Since the 1969 Stonewall Rebellion, lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ) Americans have witnessed remarkable gains in social acceptance and legal protections (e.g., same-sex marriage, the decriminalization of same-sex sexual behavior, and state- and local-level LGBT non-discrimination laws). LGBTQ youths, their families, and LGBTQ activistshave advanced LGBTQ youths’ rights to safety and equitable, appropriate treatment in public service sector systems through litigation, advocacy, and education.

Although the country has advanced well beyond its former practices of routinely imprisoning and/or executing gender-variant and same-sex-loving people, labeling them as mentally ill, and subjecting them to castration, hypothalamotomy, hormone injections, clitoridectomy, hysterectomy, or ovariectomy to change their orientation and behavior (Silverstein, 1991), discrimination, violence, and other human rights violations persist. The 45th Administration in Washington and Republican-controlled state legislatures across the country are designing new, emerging attacks on LGBTQ human rights (Movement Advancement Project [MAP], 2017).

During the first five months of 2017, state legislators introduced over 100 anti-LGBT bills in 20 states (Miller, 2017). Within the first month post-inauguration, the 45th Administration rescinded joint guidance from the US Departments of Education and Justice that directed educational institutions to include gender identity within Title IX sex discrimination protections, an action criticized by the Organization of American States’ Inter-American Commission on Human Rights (IACHR, 2017). The Administration has tried multiple times to ban transgender people from military service (Bebinger, 2018). Early in 2018, the Administration announced the creation of the Conscience and Religious Freedom Division within the US Department of Health and Human Services to protect health professionals when they refuse to care for patients based on their own religious or moral beliefs (Cha & Eilperin, 2018).

This chapter discusses human rights violations against LGBTQ people in the USA, primarily, and reviews research on adverse childhood experiences and minority stressors (e.g., stigma, discrimination) affecting LGBTQ adultsand youth. The chapter highlights advances in LGBTQ inclusion on the United Nations’ (UN) human rights agenda and historic achievements of the international LGBTQ movement in securing recognition of LGBTQ rights as human rights. An integration of LGBTQ-affirmative practice with trauma-informed (TI) service delivery principles provides guidance for professional practice with LGBTQ populations.

LGBTI Human Rights Organizations and Terminology

Although many international, regional, and national organizations advocate globally for lesbian, gay, bisexual, transgender, and intersex (LGBTI) human rights, this chapter frequently refers to the International Lesbian, Gay, Bisexual, Trans, and Intersex Association (ILGA) and ARC International (ARC), as they spearhead much of the international LGBTI advocacy. ILGA, founded in 1978, is a global federation of over 1200 member organizations across Asia, Europe, Latin America and the Caribbean, North America, Oceania, and Pan Africa (Karsay, Dos Santos, & Mosquera, 2016). ARC International, founded in 2003, and ILGA directly advocate with UN Member States and human rights mechanisms and facilitate Civil Society Organizations’ (CSOs) engagement with UN and other international human rights structures (Karsay et al., 2016). ILGA and ARC International utilize definitions of sexual orientation and gender identity found in the Yogyakarta Principles, which specify states’ obligations to ensure human rights for people of diverse sexual orientations, gender identities, and sex characteristics (Alston et al., 2017).

Sexual orientation refers to an individual’s “capacity for profound emotional, affectional and sexual attraction to, and intimate and sexual relations with, individuals of a different gender or the same gender or more than one gender” (Karsay et al., 2016, p. 15). Gender identity is a person’s “deeply felt internal and individual experience of gender, which may or may not correspond with the sex assigned at birth,” and incorporates one’s “personal sense of the body” and “other expressions of gender, including dress, speech and mannerisms” (Karsay et al., 2016, p. 14). The definition recognizes that people may or may not choose to modify their body through medical and other procedures.

Transgender is “an umbrella term for people whose gender identity and/or gender expression differs from what is typically associated with the sex assigned to them at birth” (Karsay et al., 2016, p. 15). Intersex people are “born with physical sex characteristics that do not fit medical norms for female or male bodies” (Karsay et al., 2016, p. 14). Sex characteristics refer to “each person’s physical features related to sex, including genitalia and other sexual and reproductive anatomy, chromosomes, hormones, and secondary physical features emerging from puberty” (Alston et al., 2017, p. 6). Gender expression is newly defined as each individual’s presentation of their gender “through physical appearance—including dress, hairstyles, accessories, cosmetics—and mannerisms, speech, behavioral patterns, names and personal references” (Alston et al., 2017, p. 6).

