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Published in final edited form as: Cult Health Sex. 2020 Mar 5;23(3):333–348. doi: 10.1080/13691058.2019.1710566

A Preliminary Model of Health Regarding Sexual and Ethnic Minority Older Adults.

Luciana Lagana` a,*, Ovsanna A Balian b, Marina Z Nakhla c, Juan Zizumbo a, Shayna Greenberg a
PMCID: PMC7773154  NIHMSID: NIHMS1550235  PMID: 32133922

Abstract

Older individuals with sexual/gender minority and minority racial/ethnic identities typically face multiple unique challenges, along with opportunities to overcome these obstacles. Published studies on the difficulties faced by sexual and gender minorities are available; however, research on older adults with both racial/ethnic minority and sexual and gender minority identities is rarer. These individuals must confront various forms of discrimination related to ageism, homophobia and racism. Resilience likely plays a role in their ability to manage and survive multiple challenges and discriminatory experiences, yet targeted research on these populations is lacking. This article offers a preliminary model that incorporates prevalent threats to these populations’ well-being and their deleterious psychosocial correlates, especially, whenever available, the unique challenges that older individuals must face when age, sexual orientation and race/ethnicity intersect. Recommendations are made to optimise the expansion and empirical testing of this preliminary model.

Keywords: older adults, sexual minority, gender minority, race, ethnicity

Introduction

By 2035 in the USA, there will be approximately 78.0 million people aged 65 years and older; that year, for the first time in US history, the population of older adults is expected to outnumber children (US Census Bureau 2018). The rapid escalation in the number of older adults highlights the importance of research, yet the interplay between multiple minority identities in older age has seldom been investigated.

Over 10.1 million adults in the USA identify as LGBTQ1, encompassing over 4% of the US adult population (Williams Institute 2017). Over 2% of people born between 1946 and 1964 and 1.4% of those born between 1913 and 1945 self-report as LGBT (Gates 2017). In the USA, approximately 10% of all sexual minority adults are over 65 years of age, compared to 19% of their non-LGBT peers (Williams Institute 2017). Over the years, the US population has seen a significant increase in its ethnic diversity (Perez and Hirschman 2009), with the US foreign-born population expected to almost double by 2065 (Radford and Budiman 2018).

Existing Gap in the Literature

There is a noticeable gap in published research on older people with sexual and gender minority and racial/ethnic minority identities. Given the fast-growing a) numbers of older adults in the US, b) rates of identification within the LGBTQ community, and c) size of minority ethnic populations, there is a critical need for research, programmatic training and continuing education development. In particular, it is important to study challenges related to ageism (i.e., discrimination against an individual or group on the basis of age), homophobia and racism, given that these factors are closely related to well-being. To this end, our goal is to a) summarise the published literature on ageism, homophobia and racism as they relate to the physical, mental, spiritual and social health and well-being of older individuals, and b) create a preliminary model of risk and protective factors impacting the health of older adults with sexual and gender minority and racial/ethnic minority identities.

We performed online literature searches using sources such as Web of Science, PubMed, PsychInfo and Google Scholar. We conducted systematic searches using keywords including, but not limited to, LGBT(Q) quality of life, LGBT(Q) older adults, older LGBT(Q) AND ageism, older LGBT(Q) AND racism as well as older LGBT(Q) AND homophobia. To keep within space limitations and to reasonably limit the scope of this article, we have not covered other key identities at elevated risk for discrimination and related health challenges, such as major health conditions or disabilities.

The Health Impacts of Ageism, Homophobia and Racism Alone

Impacts of Ageism on Health

The experience of ageism is commonplace in older age, as older adults typically face subjective experiences of mistreatment (Barnes et al. 2008) as well as poorer health, more limitations in their daily activities and more pain as they progress in age (Hastings, Shalev and Belsky 2019; Pascoe and Smart Richman 2009). Older age is also a risk factor for engaging in impulsive self-harm (Neufeld and O’Rourke 2009) and for heavy antidepressant use, which can precipitate mortality, attempted suicide, seizures and ischaemic stroke, among other serious problems (Trifirò et al. 2010).

Perceived discrimination stemming from ageist experiences induces higher stress responses compared to the responses of those who have not experienced discrimination (Pascoe and Smart Richman 2009). Officer and de la Fuente-Núñez (2018) emphasised that ageism originates from the perception that the individual who is being judged is too old to be a productive member of society. As documented by Gullette (2018), there are very prevalent stereotypes of older adults, which describe them, for instance, as a societal burden or an unproductive drain on resources.

