom use (34 percent). More than one in six LGBTQ adults also reported avoiding health care due to anticipated discrimination (18 percent), including 22 percent of transgender adults, while 16 percent of LGBTQ adults reported discrimination in health care encounters. LGBTQ racial/ethnic minorities had statistically significantly higher odds than whites in reporting discrimination based on their LGBTQ identity when applying for jobs, when trying to vote or participate in politics, and interacting with the legal system. Conclusions: Discrimination is widely experienced by LGBTQ adults across health care and other domains, especially among racial/ethnic minorities. Policy and pro- grammatic efforts are needed to reduce these negative experiences and their health impact on sexual and/or gender minority adults, particularly those who experience compounded forms of discrimination. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2019 The Authors. Health Services Research published by Wiley Periodicals, Inc. on behalf of Health Research and Educational Trust 1454     wileyonlinelibrary.com/journal/hesr Health Serv Res. 2019;54:1454–1466. CASEY Et Al .       1455 Health Services Research K E Y WO R D S discrimination, gender identity, Lesbian, gay, bisexual, trangender, queer (LGBTQ) health, Racial/ethnic differences in health and health care, sexual orientation, Social determinants of health, Survey research 1  |   I NTR O D U C TI O N Further, these negative consequences for health are likely to be compounded for individuals from multiple minority backgrounds, 18,25-30 Lesbian, gay, bisexual, transgender, and queer (LGBTQ) people in such as LGBTQ racial/ethnic minorities or LGBTQ women. the United States have experienced a long history of discrimina- Transgender people, with their unique health concerns, may also tion, including criminalization and classifications as mentally ill, at- face special health-related vulnerabilities as a result of discrimi- tempts to forcibly change LGBTQ people's sexual orientation and/ nation, including social and economic vulnerabilities that increase 31,32 or gender identity, hate crimes and violence, and exclusion from health risks. These effects are particularly alarming given that 1-3 employment, housing, public spaces, and social institutions. And LGBTQ people are significantly less likely than non-LGBTQ people 31,33 yet, despite this history and despite research examining beliefs to have health insurance and therefore may have less access to about discrimination generally and the consequences of experienc- medical care that could mitigate the adverse health consequences ing discrimination (discussed below), relatively few national efforts of discrimination. have been made to systematically study LGBTQ people's reported Few surveys have documented LGBTQ people's personal expe- 3-5 personal experiences of discrimination. While such efforts are riences of discrimination using national data and/or across multiple hindered by the inherent challenge of surveying a small, dispersed, domains of life. The landmark Institute of Medicine report on LGBT 6-8 difficult-to-define, and internally diverse population, it is none- health in 2011 identified the need for research to overcome some of theless critically important to study experiences of discrimination the methodological challenges that arise in studying LGBTQ popu- because of the established impact of discrimination on health and lation health, such as noninclusion of items to assess sexual orienta- well-being. tion and/or gender identity in federal surveys, small population size, Research demonstrates that experiencing discrimination or stigma, discrimination, privacy, and dispersion in sampling, among 8,34,35 harassment has significant and negative consequences for both others. Although some progress has been made, large national 9,10 physical and mental health. This field of research shows that probability studies of discrimination across multiple domains among experiences of enacted stigma, discrimination, and/or harass- LGBTQ adults remain the exception, rather than the rule. Particularly ment induce psychological, behavioral, and physiological stress needed are studies that allow comparisons by race/ethnicity within 3-6,8 responses in the body and that the impacts of these reactions ac- the LGBTQ population. This study attempts to expand on prior cumulate over time, leading to a wide range of negative health telephone polling methods by examining LGBTQ adults' experiences outcomes and health-related behaviors. Even the anticipation of across many areas of life, drawn from a large national sample of US or mental preparation for discrimination, whether discrimination adults. actually occurs (ie, felt stigma), has significantly harmful effects This study, alongside complementary articles in this issue of 12-14 on health. Health Services Research, brings a public health perspective to While much related research has focused on the effects of rac- the complexity and pervasiveness of discrimination in the United 10,15,16 16,17 ism and sexism on health, these same effects have also States today. It was conducted as part of a larger survey fielded been observed in the context of discrimination, harassment, and in 2017 in response to a growing national debate about discrim- 18-21 36 assault against nonrepresentative samples of LGBTQ people. ination in the United States today, to understand experiences In some cases, these effects persist even after basic protection of discrimination against several different groups in America, in- policies have been implemented. Experiencing discrimination cluding blacks, Latinos, Asians, Native Americans, women, and 23,24 