NEIGHBORHOODS, COMMUNITIES,

AND URBAN MARGINALITY

Marginality and
Global LGBT Communities
Conflicts, Civil Rights
and Controversy
Sheri R. Notaro
Neighborhoods, Communities, and Urban
Marginality

Series Editors
Carol Camp Yeakey
Washington University in St. Louis
St. Louis, MO, USA

Walter R. Allen
University of California
Los Angeles, CA, USA
This series examines the ecology of neighborhoods and communities in
not only twenty-first century America, but across the globe. By taking an
ecological approach, the study of neighborhoods takes into account not
just structures, buildings and geographical boundaries, but also the rela-
tionship and adjustment of humans to highly dense urban environments
in a particular area or vicinity. As the violent events of the past year in
marginalized urban neighborhoods and communities across the country
have demonstrated, “place matters.” The series contain original research
about the power of place, that is, the importance of where one lives, how
public policies have transformed the shape and geography of inequality
and disparity in our metropolitan areas, and, the ways in which residents
impacted by perceived inequality are trying to confront the problem.

More information about this series at

http://www.palgrave.com/gp/series/15097
 Sheri R. Notaro

Marginality
and Global LGBT
Communities
Conflicts, Civil Rights and Controversy
Sheri R. Notaro
Washington University in St. Louis
St. Louis, MO, USA

Neighborhoods, Communities, and Urban Marginality

ISBN 978-3-030-22414-1 ISBN 978-3-030-22415-8  (eBook)
https://doi.org/10.1007/978-3-030-22415-8

© The Editor(s) (if applicable) and The Author(s) 2020

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With gratitude for their everlasting love and support, I dedicate this book to
my husband, Paul C. Notaro, and my son, Paul M. Notaro.
To the LGBT community, I dedicate this book in deepest thanks for your
perseverance, resiliency and quest for human dignity. Your fight to live, to love,
and to simply be is the universal struggle for humanity that unites us all.
 Series Editors’ Preface

This year marks a propitious time in our nation’s history as we cele-

brate, in June 1969, the violent confrontations at the Stonewall Inn in
Greenwich Village, in Manhattan, in New York City. Little did we know
that the Stonewall riots, from fifty years ago, would become the signal
event of the modern LGBT rights movement, a previously marginalized
group on the periphery of social, political and economic life in America.
Once ostracized and hidden from public view, we now see symbols of
LGBT pride in both public and private venues. Notaro’s timely volume,
Marginality and Global LGBT Communities—Conflict, Civil Rights and
Controversy, examines just how far the LGBT movement has come and
how much more remains to be accomplished in their quest for equal jus-
tice under the law. Nowhere is LGBT pride more evident than on college
campuses, where lavender graduations have now become common-
place, as an end of the year ceremony which celebrates the achievements
of graduating LGBT college students, who, at times, faced challenges
and discrimination during their college years. According to the Human
Rights Campaign, the color lavender is important to the LGBT com-
munity for several reasons. First, lavender represents the pink triangle
that gay men were forced to wear in concentration camps. Second, the
black triangle designates lesbians who were political prisoners in Nazi
Germany. The LGBT rights movement combined them to make sym-
bols and vivid colors to denote pride and a sense of community. Notaro’s
book cover is endemic of this sense of pride, and of community. Where
appropriate, Marginality and Global LGBT Communities—Conflict, Civil

vii
viii   SERIES EDITORS’ PREFACE

Rights and Controversy, provides a lens by which to view LGBT issues

not just in the United States, but in differing nation states as well.
As co-editors of the series, Neighborhoods, Communities and Urban
Marginality, we welcome this volume as we now see the globalization of
the LGBT community and their fight for just and legal recognition and
accommodation. The extent to which any community of persons is mar-
ginalized and not afforded basic human rights is the extent to which the
rights of us all are denied.

Carol Camp Yeakey

The Marshall S. Snow Professor
of Arts and Sciences
Washington University in St. Louis
St. Louis, USA

Walter R. Allen
Distinguished Professor of Education
of Sociology and African American Studies
Allan Murray Cartter Chair in Higher Education
University of California at Los Angeles
Los Angeles, USA
 Acknowledgements

This book is a product of family, friends, and colleagues and their unwa-
vering confidence in me.
My mother, Joyce Gail Marshall Wynn, always put my needs before
her own, never letting me know of the sacrifices she made for me on a
daily basis. To see and remember her joy in my accomplishments inspired
me to always reach higher. When I lost her, my second mother took on
the role of loving me unconditionally. Thank you Aunt Tine.
My husband, Paul C. Notaro, has shared his life with me as a loving
and dedicated partner who can always make me laugh. He stands beside
me in all things, reviewing copious drafts, boosting my confidence, and
cooking the best meals I’ve ever tasted. His devotion to our son, Paul
M. Notaro, knows no bounds.
My dear friend, Carol Camp Yeakey, saw something special in me so
many years ago. Because of her faith in me, I have learned to recognize
my potential and to strive for excellence in all things.
I also want to thank Rachel Daniel, Madison Allums, and the entire
Palgrave Macmillan staff for supporting this book from inception to
publication.

ix
 Contents

1 Objectives and Significance of the Volume 1

2 Legal Status and Challenges to Homosexuality 23

3 Access to Health Care 53

4 HIV/AIDS 75

5 Substance Use and Abuse 111

6 Mental Health 139

7 Violence 165

8 A Framework for the Future 185

Index 197

xi
 List of Figures

Fig. 2.1 World laws pertaining to homosexual relationships

and expression (Courtesy of Southern, Wikimedia
Commons at https://commons.wikimedia.org/wiki/
File:World_homosexuality_laws.png) 26
Fig. 2.2 Sexual orientation employment anti-discrimination
map (Courtesy of Adrian Frith, Wikimedia Commons
at https://commons.wikimedia.org/wiki/File:
Sexual_orientation_employment_anti-discrimination_map.svg) 27
Fig. 2.3 European Union map (Courtesy of the US Central
Intelligence Agency Library) 44

xiii
 List of Tables

Table 1.1 Percent of U.S. adults identifying as LGBT by sex, race/

ethnicity, and birth cohort, 2012–2017 7
Table 1.2 Percentages of self-identified LGB adults in selected
Western European countries 9
Table 4.1 2017 estimates of HIV/AIDS worldwide
and in the United States 78
Table 4.2 2016 regional HIV and AIDS data for Africa 99
Table 4.3 2016 regional HIV and AIDS data for Asia
and the Pacific and India 102
Table 7.1 Percent of adult prison inmates reporting sexual
victimization in the United States 167

xv
 CHAPTER 1

Objectives and Significance of the Volume

Alice Walker, a poet and writer, provides a lens into the main objectives of
this volume:

Please remember, especially in these times of group-think and the right-on

chorus, that no person is your friend (or kin) who demands your silence, or
denies your right to grow and be perceived as fully blossomed as you were
intended. (Alice Walker, 1983, In Search of Our Mothers’ Gardens: Womanist
Prose)

This volume has several objectives, all of which focus on the marginality
of persons identifying as lesbian, gay, bisexual, and transgender (LGBT)
both in the United States and globally. The volume will illuminate the
ways in which health disparities and inequities experienced by the LGBT
population stem from historical and political struggles and at times violent
persecutions faced by LGBT persons throughout the world. Specifically, the
objectives of the volume are to illuminate the marginalization of the LGBT
community in its many forms and societal structures while also discussing
progress and movement from the margins of society to the mainstream in
both the United States and globally.
This chapter will present the origins, definition of homosexuality, esti-
mates of the LGBT population, an abridged history of homosexuality, and
the foundation for LGBT civil rights formed by the Stonewall Inn riots.

© The Author(s) 2020 1

S. R. Notaro, Marginality and Global LGBT Communities,
Neighborhoods, Communities, and Urban Marginality,
https://doi.org/10.1007/978-3-030-22415-8_1
2 S. R. NOTARO

This chapter explicates that although the Stonewall Inn was a turning point
and catalyst for gains in LGBT civil and political rights, the remainder of
the volume will demonstrate that significant challenges stemming from dis-
crimination, bias, and stigmatization persist among the LGBT community
in the United States and globally. The ensuing chapters of the volume will
provide ample evidence of significant barriers to full inclusion of the LGBT
community into society, with focused attention on legal challenges, access
to health care, health disparities, and violence (e.g., U.S. Department of
Health and Human Services [DHHS], 2010).
Throughout the volume, care will be taken to emphasize and analyze
the variations within this community that influence the uneven distribution
of both health risk and protective factors and resiliency. The topic of LGBT
marginalization is relevant and timely given that the 50th anniversary of
the Stonewall Inn uprising provides a moment to pause and reflect upon
ways in which the struggles for human rights of one group are indicative
of the struggles for us all. Full inclusion of LGBT persons affects the lived
experiences of all peoples. Limitations of the volume include the sometimes
uneven focus on the United States, given the lack of comparative data sets
globally as well as the inability to capture the full breadth of experience of
individuals within the LGBT community.
The minority stress model (e.g., Meyer, 2003, 2010) will be discussed
throughout the volume as an important conceptualization of the ways
in which marginalization negatively impacts health outcomes. The model
offers a framework for understanding and examining the impact of bias, dis-
crimination, homophobia, and marginality on the unequal and poor health
outcomes of LGBT individuals. Meyer (2003) emphasizes that minority
stress theory is based upon several sociological and psychological theo-
ries (e.g., Allport, 1954; Goffman, 1963) that discuss the negative effects
of social conditions such as prejudice and discrimination. Minority stress
theory posits that health disparities among LGBTQ individuals or sexual
minorities (e.g., psychological distress, substance use, HIV risk) can be
partially explained by the stressors associated with experiencing a lifetime
of homophobia, discrimination, bias, and harassment (Meyer, 2010). The
minority stress theory posits that these stressors are not experienced by
majority or non-stigmatized groups, are chronic, and are socially based
in terms of institutional structures (Meyer, 2003). The model explores
the variability within sexual minority communities by explicitly investigat-
ing the intersectional and overlapping identities within the LGBTQ com-
munity—e.g., LGBTQ individuals of color who hold unified identities as
 1 OBJECTIVES AND SIGNIFICANCE OF THE VOLUME 3

racial/ethnic minorities as well as sexual minorities. Research has demon-

strated that, at least in the United States, LGBT individuals of color have
a long and rich history of involvement in the “mainstream” gay rights
movement (e.g., Stonewall), as well as within LGBT communities of color
(Meyer, 2010). These communities of support serve as protective factors or
buffers against homophobia, harassment, and discrimination and in turn,
lower the risk of health disparities (Meyer, 2010).

