lgbt equality essay

The Rights of Lesbian, Gay, Bisexual and Transgender People

The struggle of LGBT (lesbian, gay, bisexual and transgender) people for equal rights has moved to center stage. LGBT people are battling for their civil rights in Congress, in courtrooms and in the streets. Well-known figures are discussing their sexual orientation in public. Gay and lesbian people are featured in movies and on television – not as novelty characters, but as full participants in society.

Despite these advances into the American mainstream, however, LGBT people continue to face real discrimination in all areas of life. No federal law prevents a person from being fired or refused a job on the basis of sexual orientation. The nation’s largest employer – the U.S. military – openly discriminates against gays and lesbians. Mothers and fathers lose child custody simply because they are gay or lesbian, and gay people are denied the right to marry.

One state even tried to fence lesbians and gay men out of the process used to pass laws. In 1992 Colorado enacted Amendment 2, which repealed existing state laws and barred future laws protecting lesbians, gay men and bisexuals from discrimination. The U. S. Supreme Court struck it down in the landmark 1996 Romer v. Evans decision.

We must conclude that Amendment 2 classifies homosexuals not to further a proper legislative end but to make them unequal to everyone else. This Colorado cannot do. A State cannot so deem a class of persons a stranger to its laws. — Justice Anthony Kennedy Majority Opinion in Romer v. Evans I

The modern gay rights movement began dramatically in June 1969 in New York City’s Greenwich Village. During a typical “raid,” police tried to arrest people for their mere presence at a gay bar, but the patrons of the Stonewall Inn fought back – and the gay rights movement was launched. Using many of the grass-roots and litigation strategies employed by other 20th century activists, gay rights advocates have achieved significant progress:

• Ten states, the District of Columbia, many municipalities and hundreds of businesses and universities now ban employment discrimination.
• “Domestic Partnership” programs exist in dozens of municipalities and hundreds of private institutions, including many of the country’s largest corporations and universities.
• Sodomy laws, typically used to justify discrimination against gay people, once existed nationwide; they are now on the books in only 18 states and Puerto Rico.

But the increased empowerment of LGBT people has brought about even more open and virulent anti-gay hostility:

• Although unrelated to an individual’s ability, sexual orientation can still be the basis for employment decisions in both the public and private sectors in most states and municipalities.
• Violent hate crimes, such as the 1998 murder of Wyoming student Matthew Shepherd, depict a grisly backlash against LGBTs or people perceived to be gay.
• LGBT students and teachers face daily harassment and discrimination in the schools, and LGBT student groups in high schools and colleges still face roadblocks.

In 1986, after more than two decades of support for lesbian and gay struggles, the American Civil Liberties Union established a national Lesbian and Gay Rights Project. Working in close collaboration with the ACLU’s affiliates nationwide, the Project coordinates the most extensive gay rights legal program in the nation. Increasing opposition from a well-organized, well-funded coalition of radical extremists and fundamentalists promises many battles and challenges ahead.

WHAT IS THE CONSTITUTIONAL BASIS FOR LGBT EQUALITY?

The struggle for legal equality for LGBT people rests on several fundamental constitutional principles.

Equal protection of the law is guaranteed by the Fifth and Fourteenth Amendments and reinforced by hundreds of local, state and federal civil rights laws. Although the Fourteenth Amendment, ratified at the end of the Civil War, was designed to ensure legal equality for African Americans, Congress wrote it as a general guarantee of equality, and the courts have interpreted the Equal Protection Clause to prohibit discrimination on the basis of gender, religion and disability. The ACLU believes the Equal Protection Cluase prohibits discrimination based on sexual orientation as well.

The right to privacy, or “the right to be left alone,” is guaranteed by the Fourth, Fifth, Ninth and Fourteenth Amendments. In 1965, Griswold v. Connecticut struck down a state law that prohibited married couples from obtaining contraceptives, citing “zones of privacy.” In 1967, Loving v. Virginia decriminalized interracial marriage. The 1972 Eisenstadt v. Baird decision recognized unmarried persons’ right to contraceptives. And in 1973, Roe v. Wade recognized women’s right to reproductive choice. All of these Supreme Court decisions underscore the principle that decisions about intimate relationships are personal and should be left up to the individual.

Freedom of speech and association are protected under the First Amendment. This Amendment protects the right to organize and urge government to end discrimination, to recognize lesbian and gay relationships, and to adopt laws prohibiting discrimination in the private sector. It also includes the rights to form social and political organizations, to socialize in bars and restaurants, to march or protest peacefully, to produce art with gay themes and to speak out publicly about LGBT issues.

In the Schools

Nothing is more important than making schools safe and welcoming places for gay and lesbian youth, who often face tremendous hostility from their family and community during their formative years. This means protecting students from violence, guaranteeing their right to organize events and clubs like other students, and making sure that gay teachers who might serve as healthy role models are not themselves victimized by discrimination. The ACLU has fought harassment of students in California, Nevada, Ohio and Washington, defended gay teachers in California, Idaho and Utah, and advocated for gay student groups in Alabama, Indiana, Minnesota, Utah and Wisconsin.

Harassment on the job

Mary Jo Davis had high hopes when she accepted a job offer with the Radiology Department of Pullman Memorial Hospital in Whitman County, Washington. All that changed after her supervising doctor discovered she was a lesbian. The doctor started calling her a “dyke” and “faggot,” and wouldn’t work with her or even speak to her. When Mary Jo protested this harassment, she was fired. Represented by the ACLU’s Lesbian and Gay Rights Project, Mary Jo hopes to establish that public employees have a constitutional right to be free from discrimination and harassment in the workplace.

Sodomy and Homophobia

David Weigand could take it no longer. His son was living in the home of his former wife, along with the boy’s stepfather – a convicted felon with a drinking and drug problem who was beating his wife in the presence of the child. Things got so bad that the boy had to call 911 to save his mother’s life, and as a result of all the violence, the family was ultimately evicted from their home.

David asked a Mississippi family court to give him custody of his son. The court refused to do so, in essence saying that living in a home wracked with violence was preferable to living with a father who is gay and “commits sodomy.” In addition to representing David before the Mississippi Supreme Court, the ACLU will continue fighting on behalf of lesbian and gay parents, and to eliminate state sodomy laws.

In the Child’s Best Interest

States are supposed to make rules on adoption and foster care to protect the best interest of children in need of loving homes and families. But somehow it does not work out that way in states like Florida and Arkansas, which ban gays and lesbians from adopting and being foster parents, respectively. By challenging the discriminatory policies of these states, the ACLU is working hard to prevent similar policies from being adopted in other parts of the country.

As a reminder of what is supposed to be the essence of child-welfare policy, the ACLU’s Lesbian and Gay Rights Project in 1998 published a report entitled In the Child’s Best Interest: Defending Fair and Sensible Adoption Policies. To order this, the 1998 videotape Created Equal about employment discrimination against LGBTs, or any other ACLU publication, please contact ACLU Publications at 1-800-775-ACLU.

AREN’T LGBT PEOPLE DEMANDING SPECIAL RIGHTS AND PREFERENTIAL TREATMENT?

As the Supreme Court explained in Romer v. Evans, there is nothing “special” about laws which prevent people from losing jobs and homes because of who they are. Most of us take the right to participate in daily life on an equal footing for granted, the Court said, either because we already have the right under the law, or because we are not subjected to that kind of discrimination. Laws which prohibit discrimination simply give LGBT people that basic right to be equal participants in the communities in which they live.

Most Americans do not realize that many LGBT people who face discrimination – in areas from housing and employment to parenting – have no legal recourse since federal law does not prohibit discrimination against LGBT people. Extending such protection from discrimination to LGBT people is one of the many important battles ahead for the ACLU and other advocacy organizations.

ARE LGBT PEOPLE PROTECTED AGAINST DISCRIMINATION ANYWHERE IN THE COUNTRY?

Yes, twelve states (California, Connecticut, Hawaii, Maryland, Massachusetts, Minnesota, New Hampshire, Nevada, New Jersey, Rhode Island, Vermont and Wisconsin), the District of Columbia, many municipalities, and hundreds of businesses and universities have enacted laws that protect gay, lesbian and bisexual people from employment discrimination. A smaller number of jurisdictions protect transgender people.

But in most locales in the remaining 38 states discrimination against LGBT people remains perfectly legal. Businesses openly fire LGBT employees, and every year, lesbian and gay Americans are denied jobs and access to housing, hotels and other public accommodations. Many more are forced to hide their lives, deny their families and lie about their loved ones just to get by.

The ACLU believes the best way to redress discrimination is to amend all existing federal, state and local civil rights laws and all existing business and university policies to ban discrimination based on sexual orientation.

WHAT ABOUT DOMESTIC PARTNERSHIPS?

Many cities, including New York, Los Angeles, San Francisco, Atlanta, the District of Columbia and Minneapolis, have created “domestic partnership” registries. They give official status to same-sex couples who register with the city. Scores of government and private companies recognize the domestic partnerships of their employees. The state of Hawaii recognizes domestic partners.

While these laws do not confer most of the rights and responsibilities of marriage, they generally grant partners some of the recognition accorded to married couples – typically, the right to visit a sick or dying partner in a hospital, sometimes sick and bereavement leave and in a few cases, health insurance and other important benefits.

Perhaps as important, these policies give some small acknowledgement to the intimate, committed relationships central to the lives of so many lesbians and gay men, which society otherwise ignores.

WHY SUPPORT SAME SEX MARRIAGE?

Denying lesbian and gay couples the right to wed not only deprives them of the social and spiritual significance of marriage; it has serious, often tragic, practical consequences. Since they can not marry, the partners of lesbians and gay men are not next of kin in times of crisis; they are not consulted on crucial medical decisions; they are not given leave to care for each other; they are not each other’s legal heirs, if, like most Americans, they do not have wills. Marital status is often the basis on which employers extend health insurance, pension and other benefits. The ACLU believes that since we have attached such enormous social consequences to marriage, it violates equal protection of the law to deny lesbian and gay couples the right to wed.

WHAT ARE “SODOMY LAWS” AND WHY BOTHER WORKING TO REPEAL THEM?

Sodomy statutes generally prohibit oral and anal sex, even between consenting adults. Penalties for violating sodomy laws range from a $200 fine to 20 years imprisonment. While most sodomy laws apply to both heterosexuals and lesbians and gay men, they are primarily used against gay people. For example, some courts say sodomy laws justify separating gay parents from their children. Some cities use sodomy laws to arrest gay people for talking with each other about sex, in conversations which parallel those heterosexuals have every day.

In recent years, the legislatures of Pennsylvania, Nevada and Rhode Island joined the 23 other state legislatures which repealed sodomy laws in the 60s and 70s. Courts in Georgia, Kentucky, Maryland, Montana and Tennessee have struck down the statutes. The remaining sodomy laws will be challenged in the legislatures and the courts until they are all eliminated.

“We must conclude that Amendment 2 classifies homosexuals not to further a proper legislative end but to make them unequal to everyone else. This Colorado cannot do. A State cannot so deem a class of persons a stranger to its laws.”

– Justice Anthony Kennedy Majority Opinion in Romer v. Evans

Related Issues

• LGBTQ Rights

Stay Informed

Every month, you'll receive regular roundups of the most important civil rights and civil liberties developments. Remember: a well-informed citizenry is the best defense against tyranny.

By completing this form, I agree to receive occasional emails per the terms of the ACLU’s privacy statement.

• Entertainment
• Environment
• Information Science and Technology
• Social Issues

Home Essay Samples Sociology LGBTQ

Persuading for Equality: Embracing LGBTQ Rights

Table of contents, upholding equality for all, the consequences of discrimination, the societal benefits of inclusivity, challenging misconceptions, conclusion: a call to action.

*minimum deadline

Cite this Essay

To export a reference to this article please select a referencing style below

• Violent Media Is Good For Kids
• Conversation
• Nonverbal Communication
• Masculinity

Need writing help?

You can always rely on us no matter what type of paper you need

*No hidden charges

100% Unique Essays

Absolutely Confidential

Money Back Guarantee

By clicking “Send Essay”, you agree to our Terms of service and Privacy statement. We will occasionally send you account related emails

You can also get a UNIQUE essay on this or any other topic

Thank you! We’ll contact you as soon as possible.

CONCEPTUAL ANALYSIS article

Better together: a model for women and lgbtq equality in the workplace.

• Faculty of Psychology, Work and Organizational Psychology, Philipps University of Marburg, Marburg, Germany

Much has been achieved in terms of human rights for women and people of the lesbian, gay, bisexual, transsexual, and queer (LGBTQ) community. However, human resources management (HRM) initiatives for gender equality in the workplace focus almost exclusively on white, heterosexual, cisgender women, leaving the problems of other gender, and social minorities out of the analysis. This article develops an integrative model of gender equality in the workplace for HRM academics and practitioners. First, it analyzes relevant antecedents and consequences of gender-based discrimination and harassment (GBDH) in the workplace. Second, it incorporates the feminist, queer, and intersectional perspectives in the analysis. Third, it integrates literature findings about women and the LGBTQ at work, making the case for an inclusive HRM. The authors underscore the importance of industry-university collaboration and offer a starters' toolkit that includes suggestions for diagnosis, intervention, and applied research on GBDH. Finally, avenues for future research are identified to explore gendered practices that hinder the career development of women and the LGBTQ in the workplace.

Introduction

Gender has diversified itself. More than four decades have passed since Bem (1974) published her groundbreaking article on psychological androgyny. With her work, she challenged the binary conception of gender in the western academia, calling for the disposal of gender as a stable trait consistent of discrete categories ( Mehta and Keener, 2017 ). Nowadays, people from the LGBTQ community find safe spaces to express their gender in most developed countries (see ILGA-Europe, 2017 ). Also, women-rights movements have impulsed changes for the emancipation and integration of women at every social level, enabling them to achieve things barely imaginable before (see Hooks, 2000 ).

However, there is still a lot to do to improve the situation of women and people from the LGBTQ community ( International Labour Office, 2016 ; ILGA-Europe, 2017 ). Some actions to increase gender inclusion in organizations actually conceal inequality against women, and many problems faced by the LGBTQ originate within frameworks that anti-discrimination policy reinforce (see Benschop and Doorewaard, 1998 , 2012 ; Verloo, 2006 ). For example, the gender equality, gender management, and gender mainstreaming approaches overlook most problems faced by people from the LGBTQ community and from women of color, framing their target stakeholders as white, cisgender, and heterosexual (see Tomic, 2011 ; Hanappi-Egger, 2013 ; Klein, 2016 ). These problems seem to originate in the neoliberalization of former radical movements when adopted by the mainstream (see Cho et al., 2013 ). This translates into actions addressing sexism and heterosexism that overlook other forms of discrimination (e.g., racism, ableism), resisting an intersectional approach that would question white, able-bodied, and other forms of privilege (see Crenshaw, 1991 ; Cho et al., 2013 ; Liasidou, 2013 ; van Amsterdam, 2013 ).

The purpose of this paper is to support the claim that gender equality shall be done within a queer, feminist, and intersectional framework. This argument is developed by integrating available evidence on the antecedents and consequences of GBDH against women and people from the LGBTQ community in the workplace. The authors believe that GBDH against these groups has its origin in the different manifestations of sexism in organizations. A model with the antecedents and consequences of GBDH in the workplace is proposed. It considers an inclusive definition of gender and integrates the queer-feminist approach to HRM ( Gedro and Mizzi, 2014 ) with the intersectional perspective ( Crenshaw, 1991 ; McCall, 2005 ; Verloo, 2006 ). In this way, it provides a framework for HRM scholars and practitioners working to counteract sexism, heterosexism, and other forms of discrimination in organizations.

GBDH in the Workplace

GBDH is the umbrella term we propose to refer to the different manifestations of sexism and heterosexism in the workplace. The roots of GBDH are beyond the forms that discriminatory acts and behaviors take, being rather “about the power relations that are brought into play in the act of harassing” ( Connell, 2006 , p. 838). This requires acknowledging that gender harassment is a technology of sexism, that “perpetuates, enforces, and polices a set of gender roles that seek to feminize women and masculinize men” ( Franke, 1997 , p. 696). Harassment against the LGBTQ is rooted in a heterosexist ideology that establishes heterosexuality as the superior, valid, and natural form of expressing sexuality (see Wright and Wegner, 2012 ; Rabelo and Cortina, 2014 ). Furthermore, women and the LGBTQ are oppressed by the institutionalized sexism that underscores the supremacy of hegemonic masculinity (male, white, heterosexual, strong, objective, rational) over femininity (female, non-white, non-heterosexual, weak, emotional, irrational; Wright, 2013 ; Denissen and Saguy, 2014 ; Dougherty and Goldstein Hode, 2016 ). In addition, GBDH overlaps with other frameworks (e.g., racism, ableism, anti-fat discrimination) that concurrently work to maintain white, able-bodied, and thin privilege, impeding changes in the broader social structure (see Yoder, 1991 ; Yoder and Aniakudo, 1997 ; Buchanan and Ormerod, 2002 ; Acker, 2006 ; Liasidou, 2013 ; van Amsterdam, 2013 ). The next paragraphs offer a definition of some of the most studied forms of GBDH in the workplace.

Sexual Harassment

Sexual harassment was first defined in its different dimensions as gender harassment, unwanted sexual attention, and sexual coercion ( Gelfand et al., 1995 ). Later, Leskinen and Cortina (2013) focused on the gender-harassment subcomponent of sexual harassment and developed a broadened taxonomy of the term. This was motivated by the fact that legal practices gave little importance to gender-harassment forms of sexual harassment, despite of the negative impact they have on the targets' well-being ( Leskinen et al., 2011 ). Gender harassment consists of rejection or “put down” forms of sexual harassment such as sexist remarks, sexually crude/offensive behavior, infantilization, work/family policing, and gender policing ( Leskinen and Cortina, 2013 ). The concepts of sexual harassment and gender harassment were initially developed to refer to the experiences of women in the workplace, but there is also evidence of sexual and gender harassment against LGBTQ individuals ( Lombardi et al., 2002 ; Silverschanz et al., 2008 ; Denissen and Saguy, 2014 ). In addition, studies have shown how gender harassment and heterosexist harassment are complementary and frequently simultaneous phenomena accounting for mistreatment against members of the LGBTQ community ( Rabelo and Cortina, 2014 ).

Gender Microaggressions

Gender microaggressions account for GBDH against women and people from the LGBTQ community that presents itself in ways that are subtle and troublesome to notice ( Basford et al., 2014 ; Galupo and Resnick, 2016 ). Following the taxonomy on racial microaggressions developed by Sue et al. (2007) , the construct was adapted to account for gender-based forms of discrimination ( Basford et al., 2014 ). Gender microaggressions consist of microassaults, microinsults, and microinvalidations, and although they may appear to be innocent, they exert considerably negative effects in the targets' well-being ( Sue et al., 2007 ; Basford et al., 2014 ; Galupo and Resnick, 2016 ). As an example of microassault imagine an individual commenting their colleague that their way of dressing looks unprofessional (because it is not “masculine enough,” “too” feminine, or not according to traditional gender-binary standards). A microinsult is for example when the supervisor asks the subordinate about who helped them with their work (which was “too good” to be developed by the subordinate alone). An example of microinvalidation would be if in a corporate meeting the CEO dismisses information related to women or the LGBTQ in the company regarding it as unimportant, reinforcing the message that women and LGBTQ issues are inexistent or irrelevant (for more examples see Basford et al., 2014 ; Galupo and Resnick, 2016 ). Because gender is not explicitly addressed in microaggressions, it can be especially difficult for the victims to address the offense as such and act upon them (see Galupo and Resnick, 2016 ). Hence, they are not only emotionally distressing, but also tend to be highly ubiquitous, belonging to the daily expressions of a determined context ( Nadal et al., 2011 , 2014 ; Gartner and Sterzing, 2016 ).

Disguised Forms of GBDH

It is also the case that some forms of workplace mistreatment constitute disguised forms of GBDH. Rospenda et al. (2008) found in their US study that women presented higher rates of generalized workplace abuse (i.e., workplace bullying or mobbing). In the UK, a representative study detected that a high proportion of lesbian, gay, and bisexual respondents have faced workplace bullying ( Hoel et al., 2017 ). Specifically, the results indicated that while the bullying rate for heterosexuals over a six-months period was of 6.4%, this number was tripled for bisexuals (19.2%), and more than doubled for lesbians (16.9%) and gay (13.7%) individuals ( Hoel et al., 2017 ). Moreover, 90% of the transgender sample in a US study reported experiencing “harassment, mistreatment or discrimination on the job” ( Grant et al., 2011 , p. 3). These findings suggest that many of the individuals facing workplace harassment that appears to be gender neutral are actually targets of GBDH. Hence, they experience “ disguised gender-based harassment and discrimination” ( Rospenda et al., 2009 , p. 837) that should not be addressed as a gender-neutral issue.

Intersectional, Queer, and Feminist Approaches in Organizations

In this section, a short introduction to the feminist, queer, and intersectional approaches is given, as they are applied to the analyses throughout this article.

Feminist Approaches

In the beginning there was feminism.

In the words of bell hooks, “[f]eminism is a movement to end sexism, sexist exploitation, and oppression” ( Hooks, 2000 , viii). However, feminism can be a movement, a methodology, or a theoretical approach, and it is probably better to talk about feminisms than considering it a unitary concept. In this paper, different feminist approaches (see Bendl, 2000 ) are applied to the analysis. Gender as a variable takes gender as a politically neutral, uncontested variable; the feminist standpoint focuses on women as a group; and the feminist poststructuralist approach searches to deconstruct hegemonic discourses that perpetuate inequality (for the complete definitions see Bendl, 2000 ).

Gender Subtext

The gender subtext refers to an approach to the managerial discourse that brings attention to how official speeches of inclusion work to conceal inequalities ( Benschop and Doorewaard, 1998 ). Its methodology -subtext analysis- brings discourse analysis and feminist deconstruction together to scrutiny the managerial discourse and practices in organizations ( Benschop and Doorewaard, 1998 ; Bendl, 2000 ; Bendl, 2008 ; Benschop and Doorewaard, 2012 ).

Integration and Applications of Feminist Approaches and the Gender Subtext

The gender subtext serves to understand the role that organizational factors play in the occurrence of GBDH. Gender as a variable serves to underscore how the hegemonic definition of gender excludes and otherizes the LGBTQ from HRM approaches to gender equality. The feminist standpoint is applied in this paper as a framework in which two groups—women and the LGBTQ—are recognized in their heterogeneity, and still brought together to search for synergies to counteract sexism as a common source of institutionalized oppression (see Oliver, 1992 ; Franke, 1997 ). Finally, the feminist-poststructuralist approach enables conceiving gender as deconstructed and reconstructed, and to apply the subtext analysis to the organizational discourse (see Benschop and Doorewaard, 1998 ; Monro, 2005 ).

Queer Approach

Queer theory and politics.

The origins of the queer movement can be traced to the late eighties, when lesbians, gays, bisexuals, and the transgender took distance from the LGBT community as a sign of disconformity with the depoliticization of its agenda ( Woltersdorff, 2003 ). However, the “Queer” label was later incorporated in the broader movement ( Woltersdorff, 2003 ). In terms of queer theory, the most recognized scholar is Judith Butler, whose work Gender Trouble (1990) was revolutionary because it made visible the oppressive character of the categories used to signify gender, and insisted in its performative nature (see Butler, 1990 ; Woltersdorff, 2003 ).

Queer Standpoint, the LGBTQ, and HRM

In the presented model, queer theory brings attention to the exclusion of the LGBTQ community from the organizational and HRM speech. This exclusion is observed in the policies and politics supported by the HRM literature and practitioners, as well as in the way the LGBTQ are otherized by their discursive practices (e.g., validating only a binary vision of gender, Carrotte et al., 2016 ). Although the categories that the queer theory criticizes are applied in this model, its constructed nature is acknowledged (see Monro, 2005 ). In this way, McCall's (2005) argument in favor of the strategic use of categories for the intersectional analysis of oppression is supported. This analysis is conducted adopting a queer-feminist perspective ( Marinucci, 2016 ) and the intersectional approach.

Integration of Intersectionality With the Queer and Feminist Approaches

Origin and approaches.

The concept of intersectionality was initially introduced to frame the problem of double exclusion and discrimination that black women face in the United States ( Crenshaw, 1989 , 1991 ). Crenshaw (1991) analyzed how making visible the specific violence faced by black women conflicted with the political agendas of the feminist and anti-racist movements. This situation left those women devoid of a framework to direct political attention and resources toward ending with the violence they were (and still are) subjected to ( Crenshaw, 1991 ). Intersectionality theory has evolved since then, and different approaches exist within it ( McCall, 2005 ). These approaches range from fully deconstructivist (total rejection of categories), to intracategorical (focused on the differences within groups), to intercategorical (exploring the experiences of groups in the intersections), and are compatible with queer-feminist approaches (see Parker, 2002 ; McCall, 2005 ; Chapman and Gedro, 2009 ; Hill, 2009 ).

The intracategorical approach acknowledges the heterogeneity that exist within repressed groups (see Bendl, 2000 ; McCall, 2005 ). Within this framework (also called intracategorical complexity, see McCall, 2005 ), the intersectional analysis emerges, calling for attention to historically marginalized groups, [as in Crenshaw (1989 , 1991 )]. The deconstructivist view helps to de-essentialize categories as gender, race, and ableness, making visible the power dynamics they contribute to maintain (see Acker, 2006 ). The intercategorical approach takes constructed social categories and analyzes the power dynamics occurring between groups ( McCall, 2005 ).

Integration: Queer-Feminist Intersectional Synergy

Applying these complementary approaches helps to analyze how women and people from the LGBTQ community are defined (e.g., deconstructivist approach), essentialized (e.g., deconstructivist and intracategorical approaches), and oppressed by social actors (e.g., intercategorical approach) and institutionalized sexism (e.g., Oliver, 1992 ; Franke, 1997 ). It also allows the analysis of the oppression reinforced by members of the dominant group (intercategorical approach), as well as by minority members that enjoy other forms of privilege (e.g., white privilege), and endorse hegemonic values (deconstructivist and intracategorical approaches). In addition, the analyses within the inter- and intra-categorical framework allow approaching the problems faced by individuals in the intersections between sexism, heterosexism, cissexism, and monosexism (e.g., transgender women, lesbians, bisexuals), as well as considering the way classism, racism, ableism, and ethnocentrism shape their experiences (e.g., disabled women, transgender men of color).

Support for an Integrative HRM Model of GBDH in the Workplace

This section describes an integrative model of GBDH in the workplace ( Figure 1 ). First, the effects of GBDH on the health and occupational well-being of targeted individuals are illustrated (P1 and P2). Afterwards, the model deals with the direct and moderation effects of organizational climate, culture, policy, and politics (OCCPP) on GBDH in the workplace. OCCPP acts as a “switch” that enables or disables the other paths to GBDH. OCCPP's effects on GBDH are described as: a direct effect on GBDH (P3), the moderation of the relationship between gender diversity and GBDH (P3a), the moderation of the relationship between individual characteristics and GBDH (P3b), and the moderation (P3c) of the moderation effect of gender diversity on the relationship between individual's characteristics and GBDH (P4). In other words, when OCCPP produce environments that are adverse for gender minorities, gender diversity and gender characteristics become relevant to explain GBDH. When OCCPP generate respectful and integrative environments, gender diversity, and gender characteristics are no longer relevant predictors of harassment.

Figure 1 . Integrative model of GBDH in the workplace. Continuous paths represent direct relationships. Dashed paths represent fully moderated relationships. The double-ended arrow signals the relationship between gender diversity and OCCPP, which follows a circular causation logic.

Consequences of GBDH in the Workplace

Gbdh and individuals' health.

Evidence suggests that exposure to sexist discrimination and harassment in the workplace negatively affects women's well-being ( Yoder and McDonald, 2016 ; Manuel et al., 2017 ), and that different forms of sexual harassment can constitute trauma and lead to posttraumatic stress disorder ( Avina and O'Donohue, 2002 ). In their meta-analysis ( N = 89.382), Chan et al. (2008) found a negative relationship between workplace sexual harassment, psychological health, and physical health conditions. Regarding the LGBTQ at work, Flanders (2015) found a positive relationship between negative identity events, microaggressions, and feelings of stress and anxiety among a sample of bisexual individuals in the US. This is consistent with Galupo and Resnick's (2016) results about the negative effects of microaggressions for the well-being of lesbian, bisexual, and gay workers. In another study, Seelman et al. (2017) found that microaggressions and other forms of gender discrimination relate to lowered self-esteem and increased stress and anxiety in LGBTQ individuals, with the most negative effects reported by the transgender. In a study among gay, lesbian, and bisexual emerging adults in the US, exposure to the phrase “that's so gay” related to feelings of isolation and physical health symptoms as headaches, poor appetite, and eating problems ( Woodford et al., 2012 ). In the literature on gender discrimination, Khan et al. (2017) found that harassment relates to depression risk factors among the LGBTQ. Finally, according to Chan et al. (2008) meta-analysis, targets of workplace sexual harassment suffer its detrimental job-related, psychological, and physical consequences regardless of their gender.

Proposition P1: GBDH negatively affects women and LGBTQ individuals' health in the workplace .

GBDH and Occupational Well-Being

Occupational well-being refers to the relationship between job characteristics and individuals' well-being ( Warr, 1990 ). It is defined “as a positive evaluation of various aspects of one's job, including affective, motivational, behavioral, cognitive, and psychosomatic dimensions” ( Horn et al., 2004 , p. 366). It has a positive relationship with general well-being ( Warr, 1990 ) and work-related outcomes like task performance ( Devonish, 2013 ; Taris and Schaufeli, 2015 ).

There is robust evidence on the negative effects of GBDH on indicators of occupational well-being, such as overall job satisfaction, engagement, commitment, performance, job withdrawal, and job-related stress ( Stedham and Mitchell, 1998 ; Lapierre et al., 2005 ; Chan et al., 2008 ; Cogin and Fish, 2009 ; Sojo et al., 2016 ). Its negative effects have been reported among women ( Fitzgerald et al., 1997 ), gay and heterosexual men ( Stockdale et al., 1999 ), lesbians ( Denissen and Saguy, 2014 ), and transgender individuals ( Lombardi et al., 2002 ), to name some.

Proposition P2: GBDH negatively affects the occupational well-being of women and people from the LGBTQ community in the workplace .

Antecedents of GBDH in the Workplace

Direct effect of occpp on gbdh.

In the next lines, the direct effects of OCCPP on GBDH against women and people from the LGBTQ community are explored, supporting the next proposition of this model.

Proposition P3: OCCPP affect the incidence of GBDH against women and the LGBTQ .

Organizational Culture and GBDH

Organizational culture refers to the shared norms, values, and assumptions that are relatively stable and greatly affect the functioning of organizations ( Schein, 1996 ). The most plausible link between organizational culture and GBDH seems to be the endorsement of sexist beliefs and attitudes. This is supported by evidence that sexism endorsement encourages GBDH attitudes and behavior (see Pryor et al., 1993 ; Fitzgerald et al., 1997 ; Stockdale et al., 1999 ; Stoll et al., 2016 ). The literature on sexism has mainly adopted a binary conception of gender (see Carrotte et al., 2016 ). However, the last decade more research has focused on heterosexism and anti-LGBTQ attitudes, uncovering their negative effects in the lives of LGBTQ individuals.

Sexism Against Women

Scholars focusing on sexism against women have categorized it in different ways. Old-fashioned sexism refers to the explicit endorsement of traditional beliefs about women's inferiority ( Morrison et al., 1999 ). Modern and neo sexism define the denial of gender inequality in society and resentment against measures that support women as a group ( Campbell et al., 1997 ; Morrison et al., 1999 ). Gender-blind sexism refers to the denial of the existence of sexism against women ( Stoll et al., 2016 ). Benevolent sexism defines the endorsement of an idealized vision of women that is used to reinforce their submission ( Glick et al., 2000 ). Finally, ambivalent sexism is the term for the endorsement of both hostile and “benevolent” sexist attitudes ( Glick and Fiske, 1997 , 2001 , 2011 ).

Sexism Against the LGBTQ

Sexism directed against the LGBTQ takes different forms, that can be also held by members of the LGBTQ community, as the evidence about biphobia and transphobia points out (see Vernallis, 1999 ; Weiss, 2011 ). Heterosexism is the endorsement of beliefs stating that heterosexuality is the normal and desirable manifestation of sexuality, while framing other sexual orientations as deviant, inferior, or flawed (see Habarth, 2013 ; Rabelo and Cortina, 2014 ). Monosexism and biphobia refer to negative beliefs toward people that are not monosexual , namely, whose sexual orientation is not defined by the attraction to people from only one gender (see Vernallis, 1999 ). Cissexism (also transphobia ) refers to “an ideology that denigrates and subordinates trans* people because their sex and gender identities exist outside the gender binary. Transgender people are thus positioned as less authentic and inferior to cisgender people” ( Yavorsky, 2016 , p. 950). Hence, transgender individuals experience concurrently sexism, heterosexism, and cissexism/transphobia in their workplaces (see Yavorsky, 2016 ).

Organizational Climate and GBDH

Organizational climate reflects the “social perceptions of the appropriateness of particular behaviors and attitudes [in an organization]” ( Sliter et al., 2014 ). There is evidence linking organizational climate with workplace harassment ( Bowling and Beehr, 2006 ), sexual harassment ( Fitzgerald et al., 1997 , p. 578), and gender microaggressions ( Galupo and Resnick, 2016 ).

Diversity climate is “the extent to which employees perceive their organization to be supportive of underrepresented groups, both in terms of policy implementation and social integration” ( Sliter et al., 2014 ). Hence, a gender-diversity climate reflects the employees' perceptions of their workplace as welcoming and positively appreciating gender differences ( Jansen et al., 2015 ). It has been associated with an increased perception of inclusion by members of an organization, buffering the negative effects of gender dissimilarity (i.e., gender diversity) between individuals in a group ( Jansen et al., 2015 ). Sliter et al. (2014) found a negative relationship between diversity climate perceptions and conflict at work. Also, it has been suggested that it plays a crucial role for workers' active support of diversity initiatives, which is determinant for their successful implementation ( Avery, 2011 ). A similar construct, climate for inclusion has also shown to be a positive factor in gender-diverse groups, protecting against the negative effects of group conflict over unit-level satisfaction ( Nishii, 2013 ).

Heterosexist climate refers to an organizational climate in which heterosexist attitudes and behaviors are accepted and reinforced, propitiating GBDH against the LGBTQ (see Rabelo and Cortina, 2014 ; Galupo and Resnick, 2016 ). For example, Burn et al. (2005) conducted a study using hypothethical scenarios to test the effects of indirect heterosexism on lesbians, gays, and bisexuals. The participants of their study reported that hearing heterosexist comments would be experienced as an offense, affecting their decision to share information about their sexual orientation ( Burn et al., 2005 ). In addition, it has been found that LGBTQ-friendly climates (hence, low in heterosexism), can have a positive impact on the individual and organizational level ( Eliason et al., 2011 ). Examples of positive outcomes are reduced discrimination, better health, increased job satisfaction, job commitment ( Badgett et al., 2013 ), perceived organizational support ( Pichler et al., 2017 ), and feelings of validation for lesbians that become mothers ( Hennekam and Ladge, 2017 ).

Workplace Policy and GBDH

Workplace policy plays an important role in the incidence of GBDH. Finally, evidence shows that policy affects the extent to which the work environment presents itself as LGBTQ-friendly, influencing the experience of LGBTQ individuals at work ( Riger, 1991 ; Eliason et al., 2011 ; Döring, 2013 ; Dougherty and Goldstein Hode, 2016 ; Galupo and Resnick, 2016 ; Gruber, 2016 ). Eliason et al. (2011) found that inclusive language, domestic partner benefits, child-care solutions, and hiring policies are relevant for the constitution of a gender-inclusive work environment for the LGBTQ. Calafell (2014) wrote about how the absence of policy addressing discrimination against people with simultaneous minority identities (e.g., queer Latina) contributes to cover harassment against them. Galupo and Resnick (2016) found that weak policy contributes to the incidence of microaggressions against people from the LGBTQ community. Some of the situations they found include refusal of policy reinforcement, leak of confidential information, and refusal to acknowledge the gender identity of a worker ( Galupo and Resnick, 2016 ). Moreover, existent policy may serve to reinforce inequalities if its discourse is based on power binaries (e.g., rational/masculine vs. emotional/feminine) that discredit, oppress, and marginalize minority groups ( Riger, 1991 ; Dougherty and Goldstein Hode, 2016 ). For example, Peterson and Albrecht (1999) analyzed maternity-policy and found how discourse is shaped to protect organizational interest at the cost of the precarization of women's conditions in organizations. Finally, it is very important to address the mishandling of processes and backlash after GBDH complaints are filed, since they keep targets of harassment from seeking help within their organizations (see Vijayasiri, 2008 ).

Organizational Politics and GBDH

Organizations are political entities ( Mayes and Allen, 1977 ). In the workplace, power, conceived as access to information and resources, is negotiated through political networks embedded in communication practices ( Mayes and Allen, 1977 ; Mumby, 2001 ; Dougherty and Goldstein Hode, 2016 ). These communication practices operate within power dynamics in which the majority group sets the terms of the discussion and frames what is thematized ( Mumby, 1987 , 2001 ). Since gender affects the nature of these power relations, the effects of politics in gender issues and of gender issues in politics must be considered.

Full Moderation of OCCPP of the Relationship Between Gender Diversity and GBDH

Gender diversity refers to heterogeneity regarding gender characteristics of individuals in an organization. Broadly, an organization in which most workers are cisgender, male, and heterosexual would be low in gender diversity, and one in which individuals are evenly distributed in terms of their gender identity, sexual orientation, and gender expression, would be high on gender diversity. In this section, the moderation effect of OCCPP on the relationship between gender diversity and GBDH is discussed to support the next proposition of the model.

Proposition P3a: The relationship between gender diversity and GBDH is fully moderated by OCCPP. When OCCPP propitiate a hostile environment for gender minorities, low gender diversity will lead to high GBDH. When OCCPP propitiate a context of respect and integration of gender minorities, low gender diversity will not lead to higher GBDH .

Male-Dominated Workplace

In male-dominated organizations, a hypermasculine culture is predominant, male workers represent a numerical majority, and most positions of power are occupied by men (e.g., Carrington et al., 2010 ). These organizations present an increased frequency and intensity of GBDH against women, men who do not do gender in a hypermasculine form, and individuals from the LGBTQ community ( Stockdale et al., 1999 ; Street et al., 2007 ; Chan, 2013 ; Wright, 2013 ). Women in a male-dominated workplace may be confronted with misogyny at work ( Denissen and Saguy, 2014 ), becoming targets of more intense and frequent GBDH as they depart from the policed gender-rule that demands them to behave feminine, submissive, and heterosexual ( Berdahl, 2007 ). Women refusing sexual objectification in these contexts may become targets of serious forms of mistreatment, with the case that certain women “—including lesbians and those who present as butch, large, or black—may be less able to access emphasized femininity as a resource and thus [become] more subject to open hostility” ( Denissen and Saguy, 2014 , p. 383). In other words, the more they depart from the sexist and heteronormative standard, the worse is the mistreatment they will face. At the same time, the strategies some women apply to avoid hostility have a high cost for their identity and validation at work, as pointed by Denissen and Saguy (2014 , p. 383),

the presence of lesbians threatens heteronormativity and men's sexual subordination of women […] [b]y sexually objectifying tradeswomen, tradesmen, in effect, attempt to neutralize this threat. While tradeswomen, in turn, are sometimes able to deploy femininity to manage men's conduct and gain some measure of acceptance as women, it often comes at the cost of their perceived professional competence and sexual autonomy and—in the case of lesbians—sexual identity.

However, GBDH is not only directed to women in hypermasculine contexts, as suggested by Denissen and Saguy (2014) , who observed that “tradesmen unapologetically use homophobic slurs to repudiate both homosexuality and femininity (in men)” ( Denissen and Saguy, 2014 , p. 388). Hence, men working in a male-dominated context are also expected to perform hegemonic masculinity, being punished when they do not comply. This leaves men who do not present dominant traits, that are feminine, or that are not heterosexual, at risk of becoming targets of GBDH ( Franke, 1997 ; Stockdale et al., 1999 ; Carrington et al., (2010) .

Female-Dominated Workplace

Female-dominated workplaces are those where women represent a numeric majority. It has been suggested that in these contexts (e.g., nursing) women with care responsibilities can find more tools to balance work-family schedules ( Caroly, 2011 ), and face less harassment ( Konrad et al., 2010 ). However, evidence about heterosexism and harassment against people from the LGBTQ community uncovers heteronormativity in female-dominated workplaces (e.g., among nurses, see Eliason et al., 2011 ). For example, an experiment about discrimination of gays and lesbians in recruitment processes showed that while gay males were discriminated in male-dominated occupations, lesbians were discriminated in female-dominated ones ( Ahmed et al., 2013 ).

Representation of the LGBTQ in the Workplace

At the moment this paper is being written, the authors have not found research that specifically targets LGBTQ-dominated organizations. There is evidence suggesting that having more lesbian, gay, and non-binary coworkers contributes to the development of LGBTQ-friendly workplaces ( Eliason et al., 2011 ). In addition, evidence supports the positive effects of having LGBTQ leaders that advocate for the respect and integration of LGBTQ individuals in organizations ( Moore, 2017 ).

