Questions to answer

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Sexual and Gender Minority Health: What We Know and What Needs to Be Done I Kenneth H. Mayer, MD, Judith B. Bradford, PhD, Harvey J, Makadon, MD, Ron Stall, PhD, MPH, Hilary Goldhammer, MS,

and Stewart Landers. JD. MCP

We describe the emergence of lesbian, gay, bisexual, and transgender (LGBT) health as a key area of study and practice for clinicians and public health pro- fessionals. We discuss the specific needs of LGBT populations on the basis of the most recent epidemiológica! and clinical investigations, methods for defin- ing and measuring LGBT populations, and the barriers they face in obtaining ap- propriate care and services. We then discuss how clinicians and public health professionals can improve research methods, clinical outcomes, and service de- livery for lesbian, gay, bisexual, and transgender people, {Am J Public Health. 2008;98:989-995.doi:10.2105/AJPH.2007.127811)

Over the pasl few decades, clinicians, public health researchers, and officials have become increasingly aware ttiat lesbian, gay, bisexual, and transgender (LGBT) persons constitute sexual and gender minorities who have tinique health care needs.'" This recognition was enonnously heightened by the emer- gence of the AIDS epidemic, which demon- strated that sexual behavior could have major public health consequences. But the realiza- tion that sexual minorities have specific health care needs could arguably have begun witli Alfred Kinsey. whose work illuminated the important roles that sexual expression plays in people's lives.*''•* Certainly, by the early 1970s, debates in the American Psychi- atric Association about whether homosexual behavior was pathological suggested that cli- nicians were aware that their gay and lesbian patients had specific needs that could best be addressed by knowledgeable practitioners. The American Psychiatric Association ulti- mately recognized that homosexuality was not a psychiatric illness^ but that societal and internalized homophobia may affect access |{) appn)i)riate care and cause mental distress, which in tum might compromise optimal mental health.

Changing social nonns, led by the women's liberation movement, challenged societal as- sumptions on gender roles and identities and helped to empower the gay liberation move- ment to demand dvil liberties for sexual mi- norities. As part of the ethos of community-

based activism, sexual minorities developed autonomous health facilities designed to pro- vide culturally sensitive care.

By 1980, there were dozens of loosely net- worked clinics, mental health pmgrams, and provider groups that focused on sexual mi- nority health. These institutions were among the first to recognize an increase in sexually transmitted infections among men who have sex with men and to identily the need for safer-sex interventions. Because of their emerging expertise, public health officials increasingly looked to sexual minority clinical programs to assist in understanding the spread of new infections among men who have sex with men and to test promising solu- tions. Notable examples of these collabora- tions were the first hepatitis B vaccine trials in tlie late 1970s, wliich were oñen con- ducted in centers like the Ilowaî d Brown Clinic in Qiicago, Illinois, which a cooperative of gay medical students and other health professionals founded in 1974.' The relation- ships that emerged from these collaborations enabled sexual-minoHty community programs and public healtli investigators to rapidly mo- bilize and collaborate when the AIDS epi- demic was fii-st recognized.

To respond to the spread of AIDS, many of the early sexual-minority clinical programs rapidly developed sustained partnerships with local academic centers and federal public health agencies. Clinics such as Fenway Com- munity Health in Boston, Massachusetts,

developed not only some of the first programs for the counseling and care of people living with HIV/AIDS in the United States, but also the infrastructure needed to administer com- petitively reviewed grants rr(.)m the National Institutes of Healtli and tlie Centers for Dis- ease Control and Prevention. This unprece- dented development of freestanding health centers in sexual-minority communities, as well as the enhanced attention that clinicians and reseairhers needed to devote to under- standing sexual-minority patients' lifestyles, created a new paradigm that demonstrated the feasibility of conducting large-scale sur- veys and clinical trials in these communities.

