Did you know that as recently as twenty years ago, individuals who engaged in consensual same-sex relations could be arrested in many states for violating so-called sodomy laws? The U.S. Supreme Court, which had upheld such laws in 1986, finally outlawed them in 2003 in Lawrence v. Texas, 539 US 558, by a 6–3 vote. The majority opinion of the court declared that individuals have a constitutional right under the Fourteenth Amendment to engage in consensual, private sexual activity. Despite this landmark ruling, the LGBT community continues to experience many types of problems. In this regard, sexual orientation is a significant source of social inequality, just as race/ethnicity, gender, and social class are sources of social inequality. We examine manifestations of inequality based on sexual orientation in this section. First we will explore the concept heterosexual privilege, then we will look at interactional challenges experienced through bullying and violence. Next we will examine a few of the ways that policies and social institutions create barriers for LGBTQIA+ identified individuals.

10.4.1 Heterosexual Privilege

In the study of sexual orientation and inequality, the term “heterosexual privilege” is a useful concept to help us understand the experience of those who are LGBTQIA+. This concept refers to the many advantages that heterosexuals (or people perceived as heterosexuals) enjoy simply because their sexual orientation is not LGBTQIA. There are many such advantages, and we have space to list only a few:

• Heterosexuals can be out day or night or at school or workplaces without fearing that they will be verbally harassed or physically attacked because of their sexuality or that they will hear jokes about their sexuality.
• Heterosexuals do not have to worry about not being hired for a job, about being fired, or not being promoted because of their sexuality.
• Heterosexuals can legally marry everywhere in the United States and receive all the federal, state, and other benefits that married couples receive.
• Heterosexuals can express a reasonable amount of affection (holding hands, kissing, etc.) in public without fearing negative reactions from onlookers.
• Heterosexuals do not have to worry about being asked why they prefer opposite-sex relations, being criticized for choosing their sexual orientation, or being urged to change their sexual orientation.
• Heterosexual parents do not have to worry about anyone questioning their fitness as parents because of their sexuality.
• Heterosexuals do not have to feel the need to conceal their sexual orientation.
• Heterosexuals do not have to worry about being accused of trying to “push” their sexuality onto other people.

Heterosexual privilege can have different consequences in various locations. You will learn more about discrimination and how one’s sexuality intersects with government policy and human rights in Uganda in the “Activity: A Closer Look at Discrimination Internationally.”

10.4.3 Inequalities Experienced through Interactions

Interactional examples of discrimination in the LGBTQIA+ community occur during everyday interactions and can occur in a variety of settings, including workplaces, education, and healthcare. We will focus on some of the settings, or social institutions in the next section “Policies and Social Institutions: Inequalities experienced at the Structural Level.” First, let’s look at everyday interactions and relationships to understand more about micro level processes and inequalities. Sometimes we refer to interactional examples of discrimination as microaggressions. Microaggression is a term used for commonplace daily verbal, behavioral or environmental slights, whether intentional or unintentional, that communicate hostile, derogatory, or negative attitudes toward stigmatized or culturally marginalized groups (Sue 2010). There are many micro-aggression examples to look at in how society engages with this population. We can easily see in the news that there are hateful comments and harassment made on streets, in schools, workplaces, grocery stores, sports games, etc. In the past couple years in Oregon, there have been issues with a high school that threw out racial slurs at a sports game and homophobic slurs being used during school board meetings. These examples highlight the way that one’s race and sexuality continue to be weaponized during interactions within the community. Further the intersection of race and sexuality for people of color who are LGBTQIA+, leaves them at higher risk for interactional harassment. In fact, LGBTQIA+ people who are also people of color have higher rates of harassment, assault, and mistreatment in most areas of their lives compared to their white counterparts. These issues occur throughout all areas of society for them including housing, employment, by police and within the criminal justice system, as well as higher rates in their daily lives.

10.4.3.1 Bullying and Violence

According to the Federal Bureau of Investigation (2023), there were 1,132 hate crimes (violence and/or property destruction) based on Sexual Orientation Bias, although this number is very likely an underestimate because many hate crime victims do not report their victimization to the police. That includes Anti-Bisexual, Anti-Heterosexual, and Anti-Lesbian, Gay, Bisexual, or Transgender (Mixed Group), and Anti-Biseuxal hate crimes. Anti-Trans and Anti-Gender-Nonconforming hate crimes (identity based, rather than sexual orientation based) totalled 669. An estimated 25 percent of gay men have been physically or sexually assaulted because of their sexual orientation (Egan, 2010), and some have been murdered. Matthew Shepard was one of these victims. He was a student at the University of Wyoming in October 1998 when he was kidnapped by two young men who tortured him, tied him to a fence, and left him to die. When found almost a day later, he was in a coma, and he died a few days later. Shepard’s murder prompted headlines around the country and is credited with winning public sympathy for the problems experienced by the LGBT community (Loffreda, 2001).