Gender Diversity, Tokenism, Glass Escalator, and GBDH

When gender-minority individuals are pioneers entering a gender-homogeneous workplace, they face a heightened probability of experiencing tokenism ( Maranto and Griffin, 2011 ). Tokenism refers to the performance pressures, social isolation, and role encapsulation that individuals from social minorities face in organizations in which they are underrepresented numerically ( Yoder, 1991 ). Gardiner and Tiggemann (1999) conducted a study comparing the effects of male- and female-dominated work environments on individuals' well-being and tokenism experiences. They found that women, in comparison to men, experience the highest levels of tokenism and discrimination in male-dominated sectors, and that they endure more pressure than men, even in female -dominated contexts ( Gardiner and Tiggemann, 1999 ). There is also an increasing number of reports on the experiences of tokenism by the LGBTQ ( LaSala et al., 2008 ; Colvin, 2015 ) and research on how to hinder the negative consequences of tokenism against them in organizations ( Davis, 2017 ; Nourafshan, 2018 ). The fact that men in female- dominated work settings report less levels of pressure than women in male dominated workplaces is compatible with Yoder's (1991) conception of tokenism as the oppression of social-minority members who are simultaneously a numerical minority. Because white men are a social majority, they do not experience the negative effects of tokenism when they are underrepresented numerically. Actually, evidence on the glass escalator effect shows that white men experience advantages when they enter female-dominated fields ( Williams, 1992 , 2013 , 2015 ; Woodhams et al., 2015 ). However, tokenism might be also present in female-dominated settings, as can be inferred from studies on LGBTQ experiences in women-dominated professions ( Eliason et al., 2011 ; Ahmed et al., 2013 ). Moreover, research in the US suggests that female CEOs tend to advance policies related to domestic-partner benefits and discrimination against women, but not necessarily advocate for a wider range of LGBTQ-inclusion policies ( Cook and Glass, 2016 ).

Gender Diversity, Contradictions, and the Role of OCCPP

The evidence on the effects of gender diversity in organizations is not free of contradictions. It has been found that the integration of male coworkers in female-dominated workplaces increases conflict between women ( Haile, 2012 ), and that as the proportion of male doctors in workgroups increases, the same happens with sexual harassment against female doctors ( Konrad et al., 2010 ). If taken together, it makes sense to consider an interaction of OCCPP and gender diversity to explain GBDH. In other words, it seems that gender diversity alone is not enough to end GBDH in the workplace, but can interact in a positive way with organizational factors to diminish conflict and GBDH (see Nishii, 2013 ). White, middle class, cisgender, heterosexual men would most likely not be targeted for GBDH in female-dominated contexts, since they are not a social minority, rather benefiting from their underrepresentation (see Williams, 1992 ). Finally, it is expected that gender diversity and OCCPP present a circular causation (see double-ended arrow in Figure 1 ), so that a higher representation of a particular minority group will traduce into OCCPP that promote inclusion for that group. At the same time, an organization whose OCCPP invites to respect and integrate gender minorities will attract more women and LGBTQ individuals (see Bajdo and Dickson, 2001 ; Moore, 2017 ).

OCCPP Full Moderation of the Relationship Between Individuals' Characteristics and GBDH

Individuals' gender characteristics intersect with race, class, ethnicity, and disability configuring complex identities and dynamics that affect individuals' experience of inequality in organizations (see Oliver, 1992 ; Acker, 2006 ; Verloo, 2006 ; Cunningham, 2008 ; Ericksen and Schultheiss, 2009 ; Cho et al., 2013 ; Donovan et al., 2013 ; Liasidou, 2013 ; Wright, 2013 ; Calafell, 2014 ; Moodley and Graham, 2015 ; Senyonga, 2017 ). In other words, it is difficult to isolate causes for exclusion, since they derive from complex power dynamics that shape individuals' experience. It was mentioned above that women and the LGBTQ tend to be more targeted for GBDH than white heterosexual men. However, it is in sexist organizational contexts that gender characteristics are made salient to propitiate GBDH.

Proposition P3b: The link between individuals' gender characteristics and GBDH in the workplace is fully moderated by OCCPP. This means that in a context of sexist OCCPP, individuals with gender-minority status will experience more GBDH. In contexts in which OCCPP propitiate respect and integration of gender minorities, GBDH will be low .

In other words, if the organizational context is tolerant of GBDH, harassment will occur based on individuals' sex, gender identity, sexual orientation, gender expression, or an intersection of those ( Crenshaw, 1991 ; Pryor et al., 1993 ; Franke, 1997 ; Stockdale et al., 1999 ; Galupo and Resnick, 2016 ). Some examples of how gender characteristics are used as grounds for GBDH are described in the following lines.

Sex assigned at birth refers to the gender category assigned to individuals according to their physical characteristics at birth ( ILGA-Europe, 2016 ). At the moment, the intersex category for those whose physical characteristics do not match the binary conception of gender at birth is not officially recognized in many countries ( ILGA-Europe, 2016 ).

Gender identity is the “deeply felt internal and individual experience of gender, which may or may not correspond with the sex assigned at birth” ( International Commission of Jurists, 2009 , p. 6). Despite the claims to adopt inclusive conceptions of gender, organizations continue to direct their gender-equality programs to white cisgender women, excluding the transgender and genderqueer (see Carrotte et al., 2016 ; Galupo and Resnick, 2016 ).

Gender expression is the way people handle their physical or external appearance so that it reflects their gender identity ( European Union Agency for Fundamental Rights, 2014 ). In highly sexist organizations, gender policing and harassment is directed against less gender-conforming individuals (e.g., Stockdale et al., 1999 ; Wright, 2013 ).

Sexual orientation refers to the “person's capacity for profound affection, emotional and sexual attraction to, and intimate and sexual relations with, individuals of a different gender or the same gender or more than one gender” ( ILGA-Europe, 2016 , p. 180). It is often the case that family policy in organizations consider only workers whose families are conformed by heterosexual couples and their children (e.g., Galupo and Resnick, 2016 ). This excludes those who are in same-sex or non-monosexual partnerships and families, sending the message that they are “different,” abnormal, or unnatural (see Galupo and Resnick, 2016 ). There is evidence that gender-exclusive language (using he and his instead of gender-inclusive forms) negatively affects the sense of belongingness, identification, and motivation of women in work settings ( Stout and Dasgupta, 2011 ). In the same way, the exclusion of people with non-binary or non-heterosexual gender characteristics in the organizational discourse makes them experience feelings of exclusion and otherization ( Carrotte et al., 2016 ).

Double Moderation of OCCPP: Its Effects on the Moderation of Gender Diversity of the Relationship Between Individuals' Characteristics and GBDH

Considering the literature on tokenism, gender characteristics (e.g., transgender) are expected to be a relevant predictor of GBDH if there is a reduced number of people with those characteristics in the organization (i.e., low gender diversity). Also, it is expected that this relationship will only take place in those situations in which the OCCPP propitiate a discriminatory and harassing environment for gender minorities.

Proposition P3c and P4: When OCCPP propitiate a discriminatory and harassing environment for gender minorities, women and the LGBTQ will experience more GBDH in a context low in gender diversity. If the OCCPP configure an environment that is inclusive and respectful of gender minorities, a low gender diversity will not lead to GBDH against women and the LGBTQ in that organization .

Recommendations for Academics and Practitioners

Need for industry-university collaborations: from the lab to the field.

Research that emerges from industry-university collaboration (IUC) is needed to better understand and counteract GBDH. Porter and Birdi (2018) identified twenty-two factors for a successful IUC. Some of these factors are: capacity of the stakeholders to enact change, a clear and shared vision, trust between the actors, and effective communication ( Porter and Birdi, 2018 ). Rajalo and Vadi (2017) developed a model of IUC, according to which success is more likely when preconditions from the involved partners (i.e., academics and practitioners) match. These preconditions are explained in terms of absorptive capacity (ability to process and incorporate new information), and motivation to collaborate ( Rajalo and Vadi, 2017 ). In other words, those involved in IUC need top management support, economic resources, a shared vision of gender equality, trust in each other, effective communication channels, and high motivation to collaborate. It is not a simple endeavor, but it is a necessary and possible one (see Porter and Birdi, 2018 ).

In collaborations, scholars and practitioners have the opportunity to work together in the design, development, implementation, and follow-up of HRM strategies. This must be done ensuring that projects are appropriate for each organization, and that the raised information is suitable for research purposes. Evidence on IUC spillover points out that firms and academics benefit from these collaborations (see Jensen et al., 2010 ). In the case of HRM, scholars can gain access to samples that are difficult to reach and economic resources to finance their research, while practitioners benefit from the academic expertise (see Jensen et al., 2010 ). In the context of gender equality, this can be useful to develop and implement evidence-based procedures to counteract GBDH (see Briner and Rousseau, 2011 ). To build the networks necessary for such collaborative alliances, public and private initiative must be taken (see Lee, 2018 ). Congresses and events that approach gender issues in organizations and aim to build bridges between the industry and the academia can offer opportunities for collaboration to occur. Finally, practitioners must gain awareness of gender issues in the workplace, and organizational-feminist scholars should write and reach for the practitioner audience as well.

A Small Help to Begin With: The Gender-Equality Starters' Toolkit

We know that for practitioners and researchers that are not familiarized with the poststructuralist, intersectional, queer-feminist theories, our recommendations may sound quite cryptic. For this reason, we developed a very simplified starters' toolkit ( Table 1 ). In its “HRM diagnose” section, we suggest ways to develop a first diagnose of the organization in relation to gender issues. The “HRM interventions” section refers to actions that can be taken in case further intervention is needed. In the “applied-research” section, we provide applied-research ideas to better understand GBDH and develop evidence-based tools for HRM. Finally, in the “references and resources” section we include references that support and complement the suggestions provided. Each row of the toolkit refers to one of the components of our model (health and occupational well-being were grouped together). As mentioned, the aim of this toolkit is to provide material for a first approach to GBDH in organizations, and inspire those interested in conducting applied research on GBDH in the workplace.

Table 1 . Recommendations for HRM practitioners and applied researchers: a starters' toolkit.

A Change of Perspective: Looking at the Organization with Queer-Feminist Lens

Change organizational politics, change the organization.

Organizational politics result from the interplay of discursive practices and power negotiations, and refer to who and how is determining the terms of these negotiations ( Mumby, 1987 , 2001 ). To understand organizational politics, the hegemonic discourse has to be analyzed utilizing deconstructive lens that uncover the operating power dynamics (e.g., Benschop and Doorewaard, 1998 ; Dougherty and Goldstein Hode, 2016 ). In other words, when deconstructing the organizational discourse, the researcher or practitioner analyzes both the content and structural elements of the particular text (see Peterson and Albrecht, 1999 ; Buzzanell and Liu, 2005 ). Organizational-text examples are: the sexual harassment policy of the organization, brochures from the last organizational-change campaign, the transcript of interviews on gender issues, the chart of values of the firm. The analysis of this material allows to observe the way gender issues are approached and defined (or not approached nor defined), to develop a first diagnose and lines of action (for an example see Dougherty and Goldstein Hode, 2016 ). Some questions that may help in the analysis are:

How is gender defined? (Whose gender is [not] validated?),

What actions or behaviors are constitutive of GBDH in this organization? (What forms of aggression and discrimination are hence allowed?),

What are the procedures if action is to be taken? (What is left out of procedure leaving space for leaks or inadequacies?), and

What is the organizational history in relation to GBDH claims? (Who has enjoyed impunity? Whose claims are [not] listened to?).

For example, the researcher or practitioner may realize that the sexual-harassment policy of a particular organization refers to cisgender individuals only. Moreover, it may be that this policy defines GBDH as harassment of men against women, excluding same-sex sexual harassment (see Stockdale et al., 1999 ). Furthermore, it may become evident that this policy is framed in a discourse of binary logics that serve to blame the victims and victimize harassers (see Dougherty and Goldstein Hode, 2016 ). Finally, after a follow-up of archived organization's processes, it may come out that harassers have historically enjoyed impunity (see Calafell, 2014 ). This initial analysis might be useful to develop a plan for change. Continuing with the example, this policy may be redefined so that it adopts an integrative conception of gender. In addition, it can be adapted to include cases of same-sex sexual harassment. It can be also reframed using a discourse that allows fairness for all parties involved. Finally, cases from the past may be analyzed to avoid committing old mistakes in the future, and if some of these cases are recent, rectification may be considered.

Reading Between the Lines: Disguised Forms of GBDH

Bullying and mobbing as disguised gbdh.

We argue that at least some workplace mistreatment that appears as “gender neutral” is actually gendered. Available evidence points to a higher frequency of bullying/mobbing against women and the LGBTQ in the workplace ( Rospenda et al., 2008 , 2009 ; Grant et al., 2011 ; Hoel et al., 2017 ). Hence, once data on workplace mistreatment is raised, it is advisable to evaluate gender disparities (e.g., statistically comparing means) that may point to cases of disguised GBDH. The importance of addressing disguised GBDH (i.e., “sexist” mobbing and bullying) lies on solving the problem (i.e., mistreatment) at its roots. According to our model, if sexist OCCPP are intervened and changed, their consequences (i.e., overt and disguised forms of GBDH) should disappear.

Disguised GBDH at the Task Level

We also believe that disguised GBDH might take place through task allocation processes. In other words, it may be that the processes of task allocation are such that they keep gender minorities away from career-development opportunities. Evidence signaling that women receive less challenging tasks that are relevant for career development suggests that the process of task allocation is not gender neutral ( de Pater et al., 2009 ). There is also research on the effects of illegitimate tasks that suggests that their assignation to individuals in organizations may be gendered ( Omansky et al., 2016 ). Illegitimate tasks are perceived as unreasonable and/or unnecessary by the person that undertakes them, and constitute a task-level stressor ( Semmer et al., 2010 , 2015 ). It was found that illegitimate tasks exert a stronger negative effect on perceptions of effort-reward imbalance (ERI) among male than female professionals ( Omansky et al., 2016 ). One explanation is that women are socialized to undertake these tasks, which is why they feel less disrupted by them ( Omansky et al., 2016 ). However, if this causes women to undertake more illegitimate tasks than men, that might bring negative consequences for their occupational development and well-being. Available evidence shows no gender differences in the reports of illegitimate tasks between women and men (see Semmer et al., 2010 , 2015 ; Omansky et al., 2016 ). However, it is unclear if this is because women do not perceive the tasks they undertake to be illegitimate, or if there is no difference de facto . To our knowledge, there is no evidence on illegitimate tasks assigned to LGBTQ individuals. We think that the findings on task-allocation and illegitimate-tasks call for more research in this subject, especially regarding the role of illegitimate tasks and task-allocation processes for the career development of women and the LGBTQ.

Lavender Over the Glass Ceiling

It is important to evaluate if, when, and what kind of leadership positions are available for gender minorities in organizations. This includes spotting cases when a single person or a small group is tokenized and expected to compensate for a lack of diversity of the whole organization (see Benschop and Doorewaard, 1998 ). The glass ceiling in the case of women and lavender ceiling in the case of LGBTQ individuals refer to the burdens faced by these groups to reach leadership positions as a consequence of sexism in organizations ( Hill, 2009 ; Ezzedeen et al., 2015 ). There is also evidence that female executives are appointed to leadership positions when odds of failing are high ( Ryan and Haslam, 2005 ). Regarding the LGBTQ, it is necessary to raise more evidence on the factors that make it possible for them to break through the lavender ceiling ( Gedro, 2010 ).

Limitations of This Study and Future Research

Our model was developed based on the review of available literature. The fact that it is based on secondary sources leaves space for bias and calls for its empirical testing. The mediation path that links the antecedents and consequences of GBDH should be tested in longitudinal studies, and the moderations proposed can be better assessed utilizing experimental designs. In this paper we argued for an integrative conception of gender in the HRM approach to GBDH. Nevertheless, data on the experiences of the LGBTQ in the workplace are mostly based on small samples, especially for the transgender. In addition, although we discussed the constructed nature of categories and pointed to their limitations, we considered women and the LGBTQ as relatively stable concepts. The experience of women and the LGBTQ greatly differs when looking to the heterogeneity between and within these groups. We thematized intersectionality mostly referring to sex assigned at birth, gender identity, and sexual orientation, and thus acknowledge our difficulty to account for exclusion dynamics involving identities in the intersection of race, gender, ableness, body form, and class. More research that focuses on these groups (e.g., transgender people of color) is needed. Finally, we made conjectures on the role that task-allocation processes may play as disguised GBDH that needs to be tested empirically as well. We think that since overt expressions of GBDH are in the decline in western workplaces, it is necessary to reach for gendered practices that disadvantage women and the LGBTQ in organizations.

Conclusions

There is a potential for synergy when HRM considers the needs of women and people from the LGBTQ community together, especially to propitiate gender equality and counteract gender-based discrimination and harassment. To start, organizational resources can be employed to neutralize the mechanisms through which gender oppression acts against women and members from the LGBTQ community. In this way, actions for gender equality help create safe spaces for both groups. In addition, framing gender and sexuality in inclusive ways helps dismantle heterosexist, cissexist, and monosexist paradigms that contribute to create discriminatory and harassing workplaces. Finally, queer and feminist perspectives should be integrated with the intersectional approach to counteract discrimination against those in the intersection of multiple marginalized identities. Hence, the needs of people of all genders, people of color, disabled people, people with different body shapes, and people with different cultural backgrounds are made visible and addressed. This assists in developing truly inclusive and respectful workplace environments in which workers can feel safe to be themselves and unleash their full potential.

Author Contributions

All authors contributed to the definition of the subject and the development of the hypotheses and model presented. CG drafted the manuscript and KO provided close support and supervision during the writing process and conducted revisions at all stages of the manuscript development. All authors contributed to the manuscript revision and approved the submitted version.

The authors received no specific funding for this work. CG acknowledges a doctoral scholarship (research grant) from the German Academic Exchange Service (Deutscher Akademischer Austauschdienst, DAAD).

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acker, J. (2006). Inequality regimes. Gender Soc. 20, 441–464. doi: 10.1177/0891243206289499

CrossRef Full Text | Google Scholar

Ahmed, A. M., Andersson, L., and Hammarstedt, M. (2013). Are gay men and lesbians discriminated against in the hiring process? South. Econ. J. 79, 565–585. doi: 10.4284/0038-4038-2011.317

Ali, S., and Coate, K. (2012). Impeccable advice: supporting women academics through supervision and mentoring. Gend. Educ. 25, 23–36. doi: 10.1080/09540253.2012.742219

Avery, D. R. (2011). Support for diversity in organizations. Organ. Psychol. Rev. 1, 239–256. doi: 10.1177/2041386611402115

Avina, C., and O'Donohue, W. (2002). Sexual harassment and PTSD: is sexual harassment diagnosable trauma? J. Trauma. Stress 15, 69–75. doi: 10.1023/A:1014387429057

PubMed Abstract | CrossRef Full Text | Google Scholar

Badgett, M. V. L., Durso, L., Kastanis, A., and Mallory, C. (2013). The Business Impact of LGBT-Supportive Policies. Los Angeles, CA: The Williams Institute.

Google Scholar

Bajdo, L. M., and Dickson, M. W. (2001). Perceptions of organizational culture and women's advancement in organizations: a cross-cultural examination. Sex Roles 45, 399–414. doi: 10.1023/A:1014365716222

Basford, T. E., Offermann, L. R., and Behrend, T. S. (2014). Do you see what i see? Perceptions of gender microaggressions in the workplace. Psychol. Women Q. 38, 340–349. doi: 10.1177/0361684313511420

Bem, S. L. (1974). The measurement of psychological androgyny. J. Consult. Clin. Psychol. 42, 155–162. doi: 10.1037/h0036215

Bendl, R. (2000). Gendering organization studies: a guide for reading gender subtexts in organizational theories. Finish J. Bus. Econ. 373–393.

Bendl, R. (2008). Gender subtexts – reproduction of exclusion in organizational discourse. Br. J. Manage. 19, S50–S64. doi: 10.1111/j.1467-8551.2008.00571.x

Bendl, R., Fleischmann, A., and Walenta, C. (2008). Diversity management discourse meets queer theory. Gender Manage. 23, 382–394. doi: 10.1108/17542410810897517

Benschop, Y., and Doorewaard, H. (1998). Covered by equality: the gender subtext of organizations. Organ. Stud. 19, 787–805. doi: 10.1177/017084069801900504

Benschop, Y., and Doorewaard, H. (2012). Gender subtext revisited. Equal. Divers. Inclusion Int. J. 31, 225–235. doi: 10.1108/02610151211209081

Berdahl, J. L. (2007). The sexual harassment of uppity women. J. Appl. Psychol. 92, 425–437. doi: 10.1037/0021-9010.92.2.425

Bowling, N. A., and Beehr, T. A. (2006). Workplace harassment from the victim's perspective: a theoretical model and meta-analysis. J. Appl. Psychol. 91, 998–1012. doi: 10.1037/0021-9010.91.5.998

Briner, R. B., and Rousseau, D. M. (2011). Evidence-based I–O psychology: not there yet. Ind. Organ. Psychol. 4, 3–22. doi: 10.1111/j.1754-9434.2010.01287.x

Buchanan, N. T., and Ormerod, A. J. (2002). Racialized sexual harassment in the lives of African American women. Women Ther. 25, 107–124. doi: 10.1300/J015v25n03_08

Burn, S. M., Kadlec, K., and Rexer, R. (2005). Effects of subtle heterosexism on gays, lesbians, bisexuals. J. Homosex. 49, 23–38. doi: 10.1300/J082v49n02_02

Butler, J. (1990). Gender Trouble: Feminism and the Subversion of Identity . New York, NY; London: Routledge.

Buzzanell, P. M., and Liu, M. (2005). Struggling with maternity leave policies and practices: a poststructuralist feminist analysis of gendered organizing. J. Appl. Commun. Res. 33, 1–25. doi: 10.1080/0090988042000318495

Calafell, B. M. (2014). Did it happen because of your race or sex?: university sexual harassment policies and the move against intersectionality. Front. J. Women Stud. 35, 75–95.doi: 10.1353/fro.2014.0034

Cameron, E., and Green, M. (2009). Making Sense of Change Management: A Complete Guide to the Models, Tools & Techniques of Organizational Change, 2nd Edn. London; Philadelphia: Kogan Page.

Campbell, B., Schellenberg, E. G., and Senn, C. Y. (1997). Evaluating measures of contemporary sexism. Psychol. Women Q. 21, 89–102. doi: 10.1111/j.1471-6402.1997.tb00102.x

Caroly, S. (2011). How police officers and nurses regulate combined domestic and paid workloads to manage schedules: a gender analysis. Work 40(Suppl 1):S71–82. doi: 10.3233/WOR-2011-1269

Carrington, K., Mcintosh, A., and Scott, J. (2010). Globalization, frontier masculinities and violence: booze, blokes and brawls. Br. J. Criminol. 50, 393–413. doi: 10.1093/bjc/azq003

Carrotte, E. R., Vella, A. M., Bowring, A. L., Douglass, C., Hellard, M. E., and Lim, M. S. C. (2016). “I am yet to encounter any survey that actually reflects my life”: a qualitative study of inclusivity in sexual health research. BMC Med. Res. Methodol. 16:86. doi: 10.1186/s12874-016-0193-4

Chan, D. K.-S., Chow, S. Y., Lam, C. B., and Cheung, S. F. (2008). Examining the job-related, psychological, and physical outcomes of workplace sexual harassment: a meta-analytic review. Psychol. Women Q. 32, 362–376. doi: 10.1111/j.1471-6402.2008.00451.x

Chan, P. W. (2013). Queer eye on a ‘straight’ life: deconstructing masculinities in construction. Construct. Manage. Econ. 31, 816–831. doi: 10.1080/01446193.2013.832028

Chapman, D. D., and Gedro, J. (2009). Queering the HRD curriculum: preparing students for success in the diverse workforce. Adv. Dev. Hum. Resour. 11, 95–108. doi: 10.1177/1523422308329091

Cho, S., Crenshaw, K. W., and McCall, L. (2013). Toward a field of intersectionality studies: theory, applications, and praxis. Signs J. Women Cult. Soc. 38, 785–810. doi: 10.1086/669608

Cogin, J. A., and Fish, A. (2009). An empirical investigation of sexual harassment and work engagement: surprising differences between men and women. J. Manage. Organ. 15, 47–61. doi: 10.1017/S183336720000287X

Colvin, R. (2015). Shared workplace experiences of lesbian and gay police officers in the United Kingdom. Policing 38, 333–349. doi: 10.1108/PIJPSM-11-2014-0121

Connell, R. (2006). Glass ceilings or gendered institutions? Mapping the gender regimes of public sector worksites. Public Adm. Rev. 66, 837–849. doi: 10.1111/j.1540-6210.2006.00652.x

Cook, A., and Glass, C. (2016). Do women advance equity? The effect of gender leadership composition on LGBT-friendly policies in American firms. Hum. Relat. 69, 1431–1456. doi: 10.1177/0018726715611734

Crenshaw, K. (1989). Demarginalizing the intersection of race and sex: a black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. University Chicago Legal Forum 1989, 139–167.

Crenshaw, K. (1991). Mapping the margins: intersectionality, identity politics, and violence against women of color. Stanford Law Rev. 43, 1241–1299. doi: 10.2307/1229039

Cunningham, G. B. (2008). Creating and sustaining gender diversity in sport organizations. Sex Roles 58, 136–145. doi: 10.1007/s11199-007-9312-3

Dahlborg-Lyckhage, E., and Pilhammar-Anderson, E. (2009). Predominant discourses in Swedish nursing. Policy Politics Nurs. Pract. 10, 163–171. doi: 10.1177/1527154409338493

Dashper, K. (2018). Challenging the gendered rhetoric of success? The limitations of women-only mentoring for tackling gender inequality in the workplace. Gender Work Organ. 4:139. doi: 10.1111/gwao.12262

Davis, G. K. (2017). Creating a roadmap to a LGBTQ affirmative action scheme: an article on parallel histories, the diversity rationale, and escaping strict scrutiny. Natl. Black Law J. 26, 43–84. Available online at: https://escholarship.org/uc/item/9925t9sp

de Pater, I. E., van Vianen, A. E. M., and Bechtoldt, M. N. (2009). Gender differences in job challenge: a matter of task allocation. Gender Work Organ. 39:1538. doi: 10.1111/j.1468-0432.2009.00477.x

Denissen, A. M., and Saguy, A. C. (2014). Gendered homophobia and the contradictions of workplace discrimination for women in the building trades. Gender Soc. 28, 381–403. doi: 10.1177/0891243213510781

Devonish, D. (2013). Workplace bullying, employee performance and behaviors. Empl. Relat. 35, 630–647. doi: 10.1108/ER-01-2013-0004

Donovan, R. A., Galban, D. J., Grace, R. K., Bennett, J. K., and Felicié, S. Z. (2013). Impact of racial macro- and microaggressions in Black women's lives. J. Black Psychol. 39, 185–196. doi: 10.1177/0095798412443259

Döring, N. (2013). Zur operationalisierung von geschlecht im fragebogen : probleme und lösungsansätze aus sicht von mess-, umfrage-, gender- und queer-theorie. Gender 2, 94–113. Available online at: https://www.ssoar.info/ssoar/handle/document/39660

Dougherty, D. S., and Goldstein Hode, M. (2016). Binary logics and the discursive interpretation of organizational policy: making meaning of sexual harassment policy. Hum. Relat. 69, 1729–1755. doi: 10.1177/0018726715624956

Einarsen, S., Hoel, H., and Notelaers, G. (2009). Measuring exposure to bullying and harassment at work: validity, factor structure and psychometric properties of the negative acts questionnaire-revised. Work Stress 23, 24–44. doi: 10.1080/02678370902815673

Eliason, M. J., Dejoseph, J., Dibble, S., Deevey, S., and Chinn, P. (2011). Lesbian, gay, bisexual, transgender, and queer/questioning nurses' experiences in the workplace. J. Profession. Nurs. 27, 237–244. doi: 10.1016/j.profnurs.2011.03.003

Else-Quest, N. M., and Hyde, J. S. (2016a). Intersectionality in quantitative psychological research. Psychol. Women Q. 40, 155–170. doi: 10.1177/0361684316629797

Else-Quest, N. M., and Hyde, J. S. (2016b). Intersectionality in quantitative psychological research. Psychol. Women Q. 40, 319–336. doi: 10.1177/0361684316647953

Ericksen, J. A., and Schultheiss, D. E. P. (2009). Women pursuing careers in trades and construction. J. Career Dev. 36, 68–89. doi: 10.1177/0894845309340797

Estrada, A. X., Olson, K. J., Harbke, C. R., and Berggren, A. W. (2011). Evaluating a brief scale measuring psychological climate for sexual harassment. Military Psychol. 23, 410–432. doi: 10.1080/08995605.2011.589353

European Union Agency for Fundamental Rights (2014). Violence Against Women: An EU-Wide Survey; Results at a Glance. Dignity. Luxembourg: Public Office of the European Union. Available online at http://publications.europa.eu/de/publication-detail/-/publication/42467476-532b-405e-a6f7-a80c5b48babc

Ezzedeen, S. R., Budworth, M.-H., and Baker, S. D. (2015). The Glass ceiling and executive careers: still an issue for pre-career women. J. Career Dev. 42, 355–369. doi: 10.1177/0894845314566943

Fitzgerald, L. F., Drasgow, F., Hulin, C. L., Gelfand, M. J., and Magley, V. J. (1997). Antecedents and consequences of sexual harassment in organizations: a test of an integrated model. J. Appl. Psychol. 82, 578–589. doi: 10.1037/0021-9010.82.4.578

Fitzgerald, L. F., Magley, V. J., Drasgow, F., and Waldo, C. R. (1999). Measuring sexual harassment in the military: the sexual experiences questionnaire (SEQ—DoD). Milit. Psychol. 11, 243–263. doi: 10.1207/s15327876mp1103_3

Flanders, C. E. (2015). Bisexual health: a daily diary analysis of stress and anxiety. Basic Appl. Soc. Psych. 37, 319–335. doi: 10.1080/01973533.2015.1079202

Franke, K. M. (1997). What's wrong with sexual harassment? Stanford Law Rev. 49, 691–772. doi: 10.2307/1229336

Galupo, M. P., and Resnick, C. A. (2016). “Experiences of LGBT microaggressions in the workplace: implications for policy,” in Sexual Orientation and Transgender Issues in Organizations , eds K. Thomas (Cham: Springer International Publishing), 271–287.

Gardiner, M., and Tiggemann, M. (1999). Gender differences in leadership style, job stress and mental health in male-and female-dominated industries. J. Occup. Organ. Psychol. 72, 301–315. doi: 10.1348/096317999166699

Gartner, R. E., and Sterzing, P. R. (2016). Gender microaggressions as a gateway to sexual harassment and sexual assault. Affilia 31, 491–503. doi: 10.1177/0886109916654732

Gedro, J. (2010). The lavender ceiling atop the global closet: human resource development and lesbian expatriates. Hum. Resour. Dev. Rev. 9, 385–404. doi: 10.1177/1534484310380242

Gedro, J., and Mizzi, R. C. (2014). Feminist theory and queer theory. Adv. Dev. Hum. Resour. 16, 445–456. doi: 10.1177/1523422314543820

Gelfand, M. J., Fitzgerald, L. F., and Drasgow, F. (1995). The structure of sexual harassment: a confirmatory analysis across cultures and settings. J. Vocat. Behav. 47, 164–177. doi: 10.1006/jvbe.1995.1033

Gibson, S. K. (2006). Mentoring of women faculty: the role of organizational politics and culture. Innovat. Higher Educ. 31, 63–79. doi: 10.1007/s10755-006-9007-7

Glick, P., and Fiske, S. T. (1997). Hostile and benevolent sexism. Psychol. Women Q. 21, 119–135. doi: 10.1111/j.1471-6402.1997.tb00104.x

Glick, P., and Fiske, S. T. (2001). An ambivalent alliance: hostile and benevolent sexism as complementary justifications for gender inequality. Am. Psychol. 56, 109–118. doi: 10.1037/0003-066X.56.2.109

Glick, P., and Fiske, S. T. (2011). Ambivalent sexism revisited. Psychol. Women Q. 35, 530–535. doi: 10.1177/0361684311414832

Glick, P., Fiske, S. T., Mladinic, A., Saiz, J. L., Abrams, D., Masser, B., et al. (2000). Beyond prejudice as simple antipathy: Hostile and benevolent sexism across cultures. J. Pers. Soc. Psychol. 79, 763–775. doi: 10.1037/0022-3514.79.5.763

Goldberg, A. E., and Smith, J. Z. (2013). Work conditions and mental health in lesbian and gay dual-earner parents. Fam. Relat. 62, 727–740. doi: 10.1111/fare.12042

CrossRef Full Text

Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., and Keisling, M. (2011). Injustice at Every Turn: A Report of the National Transgender Discrimination Survey . Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force.

Gruber, J. E. (2016). The impact of male work environments and organizational policies on women's experiences of sexual harassment. Gender Soc. 12, 301–320. doi: 10.1177/0891243298012003004

Habarth, J. M. (2013). Development of the heteronormative attitudes and beliefs scale. Psychol. Sex. 6, 166–188. doi: 10.1080/19419899.2013.876444

Haile, G. A. (2012). Unhappy working with men? Workplace gender diversity and job-related well-being in britain. IZA discussion paper No. 4077. Labour Econ. 19, 329–350. doi: 10.1016/j.labeco.2012.02.002

Hanappi-Egger, E. (2013). Gender and diversity from a management perspective: synonyms or complements? J. Organ. Transform. Soc. Change 3, 121–134. doi: 10.1386/jots.3.2.121_1

Hennekam, S. A. M., and Ladge, J. J. (2017). When lesbians become mothers: Identity validation and the role of diversity climate. J. Vocat. Behav. 103, 40–55. doi: 10.1016/j.jvb.2017.08.006

Hill, R. J. (2009). Incorporating queers: blowback, backlash, and other forms of resistance to workplace diversity initiatives that support sexual minorities. Adv. Dev. Hum. Resour. 11, 37–53. doi: 10.1177/1523422308328128

Hirsh, E., and Cha, Y. (2016). Mandating change. Indust. Labor Relat. Rev. 70, 42–72. doi: 10.1177/0019793916668880

Hoel, H., Lewis, D., and Einarsdottir, A. (2017). Debate: bullying and harassment of lesbians, gay men and bisexual employees: findings from a representative british national study. Public Money Manage. 37, 312–314. doi: 10.1080/09540962.2017.1328169

Hooks, B. (2000). Feminism is for Everybody: Passionate Politics. Cambridge, MA: South End Press.

Horn, J. E., Taris, T. W., Schaufeli, W. B., and Schreurs, P. J. G. (2004). The Structure of Occupational Well-Being: A Study Among Dutch Teachers. J. Occup. Organ. Psychol. 77, 365–375. doi: 10.1348/0963179041752718

ILGA-Europe (2016). Annual Review of the Human Rights Situation of Lesbian, Gay, Bisexual, Trans and Intersex People in Europe. Available online at https://www.ilga-europe.org/resources/rainbow-europe/2016

ILGA-Europe (2017). Annual Review of the Human Rights Situation of Lesbian, Gay, Bisexual, Trans and Intersex People in Europe. Available online at https://www.ilga-europe.org/resources/rainbow-europe/rainbow-europe-2017

International Commission of Jurists (2009). Yogyakarta principles on the application of international human rights law in relation to sexual orientation and gender identity. Asia Pacific J. Hum. Rights Law 9, 86–113. doi: 10.1163/157181509789025200

International Labour Office (2016). Women at Work: Trends 2016. Geneva: International Labour Office.

Jansen, W. S., Otten, S., and Van Der Zee, K. I. (2015). Being different at work: how gender dissimilarity relates to social inclusion and absenteeism. Group Process. Intergroup Relat. 20, 879–893. doi: 10.1177/1368430215625783

Jensen, R., Thursby, J., and Thursby, M. (2010). University-Industry Spillovers, Government Funding, and Industrial Consulting . Cambridge, MA: National Bureau of Economic Research.

Khan, M., Ilcisin, M., and Saxton, K. (2017). Multifactorial discrimination as a fundamental cause of mental health inequities. Int. J. Equity Health 16:43. doi: 10.1186/s12939-017-0532-z

Khubchandani, J., and Price, J. H. (2015). Workplace harassment and morbidity among US adults: results from the national health interview survey. J. Community Health 40, 555–563. doi: 10.1007/s10900-014-9971-2

Klein, U. (2016). Gender equality and diversity politics in higher education: conflicts, challenges and requirements for collaboration. Women's Stud. Int. Forum 54, 147–156. doi: 10.1016/j.wsif.2015.06.017

Kleiner, B. H., and Takeyama, D. (1998). How to prevent sexual harassment in the workplace. Equal Opportunities Int. 17, 6–12. doi: 10.1108/02610159810785539

Konrad, A. M., Cannings, K., and Goldberg, C. B. (2010). Asymmetrical demography effects on psychological climate for gender diversity: differential effects of leader gender and work unit gender composition among Swedish doctors. Hum. Relat. 63, 1661–1685. doi: 10.1177/0018726710369397

Lapierre, L. M., Spector, P. E., and Leck, J. D. (2005). Sexual versus nonsexual workplace aggression and victims' overall job satisfaction: a meta-analysis. J. Occup. Health Psychol. 10, 155–169. doi: 10.1037/1076-8998.10.2.155

LaSala, M. C., Jenkins, D. A., Wheeler, D. P., and Fredriksen-Goldsen, K. I. (2008). LGBT faculty, research, and researchers: risks and rewards. J. Gay Lesbian Soc. Services 20, 253–267. doi: 10.1080/10538720802235351

Lee, K.-J. (2018). Strategic human resource management for university-industry collaborations in Korea: financial incentives for academic faculty and employment security of industry liaison offices. Technol. Anal. Strat. Manage . 30, 461–472. doi: 10.1080/09537325.2017.1337885

Leskinen, E. A., and Cortina, L. M. (2013). Dimensions of disrespect. Psychol. Women Q. 38, 107–123. doi: 10.1177/0361684313496549

Leskinen, E. A., Cortina, L. M., and Kabat, D. B. (2011). Gender harassment: broadening our understanding of sex-based harassment at work. Law Hum. Behav. 35, 25–39. doi: 10.1007/s10979-010-9241-5

Liasidou, A. (2013). Intersectional understandings of disability and implications for a social justice reform agenda in education policy and practice. Disability Soc. 28, 299–312. doi: 10.1080/09687599.2012.710012

Liddle, B. J., Luzzo, D. A., Hauenstein, A. L., and Schuck, K. (2004). Construction and validation of the lesbian, gay, bisexual, and transgendered climate inventory. J. Career Assessm. 12, 33–50. doi: 10.1177/1069072703257722

Lloren, A., and Parini, L. (2017). How LGBT-supportive workplace policies shape the experience of lesbian, gay men, and bisexual employees. Sexuality Research Soc. Policy 14, 289–299. doi: 10.1007/s13178-016-0253-x

Lombardi, E. L., Wilchins, R. A., Priesing, D., and Malouf, D. (2002). Gender violence: transgender experiences with violence and discrimination. J. Homosex. 42, 89–101. doi: 10.1300/J082v42n01_05

Manuel, S. K., Howansky, K., Chaney, K. E., and Sanchez, D. T. (2017). No rest for the stigmatized: a model of organizational health and workplace sexism (OHWS). Sex Roles 77, 697–708. doi: 10.1007/s11199-017-0755-x

Maranto, C. L., and Griffin, A. E. C. (2011). The antecedents of a ‘chilly climate’ for women faculty in higher education. Human Relat. 64, 139–159. doi: 10.1177/0018726710377932

Marinucci, M. (2016). Feminism is Queer: The Intimate Connection Between Queer and Feminist Theory . Second edition. London: Zed Books.

Mayes, B. T., and Allen, R. W. (1977). Toward a definition of organizational politics. Acad. Manag. Rev. 2, 672–678. doi: 10.5465/amr.1977.4406753

McAllister, C. A., Harold, R. D., Ahmedani, B. K., and Cramer, E. P. (2009). Targeted mentoring: evaluation of a program. J. Soc. Work Educ. 45, 89–104. doi: 10.5175/JSWE.2009.200700107

McCall, L. (2005). The Complexity of Intersectionality. Signs 30, 1771–1800. doi: 10.1086/426800

McDonald, P., Charlesworth, S., and Graham, T. (2015). Developing a framework of effective prevention and response strategies in workplace sexual harassment. Asia Pacific J. Hum. Resour. 53, 41–58. doi: 10.1111/1744-7941.12046

Mehta, C. M., and Keener, E. (2017). Oh the places we'll go! where will Sandra Bem's work lead us next? Sex Roles 76, 637–642. doi: 10.1007/s11199-017-0735-1

Molenda, M. (2003). In search of the elusive ADDIE model. Performance Improvement 42, 34–36. doi: 10.1002/pfi.4930420508

Monro, S. (2005). Beyond male and female: poststructuralism and the spectrum of gender. Int. J. Transgender. 8, 3–22. doi: 10.1300/J485v08n01_02

Moodley, J., and Graham, L. (2015). The importance of intersectionality in disability and gender studies. Agenda 29, 24–33. doi: 10.1080/10130950.2015.1041802

Moore, J. (2017). A Phenomenological Study of Lesbian, and Gay People in Leadership Roles: How Perspectives and Priorities Shift in the Workplace as Sexual Orientation Evolves Through Social Constructs . The Faculty of the School of Education, University of San Francisco. Available online at: https://repository.usfca.edu/diss/405

Mor Barak, M. E., Cherin, D. A., and Berkman, S. (1998). Organizational and personal dimensions in diversity climate: ethnic and gender differences in employee perceptions. J. Appl. Behav. Sci. 34, 82–104. doi: 10.1177/0021886398341006

Morrison, M. A., Morrison, T. G., Pope, G. A., and Zumbo, B. D. (1999). An investigation of measures of modern and old-fashioned sexism. Soc. Indic. Res. 48, 39–49. doi: 10.1023/A:1006873203349

Mumby, D. K. (1987). The political function of narrative in organizations. Commun. Monogr. 54, 113–127. doi: 10.1080/03637758709390221

Mumby, D. K. (1996). Feminism, postmodernism, and organizational communication studies. Manage. Commun. Quart. 9, 259–295. doi: 10.1177/0893318996009003001

Mumby, D. K. (2001). “Power and politics,” in The New Handbook of Organizational Communication: Advances in Theory, Research, and Methods , eds M. J. Fredric, and L. L. Putnam (Thousand Oaks, CA; London: Sage Publications), 586–624. doi: 10.4135/9781412986243.n15

Nadal, K. L., Davidoff, K. C., Davis, L. S., and Wong, Y. (2014). Emotional, behavioral, and cognitive reactions to microaggressions: transgender perspectives. Psychol. Sex. Orient. Gender Divers. 1, 72–81. doi: 10.1037/sgd0000011

Nadal, K. L., Issa, M.-A., Leon, J., Meterko, V., Wideman, M., and Wong, Y. (2011). Sexual orientation microaggressions: death by a thousand cuts for lesbian, gay, and bisexual youth. J. LGBT Youth 8, 234–259. doi: 10.1080/19361653.2011.584204

Newman, P. K. (2018). Training Must be a Part of Every Employer's Action Plan to Stop Sexual Harassment in Their Workplaces . Columbus, OH: Ohio State Bar Association.

