Coming to terms

Before entering into the nexus of queer inequities, criminalization, and emancipation, it is important to have an understanding of the nature and implications of terms. In this review, “queer” is a preferred term deployed to both signal an umbrella for the ever-amassing collection of identities under the banner of “LGBTQ+” as well as a critical term that signals a persistent disruption and deconstruction of what is normative; often, queer and LGBTQ+ are interchangeable in this review. “Criminalization” is positioned as the often-unconscious process by which sexualities, genders, and other tangible and ideological material become rendered into criminological and forensic terms. “Mental health” is defined in broad terms, following the lead of the World Health Organization’s ³ definition that signals it is not simply about the absence of disease or pathology rather it is a function of individuals’ attributes in relation with environmental factors.

When it comes to terms around sexuality and gender, binarized and medicalized understandings can predominate. Those are one angle on these terms; a deeper, critical understanding can be helpful to not only broaden awareness, knowledge, self-reflection, and interdisciplinarity—but as well to more effectively work with clients and communities. It is important to keep in mind that this list is necessarily incomplete, unstable, evolving, and generally queer. Table 1 provides brief definitions for critical terms when working with LGBTQ+ people; the following provides more expansive and nuanced definitions.

• ▪ LGBTQITSA+—A Western-based acronym signifying a mostly stable set of identities related to sex/uality, sexual orientation, and gender identity and expression. Often, it stands for: Lesbian, Gay, Bisexual, Transgender, Questioning, Queer, Intersex, Two-Spirit (TS or 2), and Asexual (and sometimes contentiously Ally). The plus (“+”) at the end makes a nod to the fact that there are forever evolving and existing identities along this spectrum of human experiences. For the sake of efficiency, this acronym can be consolidated into labels like “LGBT,” “Gay,” or “LGBTQ+.” Whether represented as an acronym or a single word, this set of labels retains residue of positivistic ways of knowing and essentialized notions of identity. In contemporary times, these labels are often deployed in the promulgation of neoliberal discourse and political economy prioritizing individualism, rights-based social and political agendas, homonormative cultural and economic privileges, and consolidated and sanitized notions of desire and partnering (e.g., “gay marriage” debates). Queer and gay are undoubtedly strange bedmates.

• ▪ Queer—An umbrella term used by some LGBTQITSA+ people to refer to themselves, often to avoid binary and static conceptions of sex, gender, and sex/uality, among others. Based in critical, feminist, and poststructural perspectives on language, economy, gender, and sex/uality, queer is an antiessentialist, subject-less critique, necessarily indeterminate and referring more to self-identification rather than empirical observation of other peoples’ characteristics. It is the suspension and denaturalization of identity as something fixed, natural, and coherent. More appropriately, it can be better understood as a verb (vs noun), a strategy, an attitude, and a position/ality set against the normative.Reference Jagose ^{4 –}Reference Eng, Halberstam and Muñoz ⁷

• ▪ Biological/birth sex—The sex a person is assigned at birth based on visible physiological and anatomical sex characteristics; this is most often, and almost exclusively, conferred by a physician and the State, and is conflated with gender (identity).

• ▪ Sex/-uality—A constellation of biological sex, (chosen) identities, emotional/affectional impulses, sexual attraction/desires, and behaviors with, without, or toward other persons and within one’s self. Sexuality is a central aspect of being human throughout life, and encompasses (to varying degrees) sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles, and relationships. Although sexuality can include all of these dimensions, not all of them are always experienced or expressed; sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, legal, historical, and religious and spiritual factors. ³

• ▪ Sexual orientation—An individual’s physical and sexual attraction toward others. This may be to an individual of the same gender (e.g., gay), the opposite gender (e.g., straight), both (e.g., bisexual), asexual, or various others (e.g., pansexual). Sexual orientation may or may not be reflected in someone’s outward behaviors or appearance; and, their sexual behaviors may or may not be defined singularly by normative understandings of one’s sexual orientation.

• ▪ Sexual identity—How an individual describes their own sexuality and how it is expressed. Often, sexual identity interfaces with one’s sexual orientation, but not always. For example, a person can have a lesbian orientation and express a heterosexual identity.

• ▪ Gender—Refers to the social construction and meaning a given culture associates with a person’s attitudes, behaviors, and feelings, and their assigned biological sex. Gender-normative or -confirming behaviors are those that align with the person’s assigned biological sex at birth. Gender nonconformity (or -variant, -creative) occurs when the behaviors, attitudes, and feelings of a person do not align with that person’s biological sex and/or gender assigned at birth.

• ▪ Gender identity—A person’s sense of being a woman, a man, transgender, cisgender, or other gender identification (e.g., a blend of the aforementioned or beyond those categories). Gender identity includes what a person calls themselves (i.e., “preferred gender pronouns”) and may or may not be the same as their biological sex.

• ▪ Gender expression—The ways a person represents their gender to others, that is, the ways they walk in the world giving life and form to their interior experience of gender, which may or may not be congruent with dominant norms.

