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Mental health is an essential part of overall health and well-being for Californians no matter one’s age, zip code, gender identity, or sexual orientation. Everyone should have the opportunity to be healthy and thrive, yet LGBTQ+ people disproportionately experience mental health challenges compared to non-LGBTQ+ people.1The acronym “LGBTQ+” is a collective acronym for lesbian, gay, bisexual, transgender, queer or questioning, and other sexual and gender identities. The addition of the “+” indicates inclusion of other identities not encompassed by “LGBTQ,” including but not limited to those who identify as intersex, nonbinary, and asexual. For more information about terminology used in this report, see GLAAD Media Reference Guide, https://www.glaad.org/reference/terms. This was true even before the pandemic, when many Californians experienced stress, grief, isolation, depression, and other hardships.

Many LGBTQ+ Californians Reported Poor Mental Health During the Pandemic

Over the past several months, LGBTQ+ Californians have experienced more mental health hardship than cisgender and straight Californians, according to data from the US Census Bureau Household Pulse Survey collected between July 2021 and March 2022.2A cisgender person is a person whose gender identity aligns with the sex they were assigned at birth. Data reflect the period between July 21, 2021 and March 14, 2022. While the US Census Bureau began administering the Household Pulse Survey in April 2020, it only began including questions about sexual orientation and gender identity in July 2021. Overall, about half of LGBTQ+ Californians reported poor mental health during the pandemic, which is defined as symptoms of depression, anxiety, or both. Mental health hardship was particularly pronounced among transgender Californians, with about two-thirds experiencing symptoms of poor mental health. In addition, about 6 in 10 bisexual Californians and more than 4 in 10 gay or lesbian Californians experienced poor mental health, compared to less than one-third of straight Californians.

Bar Chart: Transgender Californians have experienced more mental health hardship compared to cisgender people.

The Household Pulse Survey includes relatively detailed information on gender identity and sexual orientation, which is significant because US Census Bureau surveys generally fail to capture this information, making it impossible to compare outcomes between LGBTQ+ and non-LGBTQ+ communities. However, the Household Pulse Survey data still do not fully reflect the complexity, nuance, and full spectrum of identities.

Bar Chart: Bisexual, gay, and lesbian Californians have experienced more mental health hardship compared to straight people.

Many LGBTQ+ Californians Did Not Receive Mental Health Care When Needed

More than 1 in 5 LGBTQ+ Californians reported that they needed mental health services but did not receive them, compared to about 1 in 10 straight, cisgender people. LGBTQ+ people have unique barriers in accessing care, such as discrimination or fears of discrimination as well as a lack of competent providers and gender-affirming care.3Susan H. Babey et al., Gaps in Health Care Access and Health Insurance Among LGBT Populations in California (UCLA Center for Health Policy Research, February 2022) https://healthpolicy.ucla.edu/publications/Documents/PDF/2022/Health-Care-Access-Insurance-LGBT-policybrief-feb2022.pdf. See also Jennifer Kates et el., Health and Access to Care and Coverage for Lesbian, Gay, Bisexual, and Transgender (LGBT) Individuals in the U.S. (Kaiser Family Foundation, May 3, 2018) https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-and-access-to-care-and-coverage-for-lesbian-gay-bisexual-and-transgender-individuals-in-the-u-s/. For example, providers may refuse to use the names and pronouns that correspond with an individual’s gender identity, question an individual’s stated sexual orientation, or fail to acknowledge someone’s relationship as legitimate.4Rory P. O’Brien et al., Mapping the Road to Equity: The Annual State of LGBTQ Communities (#Out4MentalHealth Project, 2018), 70-82, https://californialgbtqhealth.org/wp-content/uploads/2018/12/O4MH-Mapping-the-Road-to-Equity.pdf.