persistently leads to negative health ef fects for LGBTQ people, LGBTQ people. This particular study has four main purposes: (a) and it limits their opportunities and access to critical resources in to examine the prevalence of discrimination, harassment, and vi- 21,22 areas such as health care, employment, and public safety. It olence against LGBTQ adults specifically because of their sexual also leads to avoidance of care, further amplifying these negative orientation and, for transgender adults and gender nonconform- health consequences. For example, transgender people who ing adults, their gender identity; (b) to examine such experiences have experienced discrimination in health care are more likely than across multiple domains of life raised as areas of concern among those who have not experienced discrimination to subsequently experts, including health care, education, employment, housing, avoid both preventative and urgent health care services, including political participation, police, and the criminal justice system, as needed care due to illness or injury. This leads to worse health well as interpersonal areas including slurs, microaggressions, ha- outcomes, including higher likelihood of depression and suicidal rassment, and violence; (c) to examine variation in experiences ideation or attempts. of discrimination within LGBTQ adults by race/ethnicity, as prior CASEY Et Al . 1456       Health Services Research research illustrates that racial/ethnic minority LGBTQ adults may survey were similar demographically to LGB adults in other na- be at particular risk for experiencing discrimination; and (d) to ex- tional, population-based samples obtaining higher response rates amine experiences of discrimination and harassment among a sub- (General Social Survey and National Health Interview Survey), sample of transgender adults (including those who identified as though federal surveys are also subject to the limitations noted genderqueer or gender nonconforming), who are also at particular above. We expect these results to be generalizable to the US adult risk for experiencing discrimination. population within a margin of error of ±6.6 percentage points at the 95% confidence interval, while noting the potential for un- derreporting among the US adult LGBTQ population. See Benson, 2  |  M E T H O DS Ben-Porath, and Casey (2019) for a further description of the sur- vey methodology. 2.1 | Study design and sample Data were obtained from a nationally representative, probability- 2.2 | Survey instrument based telephone (cell and landline) survey of US adults, conducted from January 26 to April 9, 2017. The survey was jointly designed by In this poll, we analyzed 25 questions about lifetime experiences of Harvard TH Chan School of Public Health, the Robert Wood Johnson discrimination, including adults' personal experiences of discrimina- Foundation, and National Public Radio. SSRS, an independent firm, tion and perceptions of discrimination in the nation. The objective administered the survey. Because Harvard researchers were not of this study was to examine the extent of discrimination experi- directly involved in data collection and de-identified datasets were enced by LGBTQ adults in America, building on question modules in used for analysis, the study was deemed “not human subjects re- this field adapted from prior surveys on racial and LGBTQ discrimi- 3-5,42,43 search” by the Harvard TH Chan School of Public Health Office of nation. We conceptualized discrimination as differential or Human Research Administration. unfair treatment of individuals based on their LGBTQ identity, and The full sample included 3453 US adults aged 18 years and older, we include discrimination that is “institutional” (based in laws, poli- including nationally representative samples of blacks, Latinos, Asian cies, institutions, and related behavior of individuals who work in Americans, Native Americans, whites, men, women, and LGBTQ or control these laws, policies, or institutions) and “interpersonal” 8,43,44,a  adults. This paper examines the subsample of 489 LGBTQ adults, (based in individuals' beliefs, words, and behavior). including 282 whites and 201 racial/ethnic minorities and an over- For this study, we analyzed questions about personal expe- sample of 86 transgender adults. Screening questions regarding riences, covering six institutional and seven interpersonal areas sexual orientation and gender identity were asked at the beginning of discrimination (full questions and wording in Appendix S1). of the survey, so that LGBTQ respondents could be identified and Institutional areas included employment, education, health care, asked relevant questions (see Appendix S1). For sexual orienta- housing, political par ticipation, and police and cour t s. Interpersonal tion, respondents were classified as LGBQ if they identified as gay areas included anti-LGBTQ slurs, microaggressions, other people's or lesbian, bisexual, or another sexual orientation specified by the fear of LGBTQ adults, sexual harassment, being threatened or non- respondent that was not heterosexual or straight. For gender iden- sexually harassed, being harassed or questioned regarding bath- tity, respondents were classified as transgender if they identified as room use, and experiencing violence, among other experiences. transgender male, transgender female, genderqueer or gender non- We also examined two areas where individuals might avoid seeking conforming, or another gender identity specified by the respondent help or services due to anticipation or fear of being discriminated that was not male or female. against: seeking medical care or the services of police or other au- The completion