UC Berkeley The Health Equity Promotion Model Reconceptualization of LGBT HW Hi, below I will attach a document called “question”. The tutor pretty much ju

UC Berkeley The Health Equity Promotion Model Reconceptualization of LGBT HW Hi, below I will attach a document called “question”. The tutor pretty much just needs to be able to answer the question(s) in this document and it is very VERY easy! I will also attach 3 articles to help answer the questions. If you brush through the articles briefly it will help answer the questions. Overall, this assignment is very easy. Question:
Ongoing stressors, barriers to services, discrimination, stigma, and poor training among
professionals are among the many factors that contribute to disparities in three populations
discussed in the readings of November 18, 20 and 25. These populations include Lesbian, Gay,
Bisexual and Transgender (LGBT) populations, migrant women domestic workers experiencing
violence, and African American women leading up to pregnancy and childbirth. Please discuss
some ways that some components of either the “Life Course Approach” or the “Health Equity
Promotion Model” could be used to understand and reduce disparities in each of the other two of
the populations described in one of the other articles. For example, how could the Life Course
Approach be used to understand and reduce violence in migrant women domestic workers, and
to reduce health disparities in LGBT populations? Or how could the Health Equity Promotion
Model be used to reduce infant mortality among African Americans and among migrant women
domestic workers?
HHS Public Access
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Am J Orthopsychiatry. Author manuscript; available in PMC 2015 November 01.
Published in final edited form as:
Am J Orthopsychiatry. 2014 November ; 84(6): 653–663. doi:10.1037/ort0000030.
The Health Equity Promotion Model: Reconceptualization of
Lesbian, Gay, Bisexual, and Transgender (LGBT) Health
Karen I. Fredriksen-Goldsen,
University of Washington
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Jane M. Simoni,
University of Washington
Hyun-Jun Kim,
University of Washington
Keren Lehavot,
VA Puget Sound Health Care System and University of Washington
Karina L. Walters,
University of Washington, Anna Muraco, Loyola Marymount University
Joyce Yang, and
University of Washington, Anna Muraco, Loyola Marymount University
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Charles P. Hoy-Ellis
University of Washington, Anna Muraco, Loyola Marymount University
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National health initiatives emphasize the importance of eliminating health disparities among
historically disadvantaged populations. Yet, few studies have examined the range of health
outcomes among lesbian, gay, bisexual, and transgender (LGBT) people. To stimulate more
inclusive research in the area, we present the Health Equity Promotion Model—a framework
oriented toward LGBT people reaching their full mental and physical health potential that
considers both positive and adverse health-related circumstances. The model highlights (a)
heterogeneity and intersectionality within LGBT communities; (b) the influence of structural and
environmental context; and (c) both health-promoting and adverse pathways that encompass
behavioral, social, psychological, and biological processes. It also expands upon earlier
conceptualizations of sexual minority health by integrating a life course development perspective
within the health-promotion model. By explicating the important role of agency and resilience as
Correspondence concerning this article should be addressed to Karen I. Fredriksen-Goldsen, School of Social Work, University of
Washington, 4101 15th Ave. NE, Box 354900, Seattle, WA 98105. fredrikk@u.washington.edu.
Karen I. Fredriksen-Goldsen, School of Social Work, University of Washington; Jane M. Simoni, Department of Psychology,
University of Washington; Hyun-Jun Kim, School of Social Work, University of Washington; Keren Lehavot, MIRECC Postdoctoral
Fellow VA Puget Sound Health Care System and Department of Psychiatry & Behavioral Sciences, University of Washington; Karina
L. Walters, School of Social Work, University of Washington; Joyce Yang, Department of Psychology, University of Washington;
Charles P. Hoy-Ellis, School of Social Work, University of Washington; Anna Muraco, Department of Sociology, Loyola Marymount
Fredriksen-Goldsen et al.
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well as the deleterious effect of social structures on health outcomes, it supports policy and social
justice to advance health and well-being in these communities. Important directions for future
research as well as implications for health-promotion interventions and policies are offered.
health equity; health disparities; mental and physical health; sexual orientation; sexual identity;
gender identity; lesbian; gay; bisexual; transgender; minority health
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Individuals from marginalized populations in the United States are at elevated risk of poor
health, disability, and premature death (National Institutes of Health [NIH], 2010). Such
health disparities are defined as adverse health outcomes for communities that have, as a
result of “social, economic and environmental disadvantage, systematically experienced
greater obstacles to health” (U.S. Department of Health and Human Services, 2010).