Origins of Homosexuality
The origins of homosexuality have been formally debated among psychol-
ogists and psychiatrists for decades, with some claims that homosexuality
results from unhealthy relationships between parents and children (Edsall,
2003). While research has examined a number of biological, genetic, and
cultural factors that may influence sexual orientation, no definitive conclu-
sions have been reached on this issue (American Psychological Association,
2016). There is fairly widespread agreement, however, that both biological
and environmental factors impact the development of sexual orientation,
leaving the individual with little or no choice in the matter (American Psy-
chological Association, 2016). It was not until 1973 that the American
Psychiatric Association ceased to classify homosexuality as a mental illness.
The decision to remove homosexuality from the Diagnostic and Statistical
Manual (DSM) was partly influenced by gay activism as well as the failure
of established psychiatric tests such as the Rorshach to distinguish hetero-
sexual men and women from homosexual men and women.

Defining Homosexuality
The origins of the terms homosexuality and heterosexuality are attributed
to a letter written in 1869 by Karl Maria-Kertbeny, a Hungarian journalist
and human rights activist The terminology applied to the homosexual com-
munity has changed over time and put into view the struggle to positively
self-define one’s community in the face of discriminatory and pejorative
labels imposed by anti-gay sentiment. In an attempt to mitigate stigma
associated with the term homosexual, some gay and lesbian activists in the
late 1940s and early 1950s created the “homophile” or “loving the same”
movement (Carter, 2004). In direct opposition to the homophile attempt
at positive self-identification, Carter (2004) details terminology applied
4 S. R. NOTARO

to homosexuals that suggested either weakness (e.g., “fag” and “limp-

wrist”) or inappropriate expressions of gender (e.g., “drag queens” and
“transvestites” who favored women’s clothing and makeup; “scare queens
or flame queens” who adopted men’s clothing and makeup; and “butch
lesbians” who sometimes favored men’s clothing).
While the label of “gay” was associated with any persons who did not
self-identify as heterosexual from the 1930s to the 1960s, activists identi-
fying themselves as “gay” chose to link the term with their struggles for
civil rights and social services beginning in the 1960s (Los Angeles Conser-
vancy, 2016). The next change in terminology occurred in the 1970s when
women who identified as “gay” sought a distinctive way to signal solidarity
with heterosexual feminists by adopting the term “lesbian.” Early in the
1980s the LGB (lesbian, gay, bisexual) acronym overtook the term “gay”
as more of the homosexual community sought a way to better represent
their diversity of sexual identities (Los Angeles Conservancy, 2016).
In today’s lexicon, homosexuality is considered as one type of sexual ori-
entation or the patterns of emotional, romantic, and sexual attractions to
men, women, or both sexes (American Psychological Association, 2016).
According to evidence from numerous research studies conducted since the
middle of the twentieth century, sexual orientation can be conceptualized
on a continuum, from exclusive attraction to the other sex to exclusive
attraction to the same-sex (American Psychological Association, 2016).
Despite this view of a continuum of sexual orientation, it is commonly
discussed in terms of three categories: heterosexual (having emotional,
romantic, or sexual attractions to members of the other sex), homosexual
or gay/lesbian (having emotional, romantic, or sexual attractions to mem-
bers of one’s own sex), and bisexual (having emotional, romantic, or sexual
attractions to both men and women) (American Psychological Association,
2016). Sexual orientation may also include one’s identity based on attrac-
tions and behaviors as well as membership in a community who shares those
attractions and behaviors (American Psychological Association, 2016). It is
important to note that sexual orientation is distinct from biological sex (the
anatomical, physiological, and genetic characteristics associated with being
male or female), gender identity (the psychological sense of being male or
female), and social gender role (the cultural norms that define feminine
and masculine behavior) (American Psychological Association, 2016).
Various cultures and societies throughout the globe have described this
continuum of sexual attractions and behaviors, with some applying iden-
tity labels to describe persons exhibiting these attractions and behaviors
 1 OBJECTIVES AND SIGNIFICANCE OF THE VOLUME 5

and others choosing not to apply any labels (American Psychological Asso-
ciation, 2016). According to the Los Angeles Conservancy (2016), in the
United States the most frequent labels for this community are represented
by the initialism of LGBTQIA which includes “lesbians” (women attracted
to women); “gay” men (men attracted to men); “bisexual” persons (men
or women attracted to both sexes); “transgender” persons (individuals
whose personal identities and gender do not correspond to their birth sex);
“queer” persons (those who identify as queer or questioning their sexual
identity); “intersex” persons (those who do not fit the typical definitions
of exclusively male or exclusively female bodies); and “asexual” persons
(those who identify as someone who is not attracted to anyone and who
has no sexual orientation).
The changes in the LGBTQIA acronym signify the continual evolution
in the views and self-perceptions represented within the homosexual com-
munity. For example, transgender was added to the acronym to signal the
inclusion of those persons who did not identify as “cisgender” wherein
there exists a match or congruency between gender identity and gender
assigned at birth. Similarly, while the term “queer” was originally defined as
“strange,” queer scholars reclaimed the term to embrace sexual and gender
minorities who do not identify as heterosexual or cisgender (Los Angeles
Conservancy, 2016). In addition to asexual, the “A” also represents allies
who support the rights of LGBTQIA individuals, but who themselves may
not identify as part of this community. To maximize inclusivity, LGBTQ+
is used to represent the full spectrum and range of gender and sexuality.
What is clear in research focusing on LGBT communities is the fluidity of
sexual and gender identity as well as potential intersections of sexual ori-
entation and gender identity (Ranji, Beamesderfer, Kates, & Salganicoff,
2017). For example, an individual may identify sexually along a spectrum
that does not necessarily fit a specific category of lesbian, gay, or bisex-
ual (Ranji et al., 2017). A transgender individual may identify sexually as
heterosexual, lesbian, gay, bisexual, or along a spectrum of sexual iden-
tity (Ranji et al., 2017). Finally, it is important to understand how sexual
and gender identity intersect with race/ethnicity, social economic status,
and class, as these complexities then shape and influence the experiences of
LGBT individuals in positive and negative ways (Ranji et al., 2017).
One final note on sexual orientation and gender identity labels should
be mentioned. Some researchers take issue with the use of such labels for a
variety of reasons, including the differences in the ways that societies have
defined sexual orientation identities and to the changing meanings of words
such as “queer.” Research has shown that some societies embrace same-sex
6 S. R. NOTARO

acts while others ignore them, assigning no labels to their existence. These
nuances and variations necessitate a careful specification of terminology and
context in research concerning the LGBT community.

LGBT Population Estimates in the United States

and Globally
To provide context for the struggles and achievements of the LGBT com-
munity in a variety of arenas including political, health, economic, and
social, it is important to gain a sense of the size of this population both
within the United States and globally. The data estimating the size of
the LGBT population is complicated and flawed for several reasons. First,
data collected regarding sexual orientation may only inquire about some
of the elements (e.g., attraction, identity, behavior, and membership in
a community) that form this construct (American Psychological Associa-
tion, 2016). For example, some studies focus on same-sex sexual behaviors
and attractions while others inquire about identification as gay, lesbian,
bisexual, or transgender. This discrepancy is especially impactful to the
validity of LGBT population estimates given that many studies conducted
in the United States and internationally have suggested that fewer sub-
jects identify as lesbian, gay, bisexual, or transgender as compared to those
who report engaging in same-sex sexual behaviors and attractions (Gates,
2011). Additionally, data integrity is further compromised by nonrepresen-
tative studies with small sample sizes, differences in survey administration
(e.g., online versus face-to-face), issues of incidence versus prevalence of
sexual behaviors, and respondents’ concerns regarding confidentiality and
privacy (Gates, 2011).
Data from the nationally representative 2017 Gallup Daily Tracking Sur-
vey and the Gallup-Sharecare Well-Being Index Survey provide estimates
of the percentage of adults in the United States who self-identify as les-
bian, gay, bisexual, or transgender. The Gallup data are based on telephone
interviews conducted from January 2 to December 30, 2017 with a ran-
dom sample of 360,604 adults, aged 18 or older, living in all fifty states and
the District of Columbia. The Gallup estimates were derived from affirma-
tive answers to the question “Do you personally identify as lesbian, gay,
bisexual, or transgender?”.
Table 1.1 shows the total percentage of self-identifying LGBT persons,
as well as the percentages by sex, race, and birth cohort from 2012 when
Gallup began collecting this information to 2017.
 1 OBJECTIVES AND SIGNIFICANCE OF THE VOLUME 7

Table 1.1 Percent of U.S. adults identifying as LGBT by sex, race/ethnicity, and
birth cohort, 2012–2017

2012 2013 2014 2015 2016 2017

Total percent LGBT 3.5 3.6 3.7 3.9 4.1 4.5

Sex
Male 3.4 3.5 3.6 3.7 3.7 3.9
Female 3.5 3.6 3.9 4.1 4.4 5.1
Race/ethnicity
White, non-hispanic 3.2 3.3 3.4 3.5 3.6 4.0
Black, non-hispanic 4.4 4.0 4.6 4.5 4.6 5.0
Hispanic 4.3 4.7 4.9 5.1 5.4 6.1
Asian, non-hispanic 3.5 3.3 4.2 4.9 4.9 4.9
Birth cohort
Millennials (1980–1999) 5.8 6.0 6.3 6.7 7.3 8.2
Generation X (1965–1979) 3.2 3.3 3.4 3.3 3.2 3.5
Baby boomers (1946–1964) 2.7 2.7 2.7 2.6 2.4 2.4
Traditionalists (1913–1945) 1.8 1.8 1.9 1.5 1.4 1.4

Note Author created using information adapted from U.S. Adults Identifying as LGBT, 2012–2017; Per-
centage of Americans Identifying as LGBT, by Birth Cohort; Percentage of U.S. Adults Identifying as
LGBT by Gender and Birth Cohort, 2012–2017; Gallup Daily Tracking Survey and Gallup-Sharecare
Well-Being Index Survey; Release Date May 22, 2018; Retrieved from https://news.gallup.com/poll/
234863/estimate-lgbt-population-rises.aspx

Overall, the percentage of U.S. adults identifying as LGBT has increased

from 3.5% in 2012 to 4.5% in 2017 (Newport, 2018). According to Gallup,
the expanded total LGBT identification percentage is predominantly a
function of the increase in LGBT identification among the millennial birth
cohort (born between 1980 and 1999) whose percentage increased from
7.3 to 8.7 from 2016 to 2017, and from 5.8 since 2012. By compari-
son, the Generation X cohort (born between 1965 and 1979) increased its
LGBT identification 0.2% from 2016 to 2017, while there was no change
in identification from 2016 to 2017 for baby boomers (born between 1946
and 1964) or traditionalists (born before 1946).
In terms of gender, as shown in Table 1.1, estimates of LGBT identifi-
cation are higher among women, as demonstrated in the 2017 expansion
of this gender gap (Newport, 2018). The change in LGBT identification
for men has been minimal from 2012 to 2017, whereas the change in
LGBT identification for women increased from 3.5% in 2012 to 5.3% in
2017, with the largest increase occurring between 2016 and 2017 (New-
port, 2018). Estimates of LGBT identification among race/ethnicity reveal
8 S. R. NOTARO

increases since 2012, with the largest increases among Hispanics and Asians.
Overall, in 2017 the largest LGBT percentage was found among Hispanics
(6.1%) while the lowest percentage was found among Whites (4.0%). In
terms of income, since 2012, LGBT identification has consistently been
more common among those with lower incomes with 2017 data revealing
the largest ever income gap (6.2% for those earning less than $36,000 ver-
sus 3.9% for those earning $90,000 or more). No significant differences in
LGBT identification have emerged by educational attainment.

