The health and well‐being of lesbian, gay, bisexual, and transgender (LGBT) people, including their stress experiences, is a growing field of study. This entry defines LGBT identities and summarizes the forms of stress that LGBT people are likely to experience in their lives. Evidence shows that LGBT individuals experience a wide variety of stressors, as well as stressors that are distinct to sexual and gender minority members. These stressors perpetuate LGBT mental and physical health disparities, such as suicidal behaviors, substance abuse, and depression. Limitations of the current research include a lack of inclusion of bisexuals and transgender individuals, as well as a reliance on large metropolitan areas for sample selection.

Introduction In 2012, transgender persons in Pakistan were granted right for a legal third gender identity, and in 2018 the Transgender Persons (Protection) of Rights Act affirmed transgender people's right for self-perceived identity. Further, gender affirming medical treatments were also legalized to support gender transitioning in transgender persons. The current study was conducted to explore barriers faced by female-to-male (FtM) transgender persons/trans men in accessing gender affirmative treatment for the purposes of gender transition.Method To achieve the objective, 11 trans men were interviewed who had Childhood Onset of Gender Dysphoria screened through Urdu translated versions of Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults and Recalled Childhood Gender Identity Questionnaire. Semi-structured in-depth interviews were conducted and grounded theory method was used for analysis.Results Analysis revealed medical, educational, social, legal, religious, financial, and psychological barriers that participants faced during the process of transitioning.Conclusion Findings are discussed within the cultural context of Pakistan and in light of the existing literature. The findings of this research would help clinicians, academicians, policy makers and other stake holders in raising awareness regarding problems faced by FtM transgender persons.

Social scientific research on gender/sex has focused largely on important but negative phenomena like sexism, transphobia, and gender dysphoria. But how do people's gender/sexes bring joy or affirmation? In this article, we describe a newly articulated construct we call "gender pleasure," or positive affective experiences related to one's gender/sex. To explore this, we conducted focus groups with American and Canadian people minoritized on the basis of gender/sex and/or sexuality and diverse by race/ethnicity (N = 64). Reflexive thematic analyses generated four themes: (a) Accepting one's self and living in authenticity and freedom provide joy, relief, and comfort; (b) affirming and nonjudgmental interpersonal gendered experiences provide validation and belonging; (c) gender norms and intersecting systems of power shape experiences of gender pleasure; and (d) gender pleasure involves purely positive experiences, relief from negative experiences, and increases in positive affect. Ultimately, we propose a model of gender pleasure as resonance between people's gender/sex orientations, identities, and statuses. These results have implications for gender/sex diversity research, thinking of gender/sex as a process, and clinical practice. We conclude by highlighting the value of focusing on joy and thriving among marginalized communities. This article is the first of a two-part report, and the second part explores gender pleasure among gender/sex/ual majority people (Freshley et al., in press).

Individuals who identify as transgender or gender diverse (TGD) are presenting at mental health clinicians' offices with increasing frequency. Many TGD clients are seeking care related to affirming their gender identity but also may present with anxiety, depression, trauma, substance abuse, or other problems for which a clinician may commonly provide services. Some clinicians may hesitate to accept TGD clients into their practice if they have little specialized training to work with this population in an affirming manner, especially in more underserved areas where a generalist practice is the norm. Numerous professional associations and experts have developed guidelines for affirmative behavioral health care for TGD people. However, what is needed are community informed recommendations to bridge from the official guidelines to clinicians' in-session activities. The Trans Collaborations Practice Adaptations for Psychological Interventions for Transgender and Gender Diverse Adults are derived from iterative interviews with TGD community members and affirming mental health clinicians in the Central United States. The 12 practice adaptations are intended to guide clinicians to adapt their usual treatment approach to be TGD affirming, especially in underserved and rural areas. The practice adaptations cover numerous aspects of practice including the office setting and paperwork, understanding gender identity and incorporating it into the case conceptualization, therapist's self-awareness, and referrals. The Trans Collaborations Practice Adaptations will help clinicians work confidently and competently with adult TGD clients, regardless of the presenting problem, to ensure TGD communities receive the best interventions for their behavioral health concerns.