Many of the first people to respond to the HIV/.'\IDS epidemic weiT lesbians, bisexuals. and tnuisgender pereons who helped their HlV-infected peers. Many of these clinicians, public health professionals, and activists learned firsthand that HIV transmission was abetted by other clinical concerns, including other sexually transmitted infections, suh- stance use, depression, aiid sti"ess related to societal stigmatization of sexual minorities. They also became aware that other clinical problems appeared to be more prevalent among sexual minorities thaji among hetero- sexuals, such as excessive tobacco use, human papillomaviiTis-associated anal neoplasia, and body image concerns.

The recognition that most LGBT health is- sues were insulficiently understood led the In- stitute of Medicine to commission a report in 1999 on the status of lesbians' health,^ which highlighted the need for new population- based researc.:h on the true prevalence and in- cidence of clinical problems in lesbians. Na- tional LGBT organizations such as the Gay and Lesbian Medical Association, the Na- tional Gay and Lesbian Task Force, and the Human Rights Campaign recognized the im- portance of advocacy for further research and resources focused on sexual minority health and health care delivery. By the mid-1990s.

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almost 100 organizations joined together to form the National Coalition for LGBT Health to concentrate on advocating for these goals. The importance of these issues was duly rec- ognized by the Department of Health and Human Services when it included lesbians and gay men as a population group experi- encing health disparities in Healthy People 2010: Understanding and Improving Health^ and subsequently provided support to the Gay and Lesbian Medical Association and the National Coalition for LGBT Health to con- vene an expert pane! to draft a companion document to Healthy People 2010. This com- panion document" {which, unfortianately, the new admmistraüon in 2001 ignored) is still available online.

As with any minority population, the opti- mal provision of health care and prevention services to sexuid and gender minorities re- quires providers to be sensitive to historical stigmatization. to be informed about contin- ued barriers to care and the differential prev- alence of specific risk factors and health con- ditions in these populations, and to become aware of the cultural aspects of their interac- tions with LGBT patients. We present current evidence on the issues most relevant to sex- ual and gender minority health. Although additional research is needed, since Kinsey's time, other research pioneers have made im- portant strides in conducting well-designed, population-based studies on LGBT health, and practitioners have developed usefiii guidelines and programs that should inform best practices in today's society.

DEFINING AND MEASURING SEXUAL AND GENDER MINORITIES

Groups and individuals must be counted to receive attention, and enumeration requires reasonably precise definitions to label groups and sort individuals. Although the science of counting population groups is imperfect enough consensus has developed to create acceptable projections on the basis of race/ ethnicity and gender. However, increasing di- versi^ within the US population has necessi- tated the development of a more nuanced un- derstanding of minority group membership, including identification, behavior, and cultural beliefs. The LGBT population comprises

many diverse groups, increasingly referred to as seoial and gender minorities. The classifica- tion of lesbians, gays, and bisexuals within re- search studies is generally made on the basis of sexual orientation. The term sexual orienta- tion encompasses more than sexual behavior, because individuals may identify with a spe- cific sexual minority group without expressing those behaviors. Women primarily oriented to other women are referred to as lesbians. men primarily oriented to other men as gay. and individuals oriented to both men and women as bisexual.'^

Gender is a construct of hiological, psycho- social, and cultural factors generally used to classiiy individuals as male or female. Trans- gender is an inclusive term to describe people who have gender identities, expressions, or behaviors not traditionally associated with their birth sex. Transgender people may iden- tiiy more strongly with another gender (e.g., natal females who identily as men, natal males who identify as women) or with a vari- ance that falls outside dichotomotis gender constructions prevalent in Western cultures (e.g., individuals who feel they possess both or neither gender). In other cultures, ranging trom American Indian to several in Asia, transgendei' persons are recognized as part of traditional society, Intersex refers to persons bom with a p i c a l genital or reproductive anatomy who usually identily as male or fe- male, although some may change their gender identity in the course of their development'"

Sexual and gender identity are character- ized by fluidity and change, as many indi- viduals who report same-sex behavior iden- tify as heterosexual and others consider themselves to be alternately heterosexual, bisexual, and homosexual (or some other variation in pattern), and as self-perception changes over time.

