The Health of Sexual Minorities

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Edited by

Ilan H. Meyer, PhD, and

Mary E. Northridge, PhD, MPH

Mailman School of Public Health, Columbia University New York, New York, USA

The Health of

Sexual Minorities

Public Health Perspectives on Lesbian, Gay, Bisexual

and Transgender Populations

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Ilan H. Meyer, PhD

Mary E. Northridge, PhD, MPH Department of Sociomedical Sciences Mailman School of Public Health Columbia University

New York, NY 10032 USA

Library of Congress Control Number: 2005939066

ISBN-10: 0-387-28871-6 e-ISBN-10: 0-387-31334-6 ISBN-13: 978-0-387-28871-0 e-ISBN-13: 978-0-387-31334-4 Printed on acid-free paper.

Portions of Chapter 10 are adapted from Meyer I.H. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence.

Chapter 14 is adapted from Sell, R.L. Deﬁning and measuring sexual orientation: a review. Archives of Sexual Behavior 1997;26:643–658.

All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden.

The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identiﬁed as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights.

While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.

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Our collaboration on the editing of this book revives an earlier joint effort. In June 2001, we teamed up on the ﬁrst issue of the American Journal of Public Health, devoted to lesbian, gay, bisexual, and trans- gender (LGBT) health (Northridge, 2001). Five years later, we reunited to conceptualize, coordinate, and oversee the compilation of this volume on the health of sexual minorities. In both the special issues and this volume, we sought a public health perspective that was broad enough to encompass the diverse populations and communities that comprise LGBT people, yet recognized the similarities in the experiences they share across cultures and locales—often related to stigma, discrimination, rejection, and violence but also resilience and resistance (Meyer, 2001). An overarching goal for this book is that careful treatment afforded to issues such as the impact of prejudice on the health of LGBT people may thoughtfully inform research and practice on other stigmatized groups and thereby help advance civil society.

The Institute of Medicine (1988) defined the mission of public health as fulfilling society’s interest in ensuring conditions in which people can be healthy. When conceptualizing this book, we invoked this broad definition of public health to mean, quite literally, the health of the public. How are we to advance conditions in which LGBT people can be healthy? To seek answers, we called on leading researchers who are conducting formative and applied research on LGBT health for their contributions derived from empirical studies and critical analysis in the form of peer-reviewed chapters. The result is this comprehensive and rigorous text.

Conceptual Approach to Editing This Volume

Our aim from the outset when commissioning chapters was to be inclu- sive but not exhaustive. That is, we did not aim for an encyclopedic book that covers all the areas of interest to LGBT populations. Rather, we aimed for a book that would rely on the best available thought on issues of concern to LGBT health. We sought a cross-disciplinary approach. Anthropology, biology, law, medicine, psychology, and

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sociology are among the disciplines represented in this volume in addition to public health. They are interwoven in interdisciplinary and intersectional works that are at the forefront of formative and applied LGBT public health research today. In addition, we invoked an eco- logical, multilevel approach by ensuring that structural determinants of LGBT health as well as individual-level speciﬁc health concerns of sexual minorities were covered.

When choosing chapter contributors and editing the chapters, we did not impose an editorial ideology other than what is described above and implied in the organization of this book. That is, we did not seek uniformity among authors in deﬁnitions of the populations of interest, the approaches they have taken to investigate these populations, or the types of solutions sought. Rather, we allowed—indeed aimed for—the book to reﬂect current ideologic and conceptual con- troversies and debates at the cost of introducing incongruities among chapters. Thus, a reading of different chapters may give a better appre- ciation of the current state of LGBT public health research than would any single chapter.

We also sought to represent the concerns of various groups among LGBT populations—but not by paying lip service to representation at the expense of significant content. Rather, we sought areas of strong research in various specific populations (e.g., American Indians, Latinos, women, transgender individuals) with the expectation that conceptual work and certain findings from such works would be trans- ferable across populations. Finally, although this text is based in the United States, we provoked inquiry into global health issues because they provide an important perspective on LGBT health relevant both to U.S. and global populations.

Tour of the Book

Some chapters of this book are largely theoretical, others synthesize empirical research, and still others are especially hands-on. Each chapter in this volume may be read independently and understood without reference to the rest of the book. A real advantage of this text, however, is the interchange among chapters. We deliberately included different perspectives on the core topics presented. Together, their purpose is to inform readers committed to understanding and addressing social disparities in health for LGBT populations.

Careful readers will discern that, despite broad areas of agreement, contributors differ with regard to the deﬁnition of populations of interest, research methodologies employed, and health concerns targeted.

Rather than censor points of view, we championed a more provocative, comprehensive, and in-depth understanding of the central themes deliberated within the text toward evolving the ﬁeld of LGBT health.