Global Estimates of the LGBT Population

Turning toward global estimates of the LGBT population presents addi-
tional data challenges. First concepts of “gay” that are common in Western
nations including the United States, are not as prevalent in non-Western
nations. For example, some men who have sex with men do not relate to
the term “gay” or “homosexual” and do not consider sex with other men
as sexual activity, instead conceptualizing sexual activity as sex with women.
Some men in Africa and Latin America for example, refer to themselves as
heterosexual although they may engage in sexual relationships with other
men (e.g., Anyamele, Lwabaayi, Nguyen, & Binswanger, 2005; Gonza-
lez, 2007), leading to challenges in gathering data concerning the identity
component of sexual orientation. In terms of Latin America, the 2010
Brazil national census identified 60,000 same-sex couples in a population
of 190.7 million (Institute of Brazil Geography and Statistics, 2010).
In Africa, men who have sex with men typically also have sex with
women, get married, and have children. Most African countries legally
prohibit sex between those of the same gender as such laws were intro-
duced during colonization (Anyamele et al., 2005). Stigma and discrimi-
nation against those who have sex with partners of the same-sex leads to a
great deal of underreporting of the behavioral aspect of sexual orientation
(Anyamele et al., 2005). Some limited survey data regarding the behavioral
aspects of sexual orientation in sub-Saharan Africa found that 18% of males
and 44% of females in a Sengalese survey reported a homosexual experience
(Brody & Potterat, 2003). In a 2002 survey of men who have sex with men
(MSM) in Dakaar, the vast majority reported having had sex with women,
13% were married and 25% had children (Niang et al., 2002).
Regarding western European countries, a review of recent available
nationally representative survey data sheds light on the identity aspect of
 1 OBJECTIVES AND SIGNIFICANCE OF THE VOLUME 9

Table 1.2 Percentages of self-identified LGB adults in selected Western European

countries

Country Survey year LGB percentage estimate (range for both sexes) (%)

Australia 2012–2013 1.3–2.2

Israel 2012 4.8–8.2
New Zealand 2013 1.1–3
Britain 2014 1.6–2.6

Note Author created using information adapted from Richters et al. (2014), Smith, Rissel, Richters, Grulich,
and De Visser (2003), Mor and Davidovich (2016), Dickson, van Roode, Cameron, and Paul (2013), and
Office for National Statistics (2014)

sexual orientation. Data from Australia, Israel, New Zealand, and Britain
is shown in Table 1.2.
The data are quite consistent across these selected countries, and are
overall lower than estimates obtained in the United States. It is impor-
tant to note that the available global data represents the entire population
as compared with recent Gallup data from the United States that pro-
vides additional analyses of LGBT identification by gender, birth cohort,
race/ethnicity, income, and educational attainment. These differences in
data richness make comparisons between LGBT identification in the United
States and internationally problematic.
While the aforementioned estimates of the current domestic and inter-
national LGBT and LGB population are instructive, it is important to note
that historically, estimates of this population have not been based on rep-
resentative data in the United States or abroad. In fact, the discrimina-
tion and bias faced by those identifying as LGBT was a significant and
often insurmountable barrier to accurately gauging the size of this popula-
tion; moreover, nationally representative samples in both the United States
and globally did not consistently include a standard set of sexual orienta-
tion items until relatively recently (e.g., Institute of Medicine, 2011; U.S.
DHHS, 2010).

Overview of the History of Homosexuality

As the origins, definition, and size of the LGBT population have been
presented, it is informative to also consider an abridged history of homo-
sexuality, as an exhaustive and complete delineation is beyond the scope of
10 S. R. NOTARO

this volume. The history of homosexuality reveals a shifting sense of soci-

ety’s view of same-sex relationships and same-sex behaviors that depend
upon historical and political context, place, and time period. Societal atti-
tudes have ranged from widespread engagement in same-sex relationships
to acceptance, to viewing such relationships as sinful, to formally declaring
same-sex sexual behaviors as illegal and even punishable by death. Over
time, the history of homosexuality demonstrates that innumerable individ-
uals have suffered from discrimination, bias, stigmatization, and violence
due to their sexual orientation.
The history of homosexuality reveals a shifting sense of society’s view of
same-sex relationships and same-sex behaviors that depend upon historical
and political context, place, and time period. Societal attitudes have ranged
from widespread engagement in same-sex relationships to acceptance, to
viewing such relationships as sinful, to formally declaring same-sex sexual
behaviors as illegal and even punishable by death. Over time, the history
of homosexuality demonstrates that innumerable individuals have suffered
from discrimination, bias, stigmatization, and violence due to their sexual
orientation. Before providing a brief, abridged version of homosexuality,
first it is important to discuss the origins and definition of homosexuality
as well as estimates of the size of the homosexual population within the
United States and globally.
LGBT history begins with ancient civilizations around the globe, as evi-
denced by art, literary, music, and other cultural and political references.
The historical record reveals centuries of discrimination, bias, and persecu-
tion of LGBT individuals and communities, leading to secrecy and shame
as well as to resiliency and hope. From ancient Greece and Rome come the
earliest documents referencing same-sex relationships. In Greece, it was
common practice for older free men to have a younger same-sex lover who
could be a slave or free, with such relationships sometimes described as a
valued method of mentoring and teaching (Skinner, 2014). Similarly to
ancient Greece, evidence exists of same-sex relationships in ancient Rome
between older free men and young males who were slaves or free; how-
ever, by the time of the reign of Emperor Justinian in 558 homosexuality
was declared illegal and an affront to God (Skinner, 2014). Shifting to
Asia reveals references in ancient Chinese literature to homosexuality since
approximately 600 BC with some scholars concluding that homosexual-
ity was common among emperors in several dynasties including the Han,
Song, Ming, and Qing (Dynes, 2015).
 1 OBJECTIVES AND SIGNIFICANCE OF THE VOLUME 11

Painting and literature from ancient Japan, Thailand, India,

Mesopotamia, and Melanesia refer to the practice of homosexuality, often
among royalty and within religious rituals, dating back over one thou-
sand years (Dynes, 2015). In ancient Israel, homosexuality was forbid-
den by God and punished severely as depicted in the story of Sodom and
Gomorrah, in which God destroyed the city in retribution for an attempted
homosexual rape (Dynes, 2015). Although the legal definition of sodomy
encompasses oral sex, anal sex, and bestiality (sex between humans and ani-
mals), over time and in practice the term sodomy has become associated
with homosexual sexual activity that was deemed immoral and unnatural
(Newton, 2009).
Turning toward the Middle East finds disputes among Egyptologists and
historians regarding the status and practice of homosexuality in ancient
Egypt as evidence of homosexuality during that era is considered vague
and speculative. In Middle Eastern Muslin cultures, since ancient times
homosexuality has been practiced but not sanctioned, with same-sex sex-
ual behaviors labeled as illegal and punishable by death in some coun-
tries such as Saudi Arabia, Iran, Qatar, United Arab Emirates, and Yemen
(Mooney, Knox, & Schacht, 2017). In the Americas prior to European
colonization, evidence suggests that individuals of homosexual and gen-
der variant identities were included in the social and ceremonial aspects of
their communities, perhaps occupying respected spiritual and social duties
as “Two Spirit” people in some Indigenous cultures (Leland, 2006). As
Spain colonized Native Americans throughout the Americas, the Spanish
colonizers attempted to end same-sex sexual behavior through severe and
violent penalties including public execution and burning (Leland, 2006).
Similarly to ancient Greece and Rome, the Renaissance era (1300–1600)
included the common practice of same-sex sexual behavior; however, the
Roman Catholic Church led the shift from homosexual activity being legal
throughout most of Europe to being punishable in violent and cruel means
such as removal of the testicles and penis, burning, stoning, mutilations,
and execution (Dynes, 2015). By 1533 King Henry VIII had declared all
sexual activity between males punishable by death (Dynes, 2015). Mov-
ing forward in time to the late eighteenth and nineteenth century Europe
reveals that the new field of psychology often cast homosexuals as criminals,
degenerates, and psychopaths (Dynes, 2015). In 1791, France decrimi-
nalized homosexual acts, including sodomy, between consenting adults,
becoming the first West European country to do so (Dynes, 2015). Dur-
ing the late nineteenth century and up until Adolph Hitler’s Third Reich or
12 S. R. NOTARO

rule of Germany, Berlin was known for its robust LGBT rights movement
as typified by Magnus Hirschfelf, a Jewish doctor, who in 1897 founded the
first gay rights organization which sought to legalize sodomy and socially
recognize homosexual and transgender men and women (Dynes, 2015).
During the 1920s Berlin was home to bars, clubs, newspapers, and demon-
strations that benefited gay men and lesbians (Dynes, 2015). As the Third
Reich ushered in Hitler’s brutality in 1933, evidence exists of the sentenc-
ing of nearly 50,000 men to concentration camps where many of these
vulnerable prisoners died from extreme persecution levied by German sol-
diers and other prisoners (Dynes, 2015).
In the United States, prior to the American Civil War, most of the coun-
try was rural, providing less visibility and opportunities to build commu-
nity among homosexual persons. Additionally, laws in the United States
regarding homosexuality were initially based on British laws which levied
the ultimate penalty of execution for the crime of sodomy. Later in the
eighteenth century in 1786, Pennsylvania became the first state to remove
the death penalty for the practice of sodomy, with all other states following
suit within a generation (Dynes, 2015). The repeal of the death penalty for
sodomy was accompanied by a shift in language from references to religious
damnation to that of abomination (Dynes, 2015). Further, beginning in
the twentieth century, some states began to legalize anal intercourse among
heterosexual persons while still codifying homosexual anal intercourse as
illegal (Dynes, 2015).
In the early twentieth century after World War I, society’s awareness and
acceptance of homosexual culture was growing, especially in cities such as
New York where large numbers of homosexual persons developed commu-
nities within the Greenwich Village and Harlem neighborhoods (Carter,
2004). By the mid-1930s, societal mores had shifted once more to conser-
vative Victorian values, which promoted “purity” campaigns, censorship
laws, the codification of homosexuality as a mental illness, and large-scale
arrests of suspected homosexuals (Dynes, 2015). During this period, LGBT
persons were viewed as diseased but curable with treatments such as cas-
tration, lobotomies, and electroshock therapy (Dynes, 2015).
The opportunity for nearly 250,000 women to serve in the armed forces
in World War II also opened the possibility for lesbians to meet partners,
some of whom identified with “masculine” appearances and “men’s” occu-
pations such as mechanics and engineers (Dynes, 2015). After the war,
 1 OBJECTIVES AND SIGNIFICANCE OF THE VOLUME 13

many women, including lesbians, chose to remain in nontraditional gen-

der roles, providing support for nascent social movements including the
women’s movement and the gay liberation movement (Dynes, 2015).