Some radal/ethnic minorities who engage in same-sex relations may be less likely to identify as gay or bisexual,'"" pos.sibly be- cause they identify gay culture with White so- ciety or because they fear an LG BT identity would alienate them from family and commu- nity.'^ For some in the LGBT population, gay and lesbian are conventional terms, applica- ble to middle-aged and older individuals. Sexual-minority youths may prefer terms such as queer or questioning. Individuals within

transgender communities report more than 100 terms to convey what "outsiders" com- bine into the generalized term transgender. '•*

Awareness of sexual minority orientation appears to be occurring at younger ages; on average, initial same-sex experience occurs around age 14 to 16 years.'^"' On the oppo- site end of the age spectrum, it is important to note that sexual and gender minorities do age. For the first time in US history, there is an identifiable cohort of LGBT elders, many of whom lack access to culturally competent health care and sodal services.'^

From the perspective of population- and practice-based I'esearch, progi'ess has been made to indude sexual orientation as a de- mographic variable in several government surveys'**; however, these surveys typically have just one question about sexual orienta- tion and none for transgender identity. ''' Be- cause of the paucity of measures, these data can be misleading and limited in usefulness. In the first national probability sample survey to specifically examine the sexual behaviors of US adults, 3 constructs—behavior, attrac- tion, and identity—measured sexual orienta- tion.^'' individual and subgroup percentages varied substantially across these 3 measures. Men were twice as likely as women to iden- tify as homosexual and more than twice as likely to report same-sex behavior since pu- berty. Respondents who lived in or near major urban areas or had advanced educa- tion were more likely to report same-sex be- havior and were more likely to identify as ho- mosexual or bisexual than those in nonurban Eireas. Latino and Asian men were less likely to report same-sex behavior but approxi- mately twice as likely to report same-sex de- sire, attraction, or appeal compared with Black or White men. Thus, the use of a single measure may mask subgroup differences, contributing to the general perception that sexual and gender minorities are far less nu- merous and diverse than is actually the case.

Despite their limitations, government sur- veys with sexual orientation measures have helped increase awai"eness for policymakers and the genei-al public that LGBT people are distributed throughout the United States and, to some extent may help distinguish how sex- ual minorities are alike and diflerent from the general population. The most prominent

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Source. Data were from the US Census Bureau. Note. 1 doi=100 same-sei households. Total - 594391 same-sex households.

FIGURE 1-Same-sex households In the continental United States, hy county: 2000.

TABLE 1-Leading Health Indicators and Sexual and Gender Minorities

Leading Health Areas of Incfeased Indicators in the Concern for Sexual

General US Population' and Gender Minorities^

Physical activity

Overweight and obesity

Tobacco use

Substance abuse

Responsible sexual behavior

Mental heaittt

Injury and violence

Environmental quality

Immunization

Access to care

'According to Healthy People 2010.^ "According to Makadon et a l . "

government survey with a sexual orientation measure was the 2000 US Census, which counted about 1.2 million individuals who identified as living with a same-sex partner.^' (See Figure 1 for a depiction of the distribu- tion of same-sex households across the na- tion.)

Sexuai identity, behavior, and attraction were more recentiy measured in the 2002 National Survey of Family Growth, ieading to the finding that 4.1 % of the US population aged 18 to 44 years (more than 4.5 million individuals) identified as homosexual or bi- sexual.̂ ^ Among women aged 18 to 44 years in the National Survey of Family Growth, 1.3% thought of themselves as homosexual and 2.8% as bisexuai; among men aged 18 to 44 years, 2.3% thought of themselves as ho- mosexual and 1.8% as bisexual.

To increase understanding of LGBT popu- lation groups and their health-related needs, it is critical that population-based surveys and social behavioral research studies continue to expand and improve the measurement of sex- ual and gender minority identity and behav- ior. To this end, the National Institute of Child Health and Human Development has recently awaitled funding to Fenway Community Health to develop the first federally funded popula- tion research center focused on LGBT health. This initiative will be developed in conjunc- tion with the Inter-University Consortium for

Political and Social Research of Ihe University of Michigan in Ann Ai'bor; the Boston Uni- versity School of Public Health; and a na- tional consortium of academic investigators, university centers, and community-based or- ganizations.