• ▪ Cisgender or cis—A person whose self-definition (e.g., identity, expressions) is adherent to hegemonic notions of gender—which are also aligned with assigned birth sex.

• ▪ Transgender or trans—A person whose self-definition (e.g., identity, expressions) challenges and disrupts traditional binary conceptions and boundaries of gender and sexuality; often times, this self-definition is not aligned with assigned birth sex. Related terms include: gender nonconforming, gender creative, gender variant, genderbending, gender fluid.

• ▪ Sexism—A system of advantages and oppression that serves to privilege cisgender men, subordinate women (and others), denigrate women-identified values and practices, enforce male dominance and control, and reinforce forms of masculinity that are dehumanizing and damaging to all men. It operates through individual beliefs, practices, institutions, media, and ideas; and is enforced by economic structures, violence, and homo-/trans-/bi-phobias.

• ▪ Heterosexism—A system of institutional and cultural beliefs, norms, and practices that advantages heterosexuals. In turn, this system produces prejudice against nonheterosexual people.

• ▪ Biocentrism—The assumption that people whose assigned sex at birth matches their gender identity throughout their lives are more “real” and/or more “normal” than are those whose assigned sex at birth is incongruent with their gender identity. It is similar to heterosexism but focuses on gender rather than sexual orientation.

• ▪ Monosexism—A system of institutional and cultural beliefs, norms, and practices that produces the privileged belief that monosexuality (i.e., either exclusive heterosexuality or homosexuality) is superior to or more legitimate than a bisexual or other nonmonosexual orientation (e.g., pansexuality). In turn, this system produces prejudice against bisexual (and other related) people.

• ▪ Heteronormativity—A politics and everyday practice that produces hegemonic heterosexuality; simply put, the commonsense notion (and subsequent organized societal systems and social life) that heterosexuality is the only “normal” sexual identity. This belief system assumes that every person is straight—and that their behavior and sexual orientation are in-line with their gender, which is in-line with their genitalia (e.g., penis = male = acts masculine or likes women). Moreover, heteronormativity reproduces not only heterosexuality—but more importantly the expectations, demands, and constraints produced when heterosexuality is taken as normative within a society. Thus, heteronormativity draws on and reproduces discourses of consumption, class/ism, race/ism, ethnicity/ethnocentrism, nation/ality, ability/ableism, privatized intimacy and politics, and domesticity.Reference Rubin, Parker and Aggleton ^{8 ,} Reference Warner ⁹

• ▪ Homonormativity—A politics that does not contest dominant heteronormative assumptions and institutions, but upholds and sustains them, while promising the possibility of a demobilized gay constituency and a privatized, depoliticized gay culture anchored in domesticity and consumption.Reference Duggan ¹⁰ This is to say, it is a mimic of heteronormativity that does not assume that every person is gay—rather, it assumes that LGBTQ+ people want to be “just like” heteronormative people. Furthermore, it rewards homonormative LGBTQ+ people by bestowing rights, privileges, and access.

• ▪ Mononormativity—Describes the societal expectation that romantic relationships are sexually and emotionally monogamous. These norms are often reinforced by social and legal institutions, which contribute to dominant narratives about romantic and sexual relationships. Mononormative assumptions are embedded within the words of infidelity and cheating by way of conflating consensual nonmonogamy and nonconsensual nonmonogamy (i.e., infidelity), and therefore cannot account for the variety of consensual nonmonogamous relationship experiences.

• ▪ Cisnormativity—A politics and everyday practice that produces hegemonic cisgenderism; simply put, the commonsense notion (and subsequent organized societal systems and social life) that cisgender is the only “normal” gender identity. This belief system assumes that every person is assigned gender at/before birth—and that their self-identification, behavior, and general presentation in the world everyday are in-line with this assigned gender, which is in-line with their genitalia. Furthermore, cisnormativity reproduces not only cisgenderism and binarized gender—but more importantly, the expectations, demands, and constraints produced when cisgenderism is taken as normative within a society. Thus, cisnormativity draws on and reproduces discourses of consumption, class/ism, race/ism, ethnicity/ethnocentrism, nation/ality, ability/ableism, privatized intimacy and politics, and domesticity.

• ▪ Coming out/inviting in/becoming—“Coming out” describes voluntarily making public one’s sexual orientation and/or gender identity. It has also been broadened to include other pieces of potentially stigmatized personal information. Inviting in offers a more critical standpoint and locates agency, choice, and consent within the individual; likewise, becoming acknowledges that people are in a continual, lifelong process of coming into their sexuality, gender, and other identities, as well as they are highly contextual. Terms also used that correlate with this action are: “Being out” which means not concealing one’s sexual orientation or gender identity, and “Outing,” a term used for making public the sexual orientation or gender identity of another who would prefer to keep this information private. Related term: Disclosure.

Table 1.