Homosexuality as a Social Movement 1950s and 1960s

In the post-war era, the United States was fueled by a fierce anti-
communism embodied by the Army-McCarthy hearings led by Senator
Joseph McCarthy in 1954. The hearings sought to expose supposed secu-
rity risks, including those persons labeled as communists, anarchists, and
homosexuals in the U.S. government, military, and other government-
funded institutions (Carter, 2004). These hearings led to the denial of and
dismissal from federal jobs and to the dishonorable military discharges of
thousands of U.S. citizens (Adam, 1987). Homosexual persons were given
the right to serve openly in the military a half-century later when then
President Barack Obama signed a directive in 2010 (Bumiller, 2011). Dur-
ing the 1950s and 1960s, the Federal Bureau of Investigation (FBI), local
police departments, and the U.S. postal service continued to persecute and
discriminate against homosexuals on several fronts including maintaining
lists and postal addresses of “known” homosexuals (Edsall, 2003).
New York City during the 1950s and 1960s offers a prime example of
the discrimination that local police levied at the homosexual community.
“Gay” bars known to be frequented by homosexuals were often raided and
closed while local newspapers printed the names of the customers (Bausum,
2015). Similarly, undercover transit authority police attempted to entrap
and arrest homosexuals for soliciting sex in public spaces such as beaches
and parks (e.g., Adam, 1987; Carter, 2004). In 1964, Robert Wagner Jr.,
the mayor of New York City, sought a “tough on crime” reputation by
revoking the liquor licenses and closing all of the gay bars as the city geared
up for the 1964 World’s Fair and ensuing national and global publicity
(Bausum, 2015).
The election of Mayor John Lindsay in 1965 ushered in a less restrictive
attitude toward and more positive treatment of the homosexual commu-
nity and pioneering homophile activist groups such as the New York City
Mattachine Society (Bausum, 2015). While the original goals of the Matta-
chine Society and a similar organization for lesbians, the Daughters of Bili-
tis, focused on educating and unifying homosexuals and assisting with legal
issues, that approach was considered radical at the time and was replaced by
14 S. R. NOTARO

efforts to convince heterosexuals of their “normality,” similarity to hetero-

sexuals, and respectability through silent protests and educational lectures
(Carter, 2004). In 1966 bowing to pressure emanating from protests such
as a sit-in or “sip-in” at Julius’ Bar in Greenwich Village led by Dick Leitsch
and Craig Rodgwell, New York City Mattachine Society’s president and
vice president respectively, Mayor Lindsay ended the sanctioned practice
of police entrapment at gay bars and soon thereafter ordered the removal
of questions regarding homosexuality on employment applications in New
York City (Bausum, 2015). Although police and fire departments refused
to enact the new policy, the changes in law, the increased acceptance of
freedom of sexual expression, and continued activism by the Mattachine
Society paved the way for a more radical and empowering social movement
ignited by the 1969 Stonewall Inn riots.

The Stonewall Inn: Respite and Refuge

In 1969 both licensed and unlicensed “gay” bars operated in Greenwich
Village, a neighborhood of Manhattan, New York City (Bausum, 2015).
One of the most popular unlicensed gay bars was the Stonewall Inn which
began operating in 1967 in Greenwich Village at the address of 51 and 53
Christopher Street (Bausum, 2015).

For me, there was no bar like the Stonewall, because the Stonewall was like
the watering hole on the savannah. You know, it’s just, everybody was there.
We were all there. (M. Boyce, personal interview, Bausum, 2015, Stonewall:
Breaking Out in the Fight for Gay Rights, p. 23)

Although police entrapment of gay patrons at licensed bars was no longer

formally sanctioned, the practice continued this practice into the late 1960s,
creating a climate wherein organized crime operated unlicensed gay bars
such as the Stonewall Inn (Bausum, 2015).
Carter (2004) describes several aspects, features, and historical realities
which led to the immense popularity of the Stonewall Inn. First, same-
sex couples were allowed to dance together, despite a local law prohibiting
same-sex dancing and “masquerading” or wearing clothing identified as the
opposite sex’s clothes (Carter, 2004). Second, the bar’s two dance floors
with jukeboxes and flashing lights added to the ambience while also serv-
ing as a warning sign of impending and routine police raids that resulted in
arrests of the patrons and the collection of briberies from the bar’s owners
 1 OBJECTIVES AND SIGNIFICANCE OF THE VOLUME 15

(Carter, 2004). The Stonewall was unique among other gay bars in that it
provided a place for customers with intersectional identities along a spec-
trum of sexuality, gender, race, and ethnicity to find respite, friends, and
lovers (Carter, 2004). Carter (2004)’s interviews with some customers of
the Stonewall Inn also revealed bitterness that routine societal, police, and
local governmental discrimination and bias left them with few to no other
options besides the Stonewall Inn.
In fact the customers of the Stonewall Inn sought out refuge in this space
despite its physical dangers and indignities (e.g., no fire exits, unsanitary
conditions, exorbitant liquor prices, and routine police raids) in exchange
for a space to find common ground (Carter, 2004). Indeed, in 1969 in New
York City, to avoid ridicule and possible arrest, it was rare for homosexuals
to openly express their sexuality in public or show any signs of affection for
same-sex partners (Bausum, 2015).

The closet door was so tight back then. (D. Garvin, personal interview,
Carter, 2004, Stonewall: The Riots That Sparked the Gay Revolution, p. 49)

The Riots Begin

Bausum (2015) and Carter (2004) describe the details of the Stonewall
Inn riots and their significance in igniting the modern-day gay rights move-
ment. The riots occurred over a period of six days, beginning at about 1 a.m.
on Friday, June 27, 1969 in response to a police raid by the Public Morals
Squad. In contrast to prior raids which usually resulted in arrests followed
by the quick reopening of the bar, this raid sought to resolve an alleged
mafia extortion scheme involving some Stonewall Inn patrons by perma-
nently closing the Stonewall Inn. Unlike prior raids in which patrons coop-
erated with police who checked their identification and the sex of customers
dressed as women, on the night of the riots, men and women customers
refused to follow the police’s orders within the bar and lingered outside of
the bar without dispersing. This atypical resistance resulted in the police’s
attempts to transport nearly 200 customers to the police station. As patrons
exited the bar but remained outside, a fight ensued between the police and
one of the lesbian patrons of the Stonewall Inn. The police’s attack of the
woman with a club spurred the anger and frustration of local inhabitants
of Greenwich Village, including many members of the LGBT community
16 S. R. NOTARO

who routinely suffered from discrimination, bias, and harassment associ-

ated with their intersectional identities (Carter, 2004). The thousands of
people in the crowd engaged with the police by lighting trash on fire and
throwing debris, rocks, and bottles as “the tension of the night and count-
less previous nights and hundreds of lifetimes of abuse burst the dams of
person after person” (Bausum, 2015).
The Tactical Patrol Force (TPF), whose purpose was to control riots,
failed to disperse the crowds who used their knowledge of the area’s many
one-way streets to taunt and confront the police in non-traditional and
unexpected ways including forming kick lines and singing (Carter, 2004).
The riots continued for several additional days, as bystanders and even
tourists joined in the battle against the police. The publicity surrounding
the riots was mostly due to the strategic-thinking of Craig Rodwell, one of
the leaders of the Mattachine Society New York, who successfully garnered
coverage in three local newspapers (Carter, 2004). Ironically, one of the
local papers, The Village Voice, which is known today for its support of
gay civil rights and the annual Gay Pride parade, demonstrated bias and
derogatory coverage of the riots as evidenced by the outlet’s use of the
terms “the Sunday fag follies” and “Limp wrists” (Carter, 2004).
The Stonewall Inn riots had both immediate and long term conse-
quences. Clendinen and Nagourney (1999) summarize the sense of trans-
formation resulting from the resistance:

Before the riots, homosexuals were “a secret legion of people, known but
discounted, ignored, laughed at or despised…But that night, for the first
time, the usual acquiescence turned into violent resistance…From that night
the lives of millions of gay men and lesbians, and the attitude toward them of
the larger culture in which they lived, began to change rapidly. People began
to appear in public as homosexuals, demanding respect.” (p. 12)

The intense reaction to years of police harassment launched a sustained

and long-lasting movement for change, dignity, and equal treatment under
the law. At the same time, it is important to note that some of the more
“traditional” members of the gay community expressed dismay that drag
queens singing and dancing in the streets undermined their efforts of gain-
ing heterosexual’s acceptance into society (Carter, 2004). The momentum
from the Stonewall riots gave rise to new gay rights organizations such as
the Gay Liberation Front or GLF (Carter, 2004). Although the GLF, the
first group to include “gay” in its name, withstood the strain of conflicting
 1 OBJECTIVES AND SIGNIFICANCE OF THE VOLUME 17

strategic goals and principles for only a few months, activists soon formed
the Gay Activists Alliance (GAA) to focus exclusively on gay civil rights.
The GAA became known for their masterful use of the “zap,” a public,
political, and theatrical technique used to advocate for gay rights (Carter,
2004). One interesting aftershock of the Stonewall riots was the closing of
the Stonewall Inn, attributed to the damage to the building as well as to
boycotts against its mafia-ownership (Carter, 2004).
The Stonewall Inn riots were first commemorated on June 28, 1970 by
Craig Rodwell and other gay activists as the first Christopher Street Lib-
eration Day, which were attended by nearly 5000 participants marching
peacefully up Sixth Avenue in New York City (Carter, 2004). The national
publicity and interest in this initial march grew over time and eventually
became known as Gay Pride events throughout the United States and coun-
tries across the globe (Carter, 2004). The rainbow gay pride flag, the uni-
versal and global symbol of the struggle for gay civil rights created in 1978
by Gilbert Baker, was first displayed at a march protesting the assassination
of Harvey Milk, a prominent gay rights activist and politician in San Fran-
cisco (Wickman, 2013). Ironically, Baker created the flag at the request of
Milk, who had sought an enduring symbol for gay pride (Bausum, 2015).
Milk had a prescient understanding that his open fight for gay rights could
lead to his untimely death, as he expressed in 1977 taped interview that he
requested be played in the event of his assassination:

If a bullet should enter my brain, let that bullet destroy every closet door.
(quoted in Shilts, 1982, The Mayor of Castro Street: The Life and Times of
Harvey Milk)

The 1970s ushered in both unity and calls for increased acceptance of
the LGBT community as well as disagreements and struggles segmented by
race, class, and gender (Carter, 2004). Rifts between lesbians and gay men
surfaced as lesbians pointed out multiple areas of misalignment, includ-
ing the patriarchal attitudes among some gay men as well as the focus on
issues of police entrapment that did not resonate within the lesbian commu-
nity (Carter, 2004). The societal acceptance of homosexuality once again
shifted by the late 1970s as renewed religious conservatism led to new anti-
gay sentiment marked by discrimination, harassment, and bias toward the
LGBT community (Bausum, 2015).
The 1980s and 1990s gave rise to a proliferation and growth of thou-
sands of gay rights activist groups in both the United States and globally
18 S. R. NOTARO