Nishii, L. H. (2013). The benefits of climate for inclusion for gender-diverse groups. Acad. Manage. J. 56, 1754–1774. doi: 10.5465/amj.2009.0823

Nourafshan, A. M. (2018). From the closet to the boardroom: regulating LGBT diversity on corporate boards. Albany Law Rev. 81, 439–487.

Oliver, C. (1992). The antecedents of deinstitutionalization. Organ. Stud. 13, 563–588. doi: 10.1177/017084069201300403

Omansky, R., Eatough, E. M., and Fila, M. J. (2016). Illegitimate tasks as an impediment to job satisfaction and intrinsic motivation: moderated mediation effects of gender and effort-reward imbalance. Front. Psychol. 7:1818. doi: 10.3389/fpsyg.2016.01818

Owen, J., Tao, K., and Rodolfa, E. (2010). Microaggressions and women in short-term psychotherapy: initial evidence. Couns. Psychol. 38, 923–946. doi: 10.1177/0011000010376093

Parker, M. (2002). Queering management and organization. Gender Work Org. 9, 146–166. doi: 10.1111/1468-0432.00153

Peterson, L. W., and Albrecht, T. L. (1999). Where gender/power/politics collide. J. Manage. Inquiry 8, 168–181. doi: 10.1177/105649269982011

Pichler, S., Ruggs, E., and Trau, R. (2017). Worker outcomes of LGBT-supportive policies: a cross-level model. Equal. Div. Incl. Int. J. 36, 17–32. doi: 10.1108/EDI-07-2016-0058

Porter, J. J., and Birdi, K. (2018). 22 Reasons why collaborations fail: lessons from water innovation research. Environ. Sci. Policy 89, 100–108. doi: 10.1016/j.envsci.2018.07.004

Pryor, J. B., Lavite, C. M., and Stoller, L. M. (1993). A social psychological analysis of sexual harassment: the person/situation interaction. J. Vocat. Behav. 42, 68–83. doi: 10.1006/jvbe.1993.1005

Rabelo, V. C., and Cortina, L. M. (2014). Two sides of the same coin: gender harassment and heterosexist harassment in LGBQ work lives. Law Hum. Behav. 38, 378–391. doi: 10.1037/lhb0000087

Rajalo, S., and Vadi, M. (2017). University-industry innovation collaboration: reconceptualization. Technovation 62–63, 42–54. doi: 10.1016/j.technovation.2017.04.003

Riger, S. (1991). Gender dilemmas in sexual harassment policies and procedures. Am. Psychol. 46, 497–505. doi: 10.1037/0003-066X.46.5.497

Rospenda, K. M., Fujishiro, K., Shannon, C. A., and Richman, J. A. (2008). Workplace harassment, stress, and drinking behavior over time: gender differences in a national sample. Addict. Behav. 33, 964–967. doi: 10.1016/j.addbeh.2008.02.009

Rospenda, K. M., Richman, J. A., and Shannon, C. A. (2009). Prevalence and mental health correlates of harassment and discrimination in the workplace: results from a national study. J. Interpers. Violence 24, 819–843. doi: 10.1177/0886260508317182

Ryan, M. K., and Haslam, S. A. (2005). The Glass cliff: evidence that women are over-represented in precarious leadership positions. Br. J. Manage. 16, 81–90. doi: 10.1111/j.1467-8551.2005.00433.x

Schein, E. H. (1990). Organizational Culture. Am. Psychol. 45, 109–119. doi: 10.1037/0003-066X.45.2.109

Schein, E. H. (1996). Culture: the missing concept in organization studies. Adm. Sci. Q. 41:229. doi: 10.2307/2393715

Seelman, K. L., Woodford, M. R., and Nicolazzo, Z. (2017). Victimization and microaggressions targeting LGBTQ college students: gender identity as a moderator of psychological distress. J. Ethnic Cultural Diversity Soc. Work 26, 112–125. doi: 10.1080/15313204.2016.1263816

Semmer, N. K., Jacobshagen, N., Meier, L. L., Elfering, A., Beehr, T. A., Kälin, W., et al. (2015). Illegitimate tasks as a source of work stress. Work Stress 29, 32–56. doi: 10.1080/02678373.2014.1003996

Semmer, N. K., Tschan, F., Meier, L. L., Facchin, S., and Jacobshagen, N. (2010). Illegitimate tasks and counterproductive work behavior. Appl. Psychol. 59, 70–96. doi: 10.1111/j.1464-0597.2009.00416.x

Senyonga, M. (2017). Microaggressions, marginality, and mediation at the intersections: experiences of black fat women in academia. Interactions UCLA J. Edu. Inform. Stud. 13, 1–23. Available online at: https://escholarship.org/uc/item/9934r39k

Silverschanz, P., Cortina, L. M., Konik, J., and Magley, V. J. (2008). Slurs, snubs, and queer jokes: incidence and impact of heterosexist harassment in academia. Sex Roles 58, 179–191. doi: 10.1007/s11199-007-9329-7

Sliter, M., Boyd, E., Sinclair, R., Cheung, J., and Mcfadden, A. (2014). Inching toward inclusiveness: diversity climate, interpersonal conflict and well-being in women nurses. Sex Roles 71, 43–54. doi: 10.1007/s11199-013-0337-5

Sojo, V. E., Wood, R. E., and Genat, A. E. (2016). Harmful workplace experiences and women's occupational well-being. Psychol. Women Q. 40, 10–40. doi: 10.1177/0361684315599346

Stedham, Y., and Mitchell, M. C. (1998). Sexual harassment in casinos: effects on employee attitudes and behaviors. J. Gambling Stud. 14, 381–400. doi: 10.1023/A:1023025110307

Stockdale, M. S., Visio, M., and Batra, L. (1999). The sexual harassment of men: evidence for a broader theory of sexual harassment and sex discrimination. Psychol. Public Policy Law 5, 630–664. doi: 10.1037/1076-8971.5.3.630

Stoll, L. C., Lilley, T. G., and Pinter, K. (2016). Gender-blind sexism and rape myth acceptance. Violence Against Women 23, 28–45. doi: 10.1177/1077801216636239

Stout, J. G., and Dasgupta, N. (2011). When he doesn't mean you: gender-exclusive language as ostracism. Personal. Soc. Psychol. Bull. 37, 757–769. doi: 10.1177/0146167211406434

Street, A. E., Gradus, J. L., Stafford, J., and Kelly, K. (2007). Gender differences in experiences of sexual harassment: data from a male-dominated environment. J. Consult. Clin. Psychol. 75, 464–474. doi: 10.1037/0022-006X.75.3.464

Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M. B., Nadal, K. L., et al. (2007). Racial microaggressions in everyday life: implications for clinical practice. Am. Psychol. 62, 271–286. doi: 10.1037/0003-066X.62.4.271

Taris, T. W., and Schaufeli, W. B. (2015). “Individual well-being and performance at work: a conceptual and theoretical overview,” in Well-Being and Performance at Work: The Role of Context , Current Issues in Work and Organizational Psychology. ed M. Van Veldhoven (London UA: Psychology Press), 15–34.

Tomic, M. (2011). Gender Mainstreaming in der EU [Elektronische Ressource]: Wirtschaftlicher Mehrwert oder Soziale Gerechtigkeit? Wiesbaden, Berlin [U.A.]: VS Verlag für Sozialwissenschaften, Springer

van Amsterdam, N. (2013). Big fat inequalities, thin privilege: an intersectional perspective on ‘body size’. Eur. J. Women's Stud. 20, 155–169. doi: 10.1177/1350506812456461

Verloo, M. (2006). Multiple inequalities, intersectionality and the european union. Eur. J. Women's Stud. 13, 211–228. doi: 10.1177/1350506806065753

Vernallis, K. (1999). Bisexual Monogamy: twice the temptation but half the fun? J. Soc. Philos. 30, 347–368. doi: 10.1111/0047-2786.00022

Vijayasiri, G. (2008). Reporting sexual harassment: the importance of organizational culture and trust. Gender Issues 25, 43–61. doi: 10.1007/s12147-008-9049-5

Warr, P. (1990). The measurement of well-being and other aspects of mental health. J. Occupation. Psychol. 63, 193–210. doi: 10.1111/j.2044-8325.1990.tb00521.x

Wegner, R., and Wright, A. J. (2016). A psychometric evaluation of the homonegative microaggressions scale. J. Gay Lesbian Ment. Health 20, 299–318. doi: 10.1080/19359705.2016.1177627

Weiss, J. (2011). Reflective Paper: GL Versus BT: the archaeology of biphobia and transphobia within the U.S. Gay and Lesbian Community. J. Bisexual. 11, 498–502. doi: 10.1080/15299716.2011.620848

Williams, C. L. (1992). The glass escalator: hidden advantages for men in the “Female” Professions. Soc. Probl. 39, 253–267 doi: 10.2307/3096961

Williams, C. L. (2013). The glass escalator, revisited. Gender Soc. 27, 609–629. doi: 10.1177/0891243213490232

Williams, C. L. (2015). Crossing over: interdisciplinary research on men who do women's work. Sex Roles 72, 390–395. doi: 10.1007/s11199-015-0477-x

Woltersdorff, V. (2003). “(Lore Logorrhöe).queer theory and queer politics,” in Utopie Kreativ , 156, 914–913. Available online at: https://www.rosalux.de/fileadmin/rls_uploads/pdfs/156_woltersdorff.pdf

Woodford, M. R., Howell, M. L., Silverschanz, P., and Yu, L. (2012). “That's so gay!”: Examining the covariates of hearing this expression among gay, lesbian, and bisexual college students. J. Am. Coll. Health 60, 429–434. doi: 10.1080/07448481.2012.673519

Woodhams, C., Lupton, B., and Cowling, M. (2015). The presence of ethnic minority and disabled men in feminised work: intersectionality, vertical segregation and the glass escalator. Sex Roles 72, 277–293. doi: 10.1007/s11199-014-0427-z

Wright, A. J., and Wegner, R. (2012). Homonegative microaggressions and their impact on LGB individuals: a measure validity study. J. LGBT Issues Couns. 6, 34–54. doi: 10.1080/15538605.2012.648578

Wright, T. (2013). Uncovering sexuality and gender: an intersectional examination of women's experience in UK construction. Construct. Manage. Econom. 31, 832–844. doi: 10.1080/01446193.2013.794297

Yavorsky, J. E. (2016). Cisgendered organizations: trans women and inequality in the workplace. Sociol Forum 31, 948–969. doi: 10.1111/socf.12291

Yoder, J. D. (1991). Rethinking tokenism. Gender Soc. 5, 178–192. doi: 10.1177/089124391005002003

Yoder, J. D., and Aniakudo, P. (1997). “Outsider Within” the firehouse: subordination and difference in the social interactions of african american women firefighters. Gender Soc. 11, 324–341 doi: 10.1177/089124397011003004

Yoder, J. D., and McDonald, T. W. (2016). Measuring sexist discrimination in the workplace. Psychol. Women Q. 22, 487–491. doi: 10.1111/j.1471-6402.1998.tb00170.x

Keywords: diversity, gender equality, gender management, heteronormativity, heterosexism, human resources, intersectionality, LGBTQ

Citation: García Johnson CP and Otto K (2019) Better Together: A Model for Women and LGBTQ Equality in the Workplace. Front. Psychol. 10:272. doi: 10.3389/fpsyg.2019.00272

Received: 21 February 2018; Accepted: 28 January 2019; Published: 20 February 2019.

Reviewed by:

Copyright © 2019 García Johnson and Otto. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Carolina Pía García Johnson, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Prev Med Rep
• v.14; 2019 Jun

Inequalities in lesbian, gay, bisexual, and transgender (LGBT) health and health care access and utilization in Wisconsin

Linn jennings.

a Department of Population Health Sciences, University of Wisconsin-Madison, Wisconsin Alumni Research Foundation, Madison, WI, USA

Chris Barcelos

b Department of Gender and Women's Studies, University of Wisconsin-Madison, Madison, WI, USA

Christine McWilliams

Kristen malecki.

There are known health disparities between lesbian, gay, bisexual and transgender (LGBT) people and non-LGBT people, but only in the past couple of decades have population-based health surveys in the United States included questions on sexual and gender identity. We aimed to better understand LGBT disparities in health, health care access and utilization, and quality of care. Data are from the Survey of the Health of Wisconsin (SHOW) from 2014 to 2016 ( n  = 1957). The analyses focused on comparing health care access and utilization, and quality of care between LGB and non-LGB people and transgender and cisgender people. 3.8% ( n  = 73) identified as lesbian, gay or bisexual, and 1.3% ( n  = 25) were transgender. LGB adults were 2.17 (95th CI: 1.07–4.4) times more likely to delay obtaining health care. Transgender adults were 2.76 (95th CI: 1.64–4.65) times more likely to report poor quality of care and 2.78 (95th CI: 1.10–7.10) unfair treatment when receiving medical care. The results show differences in health care access and utilization and quality of care, and they add to the growing body of literature that suggest that improved health care services for LGBT patients are needed to promote health equity for LGBT populations.

• • LGBT individuals were more likely to report having fair/poor health than non-LGBT.
• • LGB individuals were more likely to delay health care than non-LGB individuals.
• • Trans respondents were more likely to report poor quality of care than non-LGBT.

1. Introduction

Health care access and utilization and quality of care are continuing to improve in the United States, but these improvements are not consistent across states or populations ( Agency for Healthcare Research and Quality, 2016 ). Health promotion initiatives in the United States, such as the Center for Disease Control's (CDC) Healthy People initiatives, have focused on understanding how these other factors differ among various populations in order to improve population health outcomes ( Alencar Albuquerque et al., 2016 ). These initiatives specifically target the health outcomes of marginalized groups, a term used to both define and understand the political and social impact of excluding and denying groups of people access to rights and services that are guaranteed to the rest of a country or society. These groups are at a higher risk of having low socioeconomic status and poor health outcomes, which contribute to why health disparities persist between marginalized and non-marginalized populations ( Agency for Healthcare Research and Quality, 2016 ; Blosnich et al., 2014 ).

Despite known health disparities between marginalized and non-marginalized populations, until recently, LGBT populations were rarely recognized as marginalized populations requiring research focus in national health initiatives ( Boehmer, 2002 ). Until the 2000's there were few surveys that included questions about sexual orientation and gender identity ( Bradford et al., 2013 ). There are vast inconsistencies in the questions on sexual and gender identity, and few use the validated questions recommended by the William's Institute: ( Bradford et al., 2013 ) three questions to establish sexual orientation (self-identification of sexual orientation, sexual behavior, and sexual attraction) ( Braveman et al., 2010 ), and a validated two-step question approach to measuring gender identity for population-based surveys (sex-assigned at birth and gender identity) ( Centers for Disease Control and Prevention, 2017 ). This incommensurability prevents surveys from identifying LGBT people with high sensitivity and specificity ( Cohen, 2017 ), which limits our ability to estimate the size of these populations, understand the health disparities, and to address these disparities on an individual, health system, and policy level.

1.1. LGBT health disparities and why they exist

The BRFSS (Behavior Risk Factor Surveillance System) and NHIS (National Health Interview Survey) survey a nationally representative sample of the United States population, and they are widely used in developing health policies at all levels of government across the United States. Previous results from national population-based studies identified several factors contributing to LGBT health disparities, including discrimination and stigma ( Conron et al., 2010 ; Cornelius and Carrick, 2015 ); limited access to health insurance ( Cruz, 2014 ); poor quality of care provided due to both discrimination based on sexual orientation and gender identity ( Conron et al., 2010 ; Durso and Meyer, 2013 ); lack of provider knowledge about LGBT health care needs ( Gates, 2014 ); and insufficient research about the health of LGBT populations ( Gorman, 2016 ; Graham et al., 2011 ). LGBT disparities in physical and mental health, health behaviors, and overall health status are shown to be linked to minority stress associated with the stigma and discrimination from having a minority status ( Grant et al., 2010 ).

Despite increased awareness about LGBT health disparities and known causes of these disparities, which are established by several decades of research, limited regional and state-level population-based data about LGBT populations continues to act as a barrier to understanding LGBT health disparities in the United States ( Bradford et al., 2013 ; Gorman, 2016 ; Graham et al., 2011 ). Health experiences of the LGBT community can vary by state and municipality due to differences in anti-discrimination laws and policies ( Green et al., 2018 ; Hasenbush et al., 2014 ). Additional evidence based research at all levels is needed to inform policies aimed at understanding the impact of these systemic biases. One of the first steps to addressing these gaps is through research to better understand LGBT health disparities in health outcomes and health care access and utilization, which can then be used to inform policy and improve provider training.

1.2. Study aims

The Survey of the Health of Wisconsin (SHOW) program, a unique state-specific population-based research infrastructure, offers an important opportunity to study LGBT health care access and utilization. Unlike other population-based health surveys (like BRFSS and NHIS) that include few questions on health insurance status and health care utilization, SHOW includes extensive questions on health care access and utilization, which help provide insight into how LGBT population use health care services differently than non-LGB/cisgender populations.

This study had two primary aims: ( Agency for Healthcare Research and Quality, 2016 ) to describe the LGB and transgender demographics, socioeconomic status, and occupation, and to compare these measure between LGB to non-LGB adults and transgender to non-LGB/cisgender adults in Wisconsin, and ( Centers for Disease Control and Prevention, 2017 ) to analyze the differences between LGB adults and non-LGB adults and between transgender and non-LGB/cisgender adults in physical and mental health, discrimination in the medical setting, health care access and utilization, and quality of care.

SHOW is an annual household-based survey that collects health-related data on a representative population in Wisconsin. The sampling strategy for 2014–2016 used a three-stage cluster sampling approach to randomly select households, using a population-weighted proportion to size with replacement (PWPPSWR) sampling protocol. First, counties were sampled based on mortality rate, and then census blocks within counties were chosen based on poverty, and third, households were randomly sampled within census blocks. The three-year sample included Milwaukee and Dane counties (the two most populated counties in the state); ten counties in total were sampled.

Since 2014, SHOW asks questions on sexual orientation and gender identity ( Table 1 ). These questions were chosen based on questions recommended by the Williams Institute and Fenway Health, but SHOW uses questions that are more similar to those used by BRFSS rather than the most recent best practice questions recommended by the Williams Institute ( Braveman et al., 2010 ; Cohen, 2017 ).

Survey of the Health of Wisconsin questions on sexual orientation and gender identity were asked during the duration of the study data (2014–2016). Questions were chosen based on the questions recommended by the Williams Institute and Fenway Health.

The SHOW data from 2014 to 2016 includes 1957 respondents who are age 18 and older. Of the survey respondents, 51 (2.6%) respondents did not answer the gender identity question, and 55 (2.8%) respondents did not answer the sexual orientation question. Of those who did not answer questions on sexual or gender identity, 41 (2.1%) respondents did not answer either of those questions.

2.1. Definitions

LGB included adults who identified as lesbian, gay or bisexual, and it included cisgender and transgender respondents. Cisgender is a term used for a person who identifies as their sex assigned at birth. Transgender is a term used for a person whose gender identity differs from their sex assigned at birth. Transgender included adults who identified as transgender or transsexual (intersex was removed from the comparison due to having a small n), and this measure included individuals who identified as LGB and non-LGB. The comparison group used for LGB and transgender was non-LGB/cisgender, which included adults who identified as heterosexual and were not transgender, transsexual or intersex. Occasionally LGBT was used to refer to both the LGB and transgender respondents.

2.2. Measures

Demographic variables included gender (for LGB and non-LGB only), age, race, occupation, income, education, and insurance status. Gender was excluded from the transgender analyses because it was unclear from the questions whether the transgender respondents answered the question about gender as sex-assigned at birth or as current gender identity. Occupation status was determined based on occupation status in the past week, income was assessed using the individual's income midpoint, and insurance status is measured by whether the respondent is currently insured.

Mental and physical health was assessed using the three measures: lifetime chronic illnesses, PHQ-2 depression screener score, Depression Anxiety Stress Scales (DASS) 21 short form scale. PHQ-2 is used as an assessment measure of depressive disorder, and it is not a diagnosis of depression. Scores range from 0 to 6, and scores of 3 and above have the highest sensitivities and specificities for identifying individuals with depressive disorders ( Igartua et al., 2009 ). DASS scores are considered a good a measure of the constructs of depression, anxiety and stress and an overall measure of emotional distress ( Ingham et al., 2018 ). We used the DASS21 z-score of 2.0 (moderate stress, anxiety, and depression) as our cut-point ( Ingham et al., 2018 ).

Health behaviors assessed were cigarette smoking and drinking habits. Cigarette smoking was divided into two categories: current smoker and former and/or never smoker. Drinking habits were divided into two categories: Heavy drinker (>14 drinks per week for men or more than drinks per week for women) and light drinker (less than these two cut-off values).

The analysis also includes measures of health care access and utilization, quality of care and discrimination: self-report of frequency of use of primary care, whether the respondent usually sees the same physician, use of preventative care services, satisfaction and quality of care received by providers, lifetime discrimination and discrimination experienced when receiving medical care.

2.3. Statistical analysis

Multiple logistic regression and multiple linear regression analyses were used to assess the relationship between LGB and non-LGB/cisgender respondents and transgender and non-LGB/cisgender respondents in Wisconsin. The analyses for LGB, transgender, and non-LGB/cisgender respondents were adjusted for age, gender (only LGB and non-LGB/cisgender respondents), race, income, and education, which were chosen based on previous survey data analyses of these populations ( Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, 2011 ). All statistical analysis was performed using SAS version 9.4 (SAS Institute Inc., Cary, North Carolina, USA) and weighted to adjust for sampling design. Sampling weights are generated for each data point by SHOW, and they are used to make the sample representative of the target population by stratifying by county, census block group, poverty, sex and race/ethnicity. The cluster, strata, and primary sampling unit estimates were used in the models run in SAS to calculate state-level estimates.

3.1. Demographic and socioeconomic characteristics

Table 2 shows the demographic and socioeconomic characteristics of LGB adults ( n  = 73) compared to non-LGB/cisgender adults ( n  = 1830) and transgender adults ( n  = 25) compared to non-LGB/cisgender adults ( n  = 1830). Socioeconomic variables were adjusted for age and gender. The weighted prevalence of lesbian, gay or bisexual respondents was 3.8% (95% CI: 2.91–4.67), and the weighted prevalence of transgender respondents was 1.33% (95% CI: 0.7–1.95). There were several differences in demographics and socioeconomic status between LGB and non-LGB/cisgender adults; the mean age of LGB adults in the sample was younger than non-LGB/cisgender adults ( p  < 0.001), fewer were married or have partners compared to non-LGB/cisgender adults ( p  < 0.001), more lived below the 200% FPL (Federal Poverty Level) than non-LGB/cisgender adults ( p  = 0.023), and more were unemployed compared to non-LGB/cisgender adults ( p  = 0.058). The mean age of transgender adults ( n  = 25) was older than non-LGB/cisgender adults ( p  = 0.03), and no transgender adults in the sample were uninsured.

Demographic characteristics for LGB ( n  = 73), transgender ( n  = 25), and heterosexual/cisgender adults ( n  = 1830) in Wisconsin from 2014 to 2016. Education, income, employment, insurance and marital status p -values were adjusted for age and gender for the comparison of LGB and heterosexual/cisgender adults and adjusted for age for the comparison of transgender and heterosexual/cisgender adults.

3.2. Health status

Table 3 presents results about health status and health behaviors, and the indicators were adjusted for by age and gender. LGB adults reported fair or poor health more often than non-LGB/cisgender adults (OR:2.12, 95% CI: 0.95–4.73), were more likely to have a depression diagnosis based on PHQ-2 (OR:2.13, 95% CI:1.26–3.62), and more likely to have a moderate to severe depression score (OR: 2.59, 95% CI: 1.15–5.83) and anxiety score (OR:1.73, 95% CI:0.99–2.99). As shown in Fig. 1 , LGB adults also scored lower on the SF-12 aggregate summary measures of mental ( p  = 0.049) and physical health ( p  < 0.01). Transgender respondents reported fair or poor health (OR: 2.22, 95% CI: 1.34–3.7), having a moderate to severe anxiety score (OR: 2.26, 95% CI:0.85–6.03), and having a history of chronic illness (OR:1.99, 95% CI: 0.86–4.6) more often than non-LGB/cisgender adults.

Adjusted odds ratios for health indicators for LGB ( n  = 73) compared to non-LGB/cisgender ( n  = 1830) (adjusted for age and gender) and for transgender ( n  = 25) compared to non-LGB/cisgender ( n  = 1830) (adjusted for age) in Wisconsin from 2014 to 2016.

Aggregate scores on mental and physical health from the SF-12 for LGB compared to non-LGB/cisgender (adjusted for age and gender) and for transgender compared to non-LGB/cisgender (adjusted for age) in Wisconsin from 2014 to 2016.

* p  < 0.05.

3.3. Health care access and utilization

Table 4 shows the adjusted odds for indicators of health care access and utilization. LGB adults were more likely not to have the cost of preventative services covered by their insurance (OR:1.89, 95% CI:1.1–3.23), to delay obtaining needed health care (OR:2.17 95% CI:1.07–4.4), and to take less medicine than prescribed, (OR:2.14, 95% CI:0.82–5.6). Transgender adults were more likely to report receiving poor quality health care (OR: 2.76, 95% CI: 1.64–4.65) and to be unfairly treated when receiving medical care (OR: 2.78, 95% CI:1.1–7.1).

Adjusted odds of healthcare access and utilization for LGB ( n  = 73) compared to non-LGB/cisgender ( n  = 1830) (adjusted for age, gender, race, education, and income) and transgender ( n  = 25) compared to non-LGB/cisgender ( n  = 1830) (adjusted for age, race, education, and income) in Wisconsin from 2014 to 2016.

4. Discussion

4.1. discussion of results on lgb health and health care access and utilization.

Few population-based studies have published results on health care access and utilization for LGBT populations. The results of this study indicate that there are differences in how LGB and non-LGB/cisgender populations access and utilize health care services in Wisconsin, and this could be due to barriers to accessing appropriate health care, such as health care cost and coverage of preventative health services. For example, although LGB respondents were equally likely to have health insurance, they were less likely to have health insurance that covers the cost of preventative health care services and more likely to delay receiving health care compared to non-LGB/cisgender respondents.

4.2. Discussion of results on transgender health and health care access and utilization

Despite having a small sample with large confidence intervals, this study is among the first statewide population-based studies to document differences in health outcomes between transgender and cis respondents. Transgender respondents were over two times more likely to report poor or fair health status (95% CI: 1.34–3.7) and to have a chronic illness (95% CI:0.86–4.6), and almost three times more likely to receive poor quality health care (95% CI: 1.64–4.65) and to be unfairly treated when receiving health care (95% CI: 1.10–7.10). Although, the study sample was small and some of the confidence intervals are quite wide, these results are similar to those from the national 2015 Transgender Survey and the twenty-one state BRFSs, which both report a higher percentage of transgender people reporting poor or fair health compared to cisgender people ( James and Herman, 2017 ; Kroenke et al., 2003 ). Our results add to the growing literature on how transgender people are more at risk for poor health outcomes and for receiving poor quality of healthcare ( Kroenke et al., 2003 ; Lerner and Robles, 2017 ; Lombardi and Banik, 2016 ). Further, these barriers and risk factors suggest opportunities towards prevention and policies to reduce discrimination need to consider transgender adults as a particularly vulnerable population.

4.3. Implications

The results from this study in Wisconsin are important in that they support previous findings about LGBT health disparities from many regions around the United States ( Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, 2011 ; Lovibond and Lovibond, 1995 ). The mounting evidence from population-based survey data support the need for federal and state public health and anti-discrimination policies to address LGBT health disparities ( Graham et al., 2011 ). Discriminatory laws and stigma faced in medical care environments have discouraged LGBT people from revealing information about their sexual orientation and gender identity, making it difficult to sufficiently identify LGBT health disparities ( Mayer et al., 2008 ). These discriminatory laws not only pose barriers to studying LGBT health disparities but also stem from stigma and bias against LGBT people, and these biases remain present in national and state policies that limit access to health care services to LGBT people and do not adequately protect the rights of LGBT people ( Green et al., 2018 ; Meyer, 1995 ; Meyer and Wilson, 2009 ).

Even with a small number of respondents in this population-based study, there are significant findings that support the notion that health insurance access is another barrier to accessing high quality health care among LGBT adults in Wisconsin. LGB respondents were more likely not to have the cost of preventative services covered by their insurance, delayed getting care and to took less medicine than prescribed, and transgender respondents were more likely to receive poor quality of care and to experience unfair treatment when receive medical care. National and state policies contribute to limiting access to health insurance and coverage for health care services. Despite significant policy changes like the Affordable Care Act (ACA) and marriage equality ( Meyer, 1995 ), disparities in access and coverage of care continue to exist in the United States. Nondiscrimination protections for health insurance and employment do not exist in most states, which prevents LGBT people from accessing and utilizing health care services to the same extent as non-LGBT people ( Meyer, 1995 ). What's more, the Trump administration has continuously worked to dismantle LGBT health protections afforded under the Obama administration, such as rolling back anti-discrimination regulations under the ACA ( Motwani and Fatehchehr, 2017 ), discouraging the use of words such as “evidence-based” or “transgender” in CDC budget documents ( Movement Advancement Project, 2018 ), and proposing that federal agencies define sex as an immutable category based on birth genitalia or chromosomes ( National Center for Transgender Equality, 2017 ).

In addition to the systemic barriers discussed above, provider discrimination and poor provider training may also prevent LGBT people from accessing necessary and appropriate health care ( Conron et al., 2010 ; Lombardi and Banik, 2016 ; Patterson et al., 2017 ). Data from this study are in agreement with previous research in other regions of the United States documenting a higher risk for poor physical and mental health due to a combination of factors related to discrimination, stigma and internalized homophobia LGBT populations ( Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, 2011 ; Lovibond and Lovibond, 1995 ). All the while LGBT populations are less likely to access and utilize health care services due to cost, not being offered appropriate preventative health screenings, or being refused care or coverage for care ( Cornelius and Carrick, 2015 ; Patterson et al., 2017 ; Ranji and Beamesderfer, 2018 ). Further, fear of discrimination in the medical care setting not only prevents transgender people from accessing health care but also influences whether they disclose their gender identity to their provider, which is an additional barrier to receiving appropriate health care ( Mayer et al., 2008 ).

These gaps in health outcomes and health care quality demonstrate that it is not sufficient to simply improve access to affordable health care. To entirely close the gap, improved provider training on LGBT health and health disparities are necessary to extend health care and high quality, appropriate health care to all LGBT populations ( Gorman, 2016 ).

4.4. Limitations

The analysis was limited by the questions asked about sexual and gender identity in the SHOW questionnaire and by the size of the survey sample. As with other population-based studies, the SHOW questionnaire includes some questions on sexual orientation and gender identity, but these questions do not follow the validated, best practice recommendations of the Williams Institute ( Braveman et al., 2010 ; Centers for Disease Control and Prevention, 2017 ; Cohen, 2017 ; Sabin et al., 2015 ). By not including all three questions about the three dimensions of sexual orientation and the two-step approach to asking about gender identity, the SHOW questionnaire most likely underestimates the percentage of respondents who are LGBT ( Centers for Disease Control and Prevention, 2017 ; Saewyc et al., 2004 ). Further, there are inconsistencies in the SHOW questionnaire with regard to time when the respondent identified with a particular gender identity or sexual orientation. The question about gender identity asks about current or past gender identity, but the sexual orientation question does not have a reference to the time (current, past, or both). The recommended practice for population-based surveys is to ask for the respondent to answer how they describe their sexual orientation and gender identity without a reference to current or past identity ( Cohen, 2017 ).

A second limitation of the survey is that reproductive health screenings are only asked of those who report their gender as female and prostate screenings are only asked of individuals who report their gender as male. Using gender as an indicator of whether a participant is eligible to answer these questions, rather than an indicator based on sex assigned at birth, prevents the survey from capturing how these services are used by transgender respondents. These are essential measures given the known barriers that prevent transgender individuals from receive appropriate preventative health screenings ( Conron et al., 2010 ; Cornelius and Carrick, 2015 ; Mayer et al., 2008 ; The GenIUSS Group and Herman, 2014 ).

Third, there are limitations to using a randomly sampled cross-sectional survey. First, the LGBT populations make up only small proportion of the population, so the survey sample of LGBT respondents is too small to estimate state-level prevalence of various health behavior and health care access and utilization indicators for LGBT sub-populations. In future studies, it will be important to make use of other sampling techniques, such as convenience sampling, in order to increase the number of LGBT respondents in the survey sample ( The Williams Institute and Badgett, 2009 ). Second, the cross-sectional survey data can only estimate current health care access and utilization and health outcomes. Without longitudinal data, we are unable to use these data to understand how these factors might contribute to LGBT disparities in health outcomes.

5. Conclusions

The goal of the CDC's Healthy People 2020 is to improve health by eliminating health disparities and promoting health equity. The results of this study are important because they add to the growing literature on LGBT health disparities and barriers to accessing and utilizing health care services. However, as we approach 2020, it becomes clear that LGBT health disparities still exist in the United States, and great changes in policy and healthcare delivery are still needed to achieve health equity for LGBT populations. Given the current knowledge of these health disparities and of the barriers that prevent LGBT populations from accessing and utilizing health care resources, steps need to be taken at many levels to reach the goals set by Healthy People 2020.

One of the next steps we need to take to begin to reduce these health disparities is to conduct more research that focuses on how health care is provided to LGBT populations at the health care system and provider levels and on how to design and implement interventions to improve provider training in serving LGBT populations. To take this next step, we need to both standardize how we measure LGBT populations and improve how we conduct population-based health survey research. First, population-based surveys need to include the recommended best practice questions published by the Williams Institute to identify LGBT respondents and questions on patient experience with providers and the health care system to better understand the health care services needs of LGBT people. Including these questions is essential for researchers, providers and policy makers to better understand the barriers to receiving necessary and appropriate health care. Second, often LGBT population samples are small, even in state and national population-based studies, which limit our ability to study these populations. This could be addressed by over-sampling LGBT populations by targeting neighborhoods are areas with larger populations of LGBT people, which has been used in other population-based studies to capture a larger sample of LGBT people ( The Williams Institute and Badgett, 2009 ). These changes to population-based survey questions are necessary to assess the patient experience so that these data can be used to design health care systems and provider training programs that are centered on improving health care services and health outcomes for LGBT populations.

Conflict of interest

Acknowledgements.

The authors would like to thank the University of Wisconsin Survey Center, SHOW administrative, field, and scientific staff, as well as all the SHOW participants for their contributions to this study. We would also like to thank Jane McElroy for her work on the sexual orientation and gender identity questionnaire to the SHOW survey, Dr. Mari Palta for her assistance with data analysis, and Dr. Bobbi Wolfe for her support on the drafting of the manuscript.

Funding for the Survey of the Health of Wisconsin (SHOW) was provided by the Wisconsin Partnership Program PERC Award (233 PRJ 25DJ), the National Institutes of Health's Clinical and Translational Science Award (5UL RR025011) and the National Heart Lung and Blood Institute (1 RC2 HL101468).

• Agency for Healthcare Research and Quality . Agency for Healthcare Research and Quality; Rockville, MD: 2016. National Healthcare Quality and Disparities Report. [ Google Scholar ]
• Alencar Albuquerque G., de Lima Garcia C., da Silva Quirino G. Access to health services by lesbian, gay, bisexual, and transgender persons: systematic literature review. BMC Int. Health Hum. Rights. 2016:16. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Blosnich J.R., Farmer G.W., Lee J.G., Silenzio V.M., Bowen D.J. Health inequalities among sexual minority adults: evidence from ten US states, 2010. Am. J. Prev. Med. 2014; 46 (4):337–349. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Boehmer U. Twenty years of public health research: inclusion of lesbian, gay, bisexual, and transgender populations. Am. J. Public Health. 2002; 92 (7):1125–1130. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Bradford J., Reisner S.L., Honnold J.A., Xavier J. Experiences of transgender-related discrimination and implications for health: results from the Virginia Transgender Health Initiative Study. Am. J. Public Health. 2013; 103 (10):1820–1829. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Braveman P.A., Cubbin C., Egerter S., Williams D.R., Pamuk E. Socioeconomic disparities in health in the United States: what the patterns tell us. Am. J. Public Health. 2010; 100 (S1):S186–S196. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Centers for Disease Control and Prevention Healthy People. 2017. www.cdc.gov/nchs/healthy_people/index.htm Available at.
• Cohen J. CDC word ban? The fight over seven health-related words in the president’s next budget. Science. 2017 [ Google Scholar ]
• Conron K.J., Mimiaga M.J., Landers S.J. A population-based study of sexual orientation identity and gender differences in adult health. Am. J. Public Health. 2010; 100 (10):1953–1960. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Cornelius J.B., Carrick J. A survey of nursing students' knowledge of and attitudes toward LGBT health care concerns. Nursing Education Perspectives (National League for Nursing) 2015; 36 (3):176–178. [ Google Scholar ]
• Cruz T.M. Assessing access to care for transgender and gender nonconforming people: a consideration of diversity in combating discrimination. Soc. Sci. Med. 2014; 110 :65–73. [ PubMed ] [ Google Scholar ]
• Durso L.E., Meyer I.H. Patterns and predictors of disclosure of sexual orientation to healthcare providers among lesbians, gay men, and bisexuals. Sexuality Research and Social Policy. 2013; 10 (1):35–42. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Gates G.J. UCLA: The Williams Institute; 2014. In US, LGBT more Likely than Non-LGBT to Be Uninsured. [ Google Scholar ]
• Gorman S.U.S. U.S. judge blocks transgender, abortion-related Obamacare protections. Reuters. 2016, December 31 http://www.reuters.com/article/us-usa-obamacare/u-s-judge-blocks-transgender-abortion-related-obamacare-protections-idUSKBN14L0OP Retrieved from. [ Google Scholar ]
• Graham R., Berkowitz B., Blum R. Institute of Medicine; Washington, DC: 2011. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. [ PubMed ] [ Google Scholar ]
• Grant J.M., Mottet L.A., Tanis J., Herman J.L., Harrison J., Keisling M. National Center for Transgender Equality and the National Gay and Lesbian Task Force; Washington, DC: 2010. National Transgender Discrimination Survey Report on Health and Health Care. [ Google Scholar ]
• Green E.L., Benner K., Pear R. ‘Transgender’ could be defined out of existence under trump administration. The New York Times. 2018, October 24 http://www.nytimes.com/2018/10/21/us/politics/transgender-trump-administration-sex-definition.html Retrieved from. [ Google Scholar ]
• Hasenbush A., Flores A., Kastanis A., Sears B., Gates G. 2014. The LGBT Divide: A Data Portrait of LGBT People in the Midwestern, Mountain & Southern States. [ Google Scholar ]
• Igartua K., Thombs B.D., Burgos G., Montoro R. Concordance and discrepancy in sexual identity, attraction, and behavior among adolescents. J. Adolesc. Health. 2009; 45 (6):602–608. [ PubMed ] [ Google Scholar ]
• Ingham M.D., Lee R.J., MacDermed D., Olumi A.F. Prostate cancer in transgender women. Urologic Oncology: Seminars and Original Investigations. October 2018; 36 (12):518–525. [ PubMed ] [ Google Scholar ]
• Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities . National Academies Press (US); Washington (DC): 2011. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. [ PubMed ] [ Google Scholar ]
• James S.E., Herman J. National Center for Transgender Equality; 2017. The Report of the 2015 US Transgender Survey: Executive Summary. [ Google Scholar ]
• Kroenke K., Spitzer R.L., Williams J.B. The patient health questionnaire-2: validity of a two-item depression screener. Med. Care. 2003:1284–1292. [ PubMed ] [ Google Scholar ]
• Lerner J.E., Robles G. Perceived barriers and facilitators to health care utilization in the United States for transgender people: a review of recent literature. J. Health Care Poor Underserved. 2017; 28 (1):127–152. [ PubMed ] [ Google Scholar ]
• Lombardi E., Banik S. The utility of the two-step gender measure within trans and cis populations. Sexuality Research and Social Policy. 2016; 13 (3):288–296. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Lovibond P.F., Lovibond S.H. The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav. Res. Ther. 1995; 33 (3):335–343. [ PubMed ] [ Google Scholar ]
• Mayer K.H., Bradford J.B., Makadon H.J., Stall R., Goldhammer H., Landers S. Sexual and gender minority health: what we know and what needs to be done. Am. J. Public Health. 2008; 98 (6):989–995. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Meyer I.H. Minority stress and mental health in gay men. J. Health Soc. Behav. 1995:38–56. [ PubMed ] [ Google Scholar ]
• Meyer I.H., Wilson P.A. Sampling lesbian, gay, and bisexual populations. J. Couns. Psychol. 2009; 56 (1):23. [ Google Scholar ]
• Motwani A., Fatehchehr S. Quality of life and health care access in transgender population: findings from 21 US states in the Behavioral Risk Factor Surveillance System (BRFSS) survey. J. Minim. Invasive Gynecol. 2017; 24 (7):S59. [ Google Scholar ]
• Movement Advancement Project Non-Discrimination Laws. 2018. http://www.lgbtmap.org/equality-maps/non_discrimination_laws Available at.
• National Center for Transgender Equality Trump Administration Plan to Roll Back Health Care Nondiscrimination Regulation: Frequently Asked Questions. 2017. https://transequality.org/HCRL-FAQ Retrieved from.
• Patterson J.G., Jabson J.M., Bowen D.J. Measuring sexual and gender minority populations in health surveillance. LGBT health. 2017; 4 (2):82–105. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Ranji U., Beamesderfer A. The Henry J Kaiser Family Foundation; 2018. Health and Access to Care and Coverage for Lesbian, Gay, Bisexual, and Transgender (LGBT) Individuals in the U.S. [ Google Scholar ]
• Sabin J.A., Riskind R.G., Nosek B.A. Health care providers' implicit and explicit attitudes toward lesbian women and gay men. Am. J. Public Health. 2015; 105 (9):1831–1841. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Saewyc E.M., Bauer G.R., Skay C.L. Measuring sexual orientation in adolescent health surveys: evaluation of eight school-based surveys. J. Adolesc. Health. 2004; 35 (4):345–e1. [ PubMed ] [ Google Scholar ]
• The GenIUSS Group, Herman J.L. UCLA: The Williams Institute; 2014. Best Practices for Asking Questions to Identify Transgender and Other Gender Minority Respondents on Population-Based Surveys. [ Google Scholar ]
• The Williams Institute, Badgett M.V.L. UCLA: The Williams Institute; 2009. Best Practices for Asking Questions about Sexual Orientation on Surveys. [ Google Scholar ]

What does the scholarly research say about the effect of gender transition on transgender well-being?