LGBTQ+ People Face Multiple Stressors That Are Harmful to Health

Even before the pandemic, Californians who reported their gender as transgender or gender nonconforming as well as those who identified as gay, lesbian, or bisexual were much more likely to report serious psychological distress compared to cisgender and straight Californians, respectively.5Serious psychological distress is an estimate of adults who have serious, diagnosable mental health disorders that warrant mental health treatment. See D. Imelda Padilla-Frausto et al., Serious Psychological Distress on the Rise Among Adults in California (UCLA Center for Health Policy Research, September 2020), 4-5, https://healthpolicy.ucla.edu/publications/Documents/PDF/2020/SPD-policybrief-sep2020.pdf. Experiences with discrimination, family or social rejection, and internalized oppression that many LGBTQ+ people face likely contribute to these higher rates of distress. For example, in a nationally representative sample of adults, including 489 adults identifying as LGBTQ, more than half of the LGBTQ respondents reported having experienced or having a LGBTQ friend or family member who had experienced personal discrimination such as slurs, harassment, violence, or threats of violence.6Harvard T.H. Chan School of Public Health, Robert Wood Johnson Foundation, and National Public Radio, Discrimination in America: Experiences and Views of LGBTQ Americans (November 2017), 1, https://cdn1.sph.harvard.edu/wp-content/uploads/sites/94/2017/11/NPR-RWJF-HSPH-Discrimination-LGBTQ-Final-Report.pdf. For more background on the factors that may contribute to higher rates of mental health challenges for specific LGBTQ+ populations, including LGBTQ+ people of color, see Pasha Mikalson Walker et al., Surveying the Road to Equity: The Annual State of LGBTQ Communities (#Out4MentalHealth Project, 2019), https://californialgbtqhealth.org/wp-content/uploads/2020/11/Surveying-the-Road-to-Equity-2019-State-of-LGBTQ-Communities-Report.pdf. About 1 in 5 reported having experienced discrimination in employment or housing.7Discrimination in America.

Economic Challenges May Worsen Mental Health for LGBTQ+ Communities

In addition to creating psychological distress, discrimination faced by LGBTQ+ individuals may lead to economic challenges such as poverty and homelessness, putting them at further risk of experiencing poor mental health outcomes. Between July 2021 and October 2021, people who identify as LGBT nationally were more likely to report difficulty paying for household expenses, such as food, rent, mortgage, and car payments than non-LGBT people, according to a report from the Williams Institute.8Kerith J. Conron et al., Food Insufficiency Among LGBT Adults During the COVID-19 Pandemic (The Williams Institute, April 2022), 4, https://williamsinstitute.law.ucla.edu/wp-content/uploads/LGBT-Food-Insufficiency-Apr-2022.pdf.

Californians who are LGBTQ+ and have low incomes have experienced an especially high rate of poor mental health during the pandemic. About 6 in 10 LGBTQ+ Californians in households with incomes less than $50,000 experienced poor mental health between July 2021 and March 2022, according to the Household Pulse Survey data. In contrast, about 4 in 10 non-LGBTQ+ Californians in households with incomes under $50,000 had poor mental health symptoms.

Income, cost of living, and socioeconomic status all impact people’s health. Research shows that low levels of household income and mental health conditions are related.9Jitender Sareen et al., “Relationship Between Household Income and Mental Disorders: Findings From a Population-Based Longitudinal Study,” Archives of General Psychiatry 68 (April 2011): 419–427, doi:10.1001/archgenpsychiatry.2011.15. Adults living in poverty are about three times more likely to report feeling nervous all or most of the time and four times more likely to report feeling sad all or most of the time compared to adults with higher incomes.10“Adults living in poverty” refers to adults who live in families with incomes below the poverty threshold. “Adults with higher incomes” refers to adults who live in families with incomes that are 200% of the poverty threshold or greater. “Interactive Summary Health Statistics for Adults,” National Center for Health Statistics (webpage), 2018 National Health Interview Survey, accessed April 18, 2022, https://www.cdc.gov/nchs/nhis/ADULTS/www/index.htm. Having a low income makes it difficult to afford health care, quality housing, and retirement savings — all of these stressors negatively impact both physical and mental health.

