1454  |  Health Serv Res. 2019;54:1454–1466.

Health Services Research

wileyonlinelibrary.com/journal/hesr

DOI: 10.1111/1475-6773.13229

S P E C I A L I S S U E : E X P E R I E N C E S O F D I S C R I M I N A T I O N I N A M E R I C A

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

Logan S. Casey PhD1 | Sari L. Reisner ScD, MA2 | Mary G. Findling PhD, SM1  | Robert J. Blendon ScD1 | John M. Benson MA1 | Justin M. Sayde MS1 | Carolyn Miller MS, MA3

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

1Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts2Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts3Research, Evaluation, and Learning Unit, Robert Wood Johnson Foundation, Princeton, New Jersey

CorrespondenceJohn M. Benson, MA, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Kresge 4th Floor, Boston, MA 02115, USA.Email: [email protected]

Funding informationRobert Wood Johnson Foundation, Grant/Award Number: 73713

AbstractObjective: To examine reported experiences of discrimination against lesbian, gay, bisexual, transgender, and queer (LGBTQ) adults in the United States, which broadly contribute to poor health outcomes.Data Source and Study Design: Data came from a national, probability-based tel-ephone survey of US adults, including 489 LGBTQ adults (282 non-Hispanic whites and 201 racial/ethnic minorities), conducted January-April 2017.Methods: We calculated the percentages of LGBTQ adults reporting experiences of discrimination in health care and several other domains related to their sexual orien-tation and, for transgender adults, gender identity. We report these results overall, by race/ethnicity, and among transgender adults only. We used multivariable models to estimate adjusted odds of discrimination between racial/ethnic minority and white LGBTQ respondents.Principal Findings: Experiences of interpersonal discrimination were common for 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.

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1  | INTRODUC TION

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) people in the United States have experienced a long history of discrimina-tion, including criminalization and classifications as mentally ill, at-tempts to forcibly change LGBTQ people's sexual orientation and/or gender identity, hate crimes and violence, and exclusion from employment, housing, public spaces, and social institutions.1-3 And yet, despite this history and despite research examining beliefs about discrimination generally and the consequences of experienc-ing discrimination (discussed below), relatively few national efforts have been made to systematically study LGBTQ people's reported personal experiences of discrimination.3-5 While such efforts are hindered by the inherent challenge of surveying a small, dispersed, difficult-to-define, and internally diverse population,6-8 it is none-theless critically important to study experiences of discrimination because of the established impact of discrimination on health and well-being.

Research demonstrates that experiencing discrimination or harassment has significant and negative consequences for both physical and mental health.9,10 This field of research shows that experiences of enacted stigma, discrimination, and/or harass-ment induce psychological, behavioral, and physiological stress responses in the body and that the impacts of these reactions ac-cumulate over time,11 leading to a wide range of negative health outcomes and health-related behaviors. Even the anticipation of or mental preparation for discrimination, whether discrimination actually occurs (ie, felt stigma), has significantly harmful effects on health.12-14

While much related research has focused on the effects of rac-ism10,15,16 and sexism on health,16,17 these same effects have also been observed in the context of discrimination, harassment, and assault against nonrepresentative samples of LGBTQ people.18-21 In some cases, these effects persist even after basic protection policies have been implemented.22 Experiencing discrimination persistently leads to negative health effects for LGBTQ people,23,24 and it limits their opportunities and access to critical resources in areas such as health care, employment, and public safety.21,22 It also leads to avoidance of care, further amplifying these negative health consequences.14 For example, transgender people who have experienced discrimination in health care are more likely than those who have not experienced discrimination to subsequently avoid both preventative and urgent health care services, including needed care due to illness or injury.22 This leads to worse health outcomes, including higher likelihood of depression and suicidal ideation or attempts.14

Further, these negative consequences for health are likely to be compounded for individuals from multiple minority backgrounds, such as LGBTQ racial/ethnic minorities or LGBTQ women.18,25-30 Transgender people, with their unique health concerns, may also face special health-related vulnerabilities as a result of discrimi-nation, including social and economic vulnerabilities that increase health risks.31,32 These effects are particularly alarming given that LGBTQ people are significantly less likely than non-LGBTQ people to have health insurance31,33 and therefore may have less access to medical care that could mitigate the adverse health consequences of discrimination.

Few surveys have documented LGBTQ people's personal expe-riences of discrimination using national data and/or across multiple domains of life. The landmark Institute of Medicine report6 on LGBT health in 2011 identified the need for research to overcome some of the methodological challenges that arise in studying LGBTQ popu-lation health, such as noninclusion of items to assess sexual orienta-tion and/or gender identity in federal surveys, small population size, stigma, discrimination, privacy, and dispersion in sampling, among others.8,34,35 Although some progress has been made, large national probability studies of discrimination across multiple domains among LGBTQ adults remain the exception, rather than the rule. Particularly needed are studies that allow comparisons by race/ethnicity within the LGBTQ population.3-6,8 This study attempts to expand on prior telephone polling methods by examining LGBTQ adults' experiences across many areas of life, drawn from a large national sample of US adults.

This study, alongside complementary articles in this issue of Health Services Research, brings a public health perspective to the complexity and pervasiveness of discrimination in the United States today. It was conducted as part of a larger survey fielded in 2017 in response to a growing national debate about discrim-ination in the United States today,36 to understand experiences of discrimination against several different groups in America, in-cluding blacks, Latinos, Asians, Native Americans, women, and LGBTQ people. This particular study has four main purposes: (a) to examine the prevalence of discrimination, harassment, and vi-olence against LGBTQ adults specifically because of their sexual orientation and, for transgender adults and gender nonconform-ing adults, their gender identity; (b) to examine such experiences across multiple domains of life raised as areas of concern among experts,36 including health care, education, employment, housing, political participation, police, and the criminal justice system, as well as interpersonal areas including slurs, microaggressions, ha-rassment, and violence; (c) to examine variation in experiences of discrimination within LGBTQ adults by race/ethnicity, as prior

K E Y W O 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

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research illustrates that racial/ethnic minority LGBTQ adults may be at particular risk for experiencing discrimination; and (d) to ex-amine experiences of discrimination and harassment among a sub-sample of transgender adults (including those who identified as genderqueer or gender nonconforming), who are also at particular risk for experiencing discrimination.

2  | METHODS

2.1 | Study design and sample

Data were obtained from a nationally representative, probability-based telephone (cell and landline) survey of US adults, conducted from January 26 to April 9, 2017. The survey was jointly designed by Harvard TH Chan School of Public Health, the Robert Wood Johnson Foundation, and National Public Radio. SSRS, an independent firm, administered the survey. Because Harvard researchers were not directly involved in data collection and de-identified datasets were used for analysis, the study was deemed “not human subjects re-search” by the Harvard TH Chan School of Public Health Office of Human Research Administration.

