1. LGBT 101
An Introduction to Lesbian, Gay, Bisexual and Transgender Issues in Public Health
MATERIALS
For this presentation, you will need a flip chart or white board and markers. Note places where it indicates DISCUSSION or BRAINSTORM, as this section is designed to engage the audience differently than in the SCRIPT section, where you can talk from the notes to deliver the main points of the presentation. There are more presentations that can be used to supplement this presentation. Please seek it out as a resource or to expand upon the topics introduced here. Note that they come with a syllabus, which includes suggested activities, readings and homework assignments.
SCRIPT
This presentation is called LGBT 101, An Introduction to Lesbian, Gay, Bisexual and Transgender Issues in Public Health . It is designed to be an overview of the issues faced by the LGBT community that are relevant to public health discussions.

2. Agenda Common terms Issues unique to LGBT people Data and risk factors
Challenges
Strategies for interventions
Conclusion
SCRIPT
We will go over many things using this agenda as our framework:
Common terms
Issues unique to LGBT people
Data and risk factors
Challenges
Strategies for interventions
Conclusion

3. Presentation Objectives
Participants will be able to define the acronym LGBT and each component.
Participants will be able to list at least two unique risk factors that exist for LGBT people.
Participants will be able to name two public health considerations specific to LGBT people.
SCRIPT
The objectives of this presentation are as follows:
Participants will be able to define the acronym LGBT and each component.
Participants will be able to list at least two unique risk factors that exist for LGBT people.
Participants will be able to name two public health considerations specific to LGBT people.

4. Terms and definitions Terms are always changing Self definition LGBT
SCRIPT
It helps to begin by talking about language, as this is the most fundamental way that we understand each other and communicate our understanding.
Terms are always changing. You don’t have to know them all, but it helps to be familiar. Remember that the words change based on the time, context, environment and people using them.
Ask individuals what terms they like to use and to define them if you don’t understand.
Self definition is important, and in public health it is crucial- people’s behaviors, attractions and identities may not be congruent. For instance, a man might be attracted to other men, but identify as straight and be married to a woman.
LGBT- This acronym is used commonly by people in the lesbian, gay, bisexual and transgender community for the sake of brevity. It is preferable to the term “the gay community” as it is more inclusive.

5. Dissecting the acronym LGBT Sexual orientation vs gender identity
LGBT- An Umbrella Term
Dissecting the acronym LGBT
Sexual orientation vs gender identity
SCRIPT
LGBT is used as an umbrella term to reflect the many identities covered in what used to be called the “gay community”. This was a term that oversimplified the community, and was rejected by many it was intended to describe. LGBT stands for lesbian, gay, bisexual, transgender. Occasionally people will add QQIA to the end, which is for queer, questioning, intersex and ally (or asexual). Some feel that this more truly encompasses those it covers, while others feel it is cumbersome. For this reason some people have taken to the term queer as an umbrella term designated to cover anyone who could fall into this category. Others remember this as a derogatory word and reject it as a reclaimed or empowering term.
The acronym LGBT is confusing to some, so it is important to break down its components and dissect the rationale for the inclusion each letter.
The first component (LGB) applies to sexual orientation - one’s attraction to another person. The latter component (T) refers to gender identity - how a person feels about their own gender, this can include how masculine, feminine or androgynous a person feels, regardless of their presentation or how they express their gender in obvious ways to the outside world.
It is important to remember and clarify that all people have a sexual orientation (whether it is gay, straight or asexual) and all people have a gender identity (not just transgender people).