The UN and the LGBTI international human rights organizations utilize the phrases and acronyms “sexual orientation, gender identity, gender expression, and sex characteristics” (SOGIESC); “sexual orientation, gender identity, and intersex” (SOGII); and “lesbian, gay, bisexual, transgender, and intersex” (LGBTI). Derivatives of these acronyms are also used (i.e., LGBT, SOGI, and SOGIE) when human rights issues related to intersex and sex characteristics are excluded from consideration (Carroll & Mendos, 2017). In this chapter, “LGBTQI2-S” (i.e., lesbian, gay, bisexual, transgender, queer, intersex, two-spirit), “LGBTQ” (i.e., queer and questioning), “LGB” and “LGBT” are used when research, policies, and practices apply to those populations. Two-spirit is a contested term used by some American Indian/Alaska Native people who are “not male and not female” or as an umbrella term for LGBT or “alternatively gendered” and Native (Bearse, 2012, p. 91).

Intersectionality and LGBTI Human Rights

An intersectional lens is critical to understanding LGBTI people’s vulnerability and experiences with traumatic events and state-sponsored/state-sanctioned human rights violations in the USA. An intersectional analysis recognizes that systems of oppression based on race, class, gender, and other social identities intersect to produce different patterns of intragroup oppression, “the complexities of compoundedness” (Crenshaw, 1989, p. 166). The Sexual Rights Initiative (SRI), another international human rights coalition, called for an intersectional analysis in global LGBTI advocacy and policy development. The SRI asserted that SOGIE-based human rights violations do not affect LGBTI people equally, that LGBTI peoples’ multiple, intersecting identities uniquely shape their experiences with systems of oppression, violence, and discrimination. LGBTI people’s vulnerability to human rights violations and traumatic events varies based on their multiple, intersecting identities, including race, class, gender identity, gender expression, national origin, disability status, age, and geographic location (Carroll & Itaborahy, 2015).

US LGBTQ adultsand youth of color, for example, experience disproportionate contact with law enforcement, and abusive, discriminatory treatment by police and within criminal justice systems, and asylum and detention facilities (Center for American Progress [CAP] & MAP, 2016). LGBTQ Americans continue to face discrimination in education, employment, housing, and health care, with LGBTQ people of color at greatest risk (Human Rights Campaign [HRC], 2018; Human Rights Watch, 2016; Palmer, Greytak, & Kosciw, 2016).

What Are LGBTI Human Rights?

LGBTI activists, human rights organizations, and CSOs have utilized the UN’s major human rights monitoring mechanisms, under the auspices of the Human Rights Council, to advocate for LGBTI inclusion: the Universal Periodic Review (UPR); the Special Procedures; and the Complaint Procedure (ARC International, 2015; Karsay et al., 2016). The Special Procedures include the special rapporteurs, independent experts, special representatives, and working groups charged with human rights investigations and reports (ARC International, 2015).

After decades of activism, LGBTI activists and CSOs dedicated to LGBTI human rights achieved, on June 30, 2016, a historic UN Human Rights Council resolution, which established an Independent Expert on the protection against violence and discrimination based on sexual orientation and gender identity (Karsay et al., 2016). Members of the Group of African States and the Organization of Islamic Cooperation (OIC), which had long-opposed efforts to promote SOGIESC human rights at the UN, organized multiple unsuccessful attempts to block the mandate during General Assembly processes. Sadly, opposing states vocalized their intentions to not cooperate, recognize, nor engage with the Independent Expert (ARC & ILGA, 2016).

Every SOGIESC-related human rights victory with UN bodies has required overcoming the historical inertia of UN entities on SOGIESC human rights issues and strong, hostile opposition from some of its 193 Member States (Karsay et al., 2016). Not until 2011 did the Human Rights Council adopt its first SOGI-specific resolution, which called for the Office of the High Commissioner for Human Rights (OHCHR) to document worldwide SOGI-related discriminatory laws, practices, and violence (Karsay et al., 2016). Several States walked out of a panel discussion on SOGI-related violence and discrimination convened the following year by the Human Rights Council, the first time a UN body formally debated SOGI issues (OHCHR, 2017). Perceiving a slowdown in progress, ILGA delivered a joint civil society statement, signed by over 500 CSOs from over 100 countries, challenging the Council to fulfill its responsibility to address systemic human rights violations against LGBTI people (ILGA et al., 2014). A second Human Rights Council resolution followed which requested an update from the OHCHR on SOGI-related violence and discrimination (Karsay et al., 2016).

The OHCHR (2017) has identified States’ core legal obligations to protect the human rights of LGBTI persons: (a) protect them from bias-motivated violence; (b) prevent torture and cruel, inhumane, and degrading treatment; (c) decriminalize homosexuality; (d) prohibit SOGI-related discrimination in employment, health care, and access to services; and (e) respect freedom of association, expression, and peaceful assembly. Twelve UN entities, in 2015, issued a precedent-setting joint statement calling upon Member States to “urgently” end violence and discrimination against LGBTI adults, adolescents, and children, and the OHCHR organized the first UN meeting devoted to intersex human rights (OHCHR, 2017).