Gay teenagers and straight teenagers thought to be gay are very often the targets of taunting, bullying, physical assault, and other abuse in schools and elsewhere (Denizet-Lewis, 2009). Survey evidence indicates that 85 percent of LGBT students report being verbally harassed at school, and 40 percent report being verbally harassed; 72 percent report hearing antigay slurs frequently or often at school; 61 percent feel unsafe at school, with 30 percent missing at least one day of school in the past month for fear of their safety; and 17 percent are physically assaulted to the point they need medical attention (Kosciw, Greytak, Diaz, & Bartkiewicz, 2010).

The bullying, violence, and other mistreatment experienced by gay teens have significant educational and mental health effects. The most serious consequence is suicide, as a series of suicides by gay teens in fall 2010 reminded the nation. During that period, three male teenagers in California, Indiana, and Texas killed themselves after reportedly being victims of antigay bullying, and a male college student also killed himself after his roommate broadcast a live video of the student making out with another male (Talbot, 2010).

In other effects, LGBT teens are much more likely than their straight peers to skip school; to do poorly in their studies; to drop out of school; and to experience depression, anxiety, and low self-esteem (Mental Health America, 2011). These mental health problems tend to last at least into their twenties (Russell, Ryan, Toomey, Diaz, & Sanchez, 2011). According to a 2011 report by the Centers for Disease Control and Prevention (CDC), LGBT teens are also much more likely to engage in risky and/or unhealthy behaviors such as using tobacco, alcohol, and other drugs, having unprotected sex, and even not using a seatbelt (Kann et al., 2011). Commenting on the report, a CDC official said, “This report should be a wake-up call. We are very concerned that these students face such dramatic disparities for so many different health risks” (Melnick, 2011).

Ironically, despite the bullying and other mistreatment that LBGT teens receive at school, they are much more likely to be disciplined for misconduct than straight students accused of similar misconduct. This disparity is greater for girls than for boys. The reasons for the disparity remain unknown but may stem from unconscious bias against gays and lesbians by school officials. As a scholar in educational psychology observed, “To me, it is saying there is some kind of internal bias that adults are not aware of that is impacting the punishment of this group” (St. George, 2010).

Many LGBT teens are taunted, bullied, and otherwise mistreated at school. This mistreatment affects their school performance and psychological well-being, and some even drop out of school as a result. We often think of the home as a haven from the realities of life, but the lives of many gay teens are often no better at home. If they “come out” or disclose their sexual orientation to their parents, one or both parents often reject them. Sometimes they kick their teen out of the home, and sometimes the teen leaves because the home environment has become intolerable. Regardless of the reason, a large number of LGBT teens become homeless. They may be living in the streets, but they may also be living with a friend, at a homeless shelter, or at some other venue. But the bottom line is that they are not living at home with a parent.

Being homeless adds to the problems that many LGBT teens already experience. Regardless of sexual orientation, homeless people of all ages are at greater risk for victimization by robbers and other offenders, hunger, substance abuse, and mental health problems.

10.4.4 Policies and Social Institutions: Inequalities Experienced at the Structural Level

In the last section we focused on some of the ways people experience discrimination at the interactional level. To get a better understanding of how inequalities persist, let’s examine inequalities at the structural level by taking a closer look at a few social institutions, such as marriage/family, healthcare, and workplaces. As you will see in the examples given in this chapter, it is nearly impossible to completely disconnect harassment in interactional situations from policies built into social institutions. For example, consider perspectives on heteronormativity and how that influences daily interactions and structures in our society, as well as gender norms and expectations. Those norms influence institutions and policy as deep rooted systems that exist on power dynamics based on binaries and patriarchal ideologies.

10.4.4.1 Marriage Equality

At the start of this chapter, we learned about how marriage equality did not exist for same-sex couples until 2015, making this a very recent step towards equality given the historical patterns of the United States. Why was same-sex/same gender marriage something that was against the law and unaccepted in society?  First of all, dominant groups in society work hard to promote their interests and ideology, thus we can assume that white, cis, hetero, male, and in many ways Christians are the idealized and dominant group that hold the current power and wants to maintain their power structures. Allowing same-sex couples to marry, through narrative, contradicts ideals of ‘marriage’ and puts at risk what is felt to be a sacred and God granted value between a ‘man and a woman’.

We find ourselves again in a place where marriage equality is going to be challenged in the highest court in the land, so the debate and conflict isn’t over, even after an institutional and legal precedent was placed in support of marriage equality almost 8 years ago. Which brings us back to the deeply institutionalized norms and values of what is acceptable and what would maintain the power dynamics and privilege of the dominant classes.