(Carter, 2004). Many of these groups still pay homage to the Stonewall Inn
riots, as is the case with Stonewall Equity Limited or Stonewall, a British
LGBT rights charity founded in 1989 and named for the Stonewall Inn
riots. This group has paid tribute to British lesbian, gay, and bisexual peo-
ple as well as allies since 2006 (“Stonewall: Acceptance without exception”,
2015).
During the presidency of Barack Obama, the LGBT community found
expanded recognition and acceptance as evidenced by President Obama’s
recognition of the contributions of the transgender community in the fight
for LGBT rights. In a 2009 proclamation, President Obama acknowl-
edged the importance of LGBT Pride Month as a way of honoring the
Stonewall legacy and confirmed his support for LGBT civil and political
rights (Obama, 2009). President Obama’s actions spoke volumes for his
support of the transgender community in 2010 when he appointed Amanda
Simpson, the first openly transgender person to serve in a U.S. government
post, as the Senior Technical Advisor to the Commerce Department (Tap-
per, 2010). Simpson’s gratitude and hope for sustained progress was cap-
tured in her quote at the time of her appointment, as she said that “as one
of the first transgender presidential appointees to the federal government,
I hope that I will soon be one of hundreds, and that this appointment
opens future opportunities for many others” (Tapper, 2010). President
Obama continued to demonstrate unprecedented executive branch sup-
port for the LGBT community by creating the first American memorial to
honor LGBT civil rights. According to President Obama, the Stonewall
National Monument, which occupies the same space that was once home
to the Stonewall Inn, “changed the nation’s history. The quest for LGBT
equality after Stonewall evolved from protests and small gatherings into a
nationwide movement” (Obama, 2016). President Obama’s support for
diversity and inclusion were apparent as he addressed the crowd gathered
to celebrate the new monument:

I’m designating the Stonewall National Monument as the newest addition to

America’s National Park System. Stonewall will be our first national monu-
ment to tell the story of the struggle for LGBT rights. I believe our national
parks should reflect the full story of our country, the richness and diversity
and uniquely American spirit that has always defined us. That we are stronger
together. That out of many, we are one. (Obama, 2016, para. 3)
 1 OBJECTIVES AND SIGNIFICANCE OF THE VOLUME 19

Structure of the Volume

This chapter provided historical context and perspective for the remain-
der of this volume. After presenting the origins, definition of homosex-
uality, and estimates of the LGBT population, the chapter provided an
abridged history of homosexuality which demonstrated that homosexuals
throughout the globe have faced continuous and severe prejudice, discrim-
ination, and violence from ancient times until today. The chapter described
the Stonewall Inn riots as the catalyst for the modern-day gay liberation
movement. The remainder of the volume argues that the failure to extend
equitable civil and political rights and equal protection under the law to
LGBT individuals as well as efforts to reverse gains in such rights has and
will continue to be associated with stress, bias, stigma and discrimination
experienced within this community, both in the United States and globally.
In turn, this sustained stress, bias and stigma are consistently and strongly
associated with a host of LGBT civil, political, and health inequalities.
As discrimination against lesbian, gay, and bisexual people in a vari-
ety of arenas remains widespread, Chapter 2 focusses on the legal status
of homosexuality regarding same-sex sexual behavior, same-sex marriage
and adoption, anti-discrimination laws and legal protections in military ser-
vice and refugee rights, and remedies for hate crimes. Chapter 3 discusses
the impacts on the health of the LGBT community emanating from their
struggles to access culturally competent health care and adequate health
insurance.
Chapter 4, which focuses on the history, transmission, risk-factors, pre-
vention and intervention of HIV/AIDS, provides context for the devas-
tation and loss of life among the LGBT community that in many ways
resulted from discrimination, stigmatization, and bias. Chapter 5 discusses
substance use and abuse in the LGBT population with a specific focus on
alcohol, cigarettes, and prescription drugs. Mental health is featured in
Chapter 6, with attention given to psychological distress, suicide, home-
lessness, reparative therapies, and resiliency and protective factors. Given
numerous surveys and reports indicating that physical abuse is still com-
monly experienced among lesbian, gay, and bisexual people, Chapter 7 dis-
cusses violence within the LGBT community in several forms and spaces
including among incarcerated individuals and victims of human trafficking.
20 S. R. NOTARO

Each chapter will also discuss the variability within and between LGBT
individuals and communities that include both protective factors and sup-
ports that may form important components of intervention and preven-
tion strategies aimed at reducing health disparities among the LGBT com-
munity domestically and throughout the globe. While the volume is not
exhaustive in its scope, it provides a cogent examination of the negative
and sometimes dire consequences stemming from deliberate, consistent
and sustained unfair and unequal treatment based solely on sexual ori-
entation. The conclusion of the volume provides a framework for future
reflection as challenges to the civil rights, health, and well-being of the
LGBT population continue to mount.

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founder, hosts the tenth and final Stonewall Awards. Retrieved from http://www.
stonewall.org.uk/news/ian-mckellen-host-stonewalls-final-awards-ceremony.
Tapper, J. (2010, January 4). President Obama names transgender appointee to com-
merce department [Web log post]. Retrieved from http://blogs.abcnews.com/
politicalpunch/2010/01/president-obama-names-transgender-appointee-to-
commerce-department.html.
U.S. Department of Health and Human Services, Office of Disease Prevention and
Health Promotion. (2010). Healthy people 2020. Washington, DC. Retrieved
from http://www.healthypeople.gov/2020/default.aspx.
Walker, A. (1983). In search of our mothers’ gardens: Womanist prose. San Diego,
CA: Harcourt.
Wickman, F. (2013, June 26). A rainbow marriage: How did the rainbow become
a symbol of gay pride? [Web log post]. Retrieved from http://www.slate.
com/articles/life/explainer/2012/06/rainbows_and_gay_pride_how_the_
rainbow_became_a_symbol_of_the_glbt_movement_.h.
 CHAPTER 2

Legal Status and Challenges

to Homosexuality

Chapter 1 of this volume provided an abridged account of the history

of homosexuality from ancient times until present day, highlighting the
constant theme of discrimination, bias, and persecution levied upon the
LGBT community. This chapter will first provide a brief overview of the
perception of and consequences of same-sex sexual behavior while also
discussing recent legal gains in marriage and adoption rights for same-sex
couples.

Once I knew this kid who very bravely and bossily came out of the closet when
she was only fourteen years old. She told me then that we can’t choose who
we love. We just love the people we love, no matter what anyone else might
want for us. Wasn’t that you? (from Madeline George, 2012, The Difference
Between Me and You)

Next, this chapter will focus on selected additional national and interna-
tional legal challenges faced by the LGBT community including discrim-
ination and legal challenges in employment, housing, education, public
accommodations, military service, refugee protections, and hate crimes.

© The Author(s) 2020 23

S. R. Notaro, Marginality and Global LGBT Communities,
Neighborhoods, Communities, and Urban Marginality,
https://doi.org/10.1007/978-3-030-22415-8_2
24 S. R. NOTARO

Same-Sex Sexual Behaviors in the United States

and Globally
Chapter 1’s historical review of homosexuality included numerous refer-
ences to same-sex sexual behavior, often codified as sodomy. While the term
sodomy originates from the homosexual activities of men in the story of
the city of Sodom and Gomorrah in the Bible, over time, sodomy became
associated with oral and anal sex among homosexuals that was deemed
unnatural and perverse by courts of law and societies across the globe (The
Free Dictionary, 2016). Sodomy was classified as a felony throughout the
United States with the exception of Illinois until the 2003 U.S. Supreme
Court decision, Lawrence v. Texas , in which the Court ruled that sexual
activities between two consenting adults were legal.
Next, the timeline of the changes in the legal status of homosexual-
ity throughout the globe will be summarized. For example, in France in
1791 during the French Revolution, sodomy was decriminalized along
with other “victimless-crimes” including heresy, witchcraft, and blasphemy
(Dynes, 2015). Similarly, during the nineteenth century, homosexual acts
were decriminalized throughout most of the countries in Europe ruled by
France, Brazil, and the Ottoman Empire (Dynes, 2015). During the early
twentieth century after Lenin and Trotsky’s Bolshevik Revolution, Rus-
sia decriminalized homosexuality, only to have it criminalized again under
Stalin’s rein in the 1920s (Dynes, 2015). While Britain had criminalized
homosexual activity in 1885, a series of arrests, prosecutions, and sensa-
tional trials of alleged homosexuals immediately after World War II as well
as the results of a report from a governmental committee chaired by Sir
John Wolfenden led to the 1957 legalization of consensual homosexual
behavior in the United Kingdom (Dynes, 2015).
As of 2018, sodomy has been decriminalized throughout Europe, North
America, South America, Israel, Japan, Kazakhstan, the Philippines, and
Thailand. Despite this trend, some nations continue to criminalize homo-
sexual activity including parts of the Caribbean (e.g., Antigua and Barbuda,
Barbados, Dominica, Grenada, Guyana, Jamaica, Saint Kitts and Nevis,
Saint Lucia, and Saint Vincent and the Grenadines). Life imprisonment
is imposed for homosexual activity in several African (e.g., Sierra Leone,
Tanzania, Uganda) and Asian (e.g., Bangladesh, the Maldives, Myanmar)
countries. The ultimate punishment of death is meted out in the African
countries of Mauritania, Sudan, Nigeria, Somalia, and the Asian countries of
 2 LEGAL STATUS AND CHALLENGES TO HOMOSEXUALITY 25

Afghanistan, Pakistan, Qatar, Brunei, Iran, Iraq, Saudi Arabia, the United
Arab Emirates, and Yemen.
The history of China’s treatment of same-sex sexual behaviors is worthy
of examination, given that China and several other Asian countries (e.g.,
Taiwan, North Korea, South Korea, Vietman) have never had Western-
style sodomy laws (Dynes, 2015). As discussed in Chapter 1 of this volume,
homosexuality and same-sex sexual behaviors have been documented in art,
culture, and music in China since ancient times; however, in China same-
sex sexual activity was illegal until 1997 and classified as a mental illness
until 2001. Currently, reports of overt crimes against homosexuals is rare;
however, the government does not promote gay issues in China, choosing
instead to support a policy of ambivalence and in some cases censorship
of same-sex sexual behaviors as portrayed in entertainment outlets such
as film, television, and the internet. On December 31, 2015, the China
Television Drama Production Industry Association officially banned the
depiction of “abnormal sexual relationships and behaviors, such as incest,
same-sex relationships, sexual perversion, sexual assault, sexual abuse, sex-
ual violence, and so on” (Lu & Hunt, 2016).