Terminology

Health, mental health, and social inequities

A recent Williams Institute ¹¹ survey estimated that 4.5% of the U.S. population is self-identified LGBT (ranging from 2.7% to 9.8% across the 50 states). Of these LGBT people, 42% are self-identified male and 58% female; 29% are raising children (ranging from 44% to 9% across the states). The majority are White (58%), while 21% are Latino, 12% Black, 5% mixed race, 2% Asian, 1% American-Indian, and 1% are Native Hawaiian or Pacific Islander. The average age is 37.3 years old, as compared to 47.9 years old for non-LGBT people; within this, 30% of LGBT people are 18 to 24 years old (12% non-LGBT are), and only 7% are over 65 years old (compared to 21% non-LGBT). Just under 10% are unemployed (as compared to 5% heterosexual), with also 15% uninsured (compared to 12%), 27% food insecure (compared to 15%), and 25% have an income less than $24,000 annually (compared to 18%). And, 41% have completed high school, 30% have completed some college, 17% hold a bachelor’s degree, and 13% have postgraduate education (as compared to heterosexuals at 39%, 29%, 18%, and 14%, respectively).

What is also known is that LGBTQ+ people bear a disproportionate burden of health, mental health, and social inequities. ^{12 , 13} LGBTQ+ individuals have increased risks for obesity, chronic illness (e.g., HIV, diabetes, asthma), mental distress,Reference Conron, Mimiaga and Landers ¹⁴ sexual risk-taking behaviors and unplanned pregnancy,Reference Saewyc, Poon and Homma ¹⁵ substance use disorder, depression,Reference Heiden-Rootes, Salas and Scherrer ^{16 ,} Reference Ryan, Huebner and Diaz ¹⁷ suicide attempts,Reference Ryan, Huebner and Diaz ¹⁷ and smoking.Reference Heiden-Rootes, Salas and Scherrer ¹⁶ LGBTQ+ people experience higher rates of HIV infection and tobacco, alcohol, and other drug use.Reference Blosnich, Farmer and Lee ¹⁸ They have higher incidence of mental health disordersReference King, Semlyn and Killaspy ¹⁹; it is estimated that the 12-month prevalence for depression for LGB people is at least twice that of heterosexual people, almost twice for anxiety, approximately two to three times for alcohol misuse, and just under three times for other drug misuse. Moreover, research indicates that the interaction of multiple marginalized statuses (e.g., sexual orientation and race) increases the odds of developing mental health challenges,Reference Bostwick, Boyd and Hughes ²⁰ parallel to the fact that rates of mental distress, substance misuse, and disability increase for elderly LGBTQ+ people. ²¹ However, estimations around LGBTQ+ people and mental illnesses are deceiving.Reference Kidd, Howison and Pilling ²² This is in large part due to frequently excluding people known to have a severe and persistent mental illness from studies about sexuality and gender, coupled with the common impulse to regard people living with a mental illness as asexual. As well, there still is a pathologizing of nonheterosexual orientations and nonconforming gender identities. The net result is difficulty in generating representative samples in order to make population-based estimates.

Social stigma, discrimination, and homo- and transphobia against LGBT people negatively affects their quality of life by affecting their employment, income, access to health insurance, and health behavior choices. ²³ Social and structural forces may impact LGBTQ+ health and mental health. For example, LGB people living in states with antisame-sex marriage amendments had significant increases in anxiety and substance disorders compared to LGBT people living in states without these amendments.Reference Hatzenbuehler, McLaughlin and Keyes ²⁴ Also, in states that enacted pro-same-sex marriage laws, there were lower levels of psychological distress and reduced medical and mental health care visits.Reference Russ, Stamatakis and Hamer ²⁵ Despite the stereotype that the LGBTQ+ community is predominately affluent, queer people experience poverty at higher rates than their heterosexual and cisgender peers. In particular, LGBT-identified women and men had poverty rates of 21.5% and 20.1%, respectively, compared to heterosexual and cisgender women (19.1%) and men (13.4%).Reference Gates and Newport ²⁶ Children of same-sex couples are twice as likely to be living in poverty compared to married, different-sex couples, with African-American children of gay male parents having the highest poverty rate of 52.3%.Reference Badgett, Durso and Sheneebaum ²⁷

Lesbians have distinct disparities, including higher rates of tobacco use,Reference Nyitray, Corran and Altman ²⁸ higher rates of obesity, and lower rates of exercise compared to heterosexual women.Reference Brittain, Baillargeon and McElroy ²⁹ They also experience higher rates of anxiety and depression, suicidal ideation, nonsuicidal self-injury related to chronic stress and discrimination, which in turn is related to heavy drinking behaviors.Reference Blosnich and Andersen ^{30 ,} Reference Poteat ³¹ They have an heightened risk for reproductive cancers, including breast, ovarian, and endometrial.Reference Zaritsky and Dibble ³² Elder lesbians are more likely to use tobacco, drink excessively, and suffer from obesity, which are due to overall poor health, cardiovascular disease, and diabetes.Reference Fredriksen-Goldsen, Hyun-Jun and Barkan ³³

