Unequal Opportunity: Health Disparities Affecting Gay and Bisexual Men in the United States

496 Pages·2007·3.097 MB·English

by  Richard J. Wolitski (editor), Ron Stall (editor), Ronald O. Valdiserri (editor)

Title Pages
Unequal Opportunity: Health Disparities
Affecting Gay and Bisexual Men in the United
States
Richard J. Wolitski, Ron Stall, and Ronald O. Valdiserri
Print publication date: 2007
Print ISBN-13: 9780195301533
Published to Oxford Scholarship Online: September 2009
DOI: 10.1093/acprof:oso/9780195301533.001.0001
Title Pages
(p.i) UNEQUAL OPPORTUNITY (p.ii)
(p.iii) UNEQUAL OPPORTUNITY
2008
(p.iv)
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Title Pages
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Library of Congress Cataloging-in-Publication Data
Unequal opportunity : health disparities affecting gay and bisexual
men in the United States /
edited by Richard J. Wolitski, Ron Stall, and Ronald O. Valdiserri.
p. cm.
Includes bibliographical references and index.
ISBN 978-0-19-530153-3
1. Gays—Medical care—United States. 2. Bisexuals—Medical care—
United States.
3. Health services accessibility—United States. 4. Discrimination in
medical care—United States.
[DNLM: 1. Health Status—United States. 2. Homosexuality, Male—
United States. 3. Bisexuality—
United States. 4. Prejudice—United States. 5. Sexually Transmitted
Diseases—United States.
6. Socioeconomic Factors—United States. WA 300 U517 2007]
I. Wolitski, Richard J. II. Stall, Ron, 1954– III. Valdiserri, Ronald O.,
1951–
RA564.9.H65U94 2007
362.1086′64–dc22 2007017174
9 8 7 6 5 4 3 2 1
Printed in the United States of America
on acid-free paper
Page 2 of 2
Dedication
Unequal Opportunity: Health Disparities
Affecting Gay and Bisexual Men in the United
States
Richard J. Wolitski, Ron Stall, and Ronald O. Valdiserri
Print publication date: 2007
Print ISBN-13: 9780195301533
Published to Oxford Scholarship Online: September 2009
DOI: 10.1093/acprof:oso/9780195301533.001.0001
Dedication
(p.v) This volume is dedicated to the health and well being of sexual minorities
in the United States and throughout the world. (p.vi)
Page 1 of 1
Contributors
Unequal Opportunity: Health Disparities
Affecting Gay and Bisexual Men in the United
States
Richard J. Wolitski, Ron Stall, and Ronald O. Valdiserri
Print publication date: 2007
Print ISBN-13: 9780195301533
Published to Oxford Scholarship Online: September 2009
DOI: 10.1093/acprof:oso/9780195301533.001.0001
(p.ix) Contributors
JOSEPH A. CATANIA PhD, College of Health and Human Sciences,
Oregon State University
KYUNG HEE CHOI PhD, MPH, Center for AIDS Prevention Studies,
University of California, San Francisco
SUSAN D. COCHRAN PhD, MS, Departments of Epidemiology, School
of Public Health, University of California, Los Angeles (UCLA) and the
UCLA Center for Research, Education, Training, and Strategic
Communications on Minority Health Disparities
RAFAEL M. DÍAZ MSW, PhD, César E. Chávez Institute, San
Francisco State University
CLAUDE EARL FOX MD, MPH, Miller School of Medicine, University
of Miami
MARK FRIEDMAN PhD, School of Public Health, University of
Pittsburgh
ARNOLD H. GROSSMAN PhD, ACSW, LMSW, Department of Applied
Psychology, Steinhardt School of Culture, Education, and Human
Development, New York University
GREGORY M. HEREK PhD, Department of Psychology, University of
California, Davis
VICKIE M. MAYS PhD, MSPH, Departments of Psychology and Health
Services, University of California, Los Angeles (UCLA) School of
Public Health and the UCLA Center for Research, Education, Training
and Strategic Communications on Minority Health Disparities
DAVID G. OSTROW MD, PhD, David Ostrow and Associates, Chicago,
IL; and the Chicago Multicenter AIDS Cohort Study, Howard Brown
Health Center, Chicago, IL
(p.x)
Page 1 of 2
Contributors
JOCELYN D. PATTERSON MPH, Division of HIV/AIDS Prevention;
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB
Prevention; Centers for Disease Control and Prevention
JOHN L. PETERSON PhD, Department of Psychology, Georgia State
University
DAVID W. PURCELL PhD, Division of HIV/AIDS Prevention; National
Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention;
Centers for Disease Control and Prevention
RAJEEV RAMCHAND PhD, RAND Health, RAND, Arlington, Virginia
GARY REMAFEDI MD, MPH, Youth and AIDS Projects and
Department of Pediatrics, University of Minnesota
SCOTT D. RHODES PhD, MPH, Departments of Social Sciences and
Health Policy, Division of Public Health Sciences, and Internal
Medicine and the Maya Angelou Research Center on Minority Health,
Wake Forest University Health Sciences
CHARLES SIMS MA, Department of Psychology, University of
California, Davis
PILGRIM S. SPIKES, JR. PhD, Division of HIV/AIDS Prevention;
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB
Prevention; Centers for Disease Control and Prevention.