Introduction With new diagnostic technologies and treatment modalities available, more people than ever are living as cancer survivors in the USA, a large percentage of whom are breast cancer survivors. These new technologies and treatments have side effects that impact women’s sexual health during treatment and throughout long-term survivorship from the disease. The purpose of this research was to understand the intersection of breast cancer survivorship and sexuality, including expressions and performance of gender, relationships, and sexual behavior in women in the Midwestern region of the USA. Methods This study used semi-structured interviews, conducted in 2015 and 2016 with 21 Midwestern women at least 6 months post-treatment. Following traditions of narrative and phenomenological qualitative research, the women’s own stories were used to explore the impact that survivorship, diagnosis, and treatment may have on a woman’s sexual self. Results Overarching themes included the role of care-giving, impact of the loss of breast tissue, and survival from breast cancer. These themes represent sexual scripts used specifically by women breast cancer survivors to understand and navigate their sexuality, including gender perceptions and performances, experiences of sexual pleasure and satisfaction, and their romantic and sexual relationships. Conclusions New scripts need to be encouraged with survivors and introduced into the social worlds that surround these individuals. Such scripts would include the importance of self-care throughout life and the importance of an individual’s quality of life beyond mere survival. Policy Implications More and better education needs to be provided to both healthcare providers and patients with regard to sexual side effects. Policies around standard of care must be adapted to go beyond survival.

Introduction There is a large body of research reporting the healthcare needs of groups identifying as lesbian, gay, bisexual, transgender, and/or queer (LGBTQ); however, a gap exists in the research literature because many epidemiological studies focus on sexual orientation rather than gender identify/incongruence. To address the lack of specific data from transgender and gender diverse (TGD) individuals, our organization designed and deployed a survey to assess the gender-affirming physical, mental, and social care needs of current patients. Methods A group of subspecialty physicians currently working with TGD patients created a list of questions and requested feedback from medical professionals familiar with the healthcare needs of this population. In addition, patients reviewed the survey for content and clarity. The final 68-item survey was distributed in April 2020 to patients or patients' representatives with an email address on file at the Nebraska Medicine Transgender Care Clinic (NMTCC). Participants were asked to respond to questions regarding their gender identity, their transition-related medical decisions, and their interest in services. Results Invitations were sent to 690 patients and 168 surveys were completed (response rate: 24.3%). Over 90% (n = 153) of the participants were patients and 9% (n = 15) answered survey questions on the patient's behalf. A majority (77.2%) had started the medical transition (hormones or puberty blockers) in the past four years. Nearly half (46.4%) identified as trans women, 43.4% identified as trans men, and 10.2% indicated they were nonbinary or gender expansive. Participants' sex assigned at birth was 50.9% female and 46.1% male. Most patients (n = 149; 92%) reported currently receiving hormone treatment within the Nebraska Medicine healthcare system. Results indicated the highest level of clinical services interest was primary care (38.4%), gender-affirming surgery (73.5%), voice therapy (49.0%), and hair removal (37.5%). In addition, participants were very likely to participate in support groups with "people of similar gender identity" (32.9%), with "others around my age" (28.6%), and "including a mix of ages and identities" (26.9%). Discussion This study suggests that our TGD patients would utilize integrated services to access a variety of clinical and non-clinical services. Ongoing community engagement and direct feedback from patients are critical to the success and growth of our gender-affirming care clinic. The results of this study will inform the planning and further evolution of a program designed to build trust and address health inequities for TGD individuals throughout the region.