10.4.4.2 Healthcare

As a social institution, healthcare affects Americans in many different ways. Individual health and access to health care is another institution of society that has problematic ties to ethnicity, race, class, gender, and sexuality. Affluent individuals have significantly higher life expectancies when compared to more socially deprived individuals due to a multitude of factors. For folks who identify as LGBTQIA+, in addition to any concerns or stigma they may have regarding the services they need to seek from a healthcare provider, they may also experience harassment or discrimination based on their sexual orientation or gender identity. We will take a closer look at how health and healthcare intersect with one’s sexual orientation and gender identity in the next sections.

10.4.4.2.1 Physical and Mental Health

It is well known that HIV (human immunodeficiency virus) and AIDS (acquired immunodeficiency syndrome) racked the LGBT community beginning in the 1980s. Many gays and lesbians eventually died from AIDS-related complications, and HIV and AIDS remain serious illnesses for gays and straights alike. An estimated 1.2 million Americans now have HIV, and about 35,000 have AIDS. Fortunately, HIV can now be controlled fairly well by appropriate medical treatment (Centers for Disease Control and Prevention 2011).

It is less well documented that LGBT adults have higher rates than straight adults of other physical health problems and also of mental health problems (Frost, Lehavot, & Meyer 2011; Institute of Medicine 2011). These problems are thought to stem from the stress that the LGBT community experiences from living in a society in which they frequently encounter verbal and physical harassment, job discrimination, a need for some to conceal their sexual identity, and lack of equal treatment arising from the illegality of same-sex marriage. We saw earlier that LGBT secondary school students experience various kinds of educational and mental health issues because of the mistreatment they encounter. By the time LGBT individuals reach their adult years, the various stressors they have experienced at least since adolescence have begun to take a toll on their physical and mental health.

Because stress is thought to compromise immune systems, LGBT individuals on the average have lower immune functioning and lower perceived physical health than straight individuals. Because stress impairs mental health, they are also more likely to have higher rates of depression, loneliness, low self-esteem, and other psychiatric and psychological problems, including a tendency to attempt suicide (Sears & Mallory, 2011). Among all LGBT individuals, those who have experienced greater levels of stress related to their sexual orientation have higher levels of physical and mental health problems than those who have experienced lower levels of stress. It is important to keep in mind that these various physical and mental health problems do not stem from an LGBT sexual orientation in and of itself, but rather from the experience of living as an LGBT individual in a homophobic (disliking LGBT behavior and individuals) society.

10.4.4.2.2 Gender and Decision Making Policies

There is a long history in the U.S. of dominant groups exerting power over subordinated groups. In this case, we can examine the way that dominant groups have medicalized subordinated bodies. Similar to what we’ve seen in other  social institutions, gender shapes and is shaped by  the medical field. The process where a condition or set of conditions becomes medical and systemically studied, diagnosed and/or treated can be thought of as the medicalization of gender. For example, intersex individuals have been hidden, treated, and dismissed by the medical practices and treatment, seemingly something that needs an intervention and label. Another way we can see the marginalization of gender through medicalization is the recent repeal of federal protections for Roe V Wade which protected women’s autonomy to choose abortion. We can also see medicalization of transgendered individuals, and for men, so in this way there is not a gender on the spectrum that seems to not be impacted by medicalization of gender.

Intersex individuals who are born intersexed have been hidden or celebrated in different societies, and managed quite differently as well. Infants who are born intersexed sometimes undergo surgery to clarify which binary (male/female) they will be categorized into. There are few medical reasons for surgical interventions of intersex individuals, instead what we see is the strong need to fit people into the small binary box can be very powerful. By making this decision for an infant, parents and doctors are taking the child’s choice away from them and potentially forcing them to live as one gender when that may not be congruent with their personal gender identity. It is important to remember that many times, parents either do not understand or know what is really happening and they do not always have the chance to intervene. This is where medicalization of intersex individuals reinforces both the binaries of sex and gender. Making sure that a baby conforms to one sex so that they may be raised in the basis and meanings instilled on that associated gender.

Now we are going to look at ways in which the medical institution systemically follows and perpetuates gender inequality and more so within an already marginalized group, women. Gender bias built into our society creates a barrier where women are not believed to be as smart or capable of rational decision making, which leads to them being listened to less and believed less when they seek medical support. The first example is with chronic pain, women experience chronic pain more than men, but are given other diagnoses and dismissals than men. They are more likely to be diagnosed with a psychological reason for the pain, or not believed that they are in as much pain as they describe. They are given less pain medication, less effective pain medication and instead are treated for mental health versus physical health in many cases of pain (Zhang et al., 2021). We see this dismissal of women with autoimmune diseases as well, they are labeled as complainers and have their descriptions and fight for diagnoses dismissed. Diagnoses such as lupus and other autoimmune disorders take longer to be diagnosed in women because of this, thus creating a disparity in care. We see the same trends with blood disorders, heart disease, mental health, and other conditions.