The Yogyakarta Principles

The Yogyakarta Principles, developed in 2006 and expanded in 2017 by international panels of human rights experts, apply the rights embodied in international human rights law to people of diverse sexual orientations, gender identities, gender expressions, and sex characteristics (Alston et al., 2017). An intersectional lens is reflected in the Yogyakarta Principles’ recognition that SOGIESC-related discrimination may be compounded by discrimination and persecution based on many other social categories (e.g., race, ethnicity, disability, marital or family status, class, HIV status, language, religion, political orientation, migration status, national origin) (Alston et al., 2017).

The Yogyakarta Principles specifically assert LGBTI individuals’ rights to equality and non-discrimination in public and private spheres; freedom of opinion and expression, including gender expression through dress, speech, and other means; and privacy, which necessitates that states end the criminalization of same-sex sexual activities between persons over the age of consent. Freedom of opinion and expression includes freedom of peaceful assembly and association and guaranteed access to SOGIE-related information and ideas, including relevant safer sex information, and the dissemination of affirmative and accurate SOGIESC-related information in educational programs.

The principles affirm rights to an adequate standard of living (e.g., food, clothing, shelter, housing, social security, and social insurance) without SOGI-related discrimination; safe and healthy work conditions; equal access to employment and unemployment benefits, health insurance, parental leave, and other family benefits. LGBTI people have rights to education, including higher education that is equally accessible, and to the enjoyment of the highest attainable standard of physical and mental health. States are obligated to protect families, recognize the diversity of family structures without subjecting them to SOGI-based discrimination, ensure non-discrimination toward all children for reasons related to their parentage, and safeguard access to adoption and assisted procreation, including alternative insemination.

The principles assert LGBTI individuals’ rights to change state-issued gendered identity documents. The principles call for simple, accessible mechanisms to change names, and an end to sex/gender markers on identity documents (e.g., birth certificates, passports, driver licenses). Whenever sex/gender markers are used, states must not require surgical and other medical procedures, or psychological and diagnostic conditions to change sex/gender markers, as such conditions violate the human rights to self-determination, and bodily and mental integrity (Alston et al., 2017).

The principles affirm LGBTI individuals’ rights to life, liberty, and security of person, free from violence, harassment, and degrading treatment or punishment. States must take measures to prevent hate violence, vigorously investigate incidents, prosecute the perpetrators, and conduct public awareness campaigns aimed at eliminating SOGIE-related prejudice that underlies hate violence. The principles call for the repeal of laws criminalizing sex work, abortion, and unintentional HIV transmission, and the enactment of measures to hold police accountable for violence, abuse, and intimidation based on people’s SOGIESC. The right to humane treatment while incarcerated obligates states to provide adequate physical and mental health care, including gender-affirming interventions; protect LGBT people from rape and sexual assault; and avoid subjecting LGBT people to solitary confinement.

To safeguard children’s self-determination and bodily and mental integrity, states must protect them from coercive, involuntary, and irreversible modification of their sex characteristics, such as with disorders of sexual development, without children’s full, free, and informed consent. States must also prohibit medical and psychological interventions that pathologize and claim to change SOGI diversity (Alston et al., 2017).

Global Trends in Human Rights and Violations

Since 2006, ILGA has annually summarized Member States’ laws that promote or violate SO-related human rights (Carroll & Mendos, 2017) and recently began mapping laws and administrative procedures governing transgender people (Chiam, Duffy, & Gil, 2016). Global trends are toward decriminalization of same-sex sexual activities, protection from discrimination and hate crimes, and recognition of LGB relationships and families (Carroll & Mendos, 2017).

However, state-sponsored and state-sanctioned human rights violations toward LGBTI people persist, including the criminalization of same-sex sexual acts between consenting adults, with eight nations allowing the death penalty; prohibitions on public promotion or expression of SOGIE issues; and barriers to the founding and/or recognition of SOGIE-related CSOs. Nearly, all nations allow conversion therapies, employment discrimination, and prohibit same-sex marriage. Hate-motivated violence against LGBTI people by police officers, other State officials, extremist organizations, and other non-State actors is pervasive globally, with many States failing to investigate and prosecute these crimes (Carroll & Mendos, 2017).

LGBTI Human Rights Violations in the USA

Neither the US government nor public discourse typically view the persecution of LGBTI people as human rights issues. Historically hostile toward the idea that economic and social policies and practices are human rights issues (Reichert, 2007), the USA never ratified the International Covenant on Economic, Social and Cultural Rights (ICESCR) (UN, 1966). However, the rights embodied in the ICESCR, essential to the well-being of all residents of the USA, are found in the Universal Declaration of Human Rights (UN, 1948), which the USA did ratify. Little chance exists for human rights advances at the federal level given the 45th Administration’s contempt for the UN (Landler, 2017) and its determination to diminish human rights for the American people (Alston, 2017), particularly for LGBT people (Caspani, 2018; MAP, 2017).