rate for this survey was 74 percent among thority figures. We examined these numerous domains in order to respondents who answered initial demographic screening ques- capture a wide range of possible discriminator y experiences across tions, with a 10 percent overall response rate, calculated based on adults' lives. the American Association for Public Opinion Research's (A APOR) Questions were only asked among a random half-sample of RR3 formula. Because data from this study were drawn from respondents to maximize the number of questions while limiting a probability sample and used the best available sampling and respondent burden (half-sample A = 259, half-sample B = 230). weighting practices in polling methods (eg, 68 percent of inter- Questions were only asked of relevant subgroups (eg, college-re- views were conducted by cell phone, and 32 percent were con- lated questions only asked among adults who had ever applied to ducted via landline), they are expected to provide accurate results or attended college). Questions about harassment (sexual and non- 38,39 consistent with sur veys with higher response rates. Sur veying sexual), violence, and avoiding institutions for fear of discrimination LGBTQ populations faces major challenges in constructing ade- were asked about yourself or friends or family members who are also quate sampling frames and sample sizes, as well as a stigmatized LGBTQ, because of the sensitive nature of the questions and prior respondent population, underreporting, and variations in ques- literature demonstrating that vicariously experiencing stress (eg, 6-8,34,35 tion wording on sexual orientation and/or gender identity. through discrimination experienced by family members) can directly While federal benchmark data are limited, respondents for this and adversely affect individuals. CASEY Et Al .       1457 Health Services Research and all tests accounted for the variance introduced by weighted 2.3 | Statistical analyses data. We first calculated the prevalence of all LGBTQ people who re- ported they had ever experienced discrimination because of their 3  |   RE S U LT S sexual orientation and/or gender identity in each of the afore- mentioned domains. Second, we generated bivariate statistics to 3.1 | Characteristics of the LGBTQ study sample assess whether experiencing discrimination because of LGBTQ identity was associated with race. Because of the sample size, Demographic and socioeconomic characteristics of US LGBTQ particularly with split-sampled questions, responses of nonwhite adults are displayed in Table 1; percentages of LGBTQ adults who racial/ethnic minorities were pooled together, and we compared have experienced discrimination because of their sexual orientation whites to racial/ethnic minorities. Six people were included in and/or gender identity are shown in Table 2; adjusted odds ratios of overall analyses but excluded from racial/ethnic comparisons be- reporting discrimination are shown in Table 3; descriptive analysis cause of insufficient race/ethnicity data. Using pairwise t tests of of transgender adults is shown in Table 4. All estimates display data differences in proportions, we made uncontrolled comparisons of weighted using survey weights. the weighted percentage of adults reporting discrimination be- Table 1 shows that a majority of the LGBTQ sample were cis- tween racial/ethnic minority and white adults, to examine where gender (77 percent), with 23 percent identifying as transgender or race/ethnicity affects LGBTQ adults' experiences of discrimina- genderqueer or gender nonconforming. A majority were also white tion, irrespective of cause. For all analyses, statistical significance (61 percent), while 39 percent identified as racial and/or ethnic mi- was determined at P < .05. norities. LGBTQ racial/ethnic minorities were significantly less likely We then conducted logistic regression models to assess than LGBTQ whites to have a college degree (23 percent vs 38 per- whether identifying as a racial/ethnic minority remained statisti- cent, P < .01) and to make $25 000 or more per year (46 percent vs cally significantly associated with discrimination after controlling 66 percent, P < .04). LGBTQ racial/ethnic minorities were also sig- for the following covariates and possible confounders: self-iden- nificantly more likely (23 percent) than LGBTQ whites (10 percent) tified gender (male or female, excluding genderqueer or gender to be without health insurance (P < .02). nonconforming due to insufficient sample size, n = 28); age in years (18-29 or 30+); self-reported household income (<$25 000 3.2 | Discrimination attributed to or $25 000+); and education (less than college degree or college sexual orientation and/or gender identity graduate). We also examined whether each of these sociodemo- graphic variables was significantly associated with experiencing Table 2 shows the weighted percent of LGBTQ adults, both in ag- discrimination across domains. Metropolitan status, region, and gregate and by race/ethnicity, who reported personally experiencing health insurance status were omitted from these models for par- various forms of discrimination because of their sexual orientation b  simony, due to the sample size. Odds ratios (OR) and 95% confi- and/or gender identity. The majority of LGBTQ adults reported dence intervals (95% CI) were estimated. personally experiencing interpersonal discrimination: 57 percent Finally, we conducted a subgroup descriptive analysis of said they have experienced slurs and 53 percent said they had ex- transgender adult s (n = 86), to assess their experiences separately perienced microaggressions related to their sexual orientation or from the larger