Gay men also experience distinct health and mental health issues, including higher rates of HIV and Hepatitis ³⁴ and higher rates of cancers such as anal, prostate, and colon. ³⁵ They are at increased risk for other sexually transmitted infections: gonorrhea, chlamydia, human papillomavirus (HPV), and syphilis. ³⁴ The ability for gay men to be out about their sexuality and sexual behaviors is essential to receiving comprehensive care. They also experience higher rates of some eating disorders, depression, and anxiety. ^36-38 As compared to heterosexual men, gay men are twice as likely to smoke, have higher odds of mental distress and life dissatisfaction, and have more activity limitations due to physical, mental and emotional problems,Reference Blosnich, Farmer and Lee ¹⁸ as well as less likely to be overweight or obese; still, they are more likely to be vaccinated for flu and have regular HIV tests than heterosexual men.Reference Blosnich, Farmer and Lee ¹⁸ Gay men are more likely to use alcohol and drugs, have higher rates of substance abuse, and are less likely to abstain from use and less likely to continue heavy drinking into later life. ^{39 ,} Reference Ostrow, Stall, Wolitski, Stall and Valdiserri ⁴⁰ Gay men are more likely than bisexual or heterosexual men to report discrimination in the past year, especially in healthcare settings, and public spaces such as sidewalks, stores, and restaurants.Reference Bostwick, Boyd and Hughes ⁴¹ And, 32% of gay men reported abuse in present or past romantic relationships.Reference Houston and McKirnan ⁴²

Bisexual people in particular have distinct disparities. Bisexual women are more likely to be uninsured compared to heterosexuals, gays, and lesbians.Reference Diamant, Wold and Spritzer ⁴³ Bisexual men who have male sexual partners report higher rates of colon cancer and HIV, similar to rates of gay men and other men who have sex with men.Reference Winn ⁴⁴ Generally, bisexual people experience intimate partner violence, which disproportionately impacts bisexual men and women.Reference VanKim and Padilla ⁴⁵ As well, biphobia can create barriers to community involvement. Resultantly, bisexual people experience greater social isolation (than their gay/lesbian counterparts).Reference Balsam and Mohr ⁴⁶ Biphobia may mean that bisexual people do not feel comfortable coming out as bisexual.Reference Scherrer ⁴⁷ And, bisexual people are likely to be misidentified as heterosexual or gay/lesbian, depending on the gender of their partner.Reference Bradford ⁴⁸ Some common examples of biphobia include the prejudice that bisexual people cannot be monogamous, are sexually promiscuous, or that they do not have a legitimate identity.

Transgender people endure a myriad of health and mental health inequities.Reference Landers and Gilsanz ⁴⁹ Some (not all) transgender people wish to medically transition (e.g., with hormones or surgeries); not all transgender people have access to or financial means to medically transition in the ways they wish. In this process and generally, transgender people face discrimination, misunderstanding, and at times denial of health care by providers.Reference Grant, Mottet and Tanis ⁵⁰ As well, trans people experience higher rates of suicide attempts and ideationReference Grossman and D’Augelli ⁵¹ and violence.Reference Stotzer ⁵² Rates of depression and anxiety are significantly higher among transgender and gender nonconforming individuals when compared with their cisgender counterparts. ^53-55 In the absence of consistent and trans affirmative care, medical settings can become sites of traumatization for transgender clients. In fact, among transgender individuals accessing health care, 28% were harassed and experienced violence in medical settings, 19% were denied care, and 2% were victims of violence in doctor’s offices.Reference Grant, Mottet and Tanis ⁵⁰ These prejudices can lead often to a myth of postsurgical “regret” and therefore a denial of gender affirming procedures; in fact, estimates are <1% to 2%. ^56-60 Regret is much higher in other medical procedures (e.g., gastric banding); comparatively in the United Kingdom, there is an estimated >65% regret for (nontransgender related) plastic surgery.

In regard to suicide specifically, LGBTQ+ people are at much more risk. ^61-63 A meta-analysis of research on LGB mental health showed a two-fold excess risk of suicide attempts in the preceding year in men and women, and four-fold excess in risk in gay and bisexual men over a lifetime.Reference King, Semlyn and Killaspy ¹⁹ There is limited data on suicide completions, deriving mostly from adolescent and young gay males; so far, there is little evidence of increased completions. As for attempts, there are higher rates of attempts compared to heterosexuals world-wide.Reference Mathy ⁶⁴ LGB adolescents are two to seven times more likely to attempt suicide, and they have more lethal means of attempts. The prevalence of suicide attempts in gay or bisexual men is four times that of their heterosexual peers; and, the prevalence for lesbian or bisexual women is twice that of their heterosexual peers. Generally, most attempts tend to occur during adolescence or young adulthood. That said, LGBTQ+ youth who have at least one accepting adult in their life are 40% less likely to report a suicide attempt in the past year. ⁶⁵ Bisexual people are the most at-risk sexual minority population for poor health outcomes, high risk health behaviors, and suicidal ideation. Alongside this, transgender people continue to have the highest reported rates of suicide attempts, with 41% of transgender adults reporting a suicide attempt.Reference Grant, Mottet and Tanis ^{50 ,} Reference Moody and Smith ^{66 ,} Reference Olson, Schrager and Belzer ⁶⁷ Of trans youth, 50% report past suicidal ideation, and 30% report at least one prior suicide attempt. There are increased attempts when trans people have marginal employment (60%) and if they are also of a minority race or ethnicity: Black (45%), Latino (44%), and American-Indian (56%). Similar to LGB data, most attempts are reported in adolescence and young adulthood. Risk also increases for trans people when they are a sexual minority.