Unfortunately, unlike sexism, homophobia, racism, and other forms of prejudice, ageism is a well-accepted pervasive bias in US society (Officer et al. 2016). Cuddy, Norton and Fiske (2005) blamed the implicit and unconscious nature of ageism as the main reason for its pervasiveness. However, empirical evidence suggests that older age and the corresponding ageism are not always risk factors impacting well-being, as Garstka et al. (2004) found that experiencing ageism was positively associated with age group identification; nonetheless, ageism has other detrimental impacts that make it less than desirable.

Impacts of Homophobia on Health

There are significant health disparities based on sexuality and sexual orientation (Williams Institute 2017). In a Canadian study, individuals who identified as LGBTQ were at times unable to obtain adequate healthcare due, at least partially, to medical professionals’ lack of cultural competency (Daley and MacDonnell 2011). This lack of competency also negatively affected the health of British Muslim gay men (Semlyen, Ali and Flowers 2018). Focus groups with Haitian transwomen and transmen revealed their experiences of beating, shootings, stoning and stabbings that increased their HIV risk (Rahill et al. 2019).

Moreover, sexual and gender minority individuals typically endure frequent microaggression in the form of intentional or unintentional racial slights or insults that may make an individual feel underestimated (McWhorter 2014). The individuals in question, regardless of their ethnic group, have a higher prevalence of psychiatric disorders than heterosexuals (Rodriguez-Seijas, Eaton and Pachankis 2019), with heterosexist discrimination, stigma expectations and low sexual minority disclosure all being related to poorer mental health (Velez et al. 2017). LGBTQ adults are at increased risk for poorer mental health regarding depression, anxiety, and suicidal ideation than the rest of the US population (Choi and Meyer 2016). Depression in particular is strongly influenced by discrimination towards sexual minority individuals (Fredriksen-Goldsen et al. 2009), with rates of suicidality being high starting at a young age (McDermott, Hughes and Rawlings 2018). Transgender adults in California reported higher rates of suicidal thoughts and attempts as well as higher psychological distress and poorer health than their cisgender counterparts (Williams Institute 2017).

In a review of the impacts of stigma and chronic stress on LGBTQ health, Mink, Lindley and Weinstein (2014) noted that challenges facing members of this population include chronic conditions, negative changes to life circumstances, traumatic events, regular experience of bias and discrimination, internalisation of negative evaluations by others and, in the case of bisexual and gay men, pressure to conform to sex roles dictated by social norms around masculinity. Compared to the heterosexual population, sexual minority individuals of all ages face disproportionate levels of victimisation, discrimination and oppression (Jones, Brewster and Jones 2014). They typically endure socioeconomic and cultural injustices (Chatterjee 2014) and are susceptible to sexual prejudice (Bartoş, Berger and Hegarty 2014). Bisexual and transgender individuals are often ostracised in heterosexual as well as in gay and lesbian communities, a situation that exacerbates their chronic stress and stigma experience (Mink, Lindley and Weinstein 2014).

Concerning potential protective factors for health outcomes among sexual and gender minority individuals, having an upper-income status is related to gaining access to LGBTQ human services, which in turn facilitates access to guidance, counselling and treatment during a crisis (Rosentel, VandeVusse and Hill 2019). Additionally, the findings of published research on positive identity among sexual minority individuals suggest the presence of a link between affirming self-perceptions and psychological well-being (e.g., Riggle et al. 2014) as well as coping (Vaughan and Rodriguez 2014). Moreover, adopting a eudaimonic approach to living (i.e. living in accordance with one’s values, finding life’s meaning and purpose) may benefit LGB individuals’ mental health by reducing minority stress (Kashdan and McKnight 2013). Engaging in self-care, having interests and hobbies as well as seeking professional help can help foster resilience to protect psychological health among LGB individuals (Dickinson and Adams 2014).

According to Mink, Lindley and Weinstein (2014), although rare in the lives of sexual minority populations, having a family of origin that provided opportunities for modelled coping and solidarity is beneficial to the wellbeing of LGBTQ individuals. Social support and community connectedness appear to further facilitate positive identity among sexual minorities (Bruce, Harper and Bauermeister 2015), encouraging resilience to offset internalised homophobia and its associated psychosocial detriments (Cooke and Melchert 2019). Similarly, constructivist thematic analyses revealed that access to safer spaces helped 18 individuals with trans experiences heal, feel a sense of belonging and share their experiences (Linander et al. 2019).