Although a primary objective of the NIH is to eliminate health disparities among
marginalized groups (NIH, 2010), it was only in Healthy People 2020 that lesbian, gay,
bisexual, and transgender (LGBT) people were for the first time identified in U.S. health
priorities as an at-risk population (U.S. Department of Health and Human Services, 2012).
The Institute of Medicine (2011) has determined LGBT populations are health disparate and
underserved, recognizing the lack of attention to sexual and gender identity as critical gaps
in efforts to reduce overall health disparities (Centers for Disease Control and Prevention,
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While health disparities research mainly documents group differences in health outcomes, a
more propelling goal is to promote health equity, defined by Whitehead and Dahlgren
(2007) as the opportunity to attain full health potential. Krieger et al. (2010) describe a
health equity perspective as “the instrumental use of human rights concepts and methods for
revealing and influencing government-mediated processes linking social determinants to
health outcomes, especially in relation to the principles of participation, nondiscrimination,
transparency, and accountability” (p. 748).
LGBT Health Disparities
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According to population-based surveys, about 3.5% of U.S. adults self-identify as lesbian,
gay, and bisexual (LGB) and 0.3% as transgender (Gates, 2011), which correspond to
approximately 9 million people. These numbers increase dramatically when same-sex sexual
attraction and behavior are also considered. Clearly, there is a sizable subgroup of
Americans whose health merits increased research attention.
Sexual and gender identity are complex constructs and are highly contingent upon culture
and social context, which can shift rapidly over time. Sexuality encompasses at least three
key components: sexual identity, sexual attraction, and sexual behavior. Sexual identity is an
individual’s own perception of his or her overall sexual self. For many people their sexual
identity, such as lesbian, gay, bisexual, or heterosexual, is consistent with their sexual
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attraction and behaviors, but for some individuals sexual identity may be inconsistent with
attraction and/or behavior. For example, a man whose primary sexual partner is a woman
may identify as heterosexual yet occasionally have sex with men. Sexual identity may be
more fluid than previously assumed, especially among women (Kinnish, Strassberg, &
Turner, 2005).
Gender refers to the behavioral, cultural, or psychological traits that a society associates with
male and female sex. Transgender generally refers to people whose gender identity is at
odds with the gender they were assigned at birth according to their sex and physiological
characteristics of their bodies. For example, a transgender woman is a person who was born
physiologically male but whose deepest sense of self is as female. It is important not to
conflate sexual and gender identity because they are separate constructs (e.g., transgender
individuals may have a heterosexual, bisexual, lesbian, or gay sexual identity).
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With the inclusion of questions on sexual identity in an increasing number of national
population-based health surveys, a growing body of research is documenting health
disparities among LGB people. Specifically, LGB people are at higher risk for poor mental
health (Diamant & Wold, 2003; Dilley, Simmons, Boysun, Pizacani, & Stark, 2010),
psychological distress (Chae & Ayala, 2010; Cochran, Mays, & Sullivan, 2003; Conron,
Mimiaga, & Landers, 2010; Riggle, Rostosky, & Horne, 2010; Wallace, Cochran, Durazo,
& Ford, 2011), suicidal ideation (Conron et al., 2010), and mental health disorders (e.g.,
depression and anxiety) compared with heterosexuals (Cochran, 2001).