LGBTQ population, given that we expected trans- gender identity. Similarly, the majority of LGBTQ adults reported gender experiences to be unique. We did not directly compare interpersonal discrimination either personally or in their immediate transgender adults to LGBQ adults because the groups are not friends or family: 57 percent said they or an LGBTQ friend or fam- mutually exclusive. Due to randomly assigned split sampling of ily member had been threatened or nonsexually harassed because the survey questionnaire, there were some questions that had of their LGBTQ identity, and 51 percent said they had experienced too few transgender respondents to report these percentages sexual harassment or violence because of their sexual orientation (half-sample A = 33, half-sample B = 55). Result s are only repor ted and/or gender identity. if n > 50. More than one-third (34 percent) of LGBTQ people said that they To compensate for known biases in telephone surveys (eg, or an LGBTQ friend or family member has personally been verbally nonresponse bias) and variations in probabilit y of selection within harassed while in a bathroom or been told or asked if they were in and across households, sample data were weighted by household the wrong bathroom. Another third (32 percent) said that they or size and composition, cell phone/landline use, and demograph- an LGBTQ friend/family member have been told or felt they would ics (gender, age, education, race/ethnicity, and census region) to be unwelcome in a neighborhood or place to live because they are reflect the true population distribution of adults in the country. LGBTQ. Other techniques, including random-digit dialing, replicate sub- In the context of institutional discrimination, 18 percent of LGBTQ samples, and random selection of a respondent within a house- adults reported they have avoided seeking health care for themselves hold, were used to ensure that the sample is representative. All or family members due to anticipated discrimination, while 16 per- analyses were conducted using STATA version 15.0 (StataCorp), cent reported discrimination in clinical encounters. One-fifth or more CASEY Et Al . 1458       Health Services Research T A B L E 1  Characteristics of LGBTQ adults in the study sample (N = 489) Racial/ethnic minority All LGBTQ adults N = 489 White LGBTQ adults N = 282 LGBTQ N = 201 Weighted percentage of respondents LGBQ (lesbian, gay, bisexual, and queer) 84 83 84 Cisgender 77 - - Transgender (including genderqueer and gender 23 25 20 nonconforming) Self-reported gender Male (cisgender and transgender) 38 35 43 Female (cisgender and transgender) 56 58 53 Genderqueer or gender nonconforming 6 6 5 Race White (non-Hispanic) 61 - - Nonwhite (racial/ethnic minority) 39 - - Age 18-29 y 41 39 45 30 + y 59 61 55 Education e * No college degree 68 62 77   College degree or more 32 38 23   Household income <$25 000 36 31 44 $25 000+ 55 61 46   Health insurance current status Uninsured 15 10 23   Insured, Medicaid 14 16 11 Insured, non-Medicaid 68 71 65 Area of residence Urban 30 26 3 Nonurban 64 67 61 Don't know/refused 6 7 4 US region of residence Northeast 23 22 26 Midwest 20 23 17 South 30 33 27 West 20 16 26 Don't know/refused 6 6 4 Percentage of US LGBTQ population estimated with survey weights to adjust for unequal probability of sampling. The sample size shown reflects the total number of respondents in each category. Percentages may not add up to 100% due to rounding and don't know/refused responses that are included in the total n but not reported in Table 1. LGBQ and transgender are not mutually exclusive. A person can identify as one or both. There were too few LGBTQ-identified racial/ethnic minority respondents to conduct independent analyses for each racial category (black, Latino, Asian American, Native American), particularly when questions are split-sampled. Including those with some college experience (including business, technical, or vocational school after high school) but no college degree, as well as those with a high school degree or GED certificate or less. Primary source of health insurance. Nonurban includes suburban and rural. Regions defined by US Census Bureau 4-region definition. *Different from whites, statistically significant at P < .05 (shown in bold). CASEY Et Al .       1459 Health Services Research T A B L E 2  Differences between white and racial/ethnic minority LGBTQ adults in reporting discrimination because of their LGBTQ identity Weighted Weighted percent of percent of all Weighted percent racial/ethnic minority b c c c Subject of discrimination N LGBTQ adults of white LGBTQ LGBTQ Belief in overall discrimination General belief that discrimination All LGBTQ adults (total 489 91 92 88 against lesbian, gay, and bisexual sample) people exists today in the United States General belief that discrimination All LGBTQ adults (total 489 91 93 88 against transgender people exists sample) today in the United States Experiences of institutional discrimination Employment Being paid equally or considered for You (half-sample A) 245 22 19 28 promotions Applying for jobs You (half-sample A) 245 20 13 32* Education Applying to or while attending You (half-sample B) 192 20 20 20 college Health care Going to a doctor or health clinic You (half-sample B) 230 16 20 9 Housing Trying to rent a room/apartment or You (half-sample B) 177 22 25 14 buy a house Political participation Trying to vote or participate in You (half-sample A) 255 11 7 16 politics Police and courts Interacting with police You (half-sample A) 258 16 11 24* Unfairly stopped or treated by the You or LGBTQ friend/family 259 26 26 26 police member (half-sample A) Unfairly treated by the courts You or LGBTQ friend/family 259 26 23 31 member (half-sample A) Experiences of interpersonal discrimination LGBTQ identity-based You (half-sample B) 230 53 64 35* microaggressions Racial identity-based You (half-sample B) 230 18 6 38* microaggressions LGBTQ identity-based slurs You (half-sample B) 230 57 65 41* Racial identity-based slurs You (half-sample B) 230 38 14 53* People acted afraid because of your You (half-sample B) 230 15 17 14 LGBTQ identity People acted afraid because of your You (half-sample B) 230 12 6 23* race/ethnicity Violence You or LGBTQ friend/family 259 51 57 42 member (half-sample A) Threatened or nonsexually harassed You or LGBTQ friend/family 259 57 60 52 member (half-sample A) Sexual harassment You or LGBTQ friend/family 259 51 57 43 member (half-sample A) (Continues) CASEY Et Al . 