UNIQUE CLINICAL CONCERNS OF SEXUAL AND GENDER MINORITY POPULATIONS

In light of previous societal and profes- sional misconceptions of sexual and gender minorities, it is not surprising that clinicians and public health researchers are only now learning about the range of health disparities and unique clinical issues afiecdng LGBT people. Existing research, although limited, points to a higher prevalence of certain condi- tions among LGBT patients that merit atten- tion.'̂ •^^• '̂' Many of the issues that dispropor- tionately affect sexual and gender minorities, such as substance abuse, overweight and obe- sity, and tobacco use,"'̂ '̂ ^ are among the leading health indicators designated by Healthy People 2010^ (Table 1). Clinicians and public health professionals need to un- derstand the dynamics and expression of these health issues in LGBT people to fill the voids left by previous biases. To educate a new generation of clinicians, the American College of Physicians has published the first

comprehensive text on the care of sexual and gender minority patients, TTie Fenway Guide to Lesbian. Gay. Bisexual, and Transgender

Among the most significant areas of clini- cal concern for LGBT patients are mental health disorders, particularly diagnoses of depression and anxiety.̂ ^ Some studies have also found a higher prevalence of eating and body image disorders among gay and bisex- ual men compared with their heterosexual peers.̂ *̂ Mental health disorders are not in- herent to being a sexual minority person but can manifest as a result of leading marginal- ized lives, enduring the stress of hiding one's sexuality, or facing verbal, emotional, or physical abuse from intolerant family mem- bers and communities."'"^^

Although adolescents and young adults today have an easier time coming out be- cause of greater general acceptance and more visible role models, recent studies s u r e s t that LGBT youths are still at greater risk for sui- dde attempts than non-LGBT youths.^" Qini- dans and service providers need to be sensi- tive to the potential Stressors of coming out and the process of forming a positive identity as an LGBT person, and should be prepared to answer questions and make referrals. Clini- cal and public health professionals can work to develop programs that spedalize in the care of LGBT populations and can advocate

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for policies that diminish the stigma LGBT people encounter.

Some studies have found higher rates of substance use in sexual and gender minorities compared with heterosexual cohorts, al- though some of the earliest research recruited participants from bars, resulting in selection hias."*' Recreational dmg use, particularly stimulant use, among gay men has been asso- ciated with higher rates of unsafe sexual prac- tices and HIV and other sexually transmitted infections.'^'" Male-to-female transgender in- dividuals may also be at higher risk foi- drug use and sexual risk behaviors.'*'' Researchers liave also found higher rates of heavy alcohol use and related problems among lesbians and bisexual women, ajid possibly gay and bisex- ual men, compared witli heterosexuals. ''""' There is strong evidence to suggest a higher prevalence of tobacco use in sexual minorities as well. " •' Several promising LGBT-specific tobacco cessation interventions have been iieveloped; more information on these pro- giBins can be found thraugh the National I.GBT Tobacco Control Network Web site."*"

Lesbians are more likely thaJi women of other sexual orientations to be overweight and obese,^' putting them at increased risk for cardiovascular disease, lipid abnormalities, glucose intolerance, and morbidity related to inactivity. Transgender patients may have en- hanced cardiovascular risks because of exoge- nous hormone use.""̂ Individuals who are HIV infected can be at higher risk for lipid abnormalities, depending on their regimen.*'

Qinidans and epidemiologists have ex- pressed concern that some LGlir populations are at increased risk tor some cancers. Because of discomfort with the medical community, lesbians may seek routine breast and cervical cancer screening less often than heterosexual women.̂ "*'̂ In addition, lesbians and their providers may underestimate their risk of cervical cancer.*'' Many lesbians may have multiple risk factors for cervical cancer, in- cluding a history of sex with men at an early age/^ Lesbians and bisexual women, inde- pendent of their airrent sexual practices, re- quire the same schedule of Papanicolaou tests and human papillomavirus vaccination as other women.