LGBTQ+ people with low incomes must navigate multiple and compounding stressors related to their economic situation as well as their gender identity and/or sexual orientation, which can be especially harmful to their mental health.

State Leaders Should Address the Mental Health Needs of LGBTQ+ Californians

State policymakers should address the unique needs of LGBTQ+ Californians as they work to increase access to mental health services and bolster the state’s mental health workforce. For instance, state leaders can promote LGBTQ+-affirming training for behavioral health providers to better serve Californians receiving health services through Medi-Cal, as some advocates have proposed. Policymakers can also invest in efforts to make sure that the behavioral health workforce better reflects the diversity of all Californians, including their gender identities and sexual orientations.

Information About the US Census Bureau Household Pulse Survey Data:

The US Census Bureau Household Pulse Survey measures how the COVID-19 pandemic has impacted households across the country from a social and economic perspective. In July 2021, the survey began collecting information on current gender identity, sex assigned at birth, and sexual orientation. For the gender identity dimension, the possible responses are 1) male, 2) female, 3) transgender, and 4) none of these. The possible responses for the sexual orientation question are 1) gay or lesbian, 2) straight, that is not gay or lesbian, 3) bisexual, 4) something else, and 5) I don’t know.

Because some transgender individuals select male or female as their primary gender identity, the data presented for transgender Californians in this report also include respondents identifying as male or female whose current gender identity is different than their sex assigned at birth.

Data Displayed in this Report:

This report does not display results for respondents who selected “none of these” on the gender identity question or those who selected “something else” or “I don’t know” to the sexual orientation question — unless the respondents were categorized as gay or lesbian, bisexual, or transgender based on other survey responses. Previous research suggests that people selecting these options may or may not identify as LGBTQ+.11Conron et al., Food Insufficiency, 17. Given the inconclusiveness of these data, it may not be appropriate to assume that people selecting these responses are LGBTQ+. However, excluding these responses means that the data do not fully represent the experiences of some groups of LGBTQ+ Californians. These groups include but are not limited to: those who identify as nonbinary, genderqueer, gender fluid, two-spirit, or another gender identity; those identifying as pansexual, asexual, or another sexual orientation; and those questioning their sexual orientation or gender identity.

Why Inclusive Information Matters for California Policy:

In order to better understand the experiences and needs of various LGBTQ+ populations, it is crucial that future federal, state, local, and nongovernmental surveys both include questions about gender identity and sexual orientation and also refine these questions to more accurately reflect the diversity of LGBTQ+ communities. Policymakers can advance health and economic equity for LGBTQ+ individuals by ensuring that publicly funded data efforts include comprehensive and inclusive information about gender identities and sexual orientations.

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Consistent access to health care is necessary for everyone to be healthy and thrive. During the pandemic, millions of Californians with low incomes have been able to keep their Medi-Cal coverage without administrative renewals and regardless of changes to their income. This is because of a temporary “continuous coverage” federal provision.1A provision in the federal Families First Coronavirus Response Act prohibits states from disenrolling Medicaid beneficiaries during the federally declared Public Health Emergency (PHE). The PHE will expire on April 16, 2022 unless the US Secretary of Health and Human Services Secretary extends it again. Despite ongoing hardships due to the pandemic, this federal provision may expire soon, which would disrupt health coverage for many.

Continuous health coverage allows children to receive preventive and primary care
services, which is crucial for very young children. Children who face housing insecurity are particularly vulnerable to losing coverage. When families move, double up with other households, or fall into homelessness, they may not receive timely information or submit paperwork required to maintain coverage, and they could lose continuity of care. About 6 in 10 children under age 5 who are income-eligible for Medi-Cal live in households that pay an unaffordable amount toward housing, placing them at risk of unstable housing and making continuous coverage critical.