1460       Health Services Research T A B L E 2  (Continued) Weighted Weighted percent of percent of all Weighted percent racial/ethnic minority b c c c Subject of discrimination N LGBTQ adults of white LGBTQ LGBTQ Harassed while using bathroom You or LGBTQ family mem- 259 34 32 36 ber (half-sample A) Been told or felt unwelcome because You or LGBTQ family mem- 489 32 34 31 of being LGBTQ ber (total sample) Actions based on concerns about discrimination Avoided doctor or health care be- You or LGBTQ family mem- 230 18 21 12 cause of concerns of discrimination/ ber (half-sample B) poor treatment Avoided calling the police because of You or LGBTQ family mem- 259 15 11 21 concerns of discrimination ber (half-sample A) Thought about moving to another You (total sample) 489 31 31 30 area because of personally experi- enced discrimination White and racial/ethnic minority LGBTQ adults aged 18+, excluding n = 6 adults with missing race/ethnicity that are included in the total sample. Most questions only asked among a randomized subsample of half of respondents. Don't know/refused responses included in the total for unad- justed estimates. Questions about you are personal experiences only; questions about you or friend/family member ask if items have happened to you or a friend/ family member because you or they are part of the LGBTQ community. Percent calculated using survey weights. Bolded and starred values show a statistically significant difference between white and nonwhite LGBTQ adults at P < .05 using a t test. Question asked as “Generally speaking, do you believe there is or is not discrimination against [lesbian, gay, and bisexual people OR transgender people] in America today?” Equal pay question only asked among respondents who have ever been employed for pay. Jobs question only asked among respondents who have ever applied for a job. College application/attendance was only asked among respondents who have ever applied for college or attended college for any amount of time. Housing question only asked among respondents who have ever tried to rent a room or apartment, or to apply for a mortgage or buy a home. Question wording: “Do you believe that you or a friend or family member who is also part of the LGBTQ community has [experienced/been _____] because you or they are part of the LGBTQ community, or not?” Question wording: “In your day-to-day life, have any of the following things ever happened to you, or not?” and respondent indicated they had expe- rienced this and believed this happened because your sexual orientation or gender identity. Slurs = someone referred to you or a group you belong to using a slur or other negative word; Microaggressions = someone made negative assumptions or insensitive or offensive comments about you; People acted afraid = people acted as if they were afraid of you. You or a friend/family member who is also part of the LGBTQ community has been told or felt you would be unwelcome in a neighborhood, building, or housing development you were interested in because you are part of the LGBTQ community. You have thought about moving to another area because you have experienced discrimination or unequal treatment where you were living. reported personally experiencing discrimination specifically because of reporting race-based microaggressions (38 percent vs 6 percent, of their LGBTQ identity across multiple domains of life: when seeking P < .01), slurs (53 percent vs 14 percent, P < .01), and racial fear (23 housing (22 percent), equal pay or promotions (22 percent), applying percent vs 6 percent, P < .01). for jobs (20 percent), and applying to or while attending college (20 percent). About one-quarter of LGBTQ adults said they or LGBTQ 3.3 | Adjusted odds of reporting personal friends or family members had also been unfairly treated by the courts experiences of discrimination in LGBTQ adults (26 percent) or unfairly stopped or treated by police (26 percent) be- cause of their LGBTQ identity. Table 3 reports odds ratios with 95% confidence intervals examin- Importantly, LGBTQ racial/ethnic minorities were more than ing whether race/ethnicity differences in reported experiences of twice as likely as LGBTQ whites to say they had personally experi- discrimination persist after controlling for pertinent demographic enced institutional discrimination because of their LGBTQ identity variables, including age, race, gender, education, and income. For when applying for jobs (32 percent vs 13 percent, P < .02) and when institutional discrimination, LGBTQ racial/ethnic minority adults interacting with police (24 percent vs 11 percent, P < .05). Compared had significantly higher odds than LGBTQ whites for reporting dis- to LGBTQ whites, LGBTQ racial/ethnic minorities reported lower crimination on the basis of being LGBTQ when applying for jobs, prevalence of some forms of interpersonal discrimination, specifi- voting or participating in politics, and being treated unfairly by the cally LGBTQ-based microaggressions (35 percent vs 64 percent, courts. LGBTQ racial/ethnic minorities had lower odds for reporting P < .01) and slurs (41 percent vs 65 percent, P < .02). However, LGBTQ-based discrimination when going to a doctor or health clinic LGBTQ racial/ethnic minorities had a higher prevalence than whites than LGBTQ whites. CASEY Et Al .       