6. Sexual Orientation Lesbian -
A woman or girl whose attraction is to the same sex
Gay –
A man or boy whose attraction is to people of the same sex
Bisexual –
A person whose attraction is to people of either sex
SCRIPT
When discussing sexual orientation, it is important to emphasize all of the ways that humans are attracted to each other. Sexual orientation is not just about sex, despite some rhetoric around the issue. Sexual orientation refers to emotional, physical, spiritual, romantic and sexual feelings about another person. This discussion is relevant to both lesbians and gay men. When discussing the term and concept bisexual, it is worth noting that while bisexuals are attracted to both men and women, it doesn’t mean they date both men and women at the same time. As with every identity, there are subcategories and nuances. Many people have a particular image of what a lesbian or bisexual looks like or behaves like, but remind people that because this is an identity that is in relation to another person, unless we see them displaying affection to a person of the same sex, we can not make assumptions about their identity.
This makes it important to ask when the information is relevant to your work, and if not to leave the stereotypes alone. Additionally, there are some groups of people who are LGB who are more visible than others. For example, we have ample examples of white wealthy LGB people.
DISCUSSION
Can your audience identify many people of color who are out as LGB? Ask them to list a few people in the public eye who have been public about their LGBT identity and are also people of color. Many people can identify one at most (examples are Wanda Sykes, Margaret Cho, B.D. Wong from Law and Order, Ru Paul). This can shape our understanding of who LGB people are, and can shape the experience of LGB people who are underrepresented or are invisible in our popular culture. It is important to remember how expansive and diverse the LGBT community is, despite the images we may have of the community.
While most people are pretty familiar with the above terms, it is always worth pausing and asking what questions people have.

7. Gender Identity Transgender-
A term used to describe someone whose gender identity falls outside of the stereotypical gender norm
SCRIPT
While most people will have heard the term transgender, it is important to spend enough time on this to ensure comprehension of the many experiences this term encompasses. Expand the conversation by breaking down the definitions of sex, gender, and gender identity.
Sex: the sum of the characteristics that distinguish organisms on the basis of their reproductive function (genitals, secondary sex characteristics, hormones).
Gender: This describes the widely shared expectations and norms within a society about appropriate male and female behavior, characteristics and roles (the clothing we wear, the way we communicate, the jobs we have/don’t have). Gender is socially and culturally constructed to differentiate women and men and defines the ways which women and men, men and men and women and women interact with each other.
Gender identity: this term describes how a person perceives their own internal sense of maleness, femaleness or something in between or outside those established genders.
Based on what you know about the culture in the US, what are some gender norms? (ex: Men are strong and macho, women are weak and nurturing) What happens to people who defy gender norms, or whose characteristics contradict them? Men who are not good at sports or who have traditionally feminine jobs (nurse- some people will refer to as a male nurse)? This is not just true of adults, when does it start? Kindergarten is when most people solidify their expectations about what boys should do and be like, and what girls should do and be like.
The next slide is an image of “the transgender umbrella” to explore more of the identities that fall under the transgender category.

8. The Transgender Umbrella Defined
Transexual
Crossdresser
Intersex
Drag performers
Gender bender, androgyne, gender queer
SCRIPT
Transgender is an umbrella term that is designed to be all encompassing for people whose anatomies or appearances do not conform to predominant gender roles or norms. There may physical or behavioral characteristics that readily identify a person as having a non-conforming gender identity. Some people prefer this term, while others prefer a term that is more suited to their specific experience.
Transexual is used generally for a person who was born into one gender but they identify psychologically and emotionally as the other gender. They may be undergoing physical transition from male to female (abbreviated to MtoF or MtF) or female to male (FtoM or FtM) through hormonal therapy, surgical interventions, and pronoun changes. It is important to note that this can include people who have transitioned to the gender other than that assigned at birth, to the fullest extent that they wish, meaning that some people may not opt for surgery, but still identify fully as the gender of choice. Many people who identify as transexual live full time as the gender they have transitioned into. The general rule with transexual people is they prefer to be identified by the pronoun matching their gender presentation.
Crossdresser is a term used for people who are comfortable with their physical gender at birth but will sometimes dress in the opposite gender. Crossdressers are frequently men who live and work full time as men, and on occasions will wear women’s clothes. While this term is used pejoratively by some, it is the preferred term in the US.
Intersex is a condition that some people exhibit at birth (or at puberty) with a combination of male and female genitalia and reproductive systems. This complicated medical condition occurs more frequently than the western medical system openly acknowledges. 1 in 2,000 births are gender ambiguous, where the baby’s genitalia, chromosomes, hormones or reproductive system are more of a combination of male and female than our binary (is it a boy or a girl?) system allows.
Most babies who are intersex are assigned one of the two genders we recognize, some undergo “corrective surgeries” to corroborate the conformity. For some, this information is unknown until puberty when hormones or reproductive functions are different than anticipated. The term hermaphrodite has been used historically for this group of people, but this is not preferred. Hermaphroditism is when an organism has both full male and female reproductive and genital systems, which is physiologically impossible in humans (though happens in worms, plants and other species.) Once an oppressed group of people, the intersex community is gaining clout and has organized to advocate on its own behalf, including correcting the terminology.
Drag performers may fall under the transgender umbrella. The term refers to people who dress in non-gender-conforming clothing (typically very fancy and flamboyant clothing) and perform dance routines - drag queens and drag kings are examples. People who dress and act like the opposite sex for entertainment. It is more of a play on gender, not identity.
Gender Benders/ Androgynes/ Gender Queer- People who blur the gender lines by presenting in gender neutral or non-conforming ways. Some use neutral pronouns, like “hir” and “ze” and do not ascribe to either gender. Others are comfortable with an assigned gender but prefer to look androgynous.
Not everyone who displays this identity will ascribe to it! Just because a term technically applies to a person that you know, does not mean that they will self identify in that way. As was mentioned before, it is important to allow for self identity.