Ajial cancer is an important health concern for men who have sex with men. Because of

the high prevalence of anal human papilloma- virus in men who engage in receptive anal in- tercourse, trials are under way to evaluate the use of the human papillomavirus vaccine in men who have anal intercourse. There is growing evidence that routine anal Papanico- laou tests for men who are HfV infected is cost efTedive in preventing anal cancer.''** Al- though tlie data are less clear on the benefit of routine anal Papanicolaou tests for at-risk HIV-uninfected men who have sex with men, some experts recommend mutine screening for this population, though perhaps less fre- quently than they do for HIV-infected men who have sex witli men.""*

Transgender individuals who have under- gone sex reassignment surgeiy but retain pre- transidon organs or tissue remnants need carelul follow-up for potential oncological problems commonly associated with tlieir natal sex, including prostatc, '̂̂ breast, cervi- cal, and ovarian cancer. Transgender health in general has not been a focus of specialized clinical care because of an even greater lack of data and resources than with gay and les- bian health. Transgender individuals have had to struggle to have their clinical issues taken seriously and to find approjjriate re- sources for care. Guidelines for the care of transgender people are available online^" but are not yet widely disseminated or taught. Transgender people also face financial barri- ers to care, given that transitional therapies with either medication or surgery are expen- sive and rarely covered by insurers in the United States.^'

Intersex individuals, sometimes referred to as people who have a variation or disorder of sex development are not traditionally included as an LGBT population, but tJiey have some of the same health care and stigmatization problems. Intersex children and adults require specialized approaches to medical, surgical, and emotional care. A consortium of cliniciajis, parents, patients, and advocates recently de- veloped guidelines on the care of children with intersex conditions. ̂ ^ ln the past few yeare, the medical community has recognized that genital vaiiations should not automati- cally be surgically altered in infancy and that gender identity formation is the result of complex biological and social factors and may not be fully evolved until adulthood.^ '

Clinical care issues are not the only con- cerns unique to LGBT patients. LGBT indi- viduals' family lives can affect their engage- ment and satisfaction with can?. Increasingly, LGBT individuals are developing socially sanctioned long-term relationships and are raising families. Many of these people seek support in finding appni[)riatc services, such as LGBT-friendly adoption agencies and legal resources. Individuals are also coming out at earlier ages'^ and turning to tlieir clinicians for support—hence Ihe need for primary pro- viders sensitized to sexual and gender miJior- ity health concem.s. In addition, many LGBT elders have fewer family connections than non-LGBT elders and are less protected whi-n a partner dies or while ho.spitalized with a life-threatening illness Ihan people who have legally sanctioned marriages by traditional family law.'' Public health advocacy for pol- icy changes and supportive pnigrams will make a difference in ensuring equity for sex- ual and gender minority patients at these later stages of life.

BARRIERS TO OPTIMAL HEALTH CARE FOR SEXUAL AND GENDER MINORITY PATIENTS

Optimal health care for LGBT populations requi] es access to both competent medical personnel and sensitive prevention services. However, sexual and gender minorities con- tinue to encounter numerous barriers to ac- cessing care, clustering around 4 main issues; {1) reluctance by some LGBT patients to disclose sexual or gender identity when re- ceiving medical care, (2) insufficient numbers of providers competent in dealing with LGBT issues as pail of the provision of medical care, (3) structural barriers that impede access to health insurance and limit visiting and med- ical decisionmaking rights for LGBT people and their partners, and (4) a lack of culturally appropriate prevention services. Each of these barriers is important individually, and together they form a challenging gauntlet of barriers to the receipt of medical care for many LGBT ciüzens (see Ramchaiid and Fox '̂' for an overview of these barriers in the case of American gay and bisexual men).