1461 Health Services Research T A B L E 3  Adjusted odds of reporting personal experiences of discrimination across institutional and interpersonal domains among US LGBTQ adults Institutional discrimination Political Employment Education Health care Housing participation Police and courts Avoidance Unfairly Avoided Equal College ap Doctor or Trying to Trying to vote stopped or Unfairly Avoided calling the doctor due to Applying pay/pro plication/ health clinic rent or buy or participate Interacting treated by the treated by police due to dis discrimina b c d e,f for jobs motions attendance visits a house in politics with Police police the courts crimination concerns tion concerns N 214 213 167 189 151 219 222 221 223 223 193 Race/ethnicity White Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref * * * * Racial/ 3.16   1.57 0.83 (0.24, 0.31   (0.10, 0.31 (0.08, 3.13   (1.00, 1.75 (0.69, 0.90 (0.41, 2.80   1.25 (0.50, 3.13) 0.56 (0.19, ethnic (1.35, (0.66, 2.81) 0.97) 1.24) 9.73) 4.48) 1.96) (1.26, 1.64) minority 7.40) 3.75) 6.24) Self-identified gender Male Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref * * * * Female 0.39   0.34   2.12 (0.77, 1.40 (0.54, 0.87 (0.26, 0.28   (0.09, 0.36 (0.13, 1.14 (0.50, 0.40   0.89 (0.32, 2.53) 1.11 (0.42, (0.15, (0.14, 5.86) 3.66) 2.96) 0.86) 0.94) 2.64) (0.17, 2.91) 0.96) 0.82) 0.96) Education <College Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref * * College+ 1.12 0.92 0.46 (0.14, 1.26 (0.41, 0.24   (0.08, 1.33 (0.35, 1.46 (0.48, 2.28 (0.93, 1.72 (0.71, 1.55 (0.53,4.51) 3.35   (1.32, (0.44, (0.38, 1.48) 3.88) 0.74) 5.09) 4.45) 5.57) 4.17) 8.48) 2.87) 2.23) Income <25k Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref Ref 25k+ 0.67 (0.29, 0.87 1.28 (0.35, 0.86 (0.24, 0.77 (0.21, 0.37 (0.11, 0.31   (0.10, 0.79 (0.32, 1.08 (0.46, 0.40 (0.14, 1.15) 0.72 (0.25, 1.56) (0.34, 4.76) 3.09) 2.86) 1.22) 0.96) 1.95) 2.56) 2.04) 2.23) Age 18-29 Ref Ref Ref Ref - Ref Ref Ref Ref Ref Ref * * 30+ 0.52 1.17 2.46 (0.53, 2.89 (0.69, - 0.86 (0.27, 0.35   (0.13, 0.84 (0.36, 1.06 (0.45, 0.41 (0.15, 1.13) 0.31   (0.11, (0.20, (0.43, 11.39) 12.12) 2.72) 0.93) 1.97) 2.50) 0.92) 1.33) 3.24) (Continues) CASEY Et Al . 1462       Health Services Research T A B L E 3  (Continued) Interpersonal discrimination LGBTQ iden Harassed Been told/felt un Thought about titybased LGBTQ identity‐ Threats or non while using the welcome because moving to another microaggressions based slurs Sexual harassment sexual harassment Violence bathroom you are LGBTQ area N 421 421 222 224 225 225 412 420 OR (95% CI) Race/ethnicity White Ref Ref Ref Ref Ref Ref Ref Ref Racial/ethnic 0.44   (0.21, 0.88) 0.51 (0.25, 1.02) 0.72 (0.33, 1.58) 0.79 (0.35, 1.76) 0.52 (0.23, 1.15) 1.43 (0.64, 3.22) 1.07 (0.59, 1.94) 0.95 (0.51, 1.77) minority Self-identified gender Male Ref Ref Ref Ref Ref Ref Ref Ref Female 1.11 (0.59, 2.05) 0.97 0.52, 1.82) 0.87 (0.41, 1.86) 0.68 (0.32, 1.45) 0.40   (0.19, 0.83) 1.28 (0.59, 2.75) 1.01 (0.57, 1.79) 1.28 (0.70, 2.34) Education <College Ref Ref Ref Ref Ref Ref Ref Ref College+ 1.06 (0.56, 2.00) 1.48 (0.79, 2.80) 1.94 (0.87, 4.32) 2.20 (0.96, 5.01) 1.29 (0.57, 2.88) 2.06 (0.89, 4.81) 1.20 (0.66, 2.17) 0.85 (0.45, 1.59) Income <25k Ref Ref Ref Ref Ref Ref Ref Ref 25k+ 1.46 (0.71, 2.99) 0.92 (0.44, 1.91) 1.04 (0.44, 2.43) 1.16 (0.49, 2.70) 0.82 (0.34, 1.99) 1.43 (0.58, 3.50) 1.22 (0.65, 2.31) 0.97 (0.50, 1.89) Age 18-29 Ref Ref Ref Ref Ref Ref Ref Ref 30+ 0.44   (0.21, 0.89) 0.88 (0.41, 1.89) 0.50 (0.22, 1.16) 0.50 (0.21, 1.20) 0.68 (0.29, 1.57) 0.72 (0.31, 1.66) 0.67 (0.36, 1.24) 0.89 (0.46, 1.73) Abbreviations: CI, confidence interval; OR, odds ratio. Individual questions only asked among a randomized half-sample of respondents. Don't know/refused responses coded as missing. Jobs question only asked among respondents who have ever applied for a job. Equal pay question only asked among respondents who have ever been employed for pay. College application/attendance only asked among respondents who have ever applied for college or attended college for any amount of time. Housing question only asked among respondents who have ever tried to rent a room or apartment, or to apply for a mortgage or buy a home. Age variable omitted in the housing model due to too few respondents aged 18-29 who had ever attempted to rent an apartment or buy a house or mortgage. White (non-Hispanic) or racial/ethnic minority (including African American/black, Hispanic/Latino, Asian, American Indian, Alaska Native, Native Hawaiian, Pacific Islander, and other nonwhite identities). *Significant at P < .05 (shown in bold). US LGBTQ adults aged 18+. CASEY Et Al .       