We conducted a systematic literature review of all peer-reviewed articles published in English between 1991 and June 2017 that assess the effect of gender transition on transgender well-being. We identified 55 studies that consist of primary research on this topic, of which 51 (93%) found that gender transition improves the overall well-being of transgender people, while 4 (7%) report mixed or null findings. We found no studies concluding that gender transition causes overall harm. As an added resource, we separately include 17 additional studies that consist of literature reviews and practitioner guidelines.

Bottom Line

This search found a robust international consensus in the peer-reviewed literature that gender transition, including medical treatments such as hormone therapy and surgeries, improves the overall well-being of transgender individuals. The literature also indicates that greater availability of medical and social support for gender transition contributes to better quality of life for those who identify as transgender.

Below are the 8 findings of our review, and links to the 72 studies on which they are based. Click here to view our methodology . Click here for a printer-friendly one-pager of this research analysis .

Suggested Citation : What We Know Project, Cornell University, “What Does the Scholarly Research Say about the Effect of Gender Transition on Transgender Well-Being?” (online literature review), 2018.

Research Findings

1. The scholarly literature makes clear that gender transition is effective in treating gender dysphoria and can significantly improve the well-being of transgender individuals.

2. Among the positive outcomes of gender transition and related medical treatments for transgender individuals are improved quality of life, greater relationship satisfaction, higher self-esteem and confidence, and reductions in anxiety, depression, suicidality, and substance use.

3. The positive impact of gender transition on transgender well-being has grown considerably in recent years, as both surgical techniques and social support have improved.

4. Regrets following gender transition are extremely rare and have become even rarer as both surgical techniques and social support have improved. Pooling data from numerous studies demonstrates a regret rate ranging from .3 percent to 3.8 percent. Regrets are most likely to result from a lack of social support after transition or poor surgical outcomes using older techniques.

5. Factors that are predictive of success in the treatment of gender dysphoria include adequate preparation and mental health support prior to treatment, proper follow-up care from knowledgeable providers, consistent family and social support, and high-quality surgical outcomes (when surgery is involved).

6. Transgender individuals, particularly those who cannot access treatment for gender dysphoria or who encounter unsupportive social environments, are more likely than the general population to experience health challenges such as depression, anxiety, suicidality and minority stress. While gender transition can mitigate these challenges, the health and well-being of transgender people can be harmed by stigmatizing and discriminatory treatment.

7. An inherent limitation in the field of transgender health research is that it is difficult to conduct prospective studies or randomized control trials of treatments for gender dysphoria because of the individualized nature of treatment, the varying and unequal circumstances of population members, the small size of the known transgender population, and the ethical issues involved in withholding an effective treatment from those who need it.

8. Transgender outcomes research is still evolving and has been limited by the historical stigma against conducting research in this field. More research is needed to adequately characterize and address the needs of the transgender population.

Below are 51 studies that found that gender transition improves the well-being of transgender people. Click here to jump to 4 studies that contain mixed or null findings on the effect of gender transition on transgender well-being. Click here to jump to 17 studies that consist of literature reviews or guidelines that help advance knowledge about the effect of gender transition on transgender well-being.

Ainsworth and spiegel, 2010.

Ainsworth, T., & Spiegel, J. (2010). Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery. Quality of Life Research , 19 (7), 1019-1024.

Objectives: To determine the self-reported quality of life of male-to-female (MTF) transgendered individuals and how this quality of life is influenced by facial feminization and gender reassignment surgery. Methods: Facial Feminization Surgery outcomes evaluation survey and the SF-36v2 quality of life survey were administered to male-to-female transgender individuals via the Internet and on paper. A total of 247 MTF participants were enrolled in the study. Results: Mental health-related quality of life was statistically diminished (P < 0.05) in transgendered women without surgical intervention compared to the general female population and transwomen who had gender reassignment surgery (GRS), facial feminization surgery (FFS), or both. There was no statistically significant difference in the mental health-related quality of life among transgendered women who had GRS, FFS, or both. Participants who had FFS scored statistically higher (P < 0.01) than those who did not in the FFS outcomes evaluation. Conclusions: Transwomen have diminished mental health-related quality of life compared with the general female population. However, surgical treatments (e.g. FFS, GRS, or both) are associated with improved mental health-related quality of life.

Bailey, Ellis, & McNeil, 2014

Bailey, L., Ellis, S. J., & McNeil, J. (2014). Suicide risk in the UK trans population and the role of gender transition in decreasing suicidal ideation and suicide attempt. The Mental Health Review , 19 (4), 209-220.

Purpose: The purpose of this paper is to present findings from the Trans Mental Health Study (McNeil et al., 2012) – the largest survey of the UK trans population to date and the first to explore trans mental health and well-being within a UK context. Findings around suicidal ideation and suicide attempt are presented and the impact of gender dysphoria, minority stress and medical delay, in particular, are highlighted. Design/methodology/approach: This represents a narrative analysis of qualitative sections of a survey that utilised both open and closed questions. The study drew on a non-random sample (n 1⁄4 889), obtained via a range of UK-based support organisations and services. Findings: The study revealed high rates of suicidal ideation (84 per cent lifetime prevalence) and attempted suicide (48 per cent lifetime prevalence) within this sample. A supportive environment for social transition and timely access to gender reassignment, for those who required it, emerged as key protective factors. Subsequently, gender dysphoria, confusion/denial about gender, fears around transitioning, gender reassignment treatment delays and refusals, and social stigma increased suicide risk within this sample. Research limitations/implications: Due to the limitations of undertaking research with this population, the research is not demographically representative. Practical implications: The study found that trans people are most at risk prior to social and/or medical transition and that, in many cases, trans people who require access to hormones and surgery can be left unsupported for dangerously long periods of time. The paper highlights the devastating impact that delaying or denying gender reassignment treatment can have and urges commissioners and practitioners to prioritise timely intervention and support. Originality/value: The first exploration of suicidal ideation and suicide attempt within the UK trans population revealing key findings pertaining to social and medical transition, crucial for policy makers, commissioners and practitioners working across gender identity services, mental health services and suicide prevention.

Bar et al., 2016

Bar, M. A., Jarus, T., Wada, M., Rechtman, L., & Noy, E. (2016). Male-to-female transitions: Implications for occupational performance, health, and life satisfaction. The Canadian Journal of Occupational Therapy , 83 (2), 72-82.

Background. People who undergo a gender transition process experience changes in different everyday occupations. These changes may impact their health and life satisfaction. Purpose. This study examined the difference in the occupational performance history scales (occupational identity, competence, and settings) between male-to-female transgender women and cisgender women and the relation of these scales to health and life satisfaction. Method. Twenty-two transgender women and 22 matched cisgender women completed a demographic questionnaire and three reliable measures in this cross-sectional study. Data were analyzed using a two-way analysis of variance and multiple linear regressions. Findings. The results indicate lower performance scores for the transgender women. In addition, occupational settings and group membership (transgender and cisgender groups) were found to be predictors of life satisfaction. Implications. The present study supports the role of occupational therapy in promoting occupational identity and competence of transgender women and giving special attention to their social and physical environment.

Bodlund and Kullgren, 1996

Bodlund, O., & Kullgren, G. (1996). Transsexualism–general outcome and prognostic factors: A five-year follow-up study of nineteen transsexuals in the process of changing sex. Archives of Sexual Behavior , 25 (3), 303-316.

Nineteen transsexuals, approved for sex reassignement, were followed-up after 5 years. Outcome was evaluated as changes in seven areas of social, psychological, and psychiatric functioning. At baseline the patients were evaluated according to axis I, II, V (DSM-III-R), SCID screen, SASB (Structural Analysis of Social Behavior), and DMT (Defense Mechanism Test). At follow-up all but 1 were treated with contrary sex hormones, 12 had completed sex reassignment surgery, and 3 females were waiting for phalloplasty. One male transsexual regretted the decision to change sex and had quit the process. Two transsexuals had still not had any surgery due to older age or ambivalence. Overall, 68% (n = 13) had improved in at least two areas of functioning. In 3 cases (16%) outcome were judged as unsatisfactory and one of those regarded sex change as a failure. Another 3 patients were mainly unchanged after 5 years. Female transsexuals had a slightly better outcome, especially concerning establishing and maintaining partnerships and improvement in socio-economic status compared to male transsexuals. Baseline factors associated with negative outcome (unchanged or worsened) were presence of a personality disorder and high number of fulfilled axis II criteria. SCID screen assessments had high prognostic power. Negative self-image, according to SASB, predicted a negative outcome, whereas DMT variables were not correlated to outcome.

Bouman et al., 2016

Bouman, W. P., Claes, L., Marshall, E., Pinner, G. T., Longworth, J., et al. (2016). Sociodemographic variables, clinical features, and the role of preassessment cross-sex hormones in older trans people. The Journal of Sexual Medicine , 13 (4), 711-719.

Introduction: As referrals to gender identity clinics have increased dramatically over the last few years, no studies focusing on older trans people seeking treatment are available. Aims: The aim of this study was to investigate the sociodemographic and clinical characteristics of older trans people attending a national service and to investigate the influence of cross-sex hormones (CHT) on psychopathology. Methods: Individuals over the age of 50 years old referred to a national gender identity clinic during a 30-month period were invited to complete a battery of questionnaires to measure psychopathology and clinical characteristics. Individuals on cross-sex hormones prior to the assessment were compared with those not on treatment for different variables measuring psychopathology. Main Outcome Measures: Sociodemographic and clinical variables and measures of depression and anxiety (Hospital Anxiety and Depression Scale), self-esteem (Rosenberg Self-Esteem Scale), victimization (Experiences of Transphobia Scale), social support (Multidimensional Scale of Perceived Social Support), interpersonal functioning (Inventory of Interpersonal Problems), and nonsuicidal self-injury (Self-Injury Questionnaire). Results: The sex ratio of trans females aged 50 years and older compared to trans males was 23.7:1. Trans males were removed for the analysis due to their small number (n = 3). Participants included 71 trans females over the age of 50, of whom the vast majority were white, employed or retired, and divorced and had children. Trans females on CHT who came out as trans and transitioned at an earlier age were significantly less anxious, reported higher levels of self-esteem, and presented with fewer socialization problems. When controlling for socialization problems, differences in levels of anxiety but not self-esteem remained. Conclusion: The use of cross-sex hormones prior to seeking treatment is widespread among older trans females and appears to be associated with psychological benefits. Existing barriers to access CHT for older trans people may need to be re-examined.

Boza and Nicholson, 2014

Boza, C., & Nicholson Perry, K. (2014). Gender-related victimization, perceived social support, and predictors of depression among transgender Australians. International Journal Of Transgenderism , 15 (1), 35-52.

This study examined mental health outcomes, gender-related victimization, perceived social support, and predictors of depression among 243 transgender Australians (n= 83 assigned female at birth, n= 160 assigned male at birth). Overall, 69% reported at least 1 instance of victimization, 59% endorsed depressive symptoms, and 44% reported a previous suicide attempt. Social support emerged as the most significant predictor of depressive symptoms (p>.05), whereby persons endorsing higher levels of overall perceived social support tended to endorse lower levels of depressive symptoms. Second to social support, persons who endorsed having had some form of gender affirmative surgery were significantly more likely to present with lower symptoms of depression. Contrary to expectations, victimization did not reach significance as an independent risk factor of depression (p=.053). The pervasiveness of victimization, depression, and attempted suicide represents a major health concern and highlights the need to facilitate culturally sensitive health care provision.

Budge et al., 2013

Budge, S. L., Katz-Wise, S. L., Tebbe, E. N., Howard, K. A. S., Schneider, C. L., et al. (2013). Transgender emotional and coping processes: Facilitative and avoidant coping throughout gender transitioning. The Counseling Psychologist , 41 (4), 601-647.

Eighteen transgender-identified individuals participated in semi-structured interviews regarding emotional and coping processes throughout their gender transition. The authors used grounded theory to conceptualize and analyze the data. There were three distinct phases through which the participants described emotional and coping experiences: (a) pretransition, (b) during the transition, and (c) posttransition. Five separate themes emerged, including descriptions of coping mechanisms, emotional hardship, lack of support, positive social support, and affirmative emotional experiences. The authors developed a model to describe the role of coping mechanisms and support experienced throughout the transition process. As participants continued through their transitions, emotional hardships lessened and they used facilitative coping mechanisms that in turn led to affirmative emotional experiences. The results of this study are indicative of the importance of guiding transgender individuals through facilitative coping experiences and providing social support throughout the transition process. Implications for counselors and for future research are discussed.

Cardoso da Silva et al., 2016

Cardoso da Silva, D., Schwarz, K., Fontanari, A.M.V., Costa, A.B., Massuda, R., et al. (2016). WHOQOL-100 Before and after sex reassignment surgery in Brazilian male-to-female transsexual individuals. Journal of Sexual Medicine , 13 (6), 988-993.

Introduction: The 100-item World Health Organization Quality of Life Assessment (WHOQOL-100) evaluates quality of life as a subjective and multidimensional construct. Currently, particularly in Brazil, there are controversies concerning quality of life after sex reassignment surgery (SRS). Aim: To assess the impact of surgical interventions on quality of life of 47 Brazilian male-to-female transsexual individuals using the WHOQOL-100. Methods: This was a prospective cohort study using the WHOQOL-100 and sociodemographic questions for individuals diagnosed with gender identity disorder according to criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The protocol was used when a transsexual person entered the ambulatory clinic and at least 12 months after SRS. Main Outcome Measures: Initially, improvement or worsening of quality of life was assessed using 6 domains and 24 facets. Subsequently, quality of life was assessed for individuals who underwent new surgical interventions and those who did not undergo these procedures 1 year after SRS. Results: The participants showed significant improvement after SRS in domains II (psychological) and IV (social relationships) of the WHOQOL-100. In contrast, domains I (physical health) and III (level of independence) were significantly worse after SRS. Individuals who underwent additional surgery had a decrease in quality of life reflected in domains II and IV. During statistical analysis, all results were controlled for variations in demographic characteristics, without significant results. Conclusion: The WHOQOL-100 is an important instrument to evaluate the quality of life of male-to-female transsexuals during different stages of treatment. SRS promotes the improvement of psychological aspects and social relationships. However, even 1 year after SRS, male-to-female transsexuals continue to report problems in physical health and difficulty in recovering their independence.

(Due to a citation error, this study was initially listed twice.)

Castellano et al., 2015

Castellano, E., Crespi, C., Dell’Aquila, R., Rosato, C., Catalano, V., et al. (2015). Quality of life and hormones after sex reassignment surgery.  Journal of Endocrinological Investigation , 38 (12), 1373-1381.

Background: Transpeople often look for sex reassignment surgery (SRS) to improve their quality of life (QoL). The hormonal therapy has many positive effects before and after SRS. There are no studies about correlation between hormonal status and QoL after SRS. Aim: To gather information on QoL, quality of sexual life and body image in transpeople at least 2 years after SRS, to compare these results with a control group and to evaluate the relations between the chosen items and hormonal status. Subjects and methods: Data from 60 transsexuals and from 60 healthy matched controls were collected. Testosterone, estradiol, LH and World Health Organization Quality of Life (WHOQOL-100) self-reported questionnaire were evaluated. Student’s t test was applied to compare transsexuals and controls. Multiple regression model was applied to evaluate WHOQOL’s chosen items and LH. Results: The QoL and the quality of body image scores in transpeople were not statistically different from the matched control groups’ ones. In the sexual life subscale, transwomen’s scores were similar to biological women’s ones, whereas transmen’s scores were statistically lower than biological men’s ones (P = 0.003). The quality of sexual life scored statistically lower in transmen than in transwomen (P = 0.048). A significant inverse relationship between LH and body image and between LH and quality of sexual life was found. Conclusions: This study highlights general satisfaction after SRS. In particular, transpeople’s QoL turns out to be similar to Italian matched controls. LH resulted inversely correlated to body image and sexual life scores.

Colizzi, Costa, & Todarello, 2014

Colizzi, M., Costa, R. & Todarello, O. (2014). Transsexual patients’ psychiatric comorbidity and positive effect of cross-sex hormonal treatment on mental health: Results from a longitudinal study.  Psychoneuroendocrinology , 39 , 65-73.

The aim of the present study was to evaluate the presence of psychiatric diseases/symptoms in transsexual patients and to compare psychiatric distress related to the hormonal intervention in a one year follow-up assessment. We investigated 118 patients before starting the hormonal therapy and after about 12 months. We used the SCID-I to determine major mental disorders and functional impairment. We used the Zung Self-Rating Anxiety Scale (SAS) and the Zung Self-Rating Depression Scale (SDS) for evaluating self-reported anxiety and depression. We used the Symptom Checklist 90-R (SCL-90-R) for assessing self-reported global psychological symptoms. Seventeen patients (14%) had a DSM-IV-TR axis I psychiatric comorbidity. At enrollment the mean SAS score was above the normal range. The mean SDS and SCL-90-R scores were on the normal range except for SCL-90-R anxiety subscale. When treated, patients reported lower SAS, SDS and SCL-90-R scores, with statistically significant differences. Psychiatric distress and functional impairment were present in a significantly higher percentage of patients before starting the hormonal treatment than after 12 months (50% vs. 17% for anxiety; 42% vs. 23% for depression; 24% vs. 11% for psychological symptoms; 23% vs. 10% for functional impairment). The results revealed that the majority of transsexual patients have no psychiatric comorbidity, suggesting that transsexualism is not necessarily associated with severe comorbid psychiatric findings. The condition, however, seemed to be associated with subthreshold anxiety/depression, psychological symptoms and functional impairment. Moreover, treated patients reported less psychiatric distress. Therefore, hormonal treatment seemed to have a positive effect on transsexual patients’ mental health.

Colizzi et al., 2013

Colizzi. M., Costa, R., Pace, V., & Todarello, O. (2013). Hormonal treatment reduces psychobiological distress in gender identity disorder, independently of the attachment style. The Journal of Sexual Medicine , 10 (12), 3049–3058.

Introduction: Gender identity disorder may be a stressful situation. Hormonal treatment seemed to improve the general health as it reduces psychological and social distress. The attachment style seemed to regulate distress in insecure individuals as they are more exposed to hypothalamic–pituitary–adrenal system dysregulation and subjective stress. Aim: The objectives of the study were to evaluate the presence of psychobiological distress and insecure attachment in transsexuals and to study their stress levels with reference to the hormonal treatment and the attachment pattern. Methods: We investigated 70 transsexual patients. We measured the cortisol levels and the perceived stress before starting the hormonal therapy and after about 12 months. We studied the representation of attachment in transsexuals by a backward investigation in the relations between them and their caregivers. Main Outcome Measures: We used blood samples for assessing cortisol awakening response (CAR); we used the Perceived Stress Scale for evaluating self‐reported perceived stress and the Adult Attachment Interview to determine attachment styles. Results: At enrollment, transsexuals reported elevated CAR; their values were out of normal. They expressed higher perceived stress and more attachment insecurity, with respect to normative sample data. When treated with hormone therapy, transsexuals reported significantly lower CAR (P < 0.001), falling within the normal range for cortisol levels. Treated transsexuals showed also lower perceived stress (P < 0.001), with levels similar to normative samples. The insecure attachment styles were associated with higher CAR and perceived stress in untreated transsexuals (P < 0.01). Treated transsexuals did not expressed significant differences in CAR and perceived stress by attachment. Conclusion: Our results suggested that untreated patients suffer from a higher degree of stress and that attachment insecurity negatively impacts the stress management. Initiating the hormonal treatment seemed to have a positive effect in reducing stress levels, whatever the attachment style may be.

Colton-Meier et al., 2011

Colton-Meier, S. L., Fitzgerald, K. M., Pardo, S. T., & Babcock, J. (2011). The effects of hormonal gender affirmation treatment on mental health in female-to-male transsexuals. Journal of Gay & Lesbian Mental Health , 15 (3), 281-299.

Hormonal interventions are an often-sought option for transgender individuals seeking to medically transition to an authentic gender. Current literature stresses that the effects and associated risks of hormone regimens should be monitored and well understood by health care providers (Feldman & Bockting, 2003). However, the positive psychological effects following hormone replacement therapy as a gender affirming treatment have not been adequately researched. This study examined the relationship of hormone replacement therapy, specifically testosterone, with various mental health outcomes in an Internet sample of more than 400 self-identified female-to-male transsexuals. Results of the study indicate that female-to-male transsexuals who receive testosterone have lower levels of depression, anxiety, and stress, and higher levels of social support and health related quality of life. Testosterone use was not related to problems with drugs, alcohol, or suicidality. Overall findings provide clear evidence that HRT is associated with improved mental health outcomes in female-to-male transsexuals.

Costantino et al., 2013

Costantino, A., Cerpolini, S., Alvisi, S., Morselli, P. G., Venturoli, S., & Meriggiola, M. C. (2013). A prospective study on sexual function and mood in female-to-male transsexuals during testosterone administration and after sex reassignment surgery. Journal of Sex & Marital Therapy , 39 (4), 321-335.

Testosterone administration in female-to-male transsexual subjects aims to develop and maintain the characteristics of the desired sex. Very little data exists on its effects on sexuality of female-to-male transsexuals. The aim of this study was to evaluate sexual function and mood of female-to-male transsexuals from their first visit, throughout testosterone administration and after sex reassignment surgery. Participants were 50 female-to-male transsexual subjects who completed questionnaires assessing sexual parameters and mood. The authors measured reproductive hormones and hematological parameters. The results suggest a positive effect of testosterone treatment on sexual function and mood in female-to-male transsexual subjects.

Davis and Meier, 2014

Davis, S. A. & Meier, S. C. (2014). Effects of testosterone treatment and chest reconstruction surgery on mental health and sexuality in female-to-male transgender people. International Journal of Sexual Health , 26 (2), 113-128.

Objectives: This study examined the effects of testosterone treatment with or without chest reconstruction surgery (CRS) on mental health in female-to-male transgender people (FTMs). Methods: More than 200 FTMs completed a written survey including quantitative scales to measure symptoms of anxiety and depression, feelings of anger, and body dissatisfaction, as well as qualitative questions assessing shifts in sexuality after the initiation of testosterone. Fifty-seven percent of participants were taking testosterone and 40% had undergone CRS. Results: Cross-sectional analysis using a between-subjects multivariate analysis of variance showed that participants who were receiving testosterone endorsed fewer symptoms of anxiety and depression as well as less anger than the untreated group. Participants who had CRS in addition to testosterone reported less body dissatisfaction than both the testosterone-only or the untreated groups. Furthermore, participants who were injecting testosterone on a weekly basis showed significantly less anger compared with those injecting every other week. In qualitative reports, more than 50% of participants described increased sexual attraction to nontransgender men after taking testosterone. Conclusions: Results indicate that testosterone treatment in FTMs is associated with a positive effect on mental health on measures of depression, anxiety, and anger, while CRS appears to be more important for the alleviation of body dissatisfaction. The findings have particular relevance for counselors and health care providers serving FTM and gender-variant people considering medical gender transition.

De Cuypere et al., 2006

De Cuypere, G., Elaut, E., Heylens, G., Maele, G. V., Selvaggi, G., et al. (2006). Long-term follow-up: Psychosocial outcome of Belgian transsexuals after sex reassignment surgery. Sexologies , 15 (2), 126-133.

Background: To establish the benefit of sex reassignment surgery (SRS) for persons with a gender identity disorder, follow-up studies comprising large numbers of operated transsexuals are still needed. Aims: The authors wanted to assess how the transsexuals who had been treated by the Ghent multidisciplinary gender team since 1985, were functioning psychologically, socially and professionally after a longer period. They also explored some prognostic factors with a view to refining the procedure. Method: From 107 Dutch-speaking transsexuals who had undergone SRS between 1986 and 2001, 62 (35 male-to-females and 27 female-to-males) completed various questionnaires and were personally interviewed by researchers, who had not been involved in the subjects’ initial assessment or treatment. Results: On the GAF (DSM-IV) scale the female-to-male transsexuals scored significantly higher than the male-to-females (85.2 versus 76.2). While no difference in psychological functioning (SCL-90) was observed between the study group and a normal population, subjects with a pre-existing psychopathology were found to have retained more psychological symptoms. The subjects proclaimed an overall positive change in their family and social life. None of them showed any regrets about the SRS. A homosexual orientation, a younger age when applying for SRS, and an attractive physical appearance were positive prognostic factors. Conclusion: While sex reassignment treatment is an effective therapy for transsexuals, also in the long term, the postoperative transsexual remains a fragile person in some respects.

Dhejne et al., 2014

Dhejne, C., Öberg, K., Arver, S., & Landén, M. (2014). An analysis of all applications for sex reassignment surgery in sweden, 1960-2010: Prevalence, incidence, and regrets. Archives of Sexual Behavior , 43 (8), 1535-1545.

Incidence and prevalence of applications in Sweden for legal and surgical sex reassignment were examined over a 50-year period (1960-2010), including the legal and surgical reversal applications. A total of 767 people (289 natal females and 478 natal males) applied for legal and surgical sex reassignment. Out of these, 89 % (252 female-to-males [FM] and 429 male-to-females [MF]) received a new legal gender and underwent sex reassignment surgery (SRS). A total of 25 individuals (7 natal females and 18 natal males), equaling 3.3 %, were denied a new legal gender and SRS. The remaining withdrew their application, were on a waiting list for surgery, or were granted partial treatment. The incidence of applications was calculated and stratified over four periods between 1972 and 2010. The incidence increased significantly from 0.16 to 0.42/100,000/year (FM) and from 0.23 to 0.73/100,000/year (MF). The most pronounced increase occurred after 2000. The proportion of FM individuals 30 years or older at the time of application remained stable around 30 %. In contrast, the proportion of MF individuals 30 years or older increased from 37 % in the first decade to 60 % in the latter three decades. The point prevalence at December 2010 for individuals who applied for a new legal gender was for FM 1:13,120 and for MF 1:7,750. The FM:MF sex ratio fluctuated but was 1:1.66 for the whole study period. There were 15 (5 MF and 10 MF) regret applications corresponding to a 2.2 % regret rate for both sexes. There was a significant decline of regrets over the time period.

Eldh, Berg, & Gustafsson, 1997

Eldh, J., Berg, A., Gustafsson, M. (1997). Long-term follow up after sex reassignment surgery. Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery , 27 (1), 39-45.

A long-term follow up of 136 patients operated on for sex reassignment was done to evaluate the surgical outcome. Social and psychological adjustments were also investigated by a questionnaire in 90 of these 136 patients. Optimal results of the operation are essential for a successful outcome. Personal and social instability before operation, unsuitable body build, and age over 30 years at operation correlated with unsatisfactory results. Adequate family and social support is important for postoperative functioning. Sex reassignment had no influence on the person’s ability to work.

Fisher et al., 2014

Fisher, A. D., Castellini, G., Bandini, E., Casale, H., Fanni, E., et al. (2014). Cross‐sex hormonal treatment and body uneasiness in individuals with gender dysphoria. The Journal of Sexual Medicine , 11 (3), 709–719.

Introduction: Cross‐sex hormonal treatment (CHT) used for gender dysphoria (GD) could by itself affect well‐being without the use of genital surgery; however, to date, there is a paucity of studies investigating the effects of CHT alone. Aims: This study aimed to assess differences in body uneasiness and psychiatric symptoms between GD clients taking CHT and those not taking hormones (no CHT). A second aim was to assess whether length of CHT treatment and daily dose provided an explanation for levels of body uneasiness and psychiatric symptoms. Methods: A consecutive series of 125 subjects meeting the criteria for GD who not had genital reassignment surgery were considered. Main Outcome Measures: Subjects were asked to complete the Body Uneasiness Test (BUT) to explore different areas of body‐related psychopathology and the Symptom Checklist‐90 Revised (SCL‐90‐R) to measure psychological state. In addition, data on daily hormone dose and length of hormonal treatment (androgens, estrogens, and/or antiandrogens) were collected through an analysis of medical records. Results: Among the male‐to‐female (MtF) individuals, those using CHT reported less body uneasiness compared with individuals in the no‐CHT group. No significant differences were observed between CHT and no‐CHT groups in the female‐to‐male (FtM) sample. Also, no significant differences in SCL score were observed with regard to gender (MtF vs. FtM), hormone treatment (CHT vs. no‐CHT), or the interaction of these two variables. Moreover, a two‐step hierarchical regression showed that cumulative dose of estradiol (daily dose of estradiol times days of treatment) and cumulative dose of androgen blockers (daily dose of androgen blockers times days of treatment) predicted BUT score even after controlling for age, gender role, cosmetic surgery, and BMI. Conclusions: The differences observed between MtF and FtM individuals suggest that body‐related uneasiness associated with GD may be effectively diminished with the administration of CHT even without the use of genital surgery for MtF clients. A discussion is provided on the importance of controlling both length and daily dose of treatment for the most effective impact on body uneasiness.

Glynn et al., 2016

Glynn, T. R., Gamarel, K. E., Kahler, C. W., Iwamoto, M., Operario, D., & Nemoto, T. (2016). The role of gender affirmation in psychological well-being among transgender women. Psychology Of Sexual Orientation And Gender Diversity , 3 (3), 336-344.

High prevalence of psychological distress, including greater depression, lower self-esteem, and suicidal ideation, has been documented across numerous samples of transgender women and has been attributed to high rates of discrimination and violence. According to the gender affirmation framework (Sevelius, 2013), access to sources of gender-affirmative support can offset such negative psychological effects of social oppression. However, critical questions remain unanswered in regards to how and which aspects of gender affirmation are related to psychological well-being. The aims of this study were to investigate the associations among 3 discrete areas of gender affirmation (psychological, medical, and social) and participants’ reports of psychological well-being. A community sample of 573 transgender women with a history of sex work completed a 1-time self-report survey that assessed demographic characteristics, gender affirmation, and mental health outcomes. In multivariate models, we found that social, psychological, and medical gender affirmation were significant predictors of lower depression and higher self-esteem whereas no domains of affirmation were significantly associated with suicidal ideation. Findings support the need for accessible and affordable transitioning resources for transgender women to promote better quality of life among an already vulnerable population. However, transgender individuals should not be portrayed simplistically as objects of vulnerability, and research identifying mechanisms to promote wellness and thriving is necessary for future intervention development. As the gender affirmation framework posits, the personal experience of feeling affirmed as a transgender person results from individuals’ subjective perceptions of need along multiple dimensions of gender affirmation. Thus, personalized assessment of gender affirmation may be a useful component of counseling and service provision for transgender women.

Gomez-Gil et al., 2012

Gomez-Gil, E., Zubiaurre-Elorz, L., Esteva, I., Guillamon, A., Godas, T., Cruz Almaraz, M., Halperin, I., Salamero, M. (2012). Hormone-treated transsexuals report less social distress, anxiety and depression. Psychoneuroendocrinology , 37 (5), 662-670.

Introduction: The aim of the present study was to evaluate the presence of symptoms of current social distress, anxiety and depression in transsexuals. Methods: We investigated a group of 187 transsexual patients attending a gender identity unit; 120 had undergone hormonal sex-reassignment (SR) treatment and 67 had not. We used the Social Anxiety and Distress Scale (SADS) for assessing social anxiety and the Hospital Anxiety and Depression Scale (HADS) for evaluating current depression and anxiety. Results: The mean SADS and HADS scores were in the normal range except for the HAD-Anxiety subscale (HAD-A) on the non-treated transsexual group. SADS, HAD-A, and HAD-Depression (HAD-D) mean scores were significantly higher among patients who had not begun cross-sex hormonal treatment compared with patients in hormonal treatment (F = 4.362, p = .038; F = 14.589, p = .001; F = 9.523, p = .002 respectively). Similarly, current symptoms of anxiety and depression were present in a significantly higher percentage of untreated patients than in treated patients (61% vs. 33% and 31% vs. 8% respectively). Conclusions: The results suggest that most transsexual patients attending a gender identity unit reported subclinical levels of social distress, anxiety, and depression. Moreover, patients under cross-sex hormonal treatment displayed a lower prevalence of these symptoms than patients who had not initiated hormonal therapy. Although the findings do not conclusively demonstrate a direct positive effect of hormone treatment in transsexuals, initiating this treatment may be associated with better mental health of these patients.

Gomez-Gil et al., 2014

Gómez-Gil, E., Zubiaurre-Elorza, L., de Antonio, E. D., Guillamon, A., & Salamero, M. (2014). Determinants of quality of life in Spanish transsexuals attending a gender unit before genital sex reassignment surgery. Quality of Life Research , 23 (2), 669-676.

Purpose: To evaluate the self-reported perceived quality of life (QoL) in transsexuals attending a Spanish gender identity unit before genital sex reassignment surgery, and to identify possible determinants that likely contribute to their QoL. Methods: A sample of 119 male-to-female (MF) and 74 female-to-male (FM) transsexuals were included in the study. The WHOQOL-BREF scale was used to evaluate self-reported QoL. Possible determinants included age, sex, education, employment, partnership status, undergoing cross-sex hormonal therapy, receiving at least one non-genital sex reassignment surgery, and family support (assessed with the family APGAR questionnaire). Results: Mean scores of all QoL domains ranged from 55.44 to 63.51. Linear regression analyses revealed that undergoing cross-sex hormonal treatment, having family support, and having an occupation were associated with a better QoL for all transsexuals. FM transsexuals have higher social domain QoL scores than MF transsexuals. The model accounts for 20.6 % of the variance in the physical, 32.5 % in the psychological, 21.9 % in the social, and 20.1 % in the environment domains, and 22.9 % in the global QoL factor. Conclusions: Cross-sex hormonal treatment, family support, and working or studying are linked to a better self-reported QoL in transsexuals. Healthcare providers should consider these factors when planning interventions to promote the health-related QoL of transsexuals.

Gorin-Lazard et al., 2012

Gorin‐Lazard, A., Baumstarck, K., Boyer, L., Maquigneau, A., Gebleux, S., Penochet, J., Pringuey, D., Albarel, F., Morange, I., Loundou, A., Berbis, J., Auquier, P., Lançon, C. and Bonierbale, M. (2012). Is hormonal therapy associated with better quality of life in transsexuals? A cross‐sectional study. The Journal of Sexual Medicine , 9 (2), 531–541.

Introduction: Although the impact of sex reassignment surgery on the self‐reported outcomes of transsexuals has been largely described, the data available regarding the impact of hormone therapy on the daily lives of these individuals are scarce. Aims: The objectives of this study were to assess the relationship between hormonal therapy and the self‐reported quality of life (QoL) in transsexuals while taking into account the key confounding factors and to compare the QoL levels between transsexuals who have, vs. those who have not, undergone cross‐sex hormone therapy as well as between transsexuals and the general population (French age‐ and sex‐matched controls). Methods: This study incorporated a cross‐sectional design that was conducted in three psychiatric departments of public university teaching hospitals in France. The inclusion criteria were as follows: 18 years or older, diagnosis of gender identity disorder (302.85) according to the Diagnostic and Statistical Manual, fourth edition text revision (DSM‐IV TR), inclusion in a standardized sex reassignment procedure following the agreement of a multidisciplinary team, and pre‐sex reassignment surgery. Main Outcome Measure. QoL was assessed using the Short Form 36 (SF‐36). Results: The mean age of the total sample was 34.7 years, and the sex ratio was 1:1. Forty‐four (72.1%) of the participants received hormonal therapy. Hormonal therapy and depression were independent predictive factors of the SF‐36 mental composite score. Hormonal therapy was significantly associated with a higher QoL, while depression was significantly associated with a lower QoL. Transsexuals’ QoL, independently of hormonal status, did not differ from the French age‐ and sex‐matched controls except for two subscales of the SF‐36 questionnaire: role physical (lower scores in transsexuals) and general health (lower scores in controls). Conclusion: The present study suggests a positive effect of hormone therapy on transsexuals’ QoL after accounting for confounding factors. These results will be useful for healthcare providers of transgender persons but should be confirmed with larger samples using a prospective study design.

Gorin-Lazard et al., 2013

Gorin-Lazard, A., Baumstarck, K., Boyer, L., Maquigneau, A., Penochet, J. C., et al. (2013). Hormonal therapy is associated with better self-esteem, mood, and quality of life in transsexuals. Journal of Nervous and Mental Disease , 201 (11), 996–1000.

Few studies have assessed the role of cross-sex hormones on psychological outcomes during the period of hormonal therapy preceding sex reassignment surgery in transsexuals. The objective of this study was to assess the relationship between hormonal therapy, self-esteem, depression, quality of life (QoL), and global functioning. This study incorporated a cross-sectional design. The inclusion criteria were diagnosis of gender identity disorder (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision) and inclusion in a standardized sex reassignment procedure. The outcome measures were self-esteem (Social Self-Esteem Inventory), mood (Beck Depression Inventory), QoL (Subjective Quality of Life Analysis), and global functioning (Global Assessment of Functioning). Sixty-seven consecutive individuals agreed to participate. Seventy-three percent received hormonal therapy. Hormonal therapy was an independent factor in greater self-esteem, less severe depression symptoms, and greater “psychological-like” dimensions of QoL. These findings should provide pertinent information for health care providers who consider this period as a crucial part of the global sex reassignment procedure.

Hess et al., 2014

Hess, J., Neto, R. R., Panic, L., Rübben, H., & Senf, W. (2014). Satisfaction with male-to-female gender reassignment surgery: Results of a retrospective analysis. Deutsches Ärzteblatt International , 111 (47), 795–801.

Background: The frequency of gender identity disorder is hard to determine; the number of gender reassignment operations and of court proceedings in accordance with the German Law on Transsexuality almost certainly do not fully reflect the underlying reality. There have been only a few studies on patient satisfaction with male-to-female gender reassignment surgery. Methods: 254 consecutive patients who had undergone male-to-female gender reassignment surgery at Essen University Hospital’s Department of Urology retrospectively filled out a questionnaire about their subjective postoperative satisfaction. Results: 119 (46.9%) of the patients filled out and returned the questionnaires, at a mean of 5.05 years after surgery (standard deviation 1.61 years, range 1–7 years). 90.2% said their expectations for life as a woman were fulfilled postoperatively. 85.4% saw themselves as women. 61.2% were satisfied, and 26.2% very satisfied, with their outward appearance as a woman; 37.6% were satisfied, and 34.4% very satisfied, with the functional outcome. 65.7% said they were satisfied with their life as it is now. Conclusion: The very high rates of subjective satisfaction and the surgical outcomes indicate that gender reassignment surgery is beneficial. These findings must be interpreted with caution, however, because fewer than half of the questionnaires were returned.

Heylens et al., 2014

Heylens, G., Verroken, C., De Cock, S., T’Sjoen, G., & De Cuypere, G. (2014). Effects of different steps in gender reassignment therapy on psychopathology: a prospective study of persons with a gender identity disorder. The Journal of Sexual Medicine , 11 (1), 119–126.

Introduction: At the start of gender reassignment therapy, persons with a gender identity disorder (GID) may deal with various forms of psychopathology. Until now, a limited number of publications focus on the effect of the different phases of treatment on this comorbidity and other psychosocial factors. Aims: The aim of this study was to investigate how gender reassignment therapy affects psychopathology and other psychosocial factors. Methods: This is a prospective study that assessed 57 individuals with GID by using the Symptom Checklist‐90 (SCL‐90) at three different points of time: at presentation, after the start of hormonal treatment, and after sex reassignment surgery (SRS). Questionnaires on psychosocial variables were used to evaluate the evolution between the presentation and the postoperative period. The data were statistically analyzed by using SPSS 19.0, with significance levels set at P < 0.05. Main Outcome Measures: The psychopathological parameters include overall psychoneurotic distress, anxiety, agoraphobia, depression, somatization, paranoid ideation/psychoticism, interpersonal sensitivity, hostility, and sleeping problems. The psychosocial parameters consist of relationship, living situation, employment, sexual contacts, social contacts, substance abuse, and suicide attempt. Results: A difference in SCL‐90 overall psychoneurotic distress was observed at the different points of assessments (P = 0.003), with the most prominent decrease occurring after the initiation of hormone therapy (P < 0.001). Significant decreases were found in the subscales such as anxiety, depression, interpersonal sensitivity, and hostility. Furthermore, the SCL‐90 scores resembled those of a general population after hormone therapy was initiated. Analysis of the psychosocial variables showed no significant differences between pre‐ and postoperative assessments. Conclusions: A marked reduction in psychopathology occurs during the process of sex reassignment therapy, especially after the initiation of hormone therapy.