Poverty

The UN Special Rapporteur on extreme poverty and human rights toured areas in the USA in 2017, as part of the UN Human Rights Council’s accountability mechanisms that apply to all Member States. In his final report, Dr. Philip Alston remarked that the USA is “alone among developed countries in insisting that while human rights are of fundamental importance, they do not include rights that guard against dying of hunger, dying from a lack of access to affordable healthcare, or growing up in a context of total deprivation” (Alston, 2017, para. 8). Alston projected that the Republicans’ tax reform package and promised cuts to welfare programs will further exacerbate the country’s inequality levels that already dwarf those of other countries, as the US endeavors “to become the most unequal society in the world” (para. 2).

Research with US LGBT populations points to their heightened vulnerability to poverty, particularly for LGBT people of color, although poverty rates have increased for many US residents. LGBT Americans are more likely to live in poverty than are heterosexual/cisgender Americans, particularly LGBT females and people of color (CAP & MAP, 2014). Of the 27,715 participants in a national transgender survey, 29% reported living in poverty, 15% lacked employment, and 30% experienced homelessness in the previous year. Transgender people of color reported higher poverty and unemployment rates compared to white transgender people. Over one-third (38%) of African-Americans lived in poverty; 41% of American Indians; 40% of multiracial persons, and 43% of Latinos/Latinas. Nearly 25% of transgender people of color lacked employment, compared to 12% of whites (James et al., 2016).

Health Care Access

The Affordable Care Act (ACA) prohibited LGBT- and HIV-related discrimination in the health insurance marketplaces, health plans offering essential benefits, and health programs and providers receiving federal funds (Kates, Ranji, Beamesderfer, Salganicoff, & Dawson, 2017). However, only 13 states and the District of Columbia ban insurance exclusions for transgender health care (HRC, 2018). Although the ACA and the legalization of same-sex marriage helped many LGBT people acquire health insurance (Kates et al., 2017), 15% of LGBT Americans still lacked insurance in 2017, compared to 7% of their heterosexual/cisgender counterparts; 25% of transgender people were uninsured, compared to 8% of cisgender people (Baker & Durso, 2017). LGBT people, especially transgender people of color, continue to report disturbing incidents of mistreatment, humiliation, and discrimination from health care providers, which dissuade them from seeking needed care (Mirza & Rooney, 2018). Republican attacks on the ACA, Medicaid, and Planned Parenthood disproportionately threaten health care access for women, particularly low-income women, women of color, and LGBT individuals (MAP, 2017).

State-Sanctioned/State-Sponsored Discrimination

Basic civil rights protections for US LGBT people and their families vary widely among and within the states. Of the estimated 9.5 million LGBT adults residing in the USA, approximately 52% live in states that permit SOGI-based discrimination, which are states in which African-American LGBT individuals more highly concentrated (Hasenbush, Flores, Kastanis, Sears, & Gates, 2014). Although same-sex couples can now marry across the USA, they risk losing their jobs if they do. No federal laws ban SOGI-based discrimination in employment, housing, and public accommodations (Carroll & Mendos, 2017).

Only 21 states and the District of Columbia prohibit SOGI-based employment and housing discrimination (HRC, 2018), and only 19 states and the District of Columbia prohibit SOGI-based discrimination in public accommodations (HRC, 2018). In 2016, state legislatures considered over 30 bills attacking transgender access to public accommodations (Singh & Durso, 2017). Research with a national representative sample of LGBT people found that, during 2016, up to 28% of LGB workers and 27% of transgender workers reported some form of employment discrimination. A quarter of transgender respondents reported avoiding stores and restaurants, 11% avoided public transportation, 12% avoided getting needed services, and 27% deliberated carefully on where to shop (Singh & Durso, 2017). Nearly one-third (30%) of the participants in the national transgender survey reported experiences with GI/GE-based employment discrimination, promotion denials, firings, workplace verbal harassment and physical assault, and interference with their use of sanitation facilities (James et al., 2016).

During the US’s Second Universal Periodic Review, the UN Working Group urged the USA to strengthen its efforts to eradicate SOGII-related discrimination and to prohibit SOGI-related discrimination based on religious beliefs (UN, 2015). Unfortunately, the 45th Administration is seeking to legalize SOGI-related discrimination through the US Supreme Court, executive orders, federalguidance and regulations, and religious exemption laws. Religious exemptions laws permit private businesses, social service agencies, federal contractors, and/or government agencies to deny services to LGBT people for religious reasons. Such laws exist in Kansas, Mississippi, South Dakota, and Texas (MAP, 2017). Illinois, Tennessee, Mississippi, and Alabama allow health professionals to deny medical treatment to LGBT people (MAP, Public Rights/Private Conscience Project, & SAGE, 2017).