1463 Health Services Research T A B L E 4  Prevalence of transgender adults reporting discrimination Weighted percent of b c Subject of discrimination N transgender adults Belief in overall discrimination General belief that discrimination against transgender All transgender adults (total sample) 86 84 people exists today in the United States Personal experiences of institutional discrimination Health care Going to a doctor or health clinic You (half-sample B) 55 10 Personal experiences of interpersonal discrimination Microaggressions You (half-sample B) 55 28 Slurs You (half-sample B) 55 38 People acted afraid You (half-sample B) 55 18 Been told or felt unwelcome because of being You or LGBTQ friend/family member (total 86 22 transgender sample) Actions based on concerns about discrimination Avoided doctor or health care because of concerns of You or LGBTQ family member (half-sample 55 22 discrimination/poor treatment B) Thought about moving to another area because of You (total sample) 86 27 personally experienced discrimination Transgender adults include transgender, genderqueer, and gender nonconforming adults aged 18+. Most individual questions only asked among a randomized subsample of half of respondents. Don't know/refused responses included in the total for unadjusted estimates. Questions about you are personal experiences only; questions about you or LGBTQ friend/family member ask if items have happened to you or a friend/family member because you or they are part of the LGBTQ community. Percent calculated using survey weights. Question asked as “Generally speaking, do you believe there is or is not discrimination against transgender people in America today?” Question wording: “In your day-to-day life, have any of the following things ever happened to you, or not?” and respondent indicated they had ex- perienced this and believed this happened because your sexual orientation or gender identity. Slurs = someone referred to you or a group you belong to using a slur or other negative word; Microaggressions = someone made negative assumptions or insensitive or offensive comments about you; People acted afraid = people acted as if they were afraid of you. You or a friend/family member who is also part of the LGBTQ community has been told or felt you would be unwelcome in a neighborhood, building, or housing development you were interested in because you are part of the LGBTQ community. You have thought about moving to another area because you have experienced discrimination or unequal treatment where you were living. Gender also had statistically significant associations in modeling 3.4 | Subsample of transgender adults institutional discrimination. Here, LGBTQ females (transgender-in- clusive) had lower odds than LGBTQ males of reporting institutional Table 4 presents the unadjusted percent of transgender adults, discrimination when applying for jobs, seeking equal pay or promo- where sample size allowed, reporting various experiences of tions, when trying to vote or participate in politics, and in unfair discrimination because of their gender identity and/or sexual treatment by the courts. Models did not meaningfully change in sen- orientation. In the context of interpersonal forms of discrimina- sitivity analyses excluding transgender adults. tion, 38 percent of transgender adults say they have personally Education was also influential: LGBTQ adults with a college degree experienced slurs, and 28 percent have experienced microaggres- had significantly higher odds than those without a college degree of sions specifically related to their gender identity and/or sexual reporting they had avoided seeking medical care out of concern they orientation. Due to split sampling, there were too few transgen- would be discriminated against or treated poorly. LGBTQ adults with a der respondents to analyze the question regarding bathroom college degree had lower odds of reporting discrimination when seek- harassment. ing housing, compared to those without a college degree. When it comes to health care, 10 percent of transgender peo- For interpersonal forms of discrimination, LGBTQ racial/ethnic ple said they have personally experienced discrimination because minorities were less likely than LGBTQ whites to report experiencing of their gender identit y when going to a doctor or health clinic, and LGBTQ-based microaggressions. LGBTQ adults aged 30 and older also more than one in five (22 percent) said they have avoided seeking had lower odds of reporting microaggressions, compared to those health care due to anticipation of discrimination or poor treat- aged 18-29. Finally, females were less likely than males to report ex- ment. With regard to the domain of housing, nearly one-quarter periencing LGBTQ-related violence. No other demographic variables (22 percent) of transgender people reported that they have been were statistically significant in models of interpersonal discrimination. told or felt they would be unwelcome in a neighborhood, building, CASEY Et Al . 1464       Health Services Research or housing development because they were transgender, while research using electronic health record data is a promising approach to over one-quarter (27 percent) said they have thought about mov- further study LGBTQ persons and other small populations, while mo- ing to another area to live because of the discrimination they have bile device or computer apps and other novel methods for data capture already experienced. may also improve research on the unique experiences of discrimination 8,46 among LGBTQ persons within the health care system. At a minimum, improving medical and administrative staff training on cultural compe- 4  |  D I S CU S S I O N tency for serving LGBTQ people, as well as improving data collection on sexual orientation and gender identity in health care, is needed. In this national US study of reported discrimination among LGBTQ adults, four key findings emerge. First, study results extend prior 4.1 | Limitations findings that LGBTQ adults in the United States experience perva- 3-6,18-21,24,27,28 sive discrimination across many areas of life. In par- The findings should be viewed with several limitations in mind. First, ticular, we found widespread interpersonal manifestations, including although we examined a broad range of domains of life, this study