9. LGBT in the United States
What images do people have?
What were you taught about LGBT people?
Not a monolithic experience!
What can shape an LGBT person’s experience?
SCRIPT
To understand LGBT people and the issues they face in the context of Public Health, it is important to consider the cultural context in the US, and how that may shape the process of coming out and coming to terms with a non-normative identity.
DISCUSSION
An interesting exercise to do with participants is ask them what images come to mind when they think of LGBT people in the US. What do LGBT people look like, do for a living, what images do we have from the media? We often have one very monolithic view of the LGBT community- it is of a white, middle or upper class person without kids, many are comedians (Ellen, Jack and Will from “Will and Grace”, David Sedaris, Rosie O’Donnell). Point this out if it is a trend in the discussion. Brainstorm alternative images of LGBT people- poor LGBT people who are well known, LGBT people of color- you will find they are limited.
The discussion can be expanded to allow participants to consider what shaped their understanding of LGBT people- what images or stories do they remember from childhood (or lack of images- this too is a powerful message)? What lessons did they learn about gender and sexual orientation from Disney movies?
Often, LGBT people grew up hearing very similar messages. While no one’s experience is the same, there are trends in what people experience when they come out. For that reason, let’s think about the coming out process first.

10. Coming Out What do you think it is like to come out?
Who would an LGBT person come out to?
SCRIPT
As we talked about, LGBT people have heard varying messages about how acceptable (or unacceptable) it is to be LGBT. What they have heard
can shape their experience in whether or not to come out and how quickly they come to accept the identity. The first person they will come out to is themselves. For some people this is a fast process, for others it takes years. Coming out is an important stage in a person’s self acceptance- which can increase their holistic health. People do not just come out once, the process happens over and over again- to new people, roommates, religious leaders, teachers, doctors, friends, family, coworkers- it never ends!
BRAINSTORM
The average age in 2010 that an LGBT person comes out is 13. Based on that, let’s brainstorm what it would be like to come out as an LGBT person. Who would they come out to first? Probably a friend or close family member. If it goes well, who might they tell next? Another family member? What if it does not go well at all? What if they totally reject you? How may you be feeling? (Make sure the answers are feelings- if not ask for rewording) Ask the group to brainstorm some emotions that they may be feeling. List answers. What are some behaviors they may engage in if this is how they are feeling? (Make sure the answers are behaviors) List answers. Some examples are listed on the next slide.