The full sample included 3453 US adults aged 18 years and older, including nationally representative samples of blacks, Latinos, Asian Americans, Native Americans, whites, men, women, and LGBTQ adults. This paper examines the subsample of 489 LGBTQ adults, including 282 whites and 201 racial/ethnic minorities and an over-sample of 86 transgender adults. Screening questions regarding sexual orientation and gender identity were asked at the beginning of the survey, so that LGBTQ respondents could be identified and asked relevant questions (see Appendix S1). For sexual orienta-tion, respondents were classified as LGBQ if they identified as gay or lesbian, bisexual, or another sexual orientation specified by the respondent that was not heterosexual or straight. For gender iden-tity, respondents were classified as transgender if they identified as transgender male, transgender female, genderqueer or gender non-conforming, or another gender identity specified by the respondent that was not male or female.

The completion rate for this survey was 74 percent among respondents who answered initial demographic screening ques-tions, with a 10 percent overall response rate, calculated based on the American Association for Public Opinion Research's (AAPOR) RR3 formula.37 Because data from this study were drawn from a probability sample and used the best available sampling and weighting practices in polling methods (eg, 68 percent of inter-views were conducted by cell phone, and 32 percent were con-ducted via landline), they are expected to provide accurate results consistent with surveys with higher response rates.38,39 Surveying LGBTQ populations faces major challenges in constructing ade-quate sampling frames and sample sizes, as well as a stigmatized respondent population, underreporting, and variations in ques-tion wording on sexual orientation and/or gender identity.6-8,34,35 While federal benchmark data are limited, respondents for this

survey were similar demographically to LGB adults in other na-tional, population-based samples obtaining higher response rates (General Social Survey and National Health Interview Survey),40 though federal surveys are also subject to the limitations noted above. We expect these results to be generalizable to the US adult 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, Ben-Porath, and Casey (2019) for a further description of the sur-vey methodology.41

2.2 | Survey instrument

In this poll, we analyzed 25 questions about lifetime experiences of discrimination, including adults' personal experiences of discrimina-tion and perceptions of discrimination in the nation. The objective of this study was to examine the extent of discrimination experi-enced by LGBTQ adults in America, building on question modules in this field adapted from prior surveys on racial and LGBTQ discrimi-nation.3-5,42,43 We conceptualized discrimination as differential or unfair treatment of individuals based on their LGBTQ identity, and we include discrimination that is “institutional” (based in laws, poli-cies, institutions, and related behavior of individuals who work in or control these laws, policies, or institutions) and “interpersonal” (based in individuals' beliefs, words, and behavior).8,43,44,a 

For this study, we analyzed questions about personal expe-riences, covering six institutional and seven interpersonal areas of discrimination (full questions and wording in Appendix S1). Institutional areas included employment, education, health care, housing, political participation, and police and courts. Interpersonal areas included anti-LGBTQ slurs, microaggressions, other people's fear of LGBTQ adults, sexual harassment, being threatened or non-sexually harassed, being harassed or questioned regarding bath-room use, and experiencing violence, among other experiences. We also examined two areas where individuals might avoid seeking help or services due to anticipation or fear of being discriminated against: seeking medical care or the services of police or other au-thority figures. We examined these numerous domains in order to capture a wide range of possible discriminatory experiences across adults' lives.

Questions were only asked among a random half-sample of respondents to maximize the number of questions while limiting respondent burden (half-sample A = 259, half-sample B = 230). Questions were only asked of relevant subgroups (eg, college-re-lated questions only asked among adults who had ever applied to or attended college). Questions about harassment (sexual and non-sexual), violence, and avoiding institutions for fear of discrimination were asked about yourself or friends or family members who are also LGBTQ, because of the sensitive nature of the questions and prior literature demonstrating that vicariously experiencing stress (eg, through discrimination experienced by family members) can directly and adversely affect individuals.45

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2.3 | Statistical analyses

We first calculated the prevalence of all LGBTQ people who re-ported they had ever experienced discrimination because of their sexual orientation and/or gender identity in each of the afore-mentioned domains. Second, we generated bivariate statistics to assess whether experiencing discrimination because of LGBTQ identity was associated with race. Because of the sample size, particularly with split-sampled questions, responses of nonwhite racial/ethnic minorities were pooled together, and we compared whites to racial/ethnic minorities. Six people were included in overall analyses but excluded from racial/ethnic comparisons be-cause of insufficient race/ethnicity data. Using pairwise t tests of differences in proportions, we made uncontrolled comparisons of the weighted percentage of adults reporting discrimination be-tween racial/ethnic minority and white adults, to examine where race/ethnicity affects LGBTQ adults' experiences of discrimina-tion, irrespective of cause. For all analyses, statistical significance was determined at P < .05.

We then conducted logistic regression models to assess whether identifying as a racial/ethnic minority remained statisti-cally significantly associated with discrimination after controlling for the following covariates and possible confounders: self-iden-tified gender (male or female, excluding genderqueer or gender nonconforming due to insufficient sample size, n = 28); age in years (18-29 or 30+); self-reported household income (<$25 000 or $25 000+); and education (less than college degree or college graduate). We also examined whether each of these sociodemo-graphic variables was significantly associated with experiencing discrimination across domains. Metropolitan status, region, and health insurance status were omitted from these models for par-simony, due to the sample size. Odds ratios (OR) and 95% confi-dence intervals (95% CI) were estimated.

Finally, we conducted a subgroup descriptive analysis of transgender adults (n = 86), to assess their experiences separately from the larger LGBTQ population, given that we expected trans-gender experiences to be unique.3 We did not directly compare transgender adults to LGBQ adults because the groups are not mutually exclusive. Due to randomly assigned split sampling of the survey questionnaire, there were some questions that had too few transgender respondents to report these percentages (half-sample A = 33, half-sample B = 55). Results are only reported if n > 50.

To compensate for known biases in telephone surveys (eg, nonresponse bias) and variations in probability of selection within and across households, sample data were weighted by household size and composition, cell phone/landline use, and demograph-ics (gender, age, education, race/ethnicity, and census region) to reflect the true population distribution of adults in the country. Other techniques, including random-digit dialing, replicate sub-samples, and random selection of a respondent within a house-hold, were used to ensure that the sample is representative. All analyses were conducted using STATA version 15.0 (StataCorp),

and all tests accounted for the variance introduced by weighted data.