Men are also affected by these exact same ideals and biases, looking back at chronic pain, men do receive stronger pain management medicines, but they are also adversely affected by the labels of ‘strong, brave, and resilient’ and may take longer to ask for care or admit that they are in pain. We see a disparity with mental health care as well, as the social pressures on men to be tough makes it extremely difficult to search out help and support. This leads to much higher suicide rates in men, and much more violent expressions of mental health struggles. Men struggle with the idea that they will be viewed as weak, even though sexism built into our culture tends to favor male-ness over female-ness and empowers men in this society. While the negative impacts of healthcare systems disproportionately affect women and other genders, men are not excluded from these negative effects.

The final piece of this topic that we will cover is trans (in use as an umbrella term for trans, non-binary, genderqueer, and gender non-conforming) marginalization in the healthcare/medical system. In the news we see stories of laws and policies attempting to bar medical interventions, we see hateful rhetoric on social media and political platforms, and all of this feeds into the marginalization and treatment in healthcare and medical institutions and practices. Trans and non-binary individuals face common rejection of their identities, and are also misgendered within the system and often missing from medical forms and records. There are many spaces where the simple boxes of male and female are the only options on forms, there is no gender box or way for individuals to express their identity.

Currently those seeking gender affirming care of any sort must be, and are diagnosed with gender dysphoria which means a distress between one’s biological sex and gender identity. This helps to justify care, but it also requires trans people to be diagnosed with a mental health/physiological disorder instead of simply being able to identify as trans and receiving care without the medical diagnosis in their patient chart. Trans people face discrimination, limited access to care and delays in care at high rates, along with barriers through insurance companies and coverage. The trans community also faces significant distrust and an unfavorable power dynamic based on the current standard of labeling them ‘diseased’ or mentally ill  through the dysphoria diagnosis, as well as through gatekeeping (controlling access or information) of their healthcare. This leads to the likelihood that they will not seek care as quickly and not be able to access the care that they need through the systems and barriers in place. Access to gender affirming care is difficult due to these barriers, as well as being inaccessible due to the financial cost and time, especially since many insurance companies do not cover gender affirming care or make it very difficult to do so with many hoops to jump through.

Figure 10.14 A genderqueer person in a hospital gown receiving a pelvic exam.

10.4.4.3 Workplace Practices and Policies

Federal law prohibits employment discrimination based on race, nationality, sex, or religion. Notice that this list does not include sexual orientation. It is entirely legal under federal law for employers to refuse to hire LGBT individuals or those perceived as LGBT, to fire an employee who is openly LGBT or perceived as LGBT, or to refuse to promote such an employee. In the workplace, almost half of LGBTQIA+ individuals reported some form of discrimination in the year 2019-2020 (May-May) (Sears et al., 2022). Discrimination in the workplace includes barriers to promotions or jobs, verbal harassment within the workplace, exclusion from work events or company sponsored events, termination, refusal of hours, as some examples. Without legal protections, one’s sexual orientation or even presumed orientation based on their presentation of self could be used against them by their employer (Figure 10.15). Daily interactions with large parts of the social world are hostile for these communities which makes feeling a sense of safety and security difficult. Research shows that many hide their identities, both gender and sexuality, to avoid interactions that are negative and decrease the likelihood that they will face negative consequences for simply being who they are openly. We can also connect these interactions to power dynamics in our society, because femininity is seen as ‘less valuable’ than masculinity and often LGBTQIA+ people are associated with feminine qualities, and masculinity is what is valued and expected, the structure itself and labels creates a space for negative interactions. Think back to the concept heteronormativity and how heterosexuality is expected and ‘normal’; those who fall outside of that idea are at higher likelihood of discrimination in most areas of their lives.

Figure 10.15. A non-binary person working.

Considering the daily exposure to negative interactions, derogatory statements and labels and institutionalized homophobia and transphobia, LGBTQIA+ individuals are also more likely to experience negative mental health outcomes. There are higher rates of suicide, self harm, depression, and anxiety, according to many data and surveys (Trevor Project, 2022). Youth are at an even higher risk of this through social rejection, youth that are LGBTQIA+ and experience this rejection are much more likely to experience depression and to have attempted suicide.

One way to understand and to support the LGBTQIA+ community through research and action is to apply and view through the lens of Queer Theory, which you will learn about in the Activity at the end of this section. Queer Theory looks at the sex assigned at birth, gender identity, and sexual orientation as a series of identities and mismatches. It goes beyond a binary ideal and looks at the queer experiences on a micro level and at the community and institutional examples on a macro level.