11. Feelings Behaviors Isolated Scared Anger Stress Relief Uncertainty
Depressed
Leave home/ forced homelessness
Drop out of school
Increase drug and alcohol use/ abuse
Self inflicted violence
Suicidal ideation and attempts
SCRIPT
When a young LGBT person comes out and the information is not received well, their life can be dramatically upended. The upheaval could be emotional- feeling less secure and supported. This can lead to a lack of concentration in school, increased escapism methods like drinking and drug use, and can even lead to suicidal ideation or attempts.
LGBT youth represent a small fraction of the adolescent population (estimates are 4-7 %) but the rate of suicides completed by LGBT youth is 30% of all adolescent youth. Similarly, LGBT youth are understood to have higher rates of substance abuse, alcohol abuse and smoking. If a youth comes out to their parent/ guardian and it doesn’t go well, they may be forced to leave home. In fact, 26% of LGBT youth report this experience. They may have alternate housing, they may live transiently with friends, or they may seek out housing from people who will financially support them in return for sex. This can increase their chances of STIs, HIV, and unwanted pregnancy.
While this scenario is the worst case, coming out for an LGBT young person is never an easy experience. Some fear these types of consequences, others battle internally with the contradiction of who they thought they would grow up to be and who they are discovering they are. This can lead to what is called internalized homophobia – negative feelings about one’s own homosexuality. For some the battle of internalized homophobia takes years to fight, and can influence when and how a person comes out. It has been described like peeling back the layers of an onion- though you think you have addressed those feelings, something can re-instigate them years later.
Not all LGBT people had the experience of coming out as a young person. Some knew from an early age but did not feel safe coming out, so concealed or denied it. Some people later in life feel a stronger attraction to the same sex, or feel it is more necessary to transition gender than it had been in previous years. Nonetheless, their worldview is shifted just as it would have been had they come out at a younger age. Having received messages about who they would be as an adult, having a picture painted and reinforced in thousands of subtle ways throughout their lifetime, LGBT people have to learn a new way of thinking about who they are and how they will live their life based on this shift. Depending on how accepting the culture is the person came from, this can be a relatively simple or insurmountably hard process.

12. In the Public Health Context Considerations for LGBT people
SCRIPT
The spaces in life that most people traverse safely may not be welcoming to LGBT people. For young people, this may be high school or college, doctors, religious leaders, sports teams. As people get older, they may still feel the need to read between the lines to determine safety zones and level of trust. This is true in the workplace, in social spaces, in housing arrangements, with family members, religious leaders, medical personnel, etc. While some people don’t understand the need for disclosure in so many settings, for many LGBT people, being open about who they are is important to feel safe in the space they are in. Discrimination and even violence have been a reality for people in the LGBT community their whole lives. This is particularly true for older LGBT adults, for people who live in more rural areas, and especially for transgender people. In the US, a person has a 1 in 18,000 chance of being a victim of a violent crime. For transgender people, that rate is 1 in 12 (according to the Empire State Pride Agenda).
In the context of healthcare and the field of public health LGBT people may either experience or perceive less support systems than their heterosexual counterparts. Frequently, questions are laden with the presumption of heterosexuality, intake forms do not always leave room for partners or reflect a transgender option. This is an easy and clear indication to many LGBT people that the environment that they are in is not considerate of their needs. We will talk about what those needs are, and why LGBT identity is important to health in the next few slides.
Unfortunately, data shows that LGBT people are less likely to seek out healthcare as a result of historic discrimination and fear of negative treatment. This, among other factors, has resulted in disproportionately negative outcomes for LGBT people over their heterosexual counterparts.