slurs, harassment, and violence. covers only a subset of types of discrimination and harassment that Second, institutional discrimination is also clearly present in LGBTQ people may experience. Second, we asked whether LGBTQ health care. Prior research has reported perceived mistreatment people had experienced these types of discrimination at any point 6,18,32 in health care settings among LGB and transgender adults. In in their life, without regard to timing or severity. This limits the abil- this study, more than one in six LGBTQ adults say they have avoided ity to estimate current levels of discrimination and harassment and health care due to anticipated discrimination and experienced dis- instead focuses on lifetime experiences. crimination in health care encounters. Among transgender adults, Third, the prevalence of many sensitive topics, including sexual ha- these estimates are even higher. This is particularly worrisome and rassment and violence, is often underreported—particularly on surveys merits further education and antidiscriminatory policies and train- administered by an interviewer, such as this study—and therefore, ing in health care, as avoiding health care can further exacerbate the “true” prevalence of LGBTQ people's experiences of discrimina- 6,14,22 health disparities between LGBTQ and non-LGBTQ adults. tion is likely higher than reported herein. Perceptions of various kinds Third, LGBTQ racial and ethnic minorities are significantly more of discrimination (eg, race-based and sexuality-based) are also signifi- 26,29,30 likely to report many forms of discrimination, even when controlling cantly associated with each other, and it is not always possible for other factors. LGBTQ racial and ethnic minority adults had a to disentangle these experiences from each other, so asking specifi- significantly lower odds of reporting LGBTQ identity-based micro- cally about LGBTQ-based discrimination may lead to underreporting aggressions relative to whites, though they were more likely than of overall discrimination experienced by some respondents. Questions LGBTQ whites to report experiencing racially based microaggres- about discrimination based on race/ethnicity and gender (among fe- sions (not adjusted for demographic characteristics). These results males only) are examined separately in other articles in this issue. are largely consistent with prior research finding higher reported Fourth, our low response rate is a notable limitation, though ev- racial discrimination among racial/ethnic sexual minorities relative idence suggests that low response rates do not bias results if the 38,39 to white sexual minorities in public settings, accompanied by both survey sample is representative of the study population. Recent sexual orientation and gender discrimination. Our findings also research has shown that such surveys, when based on probability support other studies demonstrating that racial/ethnic identity com- samples and weighted using US Census parameters, yield accurate es- pounds experiences of discrimination in addition to LGBTQ identity timates in most cases when compared with both objective measures 25-27,29,30 38,39,48,49 in many areas of life. and higher-response surveys. For instance, a recent study While it is beyond the scope of our results to promote specific showed that across 14 different demographic and personal charac- policies or practices to end discrimination in the United States, these teristics, the average difference between government estimates from findings indicate both top-down (eg, policy) and bottom-up (eg, com- high-response rate surveys and a Pew Research Center poll with a re- munity organizations or local initiatives) efforts need to take steps sponse rate similar to this poll was 3 percentage points. However, it to address this widespread discrimination, on both institutional and is still possible that some selection bias may remain that is related to (especially) interpersonal levels. For transgender people, housing the experiences being measured, particularly given the challenges of 6-8,34-45 and health care appear to be major areas of concern, while LGBTQ surveying the LGBTQ population noted earlier. racial/ethnic minorities face significant obstacles with employment Fifth, transgender people are often discriminated against due and the legal system. Multisector partnerships are urgently needed to their presumed gender or gender identity. Given that trans peo- to implement interventions, propel policy efforts, and create social ple may be of any sexual orientation, they may also be discriminated change to protect LGBTQ people across different systems, including against because of their sexual orientation. Furthermore, some people employment, health care, housing, and legal systems. may not know the difference between sexual orientation and gender In addition, more research is needed that includes both new meth- identity, so they may discriminate against someone because of their ods and novel data sources to improve the study of LGBTQ popula- gender but using language about sexual orientation (or vice versa). 6-8,34,35 tions, given the current methodological limitations. In particular, Therefore, it should be expected that transgender people report CASEY Et Al .       1465 Health Services Research There were no statistically significant differences between LGBTQ men experiences of discrimination related to both their gender identity and women in their unadjusted reported experiences of anti-LGBTQ and sexual orientation, and so we report these experiences together, discrimination. and this study was unable to distinguish between these experiences. 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