3  | RESULTS

3.1 | Characteristics of the LGBTQ study sample

Demographic and socioeconomic characteristics of US LGBTQ adults are displayed in Table 1; percentages of LGBTQ adults who have experienced discrimination because of their sexual orientation and/or gender identity are shown in Table 2; adjusted odds ratios of reporting discrimination are shown in Table 3; descriptive analysis of transgender adults is shown in Table 4. All estimates display data weighted using survey weights.

Table 1 shows that a majority of the LGBTQ sample were cis-gender (77 percent), with 23 percent identifying as transgender or genderqueer or gender nonconforming. A majority were also white (61 percent), while 39 percent identified as racial and/or ethnic mi-norities. LGBTQ racial/ethnic minorities were significantly less likely than LGBTQ whites to have a college degree (23 percent vs 38 per-cent, P < .01) and to make $25 000 or more per year (46 percent vs 66 percent, P < .04). LGBTQ racial/ethnic minorities were also sig-nificantly more likely (23 percent) than LGBTQ whites (10 percent) to be without health insurance (P < .02).

3.2 | Discrimination attributed to sexual orientation and/or gender identity

Table 2 shows the weighted percent of LGBTQ adults, both in ag-gregate and by race/ethnicity, who reported personally experiencing various forms of discrimination because of their sexual orientation and/or gender identity.b  The majority of LGBTQ adults reported personally experiencing interpersonal discrimination: 57 percent said they have experienced slurs and 53 percent said they had ex-perienced microaggressions related to their sexual orientation or gender identity. Similarly, the majority of LGBTQ adults reported interpersonal discrimination either personally or in their immediate friends or family: 57 percent said they or an LGBTQ friend or fam-ily member had been threatened or nonsexually harassed because of their LGBTQ identity, and 51 percent said they had experienced sexual harassment or violence because of their sexual orientation and/or gender identity.

More than one-third (34 percent) of LGBTQ people said that they or an LGBTQ friend or family member has personally been verbally harassed while in a bathroom or been told or asked if they were in the wrong bathroom. Another third (32 percent) said that they or an LGBTQ friend/family member have been told or felt they would be unwelcome in a neighborhood or place to live because they are LGBTQ.

In the context of institutional discrimination, 18 percent of LGBTQ adults reported they have avoided seeking health care for themselves or family members due to anticipated discrimination, while 16 per-cent reported discrimination in clinical encounters. One-fifth or more

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TA B L E 1   Characteristics of LGBTQ adults in the study sample (N = 489)a

All LGBTQ adults N = 489 White LGBTQ adults N = 282Racial/ethnic minority LGBTQ N = 201

Weighted percentage of respondentsb

LGBQ (lesbian, gay, bisexual, and queer)c 84 83 84

Cisgender 77 – –

Transgender (including genderqueer and gender nonconforming)c

23 25 20

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)d 39 – –

Age

18-29 y 41 39 45

30 + y 59 61 55

Education

No college degreee 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 statusf

Uninsured 15 10 23* 

Insured, Medicaid 14 16 11

Insured, non-Medicaid 68 71 65

Area of residenceg

Urban 30 26 3

Nonurban 64 67 61

Don't know/refused 6 7 4

US region of residenceh

Northeast 23 22 26

Midwest 20 23 17

South 30 33 27

West 20 16 26

Don't know/refused 6 6 4

aPercentage of US LGBTQ population estimated with survey weights to adjust for unequal probability of sampling. bThe 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. cLGBQ and transgender are not mutually exclusive. A person can identify as one or both. dThere 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. eIncluding 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. fPrimary source of health insurance. gNonurban includes suburban and rural. hRegions defined by US Census Bureau 4-region definition. *Different from whites, statistically significant at P < .05 (shown in bold).

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TA B L E 2   Differences between white and racial/ethnic minority LGBTQ adults in reporting discrimination because of their LGBTQ identitya

Subject of discriminationb N

Weighted percent of all LGBTQ adultsc

Weighted percent of white LGBTQc

Weighted percent of racial/ethnic minority LGBTQc

Belief in overall discrimination

General belief that discrimination against lesbian, gay, and bisexual people exists today in the United Statesd

All LGBTQ adults (total sample)

489 91 92 88

General belief that discrimination against transgender people exists today in the United Statesd

All LGBTQ adults (total sample)

489 91 93 88

Experiences of institutional discrimination

Employment

Being paid equally or considered for promotionse

You (half-sample A) 245 22 19 28

Applying for jobsf You (half-sample A) 245 20 13 32*

Education

Applying to or while attending collegeg

You (half-sample B) 192 20 20 20

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 buy a househ

You (half-sample B) 177 22 25 14

Political participation

Trying to vote or participate in politics

You (half-sample A) 255 11 7 16

Police and courts

Interacting with police You (half-sample A) 258 16 11 24*

Unfairly stopped or treated by the policei

You or LGBTQ friend/family member (half-sample A)

259 26 26 26

Unfairly treated by the courtsi You or LGBTQ friend/family member (half-sample A)

259 26 23 31

Experiences of interpersonal discrimination

LGBTQ identity-based microaggressionsj

You (half-sample B) 230 53 64 35*

Racial identity-based microaggressions

You (half-sample B) 230 18 6 38*

LGBTQ identity-based slursj 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 LGBTQ identityj

You (half-sample B) 230 15 17 14

People acted afraid because of your race/ethnicity

You (half-sample B) 230 12 6 23*

Violencei You or LGBTQ friend/family member (half-sample A)

259 51 57 42

Threatened or nonsexually harassedi You or LGBTQ friend/family member (half-sample A)

259 57 60 52

Sexual harassmenti You or LGBTQ friend/family member (half-sample A)

259 51 57 43

(Continues)

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reported personally experiencing discrimination specifically because of their LGBTQ identity across multiple domains of life: when seeking housing (22 percent), equal pay or promotions (22 percent), applying for jobs (20 percent), and applying to or while attending college (20 percent). About one-quarter of LGBTQ adults said they or LGBTQ friends or family members had also been unfairly treated by the courts (26 percent) or unfairly stopped or treated by police (26 percent) be-cause of their LGBTQ identity.

Importantly, LGBTQ racial/ethnic minorities were more than twice as likely as LGBTQ whites to say they had personally experi-enced institutional discrimination because of their LGBTQ identity when applying for jobs (32 percent vs 13 percent, P < .02) and when interacting with police (24 percent vs 11 percent, P < .05). Compared to LGBTQ whites, LGBTQ racial/ethnic minorities reported lower prevalence of some forms of interpersonal discrimination, specifi-cally LGBTQ-based microaggressions (35 percent vs 64 percent, P < .01) and slurs (41 percent vs 65 percent, P < .02). However, LGBTQ racial/ethnic minorities had a higher prevalence than whites

of reporting race-based microaggressions (38 percent vs 6 percent, P < .01), slurs (53 percent vs 14 percent, P < .01), and racial fear (23 percent vs 6 percent, P < .01).

