This is a confidential survey that is being facilitated by the Black LGBTQ+ Network. Our intent for the survey is to collect information to inform our group's recommendations about relevant service delivery in the Los Angeles area.

DEMOGRAPHICS SECTION:

We are asking the following demographics-related questions so that we can collect information that will help us describe how we identify ourselves within the Black LGBTQ+ community. We also seek to gather information to help us better describe our overall current economic realities.

2) What is your age?
3) What is your highest level of education?
5) Which best describes your current gender identity?
 
5B) Do you identify with the term "gender nonconforming"?
5C) I identify as female.
5D) I identify as male.
5E) I identify as transgender female-to-male.
5F) I identify as transgender male-to-female.
5G) I identify as cisgender, that is, not transgender.
5H) I identify as nonbinary.
5I) I identify as genderqueer / gender non-conforming.
5J) I identify as intersex.
5K) I identify as genderfluid.
5L) I identify as Two-Spirit.
6) Which best describes your current sexual orientation?
 
7) Have you ever been unhoused or homeless?
8) I am currently ________ (pick one)
 
9) I receive income from the following sources. (check all that apply)
 
10) My income is enough to meet my basic needs?
11) Are you currently or have you ever been a parent/caregiver? *
12) Who have you been a caregiver for?
 

General Health Status

We are asking the following general health status questions so that we can collect information that will help us describe the overall health conditions of our community and the experiences we have when accessing healthcare as Black LGBTQ+ people.

13A) My physical health is ___________. (pick one):
13B) Have you seen a physician or a doctor in the past 12 months?
13C) What is the reason for you seeing a physician or doctor in the past 12 months?
14A) Do you currently have health insurance? *
14B) Does your current health insurance meet your medical needs? *
15) It is important to me that I go for healthcare at an LGBTQ+ specific clinic or provider? *
16) If my doctor or medical provider knew my sexual orientation, I feel it will negatively impact the quality of health care services I receive. *
17) If my doctor or medical provider knew my gender, I feel it will negatively impact the quality of health care services I receive. *
18) Have you ever been diagnosed by a health care provider with: (If yes, please mark all that apply.)
 
19) The racial/ethnic identification of my medical doctor matters to me. (pick one)
20) The gender of my medical doctor matters to me. (pick one)
21) LA County has sufficient targeted services for Black LGBTQ+ individuals.
22) Have you ever been treated for drug and/or alcohol addiction?

Mental Health Status

We are asking the following mental health status questions so that we can collect information that will help us describe the overall mental health conditions of our community and the experiences we have when accessing mental healthcare as Black LGBTQ+ people.

23) My mental and emotional health is _____. (pick one)
24) Do you have access to mental health services?
24B) Does your insurance plan cover mental health services?
25A) Have you ever been diagnosed with a mental illness or mental health disorder?
25B1) Even though you have never been diagnosed, is there a mental health disorder that you would diagnose for yourself?
25B2) What mental health diagnosis would you describe for yourself? (check all that apply)
 
25B1) What mental health diagnosis have you received? (check all that apply)
 
25C) Did you receive professional treatment for your mental health diagnosis?
25D) The mental health treatment that I have received in the past has been ________. (pick one)
26) Are you aware of any mental illness within your family history?
27) Have you experienced increased depression in the past 12 months?
28) The following characteristics of a mental health therapist matter to me. (check all that apply)
 
28) Have you accessed or received mental health therapy in the past 12 months?
28B) When I accessed mental health services, I experienced discrimination based on ________(select all that apply)
 
29) Accessing mental health care with a provider that specializes in Black LGBTQ is important to me. (pick one)
30) COVID-19 had an impact on my emotional well-being. (pick-one)
31) Have you ever had thoughts of suicide?
31B) If you or someone you care about is in a crisis, call the Suicide Prevention Lifeline at (800) 273-8255 to talk with a caring, trained counselor. It is free, confidential, and available 24/7. (Click To Acknowledge This Message)
32) The quality of mental health services for Black LGBTQ+ people in Los Angeles are _______. (pick one)
33) The availability of clinical providers that are knowledgeable about the Black LGBTQ+ community in the Los Angeles area is ______. (pick one)

Community Connectedness / Relationships

We are asking the following mental health status questions so that we can collect information that will help us describe the overall mental health conditions of our community and the experiences we have when accessing mental healthcare as Black LGBTQ+ people.

34) Discrimination against Black LGBTQ+ individuals is a problem in the following (check all that apply)
35) Discrimination against Black Transgender individuals is a problem in the following (check all that apply)
36) Discrimination against Black LGBTQ+ individuals based on HIV status is a problem in the following (check all that apply) *
37) Do you have a fear of violence in your community?
38A) Do you live in a Los Angeles community where you see a significant and/or visible number of Black people?
38B1) I feel safe in my community with a visible Black community. (pick one)
38B2) I feel safe in my community that does not have a significant and/or visible Black community. (pick one)
38C) I feel connected to the Black community. (pick one)
39) I feel socially connected in other LGBTQ+ areas (e.g., WEHO) that are NOT predominately Black.
40) Older Black LGBTQ+ people (50+ years) are isolated from the Black LGBTQ+ community in Los Angeles.
41) I feel that Black LGBTQ+ individuals that are 50+ years of age are included and celebrated in the Black LGBTQ+ community.
42) Los Angeles is a good place to live for Black _____________ (select all that apply)
 
43) I have a healthy support system and/or individuals who can advocate for my mental health needs in Los Angeles.
44) Are you currently in an intimate partner relationship (e.g., couple, partner, etc.)?
44C) If currently in a relationship, what is your current partner's gender? (N/A if not in a relationship.)
44D) What is your current partner's race or ethnicity?
 
44E) Do you live with your current partner?
44F) Which best describes the legal status of your relationship with your partner?
45) My sexual orientation is a significant part of who I am. My sexual orientation is a central part of my identity.
45B) My Transgender or non-binary identity is a significant part of who I am. My Transgender or non-binary identity is a central part of my identity.
46) To understand who I am as a person, you have to know that I'm LGBTQ+.
47A) TRIGGER WARNING: Do you have a history of early or childhood sexual trauma?
47B) TRIGGER WARNING: The early or childhood sexual trauma that I experienced influenced my sexual orientation and/or gender identity?
48) Have you ever been sexually assaulted as an adult?
49) Is your biological family affirming of your sexual orientation?
50) Is your biological family affirming of your gender identity?
51) Check all whom you are "out" to. *
52) Have you ever been incarcerated in state or federal prison?
53) Have you ever been incarcerated in city or county jail?
54) Were you ever a part of the juvenile detention and/or court system when you were a youth?
55) Were you ever a part of the foster care system when you were a youth?
55) Mistreatment or abuse by law enforcement is a serious problem for Black _____ (Check all that apply)