by Ric Chollar, LCSW
CW: discussion of homo-/bi-/transphobia, mental illnesses and mental disorders, depression, anxiety, suicide, STI and HIV stigma, substance and drug abuse, and body image/body shaming
LGBTQ students face unique challenges related to physical and emotional health care. College counselors and health care providers need to be aware of these concerns. Many of the issues are interrelated, impacting one another, with a common theme of coping in a potentially hostile, homophobic, anti-LGBTQ world. Keep in mind that the vast majority of queer students arrive and thrive at college as extremely healthy, confident, strong, and resilient young adult. Thus not all LGBTQ students will experience these physical and emotional health problems, but a number of students might (and some with life-threatening severity). The following resource identifies ten area of concern regarding the health care and counseling of LGBTQ students. By actively being aware of these concerns, a campus can be better prepared to offer support and possibly prevent escalation of a particular issue or concern.
- ACCESS, COMFORT, AND TRUST IN PROVIDERS For campus health and counseling centers, creating a welcoming environment for LGBTQ students includes outreach, visual cues in office space, language and questions on intake forms, policies for nondiscrimination and confidentiality, and provider’s verbal and nonverbal communication. Because of negative past experiences with counselors and health providers, the power imbalance between provider/counselor and student, and student’s history and fear of anti-LGBTQ oppression, many LGBTQ students will not disclose their orientations, sexual activity, or gender variance in initial counseling or health care sessions. Others avoid seeking health care altogether. It is up to the provider to demonstrate an atmosphere of openness, inclusion, and affirmation with students of all genders and sexual orientations. Ways providers can contribute to a trusting relationship include: using open questions in their assessment interviews (e.g., “Are you attracted to men, women, or both?”); being explicit about protecting privacy and confidentiality; and learning about LGBTQ campus/community resources.
- COMING OUT The “coming out process” speaks to the experiences of many, but not all, LGBTQ students as they discover, accept, explore, and disclose to others their sexual orientation or gender identity. Understanding sexual and gender identity development is a step in gaining knowledge and perspective about the unique health and counseling issues young LGBTQ people may face. There is no one correct way or single process of coming out – in fact, some LGBTQ people do not come out at all. The process is unique for each individual, and every coming-out-related decision is a personal choice. Many queer youth come out long before they get to college. Research on sexual orientation currently suggests that the average age of initial awareness of same-sex attraction is between 10 or 11 years, while the average for self-identifying is ages 13-15. Many transgender students report having experienced conflict over the gender assigned to them, throughout childhood and puberty. Additionally, many trans youth report extreme discomfort with the sex of their bodies, starting in early childhood.
LGBTQ students experience much of their identity exploration and development in college years, and even for those who first came out much earlier, their coming out process continues through college life. Students must choose whether or not to out themselves to their family, friends, roommates, classmates, teammates, faculty, and staff. Over time, students realize that coming out is an ongoing process of decision-making, with a situation-by-situation assessment of risks versus benefits of publicly identifying oneself. These decisions are even more complicated for some subgroups of LGBTQ students: students who reject labels and/or experience their identities as fluid; students who are exploring both sexual orientation and gender variance; and/or youth who hold additional marginalized identities, such as students of color, international students, and students with cultural and religious backgrounds outside of middle-upper class, Western-European, Christian traditions.
- HEALING FROM OPPRESSION The experience of anti-LGBTQ discrimination, violence, and hate can lead to problems in physical and mental health. Victimization can take away an LGBTQ survivor’s sense of trust, safety, and security in the world; with potential after-effects of sleeping difficulties, headaches, digestive problems, agitation, substance abuse, post traumatic stress disorder, hyper-vigilance, and expectations of future rejection and discrimination. Even in the absence of external or overt experiences of violence, discrimination, or hate, LGBTQ people are also at risk of directing negative social attitudes toward themselves. This internalized oppression – homo-, bi-, or trans-phobia – can contribute to a devaluing of one’s self and poor self-regard. Although it is often most strongly felt early in one’s coming out process, it is unlikely that internalized oppression completely disappears even if the LGBTQ person has accepted his or her sexual orientation or gender identity. Because of the strength of early socialization and continued exposure to anti-LGBTQ attitudes, internalized oppression can remain a factor in the LGBTQ students’ adjustment throughout college.