RON STALL PhD, MPH, Department of Behavioral and Community
Health Sciences, Graduate School of Public Health, University of
Pittsburgh
PATRICK S. SULLIVAN DVM, PhD, Division of HIV/AIDS Prevention;
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB
Prevention; Centers for Disease Control and Prevention
RONALD O. VALDISERRI MD, MPH, Office of Public Health and
Environmental Hazards, U.S. Department of Veterans Affairs
RICHARD J. WOLITSKI PhD, Division of HIV/AIDS Prevention;
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB
Prevention; Centers for Disease Control and Prevention
LELAND J. YEE PhD, MPH, Department of Epidemiology, Graduate
School of Public Health, University of Pittsburgh
Page 2 of 2
Health Disparities Affecting Gay and Bisexual Men in the United States: An
Introduction
Unequal Opportunity: Health Disparities
Affecting Gay and Bisexual Men in the United
States
Richard J. Wolitski, Ron Stall, and Ronald O. Valdiserri
Print publication date: 2007
Print ISBN-13: 9780195301533
Published to Oxford Scholarship Online: September 2009
DOI: 10.1093/acprof:oso/9780195301533.001.0001
Health Disparities Affecting Gay and Bisexual
Men in the United States: An Introduction
Richard J. Wolitski
Ronald O. Valdiserri
Ron Stall
DOI:10.1093/acprof:oso/9780195301533.003.0001
Abstract and Keywords
This chapter places health disparities affecting gay and bisexual men within the
context of health disparities experienced by other socially marginalized groups
in the United States. It defines the population of gay and bisexual men and
examines key differences between these men and other socially marginalized
groups, including the basis of minority status, intergenerational influences,
acquisition of minority status later in life, selective disclosure of minority status,
and historical differences. The chapter describes key factors affecting health
disparities among gay and bisexual men including socioeconomic status,
prejudice and discrimination, laws and policies affecting health, health behavior,
and access to health care, and individual behavior and cultural norms in the gay
community. The chapter ends by briefly discussing public health efforts to
address health disparities.
Keywords:   health disparities, gay and bisexual men, homosexuality, socioeconomic status,
homophobia, discrimination, health care, public health
America is known as the land of opportunity—a meritocracy, where one can start
life with little or nothing, and with hard work, determination, and a little
ingenuity can go from rags to riches. America is also a land that was founded on
the principle of equality. The principle that “all men are created equal” is the
bedrock of our government and our society. Sadly, the reality is that America is
not a land of equal opportunity for everyone. Long-standing economic and social
Page 1 of 34
Health Disparities Affecting Gay and Bisexual Men in the United States: An
Introduction
inequalities have systematically denied racial and ethnic minorities, women, the
disabled, the aged, and others from getting and keeping their share of the
American dream. These inequities are visible in many aspects of contemporary
life. In 2005, working women earned 23% less than their male counterparts;1 a
larger percentage of blacks (25%) and Hispanics (22%) were living in poverty
compared to non-Hispanic whites (8%);1 and fewer blacks (48%), Hispanics
(50%), and Asian/Pacific Islanders (60%) owned their own homes, compared to
non-Hispanic whites (73%).2
Economic and social disadvantage are often closely associated with inequities in
physical and mental health, access to health care, and the quality and length of
life.3–8 Lower earnings make it more difficult for people to afford healthy diets
and lifestyles, quality housing in safe neighborhoods, health insurance, and high-
quality medical care, including vaccinations, other preventive services, and
medications to treat existing conditions. Economic disadvantage, stigma, and
discrimination also increase stress and diminish the ability of individuals to cope
with stress, which in turn contribute to poor physical and mental health.9–12
Stress can affect health directly (for example, creating anxiety, affecting the
immune system, increasing risk of hypertension, heart attack and other health
problems) and can also affect health indirectly when individuals adopt or
continue unhealthy behaviors in an effort to cope with challenging life
circumstances (e.g., use of tobacco, alcohol, or drugs) or (p.4) are unable to
access preventive care and high-quality medical treatment in a timely manner.9 ,
13
As a result, multiple health disparities adversely impact the health of
economically and socially disadvantaged groups in the United States. Although
health disparities have been shown to exist for many different groups, the
greatest amount of information is available concerning the health disparities
experienced by racial and ethnic minorities. Compared to whites, members of
some racial and ethnic minority groups experience reduced life expectancy and