LGBT patients have multiple reasons for not disclosing their sexual or gender identity

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to providers, including fears of homophobic reactions, confidentiality concerns, past nega- tive experiences with providers, and fear of being stigmatized. To the extent that these concerns cause LGBT patients to delay re- ceipt of care or withhold information that may be important to treatment effective med- icai care can be compromised. But disclosure of sexual or gender minority identity is only likely to improve care if providers offer cul- turally competent and well-informed services in return—for example, the provider is aware of the unique health concerns of LGBT popu- lations and is able to assess partnership status and sexual behavior without assumptions or judgment Although attitudes are changing.̂ ^ societal misperceptions and discomfort about homosexual behavior and identity persist, even among health care personnel.^'''^' Un- fortunately, neither professional schools nor continuing education programs provide the training needed to improve the attitudes, knowledge, and skills of physicians and other health care professionals in caring for LGBT people.̂ '̂̂ ^ Consequently, there are not enough clinicians who can provide optimal care to LG BT patients.

The structure of health insurance in the United States, which is largely financed through employers, can also inhibit LGBT people s access to clinical care. For example, only some organizations and legal jurisdic- tions extend insurance coverage to domestic partners, in efTect denying coverage to un- manied partners of employed LGBT individ- uals. Fui-thermore, when antidiscrimination laws are not in place to prevent the loss of employment as a result of being identified as a sexual or gender minority, the danger of losing health insurance coverage is amplified. In addition to structural barriers to obtaining health insurance, lack of marriage rights for most LGBT long-term relationships means that even partners in decades-old relation- ships may be denied medical decisionmaking rights and prevented from providing crucial support dtiring a partner's medical crisis.

Many of the variables associated with health risks among LGBT populations may be imique to these populations and thus require tailored prevention services.""'*^" Unfortu- nately, tliere are few LGBT-spedfic prevention services to deal with violence victimization.

substance abuse, mental health concerns, and other health care needs, except in lai^e met- ropolitan areas.^ F.ven then, most of these ser- vices have not been as thoroughly evaluated as HIV prevention services focusing on gay men. That said, the evidence base for efñcacy trials of HIV prevention models among gay men''' suggests that innovative preventioti models to address the most important epi- demics LGBT populations face might improve health outcomes, thereby lowering the de- mand for expensive health care services. Im- provements in access to medical care and ef- fective prevention services for LGBT patients could concomitantiy improve the health care delivery for other vulnerable populations.

CREATING A HEALTHIER ENVIRONMENT FOR SEXUAL AND GENDER MINORITY PATIENTS

The provision of optimal care to sexual and gender minority patients requires welcoining clinical and program environments ihat pro- mote good communication and allow individ- uals to feel comfortable discussing matters of their sexual identity, behavior, attractions, and any conflicts they may he experiencing.^^ It is critical to train providers and other staff to spetik with patients and clients in a non- judgmenteil, gender-appropriate, and profes- sional way. These techniques should be taught during professional education^^ and staff training in health care and service facili- ties and should be reinforced with nondis- crimination policies in clinical and program settings, intake forms that ask about gender identities and same-sex partners, and visual cues in waiting and examination rooms that signal acceptance, such as brochures that dis- cuss LGBT health risks and promotion."' Clinicians' efforts should be synergistic with those of public health departments, whidi could do more to ensure that their programs are culturally competent for this group. A handful of large city health departments (Boston, Chicago, Los Angeles, New York, and San Francisco) now have specific staff mem- bers dedicated to working with LGBT popula- tions. However, acknowledgment of the pub- lic health issues affecting LGBT persons and plans and resources to address those issues at the state and federal level are still lacking.

To the extent public health has acknowl- edged the public health issues affecting LGBT persons, efforts have primarily occuired in the "tradiüonal" realms of HIV/AIDS, sexu- ally transmitted infections, and hepatitis. Ac- tivities to tailor public healtli prevention mes- sages to the LGBT community in the areas of tobacco cessation, cancer, tilcohol use, healthy weight, asthma, and cardiovascular health have been scant. Further, there has been a substantial deaith of data collection and anal- ysis on the risk behaviors of and protective health factors for LGBT persons. However, Colorado, Massachusetts, North Dakota, and Vermont currently collect infonnation about sexual orientation through their Behavioral Risk Factor Surveillance System.*'"' The first transgender question to appear on a state- wide Behavioral Risk Factor Sui"veillance System survey was in Massachusetts in 2007 (K. Cranston, MDiv, director, Massachusetts HIV/AIDS Bureau, written communication. August 18. 2007).