3.3 | Adjusted odds of reporting personal experiences of discrimination in LGBTQ adults

Table 3 reports odds ratios with 95% confidence intervals examin-ing whether race/ethnicity differences in reported experiences of discrimination persist after controlling for pertinent demographic variables, including age, race, gender, education, and income. For institutional discrimination, LGBTQ racial/ethnic minority adults had significantly higher odds than LGBTQ whites for reporting dis-crimination on the basis of being LGBTQ when applying for jobs, voting or participating in politics, and being treated unfairly by the courts. LGBTQ racial/ethnic minorities had lower odds for reporting LGBTQ-based discrimination when going to a doctor or health clinic than LGBTQ whites.

Subject of discriminationb N

Weighted percent of all LGBTQ adultsc

Weighted percent of white LGBTQc

Weighted percent of racial/ethnic minority LGBTQc

Harassed while using bathroomi You or LGBTQ family mem-ber (half-sample A)

259 34 32 36

Been told or felt unwelcome because of being LGBTQk

You or LGBTQ family mem-ber (total sample)

489 32 34 31

Actions based on concerns about discrimination

Avoided doctor or health care be-cause of concerns of discrimination/poor treatment

You or LGBTQ family mem-ber (half-sample B)

230 18 21 12

Avoided calling the police because of concerns of discrimination

You or LGBTQ family mem-ber (half-sample A)

259 15 11 21

Thought about moving to another area because of personally experi-enced discriminationl

You (total sample) 489 31 31 30

aWhite 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. bQuestions 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. cPercent 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. dQuestion 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?” eEqual pay question only asked among respondents who have ever been employed for pay. fJobs question only asked among respondents who have ever applied for a job. gCollege application/attendance was only asked among respondents who have ever applied for college or attended college for any amount of time. hHousing 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. iQuestion 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?” jQuestion 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. kYou 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. lYou have thought about moving to another area because you have experienced discrimination or unequal treatment where you were living.

TA B L E 2   (Continued)

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TAB

LE 3

 A

djus

ted

odds

of r

epor

ting

pers

onal

exp

erie

nces

of d

iscr

imin

atio

n ac

ross

inst

itutio

nal a

nd in

terp

erso

nal d

omai

ns a

mon

g U

S LG

BTQ

adu

lts

Inst

itutio

nal d

iscr

imin

atio

n

Na

Empl

oym

ent

Educ

atio

nH

ealth

car

eH

ousi

ngPo

litic

al

part

icip

atio

nPo

lice

and

cour

tsAv

oida

nce

App

lyin

g fo

r job

sb

Equa

l pa

y/pr

o‐m

otio

nsc

Colle

ge a

p‐pl

icat

ion/

at

tend

ance

d

Doc

tor o

r he

alth

clin

ic

visi

ts

Tryi

ng to

re

nt o

r buy

a

hous

ee,f

Tryi

ng to

vot

e or

par

ticip

ate

in p

oliti

csIn

tera

ctin

g w

ith P

olic

e

Unf

airly

st

oppe

d or

tr

eate

d by

the

polic

e

Unf

airly

tr

eate

d by

th

e co

urts

Avoi

ded

calli

ng th

e po

lice

due

to d

is‐

crim

inat

ion

conc

erns

Avoi

ded

doct

or d

ue to

di

scrim

ina‐

tion

conc

erns

214

213

167

189

151

219

222

221

223

223

193

Race

/eth

nici

tyg

Whi

teRe

fRe

fRe

fRe

fRe

fRe

fRe

fRe

fRe

fRe

fRe

f

Raci

al/

ethn

ic

min

ority

3.16

*   (1

.35,

7.

40)

1.57

(0

.66,

3.

75)

0.83

(0.2

4,

2.81

)0.

31*   (0

.10,

0.

97)

0.31

(0.0

8,

1.24

)3.

13*   (1

.00,

9.

73)

1.75

(0.6

9,

4.48

)0.

90 (0

.41,

1.

96)

2.80

*   (1

.26,

6.

24)

1.25

(0.5

0, 3

.13)

0.56

(0.1

9,

1.64

)

Self-

iden

tifie

d ge

nder

Mal

eRe

fRe

fRe

fRe

fRe

fRe

fRe

fRe

fRe

fRe

fRe

f

Fem

ale

0.39

*   (0

.15,

0.

96)

0.34

*   (0

.14,

0.

82)

2.12

(0.7

7,

5.86

)1.

40 (0

.54,

3.

66)

0.87

(0.2

6,

2.96

)0.

28*   (0

.09,

0.

86)

0.36

(0.1

3,

0.94

)1.

14 (0

.50,

2.

64)

0.40

*   (0

.17,

0.

96)

0.89

(0.3

2, 2

.53)

1.11

(0.4

2,

2.91

)

Educ

atio

n

<Col

lege

Ref

Ref

Ref

Ref

Ref

Ref

Ref

Ref

Ref

Ref

Ref

Col

lege

+1.

12

(0.4

4,

2.87

)

0.92

(0

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2.

23)

0.46

(0.1

4,

1.48

)1.

26 (0

.41,

3.

88)

0.24

*   (0.0

8,

0.74

)1.

33 (0

.35,

5.

09)

1.46

(0.4

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)2.

28 (0

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5.

57)

1.72

(0.7

1,

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.53,

4.51

)3.

35*   (1

.32,

8.

48)

Inco

me

<25k

Ref

Ref

Ref

Ref

Ref

Ref

Ref

Ref

Ref

Ref

Ref

25k+

0.67

(0.2

9,

1.56

)0.

87

(0.3

4,

2.23

)

1.28

(0.3

5,

4.76

)0.

86 (0

.24,

3.

09)

0.77

(0.2

1,

2.86

)0.

37 (0

.11,

1.

22)

0.31

*   (0.1

0,

0.96

)0.

79 (0

.32,

1.

95)

1.08

(0.4

6,

2.56

)0.

40 (0

.14,

1.1

5)0.

72 (0

.25,

2.

04)

Age 18

-29

Ref

Ref

Ref

Ref

-Re

fRe

fRe

fRe

fRe

fRe

f

30+

0.52

(0

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1.

33)

1.17

(0

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3.

24)

2.46

(0.5

3,

11.3

9)2.

89 (0

.69,

12

.12)

-0.

86 (0

.27,

2.