We urge the reader to expand her/his scope when searching for insights in this book by exploring chapters even if their relevance to a speciﬁc population or a narrow public health question of interest is not superﬁcially apparent. To gain the most from this volume, we believe vi Preface

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it is advantageous to compare and contrast chapters within and across sections.

Although this volume was not intended to be read in order from cover to cover, the sequence and organization of its parts were pur- poseful, moving from overarching issues including conceptual and deﬁnitional frameworks; legal, social, and cultural perspectives and methodologic approaches; through speciﬁc health issues among LGBT populations; and concluding with an examination of health systems and institutions through which LGBT health is (or is not) addressed.

First, “Who Are LGBT Individuals?” By examining populations of interest, the chapters included in this part wrestle with topics such as deﬁnitions of identity; intersections across sexual, race/ethnicity, and gender identities; sexual development across the life course; and social and biologic constructions of sexuality. The following part, “LGBT Health and the State,” takes on legal, ethical, and political dilemmas as well as opportunities for policy, research, and advocacy on sexual minorities. Next, the part entitled “Prejudice and Pride in Health”

investigates the relations between societal structures and individual health, including the impact of structural violence, stigma, prejudice, and discrimination on the health of LGBT people.

Part IV, “Research Methodologies,” sets about honing the processes and means for understanding and addressing disparities in LGBT health. It is incumbent on researchers to ensure that methodologic reﬁnements and exquisite sensitivity are employed when bringing LGBT issues into public health focus. The chapters in this part cover a variety of methodologic issues that require special attention in studies of LGBT populations, including deﬁnitions, measurement, and sam- pling as well as quantitative, qualitative, and community-based par- ticipatory research approaches.

Rather than try to cover the entire spectrum of health needs, we elected to include a diversity of health issues, with particular attention to areas that have not received much attention in books and compila- tions to date. In the part entitled “Health Concerns,” we included the following three categories of LGBT issues: (1) areas in which LGBT people are at increased risk for disease because of unique exposures (e.g., use of hormones by trans-people undergoing sex change proce- dures); (2) areas in which LGBT people have a high prevalence of expo- sure and/or disease that are not caused by unique exposures (e.g., methamphetamine use and risk of HIV infection among gay men); and (3) areas in which LGBT people are not at increased risk for disease but that nevertheless require specialized, culturally appropriate approaches (e.g., general health concerns of lesbian and bisexual women, including cancer prevention and treatment).

Finally, no public health text would be complete absent a look at

“Healthcare Systems and Services.” The ﬁnal part of this book accord- ingly covers the issues of accessing and ensuring respectful health care for LGBT groups that have traditionally experienced the greatest bar- riers in U.S. systems: racial/ethnic minorities, transgender people, and youths. We end with an inspiring chapter on Fenway Community Health, a model of integrated community-based LGBT care, education,

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and research that serves as a beacon for other locales, both within the United States and abroad.

Areas and Topics Not Included in This Book

Despite the breadth of this book, there are many areas that it does not cover. These areas can be divided into two general types: The ﬁrst includes work we omitted because there are many other resources to which the reader can turn. In this, we include HIV/AIDS and psychological/mental health issues. HIV/AIDS has been a major, and pre- dominant, area of investigation in gay men’s health research. Many books have been published to provide the reader good reviews of various areas of research within public health work on HIV/AIDS.

These resources include books that provide comprehensive coverage of HIV/AIDS and sexually transmitted diseases (STDs) (e.g., Holmes, 1999; Emini, 2002) as well as books that address speciﬁc aspects of public health, such as HIV prevention (Peterson & DiClemente, 2000) and speciﬁc issues affecting HIV-positive and HIV-negative gay and bisexual men (Halkitis et al., 2005; Kalichman, 2005). Similarly, the area of mental health has been the topic of many books that provide an excellent discussion of psychological development across the life-span and mental health problems related to LGB populations (D’Augelli &

Patterson, 1996, 2001; Garnets & Kimmel, 2002; Omoto & Kurtzman, 2006).

The second area of interest excluded from this volume includes many emerging areas. We omitted them because we assessed that based on the existing research we could not commission reviews that were sufficiently comprehensive. To pursue such areas, the reader would be better served by searching scientific journals that can provide more timely coverage of emerging research areas. Such areas include topics that have not been fully developed in public health work to date. For example, the discussion of family levels of influence within the conceptual model that guided the organization of this book. Many important issues face LGBT individuals as they form families. Such a chapter might have covered issues related to conception, adoption, child rearing, cohabitation, and marriage among others. Notwith- standing notable works describing anthropologic and psychological perspectives on LGB families (Weston, 1991; Patterson & D’Augelli, 1998), public health research in this area is still forming, and links to health issues have not yet been carefully explicated, evaluated, and published in the peer-reviewed literature. The need for such work is particularly heightened as debate is growing on access for LGBT individuals to civil marriage and its public health implications (Herdt

& Kertzner, 2006). There are also speciﬁc health concerns that have not received sufﬁcient research attention (Dean et al., 2000)—for example, gay men may be at risk for anal cancer unrelated to HIV/AIDS—but the lack of research on such topics make them unsuitable for coverage in a book chapter.