With the increasing weight of evidence- based data indicating that LGBT people expe- rience substantial health disparities, it is in- cumbent upon federal and state public health officials to develop programs to remedy these disparities. Although LGBT patients make up approximately 2'Vi-i to 5% of tlic US adult population, the pî opoition of resources allo- cated for their public heaith needs is substan- tially lower, particularly when looked at on a program-by-program basis. Schools of public health have been slow to inc^oipoi-ate teach- ing and research into LGB I" hi>alth i,ssues.''̂ Advocacy for improving public health policy and the quality and number of public health programs for LGBT populations has been bainpered by a lack of resources as well as by limited population-based data and the need to focus advocacy efforts on basic civil rights issues (employment recognition of relationships, etc.).

THE ROAD AHEAD

More work is needed to improve data, I'c- sources, and public policy on sexual and gender minority health. Advocacy for better prevention, care and treatment and the elimination of health disparities among LGBT populations needs to be supported by

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well-designed studies. Accordingly, it is essen- tial that large national data sets that measure the health status of Americans include mea- sures of sexual attraction, identity, and hehav- ior and that more information is gathered on how to ask questions that best measure these constructs. Furthermore, it is important to learn how to collect this information confi- dentially, to ensure the safe^ and pnvacy of respondents. As larger data sets become available, new resources to support innovative ways to study sexual and gender minority populatioas will be essential. It will be partic- ularly important to understand the issues for people who may have multiple identides, such as LGBT people who are from racial or ethnic minority groups or who have disabilities.

Culturally appropriate programs need to be developed and refined to improve dispari- ties in smoking, alcohol use, mental health. healthy weight, cancer prevention activities, and sexually transmitted infections. Federal agencies ¿md public health organizations must disseminate the best practices of successful programs. Future national public health planning documents, such as Healthy People 2020. should incorporate new findings gath- ered on the health care needs of sexual and gender minority populations. As we learn more about health disparities and effective pro- grams to address them, medical care provid- ers, public health workers, and other human services workers who interact on a daily basis with LGBT persons will need training. Without such training, sexuai and gender mi- norities will continue to interact with a health care system that is unaware, insensi- tive, and unprepared to meet their needs. •

About the Authors Kenneth H. Mayer, Judith B. Bradford, Harvey J. Makadon, and Hilary Goldhammer are mth the Fenway Institute. Bos- ton. MA. Kenneth H. Mayer is also with Miriam Hospital, Providence, Rl Judith B. Bradford is also with Vir^nia Commonwealth University, Richmond. Harvey J. Makadon is also with the DivKion of General Medidne and Primary Care. Beth Israel Deaconess Medical Center. Harvard Medical School, Boston. MA. Ron Stall is with the Graduate School of Public Health, Unim^ty of Pittsburgh. Pittsburgh, PA. Stewart Landers is with John Snow, Inc. Boston, and the Massachusetts Department of Public Health. Boston.

Requests for reprints should be sent to Kenneth Mayer, MD, Infectious Diseases Division, Vie Miriam Hospital, ¡64 Summit Avenue, Providence. Rl 02906 (e-mail: kenneth_mayer@ brown, edu).

This article was accepted December 4. 2007.

Contributors K- Í1. Mayer and S. Landers conceptualized the artide. K.H. Mayer wrote the initial outiiiie. All aiitliors wrote content for (he artide and contributed to the editing.

Acknowledgments nils work was supported in part by the National Insti- tute of Child Health and Human Development (grant 1R21HD051178-01A2).

We give special thanks to Julie Honnold and Lau- retta Safford of the Commtinity Health Research Initia- tive Group, Virginia Commonwealth University, and to Kirsten Barrett for the census map figure.

Note. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Child Health and Human Development or the National Institutes of Health.

Human Participant Protection No protocol approval was needed for this study.

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