In terms of trauma and interpersonal violence, LGBTQ+ people bear both a disproportionate experience of various assaults and the experience of generally walking in the world feeling completely unsafe, rightfully so. LGBTQ+ people are nearly 2.5 times more likely to experience hate crimes than any other group. Hate-motivated LGBTQ+ homicides increased by 86% in 2017, alongside there being a 400-fold increase in cisgender gay/bi/queer male homicides. ⁶⁸ LGBTQ+ people of color, youth, gay men, and transgender people are the most likely to suffer injuries and require medical attention as a result of interpersonal violence.Reference Rothman, Exner and Baughman ⁶⁹ In particular, transgender people and LGBTQ+ people of color are most likely to be the victims of antiqueer murders; in the United States in 2017, there were 29 reported trans deaths due to fatal violence, 26 in 2018, and 12 already in 2019 (at the time of writing this review). ⁷⁰ Often, people resort to violence to “correct” or sensor nonconforming behavior around gender and sexuality.Reference Zou, Andersen and Blosnich ⁷¹ Trans survivors are almost twice as likely to experience physical violence, almost four times more likely to experience discrimination within violent relationships, and 2.5 times more likely to encounter incidents of interpersonal violence in public spaces. ^{68 ,} Reference Gandy-Guedes, Havig, Natale and Dentato ⁷²

For LGBTQ+ people, sexual traumas especially in early life can lead the victim to struggle to separate out the trauma experience from their sexual orientation or gender identity.Reference Walker, Hernandez and Davey ⁷³ To link sexual trauma as a cause of sexual orientation or gender identity is a discredited assertion, as is linking pedophilia to an LGBTQ+ orientation. Corrective rape, which is more often experienced by sexual minority women, is abuse caused by someone trying to “fix” the victim’s sexual orientation.Reference Walker, Hernandez and Davey ⁷³ Young LGBTQ+ people on average experience 3.8 times more sexual abuse, 1.2 times more parental physical abuse, and 1.7 times more assaults at school.Reference Friedman, Marshal and Guadamuz ⁷⁴

Religious institutions and belief systems have a longstanding difficult relationship with LGBTQ+ communities. Often, religious-based trauma can occur in conjunction with “reparative therapies,” which have been denounced by professional organizations. ⁷⁵ It is estimated that 698 000 LGBT adults (18-59 years old) in the Unites States have received conversion therapy, including 350 000 LGBT adults who received it during their teenage years. Twenty thousand LGBT youth (13-17 years old) will receive conversion therapy from a licensed healthcare professional before they reach 18 in the 41 states that do not ban the practice. Related, 57 000 LGBT youth (13-17 years old) across all states will receive conversion therapy from religious or spiritual advisors before they reach 18. As of this review, conversion therapy is banned in 18 states, one territory, and Washington, DC, alongside 32 localities most of which are in Florida. ⁷⁵

Over the lifespan for LGBTQ+ people, age of coming out is related to the number of victimizations, with the more years a person is publicly out, the more time for the person to be victimized.Reference D’Augelli ⁷⁶ More generally, traumas can negatively impact an LGBTQ+ person’s sense of self and stigmatize their identity. Shame and isolation due to trauma can compound existing negative beliefs and behaviors that the LGBTQ+ person may already face. This said, it can be that coming out can facilitate or hinder healing from traumatic events. Sometimes coming out is empowering and can facilitate increased pride.Reference Balsam ^{77 ,} Reference Balsam ⁷⁸ Or, sometimes a person my choose not to come out in fear that their sexuality or gender may be conflated with the trauma.Reference Salmon ⁷⁹

Minority stress

Left under the terms of social epidemiology, the forecast for queer people and their wellbeing is dismal. This focus privileges the scientists, psychiatrists, and other medical and mental health professionals alike. Equally, it maintains attention on incidents or event-based oppression, as well persists the focus on the individuals and individualizes the problems.Reference Das ⁸⁰ One principal effect of this is the power to define “the problem”; and, queer people have endured this and their problems being defined constantly as “deviant” within medicalized and psychiatric terms. This evacuation of the cultural and the social within the world belies the lived experiences of those who are marginalized and oppressed in society, namely in this instance LGBTQ+ people.