Impacts of Racism on Health

Empirical evidence on the negative health impacts of experiencing racism is extensive, and its full review is beyond the scope of this article. Briefly, frequent experiences of racism have been associated with elevated levels of blood pressure (e.g. Peters 2004; Steffen et al. 2003) as well as psychological distress and anger suppression, which is especially true among individuals age 40 and older (Peters 2004). Racism and/or lack of cultural sensitivity among health providers could be a factor in this discussion. Regarding this issue, in a recent literature review on racial/ethnic health inequities, Curtis et al. (2019) stressed that addressing them necessitates emphasizing the promotion of both cultural competency and cultural safety, with the latter applying to both individual health practitioners and organisational levels. The concept of cultural safety, they noted, has been viewed in the literature as reflecting either a movement along a continuum of cultural competence (which emphasizes knowledge) or a paradigm shift. Although their discussion of how to challenge racial/ethnic health inequities goes beyond the focus of the present article, interested readers could find these authors’ list of core principles for the achievement of cultural safety helpful. In particular, the authors warned readers of the dangers of merely focusing on acquiring knowledge about “other cultures”. To move beyond a process of “othering”, the authors posited, requires unmasking practices that blame racial/ethnic health inequity problems on the affected individuals. This blaming approach is typically employed due to the individualistic nature of cultural competency, which is based on identifying people as being different from oneself or the dominant culture. Curtis and colleagues highlighted the need to become aware of racism-related health correlates, including social domination, sources of repression as well as structural variables like power and class.

The Health Impacts of Ageism, Homophobia and Racism on the Intersectional Identity Individuals

Intersectionality (Crenshaw 1989), which recognises how multiple interlocking identities are defined by relative socio-cultural power and privilege (Parent, DeBlaere and Moradi 2013) is a key risk factor for poorer well-being at any age.

Health Impacts of Older Age with Sexual and Gender Minority Identity

The intersection of older age with one or more minority identities increases risk for reduced medical and psychosocial resources, lower quality of life and higher rates of daily life challenges (Balsam et al. 2011). Homophobia may exert an even more pervasive negative effect than ageism on the well-being of older LGBTQ adults, as suggested in a study by Averett, Yoon and Jenkins (2013), who investigated perceived homophobia and ageism experiences in a group of 456 lesbians over the age of 51 years. Results revealed that older lesbians generally experienced greater levels of homophobia than ageism in a variety of settings, such as within family relationships and social situations, during shopping or dining out, in employment settings as well as in their housing and healthcare experiences.

Depressive symptomatology among older LGBTQ individuals has been inversely related to healthcare engagement, with those who have a diagnosis of depression reporting the highest difficulty in adhering to treatment (Shiu, Kim and Fredriksen-Goldsen 2017). In general, quality of life for the aforementioned individuals is negatively related to experiencing discrimination (Fredriksen-Goldsen et al. 2014). In particular, single older LGBTQ adults typically report lower quality of life, poorer health and lack of resources compared to their married counterparts (Goldsen et al. 2017).

Older sexual and gender minority adults may experience negative family reactions (e.g. conflict, rejection) when coming out. Family rejection may lead to an increase in suicide attempts, depression, drug abuse and/or risky sexual behaviours (Ryan et al. 2009). Although perceived social acceptance is strongly related to having come out at a younger age (Dunlap 2016), doing so for people who are now over the age of 65 was a daring and risky action, given that they were born during sexually conservative times. Many factors may delay the coming out process, even in later years. For instance, the American Psychiatric Association classified homosexuality as a mental disorder until 1973 (Drescher 2015). By that time, the stigma of being a homosexual in a heteronormative world could have caused many sexual minority individuals who are older adults today to decide against coming out. Another reason for not coming out earlier is to protect one’s career, as recently revealed by 82-year old ‘Star Trek’ Japanese-American actor George Takei, who also had to confront racism. He reportedly suffered silently and guilt-ridden over not coming out, as he was sure that he would have not been hired again had he come out earlier on in his career (Singleton 2019).

Although coming out-related acceptance may have increased within the past decade or so, empirical evidence suggests that coming out at an older age is still difficult (e.g. creating strained family dynamics for women; Rickards and Wuest 2006). Reluctance to come out later in life may also be due to perceived discrimination by healthcare providers and caregivers (Brotman et al. 2007). In this regard, using qualitative in-depth interviews with older lesbians and bisexual women in Ontario who utilised home care services, Grigorovich (2015) found that these women experienced frequent anxiety and isolation caused by perceived overt and subtle discrimination (in addition to heterosexism). However, they also showed resilience, as they were able to cope with sexual minority stress and the related pressures of heteronormativity.