School-Based Discrimination

Alabama, Arizona, Louisiana, Mississippi, Oklahoma, South Carolina, and Texas restrict school-based discussions of LGBT issues via laws that malign SOGI-diverse people (i.e., “No Promo Homo” laws). Alabama and Texas’ laws, for example, declare that “homosexual conduct is a criminal offense” under state law (despite the Supreme Court decision overturning sodomy laws) and that homosexuality is not “a lifestyle acceptable to the general public” (Human Rights Watch, 2016, p. 12). Such laws create hostile environments for LGBT youth and prevent them from accessing accurate HIV- and sexuality-related information. During 2016, legislators in nearly 20 states introduced bills to limit transgender students’ access to school bathrooms congruent with their gender identity (Human Rights Watch, 2016). LGB youth, particularly girls, disproportionately endure police stops, school expulsions, juvenile arrests and convictions, and adult convictions, despite no higher rates of misbehavior compared to their heterosexual peers (Himmelstein & Bruckner, 2011). With school-based zero-tolerance policies, school officials disproportionately levy punitive sanctions against LGBT youth, particularly youth of color, for minor infractions (Palmer et al., 2016).

Sexual Orientation Change Efforts

Sexual orientation change efforts (SOCE) refer to discredited methods (e.g., behavioral and psychoanalytic therapies; medical, religious, and spiritual approaches) used by mental health professionals, self-help groups, religious ministries, and other non-professionals aimed at changing a person’s sexual orientation. These practices, sometimes called “conversion” or “reparative” therapy, are grounded in the assumption that homosexuality is a mental illness, maladaptive, or a developmental or spiritual failing. No research demonstrates the efficacy or effectiveness of using SOCE to alter sexual orientation (Drescher et al., 2016). The Pan American Health Organization (PAHO) denounced SOCE, deeming them unethical and unjustifiable for causing harm, lacking in scientific evidence and medical justification, and violating human rights (PAHO/WHO, 2012). All major health and mental health professional associations have issued position statements against these practices (Drescher et al., 2016).

Young people subjected to SOGE have reported their experiences on social media (Shear, 2015), before policy makers (Margolin, 2014), and in lawsuits (Stern, 2015). LGBTI youth advocates have challenged, locally to globally, SOCE that target LGBTI adolescents, developing and lobbying for state and federal legislation banning these practices. Only 10 states and the District of Columbia ban mental health professionals from using conversion therapy with minors (HRC, 2018). The UN Committee against Torture (CAT) raised serious concerns with the US State Department about the use of conversion therapy with LGBT youth, upon hearing testimonies from LGBTI activists and survivors of conversion therapy at its meeting in Geneva (Margolin, 2014). This marked the first time in history that the Committee against Torture, a UN Treaty Body, addressed conversion therapy as a global human rights issue under the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment, although other Treaty Bodies had previously addressed the issue (Kirichenko, 2017).

Surgical Procedures on Intersex Children

Surgical interventions to alter genitalia are still performed on US children with atypical sex characteristics, despite recommendations to delay such procedures until children can actively participate in the decision-making process (Human Rights Watch & InterACT-Advocates for Intersex Youth, 2017). Massachusetts-based interACT (Advocates for Intersex Youth), which promotes intersex human rights internationally, submitted a report to CAT documenting the use of premature surgery and other medical treatments on US intersex children; CAT requested a response from the US government, asking for the number of children subjected to such surgeries (UN CAT, 2017).

Hate Violence

To fulfill their obligations to protect LGBTI people from violence, States should specify SOGI as protected characteristics in hate crime laws (OHCHR, 2017). However, only 30 states and the District of Columbia include sexual orientation in hate crime laws, of which 18 also include gender identity (HRC, 2018). Hate violence against LGBTQ and HIV-affected people in the USA appears to be increasing, with people of color, transgender and gender non-conforming (TGNC) people at greatest risk (National Coalition of Anti-violence Programs [NCAVP], 2017). NCAVP, which annually publishes hate violence incidents reported to its member programs, recorded 36 hate-motivated homicides of LGBTQ and HIV-affected people by August 23, 2017, a 29% increase from 2016; 75% of the victims were people of color (NCAVP, 2017). The national transgender survey found that sexual and physical violence and verbal abuse against TGNC people are pervasive, with violence beginning early in life, occurring in multiple settings and across a lifetime, with revictimization common (James et al., 2016). Undocumented TGNC people are at high risk for violence; 24% of undocumented respondents in the national survey reported physical assaults (James et al., 2016).