13. A Snapshot of LGBT People in the Medical Institution
1869- The word “homosexual” is invented
1949: Hormone treatment for transsexuals
1973: Homosexuality is removed from the DSM
1996: Shock therapy, conversion therapy
2011: Gender Identity Disorder still in DSM
SCRIPT
To think about the context of LGBT people in the medical field, lets look at a few important factors that have contributed to the relationship that some LGBT people have to seeking, accessing and receiving quality care.
1869- Hungarian psychologist Benkert invents the word “homosexual”. This was an important attitude shift in the medical field; rather than being a criminal act (as “sodomy” was considered to be) loving someone of the same sex was now considered a psychological condition which should be cured and not punished. A lot of work has gone into undoing this assumption as well, but at the time it was a considerable achievement.
1949: Harry Benjamin starts treating transsexuals in New York and San Francisco with hormones. Until this time, there was no medical support for transition for transgender people in the US. The legal, social and medical context at this time in the United States, and around most parts of the world, dramatically contradicted this act. At the same time, people who wore cross gender clothing in public could be arrested, as it was considered illegal to wear clothing associated with the opposite sex. In many states male castration was illegal, and those who sought it were seen by doctors as ill, in need of treatment (which consisted of institutionalization, shock therapy or lobotomy).
1973: The American Psychological Association removes homosexuality from the Diagnostic and Statistical Manual of Mental Disorders. This manual offers clinicians the basis for classifying and diagnosing mental disorders. It was not completely gone from the DSM however, it was replaced by “sexual orientation disturbance”, and then “ego-dystonic homosexualitiy”. This is important to consider, that just 35 years ago, homosexuality was considered a diagnosable mental illness. It is for this reason that many people do not prefer the word homosexuality as interchangeable with gay, because it was once considered to be a mental health diagnosis. Despite this, the term is still frequently used in research.
As recently as 1996 shock therapy and conversion therapy were widely denounced, though these “treatments” are still endorsed by a very small minority of people who feel that conversion therapy is effective and LGB people can become heterosexual with enough work and psychological intervention.
2011: Gender Identity Disorder still in DSM. This is the diagnosis that transgender people must receive in order to proceed with medical transition, so its inclusion in the DSM is important for trans people, but at the same time it is pathologizing and consolidating the many experiences of trans people into a scripted and diagnosable experience. There is debate about whether or not it will be included in the latest revision of the DSM, the DSM V- due to be published in May of Some people consider its continued inclusion important, as it increases the chances of insurance companies paying for medical transition.
While these are just a few examples of the ways that LGBT people have interacted with the medical establishment historically, many of them have instilled a strong mistrust of the medical system for LGBT people.
Data shows that LGBT people experience poorer health outcomes when compared to their heterosexual and non-transgender counterparts. The next few slides expand on the areas where this is true, with some accounts as to why.

14. Health Disparities by Population
Lesbian and bisexual women
Gay and bisexual men
Transgender people
SCRIPT
Lesbian and bisexual women-
Less likely to access preventive care
More likely to have breast cancer
High rates of depression & anxiety
Higher rates of smoking
Higher rates of obesity
Higher rates of alcohol and substance abuse
Still at risk for HIV, though little information is available about risk, rates and limited targeted information to this population.
Domestic violence is an under-discussed issue, though the rates are estimated to be the same as in the heterosexual population.
Bisexual women are presumed to have similar outcomes, though most studies do not differentiate between lesbian and bisexual women, so it is impossible to be certain. Some evidence suggests they have worse outcomes than lesbian women in mental health, and are thought to have less social capital- finding less acceptance from both the gay and lesbian community, as well as the heterosexual community. More research is needed in this area.
Men-
Greatest risk for HIV (but not at the expense of all other healthcare)
Depression & anxiety
STDs, Hepatitis
Fitness- too much or too little
Prostate, testicular and colon cancer
Again, domestic Violence is an under-discussed issue, though the rates are estimated to be the same as in the heterosexual population. Men often struggle to seek shelter, as many DV shelters are still only for women (though this is changing slowly). When police intervene, they often cannot identify the aggressor, and sometimes both the victim and aggressor are arrested.
Data in studies is often a combination of gay and bisexual men, leaving us with little information about the unique experiences and differences within each group.
Transgender people
STIGMA
Violence- as was indicated before, the rate of violence for trans people is 1 in 12, while it is 1 in 18,000 for the general population. Because the federal government doesn’t recognize trans people, it has not been documented how many trans people have been murdered, but annecdotally it is a high count. This is even more true for trans women of color.
Hormones/ Injection Silicone Use- some people have access to safe and legal hormones and some do not. They can be found on the black market, where dirty needles and contaminated or diluted hormones can be a concern. Some people turn to silicone to speed up the transition process, though this is often done in non-sterile environments with industrial grade silicone (purchased at hardware stores, and commonly used as caulk) which gives immediate results, but in the long term can have fatal consequences.
Access to healthcare- many trans people document being uninsured, or not feeling they have access to safe and appropriate health care. Many people share stories of seeking help for a respiratory infection, or cold, and receiving a genital exam or being interviewed by entire medical teams about their (unrelated) sexual reassignment surgeries.
Unemployment/ homelessness- it is legal in the US to discriminate against trans people in housing and employment, and as such, this group experiences disproportionate rates of both.
Mental health
Higher rates of HIV/STDs for male to female transgender people, unknown largely for female to male transgender people.
Alcohol/ substance abuse