Same-Sex Marriage and Adoption in the United

States and Globally
Related to the acceptance or rejection of same-sex sexual behaviors, is the
topic of same-sex marriage and the legal rights associated with marriage.
In 2015, marriage between same-sex couples was declared legal in every
state as a result of the United States Supreme Court decision in Obergefell
v. Hodges . The Supreme Court ruled in a 5–4 decision that the right to
marry is guaranteed to same-sex couples by both the Due Process Clause
and the Equal Protection Clause of the Fourteenth Amendment to the
United States Constitution. Since March 2016, same-sex married couples
may legally adopt children nationwide (Barbash, 2016) as a result of a rul-
ing by Mississippi U.S. District Court judge Daniel P. Jordan III. In the
case, Campaign for Southern Equality v. Mississippi Department of Human
Services (2016), Judge Jordan ruled that Mississippi’s state ban on same-
sex adoption was unconstitutional, violating the Equal Protection Clause
of the United States constitution and denying the full benefits of marriage,
including adoption, to same-sex couples. As Mississippi’s law prohibiting
same-sex adoption was the last such state ban in the United States, Judge
26 S. R. NOTARO

Jordan’s ruling effectively cleared the way for same-sex adoption through-
out the United States (Barbash, 2016).
In terms of the global landscape for same-sex marriage, Fig. 2.1 demon-
strates the range of the legal status and recognition of unions between
same-sex individuals in countries worldwide. Some countries prohibit all
same-sex unions, while others recognize limited aspects of same-sex unions
including partnership certificates, residency rights, and civil unions. As of
2018, 25 countries, all of which are classified as developed or develop-
ing democracies, recognized same-sex marriage and all of the legal rights
associated with marriage.
As is the case with homosexuality broadly, China’s prohibition against
same-sex marriage and adoption demonstrates resistance in granting full
civil and legal rights to the LGBT community. In fact, several attempts by
Chinese activists in 2000, 2004, 2006, and 2007 failed to gain the required
support for a bill in the National People’s Congress that would have legal-
ized same-sex marriage. Today in China the tradition of family obligations
to carry on the family line continues to exert pressure on homosexuals and
gay men in particular to hide their sexual orientation and instead to marry
an opposite-sex partner and have a child.

Fig. 2.1 World laws pertaining to homosexual relationships and expression (Cour-
tesy of Southern, Wikimedia Commons at https://commons.wikimedia.org/wiki/
File:World_homosexuality_laws.png)
 2 LEGAL STATUS AND CHALLENGES TO HOMOSEXUALITY 27

Fig. 2.2 Sexual orientation employment anti-discrimination map (Courtesy of

Adrian Frith, Wikimedia Commons at https://commons.wikimedia.org/wiki/
File:Sexual_orientation_employment_anti-discrimination_map.svg)

The Legal Status of Anti-discrimination Laws

and Remedies
Discrimination and bias levied against the LGBT community in the United
States and globally has a long history, as chronicled within the realms of
housing, employment, higher education, public accommodations, military
service, refugee asylum, and hate crimes. In 2011, the United Nations
passed its first resolution aimed at bringing awareness to LGBT rights while
laying the foundation for later reports documenting violations of these
rights. Across the globe, very few countries prohibit discrimination against
homosexuals. For example, Fig. 2.2 demonstrates the lack of laws through-
out the world that protect homosexuals from employment discrimination.

Housing and Employment Discrimination

in the United States
In terms of housing discrimination, the federal Fair Housing Act protects
renters and home buyers in both publicly assisted and privately owned hous-
ing from discrimination based on race, color, religion, sex, national origin,
28 S. R. NOTARO

disability, and familial status; however, no federal laws ban housing dis-
crimination on the basis of sexual orientation or gender identity (“Ending
Housing Discrimination,” 2016). Despite this lack of federal protection,
many state, city, and county laws ban discrimination based on sexual ori-
entation and gender identity (“Ending Housing Discrimination,” 2016).
Since 2012, the U.S. Department of Housing and Urban Development’s
Office of Fair Housing and Equal Opportunity has prohibited discrimina-
tion based on sexual orientation and gender identity in federally assisted
housing programs (“Ending Housing Discrimination,” 2016).
Regarding employment, the U.S. Equal Employment Opportunity
Commission enforces bans on employment discrimination based on race,
color, sex, religion, national origin, age, disability, and genetic information
in federal, private, state, and local employment; however, no federal law
exists to address employment discrimination based on sexual orientation
or gender identity (“Facts About Discrimination,” 2016). Protections are
extended, however, at the state and local levels, with many cities, counties,
and states plus Washington, D.C. and Puerto Rico banning discrimina-
tion based on sexual orientation and gender identity or expression (“Em-
ployment Law Guide,” 2009). Supporting the anti-discrimination LGBT
employment laws at the state and local levels are two rulings from the U.S.
Equal Employment Opportunity Commission. In 2012, the U.S. Equal
Employment Opportunity Commission issued a ruling that Title VII of
the Civil Rights Act of 1964 does not allow employment discrimination
based on gender identity because it is a form of sex discrimination (“Facts
About Discrimination,” 2016).
Higher education is one area of employment where gains in protection
for the LGBT community have been realized over time; however, there
remain significant challenges and need for improvement in the daily lives
of LGBT faculty, students, and staff on college campuses across the United
States (Rankin, Weber, Blumenfeld, & Frazer, 2010). Recent estimates
(Trammell, 2014) suggest that there are nearly 1 million self-identified
LGBT students and more than 160,000 faculty and staff members at univer-
sities across the United States. The history of harassment and discrimination
against the LGBT community on U.S. college campuses is unfortunately
shameful in many respects (Trammell, 2014). In the 1920s Harvard Uni-
versity supported a secret committee which exposed and then expelled gay
faculty members, staff, and students. In the 1950s and 1960s some univer-
sities in Florida utilized the “Johns Committee” state legislative committee
investigations to harass gay and lesbian faculty members and students.
 2 LEGAL STATUS AND CHALLENGES TO HOMOSEXUALITY 29

Fortunately, the circumstances for LGBT individuals on college cam-

puses across the United States have improved over time (Trammell, 2014),
but there remain difficult and painful challenges that require the com-
mitment and focus of the leaders of college campuses. The 2010 Cam-
pus Pride’s State of Higher Education for LGBT People report is a national
research study which documents the experiences or “campus climate” of 5,
149 undergraduate and graduate students, faculty members, staff members,
and administrators who identify as LGBTQQ (lesbian, gay, bisexual, trans-
gender, questioning, and queer). This 2010 report builds on and replicates
the findings of prior campus climate surveys (e.g., Dolan, 1998; Rankin,
2003) which documented the self-reported “chilly” or unwelcoming cli-
mate on many college campuses throughout the United States.
Specifically, the 2010 report found that LGBTQQ respondents (23%)
reported significantly greater harassment and discrimination than hetero-
sexual respondents (12%) and were more than seven times more likely (83%
versus 12%) to indicate that the harassment was based on sexual identity.
Some of the discriminatory and harassing acts included derogatory remarks,
being ignored deliberately or excluded, stared at, and singled out as a res-
ident authority due to their identity. LGBTQQ respondents (70%) were
significantly less likely than heterosexual respondents (78%) to feel com-
fortable or very comfortable with the overall campus climate, their depart-
ment or work unit climate, and classroom climate. Among the LBGTQQ
respondents, faculty (60%) were significantly less likely than their student
(70%) and staff counterparts (73%) to feel very comfortable or comfort-
able with the overall campus climate and with their department/work unit
climate. Finally, LGBTQQ respondents more often seriously considered
leaving their institution and feared for their physical safety due to their sex-
ual identity, and avoided disclosure of sexual identity due to intimidation
and fear of negative consequences.
The report concludes with suggested best practices designed to improve
the climates on college campuses for those in the LGBTQQ community.
Highlights include developing inclusive policies that explicitly welcome
LGBTQQ faculty, staff, and students, integrating the concerns of all mem-
bers of the community through inclusive wording in campus documents,
recognizing the contributions of LGBTQQ scholars in all disciplines, and
supporting the study of gender and sexuality-specific topics.
30 S. R. NOTARO

Public Accommodations
In contrast to the gains described above, President Donald Trump’s admin-
istration has actively sought to reverse and weaken the civil and political
rights of LGBT individuals, with the rights of transgender persons most
impacted. In May of 2016, the Obama administration-led Justice and Edu-
cation departments issued a “Dear Colleague” letter to k-12 school districts
to provide guidance in the interpretation of Title IX (Kamenetz & Turner,
2017). The letter advised school districts that Title IX, which prohibits
sex discrimination in education, also protects the rights of transgender stu-
dents. Compliance with Title IX required school districts to ensure that
transgender students were not treated differently from students of the same
gender identity (Kamenetz & Turner, 2017). Controversial outcomes of
this guidance included ensuring that transgender students were allowed to
use the bathroom of their choice that corresponded to their gender iden-
tity and allowing all students to attend prom and graduation in clothing of
their choice (Kamenetz & Turner, 2017).
In February of 2017, the Trump administration rescinded the Obama
administration’s guidance providing states with more flexibility in inter-
preting Title IX and whether and how they accommodate transgender stu-
dents (Kamenetz & Turner, 2017). On the same day that the guidance was
rescinded, the American Academy of Pediatrics (ACP) issued a statement
disagreeing with the Trump administration’s interpretation (Stein, 2017).
The ACP argued that because transgender children’s emotional and physi-
cal health is already at risk in the school-setting, the Trump administration’s
guidance to no longer allow them to use restrooms corresponding to their
gender identity might subject these children to more harm, stigmatization,
and exclusion (Stein, 2017).
Trump’s revised guidance regarding the interpretation of Title IX and
the protection for gender identity has specific consequences for one partic-
ular transgender high school student, Gavin Grimm (Kamenetz & Turner,
2017). In 2015, before the start of his sophomore year, Grimm and his
mother notified Gloucester High School in eastern Virginia that he was
transgender, having legally changed his name to Gavin, and should be
referred to with male pronouns (ACLU of Virginia, 2017). Gavin Grimm
had been diagnosed with severe gender dysphoria, in which individuals
experience a conflict between their physical or assigned gender and their
gender identity. This conflict may then be expressed in several ways includ-
ing the desire to wear gender-identified clothing, to use appropriate gender
 2 LEGAL STATUS AND CHALLENGES TO HOMOSEXUALITY 31

