Methodology

Search Methodology for Research Analysis on the Effects of Discrimination on the Health of LGBT People:

To explore the evidence regarding the effects of discrimination on LGBT health, we conducted a comprehensive search of the literature using the population, concept, and context method (PCC) developed by the Joanna Briggs Institute (2017). The population was defined as people of any age, including children and adolescents, who are sexual and/or gender minorities (SGM). In this review, the term “sexual minority” refers to people who are lesbian, gay, bisexual, queer, or any other term denoting non-heterosexual identity (e.g., same-gender-loving), attraction, or behavior (e.g., men who have sex with men, or MSM). The term “gender minority” refers to people who are transgender or non-binary. This review does not include intersex people or those with differences of sex development because few studies have looked at these issues among intersex people. The concept of interest was minority stress in SGM populations. Minority stress is a framework that allows researchers to explore how prejudice and discrimination affect the health of individuals and their communities. The context was defined as original, peer-reviewed research articles, published in English, reporting quantitative findings about the population and concept of interest.

The search was conducted in October 2018 in PubMed, Embase, and PsycINFO. No date or geographic restrictions were imposed on the search in order to ensure that the full breadth of the available literature could be captured before more specific inclusion and exclusion criteria were applied. The search returned 11,466 non-duplicate results. Two reviewers working independently screened each title and abstract using Covidence systematic review software (Veritas Health Innovation, 2018). Given the differences between U.S. and non-U.S. legal and social environments in relation to SGM populations, we excluded studies at this stage if they were conducted outside the U.S. We also excluded studies at this stage if they were purely qualitative, did not focus primarily on an SGM population, or focused on one of the following populations: active military or veterans; people who are homeless; or people living with HIV or a mixed HIV+/HIV- population where HIV status was not controlled for or the participants were not separated by serostatus. These populations were excluded because the circumstances of serving in the military, being homeless, or living with HIV are separately related to high levels of exposure to stress, and it was beyond the scope of this review to isolate the aspects of these minority stress experiences that are due to sexual orientation and/or gender identity. Similarly, we excluded the following exposures and outcomes: childhood sexual abuse or other adverse childhood experiences, including bullying victimization, that were not clearly due to the participants’ sexual orientation, gender identity, or gender expression; adult physical or sexual assault that was not clearly due to sexual orientation, gender identity, or gender expression; intimate partner violence; and non-health outcomes such as academic performance.

At the next stage of review, two independent reviewers read the full texts of each of the remaining 1,359 studies to ensure that each study met the inclusion criteria. In addition to the criteria outlined above, studies included at this stage of review had to assess a distal (external) minority stress exposure such as discrimination, assault, bullying, or harassment, and the exposure had to be due to the participants’ sexual orientation, gender identity, or gender expression. Laws and policies were also included as a structural form of distal minority stress exposure. Studies that exclusively assessed a proximal (internal) manifestation of minority stress, such as internalized homophobia, rumination, or stigma consciousness, were excluded. Though these manifestations of minority stress are a critical component of understanding how discrimination, stigma, and prejudice “get under the skin” (Hatzenbuehler et al., 2009) of LGBT people, the role of public policy is primarily to address external minority stress exposures such as discrimination and violence. Studies describing person-level interventions to reduce minority stress, such as research in the psychology literature that describes the role of adaptive coping in mitigating minority stress, were thus also excluded. We also reviewed the reference lists of included studies to identify additional relevant studies that were not captured in our database searches.

The final group of included studies was charted in AirTable using the following data elements: authors, year, study population, number of participants, exposure variables, outcome variables, study design, analysis type, and key findings. On the basis of the results and key findings, the studies were categorized as “yes,” “mixed,” or “no” in relation to the question of whether the evidence presented shows that discrimination has negative health effects for LGBT people. Statistical significance was accepted at α = 0.05.