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References

D’Augelli, A.R., and Patterson, C.J. (1996) Lesbian, gay, and bisexual identities over the lifespan: psychological perspectives. Oxford University Press, New York.

D’Augelli, A.R., and Patterson, C.J. (2001) Lesbian, gay, and bisexual identities and youth: psychological perspectives. Oxford University Press, New York.

Dean, L., Meyer, I.H., Robinson, K., Sell, R.L., Sember, R., Silenzio, V.M.B., Bowen, D.J., Bradford, J., Rothblum, E., Scout, White, J., Dunn, P., Lawrence, A., Wolfe, D., and Xavier, J. (2000) Lesbian, gay, bisexual, and transgender health: ﬁndings and concerns. Journal of the Gay and Lesbian Medical Associa- tion 4: 102–151.

Emini, E. (2002) The human immunodeﬁciency virus: biology, immunology, and therapy. Princeton University Press, Princeton, NJ.

Garnets, L., and Kimmel, D. (2002) Psychological perspectives on lesbian, gay, and bisexual experiences. Columbia University Press, New York.

Halkitis, P.N., Gomez, C.A., and Wolitski, R.J. (2005) HIV+ sex: the psychosocial and interpersonal dynamics of HIV-seropositive gay and bisexual men’s relation- ships. American Psychological Association, Washington, DC.

Herdt, G., and Kertzner, R. (2006) I do, but I can’t: the impact of marriage denial on the mental health and sexual citizenship of lesbians and gay men in the United States. Sexuality Research & Social Policy 3: 33–49.

Holmes, K. (1999) Sexually transmitted diseases, 3rd ed. McGraw-Hill, New York.

Institute of Medicine. (1988) The future of public health. National Academy Press, Washington, DC.

Kalichman, S.C. (2005) Positive prevention: reducing HIV transmission among people living with HIV/AIDS. Springer, New York.

Meyer, I.H. (2001) Why lesbian, gay, bisexual, and transgender public health?

American Journal of Public Health 91: 856–859.

Northridge, M.E. (2001) Editor’s note: advancing lesbian, gay, bisexual, and transgender health. American Journal of Public Health 91: 855–856.

Omoto, A.M., and Kurtzman, H.S. (2006) Sexual orientation and mental health:

examining identity and development in lesbian, gay, and bisexual people. American Psychological Association, Washington, DC.

Patterson, C.J., and D’Augelli, A.R. (1998) Lesbian, gay, and bisexual identities in families: psychological perspectives. Oxford University Press, New York.

Peterson, J.L., and DiClemente, R.J. (2000) Handbook of HIV prevention. Springer, New York.

Weston, K. (1991) Families we choose. Columbia University Press, New York.

New York, New York, USA Ilan H. Meyer

Mary E. Northridge

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As we embarked on this project, we relied on established, busy researchers and public health professionals who have dedicated their work to LGBT health issues. The unanimous endorsement of this undertaking among the many researchers we approached is a remark- able testament to the devotion of contemporary public health scientists and scholars to LGBT health, to one another, and to collaborative undertakings. We thank the authors of the chapters for their dedication and trust. We also thank the following individuals for providing invaluable advice at various stages and various aspects of the book:

Gabriel Galindo, Michael Gross, Dawn Harbatkin, Linwood Lewis, John Peterson, Lauren Porsch, Randall Sell, and Donna Shelley. Finally, we thank Bill Tucker, our editor at Springer, for believing in this project and for his continued support and help in seeing this project to fruition.

We hope that this book helps encourage researchers and public health professionals to direct their attention to LGBT health. Despite the formidable challenges ahead, the future looks bright for LGBT public health. We have come too far to turn back, and we will not. The lives and welfare of too many of us hang in the balance.

New York, New York, USA Ilan H. Meyer

Mary E. Northridge

Acknowledgments

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Preface . . . . v Acknowledgments . . . . xi Contributors . . . . xvii Part I Who Are LGBT Individuals?