In fact, research and work from the social sciences have developed and applied a model of minority stress that explains the disproportionate rates of illness for LGBTQ+ people.Reference Meyer ⁸¹ Whereas the original model was developed around lesbian, gay, and bisexual people, its theoretical and practical implications extend to other minoritized and marginalized sexualities and genders as well as experiences of prejudice and oppression. ^82-84 Underlying the concept of minority stress are certain assumptions. First, queer people routinely experience stressful events not usually experienced by heterosexuals.Reference Alessi, Hartman and Dentato ⁸⁵ Second, stigma and discrimination correlate with poorer health and mental health outcomes.Reference Bostwick, Boyd and Hughes ⁴¹ Even perceived discrimination has negative health and mental health outcomes for LGBTQ+ people.Reference Holley, Mendoza and Del-Colle ⁸⁶ And, third, the stressors are unique (ie, not experienced by nonstigmatized populations), chronic (ie, related to social and cultural structures), and socially based (ie, arising from social process, institutions, structures). The minority stress model, then, is used to explain the connections between group-specific processes and negative mental health outcomes among queer people. The application of the framework of minority stress involves three parts: (1) an analysis of minority stress; (2) a consideration of general stress and coping processes; and (3) LGBTQ+-affirmative practice.

In the first part, the analysis of minority stress examines group-specific processes that are distal and proximal. Distal processes are objective prejudice events; these include understanding acute stressful events that have caused significant changes in a person’s life as well as regarding the chronic stressful events of everyday discrimination and stigma. In this, it would be effective to become aware of the effects of homo-/bi-/transphobia on the person’s development over the life course. Parallel to this, proximal processes involve stigma, internalized negative attitudes, and a concealment of one’s sexuality. In the case of stigma, stigmatized individuals have to constantly discern what people think about them, and in turn develop an expectation of stigma and a hypervigilance in interactions with people of the dominant group. This contributes then to an internalization of negative societal attitudes, that is, internalized homophobia. Resultantly, stigmatized and marginalized people engage in concealment of sexuality as means of protection from a hostile social environment, at persistent threat of their truth becoming public. In addition to these four processes, it is important to consider a fifth process of intersectionality. This is to foreground that holding more than one stigmatized identity can exacerbate minority stress, such as a minoritized race, ethnicity, class, or disability. Thus, in attending to people’s experiences with minority stress, it is necessary to understand how identities of sexuality and gender intersect with other ones of race and ethnicity, for example.

The next step is to consider general psychological processes of stress and coping. Whereas many minority group members cope with stress through developing and maintaining connections with their communities, there certainly exist individual level stress and coping that may not be immediately evident. For the fact that queer people experience chronic excess levels of stress, it is important to understand individual-level affected general psychological processes, while also understanding the group-level processes described above. Building off Meyer’sReference Meyer ⁸¹ minority stress model, HatzenbuehlerReference Hatzenbuehler ⁸⁷ proposed a mediation model linking minority stress with negative mental health outcomes. The general psychological processes encompass affective (i.e., coping abilities and emotion regulation), social (i.e., social supports and interpersonal relationships), and cognitive processes (i.e., maladaptive self-schemas). For example, in the case of concealing one’s sexuality, affected psychological responses can include cognitive (e.g., suspiciousness, preoccupation), affective (e.g., shame, guilt, anxiety), behavioral (e.g., social avoidance, impaired relationships), and negative self-evaluation (e.g., identity ambivalence, diminished self-efficacy).Reference Alessi, Hartman and Dentato ^{85 ,} Reference Pachankis ⁸⁸

The third part in applying a minority stress framework is to engage the person in LGBTQ+-affirmative work. Instead of being a singular evidenced-based clinical intervention or method (such as cognitive behavior therapy or Dialectical Behavioral Therapy), work involves overlaying or imbuing the methods used and the clinical relationship at-large with positivity, validation, multilevel attention and action, and overall affirmation for LGBTQ+ people, their sexuality, gender, and their lived experiences as intersectional people.Reference Alessi, Hartman and Dentato ^{85 ,} Reference Argüello^89–Reference Tozer and McClanahan⁹³ In a way, this affirmative care enhances existing methods or models being deployed by the practitioner; to that end, however, a crucial element to this work is the reflexivity of the practitioner and their willingness and ability to interrogate their own biases and prejudices.

This affirmative work necessarily begins with analyzing the information gathered from the first two steps above, and then formulating the person’s case from an explicit LGBTQ+-affirmative standpoint, that is, making sense of “what is going on” or “what the problem is” given the person’s experiences of living in this world over their lifetime as a queer person. Such a case formulation accounts for chronic stress, persistent prejudices, coping abilities, traumatic events, as well as a positive regard for the development of sexuality and gender over time. This formulation then links the person into a treatment plan that addresses the problems at hand as well as engages the person in an action plan to affirm their identities. This work involves continual attention to the quality of the therapeutic alliance, cultural competence, strengths of the person, and accounting for the presenting issues within a social context. It involves taking active steps to address or intervene with histories and current experiences of stigma, issues around disclosure, coping and social skills, as well as attending to presenting issues around the person’s intersecting identities. Finally, there needs to be attention and action around connecting into or with community resources, building affirmative interpersonal relationships, and other potentially indicated more macro oriented action like taking part in community organizing efforts. This is one important implication of understanding LGBTQ+ health and mental health inequities within a minority stress framework: given the multilevel experience of chronic stress, persistent discrimination, and overall oppression experienced by queer people, the attendant interventions to redress negative affects must be multilevel as well, not singularly intra- or interpersonal.