Regarding potential protective factors for health in relation to the intersectionality of older age and sexual and gender minority, religiosity and spirituality can buffer the negative impacts of homophobia on older sexual minority adults’ quality of life. Based on a single in-depth interview with a 60 year-old transgender woman, Fredriksen-Goldsen (2016) found that support offered by churches for LGBT individuals was, in this woman’s opinion, more critical for older LGBT than for younger LGBT individuals. Furthermore, Kim, Jen and Fredriksen-Golden (2017) discovered that older (age 50+) African American and Hispanic LGBT adults, compared to their White counterparts, had higher levels of spirituality, which were related to better psychological quality of life.

Among lesbian, gay and bisexual adults over the age of 60, social support decreased the damaging health impacts of stigmatisation (Grossman, D’Augelli and Hershberger 2000). Older LGBTQ individuals may cope better with stress and enhance their well-being via increasing their use of community and environmental resources (Sagie 2015). Resilience is also a critical factor. In an overview of the difficulties and strengths of older LGBT adults and related evidence-based interventions, Hash and Rogers (2013) show how, in order to overcome stigma, individuals often utilised methods to enhance their resilience, such as being flexible with their gender roles as well as cultivating crisis competence and survival skills. Furthermore, according to Fredriksen-Goldsen et al. (2017), older LGBT adults who use identity affirmations to increase resilience have better mental health and access to social resources.

Taken together, these findings reflect the multiple ways in which older gender and sexual minorities are resourceful in the use of techniques to increase resilience. Moreover, Lyons, Pitts and Grierson (2013) reported better mental health with advanced age among some sexual minorities, with older gay men’s support from family and friends, full-time employment, lack of perceived social stigma and coupled status being protective factors for mental health. Furthermore, being an older adult may serve as a protective factor among transgender and gender non-conforming individuals (Stanton, Ali and Chaudhuri 2017).

Health Impacts of Older Age and Racial/Ethnic Minority Identity

Concerning being older and having a race/ethnicity minority identity, early work suggested there were no significant differences between White and racial/ethnic minority older adults on life satisfaction and contact with relatives (Dowd and Bengston 1978). In more recent research involving older adults with different forms of cancer, older African-American and Asian-American patients reported poorer physical health compared to older non-Hispanic Whites and Hispanic Whites (Bellizzi et al. 2012). Among adults age 65 and older, racial/ethnic minorities reported more adverse health outcomes than their White counterparts, including worse sensory challenges, greater psychological symptomatology as well as more limitations on daily activities’ engagement due to disability (Ng et al. 2014). Additionally, older Hispanic and African-American adults disclosed experiencing poorer outlook and quality of life compared to their White counterparts (Carreon and Noymer 2011). Moody‐Ayers et al. (2005) discovered that approximately 95% of older African-American patients at a diabetes clinic reported experiencing racism daily.

Exposure to racism could negatively impact the doctor-patient relationship. In a large sample of older adults residing in Chicago, participants who reported higher levels of perceived racial discrimination had a higher relative risk of death (Barnes et al 2008). In semi-structured interviews, midlife and older Black women living with HIV revealed experiencing negative responses related to gender, race, age and disease (Sangaramoorthy, Jamison and Dyer 2017). Furthermore, racism can limit opportunities and facilitation of physical activities. In this regard, after controlling for sex, education level and household income, Edwards and Cunningham (2013) discovered a significant positive relationship between physical activity and self-reported health in an ethnically diverse sample of 280 older men and women living in Texas. Racism was related to lower rates of participation in those activities; specifically, perceived community racism moderated the correlation between perceived opportunities for physical activity and exercise (Edwards and Cunningham 2013). As stated by the aforementioned authors, their results show a complex type of relationship between opportunities and facilitation of physical activity, highlighting the need to address inequitable access to physical opportunities and to research ways in which different racial/ethnic groups negotiate barriers to physical activities. Spatial physical activity disparities and related health risks might stem from inequitable distributions of opportunities to engage in activities that could prevent the development of health problems. It is likely that social justice efforts have not yet been sufficiently allocated in order to ensure the equitable distribution of supportive environments where our target populations could engage in physical activities.