Imbimbo et al., 2009

Imbimbo, C., Verze, P., Palmieri, A., Longo, N., Fusco, F., Arcaniolo, D., & Mirone, V. (2009). A report from a single institute’s 14-year experience in treatment of male-to-female transsexuals. The Journal of Sexual Medicine , 6 (10), 2736–2745.

Introduction: Gender identity disorder or transsexualism is a complex clinical condition, and prevailing social context strongly impacts the form of its manifestations. Sex reassignment surgery (SRS) is the crucial step of a long and complex therapeutic process starting with preliminary psychiatric evaluation and culminating in definitive gender identity conversion. Aim: The aim of our study is to arrive at a clinical and psychosocial profile of male-to-female transsexuals in Italy through analysis of their personal and clinical experience and evaluation of their postsurgical satisfaction levels SRS. Methods: From January 1992 to September 2006, 163 male patients who had undergone gender-transforming surgery at our institution were requested to complete a patient satisfaction questionnaire. Main Outcome Measures: The questionnaire consisted of 38 questions covering nine main topics: general data, employment status, family status, personal relationships, social and cultural aspects, presurgical preparation, surgical procedure, and postsurgical sex life and overall satisfaction. Results: Average age was 31 years old. Seventy-two percent had a high educational level, and 63% were steadily employed. Half of the patients had contemplated suicide at some time in their lives before surgery and 4% had actually attempted suicide. Family and colleague emotional support levels were satisfactory. All patients had been adequately informed of surgical procedure beforehand. Eighty-nine percent engaged in postsurgical sexual activities. Seventy-five percent had a more satisfactory sex life after SRS, with main complications being pain during intercourse and lack of lubrication. Seventy-eight percent were satisfied with their neovagina’s esthetic appearance, whereas only 56% were satisfied with depth. Almost all of the patients were satisfied with their new sexual status and expressed no regrets. Conclusions: Our patients’ high level of satisfaction was due to a combination of a well-conducted preoperative preparation program, competent surgical skills, and consistent postoperative follow-up.

Johansson et al., 2010

Johansson, A., Sundbom, E., Höjerback, T., & Bodlund, O. (2010). A five-year follow-up study of Swedish adults with gender identity disorder. Archives of Sexual Behavior , 39 (6), 1429-1437.

This follow-up study evaluated the outcome of sex reassignment as viewed by both clinicians and patients, with an additional focus on the outcome based on sex and subgroups. Of a total of 60 patients approved for sex reassignment, 42 (25 male-to-female [MF] and 17 female-to-male [FM]) transsexuals completed a follow-up assessment after 5 or more years in the process or 2 or more years after completed sex reassignment surgery. Twenty-six (62%) patients had an early onset and 16 (38%) patients had a late onset; 29 (69%) patients had a homosexual sexual orientation and 13 (31%) patients had a non-homosexual sexual orientation (relative to biological sex). At index and follow-up, a semi-structured interview was conducted. At follow-up, 32 patients had completed sex reassignment surgery, five were still in process, and five—following their own decision—had abstained from genital surgery. No one regretted their reassignment. The clinicians rated the global outcome as favorable in 62% of the cases, compared to 95% according to the patients themselves, with no differences between the subgroups. Based on the follow-up interview, more than 90% were stable or improved as regards work situation, partner relations, and sex life, but 5–15% were dissatisfied with the hormonal treatment, results of surgery, total sex reassignment procedure, or their present general health. Most outcome measures were rated positive and substantially equal for MF and FM. Late-onset transsexuals differed from those with early onset in some respects: these were mainly MF (88 vs. 42%), older when applying for sex reassignment (42 vs. 28 years), and non-homosexually oriented (56 vs. 15%). In conclusion, almost all patients were satisfied with the sex reassignment; 86% were assessed by clinicians at follow-up as stable or improved in global functioning.

Keo-Meier et al., 2015

Keo-Meier, C. L., Herman, L. I., Reisner, S. L., Pardo, S. T., Sharp, C., & Babcock, J. C. (2015). Testosterone treatment and MMPI-2 improvement in transgender men: A prospective controlled study. Journal of Consulting and Clinical Psychology, 83 , 143-156.

Objective: Most transgender men desire to receive testosterone treatment in order to masculinize their bodies. In this study, we aimed to investigate the short-term effects of testosterone treatment on psychological functioning in transgender men. This is the 1st controlled prospective follow-up study to examine such effects. Method: We examined a sample of transgender men (n = 48) and nontransgender male (n = 53) and female (n = 62) matched controls (mean age = 26.6 years; 74% White). We asked participants to complete the Minnesota Multiphasic Personality Inventory (2nd ed., or MMPI–2; Butcher, Graham, Tellegen, Dahlstrom, & Kaemmer, 2001) to assess psychological functioning at baseline and at the acute posttreatment follow-up (3 months after testosterone initiation). Regression models tested (a) Gender × Time interaction effects comparing divergent mean response profiles across measurements by gender identity; (b) changes in psychological functioning scores for acute postintervention measurements, adjusting for baseline measures, comparing transgender men with their matched nontransgender male and female controls and adjusting for baseline scores; and (c) changes in meeting clinical psychopathological thresholds. Results: Statistically significant changes in MMPI–2 scale scores were found at 3-month follow-up after initiating testosterone treatment relative to baseline for transgender men compared with female controls (female template): reductions in Hypochondria (p < .05), Depression (p < .05), Hysteria (p < .05), and Paranoia (p < .01); and increases in Masculinity–Femininity scores (p < .01). Gender × Time interaction effects were found for Hysteria (p < .05) and Paranoia (p < .01) relative to female controls (female template) and for Hypochondria (p < .05), Depression (p < .01), Hysteria (p < .01), Psychopathic Deviate (p < .05), Paranoia (p < .01), Psychasthenia (p < .01), and Schizophrenia (p < .01) compared with male controls (male template). In addition, the proportion of transgender men presenting with co-occurring psychopathology significantly decreased from baseline compared with 3-month follow-up relative to controls (p < .05). Conclusions: Findings suggest that testosterone treatment resulted in increased levels of psychological functioning on multiple domains in transgender men relative to nontransgender controls. These findings differed in comparisons of transgender men with female controls using the female template and with male controls using the male template. No iatrogenic effects of testosterone were found. These findings suggest a direct positive effect of 3 months of testosterone treatment on psychological functioning in transgender men.

Kraemer et al., 2008

Kraemer, B., Delsignore, A., Schnyder, U., & Hepp, U. (2008). Body image and transsexualism. Psychopathology , 41 (2), 96-100.

Background: To achieve a detailed view of the body image of transsexual patients, an assessment of perception, attitudes and experiences about one’s own body is necessary. To date, research on the body image of transsexual patients has mostly covered body dissatisfaction with respect to body perception. Sampling and Methods: We investigated 23 preoperative (16 male-to-female and 7 female-to-male transsexual patients) and 22 postoperative (14 male-to-female and 8 female-to-male) transsexual patients using a validated psychological measure for body image variables. Results: We found that preoperative transsexual patients were insecure and felt unattractive because of concerns about their body image. However, postoperative transsexual patients scored high on attractiveness and self-confidence. Furthermore, postoperative transsexual patients showed low scores for insecurity and concerns about their body. Conclusions: Our results indicate an improvement of body image concerns for transsexual patients following standards of care for gender identity disorder. Follow-up studies are recommended to confirm the assumed positive outcome of standards of care on body image.

Landen et al., 1998

Landén, M., Wålinder, J., Hambert, G., & Lundström, B. (1998). Factors predictive of regret in sex reassignment. Acta Psychiatrica Scandinavica , 97 (4), 284-289.

The objective of this study was to evaluate the features and calculate the frequency of sex-reassigned subjects who had applied for reversal to their biological sex, and to compare these with non-regretful subjects. An inception cohort was retrospectively identified consisting of all subjects with gender identity disorder who were approved for sex reassignment in Sweden during the period 1972-1992. The period of time that elapsed between the application and this evaluation ranged from 4 to 24 years. The total cohort consisted of 218 subjects. The results showed that 3.8% of the patients who were sex reassigned during 1972-1992 regretted the measures taken. The cohort was subdivided according to the presence or absence of regret of sex reassignment, and the two groups were compared. The results of logistic regression analysis indicated that two factors predicted regret of sex reassignment, namely lack of support from the patient’s family, and the patient belonging to the non-core group of transsexuals. In conclusion, the results show that the outcome of sex reassignment has improved over the years. However, the identified risk factors indicate the need for substantial efforts to support the families and close friends of candidates for sex reassignment.

Lawrence, 2003

Lawrence, A. A. (2003). Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Archives of Sexual Behavior , 32 (4), 299-315.

This study examined factors associated with satisfaction or regret following sex reassignment surgery (SRS) in 232 male-to-female transsexuals operated on between 1994 and 2000 by one surgeon using a consistent technique. Participants, all of whom were at least 1-year postoperative, completed a written questionnaire concerning their experiences and attitudes. Participants reported overwhelmingly that they were happy with their SRS results and that SRS had greatly improved the quality of their lives. None reported outright regret and only a few expressed even occasional regret. Dissatisfaction was most strongly associated with unsatisfactory physical and functional results of surgery. Most indicators of transsexual typology, such as age at surgery, previous marriage or parenthood, and sexual orientation, were not significantly associated with subjective outcomes. Compliance with minimum eligibility requirements for SRS specified by the Harry Benjamin International Gender Dysphoria Association was not associated with more favorable subjective outcomes. The physical results of SRS may be more important than preoperative factors such as transsexual typology or compliance with established treatment regimens in predicting postoperative satisfaction or regret.

Lawrence, 2006

Lawrence, A. A. (2006). Patient-reported complications and functional outcomes of male-to-female sex reassignment surgery. Archives of Sexual Behavior , 35 (6), 717-727.

This study examined preoperative preparations, complications, and physical and functional outcomes of male-to-female sex reassignment surgery (SRS), based on reports by 232 patients, all of whom underwent penile-inversion vaginoplasty and sensate clitoroplasty, performed by one surgeon using a consistent technique. Nearly all patients discontinued hormone therapy before SRS and most reported that doing so created no difficulties. Preoperative electrolysis to remove genital hair, undergone by most patients, was not associated with less serious vaginal hair problems. No patients reported rectal-vaginal fistula or deep-vein thrombosis and reports of other significant surgical complications were uncommon. One third of patients, however, reported urinary stream problems. No single complication was significantly associated with regretting SRS. Satisfaction with most physical and functional outcomes of SRS was high; participants were least satisfied with vaginal lubrication, vaginal touch sensation, and vaginal erotic sensation. Frequency of achieving orgasm after SRS was not significantly associated with most general measures of satisfaction. Later years of surgery, reflecting greater surgeon experience, were not associated with lower prevalence rates for most complications or with better ratings for most physical and functional outcomes of SRS.

Lobato et al., 2006

Lobato M. I., Koff, W. J., Manenti, C., da Fonseca Seger, D., Salvador, J., et al. (2006). Follow-up of sex reassignment surgery in transsexuals: a Brazilian cohort.  Archives of Sexual Behavior, 35(6) , 711–715.

This study examined the impact of sex reassignment surgery on the satisfaction with sexual experience, partnerships, and relationship with family members in a cohort of Brazilian transsexual patients. A group of 19 patients who received sex reassignment between 2000 and 2004 (18 male- to-female, 1 female-to-male) after a two-year evaluation by a multidisciplinary team, and who agreed to participate in the study, completed a written questionnaire. Mean age at entry into the program was 31.21 ± 8.57 years and mean schooling was 9.2 ± 1.4 years. None of the patients reported regret for having undergone the surgery. Sexual experience was considered to have improved by 83.3% of the patients, and became more frequent for 64.7% of the patients. For 83.3% of the patients, sex was considered to be pleasurable with the neovagina/neopenis. In addition, 64.7% reported that initiating and maintaining a relationship had become easier. The number of patients with a partner increased from 52.6% to 73.7%. Family relationships improved in 26.3% of the cases, whereas 73.7% of the patients did not report a difference. None of the patients reported worse relationships

Manieri et al., 2014

Manieri, C., Castellano, E., Crespi, C., Di Bisceglie, C., Dell’Aquila, C., et al. (2014). Medical treatment of subjects with gender identity disorder: The experience in an Italian public health center. International Journal Of Transgenderism , 15 (2), 53-65.

Hormonal treatment is the main element during the transition program for transpeople. The aim of this paper is to describe the care and treatment of subjects, highlighting both the endocrine-metabolic effects of the hormonal therapy and the quality of life during the first year of cross-sex therapy in an Italian gender team. We studied 83 subjects (56 male-to-female [MtF], 27 female-to-male [FtM]) with hematological and hormonal evaluations every 3 months during the first year of hormonal therapy. MtF persons were treated with 17βestradiol and antiandrogens (cyproterone acetate, spironolactone, dutasteride); FtM persons were treated with transdermal or intramuscular testosterone. The WHO Quality of Life questionnaire was administered at the beginning and 1 year later. Hormonal changes paralleled phenotype modifications with wide variability. Most of both MtF and FtM subjects reported a statistically significant improvement in body image (p < 0.05). In particular, MtF subjects reported a statistically significant improvement in the quality of their sexual life and in the general quality of life (p < 0.05) 1 year after treatment initiation. Cross-sex therapy seems to be free of major risks in healthy subjects under clinical supervision during the first year. Selected subjects show an optimal adaptation to hormone-induced neuropsychological modifications and satisfaction regarding general and sexual life.

Megeri and Khoosal, 2007

Megeri, D., & Khoosal, D. (2007). Anxiety and depression in males experiencing gender dysphoria. Sexual & Relationship Therapy , 22 (1), 77-81.

Objective: The aim of the study was to compare anxiety and depression scores for the first 40 male to female people experiencing gender dysphoria attending the Leicester Gender Identity Clinic using the same sample as control pre and post gender realignment surgery. Hypothesis: There is an improvement in the scores of anxiety and depression following gender realignment surgery among people with gender dysphoria (male to female – transwomen). Results: There was no significant change in anxiety and depression scores in people with gender dysphoria (male to female) pre- and post-operatively.

Nelson, Whallett, & Mcgregor, 2009

Nelson, L., Whallett, E., & McGregor, J. (2009). Transgender patient satisfaction following reduction mammaplasty. Journal of Plastic, Reconstructive & Aesthetic Surgery , 62 (3), 331-334.

Aim: To evaluate the outcome of reduction mammaplasty in female-to-male transgender patients. Method: A 5-year retrospective review was conducted on all female-to-male transgender patients who underwent reduction mammaplasty. A postal questionnaire was devised to assess patient satisfaction, surgical outcome and psychological morbidity. Results: Seventeen patients were identified. The senior author performed bilateral reduction mammaplasties and free nipple grafts in 16 patients and one patient had a Benelli technique reduction. Complications included two haematomas, one wound infection, one wound dehiscence and three patients had hypertrophic scars. Secondary surgery was performed in seven patients and included scar revision, nipple reduction/realignment, dog-ear correction and nipple tattooing. The mean follow-up period after surgery was 10 months (range 2–23 months). Twelve postal questionnaires were completed (response rate 70%). All respondents expressed satisfaction with their result and no regret. Seven patients had nipple sensation and nine patients were satisfied with nipple position. All patients thought their scars were reasonable and felt that surgery had improved their self-confidence and social interactions. Conclusion: Reduction mammaplasty for female-to-male gender reassignment is associated with high patient satisfaction and a positive impact on the lives of these patients.

Newfield et al., 2006

Newfield, E., Hart, S., Dibble, S., & Kohler, L. (2006). Female-to-male transgender quality of life. Quality of Life Research , 15 (9), 1447-1457.

Objectives: We evaluated health-related quality of life in female-to-male (FTM) transgender individuals, using the Short-Form 36-Question Health Survey version 2 (SF-36v2). Methods: Using email, Internet bulletin boards, and postcards, we recruited individuals to an Internet site ( http://www.transurvey.org ), which contained a demographic survey and the SF36v2. We enrolled 446 FTM transgender and FTM transsexual participants, of which 384 were from the US. Results: Analysis of quality of life health concepts demonstrated statistically significant (p<0.0\) diminished quality of life among the FTM transgender participants as compared to the US male and female population, particularly in regard to mental health. FTM transgender participants who received testosterone (67%) reported statistically significant higher quality of life scores (/?<0.01) than those who had not received hormone therapy. Conclusions: FTM transgender participants reported significantly reduced mental health-related quality of life and

Padula, Heru, & Campbell, 2016

Padula, W. V., Heru, S. & Campbell, J. D. (2016). Societal implications of health insurance coverage for medically necessary services in the U.S. transgender population: A cost-effectiveness analysis. Journal of General Internal Medicine , 31 ( 4), 394-401.

Background: Recently, the Massachusetts Group Insurance Commission (GIC) prioritized research on the implications of a clause expressly prohibiting the denial of health insurance coverage for transgender-related services. These medically necessary services include primary and preventive care as well as transitional therapy. Objective: To analyze the cost-effectiveness of insurance coverage for medically necessary transgender-related services. Design: Markov model with 5- and 10-year time horizons from a U.S. societal perspective, discounted at 3 % (USD 2013). Data on outcomes were abstracted from the 2011 National Transgender Discrimination Survey (NTDS). Patients: U.S. transgender population starting before transitional therapy. Interventions: No health benefits compared to health insurance coverage for medically necessary services. This coverage can lead to hormone replacement therapy, sex reassignment surgery, or both. Main Measures: Cost per quality-adjusted life year (QALY) for successful transition or negative outcomes (e.g. HIV, depression, suicidality, drug abuse, mortality) dependent on insurance coverage or no health benefit at a willingness-to-pay threshold of $100,000/QALY. Budget impact interpreted as the U.S. per-member-per-month cost. Key Results: Compared to no health benefits for transgender patients ($23,619; 6.49 QALYs), insurance coverage for medically necessary services came at a greater cost and effectiveness ($31,816; 7.37 QALYs), with an incremental cost-effectiveness ratio (ICER) of $9314/QALY. The budget impact of this coverage is approximately $0.016 per member per month. Although the cost for transitions is $10,000–22,000 and the cost of provider coverage is $2175/year, these additional expenses hold good value for reducing the risk of negative endpoints —HIV, depression, suicidality, and drug abuse. Results were robust to uncertainty. The probabilistic sensitivity analysis showed that provider coverage was cost-effective in 85 % of simulations. Conclusions: Health insurance coverage for the U.S. transgender population is affordable and cost-effective, and has a low budget impact on U.S. society. Organizations such as the GIC should consider these results when examining policies regarding coverage exclusions.

Parola et al., 2010

Parola, N., Bonierbale, M., Lemaire, A., Aghababian, V., Michel, A., & Lançon, C. (2010). Study of quality of life for transsexuals after hormonal and surgical reassignment. Sexologies , 19 (1), 24-28.

Aim: The main objective of this work is to provide a more detailed assessment of the impact of surgical reassignment on the most important aspects of daily life for these patients. Our secondary objective was to establish the influence of various factors likely to have an impact on the quality of life (QoL), such as biological gender and the subject’s personality. Methods: A personality study was conducted using Eysenck Personality Inventory (EPI) so as to analyze two aspects of the personality (extraversion and neuroticism). Thirty-eight subjects who had undergone hormonal surgical reassignment were included in the study. Results: The results show that gender reassignment surgery improves the QoL for transsexuals in several different important areas: most are satisfied of their sexual reassignment (28/30), their social (21/30) and sexual QoL (25/30) are improved. However, there are differences between male-to-female (MtF) and female-to-male (FtM) transsexuals in terms of QoL: FtM have a better social, professional, friendly lifestyles than MtF. Finally, the results of this study did not evidence any influence by certain aspects of the personality, such as extraversion and neuroticism, on the QoL for reassigned subjects.

Pfäfflin, 1993

Pfäfflin, F. (1993). Regrets after sex reassignment surgery. Journal of Psychology & Human Sexuality , 5 (4), 69-85.

Using data draw from the follow-up literature covering the last 30 years, and the author’s clinical data on 295 men and women after SRS, an estimation of the number of patients who regretted the operations is made. Among female-to-male transsexuals after SRS, i.e., in men, no regrets were reported in the author’s sample, and in the literature they amount to less than 1%. Among male-to- female transsexuals after SRS, i.e., in women, regrets are reported in 1-1.5%. Poor differential diagnosis, failure to carry out the real-life- test, and poor surgical results seem to be the main reasons behind the regrets reported in the literature. According to three cases observed by the author in addition to personality traits the lack of proper care in treating the patients played a major role.

Pimenoff and Pfäfflin, 2011

Pimenoff, V., & Pfäfflin, F. (2011). Transsexualism: Treatment outcome of compliant and noncompliant patients. International Journal Of Transgenderism , 13 (1), 37-44.

The objective of the study was a follow-up of the treatment outcome of Finnish transsexuals who sought sex reassignment during the period 1970–2002 and a comparison of the results and duration of treatment of compliant and noncompliant patients. Fifteen male-to-female transsexuals and 17 female-to-male transsexuals who had undergone hormone and surgical treatment and legal sex reassignment in Finland completed a questionnaire on psychosocial data and on their experience with the different phases of clinical assessment and treatment. The changes in their vocational functioning and social and psychic adjustment were used as outcome indicators. The results and duration of the treatment of compliant and noncompliant patients were compared. The patients benefited significantly from treatment. The noncompliant patients achieved equally good results as the compliant ones, and did so in a shorter time. A good treatment outcome could be achieved even when the patient had told the assessing psychiatrist a falsified story of his life and sought hormone therapy, genital surgery, or legal sex reassignment on his own initiative without a recommendation from the psychiatrist. Based on these findings, it is recommended that the doctor-patient relationship be reconsidered and founded on frank cooperation.

Rakic et al., 1996

Rakic, Z., Starcevic, V., Maric, J., & Kelin, K. (1996). The outcome of sex reassignment surgery in Belgrade: 32 patients of both sexes. Archives of Sexual Behavior , 25 (5), 515-525.

Several aspects of the quality of life after sex reassignment surgery in 32 transsexuals of both sexes (22 men, 10 women) were examined. The Belgrade Team for Gender Identity Disorders designed a standardized questionnaire for this purpose. The follow-up period after operation was from 6 months to 4 years, and four aspects of the quality of life were examined: attitude towards the patients’ own body, relationships with other people, sexual activity, and occupational functioning. In most transsexuals, the quality of life was improved after surgery inasmuch as these four aspects are concerned. Only a few transsexuals were not satisfied with their life after surgery.

Rehman et al., 1999

Rehman, J., Lazer, S., Benet, A. E., Schaefer, L. C., & Melman, A. (1999). The reported sex and surgery satisfactions of 28 postoperative male-to-female transsexual patients. Archives of Sexual Behavior , 28 (1), 71-89.

From 1980 to July 1997 sixty-one male-to-female gender transformation surgeries were performed at our university center by one author (A.M.). Data were collected from patients who had surgery up to 1994 (n = 47) to obtain a minimum follow-up of 3 years; 28 patients were contacted. A mail questionnaire was supplemented by personal interviews with 11 patients and telephone interviews with remaining patients to obtain and clarify additional information. Physical and functional results of surgery were judged to be good, with few patients requiring additional corrective surgery. General satisfaction was expressed over the quality of cosmetic (normal appearing genitalia) and functional (ability to perceive orgasm) results. Follow-up showed satisfied who believed they had normal appearing genitalia and the ability to experience orgasm. Most patients were able to return to their jobs and live a more satisfactory social and personal life. One significant outcome was the importance of proper preparation of patients for surgery and especially the need for additional postoperative psychotherapy. None of the patients regretted having had surgery. However, some were, to a degree, disappointed because of difficulties experienced post operatively in adjusting satisfactorily as women both in their relationships with men and in living their lives generally as women. Findings of this study make a strong case for making a change in the Harry Benjamin Standards of Care to include a period of postoperative psychotherapy.

Rotondi et al., 2011

Rotondi, N. K., Bauer, G. R., Scanlon, K., Kaay, M., Travers, R., & Travers, A. (2011). Prevalence of and risk and protective factors for depression in female-to-male transgender Ontarians: Trans PULSE Project. Canadian Journal Of Community Mental Health , 30 (2), 135-155.

Although depression is understudied in transgender and transsexual communities, high prevalences have been reported. This paper presents original research from the Trans PULSE Project, an Ontario-wide, community-based initiative that surveyed 433 participants using respondent-driven sampling. The purpose of this analysis was to determine the prevalence of, and risk and protective factors for, depression among female-to-male (FTM) Ontarians (n = 207). We estimate that 66.4% of FTMs have symptomatology consistent with depression. In multivariable analyses, sexual satisfaction was a strong protective factor. Conversely, experiencing transphobia and being at the stage of planning but not having begun a medical transition (hormones and/or surgery) adversely affected mental health in FTMs.

Ruppin and Pfäfflin, 2015

Ruppin, U., & Pfäfflin, F. (2015). Long-term follow-up of adults with gender identity disorder. Archives of Sexual Behavior , 44 (5), 1321-1329.

The aim of this study was to re-examine individuals with gender identity disorder after as long a period of time as possible. To meet the inclusion criterion, the legal recognition of participants’ gender change via a legal name change had to date back at least 10 years. The sample comprised 71 participants (35 MtF and 36 FtM). The follow-up period was 10–24 years with a mean of 13.8 years (SD = 2.78). Instruments included a combination of qualitative and quantitative methods: Clinical interviews were conducted with the participants, and they completed a follow-up questionnaire as well as several standardized questionnaires they had already filled in when they first made contact with the clinic. Positive and desired changes were determined by all of the instruments: Participants reported high degrees of well-being and a good social integration. Very few participants were unemployed, most of them had a steady relationship, and they were also satisfied with their relationships with family and friends. Their overall evaluation of the treatment process for sex reassignment and its effectiveness in reducing gender dysphoria was positive. Regarding the results of the standardized questionnaires, participants showed significantly fewer psychological problems and interpersonal difficulties as well as a strongly increased life satisfaction at follow-up than at the time of the initial consultation. Despite these positive results, the treatment of transsexualism is far from being perfect.

Smith et al., 2005

Smith, Y. L. S., Van Goozen, S. H. M., Kuiper, A. J., & Cohen-Kettenis, P. (2005). Sex reassignment: Outcomes and predictors of treatment for adolescent and adult transsexuals. Psychological Medicine, 35 (1), 89-99.

Background: We prospectively studied outcomes of sex reassignment, potential differences between subgroups of transsexuals, and predictors of treatment course and outcome. Method: Altogether 325 consecutive adolescent and adult applicants for sex reassignment participated: 222 started hormone treatment, 103 did not; 188 completed and 34 dropped out of treatment. Only data of the 162 adults were used to evaluate treatment. Results between subgroups were compared to determine post-operative differences. Adults and adolescents were included to study predictors of treatment course and outcome. Results were statistically analysed with logistic regression and multiple linear regression analyses. Results: After treatment the group was no longer gender dysphoric. The vast majority functioned quite well psychologically, socially and sexually. Two non-homosexual male-to-female transsexuals expressed regrets. Post-operatively, female-to-male and homosexual transsexuals functioned better in many respects than male-to-female and non-homosexual transsexuals. Eligibility for treatment was largely based upon gender dysphoria, psychological stability, and physical appearance. Male-to-female transsexuals with more psychopathology and cross-gender symptoms in childhood, yet less gender dysphoria at application, were more likely to drop out prematurely. Non-homosexual applicants with much psychopathology and body dissatisfaction reported the worst post-operative outcomes. Conclusions: The results substantiate previous conclusions that sex reassignment is effective. Still, clinicians need to be alert for non-homosexual male-to-females with unfavourable psychological functioning and physical appearance and inconsistent gender dysphoria reports, as these are risk factors for dropping out and poor post-operative results. If they are considered eligible, they may require additional therapeutic guidance during or even after treatment.

van de Grift et al., 2017

van de Grift, T. C., Elaut, E., Cerwenka, S. C., Cohen-Kettenis, P. T., Cuypere, G. D., Richter-Appelt, H., & Kreukels, B. P. (2017). Effects of medical interventions on gender dysphoria and body image. Psychosomatic Medicine , 79 (7), 815-823.

Objective: The aim of this study from the European Network for the Investigation of Gender Incongruence is to investigate the status of all individuals who had applied for gender confirming interventions from 2007 to 2009, irrespective of whether they received treatment. The current article describes the study protocol, the effect of medical treatment on gender dysphoria and body image, and the predictive value of (pre)treatment factors on posttreatment outcomes. Methods: Data were collected on medical interventions, transition status, gender dysphoria (Utrecht Gender Dysphoria Scale), and body image (Body Image Scale for transsexuals). In total, 201 people participated in the study (37% of the original cohort). Results: At follow-up, 29 participants (14%) did not receive medical interventions, 36 hormones only (18%), and 136 hormones and surgery (68%). Most transwomen had undergone genital surgery, and most transmen chest surgery. Overall, the levels of gender dysphoria and body dissatisfaction were significantly lower at follow-up compared with clinical entry. Satisfaction with therapy responsive and unresponsive body characteristics both improved. High dissatisfaction at admission and lower psychological functioning at follow-up were associated with persistent body dissatisfaction. Conclusions: Hormone-based interventions and surgery were followed by improvements in body satisfaction. The level of psychological symptoms and the degree of body satisfaction at baseline were significantly associated with body satisfaction at follow-up.

van de Grift, T. C., Elaut, E., Cerwenka, S. C., Cohen-Kettenis, P. T., & Kreukels, B. P. (2017). Surgical satisfaction, quality of life, and their association after gender-affirming surgery: A follow-up study. Journal of Sex & Marital Therapy , 44 (2), 138-148.

We assessed the outcomes of gender-affirming surgery (GAS, or sex-reassignment surgery) 4 to 6 years after first clinical contact, and the associations between postoperative (dis)satisfaction and quality of life (QoL). Our multicenter, cross-sectional follow-up study involved persons diagnosed with gender dysphoria (DSM-IV-TR) who applied for medical interventions from 2007 until 2009. Of 546 eligible persons, 201 (37%) responded, of whom 136 had undergone GAS (genital, chest, facial, vocal cord and/or thyroid cartilage surgery). Main outcome measures were procedure performed, self-reported complications, and satisfaction with surgical outcomes (standardized questionnaires), QoL (Satisfaction With Life Scale, Subjective Happiness Scale, Cantril Ladder), gender dysphoria (Utrecht Gender Dysphoria Scale), and psychological symptoms (Symptom Checklist-90). Postoperative satisfaction was 94% to 100%, depending on the type of surgery performed. Eight (6%) of the participants reported dissatisfaction and/or regret, which was associated with preoperative psychological symptoms or self-reported surgical complications (OR= 6.07). Satisfied respondents’ QoL scores were similar to reference values; dissatisfied or regretful respondents’ scores were lower. Therefore, dissatisfaction after GAS may be viewed as indicator of unfavorable psychological and QoL outcomes.

Vujovic et al., 2009

Vujovic, S., Popovic, S., Sbutega-Milosevic, G., Djordjevic, M., & Gooren, L. (2009). Transsexualism in Serbia: A twenty-year follow-up study. The Journal of Sexual Medicine , 6 (4), 1018-1023.

Introduction: Gender dysphoria occurs in all societies and cultures. The prevailing social context has a strong impact on its manifestations as well as on applications by individuals with the condition for sex reassignment treatment. Aim: To describe a transsexual population seeking sex reassignment treatment in Serbia, part of former Yugoslavia. Methods: Data, collated over a period of 20 years, from subjects applying for sex reassignment to the only center in Serbia, were analyzed retrospectively. Main Outcome Measures: Age at the time of application, demographic data, family background, sex ratio, the prevalence of polycystic ovarian syndrome (PCOS) among female-to-male (FTM) transsexuals, and readiness to undergo surgical sex reassignment were tabulated. Results: Applicants for sex reassignment in Serbia are relatively young. The sex ratio is close to 1:1. They often come from single-child families. More than 10% do not wish to undergo surgical sex reassignment. The prevalence of PCOS among FTM transsexuals was higher than in the general population but considerably lower than that reported in the literature from other populations. Of those who had undergone sex reassignment, none expressed regret for their decision. Conclusions: Although transsexualism is a universal phenomenon, the relatively young age of those applying for sex reassignment and the sex ratio of 1:1 distinguish the population in Serbia from others reported in the literature.

Weigert et al., 2013

Weigert, R., Frison, E., Sessiecq, Q., Al Mutairi, K., & Casoli, V. (2013). Patient satisfaction with breasts and psychosocial, sexual, and physical well-being after breast augmentation in male-to-female transsexuals. Plastic and Reconstructive Surgery, 132 (6), 1421-1429.

Background: Satisfaction with breasts, sexual well-being, psychosocial well-being, and physical well-being are essential outcome factors following breast augmentation surgery in male-to-female transsexual patients. The aim of this study was to measure change in patient satisfaction with breasts and sexual, physical, and psychosocial well-being after breast augmentation in male-to-female transsexual patients. Methods: All consecutive male-to-female transsexual patients who underwent breast augmentation between 2008 and 2012 were asked to complete the BREAST-Q Augmentation module questionnaire before surgery, at 4 months, and later after surgery. A prospective cohort study was designed and postoperative scores were compared with baseline scores. Satisfaction with breasts and sexual, physical, and psychosocial outcomes assessment was based on the BREAST-Q. Results: Thirty-five male-to-female transsexual patients completed the questionnaires. BREAST-Q subscale median scores (satisfaction with breasts, +59 points; sexual well-being, +34 points; and psychosocial well-being, +48 points) improved significantly (p < 0.05) at 4 months postoperatively and later. No significant change was observed in physical well-being. Conclusions: In this prospective, noncomparative, cohort study, the current results suggest that the gains in breast satisfaction, psychosocial well-being, and sexual well-being after male-to-female transsexual patients undergo breast augmentation are statistically significant and clinically meaningful to the patient at 4 months after surgery and in the long term.

Weyers et al., 2009

Weyers, S., Elaut, E., De Sutter, P., Gerris, J., T’Sjoen, G., et al. (2009). Long-term assessment of the physical, mental, and sexual health among transsexual women. The Journal of Sexual Medicine , 6 (3), 752-760.

Introduction: Transsexualism is the most extreme form of gender identity disorder and most transsexuals eventually pursue sex reassignment surgery (SRS). In transsexual women, this comprises removal of the male reproductive organs, creation of a neovagina and clitoris, and often implantation of breast prostheses. Studies have shown good sexual satisfaction after transition. However, long-term follow-up data on physical, mental and sexual functioning are lacking. Aim: To gather information on physical, mental, and sexual well-being, health-promoting behavior and satisfaction with gender-related body features of transsexual women who had undergone SRS. Methods: Fifty transsexual women who had undergone SRS >or=6 months earlier were recruited. Main Outcome Measures: Self-reported physical and mental health using the Dutch version of the Short-Form-36 (SF-36) Health Survey; sexual functioning using the Dutch version of the Female Sexual Function Index (FSFI). Satisfaction with gender-related bodily features as well as with perceived female appearance; importance of sex, relationship quality, necessity and advisability of gynecological exams, as well as health concerns and feelings of regret concerning transition were scored. Results: Compared with reference populations, transsexual women scored good on physical and mental level (SF-36). Gender-related bodily features were shown to be of high value. Appreciation of their appearance as perceived by others, as well as their own satisfaction with their self-image as women obtained a good score (8 and 9, respectively). However, sexual functioning as assessed through FSFI was suboptimal when compared with biological women, especially the sublevels concerning arousal, lubrication, and pain. Superior scores concerning sexual function were obtained in those transsexual women who were in a relationship and in heterosexuals. Conclusions: Transsexual women function well on a physical, emotional, psychological and social level. With respect to sexuality, they suffer from specific difficulties, especially concerning arousal, lubrication, and pain.

Back to Top

Below are 4 studies that contain mixed or null findings on the effect of gender transition on transgender well-being. Click here to jump to the 17 studies that consist of literature reviews or guidelines that help advance knowledge about the effect of gender transition on transgender well-being . Click here to jump to the 51 studies that found that gender transition improves the well-being of transgender people .

Barrett, 1998.

Barrett J. (1998). Psychological and social function before and after phalloplasty. The International Journal of Transgenderism , 2 (1), 1-8.

There are no quantitative assessments of the benefits of phalloplasty in a female transsexual population. The study addresses this question, comparing transsexuals accepted for such surgery with transsexuals after such surgery has been performed. A population of 23 transsexuals accepted for phalloplasty was compared to a population of 40 who had undergone such surgery between six and one hundred and sixty months previously. The General Health Questionnaire (GHQ), Symptom Checklist 90 (SCL-90), Bem Sex Role Inventory and Social Role Performance Schedule (SRPS) were employed. Additionally, a questionnaire assessing satisfaction with cosmetic appearance, sexual function, relationship and urinary function was used, along with a semi-structured interview quantifying alcohol, cigarette and drug usage, and current sexual practice. There were significant differences between the populations. The post operative group showed higher depression ratings on the depression subscale of the GHQ. The masculine pre-operative Bem scores were neutral post-operatively as feminine sub-scores increased. There was improved satisfaction with genital appearance post-operatively, but satisfaction with relationships fell, although to a non-significant extent. Most other changes were in the expected direction but did not achieve significance. Transsexuals accepted for phalloplasty have very good psychological health. Tendency to further improvement is the case after phalloplasty. Depression is commoner, however, and quality of relationships declines somewhat, perhaps in consequence. Surgeons might advise partners as well as patients of realistic expectations from such surgery.

Lindqvist et al., 2017

Lindqvist, E. K., Sigurjonsson, H., Möllermark, C., Rinder, J., Farnebo, F., et al. (2017). Quality of life improves early after gender reassignment surgery in transgender women. European Journal of Plastic Surgery , 40 (3), 223-226.

Background: Few studies have examined the long-term quality of life (QoL) of individuals with gender dysphoria, or how it is affected by treatment. Our aim was to examine the QoL of transgender women undergoing gender reassignment surgery (GRS). Methods: We performed a prospective cohort study on 190 patients undergoing male-to-female GRS at Karolinska University Hospital between 2003 and 2015. We used the Swedish version of the Short Form-36 Health Survey (SF-36), which measures QoL across eight domains. The questionnaire was distributed to patients pre-operatively, as well as 1, 3, and 5 years post-operatively. The results were compared between the different measure points, as well as between the study group and the general population. Results: On most dimensions of the SF-36 questionnaire, transgender women reported a lower QoL than the general population. The scores of SF-36 showed a non-significant trend to be lower 5 years post-GRS compared to pre-operatively, a decline consistent with that of the general population. Self-perceived health compared to 1 year previously rose in the first post-operative year, after which it declined. Conclusions: To our knowledge, this is the largest prospective study to follow a group of transgender patients with regards to QoL over continuous temporal measure points. Our results show that transgender women generally have a lower QoL compared to the general population. GRS leads to an improvement in general well-being as a trend but over the long-term, QoL decreases slightly in line with that of the comparison group. Level of evidence: Level III, therapeutic study.

Simonsen et al., 2016

Simonsen, R. K., Giraldi, A., Kristensen, E., & Hald, G. M. (2016). Long-term follow-up of individuals undergoing sex reassignment surgery: Psychiatric morbidity and mortality. Nordic Journal Of Psychiatry , 70 (4), 241-247.

Background: There is a lack of long-term register-based follow-up studies of sex-reassigned individuals concerning mortality and psychiatric morbidity. Accordingly, the present study investigated both mortality and psychiatric morbidity using a sample of individuals with transsexualism which comprised 98% (n = 104) of all individuals in Denmark. Aims: (1) To investigate psychiatric morbidity before and after sex reassignment surgery (SRS) among Danish individuals who underwent SRS during the period of 1978–2010. (2) To investigate mortality among Danish individuals who underwent SRS during the period of 1978–2010.Method: Psychiatric morbidity and mortality were identified by data from the Danish Psychiatric Central Research Register and the Cause of Death Register through a retrospective register study of 104 sex-reassigned individuals. Results: Overall, 27.9% of the sample were registered with psychiatric morbidity before SRS and 22.1% after SRS (p = not significant). A total of 6.7% of the sample were registered with psychiatric morbidity both before and after SRS. Significantly more psychiatric diagnoses were found before SRS for those assigned as female at birth. Ten individuals were registered as deceased post-SRS with an average age of death of 53.5 years. Conclusions: No significant difference in psychiatric morbidity or mortality was found between male to female and female to male (FtM) save for the total number of psychiatric diagnoses where FtM held a significantly higher number of psychiatric diagnoses overall. Despite the over-representation of psychiatric diagnoses both pre- and post-SRS the study found that only a relatively limited number of individuals had received diagnoses both prior to and after SRS. This suggests that generally SRS may reduce psychological morbidity for some individuals while increasing it for others.

Udeze, 2008

Udeze, B., Abdelmawla, N., Khoosal, D., & Terry, T. (2008). Psychological functions in male-to-female transsexual people before and after surgery. Sexual & Relationship Therapy , 23 (2), 141-145.