How LGBTQ+ risk and inequities are criminalized

Compounding chronic, harmful minority stress, LGBTQ+ people and their health, mental health, and social inequities have been and are still today criminalized in a variety of ways. At baseline, while LGBTQ+ people are a small minority in the context of the entire U.S. population, the incarceration rate of LGB people vs all U.S. adults is 1882 vs 612 per 100,000 people. ⁹⁴ For transgender people in particular, per a national survey, 2% of trans respondents reported having been incarcerated in the past year, a rate more than twice the general population (0.87%); ⁹⁵ this rate increased accounting for trans people of color and low-income respondents. In general, it is estimated that one in six trans people—and one in two trans Black people—has been to prison. ⁹⁶ When taking into account age, LGB young people represent 12% to 20% of those youth in juvenile detention, with 85% of all incarcerated LGB youth being people of color. ⁹⁵ Male sexual minorities are 6.2% of jail populations and 9.3% of prisons; while female sexual minorities are 35.7% and 42.1%, respectively. The status of being a sexual minority is correlated with negative outcomes in correctional settings, in that, sexual minorities are more likely to receive prison terms over 20 years, more likely to have spent time in solitary confinement or disciplinary segregation, and more likely to be sexually victimized while incarcerated. ⁹⁴ And, in all, 29.3% of gay and bisexual men have experienced serious psychological distress (as compared to 13.6% straight men), and 24.7% of lesbian and bisexual women have as well (compared to 18.8% straight women).

Although these rates and overall inequities for queer people are both alarming and distressing, to say the least, LGBTQ+ people and their identities are not inherently criminogenic. In fact, queer people are de facto of acute interest to society in so far as their self-identifications around gender and sexuality challenge, disrupt, or reinforce heteronormative ideologies and structures. This is to say that bodies, ways of life, and survival strategies that do not conform to or manifest heteronormativity become subject to both social and formal policing as well as technologies of discipline, corrections, detention, and punishment. ⁹⁷ This criminalization has occurred through various ways and by various societal systems over time based on the ways in which LGBTQ+ people have been regarded. Historically and contemporaneously, queer people have been subjected to the medicalization of homosexuality (e.g., deviants, infectious, aberrations), the psychiatrization of their mental health (e.g., sick, objects of interventions, insane, pathological sexual interests), and the pathologization of queer socializing and ways of life (e.g., immoral, dangerous, degenerates). There are well known archives interrogating these experiences and histories.Reference Grzanka and Miles^98–Reference Terry¹⁰³ The intention here is not to replicate those works, rather to diagram how these processes that promote criminalization continue to occur by structures and societal systems and in the everyday lives of LGBTQ+ people across the United States. Below, this criminalization is diagrammed from predetainment experiences, through detainment and experiences being in the system, and then through re-entry into the community.

Before entering into the diagram of criminalization, it is imperative to understand that LGBTQ+ people become criminalized through their experience of holding multiple identities. Queer people are not singularly their sexuality or gender, rather they hold multiple identities that intersect; and, from an intersectional perspective,Reference Crenshaw ¹⁰⁴ the lived experience of minority stress, oppression, and inequities is a function of how these multiple identities are targeted and/or allowed by social structures and systems. For example, a person is not queer or Black, rather they are queer and Black, and other identities around class, ethnicity, gender, age, and beyond. What is important about using an intersectional analysis is that the more intersecting identities that are operating in people’s lives, the more compounding are the injustices and inequities. Although all queer people are criminalized in various ways that experience of criminalization is only intensified by additional experiences of racism, ethnocentrism, sexism, classism, ageism, and beyond. ⁹⁷ This is starkly exemplified by the U.S. criminal justice system—a system that is overrepresented by Black people, people of color, immigrants, people living with mental illness and/or addiction, and low-income people. When squared with sexuality and gender in particular, as is discussed in the whole of this review, those LGBTQ+ people who are further disproportionately overrepresented and captured into the system are young queer people and people of color, trans and gender nonconforming people, and those low income and homeless.Reference Mogul, Ritchie and Whitlock ^{1 ,} Reference Stanley and Smith ²

Strategies for LGBTQ+ wellbeing: Decriminalizing safe(r) spaces and operationalizing affirmation