Concerning protective factors related to the intersectionality between age and racial/ethnic minority identity, not all older adults are impacted by perceived racism in the same way. At times, older age can work as a buffer that allows older individuals to protect themselves mentally against institutional racism. In this regard, older African-American adults who were exposed to racism at an earlier age were more likely to adapt and face less severe negative consequences than younger adults, who were more likely to suffer negative consequences of racism due to having less experience and preparation to cope with it than older adults (Greer and Spalding 2017).

Health Impacts of Sexual and Gender Minority and Racial/Ethnic Minority Identity

Experiencing microaggression is common in sexual and gender minority populations, and is usually related to a) lower self-esteem, higher depression rates, increased stress and anxiety levels as well as poorer general well-being among LGBT individuals (Ghabrial 2017) as well as b) higher levels of multiple minority stress for ethnic minority lesbians and gay men than for ethnic minority bisexual women and men (Balsam et al. 2011). Some authors have suggested that microaggression is the new racism (e.g. McWhorter 2014), which highlights the importance of carefully investigating experiences of microaggression through intersecting identities (Nadal et al. 2015). Experiencing both homophobia and racism can lead to an increase in risky sexual behaviours (e.g. Nakamura and Zea 2010). Regarding experiencing social discrimination and related HIV risk behaviours among homosexual Latino men, more than 40% of Mizuno et al.’s (2012) sample had been exposed to homophobia and racism in the past year. This exposure was influenced by factors such as income, education and HIV status, and was associated with an increase in binge drinking and in engaging in multiple risky behaviours, such as being the receptive partner in unprotected sex.

In general, individuals with sexual and gender minority and racial/ethnic minority identities typically face several social challenges associated with their double minority identity including aggression, loss of relationships, stress and sexual problems (Zamboni and Crawford 2007). Receiving social support may be often difficult for racial/ethnic and sexual and gender minority individuals. For example, regardless of age, African-American same-sex couples often experience rejection from family members, which can result in the permanent dissolution of personal relationships (Mink, Lindley and Weinstein 2014).

Among racial/ethnic minority gay men, the report of experiences with both racism and homophobia with their heterosexual friends was related to research participants’ likelihood of developing depression and anxiety (Choi et al. 2013). Concerning racism in LGBTQ spaces, lesbian, bisexual and queer racial minority women have reported that ‘White privilege’ excluded them from LGBTQ safe spaces that were predominantly White (Logie and Rwigema 2014). White LGBTQ spaces enforced the marginalisation of racial and sexual minority women through false stereotypes, such as their being aggressive and emotional. Regarding the mediating role of cyber and bias-based victimisation in accounting for sexual and gender minority orientation disparities in mental health, young Black gay, lesbian, bisexual and mostly heterosexual participants reported experiencing more cyber and bias-based victimisation than their Black heterosexual counterparts (Mereish et al. 2019). Race is mentioned more often in online personal ads posted by gay men than by heterosexual men; this could indicate that race is a particularly significant issue within sexual and gender minority communities (Phua and Kaufmann 2003).

Regarding potential protective factors, pride in one’s ethnic/racial minority identity and gender was a main theme regarding resilience in response to traumatic life events among transgender ethnic minorities (Singh and McKleroy 2011). Because LGBTQ racial minorities may depend more heavily on belonging to racial/ethnic communities relative to people who only identify as LGBTQ (Balsam et al. 2011), if such communities are available and provide support to the individuals in question, this may constitute a protective factor in their lives. Importantly, focus group research on Black sexual and gender minority men has shown that LGBT-affirming churches can serve as a space where modelling loving same-sex relationships, emotional healing and acceptance can take place (White et al. 2019).

Health Impacts of Older Age, Sexual and Gender Minority and Racial/Ethnic Minority Identity

Research on the interrelation between ageism, homophobia and racism was practically non-existent until recently (Grov et al. 2006). This may be attributable, at least in part, to a lack of proper assessment tools to carefully capture the unique experiences of this population (Balsam et al. 2011). However, to our knowledge, there are still only a few researchers who have covered all three of the identity dimensions in question. Among them, Kim, Jen and Fredriksen-Golden (2017) found that, after the age of 50, identifying as a Black or Hispanic LGBT individual (compared to being White) was associated with poorer health and worse psychological quality of life. Bowleg et al. (2008) have argued that coming out for racial/ethnic minority older adults can be more challenging due to the intersection of race and sexual orientation, noticing that the decision for older African-American LGBT adults to come out is often influenced by concerns and worries about religious, family and community factors. It is particularly difficult for older racial/ethnic minority and sexual and gender minority individuals to deal with having an HIV-positive status. In this regard, older gay and bisexual African-American men found the social and medical institutions’ stigma dehumanising, making them feel as though they lived in an HIV ghetto (Haile, Padilla and Parker 2011).