State policymakers should provide continuous coverage for children on Medi-Cal until at least their fifth birthday.

The loss of continuous health coverage will particularly affect Latinx children in California.
Latinx children make up about 2 in 3 (66%) young children who are income-eligible for
Medi-Cal and live in households that pay an unaffordable amount of their income toward
housing, exposing the damaging effects of racism.

State policymakers should provide continuous coverage for children on Medi-Cal until at
least their fifth birthday. Every child should have the resources and opportunity to grow up
healthy and thrive.

  • 1
    A provision in the federal Families First Coronavirus Response Act prohibits states from disenrolling Medicaid beneficiaries during the federally declared Public Health Emergency (PHE). The PHE will expire on April 16, 2022 unless the US Secretary of Health and Human Services Secretary extends it again.

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Overview

Undocumented Californians and their families are deeply engrained in the state’s social fabric — they are members of the state’s workforce, pay taxes, attend schools, own businesses, and raise families who invest in local communities. Yet, racist and xenophobic federal policies have historically excluded them from accessing comprehensive coverage through Medi-Cal (California’s Medicaid program), also known as full-scope Medi-Cal. In recent years, California has expanded eligibility for full-scope Medi-Cal to undocumented immigrants, including children and young adults up to age 25 as well as adults age 50 and older.

This year, state leaders have the opportunity and resources to expand access to income-eligible undocumented adults ages 26 to 49 — ending the unjust exclusion once and for all. By advancing this policy change along with investing in other equitable health policies that focus on the well-being of communities of color, policymakers can ensure all Californians are valued and have the opportunity to be healthy and thrive.

Here’s a timeline of policy changes that have expanded access to comprehensive Medi-Cal coverage:

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Everyone should have the opportunity to be healthy and thrive, regardless of their race, gender identity, sexual orientation, income, or zip code. The California Department of Public Health as well as local public health departments play a critical role in protecting and promoting Californians’ health and well-being.1State departments other than the Department of Public Health often contribute to efforts to protect and promote public health. For example, the Department of Toxic Substances Control protects Californians from toxic substances. This analysis excludes such expenditures. Their core functions include infectious disease control, chronic disease prevention, health promotion, and more. Yet despite these important responsibilities, funding has not kept pace with the cost of preparing for and responding to ongoing and emerging health threats that endanger Californians.

State public health spending was generally stagnant or declining prior to the COVID-19 pandemic – leaving Californians vulnerable. Spending only recently increased largely due to the pandemic. Due to chronic underfunding of public health systems, counties and cities across the state were not adequately prepared to respond to COVID-19 and many Californians suffered as a result. The virus disproportionately impacted Black and brown communities, exposing the damaging effects of racism in California.

The California Department of Public Health as well as local public health departments play a critical role in protecting and promoting Californians’ health and well-being.

The governor’s proposed 2022-23 budget includes a new investment of $300 million for public health infrastructure at the state and local level, which would support workforce expansion, data collection, and more.2Department of Finance, Governor’s Budget Summary 2022-23 (January 10, 2022), 132-134, https://www.ebudget.ca.gov/2022-23/pdf/BudgetSummary/FullBudgetSummary.pdf. The budget also includes $235 million for state-level disease surveillance and IT operations. This commitment is a critical first step in reversing the chronic underfunding of public health systems and ensuring that Californians, especially communities of color, don’t bear the costs of an unprepared state.

  • 1
    State departments other than the Department of Public Health often contribute to efforts to protect and promote public health. For example, the Department of Toxic Substances Control protects Californians from toxic substances. This analysis excludes such expenditures.
  • 2
    Department of Finance, Governor’s Budget Summary 2022-23 (January 10, 2022), 132-134, https://www.ebudget.ca.gov/2022-23/pdf/BudgetSummary/FullBudgetSummary.pdf.

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