Chapter 1

Shifting Sands or Solid Foundation? Lesbian, Gay, Bisexual,

and Transgender Identity Formation . . . . 3 Michele J. Eliason and Robert Schope

Chapter 2

Development of Same-Sex Attracted Youth . . . . 27 Ritch C. Savin-Williams and Kenneth M. Cohen

Chapter 3

Developmental Issues in Lesbian and Gay Adulthood . . . . 48 Robert M. Kertzner

Chapter 4

Biology and Sexual Minority Status . . . . 65 William Byne

Part II LGBT Health and the State Chapter 5

The Importance of Being Perverse: Troubling Law, Identities,

Health and Rights in Search of Global Justice . . . . 93 Stefano Fabeni and Alice M. Miller

Chapter 6

Ethical, Legal, Social, and Political Implications of

Scientiﬁc Research on Sexual Orientation . . . . 130 Edward Stein

Chapter 7

Targeting the State: Risks, Beneﬁts, and Strategic Dilemmas of Recent LGBT Health Advocacy . . . . 149 Steven Epstein

Contributors

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Stefano Fabeni, School of Law, Columbia University, New York, New York, USA

Karen C. Fieland, School of Social Work, University of Washington, Seattle, Washington, USA

Hilary Goldhammer, The Fenway Institute, Fenway Community Health, Boston, Massachusetts, USA

Gregory L. Greenwood, Behavioral Health Sciences, United Behavioral Health, San Francisco, California, USA

Elisabeth P. Gruskin, Kaiser Permanente, Oakland, California, USA Gregory M. Herek, Department of Psychology, University of California–

David M. Huebner, Center for AIDS Prevention Studies, University of California–San Francisco, San Francisco, California, USA

Joyce Hunter, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Department of Psychiatry; and Department of Psychiatry, Columbia University, New York, New York, USA

Christy M. Isler, Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA

Robert M. Kertzner, Department of Psychiatry, Columbia University, New York, New York, USA

Sam Quan Krueger, United Way of New York, New York, New York, USA Anne A. Lawrence, Seattle, Washington, USA

Emilia Lombardi, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA

David Malebranche, School of Medicine, Emory University, Atlanta, Georgia, USA

Kenneth H. Mayer, Medicine and Community Health, Brown Univer- sity, Providence, Rhode Island; and The Fenway Institute, Fenway Community Health, Boston, Massachusetts, USA

Brian P. McGrath, Graduate School of Architecture, Planning and Preservation, Columbia University, New York, New York, USA Ilan H. Meyer, Mailman School of Public Health, Columbia University, New York, New York, USA

Alice M. Miller, Mailman School of Public Health, Columbia University, New York, New York, USA

Gregorio A. Millett, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Matthew J. Mimiaga, The Fenway Institute, Fenway Community Health, Boston, Massachusetts, USA

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Mary E. Northridge, Mailman School of Public Health, Columbia Uni- versity, New York, New York, USA

Katherine A. O’Hanlan, Gynecologic Oncology Associates, Portola Valley, California, USA

Mark B. Padilla, Mailman School of Public Health, Columbia Univer- sity, New York, New York, USA

Richard G. Parker, Mailman School of Public Health, Columbia Univer- sity, New York, New York, USA

John L. Peterson, Department of Psychology, Georgia State University, Atlanta, Georgia, USA

Jesus Ramirez-Valles, School of Public Health, University of Illinois–

Chicago, Chicago, Illinois, USA

Esther D. Rothblum, Women’s Studies Department, San Diego State University, San Diego, California, USA

Marla Russo, School of Public Health and Community Medicine, University of Washington, Seattle, Washington, USA

Ritch C. Savin-Williams, Department of Human Development, Cornell University, Ithaca, New York, USA

Robert Schope, Department of Social Work, The University of Wisconsin Oshkosh, Oshkosh, Wisconsin, USA

Randall L. Sell, School of Public Health, Drexel University, Philadelphia, Pennsylvania, USA

Jane M. Simoni, Department of Psychology, University of Washington, Seattle, Washington, USA

Edward Stein, Benjamin N. Cardozo School of Law, New York, New York, USA

Darryl Strohl, Department of Psychology, University of California–

Rodney VanDerwarker, The Fenway Institute, Fenway Community Health, Boston, Massachusetts, USA

Ernesto Váquez del Aguila, Mailman School of Public Health, Columbia University, New York, New York, USA

Karina L. Walters, School of Social Work, University of Washington, Seattle, Washington, USA

Patrick A. Wilson, Yale University School of Medicine, New Haven, Connecticut, USA

William J. Woods, Center for AIDS Prevention Studies, University of California–San Francisco, San Francisco, California, USA

Hirokazu Yoshikawa, Harvard Graduate School of Education, Cam- bridge, Massachusetts, USA

Contributors xix

The Health of Sexual Minorities

The Health of

Sexual Minorities

Public Health Perspectives on Lesbian, Gay, Bisexual

and Transgender Populations

Preface

Acknowledgments

Contents

Contributors