72)

0.35

*   (0.1

3,

0.93

)0.

84 (0

.36,

1.

97)

1.06

(0.4

5,

2.50

)0.

41 (0

.15,

1.1

3)0.

31*   (0

.11,

0.

92)

(Con

tinue

s)

1462  |    Health Services Research

CASEY Et Al.

Inte

rper

sona

l dis

crim

inat

ion

Na

LGBT

Q id

en‐

tity‐

base

d m

icro

aggr

essi

ons

LGBT

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entit

y‐ba

sed

slur

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ent

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assm

ent

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Been

told

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t un‐

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com

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caus

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e LG

BTQ

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ght a

bout

m

ovin

g to

ano

ther

ar

ea

421

421

222

224

225

225

412

420

OR

(95%

CI)

Race

/eth

nici

tyg

Whi

teRe

fRe

fRe

fRe

fRe

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fRe

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f

Raci

al/e

thni

c m

inor

ity0.

44*   (0

.21,

0.8

8)0.

51 (0

.25,

1.0

2)0.

72 (0

.33,

1.5

8)0.

79 (0

.35,

1.7

6)0.

52 (0

.23,

1.1

5)1.

43 (0

.64,

3.2

2)1.

07 (0

.59,

1.9

4)0.

95 (0

.51,

1.7

7)

Self-

iden

tifie

d ge

nder

Mal

eRe

fRe

fRe

fRe

fRe

fRe

fRe

fRe

f

Fem

ale

1.11

(0.5

9, 2

.05)

0.97

0.5

2, 1

.82)

0.87

(0.4

1, 1

.86)

0.68

(0.3

2, 1

.45)

0.40

*   (0.1

9, 0

.83)

1.28

(0.5

9, 2

.75)

1.01

(0.5

7, 1

.79)

1.28

(0.7

0, 2

.34)

Educ

atio

n

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lege

Ref

Ref

Ref

Ref

Ref

Ref

Ref

Ref

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lege

+1.

06 (0

.56,

2.0

0)1.

48 (0

.79,

2.8

0)1.

94 (0

.87,

4.3

2)2.

20 (0

.96,

5.0

1)1.

29 (0

.57,

2.8

8)2.

06 (0

.89,

4.8

1)1.

20 (0

.66,

2.1

7)0.

85 (0

.45,

1.5

9)

Inco

me

<25k

Ref

Ref

Ref

Ref

Ref

Ref

Ref

Ref

25k+

1.46

(0.7

1, 2

.99)

0.92

(0.4

4, 1

.91)

1.04

(0.4

4, 2

.43)

1.16

(0.4

9, 2

.70)

0.82

(0.3

4, 1

.99)

1.43

(0.5

8, 3

.50)

1.22

(0.6

5, 2

.31)

0.97

(0.5

0, 1

.89)

Age 18

-29

Ref

Ref

Ref

Ref

Ref

Ref

Ref

Ref

30+

0.44

*   (0.2

1, 0

.89)

0.88

(0.4

1, 1

.89)

0.50

(0.2

2, 1

.16)

0.50

(0.2

1, 1

.20)

0.68

(0.2

9, 1

.57)

0.72

(0.3

1, 1

.66)

0.67

(0.3

6, 1

.24)

0.89

(0.4

6, 1

.73)

Abb

revi

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ns: C

I, co

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; OR,

odd

s ra

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a Indi

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ions

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sked

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who

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r a jo

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resp

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who

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empl

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ay.

d Col

lege

app

licat

ion/

atte

ndan

ce o

nly

aske

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ong

resp

onde

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who

hav

e ev

er a

pplie

d fo

r col

lege

or a

tten

ded

colle

ge fo

r any

am

ount

of t

ime.

e H

ousi

ng q

uest

ion

only

ask

ed a

mon

g re

spon

dent

s w

ho h

ave

ever

trie

d to

rent

a ro

om o

r apa

rtm

ent,

or to

app

ly fo

r a m

ortg

age

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uy a

hom

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f Age

var

iabl

e om

itted

in th

e ho

usin

g m

odel

due

to to

o fe

w re

spon

dent

s ag

ed 1

8-29

who

had

eve

r att

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ed to

rent

an

apar

tmen

t or b

uy a

hou

se o

r mor

tgag

e.

g Whi

te (n

on-H

ispa

nic)

or r

acia

l/eth

nic

min

ority

(inc

ludi

ng A

fric

an A

mer

ican

/bla

ck, H

ispa

nic/

Latin

o, A

sian

, Am

eric

an In

dian

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ska

Nat

ive,

Nat

ive

Haw

aiia

n, P

acifi

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land

er, a

nd o

ther

non

whi

te

iden

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*Sig

nific

ant a

t P <

.05

(sho

wn

in b

old)

. US

LGBT

Q a

dults

age

d 18

+.

TAB

LE 3

 (C

ontin

ued)

     |  1463Health Services Research

CASEY Et Al.

Gender also had statistically significant associations in modeling institutional discrimination. Here, LGBTQ females (transgender-in-clusive) had lower odds than LGBTQ males of reporting institutional discrimination when applying for jobs, seeking equal pay or promo-tions, when trying to vote or participate in politics, and in unfair treatment by the courts. Models did not meaningfully change in sen-sitivity analyses excluding transgender adults.

Education was also influential: LGBTQ adults with a college degree had significantly higher odds than those without a college degree of reporting they had avoided seeking medical care out of concern they would be discriminated against or treated poorly. LGBTQ adults with a college degree had lower odds of reporting discrimination when seek-ing housing, compared to those without a college degree.

For interpersonal forms of discrimination, LGBTQ racial/ethnic minorities were less likely than LGBTQ whites to report experiencing LGBTQ-based microaggressions. LGBTQ adults aged 30 and older also had lower odds of reporting microaggressions, compared to those aged 18-29. Finally, females were less likely than males to report ex-periencing LGBTQ-related violence. No other demographic variables were statistically significant in models of interpersonal discrimination.

3.4 | Subsample of transgender adults

Table 4 presents the unadjusted percent of transgender adults, where sample size allowed, reporting various experiences of discrimination because of their gender identity and/or sexual orientation. In the context of interpersonal forms of discrimina-tion, 38 percent of transgender adults say they have personally experienced slurs, and 28 percent have experienced microaggres-sions specifically related to their gender identity and/or sexual orientation. Due to split sampling, there were too few transgen-der respondents to analyze the question regarding bathroom harassment.