higher rates of infant mortality, certain types of cancer, diabetes, hypertension,
sexually transmitted infections, HIV and AIDS, hepatitis, tuberculosis, and other
health problems, including poorer mental health.14–17 In addition to increased
incidence and prevalence of disease, racial and ethnic minorities often have
poorer access to quality health care and have lower survival rates compared to
whites.3 , 6 , 18 , 19
Like racial and ethnic minorities, sexual minorities also experience a wide range
of health disparities. However, gay, lesbian, bisexual, and transgender persons
are frequently invisible in research that seeks to measure health disparities
because questions about sexual orientation and gender identity are often not
included in these studies. As a result, the specific needs and experiences of
sexual minorities are often neglected in public health efforts to improve the
health and well-being of disadvantaged groups. There are no easy answers as to
Page 2 of 34
Health Disparities Affecting Gay and Bisexual Men in the United States: An
Introduction
why the specific experiences of gay, lesbian, bisexual, and transgender persons
are so often neglected in research, policy, and programmatic efforts addressing
health disparities. We suspect that there are many reasons for this: the historical
invisibility of sexual minorities; a failure on the part of some to recognize that
sexual minorities are differentially vulnerable to multiple health threats; a
reluctance to consider sexual minorities as “authentic” minorities; and negative
societal attitudes toward homosexuality that may have caused some to be
indifferent to these issues or to opine that the “immoral” lifestyles of sexual
minorities are the root cause of their poor health outcomes.
In recent years, however, increased attention has been given to the health-
related issues of sexual minorities. A growing number of studies have examined
disparities among sexual minorities and have documented significant differences
in rates of disease, mental health problems, and risk behaviors that can lead to
poor health.20–22 Although there are notable exceptions,10 , 23–27 sexual
orientation has not yet been fully integrated into research and theory regarding
health disparities, nor has it been consistently addressed in public health efforts
to eliminate inequities in health and health care.
This chapter provides an introduction to key issues related to health disparities
experienced by gay, bisexual, and other men who have sex with men (MSM). It
begins by considering the various ways that this population has been defined,
which have important implications for interpreting prior research and describing
the size and characteristics of this population. We then argue that the issues
faced by MSM should be considered as part of broader efforts to document,
understand, and eliminate health disparities in the (p.5) United States. Finally,
we provide an overview of the issues that will be examined in the chapters that
follow and articulate the overarching aims of this volume.
Like the remainder of this volume, this chapter focuses specifically on the health
of gay, bisexual, and other MSM in the United States. Given this explicit focus,
there is a danger that some readers may incorrectly assume that we are either
unaware or unconcerned about the social and health-related disparities
experienced more generally by sexual minorities and more specifically by lesbian
women and transgender persons. This is not the case. We chose to limit our
focus to MSM because we did not believe that we could adequately address the
health care needs of lesbians and other sexual minorities in a single volume.
Others have documented multiple health disparities experienced by lesbian and
bisexual women, but much work remains to be done in this important and
understudied area.28–36 Even less is known about the prevalence of various
health problems among transgender men and women, but alarmingly high rates
of HIV infection and other disparities also have been documented among
transgender persons.37–41
Page 3 of 34
Health Disparities Affecting Gay and Bisexual Men in the United States: An
Introduction
It is likely that many of the disparities experienced by members of all sexual
minority groups share a common etiology that is driven, at least in part, by the
direct and indirect effects of stigma and discrimination. Similarly, although MSM
around the world may have much in common, those living outside the United
States are affected by different cultural, societal, and historical influences; they
receive care from different health care systems, and they are afforded different
legal rights and protections. Given the complexity of these issues, we did not
believe that we could adequately address all of these issues in this volume. We
hope that this work will provide an impetus for increased examination of health
issues among sexual minorities and for greater attention to the need to prevent
and eliminate health disparities experienced by all sexual minorities in the
United States and other parts of the world.