Persecution Within Criminal Justice, Asylum, and Immigration Systems

Discrimination, harassment, and abuse of LGBT and HIV-affected people by US law enforcement officials are widespread, particularly against LGBT people of color (James et al., 2016; Lambda Legal, 2015). Mistreatment takes the form of profiling LGBT youth and adults as criminals; physical and sexual assaults; verbal harassment and abuse; arbitrary searches; entrapment; criminalizing people living with HIV; and unjustified arrests (Lambda Legal, 2015). Over 30 states have laws that target consensual sex, impose harsher penalties on persons living with HIV, and reflect ignorance about HIV transmission (Lambda Legal, 2015). Findings from the national transgender survey revealed that more than half (58%) of the respondents that had interacted with police reported mistreatment (e.g., physical or sexual assault, verbal harassment) (James et al., 2016). NCAVP (2017) found that 41% of the 1036 LGBT hate crime survivors interacted with law enforcement, of which approximately one-third found police indifferent or hostile. Black survivors were nearly three times more likely to experience excessive force than were other survivors (NCAVP, 2017).

Within prisons and immigration detention facilities, LGBT people are disproportionately subjected to rape, sexual harassment, other assaults by staff and inmates, and solitary confinement and, if transgender, denied medically necessary health care and housed, dangerously, according to their sex assigned at birth (Lambda Legal, 2015). Prior to the US’s sixth periodic review before CAT, the Treaty Body asked the USA for clarification on the care of transgender detainees, including use of solitary confinement and sexual assaults within detention facilitates (UN CAT, 2017). Serious deficiencies exist with the Prison Rape Elimination Act’s implementation, including lack of full state compliance, corrections industry resistance, lack of vigorous promotion by the USDOJ and inconsequential penalties for noncompliance (Sontag, 2015). Recently, the US Bureau of Prisons rescinded prior protections for transgender inmates and declared its intent to house transgender inmates according to their sex assigned at birth, elevating their risk for rape and other assaults (Caspani, 2018).

Barriers to Changing Sex/Gender Markers

US states vary widely on criteria for changing sex/gender markers on birth certificates, driver licenses, and other documents. Approximately 22 states in the USA require proof of sex reassignment surgery (SRS) to change birth certificates, and 13 states require such proof to modify driver licenses. Tennessee (legally) and Idaho (procedurally) forbid correction of a birth certificate for transgender people and require SRS to change a driver license, while California, in contrast, requires a licensed physician’s statement attesting that the individual has undergone clinically appropriate treatment for gender transitioning. Most states allow modifications of driver licenses without SRS, but with Social Security Administration-approved name changes, documents from medical professionals, and court orders (Chiam et al., 2016). However, under the Yogyakarta Principles, these barriers constitute human rights violations (Alston et al., 2017).

Adverse Childhood Experiences, Structural Stigma, Minority Stress, and Associated Health Outcomes

LGBT populations experience adverse childhood experiences (ACEs) at rates that exceed those of their heterosexual/cisgender counterparts (Andersen & Blosnich, 2013; Hughto, Reisner, & Pachankis, 2015). Multiple studies with LGB populations reveal higher rates of childhood sexual abuse, parental physical and emotional abuse, and peer victimization, compared to heterosexuals (Friedman et al., 2011), with childhood abuse and other forms of interpersonal trauma accounting for disparities in PTSD (Roberts, Austin, Corliss, Vandermorris, & Koenen, 2010; Roberts, Rosario, Corliss, Koenen, & Austin, 2012). Among veterans, LB women report higher rates of trauma across the life span than do their heterosexual peers (Lehavot & Simpson, 2014). Higher ACE scores among LGB people have been associated with adverse health outcomes and health disparities (Austin, Herrick, & Proescholdbell, 2016; McLaughlin, Hatzenbuehler, Xuan, & Conron, 2012).

LGBT youth consistently report greater exposure to family, school, and community violence, compared to their heterosexual/cisgender peers (Eisenberg et al., 2017; Mitchell, Ybarra, & Korchmaros, 2014). LGBTQ adolescents have reported high rates of diverse forms of victimization, with 41% reporting polyvictimization (Sterzing et al., 2017). Although evidence exists that victimization decreases for many LGBT youths as they enter early adulthood, the cumulative victimization experienced by some youths has deleterious effects on their mental health (Mustanski, Andrews, & Puckett, 2016).