Patients with gender dysphoria (GD) suffer from a constant feeling of psychological discomfort related to their anatomical sex. Gender reassignment surgery (GRS) attempts to release this discomfort. The aim of this study was to compare the functioning of a cohort or patients with GD before and after GRS. We hypothesized that there would be an improvement in the scores of the self-administered SCL-90R following gender reassignment surgery among male-to-female people with gender dysphoria. We studied 40 patients with a DSM-IV diagnosis of Gender Identity Disorder (GID) who attended Leicester Gender Identity Clinic. We compared their functioning as measured by Symptom Check List-90R (SCL-90R) which was administered to 40 randomly selected male-to-female patients before and within six months after GRS using the same sample as control pre-and post-surgery. There was no significant change in the different sub-scales of the SCL-90R scores in patients with male-to-female GID pre- and within six months post-surgery. The results of the study showed that GRS had no significant effect on functioning as measured by SCL-90R within six months of surgery. Our study has the advantage of reducing inter-subject variability by using the same patients as their own control. This study may be limited by the duration of reassessment post-surgery. Further studies with larger sample size and using other psychosocial scales are needed to elucidate on the effectiveness of surgical intervention on psychosocial parameters in patients with GD.

Below are 17 studies that consist of literature reviews or guidelines that help advance knowledge about the effect of gender transition on transgender well-being. Click here to jump to the 4 studies that contain mixed or null findings on the effect of gender transition on transgender well-being. Click here Click here to jump to the 51 studies that found that gender transition improves the well-being of transgender people .

American psychological, 2015.

Guidelines for psychological practice with transgender and gender nonconforming people. (2015). American Psychologist, 70 (9), 832-864.

In 2015, the American Psychological Association adopted Guidelines for Psychological Practice with Transgender and Gender Nonconforming Clients in order to describe affirmative psychological practice with transgender and gender nonconforming (TGNC) clients. There are 16 guidelines in this document that guide TGNC-affirmative psychological practice across the lifespan, from TGNC children to older adults. The Guidelines are organized into five clusters: (a) foundational knowledge and awareness; (b) stigma, discrimination, and barriers to care; (c) lifespan development; (d) assessment, therapy, and intervention; and (e) research, education, and training. In addition, the guidelines provide attention to TGNC people across a range of gender and racial/ethnic identities. The psychological practice guidelines also attend to issues of research and how psychologists may address the many social inequities TGNC people experience.

Bockting et al., 2016

Bockting, W., Coleman, E., Deutsch, M. B., Guillamon, A., Meyer, W., et al. (2016). Adult development and quality of life of transgender and gender nonconforming people. Current Opinion in Endocrinology & Diabetes and Obesity , 23 (2), 188–197.

Purpose of review: Research on the health of transgender and gender nonconforming people has been limited with most of the work focusing on transition-related care and HIV. The present review summarizes research to date on the overall development and quality of life of transgender and gender nonconforming adults, and makes recommendations for future research. Recent findings: Pervasive stigma and discrimination attached to gender nonconformity affect the health of transgender people across the lifespan, particularly when it comes to mental health and well-being. Despite the related challenges, transgender and gender nonconforming people may develop resilience over time. Social support and affirmation of gender identity play herein a critical role. Although there is a growing awareness of diversity in gender identity and expression among this population, a comprehensive understanding of biopsychosocial development beyond the gender binary and beyond transition is lacking. Summary: Greater visibility of transgender people in society has revealed the need to understand and promote their health and quality of life broadly, including but not limited to gender dysphoria and HIV. This means addressing their needs in context of their families and communities, sexual and reproductive health, and successful aging. Research is needed to better understand what factors are associated with resilience and how it can be effectively promoted.

Byne et al., 2012

Byne, W., Bradley, S.J., Coleman, E., et al. (2012). Report of the American Psychiatric Association task force on treatment of gender identity disorder. Archives of Sexual Behavior, 41 (4): 759–796.

Both the diagnosis and treatment of Gender Identity Disorder (GID) are controversial. Although linked, they are separate issues and the DSM does not evaluate treatments. The Board of Trustees (BOT) of the American Psychiatric Association (APA), therefore, formed a Task Force charged to perform a critical review of the literature on the treatment of GID at different ages, to assess the quality of evidence pertaining to treatment, and to prepare a report that included an opinion as to whether or not sufficient credible literature exists for development of treatment recommendations by the APA. The literature on treatment of gender dysphoria in individuals with disorders of sex development was also assessed. The completed report was accepted by the BOT on September 11, 2011. The quality of evidence pertaining to most aspects of treatment in all subgroups was determined to be low; however, areas of broad clinical consensus were identified and were deemed sufficient to support recommendations for treatment in all subgroups. With subjective improvement as the primary outcome measure, current evidence was judged sufficient to support recommendations for adults in the form of an evidence-based APA Practice Guideline with gaps in the empirical data supplemented by clinical consensus. The report recommends that the APA take steps beyond drafting treatment recommendations. These include issuing position statements to clarify the APA’s position regarding the medical necessity of treatments for GID, the ethical bounds of treatments of gender variant minors, and the rights of persons of any age who are gender variant, transgender or transsexual.

Carroll, 1999

Carroll, R. A. (1999). Outcomes of treatment for gender dysphoria. Journal of Sex Education and Therapy , 24 (3), 128–136.

This paper reviews the empirical research on the psychosocial outcomes of treatment for gender dysphoria. Recent research has highlighted the heterogeneity of transgendered experiences. There are four possible outcomes for patients who present with the dilemma of gender dysphoria: an unresolved outcome, acceptance of one’s given gender, engaging in a cross-gender role on a part-time basis, and making a full-time transition to the other gender role. Clinical work, but not empirical research, suggests that some individuals with gender dysphoria may come to accept their given gender role through psychological treatment. Many individuals find that it is psychologically sufficient to express the transgendered part of themselves through such activities as cross-dressing or gender blending. The large body of research on the outcome of gender reassignment surgery indicates that, for the majority of those who undergo this process, the outcome is positive. Predictors of a good outcome include good pre-reassignment psychological adjustment, family support, at least 1 year of living in the desired role, consistent use of hormones, psychological treatment, and good surgical outcomes. The outcome literature provides strong support for adherence to the Standards of Care of the Harry Benjamin International Gender Dysphoria Association. Implications to be drawn from this research include an appreciation of the diversity of transgendered experience, the need for more research on non-reassignment resolutions to gender dysphoria, and the importance of assisting the transgendered individual to identify the resolution that best suits him or her.

Cohen-Kettenis and Gooren, 1999

Cohen-Kettenis, P. T., & Gooren, L. J. G. (1999). Transsexualism: A review of etiology, diagnosis and treatment. Journal of Psychosomatic Research , 46 (4), 315-333.

Transsexualism is considered to be the extreme end of the spectrum of gender identity disorders characterized by, among other things, a pursuit of sex reassignment surgery (SRS). The origins of transsexualism are still largely unclear. A first indication of anatomic brain differences between transsexuals and nontranssexuals has been found. Also, certain parental (rearing) factors seem to be associated with transsexualism. Some contradictory findings regarding etiology, psychopathology and success of SRS seem to be related to the fact that certain subtypes of transsexuals follow different developmental routes. The observations that psychotherapy is not helpful in altering a crystallized cross-gender identity and that certain transsexuals do not show severe psychopathology has led clinicians to adopt sex reassignment as a treatment option. In many countries, transsexuals are now treated according to the Standards of Care of the Harry Benjamin International Gender Dysphoria Association, a professional organization in the field of transsexualism. Research on postoperative functioning of transsexuals does not allow for unequivocal conclusions, but there is little doubt that sex reassignment substantially alleviates the suffering of transsexuals. However, SRS is no panacea. Psychotherapy may be needed to help transsexuals in adapting to the new situation or in dealing with issues that could not be addressed before treatment.

Coleman et al., 2012

Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., et al. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism , 13 (4), 165-232.

The Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People is a publication of the World Professional Association for Transgender Health (WPATH). The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments. The SOC are based on the best available science and expert professional consensus. Because most of the research and experience in this field comes from a North American and Western European perspective, adaptations of the SOC to other parts of the world are necessary. The SOC articulate standards of care while acknowledging the role of making informed choices and the value of harm reduction approaches. In addition, this version of the SOC recognizes that treatment for gender dysphoria i.e., discomfort or distress that is caused by a discrepancy between persons gender identity and that persons sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) has become more individualized. Some individuals who present for care will have made significant self-directed progress towards gender role changes or other resolutions regarding their gender identity or gender dysphoria. Other individuals will require more intensive services. Health professionals can use the SOC to help patients consider the full range of health services open to them, in accordance with their clinical needs and goals for gender expression.

Committee on Health Care for Underserved, 2011

Committee Opinion No. 512: Health Care for Transgender Individuals. (2011). Obstetrics & Gynecology , 118 (6), 1454–1458.

Transgender individuals face harassment, discrimination, and rejection within our society. Lack of awareness, knowledge, and sensitivity in health care communities eventually leads to inadequate access to, underutilization of, and disparities within the health care system for this population. Although the care for these patients is often managed by a specialty team, obstetrician–gynecologists should be prepared to assist or refer transgender individuals with routine treatment and screening as well as hormonal and surgical therapies. The American College of Obstetricians and Gynecologists opposes discrimination on the basis of gender identity and urges public and private health insurance plans to cover the treatment of gender identity disorder.

Costa and Colizzi, 2016

Costa, R., & Colizzi, M. (2016). The effect of cross-sex hormonal treatment on gender dysphoria individuals’ mental health: A systematic review. Neuropsychiatric Disease and Treatment , 12 , 1953-1966.

Cross-sex hormonal treatment represents a main aspect of gender dysphoria health care pathway. However, it is still debated whether this intervention translates into a better mental well-being for the individual and which mechanisms may underlie this association. Although sex reassignment surgery has been the subject of extensive investigation, few studies have specifically focused on hormonal treatment in recent years. Here, we systematically review all studies examining the effect of cross-sex hormonal treatment on mental health and well-being in gender dysphoria. Research tends to support the evidence that hormone therapy reduces symptoms of anxiety and dissociation, lowering perceived and social distress and improving quality of life and self-esteem in both male-to-female and female-to-male individuals. Instead, compared to female-to-male individuals, hormone-treated male-to-female individuals seem to benefit more in terms of a reduction in their body uneasiness and personality-related psychopathology and an amelioration of their emotional functioning. Less consistent findings support an association between hormonal treatment and other mental health-related dimensions. In particular, depression, global psychopathology, and psychosocial functioning difficulties appear to reduce only in some studies, while others do not suggest any improvement in these domains. Results from longitudinal studies support more consistently the association between hormonal treatment and improved mental health. On the contrary, a number of cross-sectional studies do not support this evidence. This review provides possible biological explanation vs psychological explanation (direct effect vs indirect effect) for the hormonal treatment-induced better mental well-being. In conclusion, this review indicates that gender dysphoria-related mental distress may benefit from hormonal treatment intervention, suggesting a transient reaction to the nonsatisfaction connected to the incongruent body image rather than a stable psychiatric comorbidity. In this perspective, timely hormonal treatment intervention represents a crucial issue in gender dysphoria individuals’ mental health-related outcome.

Dhejne et al., 2016

Dhejne, C., Van Vlerken, R., Heylens, G., & Arcelus, J. (2016). Mental health and gender dysphoria: A review of the literature. International Review Of Psychiatry , 28 (1), 44-57.

Studies investigating the prevalence of psychiatric disorders among trans individuals have identified elevated rates of psychopathology. Research has also provided conflicting psychiatric outcomes following gender-confirming medical interventions. This review identifies 38 cross-sectional and longitudinal studies describing prevalence rates of psychiatric disorders and psychiatric outcomes, pre- and post-gender-confirming medical interventions, for people with gender dysphoria. It indicates that, although the levels of psychopathology and psychiatric disorders in trans people attending services at the time of assessment are higher than in the cis population, they do improve following gender-confirming medical intervention, in many cases reaching normative values. The main Axis I psychiatric disorders were found to be depression and anxiety disorder. Other major psychiatric disorders, such as schizophrenia and bipolar disorder, were rare and were no more prevalent than in the general population. There was conflicting evidence regarding gender differences: some studies found higher psychopathology in trans women, while others found no differences between gender groups. Although many studies were methodologically weak, and included people at different stages of transition within the same cohort of patients, overall this review indicates that trans people attending transgender health-care services appear to have a higher risk of psychiatric morbidity (that improves following treatment), and thus confirms the vulnerability of this population.

Gijs and Brewaeys, 2007

Gijs, L., & Brewaeys, A. (2007). Surgical treatment of gender dysphoria in adults and adolescents: Recent developments, effectiveness, and challenges. Annual Review of Sex Research , 18 (1), 178-224.

In 1990 Green and Fleming concluded that sex reassignment surgery (SRS) is an effective treatment for transsexuality because it reduced gender dysphoria drastically. Since 1990, many new outcome studies have been published, raising the question as to whether the conclusion of Green and Fleming still holds. After describing terminological and conceptual developments related to the treatment of gender identity disorder (GID), follow-up studies, including both adults and adolescents, of the outcomes of SRS are reviewed. Special attention is paid to the effects of SRS on gender dysphoria, sexuality, and regret. Despite methodological shortcomings of many of the studies, we conclude that SRS is an effective treatment for transsexualism and the only treatment that has been evaluated empirically with large clinical case series.

Gooren, 2011

Gooren, L. J. (2011). Care of transsexual persons. New England Journal of Medicine , 364 (13), 1251–1257.

This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author’s clinical recommendations. A healthy and successful 40-year-old man finds it increasingly difficult to live as a male. In childhood he preferred playing with girls and recalls feeling that he should have been one. Over time he has come to regard himself more and more as a female personality inhabiting a male body. After much agonizing, he has concluded that only sex reassignment can offer the peace of mind he craves. What would you advise? A healthy and successful 40-year-old man finds it increasingly difficult to live as a male. In childhood he preferred playing with girls and recalls feeling that he should have been one. Over time he has come to regard himself more and more as a female personality inhabiting a male body. After much agonizing, he has concluded that only sex reassignment can offer the peace of mind he craves. What would you advise?

Hembree et al., 2009

Hembree, W. C., Cohen-Kettenis, P., Delemarre-van de Waal, H. A., Gooren, L. J., Meyer, W., et al. (2009). Endocrine treatment of transsexual persons: An endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 94 (9), 3132–3154.

Objective: The aim was to formulate practice guidelines for endocrine treatment of transsexual persons. Evidence: This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe the strength of recommendations and the quality of evidence, which was low or very low. Consensus Process: Committees and members of The Endocrine Society, European Society of Endocrinology, European Society for Paediatric Endocrinology, Lawson Wilkins Pediatric Endocrine Society, and World Professional Association for Transgender Health commented on preliminary drafts of these guidelines. Conclusions: Transsexual persons seeking to develop the physical characteristics of the desired gender require a safe, effective hormone regimen that will 1) suppress endogenous hormone secretion determined by the person’s genetic/biologic sex and 2) maintain sex hormone levels within the normal range for the person’s desired gender. A mental health professional (MHP) must recommend endocrine treatment and participate in ongoing care throughout the endocrine transition and decision for surgical sex reassignment. The endocrinologist must confirm the diagnostic criteria the MHP used to make these recommendations. Because a diagnosis of transsexualism in a prepubertal child cannot be made with certainty, we do not recommend endocrine treatment of prepubertal children. We recommend treating transsexual adolescents (Tanner stage 2) by suppressing puberty with GnRH analogues until age 16 years old, after which cross-sex hormones may be given. We suggest suppressing endogenous sex hormones, maintaining physiologic levels of gender-appropriate sex hormones and monitoring for known risks in adult transsexual persons. Endocrine treatment of transsexual persons should include suppression of endogenous sex hormones, physiologic levels of gender-appropriate sex hormones, and suppression of puberty in adolescents (Tanner stage 2).

Michel et al., 2002

Michel, A., Ansseau, M., Legros, J., Pitchot, W., & Mormont, C. (2002). The transsexual: What about the future? European Psychiatry , 17 (6), 353-362.

Since the 1950s, sexual surgical reassignments have been frequently carried out. As this surgical therapeutic procedure is controversial, it seems important to explore the actual consequences of such an intervention and objectively evaluate its relevance. In this context, we have carried out a review of the literature. After looking at the methodological limitations of follow-up studies, the psychological, sexual, social, and professional futures of the individuals subject to a transsexual operation are presented. Finally, prognostic aspects are considered. In the literature, follow-up studies tend to show that surgical transformations have positive consequences for the subjects. In the majority of cases, transsexuals are very satisfied with their intervention and any difficulties experienced are often temporary and disappear within a year after the surgical transformation. Studies show that there is less than 1% of regrets, and a little more than 1% of suicides among operated subjects. The empirical research does not confirm the opinion that suicide is strongly associated with surgical transformation.

Murad et al., 2010

Murad, M. H., Elamin, M. B., Garcia, M. Z., Mullan, R. J., Murad, A., Erwin, P. J., & Montori, V. M. (2010). Hormonal therapy and sex reassignment: A systematic review and meta-analysis of quality of life and psychosocial outcomes. Clinical Endocrinology , 72 (2), 214-231.

Objective: To assess the prognosis of individuals with gender identity disorder (GID) receiving hormonal therapy as a part of sex reassignment in terms of quality of life and other self‐reported psychosocial outcomes. Methods: We searched electronic databases, bibliography of included studies and expert files. All study designs were included with no language restrictions. Reviewers working independently and in pairs selected studies using predetermined inclusion and exclusion criteria, extracted outcome and quality data. We used a random‐effects meta‐analysis to pool proportions and estimate the 95% confidence intervals (CIs). We estimated the proportion of between‐study heterogeneity not attributable to chance using the I2 statistic. Results: We identified 28 eligible studies. These studies enrolled 1833 participants with GID (1093 male‐to‐female, 801 female‐to‐male) who underwent sex reassignment that included hormonal therapies. All the studies were observational and most lacked controls. Pooling across studies shows that after sex reassignment, 80% of individuals with GID reported significant improvement in gender dysphoria (95% CI = 68–89%; 8 studies; I2 = 82%); 78% reported significant improvement in psychological symptoms (95% CI = 56–94%; 7 studies; I2 = 86%); 80% reported significant improvement in quality of life (95% CI = 72–88%; 16 studies; I2 = 78%); and 72% reported significant improvement in sexual function (95% CI = 60–81%; 15 studies; I2 = 78%). Conclusions: Very low quality evidence suggests that sex reassignment that includes hormonal interventions in individuals with GID likely improves gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life.

Reisner et al., 2016

Reisner, S. L., Poteat, T., Keatley, J., Cabral, M., Mothopeng, T., et al. (2016). Global health burden and needs of transgender populations: A review. The Lancet , 388 (10042), 412-436.

Transgender people are a diverse population affected by a range of negative health indicators across high-income, middle-income, and low-income settings. Studies consistently document a high prevalence of adverse health outcomes in this population, including HIV and other sexually transmitted infections, mental health distress, and substance use and abuse. However, many other health areas remain understudied, population-based representative samples and longitudinal studies are few, and routine surveillance efforts for transgender population health are scarce. The absence of survey items with which to identify transgender respondents in general surveys often restricts the availability of data with which to estimate the magnitude of health inequities and characterise the population-level health of transgender people globally. Despite the limitations, there are sufficient data highlighting the unique biological, behavioural, social, and structural contextual factors surrounding health risks and resiliencies for transgender people. To mitigate these risks and foster resilience, a comprehensive approach is needed that includes gender affirmation as a public health framework, improved health systems and access to health care informed by high quality data, and effective partnerships with local transgender communities to ensure responsiveness of and cultural specificity in programming. Consideration of transgender health underscores the need to explicitly consider sex and gender pathways in epidemiological research and public health surveillance more broadly.

Schmidt and Levine, 2015

Schmidt, L., & Levine, R. (2015). Psychological Outcomes and Reproductive Issues Among Gender Dysphoric Individuals. Endocrinology and Metabolism Clinics of North America , 44 (4), 773-785.

Gender dysphoria is a condition in which a person experiences discrepancy between the natal anatomic sex and the gender he or she identifies with, resulting in internal distress and a desire to live as the preferred gender. There is increasing demand for treatment, which includes suppression of puberty, cross-sex hormone therapy, and sex reassignment surgery. This article reviews longitudinal outcome data evaluating psychological well-being and quality of life among transgender individuals who have undergone cross-sex hormone treatment or sex reassignment surgery. Proposed methodologies for diagnosis and initiation of treatment are discussed, and the effects of cross-sex hormones and sex reassignment surgery on future reproductive potential.

White Hughto and Reisner, 2016

White Hughto, J. M., & Reisner, S. L. (2016). A systematic review of the effects of hormone therapy on psychological functioning and quality of life in transgender individuals. Transgender Health , 1 (1), 21–31.

Objectives: To review evidence from prospective cohort studies of the relationship between hormone therapy and changes in psychological functioning and quality of life in transgender individuals accessing hormone therapy over time. Data Sources: MEDLINE, PsycINFO, and PubMed were searched for relevant studies from inception to November 2014. Reference lists of included studies were hand searched. Results: Three uncontrolled prospective cohort studies, enrolling 247 transgender adults (180 male-to-female [MTF], 67 female-to-male [FTM]) initiating hormone therapy for the treatment of gender identity disorder (prior diagnostic term for gender dysphoria), were identified. The studies measured exposure to hormone therapy and subsequent changes in mental health (e.g., depression, anxiety) and quality of life outcomes at follow-up. Two studies showed a significant improvement in psychological functioning at 3–6 months and 12 months compared with baseline after initiating hormone therapy. The third study showed improvements in quality of life outcomes 12 months after initiating hormone therapy for FTM and MTF participants; however, only MTF participants showed a statistically significant increase in general quality of life after initiating hormone therapy. Conclusions: Hormone therapy interventions to improve the mental health and quality of life in transgender people with gender dysphoria have not been evaluated in controlled trials. Low quality evidence suggests that hormone therapy may lead to improvements in psychological functioning. Prospective controlled trials are needed to investigate the effects of hormone therapy on the mental health of transgender people.

Share this:

LGBT Community and Gender Equality in America

How it works

In America, the LGBT community is surrounded by queer excellence and promotes pride to those who support gay rights. However, the new liberal mindset of people regarding characteristics such as race and sexual orientation would not be possible without the relentless protesters and dedicated activists who fought hard to make their views heard through a movement that would greatly impact and shape the future of this country.

The word “equality” has been used a lot over our recent fight for rights but truly believe it is the most accurate term to convey what is so lacking for the LGBT community.

As a gay male I have an insight to this fight and the a connection to a community that has been oppressed, looked down on, fought prejudice and hate crimes and continues to fight ignorance and injustice on a daily basis. Children that are gay continue to go through the same shame and anguish that LGBT youth have gone through in the past. They are bullied and beaten by their classmates, neighbors and even their own families.

A main concern that should be brought up is the trans rights movement. A main issue that surrounds this topic is that “trans right = human rights”. Transgender people are deserving of their rights, whether they are a man or woman; they are still human. It isn’t very civil to strip them of the rights they receive at birth is unacceptable.

Most people believe that they deserve the rights they are granted by the government. An upstanding citizen who pays their taxes, serves their community and abides by the law should be afforded the rights of an American. However, not all citizens are afforded equal rights. Gay and lesbians are consistently denied rights that are typically taken for granted by the average American. Specifically, gay and lesbians couples are denied the right to marry even if they are upstanding citizens. They are held at an unfair disadvantage solely because of their sexual orientation. This discrimination must stop because gay and lesbian couples are law-abiding citizens too, who should be afforded the same rights as heterosexual couples.

One common problem that plagues gay and lesbian couples that are denied the right to marry is their inability to claim their partner’s social security after he or she has died. The Human Rights Campaign, which work to achieve equal rights for lesbian, gay, bi-sexual and transgender people, is supporting the effort to attain survivor benefits for domesticate partners. They believe, “Any alteration to the Social Security system must include partners of gays and lesbians in its definition of survivor”(Survivor Benefits 1). Currently, there are no programs that give homosexuals survivor benefits like the ones that are provided for heterosexuals who are married or divorced. Gay and lesbian partners are not able to claim benefits of their deceased, regardless of the fact that all working citizens heterosexual or homosexual pay into the Social Security system for survivor benefits (Survivor Benefits 1). Sadly, this leaves many gay and lesbian couples with an unstable retirement. The most disturbing fact is that even though homosexuals and heterosexual both pay the government for survivor benefits, even people who divorced can even claim survivor benefits whereas a lifelong gay/lesbian partner cannot (Survivor Benefits 1). This is blatant discrimination against people of different sexual orientation. This is only one example of how the government’s refusal to recognize same-sex marriages denies homosexuals rights that are supposedly protected by the state.

The ones who suffer the greatest repercussions of such prejudices are the children of gay and lesbian couples. Non-biological children of gays and lesbians cannot receive survivor benefits if the deceased partner did not legally adopt them. But how is this related to whether or not homosexuals should be allowed to marry? Same-sex couples do have the privilege of adopting children to begin a family of their own. However, they are often rejected because of their unmarried status. Even if the government does not wish to provide some financial security for homosexual couples, it should not punish the children of such relationships. The government directly discriminates against the children of same-sex marriages by not allowing them the same rights as children who have heterosexual parents. Children do not chose who their parents are regardless of your stance on the issue. The Human Rights Campaign has adopted the idea that, “any change must also define survivor to include non-biological children of gays and lesbians found in the changing American family”(Survivor Benefits 2). This is absolutely necessary because it is absurd that innocent children are being denied basic rights due to the sexual orientation of their parents. Death is a painful enough experience; nobody should not have to worry about their financial standings with the government after dealing with the loss of a loved one, let alone, a child. Survivor Benefits must include same-sex unions not only because it denies homosexuals rights that are regularly afforded to heterosexual couples; but because the children of these relationships are being discriminated against as well.

Homosexual’s lack of legal recognition effects them in numerous ways. The argument is much deeper then weather or not they should be married because they live together. If same-sex couples are paying taxes to build roads and help public schools like the heterosexual couples, they should be afforded the same rights. This is the exact argument the gays and lesbians of Vermont are using. In the Baker v. Vermont court case, “gay and lesbian couples had argued that they were denied the protection of more than 300 laws as a result of not being allowed to marry” (Meredith 1). Homosexuals are finally suing the state because they are not receiving protection under the laws of state strictly because they are gay. In fact, the Vermont House of Representatives voted in favor (76-69) of a same-sex civil union bill. This shows that looking at the matter as a legal issue, it is evident that homosexuals are not regarded equally in the eyes of the law, and that the first steps to fix this social injustice are just now being taken; however, the controversy is still obvious as the vote is very close . The Director of Education for the Human Rights campaign state, “It’s a big step in the right direction…while its no full marriage, it’s very close.” Same-sex civil unions are clearing the path for nation-wide legal recognition of same-sex relationships. These same-sex civil marriages are demonstrating that the concept of “marriage” and the rights an American deserves, regardless of gender, race or sexual orientation, can be simultaneously respected. The fight is for gay and lesbian couples to gain legal recognition, not religious recognition.

Even most people against same-sex marriages agree that they do not hate gays they just disagree with their lifestyle because of their religious beliefs and church affiliation. The battle to legalize same-sex civil unions is not trying to infringe upon the beliefs of the churches. These unions are to be recognized by the state, not by all churches. Priests do not have to perform these ceremonies, nor do they have to be held in a church. It would be unfair for the government to decide in what people should and should not believe, this would be an infringement upon our right to freedom of religion. However, this does not give the government the right to discriminate against gay and lesbian couples in the eyes of the law because the government and religious beliefs are supposed to be separate. Weather same-sex civil unions should be recognized legally is not a religious question. This is a debate over whether or not people of different sexual orientation are to be viewed equally in the eyes of the government, and will be accepted into mainstream America.

However, some people argue that same-sex marriage would be tolerable if they were confined to their own communities. That way the general public would not be “subjected” to their practices. Gay people are not lepers. We can not isolate a faction of the population and force them to live in designated areas. This idea parallels the concept of moving all the Native Americans onto reservations. Thinking such as this is archaic and regresses back to another closely related idea: segregation. Do people really want to repeat one of the largest social injustices of American history? As established by the segregation trials during the 1960’s and 1970’s, separate but equal is not equal. It creates a division and a difference.

The trials that are now finally questioning the treatment of gay and lesbian couples are easily compared to those of inter-racial marriages. One example is the famous case of Loving vs. Virginia. In this case, a white man and black woman were married in Washington D.C., however, their home state of Virginia fused to recognize the marriage and exiled them for twenty years. Later when they took the state of Virginia to court it was decided that they could not be denied the right to live where they pleased due to their inter-racial marriage (Oyez 1). This court decision is arguably one of the strongest forces in nation-wide legal recognition of inter-racial marriages. It is evident that the same-sex civil unions that are now being recognized in Vermont are slowly making the way for other states to join the movement. The Baker vs. Vermont case is a strong reminder of the troubles America once faced. Separate but equal is inherently unequal and unfair.

Therefore, it is necessary to set aside religious issues to look at this debate from a legal standpoint. It is necessary that the government recognize the civil unions of same sex couples because all citizens of the United States should be afforded equal rights regardless of race, gender or sexual orientation. It is because of this legal discrimination that homosexuals are denied such rights as hospital visitation, socials security and disability insurances. Discrimination is wrong. The first step in correcting social injustice must be taken soon. The issue of legal marriage between two people of the same- sex must be settled now to stop the discrimination that is openly occurring across America.

Cite this page

LGBT Community and Gender Equality in America. (2021, Jun 30). Retrieved from https://papersowl.com/examples/lgbt-community-and-gender-equality-in-america/

"LGBT Community and Gender Equality in America." PapersOwl.com , 30 Jun 2021, https://papersowl.com/examples/lgbt-community-and-gender-equality-in-america/

PapersOwl.com. (2021). LGBT Community and Gender Equality in America . [Online]. Available at: https://papersowl.com/examples/lgbt-community-and-gender-equality-in-america/ [Accessed: 30 Apr. 2024]

"LGBT Community and Gender Equality in America." PapersOwl.com, Jun 30, 2021. Accessed April 30, 2024. https://papersowl.com/examples/lgbt-community-and-gender-equality-in-america/

"LGBT Community and Gender Equality in America," PapersOwl.com , 30-Jun-2021. [Online]. Available: https://papersowl.com/examples/lgbt-community-and-gender-equality-in-america/. [Accessed: 30-Apr-2024]

PapersOwl.com. (2021). LGBT Community and Gender Equality in America . [Online]. Available at: https://papersowl.com/examples/lgbt-community-and-gender-equality-in-america/ [Accessed: 30-Apr-2024]

Don't let plagiarism ruin your grade

Hire a writer to get a unique paper crafted to your needs.

Our writers will help you fix any mistakes and get an A+!

Please check your inbox.

You can order an original essay written according to your instructions.

Trusted by over 1 million students worldwide

1. Tell Us Your Requirements

2. Pick your perfect writer

3. Get Your Paper and Pay

Hi! I'm Amy, your personal assistant!

Don't know where to start? Give me your paper requirements and I connect you to an academic expert.

short deadlines

100% Plagiarism-Free

Certified writers

Share this via Facebook Share this via X Share this via WhatsApp Share this via Email Other ways to share Share this via LinkedIn Share this via Reddit Share this via Telegram Share this via Printer

Download the full report

Download the summary and recommendations in Tagalog

“Just Let Us Be”

Discrimination Against LGBT Students in the Philippines

A girl covers anti-LGBT messages in rainbow handprints during a Pride rally in Manila on June 27, 2015.  © 2015 Bullit Marquez/AP Photo.

[Senator and boxing legend] Manny Pacquiao says we’re not human. They should just let us be. – Edgar T., an 18-year-old gay high school student in Manila, February 2017

Schools should be safe places for everyone. But in the Philippines, students who are lesbian, gay, bisexual, and transgender (LGBT) too often find that their schooling experience is marred by bullying, discrimination, lack of access to LGBT-related information, and in some cases, physical or sexual assault. These abuses can cause deep and lasting harm and curtail students’ right to education, protected under Philippine and international law.

In recent years, lawmakers and school administrators in the Philippines have recognized that bullying of LGBT youth is a serious problem, and designed interventions to address it. In 2012, the Department of Education (DepEd), which oversees primary and secondary schools, enacted a Child Protection Policy designed to address bullying and discrimination in schools, including on the basis of sexual orientation and gender identity. The following year, Congress passed the Anti-Bullying Law of 2013, with implementing rules and regulations that enumerate sexual orientation and gender identity as prohibited grounds for bullying and harassment. The adoption of these policies sends a strong signal that bullying and discrimination are unacceptable and should not be tolerated in educational institutions.

But these policies, while strong on paper, have not been adequately enforced. In the absence of effective implementation and monitoring, many LGBT youth continue to experience bullying and harassment in school. The adverse treatment they experience from peers and teachers is compounded by discriminatory policies that stigmatize and disadvantage LGBT students and by the lack of information and resources about LGBT issues available in schools.

This report is based on interviews and group discussions conducted in 10 cities on the major Philippine islands of Luzon and the Visayas with 76 secondary school students or recent graduates who identified as LGBT or questioning, 22 students or recent graduates who did not identify as LGBT or questioning, and 46 parents, teachers, counselors, administrators, service providers, and experts on education. It examines three broad areas in which LGBT students encounter problems—bullying and harassment, discrimination on the basis of sexual orientation and gender identity, and a lack of information and resources—and recommends steps that lawmakers, DepEd, and school administrators should take to uphold LGBT students’ right to a safe and affirming educational environment.

The incidents described in this report illustrate the vital importance of expanding and enforcing protections for LGBT youth in schools. Despite prohibitions on bullying, for example, students across the Philippines described patterns of bullying and mistreatment that went unchecked by school staff. Carlos M., a 19-year-old gay student from Olongapo City, said: “When I was in high school, they’d push me, punch me. When I’d get out of school, they’d follow me [and] push me, call me ‘gay,’ ‘faggot,’ things like that.” While verbal bullying appeared to be the most prevalent problem that LGBT students faced, physical bullying and sexualized harassment were also worryingly common—and while students were most often the culprits, teachers ignored or participated in bullying as well. The effects of this bullying were devastating to the youth who were targeted. Benjie A., a 20-year-old gay man in Manila who was bullied throughout his education, said, “I was depressed, I was bullied, I didn’t know my sexuality, I felt unloved, and I felt alone all the time. And I had friends, but I still felt so lonely. I was listing ways to die.”

Share this via Facebook Share this via X Share this via WhatsApp Share this via Email Other ways to share Share this via LinkedIn Share this via Reddit Share this via Telegram

The mistreatment that students faced in schools was exacerbated by discriminatory policies and practices that excluded them from fully participating in the school environment. Schools impose rigid gender norms on students in a variety of ways—for example, through gendered uniforms or dress codes, restrictions on hair length, gendered restrooms, classes and activities that differ for boys and girls, and close scrutiny of same-sex friendships and relationships. For example, Marisol D., a 21-year-old transgender woman, said:

When I was in high school, there was a teacher who always went around and if you had long hair, she would call you up to the front of the class and cut your hair in front of the students. That happened to me many times. It made me feel terrible: I cried because I saw my classmates watching me getting my hair cut.

These policies are particularly difficult for transgender students, who are typically treated as their sex assigned at birth rather than their gender identity. But they can also be challenging for students who are gender non-conforming, and feel most comfortable expressing themselves or participating in activities that the school considers inappropriate for their sex.

Efforts to address discrimination against LGBT people have met with resistance, including by religious leaders. The Catholic Bishops’ Conference of the Philippines (CBCP) has condemned violence and discrimination against LGBT people, but in practice, the Roman Catholic Church has resisted laws and policies that would protect LGBT rights. The CBCP has sought to weaken anti-discrimination legislation pending before Congress, for example, and has opposed implementation of comprehensive sexuality education in schools. Representatives of the Church warn that recognizing LGBT rights will open the door to same-sex marriage, and oppose legislation that might promote divorce, euthanasia, abortion, total population control, and homosexual marriage, which they group under the acronym “DEATH.” In a country that is more than 80 percent Catholic, opposition from the Church influences how LGBT issues are addressed in families and schools, with many parents and teachers telling students that being LGBT is immoral or wrong.

One way that schools can address bullying and discrimination and ameliorate their effects is by providing educational resources to students, teachers, and staff to familiarize them with LGBT people and issues. Unfortunately, positive information and resources regarding sexual orientation and gender identity are exceedingly rare in secondary schools in the Philippines. When students do learn about LGBT people and issues in schools, the messages are typically negative, rejecting same-sex relationships and transgender identities as immoral or unnatural. Juan N., a 22-year-old transgender man who had attended high school in Manila, said, “There would be a lecture where they’d somehow pass by the topic of homosexuality and show you, try to illustrate that in the Bible, in Christian theology, homosexuality is a sin, and if you want to be a good Christian you shouldn’t engage in those activities.” Virtually all the students interviewed by Human Rights Watch said the limited sexuality education they received did not include information that was relevant to them as LGBT youth, and few reported having access to supportive guidance counselors or school personnel.

When students face these issues—whether in isolation or together—the school can become a difficult or hostile environment. In addition to physical and psychological injury, students described how bullying, discrimination, and exclusion caused them to lose concentration, skip class, or seek to transfer schools—all impairing their right to education. For the right to education to have meaning for all students—including LGBT students—teachers, administrators, and lawmakers need to work together with LGBT advocates to ensure that schools become safer and more inclusive places for LGBT children to learn.

Key Recommendations

To the congress of the philippines.

• Enact an anti-discrimination bill that prohibits discrimination on the basis of sexual orientation and gender identity, including in education, employment, health care, and public accommodations.

To the Department of Education

• Create a system to gather and publish data about bullying on the basis of sexual orientation and gender identity in schools. Revise forms to more clearly differentiate and record incidents of gender-based bullying on the basis of sex, sexual orientation, and gender identity, and include these categories on all forms related to bullying, abuse, or violence against children.
• Revise the standard sexuality education curriculum to ensure it aligns with UNESCO’s guidelines for comprehensive sexuality education, is medically and scientifically accurate, is inclusive of LGBT youth, and covers same-sex activity on equal footing with other sexual activity.
• Issue an order instructing schools to respect students’ gender identity with regard to dress codes, access to facilities, and participation in curricular and extracurricular activities.

To Local Officials

• Enact local ordinances to prohibit discrimination on the basis of sexual orientation and gender identity, particularly in education, employment, healthcare, and public accommodations.

To School Administrators

• Adopt anti-bullying and anti-discrimination policies that are inclusive of sexual orientation and gender identity, inform students how they should report incidents of bullying, and specify consequences for bullying.

Methodology

Human Rights Watch conducted the research for this report between September 2016 and February 2017 in 10 cities on the major islands of Luzon and the Visayas in the Philippines. To identify interviewees, we conducted outreach through LGBT student groups, particularly at the university level. Human Rights Watch interviewed members of those groups as well as students who were known to those groups, whether or not they had experienced discrimination in school. We sought interviews with students of diverse sexual orientations and gender identities, but gay boys and transgender girls were disproportionately represented among the students identified by LGBT groups and the students who attended the group discussions.

Human Rights Watch conducted a total of 144 interviews, including with 73 secondary school students or recent graduates who affirmatively identified as LGBT or questioning, 25 students or recent graduates who did not affirmatively identify as LGBT or questioning, and 46 parents, teachers, counselors, administrators, service providers, and experts on education. Of the LGBT students, 33 identified as gay, 12 identified as transgender girls, 10 identified as bisexual girls, 6 identified as lesbians, 4 identified only as “LGBT,” 3 identified as transgender boys, 2 identified as bisexual boys, 2 identified as questioning, and 1 identified as a panromantic girl.

Interviews were conducted in English or in Tagalog or Visayan with the assistance of a translator. No compensation was paid to interviewees. Whenever possible, interviews were conducted one-on-one in a private setting. Researchers also spoke with interviewees in pairs, trios, or small groups when students asked to meet together or when time and space constraints required meeting with members of student organizations simultaneously. Researchers obtained oral informed consent from interviewees after explaining the purpose of the interviews, how the material would be used, that interviewees did not need to answer any questions, and that they could stop the interview at any time. When students were interviewed in groups, those who were present but did not actively volunteer information were not counted in our final pool of interviewees.

Human Rights Watch sent a copy of the findings in this report by email, fax, and post to DepEd on May 15, 2017 to obtain their input on the issues students identified. Human Rights Watch requested input from DepEd by June 2, 2017 to incorporate their views into this report, but did not receive a response.

In this report, pseudonyms are used for all interviewees who are students, teachers, or administrators in schools. Unless requested by interviewees, pseudonyms are not used for individuals and organizations who work in a public capacity on the issues discussed in this report.