- COPING WITH STRESS, ANXIETY, AND DEPRESSION As previously mentioned, coming out (or not) strategies and dealing with oppression can add tremendous stress to an LGBTQ student’s already stressful college life. Research suggests that queer people may literally embody these stresses, leading to higher rates of anxiety and depression. One study found that gay and bisexual men were three times more likely to have had major depression, and four times more likely to have a panic disorder than heterosexual men. Lesbian and bisexual women showed greater prevalence (four times more likely) of generalized anxiety disorder than heterosexual women. Researchers suggested potential reasons for these difference: (a) social stigma of homosexuality, (b) ways that LGBTQ lives differ from heterosexuals, (c) experiences of discrimination, and (d) lack of social support. Through coming out, accepting themselves, and reaching out for support from family, peers, and professions, LGBTQ students can learn to cope effectively with stress. Studies have shown that family support and self-acceptance reduce the impact of anti-LGBTQ abuse on anxiety and depression; and that LGBTQ people counteract stress by establishing alternative structures and values that enhance their community. Thus, the presence of active LGBTQ student organizations, resource centers, and affirmative counseling and health centers all play crucial roles in countering stress, anxiety, and depression in LGBTQ college students.
- SURVIVING SUICIDAL THOUGHTS, PLANS, OR ATTEMPTS Decades of research have consistently documented a link between LGBTQ young people and suicide (thoughts, plans, and/or attempts). In a Massachusetts survey of high school students, students who described themselves as gay, lesbian, or bisexual were over five times more likely to have attempted suicide in the past year, and over eight times likely to have required medical attention as a result of a suicide attempt. One potential factor in higher suicide rates in LGBTQ youth may be gender identity and/or expression. In one study, college students who reported “cross gender roles” – having gender traits or expressions more often associated with the other sex – were at higher risk for suicidal symptoms, regardless of their sexual orientation. And among self-identified transgender youth, some experts estimate that many as 50 to 88 percent have seriously considered or attempted suicide.
- SEXUAL HEALTH CONCERNS Sexually transmitted infections (STIs) are a consequence of specific risk-taking behaviors, not sexual orientation or gender identity themselves. Regardless of how a student self-identifies providers should inquire about a range of sexual behaviors, number and gender of sexual partners, and safer sex practices. Health care providers should be aware of the STIs for which LGBTQ college students are at risk and the necessary screening, testing, and treatment. However, while it is vital to recognize that LGBTQ students are at risk for STIs, it is also important not to view the youth restrictively within this narrow perspective. Many of today’s LGBTQ students understand the importance of condom use (although do not always practice it) during vaginal and anal sex; however, they seldom use barrier protection (condoms, gloves, or dams) in sexual contact involving mouths, fingers, hands, and toys used in penetration. In a recent internet survey, 89 percent of U.S. LGBTQ college students reported having sex with someone of the same sex and 45 percent had six or more sex partners during their lifetime. Most reported using a condom consistently during penile-vaginal (61 percent) and anal sex (63 percent). However, only 4 percent used a condom or other barrier consistently during oral sex. While epidemiological rates of gonorrhea, chlamydia, and syphilis have generally decreased in adolescents over the past fifteen years, the rates for all three of these STIs have increased in the populations of young men who have sex with men (MSM).
Many women who partner with women believe they are not at risk of STI transmission. Yet sex between women can transmit herpes (HSV) chlamydia (gonorrhea, hepatitis A and B, trichomonas, and human papilloma virus (HPV). Sexual health education of lesbian and bi women should correct the assumptions that sex between women carries at risk. Most cervical cancers are linked to the presence of HPV. Yearly pap smears are the best defense against cervical cancer because they reveal HPV and other precancerous changes that can be stopped and they detect cancer at its earliest stages, when it is much easier to treat – and defeat. Yet many women are not properly screened for HPV, and health care providers don’t always tell women that they need pep tests. Regular gynecological exams (including pap, pelvic, and breast exams) are important for queer women because they can detect many kinds of abnormalities which, if undetected, could lead to serious health problems. A student’s gender presentation does not necessarily equate with the sexual and reproductive organs in his or her body. For example, not all sexual organs from birth may have been surgically removed in transgender individuals, and there may be consequent screening exams that need to be performed. Students of all genders who are assigned female at birth require regular pap tests. Also it would be appropriate to conduct prostate exams for students assigned male at birth who have prostate glands. Respectfully ask the student what sex they were assigned at birth, and which steps to medically transition, if any, they have undergone.
- HIV/AIDS In the United States, the rates of new HIV infection among men who have sex with men have recently begun to increase (up 8 percent in 2004) after over thirteen years of decreasing and stable infection rates. Center for Disease Control (CDC) data showed that 61 percent of new male diagnoses came from men who had sex with other men, compared to 17 percent of transmissions from heterosexual sex and 16 percent from intravenous drug use. The survey found the rate of infection was eight times higher for black men than white men, and black men make up more that half of all HIV diagnoses. Transgender youth, particularly trans girls and women, are at extremely high risk for HIV infection. Studies of urban transgender populations have found HIV seroprevalence rates ranging from 14 to 70 percent, and once again, people of color are disproportionately affected (in the Washington, D.C. Area, the rate is four times higher than white trans youth. In queer communities in the United States, not using a condom during anal inter-course continues to represent the greatest risk of HIV transmission.