Structural stigma (Hatzenbuehler et al., 2014) and the minority stress model (Brooks, 1981; Meyer, 2003, 2016) provide two frameworks for conceptualizing the associations between structural inequalities, minority stressors, and adverse health outcomes among LGBT people. Research with LGBT adults and youth points to the role of structural stigma (i.e., anti-LGBT laws, policies, and cultural norms) in explaining adverse health outcomes and health disparities (Hughto et al., 2015). For example, LGB adults living in highly prejudicial communities suffer from elevated suicide, homicide, and cardiovascular death rates (Hatzenbuehler et al., 2014). Transgenderveterans living in states without SOGI-inclusive employment non-discrimination laws are at higher risk for mood disorders (Blosnich et al., 2016). LGB youths’ risk for adverse health outcomes increases when they reside in neighborhoods with higher rates of anti-LGBT hate crimes, and in counties with fewer school districts with SOGI-inclusive anti-bullying policies (Hatzenbuehler & Pachankis, 2016).

The minority stress model (MSM) has informed nearly four decades of research on LGB health and health disparities (Brooks, 1981; Meyer, 2016), and, more recently, emerging research on the well-being of TGNC populations (Testa et al., 2017). The MSM and the GenderMinority Stress and Resilience (GMSR) model posit that the chronic psychosocial stress related to anti-LGBT prejudice, discrimination, and stigmatization could explain the higher prevalence of physical and mental health problems among LGBT populations. The models distinguish between distal or external stressors (i.e., actual experiences of discrimination, violence, rejection, and identity non-affirmation by individuals, institutions, and communities), and internal or proximal stressors (i.e., expectations of rejection and discrimination, identity concealment or non-disclosure, chronic vigilance, and internalized homophobia/transphobia) (Meyer, 2003; Testa, Harbarth, Peta, Balsam, & Bockting, 2015).

Extant research has shown relationships between minority stressors and a diverse array of adverse physical and mental health outcomes in LGB (Baams, Grossman, & Russell, 2015; Goldbach, Tanner-Smith, Bagwell, & Dunlap, 2014; Lick, Durso, & Johnson, 2013), and TGNC people (Bariola et al., 2015; Bockting, Miner, Romine, Hamilton, & Coleman, 2013; Gonzalez, Gallego, & Bockting, 2017; Testa et al., 2017). Researchers have investigated the role of protective factors in mitigating poor health outcomes associated with minority stressors (Goldbach & Gibbs, 2017; Hoy-Ellis et al., 2017) and the role of psychological processes (Hatzenbuehler, 2009) and other risk factors in mediating relationships between stressors and outcomes (Mereish, Goldbach, Burgess, & DiBello, 2017). The GMSR model explicitly incorporates resilience factors (i.e., community connectedness and pride) that may attenuate the impact of stressors on TGNC individuals’ well-being (Testa et al., 2015).

The Resilience of LGBTQ Populations

LGBTQ people exhibit tremendous resilience in the face of oppression, if resilience means successful, adaptive functioning when confronted with adversity (Meyer, 2015). LGBTQ people have faced decades of oppression with increased visibility and political activism; the creation of diverse family constellations and affirming community organizations; the proliferation of local to global advocacy organizations; and public/private celebratory events. Researchers have noted the importance of individual- and community-based resilience factors in mitigating minority stressors among LGBT populations (Breslow et al., 2015; Meyer, 2015).

LGBTQ-Affirmative Practice and Trauma-Informed Service Delivery

The Substance Abuse and Mental Health Services Administration (SAMHSA) has long recognized the trauma and health disparities affecting LGBT populations and has engaged with LGBT communities to addresses their behavioral health care needs since the early 1990s (Craft & Mulvey, 2001; SAMHSA, 2014a). SAMHSA has collaborated with other entities to enhance policy and service delivery to LGBTQI2-S youth and their families in systems of care and to disseminate LGBTQI2-S-affirmative practice guidelines (Fisher, Poirier, & Blau, 2012). Best practice guidelines, training curricula, standards for care, and model policies exist to guide delivery of culturally sensitive services to LGBTQI2-S youth in diverse service settings and systems (Fisher et al., 2012; Hadland, Yehia, & Makadon, 2016; Poirier, 2015).

LGBTQ-affirmative practice and TI service delivery share some underlying principles that inform both the delivery of care and organizational transformation (Mallon, 2009; SAMHSA, 2014b). However, TI service delivery requires LGBTQ-affirmative practice. Services that are not LGBTQ-affirmative are inherently not trauma-informed. Just as TI services recognize the potential for any client to possess a trauma history, LGBTQ-affirmative services understand that any client could identify as LGBTQ. Whenever individual providers and service delivery systems assume that clients are heterosexual and/or cisgender, the principles of TI service delivery are immediately lacking for LGBTQ clients. Both TI- and LGBTQ-affirmative practices demand that providers take a stance of curiosity, asking, “What happened to this person?,” rather than “What is wrong with this person?” (American Psychological Association [APA], 2012, 2015; SAMHSA, 2014b).