When it comes to health care, 10 percent of transgender peo-ple said they have personally experienced discrimination because of their gender identity when going to a doctor or health clinic, and more than one in five (22 percent) said they have avoided seeking health care due to anticipation of discrimination or poor treat-ment. With regard to the domain of housing, nearly one-quarter (22 percent) of transgender people reported that they have been told or felt they would be unwelcome in a neighborhood, building,

TA B L E 4   Prevalence of transgender adults reporting discriminationa

Subject of discriminationb NWeighted percent of transgender adultsc

Belief in overall discrimination

General belief that discrimination against transgender people exists today in the United Statesd

All transgender adults (total sample) 86 84

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

Microaggressionse You (half-sample B) 55 28

Slurse You (half-sample B) 55 38

People acted afraide You (half-sample B) 55 18

Been told or felt unwelcome because of being transgenderf

You or LGBTQ friend/family member (total sample)

86 22

Actions based on concerns about discrimination

Avoided doctor or health care because of concerns of discrimination/poor treatment

You or LGBTQ family member (half-sample B)

55 22

Thought about moving to another area because of personally experienced discriminationg

You (total sample) 86 27

aTransgender 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. bQuestions 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. cPercent calculated using survey weights. dQuestion asked as “Generally speaking, do you believe there is or is not discrimination against transgender people in America today?” eQuestion 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. fYou 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. gYou have thought about moving to another area because you have experienced discrimination or unequal treatment where you were living.

1464  |    Health Services Research

CASEY Et Al.

or housing development because they were transgender, while over one-quarter (27 percent) said they have thought about mov-ing to another area to live because of the discrimination they have already experienced.

4  | DISCUSSION

In this national US study of reported discrimination among LGBTQ adults, four key findings emerge. First, study results extend prior findings that LGBTQ adults in the United States experience perva-sive discrimination across many areas of life.3-6,18-21,24,27,28 In par-ticular, we found widespread interpersonal manifestations, including slurs, harassment, and violence.

Second, institutional discrimination is also clearly present in health care. Prior research has reported perceived mistreatment in health care settings among LGB and transgender adults.6,18,32 In this study, more than one in six LGBTQ adults say they have avoided health care due to anticipated discrimination and experienced dis-crimination in health care encounters. Among transgender adults, these estimates are even higher. This is particularly worrisome and merits further education and antidiscriminatory policies and train-ing in health care, as avoiding health care can further exacerbate health disparities between LGBTQ and non-LGBTQ adults.6,14,22

Third, LGBTQ racial and ethnic minorities are significantly more likely to report many forms of discrimination, even when controlling for other factors. LGBTQ racial and ethnic minority adults had a significantly lower odds of reporting LGBTQ identity-based micro-aggressions relative to whites, though they were more likely than LGBTQ whites to report experiencing racially based microaggres-sions (not adjusted for demographic characteristics). These results are largely consistent with prior research finding higher reported racial discrimination among racial/ethnic sexual minorities relative to white sexual minorities in public settings, accompanied by both sexual orientation and gender discrimination.18 Our findings also support other studies demonstrating that racial/ethnic identity com-pounds experiences of discrimination in addition to LGBTQ identity in many areas of life.25-27,29,30

While it is beyond the scope of our results to promote specific policies or practices to end discrimination in the United States, these findings indicate both top-down (eg, policy) and bottom-up (eg, com-munity organizations or local initiatives) efforts need to take steps to address this widespread discrimination, on both institutional and (especially) interpersonal levels. For transgender people, housing and health care appear to be major areas of concern, while LGBTQ racial/ethnic minorities face significant obstacles with employment and the legal system. Multisector partnerships are urgently needed to implement interventions, propel policy efforts, and create social change to protect LGBTQ people across different systems, including employment, health care, housing, and legal systems.

In addition, more research is needed that includes both new meth-ods and novel data sources to improve the study of LGBTQ popula-tions, given the current methodological limitations.6-8,34,35 In particular,

research using electronic health record data is a promising approach to further study LGBTQ persons and other small populations, while mo-bile device or computer apps and other novel methods for data capture may also improve research on the unique experiences of discrimination among LGBTQ persons within the health care system.8,46 At a minimum, improving medical and administrative staff training on cultural compe-tency for serving LGBTQ people, as well as improving data collection on sexual orientation and gender identity in health care, is needed.

4.1 | Limitations

The findings should be viewed with several limitations in mind. First, although we examined a broad range of domains of life, this study covers only a subset of types of discrimination and harassment that LGBTQ people may experience. Second, we asked whether LGBTQ people had experienced these types of discrimination at any point in their life, without regard to timing or severity. This limits the abil-ity to estimate current levels of discrimination and harassment and instead focuses on lifetime experiences.

Third, the prevalence of many sensitive topics, including sexual ha-rassment and violence, is often underreported—particularly on surveys administered by an interviewer,47 such as this study—and therefore, the “true” prevalence of LGBTQ people's experiences of discrimina-tion is likely higher than reported herein. Perceptions of various kinds of discrimination (eg, race-based and sexuality-based) are also signifi-cantly associated with each other,26,29,30 and it is not always possible to disentangle these experiences from each other, so asking specifi-cally about LGBTQ-based discrimination may lead to underreporting of overall discrimination experienced by some respondents. Questions about discrimination based on race/ethnicity and gender (among fe-males only) are examined separately in other articles in this issue.

Fourth, our low response rate is a notable limitation, though ev-idence suggests that low response rates do not bias results if the survey sample is representative of the study population.38,39 Recent research has shown that such surveys, when based on probability samples and weighted using US Census parameters, yield accurate es-timates in most cases when compared with both objective measures and higher-response surveys.38,39,48,49 For instance, a recent study showed that across 14 different demographic and personal charac-teristics, the average difference between government estimates from high-response rate surveys and a Pew Research Center poll with a re-sponse rate similar to this poll was 3 percentage points.38 However, it is still possible that some selection bias may remain that is related to the experiences being measured, particularly given the challenges of surveying the LGBTQ population noted earlier.6-8,34-45

Fifth, transgender people are often discriminated against due to their presumed gender or gender identity. Given that trans peo-ple may be of any sexual orientation, they may also be discriminated against because of their sexual orientation. Furthermore, some people may not know the difference between sexual orientation and gender identity, so they may discriminate against someone because of their gender but using language about sexual orientation (or vice versa). Therefore, it should be expected that transgender people report

     |  1465Health Services Research

CASEY Et Al.

experiences of discrimination related to both their gender identity and sexual orientation, and so we report these experiences together, and this study was unable to distinguish between these experiences.