Research points to the following possible factors for increases in unprotected anal sex: improvements in HIV treatment, substance abuse, complex sexual decision making, seeking sex partners on the internet, and failure to maintain prevention practices. The rates of risky behaviors are higher among queer youth than older LGBT people. Not having seen firsthand the toll of AIDS, young people may be less motivated to practice safer sex. Almost twenty-five years into the HIV epidemic, today’s generation of queer youth seem to underestimate their risk, have trouble maintaining safer sexual practices, and require new and creative HIV prevention efforts. Given the disproportionate rate of HIV infection within young MSM and trans women of color, culturally competent prevention and education services are crucial.
- SMOKING The effects of smoking kill more LGBTQ people than HIV/AIDS, hate crimes, suicide, and breast cancer combined. In the first statewide survey in the United States to assess tobacco use in the LGBTQ population, the California Department of Health Services found that over 43 percent of young gay men and lesbians (aged 18 – 24 years-old) smoke, compared with approximately 17 percent of the general population of 18 – 24 year-olds (2.5 times higher).
Researchers suggest several possible factors for the high smoking rates in LGBTQ youth: (1) The tobacco industry has targeted initiatives and advertising directly at LGBTQ communities, (2) many queer youth spend significant time in the clubs where cigarettes are a social connection, (3) smoking may be used to medicate stress and feelings of loneliness and alienation, and to alleviate depression (nicotine affects the same neurotransmitters as many antidepressants). Suggestions for successful tobacco cessation programming for LGBTQ college students include: (1) involve LGBTQ students in program design and implementation, (2) address positive LGBTQ identity development and coming issues, (3) be entertaining, supportive, and interactive, (4) address the LGBTQ-related psychosocial and cultural underpinnings of tobacco use, (5) offer practical nonsmoking alternatives and tools, and (6) include options of pharmacological smoking cessation aids.
- DRINKING AND OTHER DRUG USE Studies indicate that, when compared with the general population, LGBTQ people are morel likely to use alcohol and other drugs, have higher rates of substance abuse, and are less likely to abstain from use. Studies that compared gay men and lesbians with heterosexuals have found that from 20 to 25 percent of gay men and lesbians are heavy alcohol users, compared with 3 to 10 percent of the heterosexuals studied. Within the transgender community, one urban study found that 34 percent reported alcohol problems. Risk factors for abusing alcohol include relying on clubs for socializing and peer support; the negative effects of homophobia, heterosexism, biphobia, transphobia, and/or internalized oppression; additional stress related to coming out or hiding/concealing one’s identity; and the effects of trauma from history of violence or abuse.
Some drugs seem to be more popular in the LGBTQ communities than in majority populations. Greater marijuana and cocaine use has been found among lesbians than among heterosexual women. Studies have also found that gay and bisexual men, and other MSM are more likely to have used marijuana, psychedelics, hallucinogens, stimulants, sedatives, cocaine, barbituates, MDMA (methylenedioxymethamphetamine, also known as ecstacy, XTC, or X), Special K (ketamine), and GHB (gamma hydroxybutyrate) than are heterosexual men. Party or club drugs (including ecstasy, Special K, GHB, and crystal meth (methamphetamine) – often used during raves and circuit parties – decrease inhibition, impair judgment, and increase risky sexual behavior.
- BODY IMAGE Bi and lesbian women’s experience of body image and what they expect of themselves can be complicated, as they are socialized as women, but also influenced by their LGBTQ communities. They are exposed to conflicting ideals of beauty espoused by both mainstream and queer communities. Women in the queer community may reject traditional standards of beauty for women, while embracing alternative ideals. Some queer women may feel pressure from heir community to reject concerns about weight, or to believe that wanting to lose weight is wrong – potentially at the expense of physical health and well-being.
While queer women may fight with conflicting ideals about body image and femininity, queer men may struggle to achieve an exaggerated sense of male attractiveness. Gay and bisexual men are expected (by both mainstream and gay cultures) to be fit, muscular, well-dressed, and into trends and fashion. Some queer men report fearing that being to fat, too thin, too unattractive, or too old will prevent them from finding partners and/or achieving loving relationships. Others describe feeling that working out and being physically fit will help them regain control of their own lives and bodies, which are all too often taken over by discussions of what men should or should not look like.