Guidelines for LGBTQ-affirmative service delivery have evolved over decades of scholarship and practice by researchers and clinicians in the health and mental health professions (APA, 2012, 2015; Chang & Singh, 2016). LGBTQ-affirmative guidelines essentially provide a map for executing TI principles with LGBTQ people. LGBTQ-affirmative servicesrecognize that LGBTQ clients may possess trauma histories similar to those of heterosexual/cisgender people. They also recognize that LGBTQ clients may come with histories of bias-motivated traumatic experiences, which have far-reaching impact on LGBTQ individuals, their families, and their communities (APA, 2012, 2015; SAMHSA, 2014b). LGBT-affirmative providers, however, understand that LGBT clients may seek services for problems unrelated to their sexual orientation and/or gender identity (APA, 2012, 2015).

LGBTQ-affirmative practitioners understand the distinctions between gender identity, gender expression, and sexual orientation and interrogate their own biases, beliefs, values, and attitudes about SOGIE diversity. They affirm and value clients’ diverse sexual orientations, gender identities, and preferred pronouns; recognize that same-gender desire, romantic and sexual attractions, and behaviors are normal, positive variations of human sexuality; and understand that heterosexist oppression is the problem, not sexual orientation or gender identity per se. They possess accurate knowledge about the diversity of LGBTQ people and their life experiences, including identity development trajectories; relationships with friends, families of origin and families of choice; romantic and/or sexual partners; and unique challenges and risks they face over the life span (APA, 2012, 2015).

LGBTQ-affirmative practitioners are knowledgeable about the societal manifestations of heterosexism and intersecting systems of oppressions, and their potential impacton LGBTQpeople’s development, life options, access to resources, and physical, emotional, social, and spiritual well-being. They possess knowledge about the pervasiveness of violence, harassment, discriminatory laws and policies, and other traumas andhuman rights violations affectingLGBTQ people (e.g., APA, 2012, 2015; Chang & Singh, 2016; Singh & dickey, 2016), and they advocate on behalf of clients (APA, 2012; Singh & dickey, 2016). As they practice, they obtain LGBTQ-knowledgeable supervision and consultation and address insensitive organizational climates and discriminatory policies, procedures, and practices (APA, 2012, 2015).

Organizational transformation toward becoming LGBTQ-affirmative and TI requires administrative support and investment; policies and procedures that reflect LGBTQ-affirmative and TI principles; changes in the physical environment to promote safety and inclusion; engagement with LGBTQ service recipients, trauma survivors, and family members in implementing the principles; and asserting LGBTQ-affirmative and TI principles in cross-sector collaborations (Mallon, 2009; SAMHSA, 2014b). LGBTQ-TI affirmative services screen, assess, and treat clients utilizing culturally appropriate, evidence-based, or evidence-informed instruments and interventions, particularly those that have shown efficacy or effectiveness with LGBTQ populations (APA, 2012, 2015). SAMHSA and its collaborators developed ten standards of care, congruent with principles underlying TI-organizational transformation, to guide agencies and systems in evaluating policies and procedures for LGBTQI2-S cultural and linguistic sensitivity across youth-serving systems (Fisher et al., 2012).

Conclusion

When this chapter was readied to go to press, the USA was in the throes of a partial government shutdown that was imposed by the 45th Administration in late December, demanding billions of dollars from Congress for a border wall. Following its first submission date, the US Senate confirmed an anti-reproductive freedom, anti-regulatory, pro-corporate, anti-worker individual to the US Supreme Court, amid sexual assault allegations, with a documented “stunningly expansive view of presidential power and impunity” (The Editorial Board, 2018), as an unindicted co-conspirator sits in the White House. Additionally, November midterm elections returned control of the House of Representatives to the Democrats, sending an unprecedented number of women, African-American, and Latino/a citizens to Congress, among them the first two Muslim women (i.e., a Somali-American and a Palestinian-American) and the first two Native American women, one of whom is a lesbian (Newberger, 2019). Within the first week of the new year, the US House of Representatives adopted a rules package protecting LGBTQ congressional employees from discrimination (Clymer, 2019), and the newly-elected governors of Wisconsin (Metzger, 2019a) and Michigan (Metzger, 2019b) signed executive orders protecting LGBTQ state employees from discrimination. However, state policies profoundly impact people’s daily lives, and Republicans still hold the majority of governorships. Just before the new year, Governor Kasich (R-Ohio) signed legislation banning the most common method of abortion used in the second trimester of pregnancy (i.e., dilation and evacuation), with no exceptions for pregnancies resulting from rape or incest (Rosenberg, 2018). We can expect the 45th Administration and some of the states to continue their wars on people of color, women, LGBTQ communities, immigrants and refugees, and people who are poor. LGBTQ people, our families, our advocacy organizations are resilient. LGBTQ people will continue to fight for LGBTQ human rights and populate the ranks of the resistance across all social justice issues. There is no conclusion.