Gay, Bisexual, and Other Men Who Have Sex with Men
Although men with same-gender partners have become increasingly visible in
contemporary society in recent decades, these men often remain uncounted and
invisible in many large-scale surveys that seek to describe the demographic
characteristics and health-related needs of Americans. Even when efforts have
been made to document the size of this population and its health-related needs,
methodological issues have presented challenges to the use and interpretation of
these data. A fundamental issue is the multitude of definitions that have been
used to assess sexual orientation. Studies of homosexual and bisexual men have
used different definitions of sexual orientation that define homosexuality and
bisexuality in terms of three basic aspects: (1) sexual desire or attraction, (2)
sexual behavior, and (3) sexual identity. Although these three aspects of sexual
orientation are often used interchangeably, each (p.6) represents a distinct
construct that has its own meaning and implications for research and
practice.42–45
People differ in the degree to which they are sexually attracted to members of
their own or the opposite gender. Measures of sexual attraction assess responses
toward members of the same or opposite gender using (1) self-report measures
of sexual or romantic attraction/desire or sexual fantasy or (2) physiological
measures of sexual arousal. Individuals may be sexually attracted to only
members of the opposite gender, the same gender, both genders, or neither
gender.46 Although most assessments of sexual attraction rely on self-report
measures, these measures do not always correspond to physiological measures
of sexual arousal that are taken while individuals view erotic images of men or
women.47
Same-gender attraction often leads to same-gender sexual behavior, but
individuals' sexual behavior is not necessarily consistent with their degree of
attraction to partners of a given gender. Individuals' ability and willingness to
act on their sexual attraction to same- or opposite-gender partners can be
affected by many factors, including cultural norms regarding sexual
Page 4 of 34
Health Disparities Affecting Gay and Bisexual Men in the United States: An
Introduction
relationships, familial expectations, personal beliefs and attitudes, and the
availability of partners. Behavioral definitions of sexuality are based on the
gender of persons with whom individuals report having had sexual relations.
These definitions rely on self-reports of same-gender sexual relations and
typically classify individuals as homosexual, bisexual, or heterosexual, based on
the gender of their sex partners. Men who report only male sex partners are
classified as homosexual, those reporting only female partners are classified as
heterosexual, and those reporting both male and female partners during a
specified period of time are classified as bisexual. In public health, another
behaviorally defined category, MSM, is also commonly used. This classification
combines behaviorally homosexual and bisexual men into a single category and
is often used when same-gender behavior may place men at increased risk of
HIV or other sexually transmitted infections. Although defining sexual
orientation based on sexual behavior seems rather straightforward, definitions
that do so vary considerably, based on the recall period that is used (e.g., during
a respondent's lifetime, since age 18, the past 5 years, the past year), making
comparisons across studies difficult.
Sexual identity refers to the label that individuals use to describe their sexual
orientation to themselves or others. These labels may, or may not, correspond
with individual's sexual attraction or behavior. Most definitions of sexual identity
classify individuals into one of the three standard classifications of sexual
orientation: homosexual (gay), heterosexual (straight), and bisexual. Many
studies also include a fourth category (e.g., questioning, don't know, not sure),
reflecting the fact that having a well-defined sexual identity is often a
developmental process that is affected not only by attraction and sexual
behavior, but also by contextual influences, group affiliation, and social and
cultural norms.48 , 49 For example, men whose sexual behavior with other men is
primarily determined by external forces that limit the availability of female (p.
7) partners (e.g., incarceration, military service, same-gender boarding school)
or is driven by drug dependency or economic need may not identify as gay or
bisexual even if they report having had sex with other men.50–53
Size of the Population
As Kinsey, Laumann, and others have pointed out, accurately assessing the size
of the gay/homosexual/MSM population is difficult, if not impossible.43 , 44 , 54
Challenges to estimating the size of this group include the multidimensional
nature of sexual orientation, the stigma associated with homosexuality, the
reluctance of some individuals to disclose same-gender behavior, variability in
the expression of sexual orientation within different subgroups, and the
developmental course of human sexual relationships and identity over a lifetime.
Most systematic efforts to document the prevalence of homosexuality among
American men have been based wholly, or in part, on behavioral definitions of
sexual orientation. Kinsey and colleagues54 reported that 37% of men had one or
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