pronouns and bathrooms, and to medically transition with sex-affirmation

surgery and/or hormone treatment (Parekh, 2016).
When Grimm sought to use the boy’s bathroom at school, he was ini-
tially allowed to use the boys’ bathroom until parents and others com-
plained, resulting in the school board enacting a new policy requiring
bathrooms to be used by students according to their “corresponding bio-
logical gender” (ACLU of Virginia, 2017). To protest this policy and
the requirement that Gavin and other transgender students use unisex
bathrooms, Gavin obtained representation by the American Civil Liber-
ties Union (ACLU) and filed a lawsuit (G.G. v. Gloucester County School
Board) in June 2015 against the Gloucester County School Board (ACLU
of Virginia, 2017). The lawsuit was based on the ACLU’s assertion that
the Gloucester School Board’s policy violates Title IX’s prohibition of sex
discrimination in public schools that receive federal funds (ACLU of Vir-
ginia, 2017). In September 2015 the district court denied Gavin’s request
for a preliminary injunction that would allow him to use the boys’ restroom
pending a final decision on the case (ACLU of Virginia, 2017). That deci-
sion was appealed before the U.S. Court of Appeals for the Fourth Cir-
cuit. The Fourth Circuit Court of Appeals overturned the lower court’s
decision in August 2016 based on the Obama administration’s guidance
on Title IX that has now been rescinded (ACLU of Virginia, 2017). The
Fourth Circuit’s decision would have allowed Gavin to use the boys’ bath-
room pending a final decision on the case; however, the Gloucester County
School Board responded by requesting a Writ of Certiorari to the Supreme
Court of the United States to review the Fourth Circuit’s decision (ACLU
of Virginia, 2017).
In March 2017, the Supreme Court refused to hear the case and sent it
back to the Fourth Circuit Court of Appeals citing Trumps’ rescinding of
the Obama era Title IX guidance (ACLU of Virginia, 2017). Grimm’s case
had been stalled in the appeal process as the focus was on the preliminary
injunction and whether the case is moot given that Grimm has since grad-
uated from high school (Marimow, 2017). The ACLU continues to argue
that Grimm’s intention to attend future school events provides enough of
a connection to the school to allow the court to continue to consider the
case (Marimow, 2017). The school board refutes the ACLU’s argument
claiming that their bathroom policy does not necessarily apply to alumni
of the school (Marimow, 2017). More broadly, the legal limbo and uncer-
tainty of Grimm’s case means that states and school districts may determine
whether or not Title IX and its protections regarding “sex” should include
32 S. R. NOTARO

gender identity and whether or not they provide equal access to facilities
on the basis of gender identity (Kamenetz & Turner, 2017). The lack of
unresolved constitutional issues may result in an increase in persons on
both sides of the issue suing school districts (Brown & Balingit, 2017). As
of March 2017, 14 states and the District of Columbia explicitly provided
protections for transgender students (Brown & Balingit, 2017).
North Carolina is one prominent example of a state with a turbulent his-
tory regarding the LGBT community as it holds the distinction of being
the only state in the U.S. to prohibit transgender people’s right to use
the bathroom of their choice (Hanna, Park, & McLaughlin, 2017). In
2016, the state of North Carolina passed House Bill 2 (HB2), commonly
known as the “bathroom bill” (Hanna et al., 2017) which required peo-
ple to use bathrooms and locker rooms at government-funded facilities
that corresponded to the sex on their birth certificate, if the rooms are
multi-occupancy (Hanna et al., 2017). HB2 was controversial from the
outset, generating more than a year of protests from internal and external
constituencies including LGTBQ advocacy groups, businesses and organi-
zations (e.g., the NCAA, the ACC, and the NBA) who left the state or
refused to hold major conferences and events there (Hanna et al., 2017).
In March of 2017, the state legislature of North Carolina partially repealed
HB2 by removing the requirement that individuals must use the bath-
room corresponding to the sex on their birth certificate in government
facilities; however, it retained the state legislature’s regulation of bathroom
access without ceding any control to local governments until December
2020 (Hanna et al., 2017). This “compromise” bill, HB142, failed to
satisfy LGBTQ advocacy groups who allege that the revised law still dis-
criminates against LGBT residents by preventing local governments from
passing ordinances similar to the one passed by the Charlotte, North Car-
olina City Council in February 2016 which added gender identity to the
city’s protections against discrimination in public accommodations includ-
ing bathrooms (Hanna et al., 2017). In 2015, the Justice Department
under the Obama administration filed a lawsuit challenging HB2, but in
March 2017, the Trump administration-led Justice Department dropped
the lawsuit in a shift that would allow states and local governments to deter-
mine the rights of transgender individuals to access public accommodations
including bathrooms (Drew, 2017).
Lamba Legal and the ACLU continued their separate federal lawsuit on
behalf of six plaintiffs, arguing that HB142, the replacement law, still vio-
lated the rights of transgender individuals, in part by leaving them confused
 2 LEGAL STATUS AND CHALLENGES TO HOMOSEXUALITY 33

on which bathrooms they could use. (Drew, 2017). In October 2017, the
Governor of North Carolina, Roy Cooper, and transgender rights advo-
cates settled the federal lawsuit through a proposed consent decree (Faus-
set, 2017). Cooper, elected in part due to his opposition to HB2, had pre-
viously called the revised law, HB142, a first step to increasing transgender
rights in North Carolina (Fausset, 2017). Along with the consent decree
that would allow transgender people to use the bathrooms that matched
their gender identity, Cooper also issued an executive order offering pro-
tections based on sexual orientation and gender identity to state govern-
ment employees (Fausset, 2017). Cooper’s executive order was met with
considerable opposition from some conservative groups including the NC
Values Coalition who argued that the settlement represents an attempt to
take authority and power away from the state legislature who alone has the
authority to institute such changes (Fausset, 2017).

Discrimination Within the Military

In 2010, President Barack Obama finalized his decision to repeal the
“Don’t Ask, Don’t Tell” executive order implemented eighteen years ear-
lier by President Bill Clinton which had prevented gay men and women
from revealing their sexual orientation and gender identities while serving
in the military (Bumiller, 2011). President Obama’s administration had
planned to start enlisting transgender troops in all branches of the military
by July 1, 2017; however, the Trump administration postponed and then
canceled the policy entirely in another attempt at reversing gains made by
transgender individuals (McLaughlin, 2017). In August 2017 President
Trump issued a series of tweets and a memo formally ordering the Pen-
tagon to ban transgender people from serving in the United States military
by immediately prohibiting their “accession” or enlistment in the military
and most likely discharging those transgender individuals currently serv-
ing no later than March 23, 2018 (McLaughlin, 2017). President Trump
tweeted that the United States military’s ability to be decisive in victory
should not be impacted by the burden, expensive medical costs, and dis-
ruption of transgender military personnel (McLaughlin, 2017). The memo
also required the Pentagon to stop funding all new gender-related surg-
eries and granted former Secretary of Defense Jim Mattis six months to
create a policy on how to handle the issue of transgender individuals who
were already serving in the U.S. military (McLaughlin, 2017). Mr. Mattis
34 S. R. NOTARO

assembled a panel to advise him on appropriate policy regarding transgen-

der individuals serving in the military (McLaughlin & Martinez, 2018). In
September 2017, General Joseph Dunford, the chairman of the Joint Chief
of Staffs, provided testimony to the Senate Armed Services Committee in
which he asserted that any individuals who meet physical and mental stan-
dards and who is currently serving should be allowed to continue to serve;
further, Dunford informed Congress that he had privately recommended
that transgender individuals be allowed to continue serving in the military
(Mclaughlin, 2017).
In response to President Trump’s directive, four federal lawsuits were
filed resulting in the U.S. Department of Justice’s attempt to have one of
the lawsuits dismissed due to it being premature in light of the Defense
department’s revue of President Trump’s directive to ban transgender per-
sonnel from the military (Sands & Seyler, 2017). The lawsuits drew upon
data, including that furnished by the RAND Corporation, to argue against
the Trump administration’s rationale for banning transgender military per-
sonnel. The RAND Corporation estimated in 2016 that there were approx-
imately 2450 transgender personnel serving in the active portion of the U.S.
military out of about 1.3 million active personnel and about 1510 serving
in the reserves (Schaefer et al., 2016). Of those transgender military per-
sonnel, the RAND report estimated that between 29 and 129 individuals
serving in the active portion of the military would seek transition-related
or gender confirmation surgery that could impede their ability to deploy
(Schaefer et al., 2016). Further, the cost of such health care was estimated
to increase the military’s active component health care costs by $2.4 million
to $8.4 million annually, representing a .04 to .13% increase (Schaefer et al.,
2016). At the time of the 2016 RAND study, 18 close allies of the United
States, including England, Israel, Canada and Australia, allowed transgen-
der individuals to serve openly in the military (McLaughlin & Martinez,
2018).
In October 2017 Judge Colleen Kollar-Kotelly blocked the Trump
administration’s ban on enlisting and retaining transgender military per-
sonnel, asserting that the plaintiffs who filed the federal lawsuit demon-
strated that the directive would cause injury from inequality and from
the risk of discharge and denial of enlistment (de Vogue, 2017). Judge
Kollar-Kotelly, who ordered the government to begin enlisting transgen-
der individuals as of January 1, 2018, also criticized President Trump’s use
of Twitter to announce the new policy, as this mode of communication
did not conform to the typical formal processes that accompany a major
 2 LEGAL STATUS AND CHALLENGES TO HOMOSEXUALITY 35

policy change with such a wide impact (de Vogue, 2017). Further, in her
76-page opinion, Judge Kollar-Kotelly asserted that the reasons offered
by Mr. Trump for banning transgender military personnel were contra-
dicted by conclusions and studies conducted over a year-long period by
the military (de Vogue, 2017). Two significant outcomes of this ruling
include the judge’s conclusion that the Constitution limits federal discrim-
ination against transgender individuals and that the President’s tweets may
be viewed as official presidential policies (de Vogue, 2017). On Decem-
ber 11, 2017, Judge Kollar-Kotelly declined the Trump administration’s
request to put her order on hold that would allow transgender individuals
to enlist in the military beginning January 1, 2018. The Pentagon asserted
that it was prepared to follow Judge Kollar-Kotelly’s court order as of Jan-
uary 1, 2018, allowing transgender individuals to join the military if they
met strict criteria including certifications from a medical provider about the
status of their health (McLaughlin & Martinez, 2018). Two transgender
individuals are already under contract to serve in the U.S. military since
that court ruling (McLaughlin & Martinez, 2018).
Despite their claim of compliance with the court ruling, the Justice
Department appealed the judge’s ruling to a federal appeals court based
in the District of Columbia (Crawford & de Vogue, 2017). On March 23,
2018, President Trump rescinded his previous memorandum banning all
transgender service in the military (Geidner, 2018). The second version of
the ban prohibits most transgender people from serving in the military if
they undergo gender transition or affirmation surgery, with some excep-
tions for about 900 transgender people who are already serving openly and
for others who would agree to serve without undergoing gender transition
surgery (Marimow, 2018). The revised ban further states that transgender
individuals who had received a diagnosis of gender dysphoria would be
prohibited from serving except under limited circumstances (McLaughlin
& Martinez, 2018). On November 23, 2018 the Justice Department asked
the Supreme Court to review three cases challenging the Trump admin-
istrations’ efforts to bar transgender people from serving in the military
based on his revised ban (Geidner, 2018). The request is viewed as unusual
as it requests that the Supreme Court review the cases before appeals courts
have had an opportunity to rule on the matter (Geidner, 2018).
In January 2019 the Supreme court ruled that Trump’s ban on transgen-
der troops serving openly in the military could take effect pending ongoing
litigation (Tillet, 2019). As of April 12, 2019, transgender troops, includ-
ing those diagnosed with gender dysphoria, are prohibited from serving
36 S. R. NOTARO