Despite these limitations, this study was strengthened by its probability sampling design and by the breadth of questions asked on LGBTQ-based discrimination across institutions and interper-sonal experiences. It allowed us to examine personal experiences of discrimination and harassment among LGBTQ adults. Our findings may underreport experiences of discrimination and harassment; thus, our results can be considered a lower bound estimate of dis-crimination and harassment in the United States today. We may also underreport the added burden of discrimination against LGBTQ people who are racial/ethnic minorities.

This study highlights the wide extent to which the LGBTQ adult pop-ulation as one group experiences discrimination, providing important data to inform national discussions and current policy debates. Yet, fu-ture research is needed to assess the distribution and burden of discrim-ination experiences faced by subgroups within the LGBTQ population.

5  | CONCLUSION

This study shows that lesbian, gay, bisexual, transgender, and queer adults in America share common, yet diverse experiences of consistent and pervasive discrimination based on their sexual orientation and/or gender identity. Some of the most widespread reported experiences of enacted stigma include slurs, microaggressions, violence, threats, and both sexual and nonsexual harassment. In health care, additional efforts are needed to reduce discrimination against LGBTQ adults. LGBTQ racial/ethnic minorities experience particularly high rates of LGBTQ-based discrimination in employment and workplace settings and inter-acting with the legal system, while transgender adults report significant discrimination in both housing and health care. Findings of this study further illustrate the need for substantial changes in institutional poli-cies and practices to protect the civil rights of LGBTQ people. Changes in social norms are also needed to confront stigma and counteract the harmful effects of discrimination in personal interactions. Addressing both institutional and interpersonal discrimination will be vital to im-proving and ensuring the health and well-being of LGBTQ Americans.

ACKNOWLEDG MENT

Joint Acknowledgment/Disclosure Statement: This work was sup-ported by Grant #73713 from the Robert Wood Johnson Foundation.

ORCID

Mary G. Findling https://orcid.org/0000-0002-7214-5239

ENDNOTE Sa Institutional and interpersonal forms of discrimination are not mutually

exclusive, but this framework is used here for organizational purposes.

b There were no statistically significant differences between LGBTQ men and women in their unadjusted reported experiences of anti-LGBTQ discrimination.

R E FE R E N C E S

1. Association of Gay & Lesbian Psychiatrists. The History of Psychiatry and Homosexuality; 2012. https ://www.aglp.org/gap/1_histo ry/. Accessed November 1, 2018.

2. Waters E, Pham L, Convery C.A Crisis of Hate: A Report on Homicides Against Lesbian, Gay, Bisexual and Transgender People National Coalition of Anti-Violence Programs; 2018. http://avp.org/wp-conte nt/uploa ds/2018/01/a-crisis-of-hate-janua ry-relea se-12218.pdf. Accessed November 1, 2018.

3. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality; 2016. https ://trans equal ity.org/sites/ defau lt/files/ docs/usts/USTS-Full-Report-Dec17.pdf. Accessed November 1, 2018.

4. Singh S, Durso LE. Widespread Discrimination Continues to Shape LGBT People's Lives in Both Subtle and Significant Ways. Center for American Progress; 2017. https ://www.ameri canpr ogress.org/issue s/lgbt/news/2017/05/02/42952 9/wides pread-discr imina tion-conti nues-shape-lgbt-peopl es-lives-subtle-signi ficant-ways/. Accessed November 1, 2018.

5. Pew Research Center. A Survey of LGBT Americans: Attitudes, Experiences and Values in Changing Times; 2013. http://pewrsr.ch/13GWw5s. Accessed November 1, 2018.

6. Institute of Medicine. The health of lesbian, gay, bisexual, and transgender people: building a foundation for better understanding. Washington, DC: The National Academies Press; 2011. https ://www.ncbi.nlm.nih.gov/books/ NBK64 806/pdf/Books helf_NBK64 806.pdf. Accessed November 1, 2018.

7. Gates GJ. LGBT identity: a demographer's perspective. Loyola Los Angel Law Rev. 2012;45(3):693-714.

8. National Academies of Sciences, Engineering, and Medicine. Improving Health Research on Small Populations: Proceedings of a Workshop. Washington, DC: The National Academies Press; 2018.

9. Mays VM, Cochran SD. Mental health correlates of perceived dis-crimination among lesbian, gay, and bisexual adults in the United States. Am J Pub Health. 2001;91(11):1869-1876.

10. Williams DR, Mohammed SA. Discrimination and racial dis-parities in health: evidence and needed research. J Behav Med. 2009;32(1):20-47.

11. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129:674-697.

12. Herek GM, Gillis JR, Cogan JC. Internalized stigma among sexual minority adults: insights from a social psychological perspective. Stigma Health. 2015;1(S):18-34.

13. Hicken MT, Hedwig L, Ailshire J, Burgard SA, Williams DR. ‘Every shut eye, ain't sleep': the role of racism-related vigilance in racial/ethnic disparities in sleep difficulty. Race Soc Probl. 2013;5(2): 100-112.

14. Seelman KL, Colón-Diaz M, LeCroix RH, Xavier-Brief M, Kattari L. Transgender noninclusive healthcare and delaying care because of fear: connections to general health and mental health among trans-gender adults. Transgend Health. 2017;2(1):17-28.

15. Paradies Y. A systematic review of empirical research on self-re-ported racism and health. Int J Epidemiol. 2006;35(4):888-901.

16. Krieger N, Waterman PD, Hartman C, et al. Social hazards on the job: workplace abuse, sexual harassment, and racial discrimination: a study of black, Latino, and white low-income women and men workers in the United States. Int J Health Serv. 2006;36(1):51-85.

1466  |    Health Services Research

CASEY Et Al.

17. Pavalko EK, Mossakowski KN, Hamilton VJ. Does perceived dis-crimination affect health? Longitudinal relationships between work discrimination and women's physical and emotional health. J Health Social Behav. 2003;43:18-33.

18. Bostwick WB, Boyd CJ, Hughes TL, West BT, McCabe SE. Discrimination and mental health among lesbian, gay, and bisexual adults in the United States. Am J Orthopsychiatry. 2014;84(1):35-45.

19. Hatzenbuehler ML. How does sexual minority stigma ‘get under the skin?’. A psychological mediation framework. Psychol Bull. 2009;135:707-730.

20. Nadal KL. Contemporary Perspectives on Lesbian, Gay, and Bisexual Psychology. That's so Gay! Microaggressions and the Lesbian, Gay, Bisexual, and Transgender Community. Washington, DC: American Psychological Association; 2013.

21. White Hughto JM, Reisner SL, Pachankis JE. Transgender stigma and health: a critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med. 2015;147:222-231.

22. Reisner SL, Hughto J, Dunham EE, et al. Legal protections in public accommodations settings: a critical public health issue for transgender and gender-nonconforming people. Milbank Q. 2015;93(3):484-515.