Bringing all the evidence together, Figure 1 offers a preliminary visual representation of our model of risk and protective health factors, when seen together. For simplicity of illustration, it groups together each set of variables without separating the sets by minority group.

Figure 1:

Figure 1:

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Multigroup model of risk and protective health factors for older individuals with racial/ethnic as well as sexual and gender minority identities.

Recommendations for Future Research

Our analysis has the potential to help explain the unique experiences of older adults with sexual/gender minority and minority racial/ethnic identities as well as the risk and protective factors that could impact their health outcomes. Our model is preliminary, mainly descriptive and thus limited in many ways, which is often the case when attempting to address multiple layers of interacting factors affecting different groups. Interested researchers may wish to consider expanding the model by adding variables such as gender, disability status and antecedents of the three negative societal attitudes represented in the model. Each construct of the model is a variable, which will have differing values in each application for each individual being studied. It was challenging to create a model on this topic, due to the very limited literature in this area and the fact that most of the studies cited herein have small sample sizes and cover only a few minority groups.

The need for more research in this area is particularly apparent when we consider the extent of the intersectional complexities affecting the target population. For example, older age (which is both an agent characteristic and a potential mediator) could mitigate, to a certain extent, racism’s negative health impacts (Greer and Spalding 2017), but it is also a predictor of worse physical health (Prince et al. 2015). Interested researchers could explore the interrelationship between variables within this model, such as the relationship between advanced age and different health outcomes as well as other mediators.

Some of the factors depicted in our model are also included in Mink, Lindley and Weinstein (2014)’s Intersectional Ecology Model of LGBTQ Health. Briefly, this model identifies ways in which the health-related impacts of sexual minority status can be measured, explored, explained and predicted, as the hypervigilance often stemming from identifying as being a sexual minority within a heteronormative society produces deleterious impacts on health outcomes through self-stigma as well as chronic and elevated stress levels. While an in-depth discussion of how Mink, Lindley and Weinstein (2014)’s model might inform the development of the framework offered here would be valuable but goes beyond the scope of this article.

Finally, our preliminary model contains several environmental factors that raise questions to be addressed in future research. For instance, are there ways in which researchers, practitioners and community advocates can help design safe spaces as well as high-quality therapeutic approaches and programmes to counteract the negative effects of ageism and homophobia in the lives of our target population? Would the creation of safe spaces - in the form of exercise facilities and other needed health-enhancement locations – result in high attendance to these facilities as well as high satisfaction with the proposed community initiatives? How can outcome research be integrated into the development and improvement of clinician training programmes to enhance the knowledge and cultural competence of professionals involved in the care of older, racial/ethnic and sexual and gender minority individuals?

Concluding Comments

Our model offers a preliminary contribution to future investigations seeking to clarify the health-related challenges faced by older adults with racial/ethnic minority and sexual and gender minority identities. The conceptual model developed represents an approximation of a health model that, ideally, could integrate all the published research on each set of groups into a single, cohesive and empirically informed framework to help us better understand intersectional impacts. Interested researchers could further study each of the model’s variables within each set of marginalised groups as part of innovative minority group-specific research, studying each minority in relation to a variety of health outcomes. The causative relations implied by the model should be the focus of future research.

Acknowledgments

Funding

This work was supported by the US National Institute of General Medical Sciences (NIGMS) grant 5SC3GM094075 (Luciana Laganá, Principal Investigator). Additional support for the project was provided by the NIGMS grant GM063787 (Research Initiative for Scientific Enhancement) and by the National Institutes of Health (NIH) Building Infrastructure Leading to Diversity (BUILD) grant 5TL4GM118977. The content of this article does not necessarily represent the official views of NIH or of NIGMS and is solely the responsibility of the authors.

Footnotes

1

Throughout this article, we use disparate acronyms such as LGBTQ, LGBT, or LGB in order to preserve the use of these terms by the original authors. For similar reasons, although the term “homonegativity” has started to gain popularity in research (for example, in the 2017 model of LGB minority stress by Conlin, Douglass and Ouch), we have used the term “homophobia” instead, to match the terminology most often used in the published literature. We also use the term ‘sexual and gender minority’, as this more inclusive term is starting to replace LGBTQ by medical research agencies such as the National Institutes of Health (Light and Obedin-Maliver 2019).

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