I. Background

The Philippines has a long history of robust LGBT advocacy. In 1996, LGBT individuals and groups held a solidarity march to commemorate Pride in Manila, which many activists describe as the first known Pride March in Asia. [1] Lawmakers began introducing bills to advance the rights of LGBT people in the country in 1995, including variations of a comprehensive anti-discrimination bill that has been reintroduced periodically since 2000. [2]

In the absence of federal legislation, local government units across the Philippines have begun to enact their own anti-discrimination ordinances that prohibit discrimination on the basis of sexual orientation and gender identity. As of June 2017, 15 municipalities and 5 provinces had ordinances prohibiting some forms of discrimination on the basis of sexual orientation or gender identity. [3] Attitudes toward LGBT people are relatively open and tolerant; a survey conducted in 2013 found that 73 percent of Filipinos believe “society should accept homosexuality,” up from 64 percent who believed the same in 2002. [4] President Rodrigo Duterte has generally been supportive of LGBT rights as well. During his time as mayor, Davao City passed an LGBT-inclusive anti-discrimination ordinance, and on the campaign trail, he vocally condemned bullying and discrimination against LGBT people. [5]

Nonetheless, many of the basic protections sought by activists remain elusive. A bill that would prohibit discrimination based on sexual orientation—and in later versions, gender identity—in employment, education, health care, housing, and other sectors has been regularly introduced in Congress since 2000. [6] The Anti-Discrimination Bill, or ADB, passed out of committee in the House of Representatives for the first time in 2015, but never received a second reading on the House floor and never passed out of committee in the Senate. [7] In the current Congress, the ADB has passed out of committee in the Senate for the first time, but at time of writing, it has not yet passed out of committee in the House. [8]

The anti-discrimination ordinances that have passed in the absence of federal legislation remain largely symbolic, as Quezon City is the only local government unit to follow the passage of its ordinance with implementing rules and regulations that are required to make such an ordinance enforceable. [9] Even if fully enforced, these municipal and provincial ordinances would collectively cover only 15 percent of the population of the Philippines. [10]

In a pair of decisions, the Supreme Court limited the possibility of legal gender recognition, ruling that intersex people may legally change their gender under existing law but transgender people may not. [11] The Philippines does not recognize same-sex partnerships, and although Duterte signaled openness to marriage equality in early 2016 while campaigning for the presidency and his legislative allies promised to support same-sex marriage legislation, he appeared to reverse course and express opposition to marriage equality in a speech in early 2017. [12] Moreover, HIV transmission rates have soared in recent years among men who have sex with men (MSM) and transgender women, due to a combination of stigma, a lack of comprehensive sexuality education, barriers to obtaining condoms, and laws that prevent children under age 18 from purchasing condoms or accessing HIV testing without parental consent. [13]

Many of the efforts to advance LGBT rights have met with resistance from the Catholic Church, which has been an influential political force on matters of sex and sexuality. While the CBCP rejects discrimination against LGBT people in principle, it has frequently opposed efforts to prohibit that discrimination in practice. In 2017, for example, the Church sought amendments to pending anti-discrimination legislation that would prohibit same-sex marriage and allow religious objectors to opt out of recognizing LGBT rights. [14] It has also resisted efforts to promote sexuality education and safer sex in schools. [15]

The Church vocally opposes divorce, euthanasia, abortion, total population control, and homosexual marriage—which it groups under the acronym “DEATH”—and rejects recognition of LGBT rights with particular fervor when it is concerned those rights might eventually open the door to same-sex unions. [16] Beyond its influence in law and policy, the Church has shaped attitudes toward homosexuality and transgender identities throughout the country; citing religious doctrine, teachers, counselors, and other authority figures often impress upon students that it is immoral or unnatural to be LGBT.

In spite of this opposition, activists’ lengthy efforts to engage policymakers on LGBT issues have led to important protections for LGBT youth, as discussed below. But these protections have not been effectively implemented. They will need to be strengthened and expanded if they are to uphold the rights of LGBT youth in schools.

Existing Protections for LGBT Youth and Their Limitations

Child protection policy.

In 2012, DepEd enacted a Child Protection Policy, which it describes as a “zero tolerance policy for any act of child abuse, exploitation, violence, discrimination, bullying and other forms of abuse.” [17] Among the acts prohibited by the policy are all forms of bullying and discrimination in schools, including on the basis of sexual orientation and gender identity. [18]

The policy requires all public and private schools to establish a “child protection committee,” which is to draft a school child protection policy to be reviewed every three years; develop programs to protect students and systems to identify, monitor, and refer cases of abuse; and coordinate with parents and government agencies. [19] The Child Protection Policy also details a clear protocol for handling bullying incidents and dictates that investigation by school personnel and reporting by the school head or schools division superintendent should be swift. [20]

As advocates have pointed out, however, monitoring and implementation of the Child Protection Policy is uneven. One analysis notes that “[u]nfortunately, no monitoring is done on its implementation and hence whether it is helping LGBT children in schools.” [21] A collective of LGBT organizations in early 2017 concluded “such mechanisms did not deter the prevalence of violence [LGBT] children experience.” [22] In interviews with Human Rights Watch, advocates and school personnel noted that many child protection committees are not trained to recognize or deal with LGBT issues, and overlook policies and practices, discussed below, that overtly discriminate against LGBT youth. [23]

The Anti-Bullying Law

In 2013, the Philippine Congress passed the Anti-Bullying Law of 2013, which instructs elementary and secondary schools to “adopt policies to address the existence of bullying in their respective institutions.” [24] At a minimum, these policies are supposed to prohibit bullying on or near school grounds, bullying and cyberbullying off school grounds that interferes with a student’s schooling, and retaliation against those who report bullying. The policies should also identify how bullying will be punished, establish procedures for reporting and redressing bullying, enable students to report bullying anonymously, educate students, parents, and guardians about bullying and the school’s policies to prevent and address it, and make a public record of statistics on bullying in the school. [25]

The Anti-Bullying Law does not specify classes of students at heightened risk for bullying. The implementing rules and regulations for the law, however, explain that the term “bullying” includes “gender-based bullying,” which “refers to any act that humiliates or excludes a person on the basis of perceived or actual sexual orientation and gender identity (SOGI).” [26] With the promulgation of these implementing rules and regulations, the Philippines became the first country in the region to specifically refer to bullying on the basis of sexual orientation and gender identity in its laws. [27]

The Anti-Bullying Law does not shield against all types of bullying, however. It does not account for instances where teachers bully LGBT youth. [28] As described in this report, many students and administrators are unaware of school bullying policies. Further, many students told Human Rights Watch that they did not feel comfortable reporting bullying, or did not know how to report bullying or what the consequences would be for themselves or the perpetrator. The datasets that DepEd releases regarding reported incidents do not disaggregate bullying on the basis of SOGI, so there is no available data to identify when such bullying occurs or what steps might be effective in preventing it. [29]

As with the Child Protection Policy, the implementation and monitoring of the Anti-Bullying Law has proven difficult. A United Nations Education, Scientific and Cultural Organization (UNESCO) report observed that only 38 percent of schools submitted child protection or anti-bullying policies in 2013, and the “low rate of submission has been attributed to a low level of awareness of requirements of the Act and weak monitoring of compliance.” [30]

Comprehensive Sexuality Education

LGBT rights activists in the Philippines have long called for comprehensive sexuality education in schools. In 2012, Congress passed the Responsible Parenthood and Reproductive Health Law, which provides that “[t]he State shall provide age- and development-appropriate reproductive health education to adolescents which shall be taught by adequately trained teachers.” [31] The law and its implementing rules and regulations require public schools to use the DepEd curriculum and allow private schools to use the curriculum or submit their own curriculum for approval from DepEd, promoting a uniform baseline of information in both private and public schools. [32] In response to lengthy delays, President Duterte issued an executive order in January 2017 requiring agencies to implement the law; in part, the order instructs DepEd to “implement a gender-sensitive and rights-based comprehensive sexuality education (CSE) in the school curriculum.” [33]

DepEd has previously incorporated some sexuality education materials into school curricula, but implementation is uneven. The sexuality education curriculum has not yet incorporated the recommendations developed by experts, teachers, parents, students, and other stakeholders, nor has it been accompanied to date by training to ensure that it is taught correctly and effectively. [34] At the time of writing, there were no sexuality education modules targeted at LGBT youth. [35]

Effects of Bullying and Discrimination

As DepEd and the Congress recognized with their initial efforts to address bullying in schools, exclusion and marginalization can exact a damaging toll on the rights and well-being of LGBT youth. In addition to the documentation contained in this report, data collected by the Philippine government, academics, and civil society organizations illustrate how bullying and harassment, discrimination, and a lack of access to information and resources are adversely affecting LGBT youth across the Philippines.

In the Philippines, as elsewhere, violence and discrimination place LGBT youth at heightened risk of adverse physical and mental health outcomes, including depression, anxiety, substance use, and suicide. [36] As the Psychological Association of the Philippines has noted, “LGBT Filipinos often confront social pressures to hide, suppress or even attempt to change their identities and expressions as conditions for their social acceptance and enjoyment of rights. Although many LGBTs learn to cope with this social stigma, these experiences can cause serious psychological distress, including immediate consequences such as fear, sadness, alienation, anger and internalized stigma.” [37] This has been borne out in small-scale empirical studies on LGBT youth and mental health in schools. One such study found that LGBT high schoolers were preoccupied with stigma, violence, bullying, discrimination in school, and anxiety over their future career prospects. [38] Nor do these problems end upon graduation from high school; another study determined that “LGBT college students exhibited extremely underdeveloped emotional and social capacity because they continue to experience stigma, prejudice and discrimination in the Philippine society that served as specific stressors that have an impact on their emotional and social intelligent behaviors.” [39]

On a broader scale, the increased risk of suicidal thoughts and attempts for LGBT youth is evident in nationally representative data. The results of the Young Adult Fertility and Sexuality Survey 3, for example, indicate that 16 percent of young gay and bisexual men in the Philippines had contemplated suicide, while only 8 percent of young heterosexual men had done so. [40] Young gay and bisexual men were also more likely to attempt suicide, with 39 percent of those who had contemplated suicide actually attempting suicide, compared to 26 percent of their heterosexual peers. [41] A similar trend was evident for young lesbian and bisexual women; 27 percent of young lesbian and bisexual women contemplated suicide compared to 18 percent of young heterosexual women, [42] and of those who considered suicide, 6.6 percent of lesbian and bisexual women made suicide attempts compared to only 3.9 percent of their heterosexual peers. [43] GALANG, a Philippine nongovernmental organization that works with lesbian and bisexual women and transgender people, found even higher rates among their constituencies. In a survey conducted in 2015, researchers from GALANG found that 18 percent of LBT respondents, who were almost all between the ages of 18 and 29, had attempted suicide. [44]

II. Bullying and Harassment

Whether it takes physical, verbal, or sexualized forms, in person or on social media, bullying endangers the safety, health, and education of LGBT youth. [45] Studies in the Philippines and elsewhere have found that, among young LGBT people, “low self-esteem and poor self-acceptance, combined with discrimination was also linked to destructive coping behaviours such as substance use or unprotected sex due to anxiety, isolation and depression.” [46] Benjie A., a 20-year-old gay man in Manila who was bullied throughout his education, said, “I was depressed, I was bullied, I didn’t know my sexuality, I felt unloved, and I felt alone all the time. And I had friends, but I still felt so lonely. I was listing ways to die.” [47]

When schools are unwelcoming, students may skip classes or drop out of school entirely. Felix P., a 22-year-old gay high school student in Legazpi, said, “I’ve skipped school because of teasing. In order to keep myself in a peaceful place, I tend not to go to school. Instead, I go to the mall or a friend’s house. I just get tired of the discrimination at school.” [48] Francis C., a 19-year-old gay student from Pulilan, said, “I just felt like I was so dumb. I wanted to stay at home, I didn’t want to go to school. And I would stay at home. Once I stayed at home for two weeks.” [49]

In many instances, the repercussions of bullying are long-lasting. Geoff Morgado, a social worker, observed that for some students bullying “turns into depression, because they feel they don’t belong,” and he believed that many students drop out because “[t]hey feel they don’t have a support group and feel isolated.” [50] Students who skip class, forgo educational opportunities, or drop out of school may experience the effects of these decisions throughout their lifespan. As a UNESCO report on school bullying notes, “[e]xclusion and stigma in education can also have life-long impacts on employment options, economic earning potential, and access to benefits and social protection.” [51]

Physical Bullying

In interviews with Human Rights Watch, students described physical bullying that took various forms, including punching, hitting, and shoving. Most of the students who described physical bullying to Human Rights Watch were gay and bisexual boys or transgender girls. These incidents persisted even after the passage of the Anti-Bullying Law. Carlos M., a 19-year-old gay student from Olongapo City, said: “When I was in high school, they’d push me, punch me. When I’d get out of school, they’d follow me [and] push me, call me ‘gay,’ ‘faggot,’ things like that.” [52] Felix P., a 22-year-old gay high school student in Legazpi, said, “People will throw books and notebooks at me, crumpled paper, chalk, erasers, and harder things, like a piece of wood.” [53] Benjie A., a 20-year-old gay man in Manila, said that once a classmate pushed him down the stairs at his high school, and added he still avoided his assailant as an adult for fear of physical violence. [54]

As detailed below, very few of the students interviewed reported bullying to teachers, either because they felt that reporting would not resolve the bullying or because they feared that reporting would lead to retaliation by other students and make the situation worse. In some instances, teachers also participated in harassment. Such behavior is not only discriminatory toward students of different sexual orientations and gender identities, but deters students from turning to teachers and administrators for help when they are bullied or harassed by their peers.

Sexual Assault and Harassment

For many LGBT students, bullying is often sexual in nature. Eric Manalastas, a professor of psychology at the University of the Philippines who has studied LGBT youth issues, observed “a theme of being highly sexualized and sexually harassed, especially for the gender non-conforming male students.” [55] Geoff Morgado, a social worker, described working with LGBT youth who told him that other students “grab the hand, or arm lock the child, or they force them into doggy style position. ‘This is what you want, right, this is what you want?’” [56] In interviews with Human Rights Watch, LGBT students described similar patterns of harassment and sexual assault in schools.

Gabby W., a 16-year-old transgender girl at a school in Bayombong, described a series of incidents that she experienced, including other students attempting to strip off her clothes in public, being forced into a restroom and sexually assaulted, and—on a separate occasion—being locked in a cubicle in a men’s restroom and sexually assaulted. [57]

Several gay or bisexual boys and transgender girls told Human Rights Watch that their fellow students had subjected them to simulated sexual activity or mock rape. Ruby S., a 16-year-old transgender girl who had attended high school in Batangas, described “[s]tudents acting like they were raping me, and then my friends saying, oh you enjoyed it, he’s cute. One of my classmates even said that LGBT people are lustful in nature, so it’s because you’re a flirt.” [58]

Gabriel K., a 19-year-old gay student who attended high school in Manila, similarly noted his classmates would “grab my hands, and they’d touch them to their private parts, and they’ll say to me that’s what gay is, that’s it.” [59] Jerome B., a 19-year-old gay man from Cebu City, recalled: “The worst thing, physically speaking, is they would—ironically, they hate gays, but they would dry hump me.… It was like rape to me. I felt violated.” [60]

Other LGBT students recounted slurs and stereotypes that were highly sexualized—for example, being catcalled in school or being labeled as sex workers. Sean B., a 17-year-old gay student in Bayombong, recalled how other students would shout “50 pesos, 50 pesos!” as he walked past, because “[t]hey think that we’re prostitutes.” [61] Gabby W., a 16-year-old transgender girl at the same school, said: “I feel bad about it—it’s so embarrassing. You’re walking around hundreds of people, and they shout that… and that shapes the perception of other people about us, that yelling by other people.” [62] Melvin O., a 22-year-old bisexual man from Malolos, recalled how in high school “people, especially the guys, would just sexually harass you, like you’re gay, you want my dick, stuff like that.” [63]

Rhye Gentoleo, a member of the Quezon City Pride Council, a city commission designed to enforce LGBT rights protections, observed that LGBT youth often face considerable pressure from heterosexual, cisgender peers to be sexually active because they are LGBT: “And that’s how the LGBT kids are being bullied as well. ‘Oh, you’re gay, can you satisfy me?’ They’re being challenged, how far can you go as a gay, how far can you go as a lesbian. And they have different ways of coping—some are hiding, but a lot of them are taking the challenge, being sexually active, without thinking of the consequences.” [64] As discussed below, the sexualization of LGBT youth is exacerbated by the absence of LGBT-inclusive sexuality education, which leaves many youth ill-equipped to protect themselves and their sexual health.

Verbal Harassment

The most common form of bullying that LGBT students reported in interviews with Human Rights Watch was verbal harassment. This included chants of “ bakla , bakla ,” “ bayot , bayot ,” “tomboy,” or “ tibo ,” using local terms for gay, lesbian, or transgender students in a mocking fashion. [65]

Daniel R., an 18-year-old gay student in Bacacay, said “People will say gay—they’ll say ‘gay, gay,’ repeating it, and insulting us.” [66] Ernesto N., a gay teacher in Cebu City, observed, “Here in the Philippines, being called bayot , it’s discrimination. It’s being told you’re nothing, you’re lower than dirt. That you’re a sinner, that you should go to Hell.” [67]

Many students described being labeled as sinners or aberrations. Leon S., a 19-year-old gay student from Malolos, said that “[s]tudents would say that homosexuality is a sin.” [68] Marco L., a 17-year-old gay student in Bacacay, said that “[p]eople say ipako sa krus , that you should be crucified.” [69] Gabriel K., a 19-year-old gay student who attended high school in Manila, said people told gay students “that you have to be crucified because you’re a sinner.” [70]

Anthony T., a gay student at a high school in Cebu City, said: “Some of my classmates who are religious say, ‘Why are you gay? It’s a sin. Only men and women are in the Bible.’ And I say, ‘I don’t want to be like this, but it’s what I’m feeling right now.’ Even if I try, I can’t change it. And if they ask why I am a gay and why do I like gays, I say, ‘it’s how I feel, I’ve tried, and I can’t be a man.’” [71]

Others described how they were treated as though they were diseased or contagious. Felix P., a 22-year-old gay high school student in Legazpi, noted: “Here, they call us ‘carriers’—there’s a stereotype that gays are responsible for HIV.” [72] Benjie A., a 20-year-old gay man in Manila, recalled a classmate telling him “don’t come near me because you’ll make me gay.” [73]

Some students noted verbal harassment that was predicated on the idea that their sexual orientation or gender identity was a choice. Analyn V., a 17-year-old bisexual girl in Mandaue City, observed, “It is inevitable that they’ll judge—like, you should date a real man instead of a lesbian because your beauty is wasted.” [74] Dalisay N., a 20-year-old panromantic woman who had attended high school in Manila, said: “When I was walking with my girlfriend, [other students] would tease us—they would say things like ‘it’s better if you have a boyfriend,’ or they would shout things like ‘you don’t even have a penis.’” [75]

The high levels of verbal harassment that LGBT youth faced in schools had repercussions for their experiences in schools. Teasing prompted some students to remain closeted, particularly in the absence of other positive resources to counteract negative messaging. Jerome B., a 19-year-old gay man from Cebu City, remarked, “For the majority of my life, I was in the closet. It’s really hard for me to express what I feel. In my school, being gay is really—it’s really the worst thing you could be. You’ll be treated like shit…. So being gay was a curse, I thought for a long time.” [76]

Some students altered their behavior or personality in an attempt to avoid disapproval from classmates. Patrick G., a 19-year-old gay man who had attended high school in Cainta, said:

They were teasing me for being effeminate. I developed this concept of how a man should walk, how a man should talk. It became—maybe because of them calling me malamya [effeminate], I became the person that I’m not. I was forced to be masculine, just for them to stop teasing me. [77]

Patrick’s experience is not unique. As one elementary school counselor observed, youth are “quite intimidated that kids will call them gay—even in Grade Six, you can tell that they don’t want to be called gay or lesbian.” [78] When verbal harassment became unbearable, some students removed themselves from the school environment entirely. Ella M., a 23-year-old transgender woman who had attended high school in Manila, noted that “[v]erbal bullying was why I transferred.” [79]

In addition to verbal harassment by peers, many LGBT students described verbal harassment and slurs from teachers and administrators. Patrick G., a 19-year-old gay man, said that at his high school in Cainta, “[s]ometimes teachers would join in with ‘ bakla , bakla .’” [80] Jerome B., a 19-year-old gay man from Cebu City, said that “it really feels bad, because the only figure you can count on is your teacher, and they’re joining in the fun, so who should I tell about my problems?” [81]

Often, disapproval from teachers was expressed in overtly religious terms. Wes L., an 18-year-old gay student at a high school in Bacacay, said, “My teacher in school told me that people are created by God, and God created man and woman. They say that gays are the black sheep of the family, and sinners.” [82] Danica J., a 19-year-old lesbian woman who had attended a high school in Cainta, described how a teacher “told me not to be lesbian anymore, and then he prayed over my head. He prayed for me. There were no supportive teachers at the school.” [83]

In some cases, disapproval from teachers was voiced in front of other students, reinforcing the idea that LGBT youth are wrong or immoral. Gabriel K., a 19-year-old gay student who attended high school in Manila, recalled how a teacher brought him before his peers and “compared me to the others—that being gay is not welcome into heaven, and made an example in front of the whole class.” [84] Benjie A., a 20-year-old gay man in Manila, recalled how a teacher in elementary school called him and two other effeminate students in front of her biology class to tell the students:

There’s no such thing as gays and lesbians. There’s man and woman, and marriage is only between a man and a woman.” And I was only turning 12—I hadn’t hit puberty at the time, and you’re telling me not to be gay!? How could I even tell? And everyone was looking at me—I was like, okay, teacher, I respect your religion, but come on, I’ve been bullied for five years. Haven’t I had enough? [85]

Cyberbullying

As students interact with their peers on social media and in other virtual spaces, cyberbullying has increasingly impacted LGBT youth in schools. LGBT students described anti-LGBT comments and slurs as well as rapidly spreading rumors facilitated by social media.

Leon S., a 19-year-old gay student from Malolos, said: “They would post things online, which is a far easier thing to do than say it personally.... I would post something, and they would comment about my sexual orientation. It was the usual, bakla , bading .” [86] Marisol D., a 21-year-old transgender woman, similarly noted, “Some of my friends would put comments like bakla , bakla on my posts. You just ignore it… [b]ecause if they see that you’re being affected they’ll bully you more.” [87] Carlos M., a 19-year-old gay student from Olongapo City, said, “My classmates would post stuff online—memes against LGBT, Satan saying ‘I’m waiting for you here.’” [88]

Jack M., an 18-year-old gay high school student in Bayombong, was a victim of rumors spread through social media: “They’ll make up stories. People will tell others [online] that I had sex with a person, even if it’s not true.” [89]

Cyberbullying also draws on stereotypes about LGBT students, and particularly transgender women and girls, with harsh disapprobation for those who were perceived to fall short of social expectations. Geoff Morgado, a social worker, observed that:

There are lots of trans women who are coming out on different platforms on social media, and they’re really bullied. Because people will base it on the looks—if you’re a trans woman, especially, they’ll say you’re not allowed to be a trans woman because you’re too ugly, or your skin is so dark. They say you have to be pretty, you have to be white, or you have to look like a woman before they decide you’re a transgender woman. [90]

Morgado added that many same-sex couples in schools must also contend with comments on social media criticizing their conformity to gender norms and the appropriateness of same-sex pairings. [91]

Intervention and Reporting

Human Rights Watch heard repeatedly that schools fail to instruct students about what bullying entails, how to report incidents when they occur, and what the repercussions will be. As a result, many schools convey tacit acceptance to perpetrators and leave victims unaware of whether or how they can seek help.

Both the Child Protection Policy and Anti-Bullying Law require that schools develop and convey policies regarding bullying and harassment. Nonetheless, many students interviewed by Human Rights Watch indicated they were unaware of the policies in place. Danica J., a 19-year-old lesbian woman who had attended high school in Cainta, said, “We didn’t get any information about bullying as high school students.” [92] Others said they had received some instruction on bullying, but it was incomplete or did not address LGBT issues. Leon S., a 19-year-old gay student from Malolos, said “[t]he school did anti-bullying seminars, but it didn’t really address bullying about your sexual identity—the seminar is more general in scope.” [93]

When students do not know how to report bullying and harassment or do not believe that reporting would be effective, they are unlikely to bring incidents to the attention of teachers and administrators. Jerome B., a 19-year-old gay man from Cebu City, said:

I would not tell the teacher. I was too ashamed. Because if I would tell the teacher, they would say, oh, you’re such a gay person, you have such weak feelings, you’re such a tattle tale. So I would just keep it to myself and endured the harassment for a long time, until I graduated. [94]

Some students attributed their reluctance to report bullying to the negative messages about LGBT people they’d received from teachers. Students identified negative messaging in various classes, including “values education,” a subject taught throughout secondary school to instill positive values and morals in Filipino youth. Although many students told Human Rights Watch that their values education courses were largely secular and focused on topics like respect and responsibility, others described overtly religious lessons that disparaged LGBT people. Dalisay N., a 20-year-old panromantic woman who had attended high school in Manila, remarked: “There’s a lot of teasing and bullying, but we don’t talk about it with teachers or counselors. I think that’s because of what they’re trying to teach us, in values education, things like that.” [95]

Interviews with LGBT students indicate that many teachers fail to intervene when they witness bullying or harassment occurring or it is brought to their attention, even since passage of the Anti-Bullying Law, which in turn discourages students from reporting cases of bullying. Analyn V., a 17-year-old bisexual girl in Mandaue City, said, “Teachers don’t step in. They think it’s a joke. But some jokes are below the belt. We conceal being hurt because maybe they think it’s overreacting.” [96] “The teachers don’t say anything or get mad —if they hear people saying bakla , they just smile or laugh,” said Felix P., a 22-year-old gay high school student in Legazpi. “Teachers might ask the students to stop, but they don’t punish them. And as soon as they leave, the bullying happens again.” [97]

In some instances, teachers and administrators may not have intervened because they had not received proper training or were unsure of their responsibilities. In one interview, a high-level administrator at a high school in Mandaue City remarked that she had never heard of the Anti-Bullying Law. [98] In another interview, a DepEd trainer and educator erroneously stated that the law did not cover LGBT students. [99] According to Rowena Legaspi of the Children’s Legal Rights and Development Center, uncertainty about existing protections is due in part to the tendency for school administrators to simply adopt policy templates from DepEd without tailoring them to the school environment, undergoing training, or fully understanding what is being implemented. [100]

As a coalition of Philippine organizations has noted, in many instances, “[b]ullying and other forms of violence within the schools or education settings is steered by institutional policies,” for example, “through gender-insensitive curricula, SOGI-insensitive school policies (e.g. required haircuts and dress codes), and [a] culture of bullying.” [101] As evidenced in the following sections, the many forms of exclusion and marginalization that LGBT youth experience in Philippine schools can reinforce one another. In schools where LGBT youth lack information and resources, for example, they may struggle more deeply with their sexual orientation or gender identity or be unsure where to turn for help. In schools where policies discriminate against LGBT youth, they may be placed in situations where bullying by peers is likely to occur and may feel administrators are unlikely to help them.

III. Creating a Hostile Environment

In addition to bullying and harassment, LGBT students encounter various forms of discrimination that make educational environments hostile or unwelcoming. To ensure that all youth feel safe and included in schools, school administrators should examine policies and practices that punish LGBT students for relationships that are considered acceptable for their heterosexual peers, restrict gender expression and access to facilities, and stereotype LGBT youth in a discriminatory manner.

Discrimination takes a toll on LGBT students’ mental health and ability to learn. Some students who encountered discrimination in schools reported that they struggled with depression and anxiety. [102] Others told Human Rights Watch that discrimination made it difficult to concentrate on the material or participate in class, [103] or caused them to skip classes, take a leave of absence, or drop out entirely. [104]

Both the Philippine Constitution and the Philippines’ international treaty obligations recognize a right to education. The UN Committee on Economic, Social and Cultural Rights has emphasized that the right to education, like other rights, must not be limited on the basis of sexual orientation or gender identity. [105] For educational environments to effectively serve all youth, they must treat LGBT youth the same as they treat their non-LGBT peers.

School Enforcement of Stereotyped Gender Norms

Uniforms and hair length restrictions.

It is common practice for secondary schools in the Philippines to require students to wear uniforms. Under these policies, the attire is gender-specific and the two options, male or female, are typically imposed upon students according to the sex they were assigned at birth.

In addition to clothing, many secondary schools have strict hair-length restrictions for their students, particularly for boys. Almost all interviewees reported that boys could not grow out their hair past ear-length or dye their hair at their schools, and many also noted that girls were prohibited from wearing their hair shorter than a permissible length.

Students whose gender expression differed from the norms associated with their sex assigned at birth told Human Rights Watch how these restrictions impeded their education. Students reported that being forced to dress or present themselves in a manner that was inconsistent with their gender expression made them unhappy [106] and uncomfortable, [107] lessened their confidence, [108] and impaired their concentration. [109] As Del M., a 14-year-old lesbian student who was allowed to wear the boys’ uniform, remarked, “It’s easier for me to learn wearing the boys’ uniform.” [110]

At many of these schools, students who did not conform to the uniform and hair-length requirements faced disciplinary action. Common punishments included being sent to the guidance or discipline offices and mandatory community service. Ella M., a 23-year-old transgender woman who had attended high school in Manila, described being punished solely on this basis of her general gender presentation. She said that her school’s handbook punished an “act of effeminacy,” not further defined, with “a conduct grade of 75, which basically means you did something really really bad. I might as well have cheated.” [111]

For many transgender or gender non-conforming students, the strict uniform and hair-length requirements were sources of intense anxiety and humiliation, and in some cases led to extended school absences and even leaving schooling entirely. [112]

Marisol D., a 21-year-old transgender woman, said:

When I was in high school, there was a teacher who always went around and if you had long hair, she would call you up to the front of the class and cut your hair in front of the students. That happened to me many times. It made me feel terrible. I cried because I saw my classmates watching me getting my hair cut. [113]

Other interviewees reported similar incidents in which teachers or prefects would publicly call out students in violation of the restrictions and forcibly cut their hair in front of the class.

Jerome B., a 19-year-old gay man, said that in his high school in Cebu City:

It applies for all boys. If [your hair] touches the ear and you don’t cut it, the school will cut it for you, and they do it in front of your classmates. The Student Affairs Officer who enforces the rules, once a month he would go to each classroom and knock, and say, “All those with long hair go outside,” and he would go one by one with these large, rusty scissors like the kind you see in horror movies, and they’d cut our hair in front of everybody…. I think on purpose, he’d cut it very badly. [114]

In most cases, teachers and administrators provided little to no explanation for the hair-length requirements when students asked about the policies at their respective schools. Felix P., a 22-year-old gay high school student in Legazpi, told Human Rights Watch:

Before, I used to have long hair. I entered the school grounds, but the school administrator asked me to cut [my] hair or else I couldn’t go in. So I was forced to cut my hair and wear the male uniform.… There’s no explanation about cutting the hair. I’ve asked them if having short or long hair will affect my performance as a student, and the administrators say, “No, you just have to cut your hair, you’re a boy.” [115]

As Lyn C., a 19-year-old transgender woman in Manila, recounted, gendered clothing requirements also extended to school-sponsored events such as prom nights:

For our prom night, I asked our principal if I could wear a gown, but he didn’t allow it. Back in high school I didn’t have long hair or makeup, so he said, “What would you look like as a boy wearing a gown? It’s ridiculous!” I felt really discriminated against. I had a friend who was also transgender and we were both begging the administration but they wouldn’t allow it. They told us that we would be an embarrassment to the school, that people would laugh at us at prom, and that “You’re guys and you need to wear guys’ clothes.” [116]

In some instances, students were able to request a full switch of the uniforms according to their gender identity. However, agreements to alter uniform requirements were usually not the result of consistently applied policies designed to respect students’ right to free expression of their gender identity, but rather of the compassion of a specific school administrator or principal. In one of the few such cases Human Rights Watch documented, a lesbian student was permitted to wear the boys' uniform primarily because the school’s principal was himself openly gay and supportive of the petition. [117]

Even when students are formally permitted to wear the uniforms of their choice, however, school personnel at times harass or humiliate them in practice. Gabby W., a 16-year-old transgender girl in high school in Bayombong, told Human Rights Watch:

They’re questioning us about our makeup and dress… not only the students, but the teachers too. It’s so disrespectful. We enter the gate and the security guard will say, “Why is your hair so long, are you a girl?” And it really hurts our feelings. [118]

Access to Facilities

For students who are transgender or identify as a sex other than their sex assigned at birth, rigid gender restrictions can be stressful and make learning difficult. One of the areas where gender restrictions arose most often for LGBT interviewees was in access to toilet facilities, known in the Philippines as “comfort rooms” (CRs). Most interviewees said that their schools required students to use CRs that aligned with their sex assigned at birth, regardless of how they identified or where they were most comfortable. Some said that both female and male CRs posed safety risks or made them uncomfortable, but that all-gender restrooms were scarce.

Requiring students to use restrooms that did not match their gender identity or expression put them at risk of bullying and harassment. Gabby W., a 16-year-old transgender girl in Bayombong, said that “boys peep on us when we use the boy’s restroom,” and “they say we’re trying to have sex with them, things like that.” [127] Reyna L., a 24-year-old transgender woman, agreed: “Boys or male persons are always vigilant when it comes to gays and transgenders. Any time they see us going in the CR, they sometimes look at you like I’m going to do something, with malice, or look at us like a maniac.” [128] Because of this, Gabby said, “Sometimes you don’t have a choice but to go home and use your own restroom.” [129]

Some schools punish students for using the CRs where they felt comfortable. Ruby S., a 16-year-old transgender girl who attended high school in Batangas, said:

I was called by the administration when I used the CR for the girls. They said you’re not allowed to use it just because you feel like you’re a girl. They used that as a black mark on my campaign for student council. They said, even though he wants to be student council president, he doesn’t follow the rules. [130]

Even students who were not formally punished described being humiliated by faculty and staff policing gendered spaces. Alon B., a gay teacher in Cebu City, said that the administration at the school where he taught had posted “a printed sign that says only biological females are able to be in this bathroom.” [131]

At least one secondary school has created all-gender CRs that any person can use regardless of their gender identity. [132] But while some students may feel more comfortable using all-gender CRs, others prefer to use the same CRs that everybody else uses. Reyna L., a 24-year-old transgender woman, said, “I’d like to use the female comfort room, and be treated as a normal person…. If I can’t, I’d rather not use it at all.” [133] Allowing students to use CRs consistent with their gender identity can be a simple and uncontroversial step that makes a positive difference for transgender youth. Ella M., a 23-year-old transgender woman from Manila, noted that when she transferred to a new high school:

I was able to use the girls’ bathroom, freely, since most of the peers were really supportive. And there hasn’t been any incidents of, like, adverse reactions to some guys going into the girls’ bathroom. My teacher knew I was doing it—he just warned me that some girls might get offended. But nobody complained. [134]

Gender Classifications

Even when students identify as transgender, some teachers and administrators insist on treating them as their sex assigned at birth. David O., a high school teacher in Mandaue City, recounted a story in which a transgender boy and his parent wanted the school to socially recognize him as a boy, but another teacher insisted that the student was female and should be treated as a girl. [138]

Imposing strictly gendered activities and requiring students to participate according to their sex assigned at birth can constitute discrimination and impair the right to education. Human Rights Watch found that some schools require boys to take physical education classes and girls to take arts classes, for example, which reinforces stereotypes and deprives boys who want to pursue art and girls who want to pursue sports of educational opportunities. [139] It can also be profoundly stigmatizing and uncomfortable for students. As Felix P., a 22-year-old gay high school student in Legazpi, said: “During flag ceremony, students used to line themselves up by male or female, and I think it’s really difficult—which line should I go in? I don’t think I’m welcome in the boys’ group, and I’m not allowed to go in the women’s group.” [140]

Hostility Toward Same-Sex Relationships

Many schools in the Philippines have policies restricting public displays of affection among students, and outline those policies in student handbooks or codes of conduct. Yet LGBT students reported that their relationships were policed more carefully or punished more harshly than their non-LGBT peers. In particular, young lesbian and bisexual women and transgender men who attended exclusive schools—those that are only open to one sex—reported that their friendships and relationships were closely scrutinized and policed by school staff.

Juan N., a 22-year-old transgender man who had attended high school in Manila, said:

When I was in high school, I had a girlfriend, but we were really careful about it, because once it becomes known—especially to admins, who are mostly nuns, and when your teachers know you’re in a relationship with another woman, they try to correct you, they would reprimand you, give you violations based on what you’ve done. [141]

Angelica R., a 22-year-old bisexual woman who had attended high school in Manila, said that more masculine girls were especially targeted to keep them from becoming close with other girls:

If someone is really butch, our professors are always watching us. They’re talking among themselves and student council to pinpoint who was involved in same-sex relationships. There’s not much bullying among the students, but it was oppression from the administration. I remember this particular experience where one of our professors went into our class and said, did you know, girls are for boys, girls are not for girls, we know who’s involved in same-sex relationships, and if you don’t stand up, we’ll make you stand up.… So as a result, some of my butch classmates would attempt to be feminine, they would hide it, they would wear more feminine clothes. You could see they were unhappy. It’s a struggle. [142]

The same standards were not applied to heterosexual students, as teachers and administrators acknowledged. Even a gay teacher defended this double standard, citing social and religious conventions. Ernesto N., a gay teacher in Cebu City, said of same-sex couples dating in schools: “It’s just like having sex in school! Goodness! It’s really our culture.... For boys and girls it’s okay, but not for LGBT.” [143]

Pressure to Conform to Stereotypes

LGBT youth also described the pressure that teachers and administrators imposed on them to act in a stereotypical fashion.

Many of the LGBT youth interviewed by Human Rights Watch emphasized that, to the extent they were respected in school, they had earned that respect by being better students than their peers. Often, this meant that LGBT students were tasked with more work or responsibilities than other students as part of the price they paid to be accepted and respected. Eric Manalastas, a psychology professor at the University of the Philippines who has conducted research on LGBT youth issues, found that:

[G]ay students or those who are out or coded as gay [are sometimes] given extra work at school, including extracurricular work—being asked to be the MC at an event, or fixing the stage for a performance, being asked to clean up after school. Because of a stereotype that they’re reliable, or combine the best of both male and female students, a kind of androgynous thing going on. I hear that from students but also teachers—teachers who say, I love my gay students, they’re so helpful, I ask them to stay after school. They’re tasked with leadership roles. [144]

In a similar vein, one university instructor told Human Rights Watch that “as faculty members, we’re often delegating responsibilities to members of the LGBT community because we know they’ll do it well.” [145] Rodrigo S., a gay high school teacher in Dipolog City, observed: “I guess there are pressures for gay children—and I see this—to do really well in class, I guess, because that kind of saves you from being bullied. Like, you ought to get somewhere so people won’t make fun. A lot of my students wanted to excel in whatever they were doing, being artistic, because they wanted to be accepted. A lot of my gay students were at the top of the class.” [146]

In interviews, it appeared that many LGBT students had internalized the message that their acceptance as LGBT was conditional on being dutiful, talented members of the school community. Virgil D., a 20-year-old gay man in high school in Bacacay, said, “I think the gays should dress properly and be responsible. And then they’ll be treated well.” [147] Mary B., an 18-year-old transgender woman in a high school in Manila, said:

For us to be better accepted, we’re taking proactive measures to be accepted into the community. We’re setting good examples. We engage in extracurricular activities, we organize events for the school, we stop bullying when we see it, we promote child protection. We become model citizens, model students, and it improves our stature. [148]

Manalastas found that the demand to be “respectable” put a heavy burden on LGBT students who did not conform: “It may be that gay students are warmly received, generally speaking, but if you’re characterized as one of the indecent ones—perceived as very sexual, very loud, very gender non-conforming or outré, it’s different.” He added that LGBT people from lower socioeconomic strata often face double discrimination, as exemplified by the common insult baklang kalye —“you’re bakla and also you come from the streets, you don’t have a proper house, you’re poor.” [149]

Some students were keenly aware of these conditions and expressed frustration with them, voicing a desire to be treated with the same inherent respect as their non-LGBT classmates. Felix P., a 22-year-old gay high school student in Legazpi, said:

Sometimes teachers say things like you have to respect gays and lesbians because they’re the breadwinners for their family, they’re reliable, they’re good at makeup, costume making, talent…. I’m proud of being gay—my teacher says something good about being gay, but why do I have to earn that respect? It’s not 100 percent good. Some of my gay classmates don’t have those talents, and how does that make them feel? [150]

Jerome B., a 19-year-old gay man from Cebu City, described another stereotype that he found oppressive: the idea that gay males should be entertainers, jokers, and talented performers. He said classmates and teachers:

…put so much pressure on me that because I’m gay, I should be comedic, I should be funny all the time, I should joke—and I’m not that kind of person, to crack jokes and sing and entertain. In our entertainment industry, gays are usually presented as comic relief. And that’s okay at some point, but that’s it? There’s more to being gay than being funny and entertainers. And because of that, usually our job opportunities are being limited to being a hairdresser, working at a salon, being a comedian. And I’d like to be a researcher or a lawyer. We’re diverse people, like straight people. [151]

When students and teachers reinforce these stereotypes, they put pressure on those who do not fit preconceived notions of being gay and constrain their education and employment options. In an interview with Human Rights Watch, a local government official who had organized a job training program for LGBT people noted that the program specifically trained LGBT people to be clowns and hosts for pageants and other events. [152]

Young lesbian women encounter different stereotypes. Dalisay N., a 20-year-old panromantic woman who had attended high school in Manila, observed that lesbian girls were particularly disadvantaged by teachers because “the lesbian community, they don’t see us like that, like the gays, the creative ones who do something artsy, that gay people are at the top of the list.” [153] Instead, according to Eric Manalastas, “the stereotype with lesbians is that they’re dangerous, a danger to other female students. Not in terms of being violent, but maybe as predatory. Or generally a bad influence—not good for moral development—as though they aren’t also adolescents themselves.” [154] In interviews with Human Rights Watch, young bisexual women recounted how teachers scrutinized girls they considered “butch” or masculine, and took steps to separate them from other girls to prevent them from becoming close. [155]

For youth who are transgender, pressure to “pass” according to their gender identity and, for transgender girls, to achieve high standards of physical beauty, were a serious source of stress for those who felt they lacked the ability or resources to meet the expectations of others.

These stereotypes were among the most consistent themes in interviews with LGBT youth. They illustrate how attitudes and informal practices, even when well-intentioned, can place heavy expectations on LGBT youth and undermine the notion that all youth are deserving of respect and acceptance. They underscore the importance of anti-bullying efforts, information and resources, and antidiscrimination policies that emphasize that all students, regardless of sexual orientation or gender identity, have rights that must be respected in schools.