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More recent research is investigating the physical health of LGBT people. Relative to
heterosexuals, LGB populations have higher rates of disability (Fredriksen-Goldsen, Kim, &
Barkan, 2012; Fredriksen-Goldsen, Kim, Barkan, Muraco, & Hoy-Ellis, 2013; Wallace et
al., 2011), more physical limitations (Conron et al., 2010; Dilley et al., 2010), and poorer
general health (Conron et al., 2010; Wallace et al., 2011). Elevated rates of HIV are also
observed among gay and bisexual men (Centers for Disease Control and Prevention, 2013)
and transgender women (Herbst et al., 2008; Schulden et al., 2008). Among lesbian and
bisexual women, there are higher rates of overweight and obesity (Boehmer, Bowen, &
Bauer, 2007; Case et al., 2004; Dilley et al., 2010). Although findings are mixed, some
studies have indicated LGB adults may be at elevated risk of some cancers (Case et al.,
2004; Dibble, Roberts, & Nussey, 2004; Valanis et al., 2000) and cardiovascular disease
(Case et al., 2004; Fredriksen-Goldsen, Kim et al., 2013; Hatzenbuehler, McLaughlin, &
Slopen, 2013). Large population-based studies have found that LGB adults are more likely
to report diagnoses of asthma than their heterosexual counterparts (Conron, Mimiaga, &
Landers, 2010; Dilley et al., 2010).
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With few exceptions, limited research has focused specifically on the health status of
transgender individuals. Two recent studies with large national samples of transgender
individuals found that rates of depression, anxiety, and overall psychological distress were
disproportionately higher for this population than for non-transgender women and men
(Bockting, Miner, Swinburne Romine, Hamilton, & Coleman, 2013; Fredriksen-Goldsen,
Cook- Daniels, et al., 2014). Research findings also document disproportionate rates of
military service (Fredriksen-Goldsen et al., 2011; Grant et al., 2011), incarceration (Grant et
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al., 2011; Jenness, Maxson, & Sumner, 2007), sexual violence (Jenness et al., 2007), and
poor general health (Fredriksen-Goldsen et al., 2011) among transgender people.
LGBT Historical Context
Historically, homosexuality in the United States has been largely invisible, because it was
often equated with deviancy, sickness, and shame. Same-sex sexual behavior was against the
law, with sodomy a criminal offense in all 50 states prior to 1961 (Kane, 2003). Until its
removal from the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1973
(Silverstein, 2009), homosexuality was treated as a “sociopathic personality disorder.” Both
prejudice and stigma likely result in higher rates of mental health problems among LGBT
people (Garnets, Herek, & Levy, 2003; Herek, 1998), which is reflective of the historical
practice of pathologizing and criminalizing LGBT people.
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Despite the larger social stigma, underground communities accessible to sexual minorities
began to develop in major metropolitan areas during and after World War II (Canaday,
2009). In 1969 after a routine police raid on an LGBT night club in New York City, the
Stonewall Riots erupted as an act of resistance, sparking the modern U.S. gay rights
movement. Despite the progress, a growing backlash from conservative and religious
elements in society combined with AIDS-related losses in the early 80s and into the
mid-90s, shifted the dominant discourse of homosexuality to a sin punishable by death (i.e.,
AIDS; Hammack & Cohler, 2011). Yet, this too was actively resisted by LGBT activists and
grassroots political organizations shifting from resistance to a growing urgency for
“emancipation” (Weststrate & McLean, 2010).
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More recently, the marriage equality debate has shifted dramatically since the federal
prohibition of same-sex marriage through the Defense of Marriage Act. LGBT people can
now legally marry in more than 30 states and Washington, DC, and lawsuits regarding
marriage equality are pending in all other states, as well as the Commonwealth of Puerto
Rico (Freedom to Marry, 2014; Human Rights Campaign, 2014b). Yet, still today,
discrimination in employment, housing, and public accommodations is not prohibited on the
basis of sexual orientation or gender identity by federal law (Human Rights Campaign,
2014a). In 2013, while the DSM-5 reclassified “gender identity disorder” as “gender
dysphoria,” which is no longer pathological per se, the classification continues to stigmatize
transgender people via a “mental disorder” classification that is dependent on “clinically
significant distress or impairment” (American Psychiatric Association & DSM-5 Task
Force, 2013).
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Risk Factors for LGBT Health Disparities
While biological and genetic influences on health in the general population receive ample
attention (Human Genome Project Information Archive, 2013), much less is known about
the effects of structural and environmental contexts on health and the roles of social
determinants, which may vary considerably across marginalized groups. Indeed, the World
Health Organization has affirmed that “the root causes of health inequities are to be found in
the social, economic, and political mechanisms” (Solar & Irwin, 2007, p. 67). Yet, only a
handful of studies have examined the effect of discrimination and social stigma on physical
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as well as mental health outcomes in LGBT populations (Balsam, Molina, Beadnell, Simoni,
& Walters, 2011; Bockting et al., 2013; Chae & Walters, 2009; Feinstein, Goldfried, &
Davila, 2012; Fredriksen-Goldsen, Emlet, et al., 2013; Lehavot & Simoni, 2011).