23. McCabe SE, Hughes TL, Matthews AK, et al. Sexual orientation discrimination and tobacco use disparities in the United States. Nicotine Tob Res. 2019;21(4):523-531.

24. Slater ME, Godette D, Huang B, Ruan WJ, Kerridge BT. Sexual orientation-based discrimination, excessive alcohol use, and sub-stance use disorders among sexual minority adults. LGBT Health. 2017;4(5):337-344.

25. Balsam KF, Molina Y, Beadnell B, et al. Measuring multiple minority stress: The LGBT people of color microaggressions scale. Cultur Divers Ethnic Minor Psychol. 2011;17:163-174.

26. Bowleg L. The problem with the phrase women and minorities: Intersectionality-an important theoretical framework for public health. Am J Pub Health. 2012;102:1267-1273.

27. Perez AE, Gamarel KE, van den Berg JJ, Operario D. Sexual and behavioral health disparities among African American sexual minority men and women. Ethn Health. 2018;1-12. https ://doi.org/10.1080/13557 858.2018.1444149

28. Lee JH, Gamarel KE, Bryant KJ, Zaller ND, Operario D. Discrimination, mental health, and substance use disorders among sexual minority populations. LGBT Health. 2016;3(4):258-265.

29. Grollman EA. Multiple disadvantaged statuses and health: the role of multiple forms of discrimination. J Health Soc Behav. 2014;55(1):3-19.

30. Hsieh N, Ruther M. Sexual minority health and health risk factors: Intersection effects of gender, race, and sexual identity. Am J Prev Med. 2016;50:746-755.

31. Gonzales G, Henning-Smith C. Barriers to care among transgender and gender nonconforming adults. Milbank Q. 2017;95(4):726-748.

32. Bradford J, Reisner SL, Honnold JA, Xavier J. Experiences of trans-gender-related discrimination in the implications for health: results from the Virginia Transgender Health Initiative Study. Am J Pub Health. 2013;103(10):1820-1829.

33. Gates GJ. In U.S., LGBT More Likely Than Non-LGBT to Be Uninsured. Gallup. August 26, 2014. https ://news.gallup.com/poll/17544 5/lgbt-likely-non-lgbt-unins ured.aspx. Accessed November 9, 2018.

34. Henderson ER, Blosnich JR, Herman FL, Meyer IH. Considerations on sampling in transgender health disparities research. LGBT Health. 2019;6(6):267-270.

35. Reisner SL, Deutsch MB, Bhasin S, et al. Advancing methods for U.S. transgender health research. Curr Opin Endocrinol Diabetes Obes. 2016;23(2):198-207.

36. The Leadership Conference on Civil and Human Rights, The Leadership Conference Education Fund, The Lawyers' Committee for Civil Rights Under Law, the National Association for the Advancement of Colored People. Falling further behind: combating

racial discrimination in America; 2014. https ://tbint ernet.ohchr.org/Treat ies/CERD/Share d%20Doc ument s/USA/INT_CERD_NGO_USA_17654_E.pdf. Accessed June 20, 2019.

37. American Association for Public Opinion Research. Standard definitions: final disposition case codes and outcome rates for surveys; 2016. https ://www.aapor.org/AAPOR_Main/media/ publi catio ns/Stand ard-Defin ition s2016 9thed ition final.pdf. Accessed September 24, 2019.

38. Keeter S, Hatley N, Kennedy C, Lau A.What low response rates mean for telephone surveys. Pew Research Center; 2017. http://www.pewre search.org/2017/05/15/what-low-respo nse-rates-mean-for-telep hone-surve ys/. Accessed November 1, 2018.

39. Kohut A, Keeter S, Doherty C, Dimock M, Christian L.Assessing the rep-resentativeness of public opinion surveys. Pew Research Center; 2012. http://www.people-press.org/2012/05/15/asses sing-the-repre senta tiven ess-of-public-opini on-surve ys/. Accessed November 1, 2018.

40. Gates GJ. LGBTdemographics: comparisons among population-based surveys. The Williams Institute, University of California School of Law. October 2014. http://willi amsin stitu te.law.ucla.edu/wp-conte nt/uploa ds/lgbt-demogs-sep-2014.pdf. Accessed June 20, 2019.

41. Benson JM, Ben-Porath EN, Casey LS. Methodology of the dis-crimination in the United States Survey. Health Serv Res. 2019;54: 1389-1398. https://doi.org/10.1111/1475-6773.13226.

42. Krieger N, Smith K, Naishadham D, Hartman C, Barbeau EM. Experiences of discrimination: validity and reliability of a self-report measure for population health research on racism and health. Soc Sci Med. 2005;61(7):1576-1596.

43. Kessler RC, Mickelson KD, Williams DR. The prevalence, distribu-tion, and mental health correlates of perceived discrimination in the United States. J Health Soc Behav. 1999;40(3):203-230.

44. Pincus F. Discrimination comes in many forms. Am Behav Sci. 1996;40(2):186-194.

45. Cohen S, Kessler RC, Gordon LU. Strategies for measuring stress in studies of psychiatric and physical disorders. In: Cohen S, Kessler RC, Lynn UG, eds. Measuring stress: A Guide for Health and Social Scientists. New York, NY: Oxford University Press; 1995:3-26.

46. Devers K, Gray B, Ramos C, Shah A, Blavin F, Waidmann T. The feasibility of using electronic health records (EHRs) and other electronic health data for research on small populations. Urban Institute for the Office of the Assistant Secretary for Planning and Evaluation at HHS; 2013. https ://www.urban.org/resea rch/publi catio n/feasi bility-using-elect ronic-healt hdata resea rch-small-popul ations. Accessed September 24, 2019.

47. Tourangeau R, Yan T. Sensitive questions in surveys. Psychol Bull. 2007;33(5):859-883.

48. Yeager DS, Krosnick JA, Chang LinChiat, et al. Comparing the accuracy of RDD telephone surveys and internet surveys conducted with proba-bility and non-probability samples. Public Opin Q. 2011;75(4):709-747.

49. Keeter S, Kennedy C, Dimock M, Best J, Craighill P. Gauging the impact of growing nonresponse from a national RDD telephone survey. Public Opin Q. 2006;70(5):759-779.

SUPPORTING INFORMATION

Additional supporting information may be found online in the Supporting Information section.

How to cite this article: Casey LS, Reisner SL, Findling MG, et al. Discrimination in the United States: Experiences of lesbian, gay, bisexual, transgender, and queer Americans. Health Serv Res. 2019;54:1454–1466. https ://doi.org/10.1111/1475-6773.13229

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