IV. Exclusion from Curricula and Resources

When LGBT students face hostility in their homes, communities, and peer groups, access to affirming information and resources is vitally important. In interviews, however, few LGBT students in the Philippines felt that their schools provided adequate access to information and resources about sexual orientation, gender identity, and being LGBT.

As scholars have noted, heterosexism—or the assumption that heterosexuality is the natural or preferable form of human sexuality—can take two different forms in educational settings: “(1) denigration, including overt discrimination, anti-gay remarks, and other forms of explicit homophobia against gay and lesbian students and teachers, or (2) denial, the presumption that gay and lesbian sexualities and identities simply do not exist and that heterosexual concerns are the only issues worth discussing.” [156] By neglecting or disparaging LGBT youth, both forms of heterosexism, alongside cisnormativity—the assumption that people’s gender identity matches the sex they were assigned at birth, sometimes accompanied by denigration of transgender identities—are harmful to the rights and well-being of LGBT students in the Philippines.

A recent analysis of issues related to sexual orientation and gender identity in the Philippines found that LGBT youth are often neglected in school environments, particularly in light of strong constitutional protections for academic freedom, which give schools considerable leeway to design curricula and resources. [157] In interviews with Human Rights Watch, LGBT students described how the absence of information and resources proved detrimental to their rights and well-being and why DepEd, lawmakers, and school administrators should embrace inclusive reforms.

School Curricula

Very few of the LGBT students interviewed by Human Rights Watch said they encountered positive portrayals of LGBT people as part of the school curriculum.

In many cases, LGBT people were simply invisible, with no acknowledgment that people are LGBT or discussion of LGBT history, literature, or other issues. One study found that, in elementary school textbooks required by DepEd:

[C]haracters that portray femininity are always women, while men always portray masculinity. There is a clear binary and strict gender attributes and roles between the two genders; and both gender are always portrayed in a ‘fixed’ stereotypical manner…. Hence, with the strict portrayal of women as feminine and continuously at home, while men [are] masculine as the breadwinner, couples, as heterosexuals, are legitimized and naturalized, leaving no room for other forms of sexuality…. These discourses do not leave any room for diverse forms of family, such as single-headed families, families with overseas contract workers, families that are cared for by young or aging people, homosexual couples, to name a few. It only legitimizes the heterosexual couple and renounc[es] other forms. [158]

Students confirmed that discussions of LGBT people in classes where LGBT issues might arise—for example, history, literature, biology, or psychology—are exceedingly rare. As Leah O., a 14-year-old bisexual girl in Marikina, said, “The teachers don’t mention LGBT.” [159] Alex R., a 17-year-old gay boy from San Miguel, similarly noted, “I didn’t hear teachers say anything about LGBT issues in class.” [160]

Interviews with teachers and administrators illustrated why LGBT issues are absent from the curriculum. Alon B., a gay teacher in Cebu City, recalled how a gay student asked a question about LGBT identities, which he answered in front of the class. Alon's department chair overheard the conversation and reprimanded him, and relieved him of his teaching load the following semester. [161] One LGBT advocate recalled asking his aunt, who was a high school principal, how LGBT issues were handled in the school: “She told me—I was surprised, she said, ‘I don’t want to touch on that subject.’ And I asked why immediately, and she said it was a sensitive issue…. [T]hey’re careful not to offend parents.” [162]

Interviews with LGBT students suggest that when LGBT issues are discussed in class, teachers frequently portray them in a negative light. Often, this was the case in values education or religion classes, which were offered in public as well as private schools but often had a strongly Catholic orientation. Juan N., a 22-year-old transgender man who had attended high school in Manila, said that in theology classes, “There would be a lecture where they’d somehow pass by the topic of homosexuality and show you, try to illustrate that in the Bible, in Christian theology, homosexuality is a sin, and if you want to be a good Christian you shouldn’t engage in those activities.” [163] Jessica L., a 22-year-old transgender woman from Pampanga province, noted how challenging this was as a student who was questioning her gender identity: “[T]eachers would say, oh God only created man and woman, and so I’m like who created me, I want to know? And who created us? So we’re the imperfections of God? It’s so hard. It’s like you’re taking the bull by the horns every day.” [164]

Ernesto N., a gay teacher in Cebu City, recalled walking down a hallway past a class being taught by a values education teacher, who “says that you should not be gay because you will go to hell. You will no longer go to heaven.” [165] One values education teacher explained why she taught students that a proposed anti-discrimination bill protecting LGBT rights was wrong:

I informed them of the SOGI bill, I told them that it will become a law soon. For some of us Christians it’s alarming, because for example two boys will be approaching a priest, and will ask them to be married. And if the priest wants to marry them, again as Christians, we have this kind of same-sex marriage, what can be next—it’s a slippery slope, there will be sexual intercourse, I don’t think that will be good. [166]

Juan N. said, “I remember even in a physics class, we had the topic of negative and positive attraction, and negative doesn’t attract, and [the teacher] said men are for women only, and never men for men or women for women. And I remember it because it came out of nowhere—we were talking about magnets!” [167] In a speech class, Ruby S., a 16-year-old transgender girl who had attended high school in Batangas, recalled delivering a presentation “about coming out, coming out of your shell, coming out as a gay man—which I was then—and I said coming out was a good thing to do, but the teacher commented, ‘I support you gay people, but if you have a relationship with a man, it’s a sin,’ the Bible says this, the Bible says that.” [168] Pablo V., an 18-year-old gay student who attended high school in San Jose, said: “In our school, we presented a play—there’s a gay character—and then our principal told me that it’s not possible for us to present because there’s a gay character in our presentation.” [169]

Without training teachers about LGBT identities and issues, stereotypes and misinformation spread unchecked. Jerome B., a 19-year-old gay man from Cebu City, recalled an instance in high school where “one teacher said that if you eat a lot of chicken, you turn gay. And she said if you would eat a lot of ramen, you turn lesbian. I wouldn’t dare question her, because she’s in charge of my grade, but deep inside I was shaking—I mean, how unbelievable. Eating chicken will turn you gay? That’s crazy. It would really help if they would undergo training. Because they’re teaching the kids wrong stuff. It’s a cycle—if they teach this, they pass it on to the next generation.” [170]

In discussions about curricular offerings, students of all sexual orientations and gender identities voiced a desire to learn about LGBT topics in school. As Isabel A., a 16-year-old heterosexual girl in Cebu City, observed: “We want to understand, even if we’re not lesbian or gay, so we can understand gays and lesbians.” [171] For LGBT students, discussing LGBT issues was particularly important. Felix P., a 22-year-old gay high school student in Legazpi, suggested that “it would be better if there was education on LGBT rights in the school, because it would be easier to respect and value individuals, regardless of whether they’re women or men—and LGBT people in school wouldn’t be stereotyped as infected with HIV.” [172]

Discussions of LGBT topics in high schools were rare, but occurred more frequently at the university level. There, professors who were open to discussing LGBT topics observed how inclusivity improved the educational environment. According to one literature professor, “If they’re out as members of the LGBTQ community, I can ask them questions about it, and they’re more engaged…. When I’m open with my students about their relationships, they tend to study better. They’re never absent. They’re more comfortable…. If the teacher is more discriminatory, they won’t be open to talking about how it affects them and what they think about it.” [173]

In order to understand their own sexuality and to make responsible choices, LGBT students, as well as other students, need access to information about sexuality that is non-judgmental and takes into account the whole range of human intimacy. In recent years, many countries have moved toward providing comprehensive sexuality education, which UNESCO describes as an “age-appropriate, culturally relevant approach to teaching about sex and relationships by providing scientifically accurate, realistic, non-judgmental information.” [174]

As part of comprehensive sexuality education, LGBT students as well as their heterosexual, cisgender peers should have access to relevant material about their development, relationships, and safer sex. Scholars in the Philippines have found that “[r]esearch on Filipino young adult sexuality has been explicit in stressing the need for a comprehensive educational framework that addresses gender and sexuality issues.” [175] One study found that gay learners “expressed dissatisfaction about sexuality education in high school, both for its heterosexist bias and its restrictive philosophy,” and desired more information about sexual identity and orientation, body image, love and friendship, HIV/AIDS, and gender roles. [176] This is more generally true across the Asia-Pacific region, where UNESCO has found that young people “want more inclusive content that address same-sex attraction and diversity.” [177]

The passage of the 2012 Reproductive Health Law, which calls for DepEd to issue a sexuality education curriculum and for schools to adopt minimum standards, created an opening for accurate and non-judgmental discussions of LGBT identities and sexuality. UNESCO, in a 2015 report, noted that “NGOs are working with experts and Department of Education officials to establish minimum standards on sexuality education that include anti-bullying standards addressing both gender-based violence and other bullying and violence on the basis of sexual orientation, gender identity and expression.” [178]

However, at the time of this writing, DepEd had only recently incorporated sexuality education into school curricula, five years after the passage of the law, without adopting standards developed by a panel of experts or training teachers in sexuality education. Both the UN Population Fund and the government’s task force on the implementation of the law have noted that implementation of the law has fallen short, leaving students across the Philippines without access to comprehensive sexuality education. [179] Professionals who work with students have found that existing sexuality education modules are limited for youth of all sexual orientations and gender identities but also routinely exclude instruction about LGBT concerns. Perci Cendana, a commissioner with the National Youth Commission, explained that at present, “Young people don’t get information about safer sex, period. And young [men who have sex with men] and [transgender] kids don’t get it from the sources where they should get it.” [180] Human Rights Watch recently documented how resistance from conservative lawmakers and school administrators has stymied comprehensive sexuality education in schools in the Philippines, exacerbating rapidly rising rates of HIV transmission among MSM and transgender women. [181]

In interviews with Human Rights Watch, students who received sexuality education described receiving that education at various grade levels, with varying degrees of comprehensiveness. But across the board, they stated that their sexuality education classes either excluded any discussion of LGBT people or conveyed inaccurate and stigmatizing messages about same-sex conduct and the existence of transgender people.

While some students only discussed anatomy and reproduction in their sexuality education curriculum, others learned about sexually transmitted infections, HIV/AIDS, safer sex, and family planning. In virtually all cases, however, sexuality education was limited to discussions of heterosexual reproduction and sex. Mary B., an 18-year-old transgender woman in a high school in Manila, said, “We had classroom instruction on sexual health. They told us about sexuality—my teacher strongly believes in the Bible, and the idea that God created only men and women. They haven’t mentioned LGBT people.” [182] Efren D., an 18-year-old bisexual man who had attended high school in Quezon City, said, “we tackled the planning methods, the condoms, other contraceptives. But it’s basic. Not deeper than that. And it was all boy-girl. I’d like LGBT sexuality education, to be a little more aware, as LGBT people.” [183]

In many instances, sexuality education conveyed misinformation or disapproval about LGBT identities and relationships. Gabby W., a 16-year-old transgender girl at a high school in Bayombong, said that teachers “always say that gay is a disease, that it’s a contagious disease. Or say being gay is a sin.” [184] Bea R., a 22-year-old transgender woman at another school in the area, said that although science teachers do cover safer sex at her school, “They say that LGBT are the ones spreading HIV and chlamydia.” [185] Francis C., a 19-year-old gay student from Pulilan, was similarly told by teachers “ that there were same-sex who were doing those activities, but they would say that if two males or two female did those activities, they would become sick or ill.” [186] Jonas E., a 17-year-old gay boy in high school in Mandaue City, noted: “I get really offended when they talk about HIV. They say that gays are the main focus of HIV… I’m a bit ashamed of that, because I was once in section where I’m the only gay, and they kept pointing at me.” [187]

When comprehensive sexuality education is not provided in schools, students may not receive information about their physical and emotional development, relationships, decision making, HIV and sexually transmitted infections, safer sex, contraception, and reproductive health at all. Past research has suggested that, especially for LGBT youth, “[s]exuality is rarely discussed informatively in the home, and being gay not at all.” [188] Rodrigo S., a gay high school teacher in Dipolog City, observed that “parents avoid [sexuality] as much as possible. I don’t know if it’s actually easy for students to find a figure, someone they can ask about things like that.” [189]

With little guidance at home or in school, LGBT students turned to various sources of uncertain quality for information about sexuality. Students told Human Rights Watch that they had learned what they knew about LGBT identities, relationships, and sexual health from friends, the internet, pornography, and experience. As previous research has suggested, “[p]eers may provide very vivid information presented using shared meanings, but the adequateness of this information is, in hindsight, suspect.” [190] Students themselves doubted the information they received. Tricia C., a 14-year-old girl in Marikina, admitted, “The information we get from other people is not accurate. It’s too early for us to know what’s true.” [191] Reports that LGBT students learned about sexuality from what Jin W., a 20-year-old man who attended high school in Manila described as “live action” [192] are particularly worrying, as they illustrate how LGBT youth engage in sexual activity before they have access to information about how to keep themselves safe.

Counseling and Support

In addition to formal curricula, schools provide a variety of resources to students. Support from teachers, guidance counselors, school psychologists, and other school personnel is a valuable asset, and should be available to guide LGBT youth as well as their non-LGBT peers. According to UNESCO, “support from teachers can have a particularly positive impact on LGBT and intersex students, improving their self-esteem and contributing to less absenteeism, greater feelings of safety and belonging and better academic achievement.” [193]

Students in the Philippines have signaled a desire for faculty and staff support. As one study found, “[s]tudents want their teachers, who are in a position of influence and credibility, to dispel common misconceptions and misperceptions about gay and bisexual people.” [194] Nonetheless, few teachers or guidance counselors are trained to provide support for LGBT youth. As Rina Fulo of the Women and Gender Institute at Miriam College noted, “We do a lot of training related to gender fair education, and we see that teachers and administrators have their biases. We’re worried if they can actually follow through.” [195] Remedios Moog, a guidance counselor at the University of the East in Caloocan, similarly recalled that when she presents papers on LGBT-inclusive counseling, “there are different reactions, negative, positive, some counselors saying great job, and you see the affirmation, and other counselors, ‘No, you should not label, you should not call them lesbian, gay, bisexual,’” seeming to suggest that guidance counselors should ignore students’ sexual identities altogether. [196]

Although some counselors have created successful programs for LGBT students, such as support groups, such efforts need to have support from the school administration to ensure counselors are recognized as affirming, non-judgmental resources. [197] As one study found, “it has been the experience of gay students (or perhaps students in general) that the guidance counselor is associated with delinquent and problem students. This image of the guidance counselor may contribute to the problematization of gay identity in school settings, that being gay is something that has to be ‘dealt with’ with and by these counselors.” [198]

Interviews with LGBT youth in the Philippines underscore the urgent need for resources and support. Jerome B., a 19-year-old gay man from Cebu City, recalled that in secondary school, “I was questioning for a long time—is there something wrong with me? Am I mentally ill? I planned to talk to a psychiatrist because I thought I had a mental illness… . We had a guidance counselor. But I wouldn’t go to them, because I was too ashamed.” [199] For some students, bullying and a lack of resources led to depression and thoughts of suicide. Benjie A., a 20-year-old gay student from Manila, recounted struggling to make sense of his identity until “I thought about getting a gun from a policeman and shooting myself.” [200]

Many students declined to go to counselors for help and support, expecting that they would be hostile to LGBT youth. Patrick G., a 19-year-old gay man who had attended high school in Cainta, recalled that his high school guidance counselor would quote Bible passages and say “that God created Adam and Eve, and not Adam and Steve, things like that.” [201] As a result, Patrick said, “I didn’t really have the courage to come out of the closet, or at least accept or think I was gay…. I think it made me step back farther in the closet.” [202]

When students did seek out help, some counselors declined to discuss LGBT issues. Ella M., a 23-year-old transgender woman who had attended high school in Manila, recalled an instance when a counselor asked about her personal life. When she confided that she thought she might be attracted to a boy, the counselor told her “I’m not going to comment on that, because I don’t have any information on that.” [203]

Other LGBT students described going to counselors and facing outright hostility or condemnation. Ace F., a 24-year-old gay man who had attended high school in Manila, said that his school counselor used decades-old psychological materials:

What they taught us was DSM-3 or DSM-2—where being gay is still classified as a mental disorder. [204] That’s what they taught us. I was pretty well informed because I was a debater, so I would question them about it: it’s already outdated, it’s not the standard, it’s not considered a mental disease. But they would institutionally still say that it was a disease, a mental disorder, it’s bad. [205]

LGBT students interviewed said some counselors passed moral judgment on them. Reyna, a 24-year-old transgender woman, recalled being told to go to her high school counselor because she wore nail polish and makeup, and said “they would read some biblical passage or verses that includes, you know, Sodom and Gomorrah. They would always tell me, ‘Reyna, you will go to Hell if you don’t change.’ And I was afraid that time, because of course, who wants to go to Hell?” [206]

When guidance counselors were willing to discuss LGBT identities in an open and non-judgmental way, many LGBT students said they felt affirmed and supported. For instance, Nathan P., a 19-year-old gay man who attended a high school in Bulacan, said “I did talk to my counselors in high school, and I was thankful they’re so open minded, and helping me, when I’m so confused.” [207] For Nathan, whose friends were pressuring him to disclose his sexuality and causing him stress, having a supportive counselor was a source of comfort that ultimately helped him resolve the situation with his peers.

Student Organizations

LGBT student groups are extremely rare at the secondary school level in the Philippines. Yet at the university level, these groups have been a powerful resource for LGBT students. Since at least 1992, when UP Babaylan formed at the University of the Philippines, these groups have provided educational programming to the university community, advocated for policy changes, and offered peer support to LGBT members. [208] As a recent UNESCO study notes, these organizations can be powerful sources of information and support in school environments:

School-based and school-linked programmes providing peer support [for LGBT students] engage students in rejecting bullying, violence and other forms of discrimination. These can include student associations, youth groups, peer mentoring systems, extra-curricular or club-based activities as well as other pairing or peer networks within schools. These programmes can help to create feelings of connectedness, and respectful and supportive relationships that develop empathy, responsibility and concern for others. They can also build confidence, leadership behaviours and social skills. [209]

LGBT students have expressed a need for organizational support structures such as LGBT student groups. [210] Yet despite their many advantages and student demand, LGBT groups in Philippine secondary schools are rare. As Carlos M., a 19-year-old gay student from Olongapo City, observed: “I wish they had it when I was in high school. There were so many of us LGBT when I was in high school…. I wish they had a program to strengthen the bonds of LGBT students.” [211] Gloria Z., a 22-year-old bisexual woman from Cavite, said: "I wish we had a support group. There were other female students, lesbians, and they were forced to be straight because of our Catholic upbringing. They would discriminate [against] them, just like me. And there were so many of us trying to act straight, and we were part of the rainbow community.” [212]

In some instances reported to Human Rights Watch, school personnel have been unsupportive of LGBT groups. Sean B., a 17-year-old gay student in Bayombong, said: “I tried to start a student organization, but we don’t have enough allies with teachers. It’s all about awareness, to make other students understand what we are, to be able to reach out to them, to make them feel, we’re gays, we’re also humans, not animals or trash.” [213]

V. Philippines’ Legal Obligations to Protect LGBT Students

In recent years, the Philippines has enacted important laws and regulations that affirm the rights of LGBT learners in schools. DepEd’s Child Protection Policy, the Anti-Bullying Law, and the Reproductive Health Law—as well as anti-discrimination ordinances at the local level—reiterate the government’s commitment to ensuring that all youth are safe, healthy, and able to learn in schools.

The Philippines has also ratified core international agreements that obligate lawmakers, administrators, and teachers to protect the rights of LGBT youth, including the Convention on the Rights of the Child (CRC), the International Covenant on Civil and Political Rights (ICCPR), International Covenant on Economic, Social and Cultural Rights (ICESCR), and the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW). [217] The UN expert bodies that interpret these agreements have expressed concern about discrimination against LGBT students in schools, [218] prompting the UN High Commissioner for Human Rights to recommend “that States establish national standards on non-discrimination in education, develop anti-bullying programmes and helplines and other services to support LGBTI youth, and to provide comprehensive, age-appropriate sexuality education.” [219]

Right to Education

The right to education is enshrined in international law, notably in the ICESCR and the CRC, both ratified by the Philippines. [220] The CRC specifies that education should be directed toward, among other objectives, “[t]he development of the child’s personality, talents and mental and physical abilities to their fullest potential,” “[t]he development of respect for human rights and fundamental freedoms,” and “[t]he preparation of the child for responsible life in a free society, in the spirit of understanding, peace, tolerance, equality of sexes, and friendship among all peoples, ethnic, national and religious groups and persons of indigenous origin.” [221]

LGBT students are denied the right to education when bullying, exclusion, and discriminatory policies prevent them from participating in the classroom or attending school. LGBT students’ right to education is also curtailed when teachers and curricula do not include information that is relevant to their development or are outwardly discriminatory toward LGBT people.

To make the right to education meaningful, schools should ensure that school curricula, interactions with school personnel, and school policies are non-discriminatory and provide information to LGBT youth on the same terms as their non-LGBT peers. [222]

The right to education includes the right to comprehensive sexual education, [223] which is especially lacking for LGBT youth in the Philippines. As the UN Special Rapporteur on the Right to Education has explained: “The right to education includes the right to sexual education, which is both a human right in itself and an indispensable means of realizing other human rights, such as the right to health, the right to information and sexual and reproductive rights.” [224] A curriculum that only prepares students for heterosexual sex inside of marriage “normalizes, stereotypes, and promotes images that are discriminatory because they are based on heteronormativity; by denying the existence of the lesbian, gay, transsexual, transgender and bisexual population, they expose these groups to risky and discriminatory practices.” [225]

The Philippine Congress recognized the importance of sexuality education with the passage of the Reproductive Health Law, which mandates age- and development-appropriate sexuality education in schools. [226] The Philippines should take further steps to implement the law in a manner that is consistent with its treaty obligations. To ensure the right to education is respected, the Committee on the Rights of the Child has said that sexuality education provided by schools:

…should include self-awareness and knowledge about the body, including anatomical, physiological and emotional aspects, and should be accessible to all children, girls and boys. It should include content related to sexual health and well-being, such as information about body changes and maturation processes, and designed in a manner through which children are able to gain knowledge regarding reproductive health and the prevention of gender-based violence, and adopt responsible sexual behavior. [227]

This information must not only be provided to heterosexual, cisgender students. Schools must also provide LGBT students with relevant content to ensure they enjoy the same right to education without discrimination. Comprehensive sexuality education “must be free of prejudices and stereotypes that could be used to justify discrimination and violence against any group,” [228] and “must pay special attention to diversity, since everyone has the right to deal with his or her own sexuality without being discriminated against on grounds of sexual orientation or gender identity.” [229]

Violence and Bullying

Under domestic and international law, LGBT children in the Philippines have the right to be free from bullying, harassment, and violence. The Constitution of the Philippines obligates the government to defend “[t]he right of children to assistance, including… special protection from all forms of neglect, abuse, cruelty, exploitation and other conditions prejudicial to their development.” [230] To this end, the Anti-Bullying Law requires elementary and secondary schools “to adopt policies to address the existence of bullying in their respective institutions,” and outlines baseline requirements for such policies. [231] Similarly, DepEd’s Child Protection Policy requires that school administrators, among other responsibilities, “[e]nsure the institution of effective child protection policies and procedures, and monitor compliance thereof,” “[c]onduct the appropriate training and capability-building activities on child protection measures and protocols,” and “[e]nsure that all incidents of abuse, violence, exploitation, discrimination, bullying and other similar acts are addressed.” [232]

The terms of the Anti-Bullying Law and Child Protection Policy echo the Philippines’ obligations under international law. The ICCPR states that "[e]very child shall have… the right to such measures of protection as are required by his status as a minor, on the part of his family, society and the State," [233] while the CRC requires governments to “protect the child from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation.” [234] The government of the Philippines signed UNESCO’s Call for Action on Homophobic and Transphobic Violence, issued in November 2016, which commits it to monitoring the prevalence of homophobic and transphobic bullying in schools, providing students with information about harmful gender-based stereotypes, training school personnel, and taking steps to make schools safe for LGBT youth. [235]

Children who are especially likely to face violence, including bullying, merit specific attention and protection from the state. As the Committee on the Rights of the Child, the UN body that monitors implementation of the CRC, has noted, “[g]roups of children which are likely to be exposed to violence include, but are not limited to, children … who are lesbian, gay, transgender or transsexual.” [236] The committee has repeatedly described bullying, harassment, and violence against LGBT youth as violations of children’s rights, [237] and emphasized that “[a] school which allows bullying or other violent and exclusionary practices to occur is not one which meets the requirements of article 29(1),” the CRC provision specifying the aims of education. [238]

The Committee on the Rights of the Child has identified steps that governments should take to protect children from bullying, harassment, and other forms of violence. These include challenging discriminatory attitudes that allow intolerance and violence to flourish, [239] establishing reporting mechanisms, [240] and providing guidance and training for teachers and administrators to know how to respond when they see or hear about incidents of violence. [241] When taking these steps, the committee has stressed that children themselves should be involved “in the development of prevention strategies in general and in school, in particular in the elimination and prevention of bullying, and other forms of violence in school.” [242]

Right to Health

Bullying, exclusion, and discrimination generate physical and mental health risks that threaten the right to health for LGBT youth. The Committee on the Rights of the Child has expressed concern about the health consequences of bullying, including suicide, and has urged governments to “take the necessary actions to prevent and prohibit all forms of violence and abuse, including sexual abuse, corporal punishment and other inhuman, degrading or humiliating treatment or punishment in school, by school personnel as well as among students.” [243]

The ICESCR recognizes “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.” The CRC reinforces that children must enjoy this right, and states that, in pursuit of that goal, governments will “ensure that all segments of society, in particular parents and children, are informed [and] have access to education,” and will “develop preventive health care, guidance for parents and family planning education and services.” [244]

The Committee on the Rights of the Child has said that “[i]n order to fully realize the right to health for all children, States parties have an obligation to ensure that children’s health is not undermined as a result of discrimination, which is a significant factor contributing to vulnerability,” including discrimination on the basis of “sexual orientation, gender identity and health status.” [245]

The significant shortcomings of sexuality education in schools in the Philippines also undermine the right to health for all students, but particularly LGBT students. The Committee on the Rights of the Child has explained that youth are "vulnerable to HIV/AIDS because their first sexual experience may take place in an environment in which they have no access to proper information and guidance.” [246] Omitting information about same-sex activity and transgender identity from sexuality education curricula undermines LGBT students’ right to health. To ensure their rights are respected, the committee has said that governments must “refrain from censoring, withholding, or intentionally misrepresenting health-related information, including sexual education and information, and… ensure children have the ability to acquire the knowledge and skills to protect themselves and others as they begin to express their sexuality.” [247]

Freedom of Expression

The ICCPR recognizes that “everyone shall have the right to freedom of expression,” [248] and the CRC expressly recognizes that the right extends to children. [249]

The right to free expression is violated when schools limit displays of same-sex affection or gender expression solely for LGBT youth. Schools need to ensure that LGBT students are able to participate in the school environment on the same terms as other students, regardless of their sexual orientation or gender identity.

Freedom from Discrimination

Even as municipalities and provinces pass anti-discrimination ordinances to protect the rights of LGBT people, the Philippines has not passed comprehensive legislation prohibiting discrimination on the basis of sexual orientation and gender identity.

Discrimination on the basis of sexual orientation and gender identity is prohibited under many of the treaties the Philippines has ratified. [250] As the UN High Commissioner for Human Rights has concluded:

…freedom from discrimination is a fundamental obligation of States under international law, and requires States to prohibit and prevent discrimination in private and public spheres, and to diminish conditions and attitudes that cause or perpetuate such discrimination. To this end, States should enact comprehensive anti-discrimination legislation that includes sexual orientation and gender identity among protected grounds.” [251]

The Committee on the Rights of the Child has explained that discrimination in the school setting, “whether it is overt or hidden, offends the human dignity of the child and is capable of undermining or even destroying the capacity of the child to benefit from educational opportunities.” [252] Because of the dangers that discrimination poses to health and development, children at risk of discrimination are “entitled to special attention and protection from all segments of society.” [253] The committee has specifically expressed concern about discrimination against children on the basis of their sexual orientation and gender identity in its review of state policies. [254]

Students who are transgender or do not identify as their sex assigned at birth face especially pervasive discrimination as a result of uniform and hair-length policies and other gendered restrictions. The UN High Commissioner for Human Rights has expressed concern about “discriminatory dress codes that restrict men dressing a manner perceived as feminine and women dressing in a manner perceived as masculine, and punish those who do so,” [255] and noted that “United Nations mechanisms have called upon States to legally recognize transgender persons’ preferred gender, without abusive requirements.” [256] To make schools less discriminatory and more inclusive of transgender youth, UNESCO recommends that laws and policies “should recognise self-defined gender identity with no medical preconditions or exclusions based on age, marital or family status or other grounds.” [257]

Recommendations

To the president of the philippines.

• Speak out, as you have done in the past, against bullying in schools, reiterating that bullying of LGBT youth is harmful and unacceptable.
• Speak out in support of an anti-discrimination bill that prohibits discrimination on the basis of sexual orientation and gender identity, including in education, employment, health care, and public accommodations.
• Authorize funding for the implementation of the Reproductive Health Law and any necessary support for comprehensive sexuality education in schools.
• Undertake a comprehensive review of school compliance with the provisions of the Child Protection Policy and the Anti-Bullying Law.
• Collect and publish data on the number of schools nationally that address sexual orientation and gender identity in their Child Protection Policy and Anti-Bullying Law. Recommend that schools that do not address sexual orientation and gender identity revise their policies to do so.
• Immediately review all curricula, including textbooks and teaching materials, to ensure that LGBT issues are incorporated. Remove content that is inaccurate or derogatory toward LGBT people and include content that is relevant to LGBT youth and promotes respect for gender diversity.
• Conduct trainings, in collaboration with LGBT rights groups where possible, to familiarize DepEd personnel at the division and district levels with LGBT terminology and issues.
• Enact local ordinances to prohibit discrimination on the basis of sexual orientation and gender identity, including in education, employment, health care, and public accommodations.
• Promulgate implementing rules and regulations to ensure that existing anti-discrimination ordinances are applied and enforced.
• Conduct trainings, in collaboration with LGBT civil society groups where possible, for child protection committees and school staff to ensure that they are sensitive to the needs and vulnerabilities of LGBT youth. The trainings should inform school staff about proper terminology, the forms of bullying and discrimination that LGBT youth face, the rights that LGBT youth enjoy under domestic and international law, and resources and services available for LGBT youth.
• Conduct trainings, in collaboration with children’s rights groups where possible, for child protection committees and school staff to ensure they are able to recognize and intervene in bullying and harassment when they witness it occurring or it is brought to their attention.
• Promulgate guidelines instructing school staff to respect the gender identity of students with regard to dress codes, access to facilities, and participation in curricular and extracurricular activities.
• Commemorate occasions like Human Rights Day and National Women’s Month with programming that promotes human rights and respect for gender diversity in schools.
• Ensure that the school has resources available for LGBT youth, for example, books and printed material, access to counselors or other supportive personnel, and curricular resources that are inclusive of LGBT youth.

Acknowledgments

Ryan Thoreson, a researcher in the LGBT Rights Program, wrote this report based on research that he undertook from September 2016 to February 2017. Daniel Lee, associate with the Asia division, conducted additional interviews and wrote a section of the report.

The report was reviewed by Neela Ghoshal, senior researcher in the LGBT Rights Program; Michael Bochenek, senior counsel in the Children’s Rights Division; and Carlos Conde, Philippines researcher in the Asia Division. James Ross, legal and policy director, and Joe Saunders, deputy program director, provided legal and program review, respectively. Production assistance was provided by Olivia Hunter, publications associate; Fitzroy Hepkins, administrative manager; and Jose Martinez, senior coordinator.

Human Rights Watch would like to thank the experts and organizations that provided information for the report, including ASEAN SOGIE Caucus, Babaylanes, Inc., Bisdak Pride, Bulsu Bahaghari, ChildFund Philippines, the Children’s Legal Rights and Development Center, GALANG, Gayon Albay, Happy Hearts, Lagablab, MCC Marikina, Side B, TransMan Pilipinas, and UP Babaylan. Particular thanks go to the many students who shared their experiences with us.

Related Content

Philippines: lgbt students face bullying, abuse.

Discrimination and Lack of Support Undermine Right to Education

End Gendered Uniform Restrictions for LGBT Students in Philippine Schools

Bullied as a Child, Gay Filipino Comes Into His Own

University’s LGBT Student Group Provides Support System

• Philippines
• Children's Rights
• LGBT Rights

Protecting Rights, Saving Lives

Human Rights Watch defends the rights of people in close to 100 countries worldwide, spotlighting abuses and bringing perpetrators to justice

Argument Essay: Equality For The LGBT Community

EQUALITY FOR LESBIAN, GAY, 3 Equality for LGBT Lesbians, gays, bisexuals, transgender, and queer community needs equality because they are humans, they need love and care, and they should be respected by everyone. This community is also known as LGBT or LGBTQ community. LGBTQ community is a group of people who are lesbians, gays, bisexual, transgender, and queer. This group of people is also known as homosexuals. This people experienced harassment, discrimination, and threat of violence because of their sexual orientation. They experienced this things because of homophobia or hatred of homosexuality. LGBT has many problems that they need to face. In some countries, being homosexual is a moral sin. There are many argument about sexuality and religion. And in some …show more content…

They continue to face the discrimination and exclusion in the world and violence. Like in EU, the same-sex couples and the opposite-sex couples have big difference because the same-sex couples do not enjoy their rights and protection compare to the opposite-sex couples. And same-sex couples suffer from discrimination and disadvantages in access to social protection scheme. Majority of LGBT hide their sexuality out of fear of losing their jobs. Youth LGBT are vulnerable. This youths experienced of estrangement from their family and friends, invisibility and harassment at school that may cause a mental ill-health, dropping on their school, and homelessness. This discrimination affects the equal access to key social goods, such as employment, health care, education and housing of the LGBT people. And they also experienced marginalization in the society that leads to them of being vulnerable group(Subhrajit,

Stonewall Riots Essay

Many LGBTQ+ individuals still face discrimination, violence, and harassment, especially in countries where homosexuality is still criminalized. In some places, LGBTQ+ individuals can face imprisonment, torture, or even death. Despite these challenges, the LGBTQ+ community continues to fight for their rights and visibility. They have created spaces and events to celebrate their identities, such as Pride parades, LGBTQ+ film festivals, and drag shows.

Gay Rights Dbq Research Paper

1) The rights of LGBTQ (Lesbian Gay Bisexual Transgender Queer) citizens are a must, and it 's our responsibility to be on the right side of history. Even though gay marriage is legalized, there is still a long way to go with LGBT rights and State and Federal Law. 2) Discriminating against anybody based on their lifestyle is a violation of human rights, and protection of human rights is the soul of a healthy democracy. 3) We should help build hope and start to create a world where everyone can live without the constant fear of being discriminated based on who they are and who they love. 4) Powerful lessons we have learned from past human right movements is that the battles we fought were painful and tough, but in the end they brought sweeping changes in American society by making it more caring and just.

Model Of Discrimination

Regardless of the recent legislated law, the LGBT is a sensitive population that is still crucially not well accepted in

Queer Community Charter Analysis

The Charter of Rights and Freedoms has allowed a rapid advancement of the rights of the Lesbian, Gay, Bisexual, Transgender, and Queer Canadians hereafter referred to as the queer community. The Charter’s guarantee of equality for all inspired a rights- based approach to queer rights that led to the queer community being granted the same rights as heterosexual men and women ultimately culminating in the legalization of same- sex marriages. This advancement in rights has primarily proceeded through the Courts as they proved much more willing to recognize the rights of the queer community than the government of Canada. This recognition of the equality of queer Canadians was made possible by the Charter accelerating a pre-existing process of separation

White Privilege And Racism

In these concepts, heterosexuality has the power to define GLBTI people as marginal and abnormal. This socially constructed norm has created health inequalities among GLBTI people and contributed to poor mental health because of the inequality, discrimination and a lack of cultural competency in healthcare system. One reason leading to poor mental health is fear of stigma or discrimination. Many GLBTI people need to concern and modify their daily activities in order to avoid discrimination (Willis & Elmer, 2011, p.

The Oppression Of Discrimination In The LGBT Community

The LGBT community has faced endless oppression for identifying as something other than heterosexual and cisgender (identifying as the gender you were assigned at birth). This maltreatment ranges from giving a homosexual a dirty look for kissing their boyfriend or to the extreme act of declaring it as illegal across a whole country. When people think of the LGBT community, they think of it as only homosexuals. This community consists of those who love the same sex or identify as a gender other than the one on their birth certificate.

Arguments Against Cbt

Adolescence is a developmental stage fraught with uncertainty, confusion, conflict, and growth. LGBT youth are unique in that face common challenges that are pervasive in most youth cultures, along with the difficulties encountered by the LGBT minority population. As a young person, common challenges such as grades in school, conflicts with friends and/or family, and struggling with romantic issues can become extremely difficult to manage when coupled with discovering and coming to terms with one’s identity. (LGBT, 2015) When engaging in a working relationship with young LGBT clients, the worker must tune in and understand the ways in which being considered a part of a sexual minority affects what some would consider the “normal” struggles of adolescence.

Latino LGBT Community Analysis

Hispanic or Latino face physical, psychological and social discrimination especially Latino LGBT communities which are most suppressed one, due to their gender and sexual identity. This problem persists since longtime. Discrimination is born when one feels that his identity is different from others and superior. They are discriminated economically, socially and psychologically. LGBT face discrimination not only at work place but also at home and schools.

Argumentative Speech About Transgender

Our society has been consistently changing throughout the years. It is developing new laws, new customs, and different beliefs. Things that we believed could never happen, are happening now. Society and culture in America today, is very different than the America we knew back in the day. Something that has been changing within our society, is transgender.

Edith M. Reno's Transgender Equality Rights

LGBT are fighting for bathroom rights, transgender marriage, and how transgender don’t qualify on health care. Bathroom rights has just became a very popular topic in the press. Starting out transgenders using the restroom that they identify as wasn’t so much an issue. The more and more trans people became comfortable the more they get pushed back because of the opinions of others. The main problem is genitals.

Sexual Minority Adolescents

LITERATURE REVIEW Adolescents are having a hard time in school when they realize that they are gay, lesbian, or bisexual. It baffles teachers, parents, counselors and other students. Sexual minority youth are having issues being bullied, having lower GPAs and negative school attitudes. It is very troubling for some youths to come out to their parents or peers and it can cause a negative effect in the household. Many surveys were done to show parent/child relationships and how the family was effected when a child told them they were gay, lesbian, or bisexual (Russel, Seif, &Troung).

Stereotypes: What Are Stumbling Blocks Of LGBTQ?

Verbal harassments, street harassments and casual homophobic comments experienced by LGBT people are common in societies. According to Stop Street Harassment survey, it was found that 25% of LGBTQ people experienced street harassment, 18% of them experienced verbal harassment and 16% of them experienced physically aggressive forms. LGBT people often get discriminated and ignored in the workplace as well. Discrimination is considered to be the major reason for their job instability which results in unemployment, poverty, etc. It causes socio-economic inequalities in the society.

Essay On Homophobia And Heterosexism

When we were talking about the issue of homophobia and heterosexism, a group of actors were invited to the classroom to do a scene. The scene is about a simulated daily event happened in Mizzou. It is about the hate of homosexuality on campus. I think the purpose of this activity is to make people recognise homophobia is not far away from us. I think it also serves as an education of how to deal with this kind of conflict in everyday life.

Equality And Justice Essay

“An unjust law is no law at all” stated by the civil rights activist, extremist, Martin Luther King Jr. If that being the case, then why is it looked down upon to be the individual to create change resulting in equality for all? Equality is not only for oneself, but the rest of society as well. Martin Luther King Jr’s Letter From Birmingham Jail, Earl Lovelace’s Wine of Astonishment, and chapters in Michael J. Sandel’s Justice: What’s the Right Thing to Do have all encompassed the topic justice.

The Importance Of Mate Selection

By the 2016 census, there were more than 72,880 declared same-sex couple which are 0.9 per cent of the total number of couples and 33.4 per cent of those same-sex couples were married. That represents a tripling in the number of married, same-sex unions across the country between 2006 and 2016. (Eichler, 2018). However, the common factors like the religious people and the society more that the family members have lot of issues such marriages which were the overcome by the couples on the different time as they have to choose one as a wife and another as a husband to run the domestic life smoothly. Same sex marriage also have the issues and get divorced as the partners are not satisfied from the personal livings or get someone other

More about Argument Essay: Equality For The LGBT Community

Home / Essay Samples / Sociology / LGBT / LGBTQ+ Rights: Navigating Society’s Challenges

LGBTQ+ Rights: Navigating Society's Challenges

• Category: Sociology , Social Issues
• Topic: Community Violence , Gender Discrimination , LGBT

Pages: 3 (1488 words)

Views: 1123

• Downloads: -->

--> ⚠️ Remember: This essay was written and uploaded by an--> click here.

Found a great essay sample but want a unique one?

are ready to help you with your essay

You won’t be charged yet!

Communication Skills Essays

Propaganda Essays

First Impression Essays

Nonverbal Communication Essays

Public Speaking Essays

Related Essays

We are glad that you like it, but you cannot copy from our website. Just insert your email and this sample will be sent to you.

By clicking “Send”, you agree to our Terms of service  and  Privacy statement . We will occasionally send you account related emails.

Your essay sample has been sent.

In fact, there is a way to get an original essay! Turn to our writers and order a plagiarism-free paper.

samplius.com uses cookies to offer you the best service possible.By continuing we’ll assume you board with our cookie policy .--> -->