category of variables, in addition to social support and coping, that can affect the association between minority stress and distress. Most research on resiliency factors involves studies with heterosexual children, adolescents, and adults. The studies cited in this section include the few notable exceptions that have examined resiliency factors associated with health among gay and lesbian adults. More research on the impact of resilience on the association between risk factors and health outcomes in sexual-minority populations is warranted.

The limited amount of research on transgender people has focused less on protective factors than on the factors associated with positive outcomes of sex reassignment. These factors, mentioned earlier in this chapter, include psychological adjustment, family support, psychological treatment, and good surgical outcomes (Carroll, 1999; Lawrence, 2003).

HEALTH SERVICES

Most of the available research on the interactions of LGBT adults with various aspects of the health system tends to focus on the different patterns of access to and utilization of health care services by the LGBT community. Very few studies have examined how lack of access and utilization affects the health status of LGBT populations, an area that requires more research. Similarly, the literature tends to focus on processes of care rather than on the outcomes of the delivery or quality of care.

Access and Utilization

The limited research available suggests that LGBT adults have different patterns of access and utilization of health care services than heterosexual adults. For example, Sanchez and colleagues (2007) compared 360 self-identified LGB individuals and 10,000 adults in New York City and found that the former had higher rates of emergency department use than the general population. In another example, Kerker and colleagues (2006) conducted a multilingual population-based survey in New York City to determine the use of Pap tests and mammograms among women who have sex with women (n = 269). They found that these women were significantly less likely than other women to have had a Pap test in the past 36 months or a mammogram in the past 24 months. Earlier research had yielded similar findings (Cochran et al., 2001; Diamant et al., 2000b; Marrazzo et al., 2001).

Much of the research that specifically examines access issues for sexual minorities relates to the use of mental health services. One study, examining data from the MIDUS survey, found that individuals who self-identified as either homosexual or bisexual used mental health services more than



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