In conceptualizing the determinants of LGBT health disparities, researchers have relied
almost exclusively on stress and coping models. The Stress Process Model (Pearlin,
Lieberman, Menaghan, & Mullan, 1981) first addressed the influence of stressful life events
associated with structural inequalities on mental health. According to the model,
disadvantaged status, traumatic early events, and unexpected life transitions in one’s social
role, behaviors, and social relationships cause both long-term stressors and proliferated
stressors, which, in turn, impact health and well-being.
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Most notably, the Minority Stress Model (Meyer, 2003) postulates that sexual minorities
experience increased mental health problems because of stress processes unique to their
status, namely discrimination, expectations of rejection, concealment, and internalized
homophobia. Hatzenbuehler (2009) expanded upon this model with the Psychological
Mediation Framework, which suggests that emotion dysregulation, interpersonal problems,
and cognitive processes mediate the link between heightened stressors because of sexual
minority status and psychopathology.
While these theories advance our understanding of LGBT mental health disparities, current
conceptualizations fail to explain why many LGBT people enjoy good health despite
adversity and to articulate the multilevel factors that may influence the continuum of LGBT
health over the life course.
Reconceptualization of LGBT Disparities: The Health Equity Promotion
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We propose a new conceptual framework that situates LGBT health across the life course
and focuses on how minority status related to sexual and gender identity can result in
variations in health for LGBT populations over time. Examining the resilience as well as
risks that influence LGBT people is a first step toward a comprehensive understanding of
their health across the life course. Resilience factors that may delink the relationship
between stressors in early life and consequential health deterioration in later life have not
been adequately addressed in previous frameworks.
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Based on a conception of health equity, a primary premise of this framework is that all
individuals have a right to good health, and it is a collective responsibility to ensure all
obtain their full health potential. Highlighting the importance of intersecting social positions
within a life course perspective, the framework acknowledges both inter- and intragroup
variability, and that an individual’s development of health potential can vary within a group
of individuals who share a similar life course (Spiro, 2007).
The framework points to structural and environmental factors as determinants of health as
well as community and individual-level factors, highlighting resources, resilience, human
agency, and risks. A life course perspective provides a means for taking into consideration
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both historical and social contexts that are shared by age cohorts and the unique needs,
adaptation, and resilience of LGBT individuals as human agency. This perspective
highlights differences in experience between an LGBT person who came of age when
homosexuality was considered a psychiatric disorder compared with an LGBT adult now in
early adulthood during the marriage equality debates. Equally important, a life course
perspective identifies an individual life trajectory as important in understanding current
health outcomes (Mayer, 2009).
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The Health Equity Promotion Model considers the ways in which both the exclusion and
resistance of LGBT people has played out over time given the shifting historical and social
context. According to Elder (1998, p. 4), “Individuals construct their own life course
through the choices and actions they take within the opportunities and constraints of history
and social circumstances.” For example, despite historical and social marginalization, LGBT
individuals have developed their own ways of building communities (e.g., strong social ties
and mutual support) and behavioral and psychological coping skills (e.g., shifting identity
management techniques based on differing historical and social circumstances).
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The Health Equity Promotion Model, building upon the Minority Stress Theory and the
Psychological Mediation Framework, integrates a life course development perspective
within a health equity framework to highlight how (a) social positions (socio-economic
status, age, race/ethnicity) and (b) individual and structural and environmental context
(social exclusion, discrimination, and victimization) intersect with (c) health-promoting and
adverse pathways (behavioral, social, psychological, and biological processes) to influence
the continuum of health outcomes in LGBT communities (Figure 1). While not intended as a
theory or exhaustive classification of the determinants of LGBT health, the framework
provides a guide to consider the multiple levels and intersecting influences on the full
continuum of LGBT health, especially as they relate to equity and resilience in LGBT
communities. It aims to stimulate research that addr…
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