15. Barriers to adequate healthcare
Lack of legal protections
Sporadic inclusive policies
Invisibility
Historic experiences
Limited insurance coverage
Lack of competent providers
SCRIPT
Many states continue to lack protections for LGBT people’s right to receive safe and appropriate medical care, job protections, housing without discrimination, equal access to health insurance and other benefits. There is no mandate that requires that inclusive policies exist in the healthcare setting. These would include a transgender option on intake forms, mandatory training for staff, questions about sex that didn’t presume heterosexuality, etc. The lack of inclusion in the medical setting can further perpetuate the invisibility of the specific needs of LGBT people. For many LGBT people, it has never seemed relevant to include, because it has not been a part of their dialogue with their care provider. Particularly older LGBT adults don’t always think it is anyone else’s business to know. This can cause missed opportunities for targeted preventive health discussions. Historic experiences of bias, discrimination and stigmatization can shape a persons trust in their provider, a hospital, or the medical system all- together. LGBT people have been documented to access preventive healthcare less than their heterosexual counterparts, and are known to be diagnosed with cancers and other diseases later. For transgender people, their healthcare needs may not match their external presentation. Transgender men who have not had surgery to remove their ovaries and uterus still require annual exams, and some transgender women still need to be concerned about their prostate health. These are all barriers for people who have access to healthcare. There is limited insurance coverage (partner benefits vary) and LGBT people are reported to be less insured than their heterosexual counterparts, making access an even bigger barrier to receiving quality care.

16. Barriers continued SCRIPT
Limited funding for improving LGBT outcomes
Inadequate data collection efforts
SCRIPT
HIV has been synonymous with LGBT healthcare since the 1980’s- this affects funding, visibility and other healthcare needs. There is limited funding for improving outcomes for LGBT people, and it is commonly in large metropolitan areas, leaving rural areas and smaller cities with little.
Inadequate data collection impacts ability to receive grants and demonstrate need and legitimize the issue within the field of public health and medicine. Most of the BRFSS studies do not include questions about LGBT identity on their demographic section, the census for the first time in 2010 asked a question where gay or lesbian identity can be extrapolated, but only for people living with their same sex partners, as it asked if cohabitants were same sex partners. Even when the questions are available, participation from the LGBT community may depend on how open the participant is about their identity.

17. The silver lining… SCRIPT
LGBT as a protective factor
Many LGBT people have high social capital
Visibility is increasing in medical/academic field
SCRIPT
Important to remember: These negative outcomes are not intrinsic in LGBT people, but are consequences of how LGBT people are treated in our society.
LGBT identity is increasingly considered a protective factor despite the negative outcomes that many face, there is evidence to suggest that LGBT people have more resilience than their heterosexual counterparts. Out of necessity, many LGBT people are more well connected and have stronger support systems that are outside of their nuclear family. Social capital is considered an asset to good health. The issues facing LGBT people, and the disparities they face have received more attention in the medical field and in public health. This is increasing funding for research in this area and is slowly improving the quality of care people are receiving.

18. Acknowledgements
This presentation was designed in Spring 2011 by Curran Saile, Program Director of the Pride Center of the Capital Region done in partial completion of Masters in Public Health requirements at the University at Albany School of Public Health. The project would not have been possible without the support of Mary Applegate, Jennifer Manganello, Cheryl Reeves and the Pride Center of the Capital Region.

19. References
Bradford J, Ryan C. The National Lesbian Health Care Survey. National Lesbian
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Centers for Disease Control. Cigarette smoking among adults – United States,
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Healthy People 2010 Companion Document for Lesbian, Gay, Bisexual and
Transgender (LGBT) Health published by the Gay and Lesbian Medical Association\
and the National Coalition for LGBT Health in 2001: Fergusson, Hoorwood and
Beautrais, 1999.

20. References
Makadon, Harvey J. Improving Health Care for the Lesbian and Gay Communities. New England Journal of Medicine. 3/2/2006, Vol. 354 Issue 9,
Male-to-Female Transgender Individuals Building Social Support and Capital from Within a
Gender-Focused Network. Journal of Gay& Lesbian Social Services. 2008, Vol. 20 Issue 3,
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