This chapter examines the first-hand experiences of self-identified lesbian women in a portion of the Deep South (Alabama, Georgia, and Mississippi) and how these women navigate healthcare settings, their conceptualizations of lesbian health, as well as suggestions for improved provider competency. The authors utilize a grounded theory approach, prioritizing the experiences of these women to build up our understanding of lesbian health. Qualitative interviews were conducted with 23 self-identified lesbians. Data points to how women experience the intersection of their healthcare and sexual identity. Implications for the inclusion of lesbians into healthcare practices in the Deep South can be gleaned.

Transgender people remain one of the groups most susceptible to discrimination in the U.S. Previous studies have examined the discrimination and stress transgender people face, but few studies have examined trans identities using existing sociological theories of marginalized groups and identity formation. Using the theories of Dubois and Cooley, this study explores identity formation in conjunction with the phenomenon of passing among transgender people residing in Nebraska. Results suggest that while trans people do pass as a mechanism for subverting discrimination, there are other factors that influence an individual’s choice and strategy to pass or not. The current investigation lends a sociological perspective on the social aspect of gender presentation and gender visibility for trans individuals in a largely conservative Midwestern state.

The sexual satisfaction of couples during pregnancy is an under-researched area of study. Several limitations exist within the current literature, including a lack of inquiry into attitudes about sex during pregnancy, analysis of the relationship between sexual satisfaction and sexual behaviors, and analysis of dyadic interactions within the couple. The purpose of the current study was to examine the relationships between attitudes toward having sex during pregnancy, various sexual behaviors, and sexual satisfaction among expectant couples via multilevel structural equation modeling. Recruitment focused on mixed-gender monogamous couples where the pregnant individual was between 8 and 12 weeks of gestation, and both partners were soon-to-be first time parents. Touching, hugging, or holding, kissing, vaginal and oral sex, and rubbing each other’s genitals were all common behaviors among the 116 couples in the current investigation. Anal sex and sex toy use were less common, but far from absent. According to our model, attitudes toward having sex during pregnancy significantly predicted sexual satisfaction by operating through specific sexual behaviors: kissing, vaginal fingering, and vaginal intercourse, while use of a toy alone and use of a toy with partner were independent predictors of sexual satisfaction. Gender had a direct relationship with satisfaction (men were more satisfied), as well as indirect relationship with satisfaction through an interaction with vaginal fingering and use of a sex toy alone. While multiple past month sexual behaviors were likely to increase satisfaction among pregnant and non-expectant couples alike, this improvement might depend on which behaviors are included and the gender of the individual.

Background: Transgender and gender-nonconforming individuals experience more discrimination than their cisgender peers, and this discrimination can be associated with poorer mental health. This study used the gender minority stress model as a framework to examine the relationship among gender-related stressors and resilience factors and mental health outcomes. The study particularly aimed to increase knowledge of the gender-nonconforming population. Methods: A community sample of 83 individuals that identify as a gender different than the sex assigned to them at birth completed an online survey. Depression and anxiety were assessed using the Center for Epidemiological Studies Depression Scale (CES-D) and Beck Anxiety Inventory (BAI), respectively. The Gender Minority Stress and Resilience measure was used to assess distal and proximal stressors and resilience factors. Results: The median CES-D and BAI scores were 16 and 13, respectively. Forty percent had a history of non-suicidal self-injury (NSSI), 75% had experienced suicidal ideation, and 45% had attempted suicide. Proximal stress was found to be a positive predictor of depressive symptoms. Resilience was a weak negative predictor of anxiety symptoms. Distal stress was a positive predictor of suicide attempts, and resilience factors and hormone use were marginal negative predictors of suicide attempt. Trans women were significantly less likely to have engaged in NSSI, but had a significantly higher proximal stress score than trans men and gender-nonconforming individuals. Conclusion: Our study found high rates of mental health problems in the trans and gender-nonconforming sample. Our findings in part support the gender minority stress model, with gender-related stress predicting certain mental health problems and resilience being a negative predictor. Overall, gender-nonconforming individuals have had similar experiences and mental health findings as transgender individuals.