The wellbeing of LGBTQ+ people is a function of the person in environment, drawing on the expansive framework of the World Health Organization regarding health and mental health. ³ Central to this calculus is an appreciation for the maneuvers of chronic minority stress as well as the haphazard incitement to treat bodies, sexualities, and genders as criminogenic when they exceed the confines of heteronormative conceptions and practices. The known inequities that continue to be borne by queer people, while both troubling and preventable, do offer an instructive opportunity to consider how intentional work can be done in order to resist, redress, and repair those inequities. The multilevel nature of the chronic stress both targeting and experienced by LGBTQ+ people points to the fact that the interventions professionals deploy necessarily must be multilevel and multifaceted. In this section on applied practices, it is obvious that an exhaustive list is not provided for all the ways in which institutions and practitioners could operationalize culturally responsive and affirmative practices with LGBTQ+ communities. Rather, these multilevel strategies offered here are ones readily applicable to the work in correctional, forensic, and other detention facilities, as well as to the clients who may be seen in the community at risk for detention or who hold that history therein. And, these practices are ones that can be enacted by individuals, teams, organizations, and institutions. They include provider competence, affirmative case work, indicated interventions, and progressive policies.

LGBTQ+-affirmative case work

Holding education about or having competence with LGBTQ+ communities and common issues does not equate to the intentional action of conducting queer-affirmative work with individuals, groups, organizations, or institutions. Continuing the discussion on this topic began above, affirmative work (Figure 1) starts at baseline with an explicit validation of and appreciation for the wide spectrum of LGBTQ+ identities and expressions therein. And, sexualities and gender identities and expressions are not incidental demographic variables to check off assessment boxes, rather they are figured at the center of the client’s life experience as well as considered a central part of how they are coping and behaving in detention facilities. Building off an understanding of minority stress and a model for stress and coping,Reference Alessi^131–Reference Pachankis¹³⁴ an affirmative approach is a three-part process that can be overlaid onto whatever intervention or modality with which a team or individual practitioner commonly uses.Reference Argüello ^{89 ,} Reference Argüello ¹³⁵ The first part is to adequately assess the client’s experience of queer stress, accounting for histories with stigmas, phobias (external and internal), chronic stress (both individual and community level), and disclosure and concealment of identities. The second part is to assess for coping, understanding abilities and skills for emotion regulation, social and interpersonal functioning, cognitive schemas, and sexual and intimate relationships. This area also tends to qualities of resilience that the clients hold in these areas and beyond. The third part is to formulate the case within a queer-affirmative perspective parallel to the clinical modality or tradition that the practitioner uses. For example, a DBT-oriented practitioner formulates the case within a tradition of behaviorism as well as one that is queer-affirmative. To this end, alongside the traditional interventions conducted with the client, queer-affirmative action is taken. This would include consistent attention to the therapeutic alliance, cultural competence, strengths, and a person-in-environment understanding of mental health. As well, the interventions offered tend to issues of stigma, disclosure, stress and coping, and intersectional identities. This is all in service of cultivating wellbeing, a positive sense of self, and increased connections with communities. Finally, the work is multilevel, when possible, as chronic minority stress is multilevel; therefore, interventions need to appropriately and adequately address forces that impinge on or facilitate the client’s mental health.

Figure 1.

LGBTQ+-affirmative case work.

It can be illusive in practice to see blatant examples of queer-affirmative work; or, practitioners may side-step such an approach to formulating and intervening with cases due to a variety of reasons, one of which may be lack of training and education. Nonetheless, queer-affirmative work can operationalize in an endless number of ways as, ultimately, it is contextually oriented to the setting, population, client, and team of providers.Reference Argüello ⁸⁹ This is when consultation, supervision, as well as thorough and on-going conversations with clients can be helpful. For example, it can be helpful for organizations to have an LGBTQ+ client advocate on care teams when staffing clients, or to appointment one or more lead clinicians who are obligated to ensure that the advocacy and care for LGBTQ+ clients is responsive and affirmative.

One decided place to start is considering the lines of inquiry utilized in intake paperwork, onboarding clients into new systems, and clinical assessment interviews and initial encounters. A persistent problem and effect of heteronormative and cisnormative systems and institutions is the encouragement toward an uncritical usage of identity categories, an insistence on minority sexualities and genders as deviant or problematic, as well as an individual focus at the expense of an appreciation for client’s experiences interacting with prejudiced systems. Equally, providers may have the best intentions to serve LGBTQ+ clients, but they can at times focus too much or too little on the client’s sexuality or gender identity, either over-associating or under-correlating it with health and mental health issues.Reference O’Brien, Walker and Poteet ¹⁰⁵ Accordingly, a queer-affirmative approach would encourage a conversation with clients about how they square their sexuality and gender with the situation or problems at hand.Reference Semp ¹³⁶ This can be achieved through more narrative oriented lines of inquiry; for example: How do you describe or think about your sexuality and/or gender to yourself? Is your sexuality or gender important to how you see yourself; if so, in what ways? Are there any other important areas of your identity? Have you had concerns about your sexuality or gender? How does your sexuality or gender figure into your health and mental health? From there, it is important for clinicians and staff to consider how is this information documented, recorded, and then used to inform treatment and care.