Purpose: This study assessed within a Midwestern LGBT population whether, and the extent to which, transgender identity was associated with elevated odds of reported discrimination, depression symptoms, and suicide attempts. Methods: Based on survey data collected online from respondents who self-identified as lesbian, gay, bisexual, and/or transgender persons over the age of 19 in Nebraska in 2010, this study performed bivariate t- or chi-square tests and multivariate logistic regression analysis to examine differences in reported discrimination, depression symptoms, suicide attempts, and self-acceptance of LGBT identity between 91 transgender and 676 nontransgender respondents. Results: After controlling for the effects of selected confounders, transgender identity was associated with higher odds of reported discrimination (OR=2.63, p<0.01), depression symptoms (OR=2.33, p<0.05), and attempted suicides (OR=2.59, p<0.01) when compared with nontransgender individuals. Self-acceptance of LGBT identity was associated with substantially lower odds of reporting depression symptoms (OR=0.46, p<0.001). Conclusion: Relative to nontransgender LGB individuals, transgender individuals were more likely to report discrimination, depression symptoms, and attempted suicides. Lack of self-acceptance of LGBT identity was associated with depression symptoms among transgender individuals.

PURPOSE Researchers have documented that lesbian, gay, bisexual, and transgender (LGBT) people have a higher proportion of tobacco use as compared to general population smoking rates. This study examined the relationships between tobacco use and social determinants of health in a sample of self-identifying LGBT people who spend time in Nebraska. METHODS A community-based participatory research approach was used to develop an online survey to assess the physical, mental, social, and sexual health of LGBT populations who live, work, or play in Nebraska. Chi-squared and logistic regression analyses explored the use of tobacco among respondents. RESULTS Of the 770 people who completed the survey, 763 respondents completed questions about smoking status. The prevalence of current smoking among these 763 respondents was 26.47%. Some LGBT-specific social determinants of health had significant relationships to smoking status. However, after controlling for known risk factors of smoking in logistic regression models, these variables were not related to smoking status. CONCLUSIONS This study shows that there is a significant relationship between smoking and several general social determinants of health, including employment status, education, and income as well as binge drinking. Limitations include lack of adequate survey respondents to divide subgroups of LGBT individuals and inherent limitations of convenience sampling, which may not allow for an accurate representation of the situation faced by LGBT in Nebraska. In addition to this, the list of LGBT-specific determinants of health used in the survey may not be exhaustive, and there may be additional factors facing LGBT individuals. Public health professionals can use this information in designing smoking reduction campaigns for LGBT populations in Nebraska and culturally similar regions of the United States. These programs and interventions may want to consider a more holistic approach to smoking cessation grounded in the social-ecological model.

Research into the health and wellbeing of rural lesbian, gay, bisexual, and transgender (LGBT) populations is limited. A community-based participatory research (CBPR) approach was used to develop an online survey for LGBT Nebraskans. The 770 participants replied to an array of questions on social determinants of health and basic health outcomes. Only significant differences in having health insurance were found between urban and rural participants. Social determinants of health were explored. Results of this study suggest that regional culture may be more salient to health for lesbian, gay, bisexual, and transgender persons living in the Midwest than rural or urban residence.

Previous studies demonstrated the utility of the minority stress model in understanding health disparities for lesbian, gay, bisexual, and transgender (LGBT) populations. Since most research has considered large metropolitan areas, predominantly in coastal regions of the United States, this research focuses on a midwestern state, Nebraska. This study sought to assess the relationships between depressive symptoms experienced by participants (N = 770) and minority stress variables, including experiences with violence, perceptions of discrimination, and respondents' degree of self-acceptance of their LGBT identity. Regression analysis revealed that after controlling for demographic variables, self-acceptance, and perceived discrimination were correlated with depressive symptoms. These findings have implications for policy makers, public health planners, and health care providers.

The social, political, and public health landscape as it relates to lesbian, gay, bisexual, and transgender (LGBT) persons has dramatically shifted both in the United States and across the globe in...