in the U.S. military unless they are willing to serve in their “biological”
sex without surgery or hormone treatment (Tillet, 2019). Troops who had
already transitioned or who had requested gender reassignment surgery
prior to the April 12, 2019 deadline were allowed to continue serving in
the military. The Defense Department estimates that up to 15,000 troops
identify as transgender and are thus subject to this policy.
Overall, the Trump administration has attempted to reverse the gains in
transgender individual’s civil rights that were afforded under the Obama
administration, including the right to access public accommodations and
to serve openly in the United States military. The transgender commu-
nity had many allies including LGBT rights groups such as Lambda Legal
and the ACLU, who have filed federal lawsuits on behalf of transgender
plaintiffs. After months of litigation, the results are mixed for the transgen-
der community. In terms of transgender students enrolled in k-12 publicly
funded schools who sought the right to use bathrooms corresponding to
their gender identity, as of October 2018 Gavin Grimm’s lawsuit against
the Gloucester County School board is now back at the trial court and is in
the discovery phase (ACLU of Virginia, 2019). In North Carolina, a con-
sent decree will allow transgender individuals to use the publicly funded
restrooms and facilities of their choice; furthermore, the rights of the trans-
gender community have been bolstered by Governor Cooper’s sweeping
executive order providing protections for sexual orientation and gender
identity to state employees. Finally, Mr. Trump’s most recent memo of
March 2018 outlining his policy regarding transgender troops took full
effect as of April 12, 2019.
In contrast to the erosion of civil rights for the LGBT community under
the Trump administration, some recent gains in political representation in
the United States have been achieved by LGBT politicians in state and
local elections. In Virginia, former journalist Danica Roem was elected to
the state legislature in 2017, becoming the nation’s first openly transgen-
der woman elected to a state legislature (Stracqualursi & Chavez, 2017).
Roem defeated incumbent Robert Marshall who described himself as a
homophobe and allegedly referred to Roem with male pronouns during
the campaign (Stracqualursi & Chavez, 2017). Roem asserted in her accep-
tance speech that “No matter what you look like, where you come from,
how you worship, who you love, how you identify…if you have good public
policy ideas, if you’re well qualified for office, bring those ideas to the table,
because this is your America too” (Stracqualursi & Chavez, 2017). Also in
 2 LEGAL STATUS AND CHALLENGES TO HOMOSEXUALITY 37

2017 Andrea Jenkins was elected to a council seat in Minneapolis, becom-

ing the first African American transgender woman to win a council seat in
a major city (Stracqualursi & Chavez, 2017). Jenkins’ statement after her
win expressed her feelings of marginalization and exclusion, stating that
transgender individuals… “don’t just want a seat at the table. We want
to set the table. My election is what resistance looks like. It’s also about
hope” (Stracqualursi & Chavez, 2017). Seattle, Washington elected its first
openly lesbian mayor and first female mayor in 90 years as Jenny Durkan
ascended to the position after serving as the first openly gay U.S. attorney
(Stracqualursi & Chavez, 2017). Durkan was appointed by former Presi-
dent Obama in 2009 to the Western District of Washington (Stracqualursi
& Chavez, 2017). In April 2019, Jane Castor became Tampa, Florida’s first
openly LGBTQ mayor as she defeated her opponent with 73% of the votes
cast (Weinberg, 2019). As of 2019, it is estimated that 38 openly LGBTQ
mayors are serving nationwide (Weinberg, 2019).

Global Advances and Challenges in LGBT Civil

Rights
Refugees and Asylum Seekers in the United States and Globally
As previously discussed in this chapter, homosexuality remains illegal and
even punishable by death in many parts of the globe. Thus, it is imperative
to examine the plight of sexual and gender minority “refugees” who are
searching for safe havens to escape persecution and to secure a safer life
(Sherwood, 2017). Those individuals who claim persecution for their sex-
ual orientation and gender identities constitute a portion of the estimated
21 million refugees worldwide (Kushner, 2017). The United Nations High
Commissioner For Refugees (UNHCR) is the body designated to process
refugee status and aid those seeking asylum (Kushner, 2017). The UNHCR
interviews asylum seekers who make it to a refugee camp and then decides
which among them to prioritize for resettlement in a very limited number
of slots in nations in Europe and North America (Kushner, 2017). The
decisions are difficult forcing the UNHCR officials to choose among those
who identify as political and economic refugees; families, individuals, the
elderly, and the disabled forced to flee their homes due to wars and famine;
and sexual and gender minorities escaping persecution (Kushner, 2017).
If a refugee is chosen for resettlement by the UNHCR, then the lengthy
38 S. R. NOTARO

process of security and medical vetting and processing begins before the
host country determines admittance (Kushner, 2017).
In 2014, an estimated 105,000 people, or a small portion of the 866,000
applicants, were approved for resettlement (Kushner, 2017). Historically,
the United States has admitted more refugees than any other country, as
evidenced in 2014 when the U.S. accepted about 49,000 people or about
two-thirds of the total 77,331 that the UNHCR helped to resettle (Kush-
ner, 2017). In Canada, approximately 2200 refugees applied for asylum
based on their sexual orientation between 2013 and 2015, with about 70%
of the claims being granted as compared to about 63% of claims granted to
all refugees (Bielski, 2017). In May of 2017, for the first time, Canada for-
malized the guidelines, which were crafted with guidance from LGBT advo-
cates, lawyers, social workers, and researchers, regarding LGBTQ refugees
(Bielski, 2017). The guidelines must be followed by the refugee boards
throughout Canada (e.g., the Immigration and Refugee Board of Canada)
who decide on whether or not to grant asylum to LGBT individuals who
consider themselves as “persecuted minorities” in their home countries,
based on proof of same-sex relationships including texts, letters, pho-
tographs, or other artifacts such as prison records. These requirements
are an added burden on many LGBT individuals seeking asylum as most
spend the majority of their lives hiding their sexual orientation, romantic
relationships, and other “indicators” to avoid persecution, torture, jail, and
even death (Beilski, 2017).
As asylum seekers navigate the refugee guidelines over months and even
years, some are in such immediate danger and desperate straits that in June
2017 Canada began a secret program to evacuate gay men from Chechnya,
a republic within the Russian Federation, into Canada (Ibbitson, 2017a).
The secret program is controversial as it is not sanctioned by conventional
international law and places further strain on the tense relationship between
Russia and Canada (Ibbitson, 2017a). Despite the political ramifications,
Canada’s Liberal government decided it must take action given the recent
practice of Chechen security forces placing gay men in detention centers,
prisons, and other undisclosed locations, beating them, and demanding the
names of sexual partners (Walker, 2017). Several survivors of such torture
have claimed that upon their release, they were “outed” to family members
who expressed hostility and condemnation of homosexuality (Ibbitson,
2017a). At least two reports of familial beatings and “honor” killings for a
few of these men have surfaced but cannot be confirmed (Ibbitson, 2017a).
 2 LEGAL STATUS AND CHALLENGES TO HOMOSEXUALITY 39

While NGOs or nongovernmental organizations dedicated to protect-

ing and advancing the civil rights of LGBT individuals across the globe
have called upon other governments to provide asylum to gay Chechens,
the matter is complicated because homosexuality is technically legal in Rus-
sia despite President Putin’s ban of gay “propaganda” in 2012 (Ibbitson,
2017a). Further, other countries have not been willing to make the excep-
tion to international laws that refugee claimants must leave their home
countries before seeking refugee status (Ibbitson, 2017a). Canada acknowl-
edged the need for the exception, allowing gay refugee claimants who were
still located in Russia—mostly in safe houses operated by the Russian LGBT
Network, to be evacuated immediately and allowed to enter Canada (Ibbit-
son, 2017a). The exact number of gay men who have been affected by the
Chechnyan “pogrom” or deliberate persecution is unknown; however, the
Russian LGBT Network bases its estimate of 75 affected gay men on the
number of calls received at a hotline that the organization established when
reports of the persecution first surfaced (Ibbitson, 2017a).
Violence within spaces designed to provide sanctuary and safety are often
dangerous places for LGBT people, as is the case in the Kakuma Refugee
camp in Kenya. The Kakuma camp hosts approximately 180,000 refugees
from several African countries including Burundi, the Democratic Repub-
lic of Congo, Ethiopia, Sudan, South Sudan, Somalia, and Uganda (e.g.,
Onyulo, 2018). Of the purportedly 200 self-identified LGBT refugees liv-
ing in the camp, many claim that they are victims of homophobic acts of
violence perpetrated by other refugees who are encouraged by religious
leaders in the camp who oppose homosexuality and urge LGBT refugees
to change their sexual orientation (Onyulo, 2018).
One South Sudanese Pentecostal pastor who resides within the camp,
Peter Long, asserted that LGBT refugees might influence heterosexual
refugees within the camp to experiment with or embrace a LGBT sex-
ual orientation (Onyulo, 2018). LGBT refugees claimed that the refugee
camp officers separated them from the other refugees in worse conditions
with sparse accommodations and supplies (Onyulo, 2018). While some of
the LGBT individuals have attempted to form their own church and pray
together, they live in fear of the other refugees as well as from Kenyans out-
side the camps (Onyulo, 2018). Given this dangerous environment, LGBT
refugees have expressed their desire to relocate to the U.S. or Europe where
they believe they will be protected (Onyulo, 2018).
40 S. R. NOTARO

In another stride forward for LGBT civil rights, several countries, includ-
ing Australia, England, Germany, and Canada, have issued apologies in var-
ious forms and in some cases reparations, to individuals in the LGBT com-
munity who were persecuted and/or prosecuted for homosexuality prior
to the decriminalization of homosexual acts (Ibbitson, 2017b). In May
2016 the Victorian parliament in Australia became the first government to
apologize to men who had been convicted for homosexuality (Ibbitson,
2017b). In his address to Parliament, Australian Premier Daniel Andrew
stated:

I move that this house apologize for laws that criminalized homosexuality in
this State, laws which validated hateful views, ruined people’s lives and forced
generations of Victorians to suffer in fear, silence, and isolation. These laws
did not just punish homosexual acts, they punished homosexual thought.
They had no place in a liberal democracy. They have no place anywhere. The
Victorian Parliament and the Victorian Government were at fault. For this
we are sorry. (Andrew, 2016, para. 4)

By the summer of 2017, Britain and Germany had both issued their
own apologies to LGBT individuals who had been discriminated against,
with Germany promising to compensate those affected as well as to over-
turn convictions for homosexuality (Ibbitson, 2017b). In the fall of 2016
Canada’s Prime Minister, Justin Trudeau, appointed Randy Boissonnault,
a Liberal Member of Parliament, to frame an apology and possible repara-
tions for those individuals who had been convicted and imprisoned prior
to 1969, when homosexuality was illegal in Canada (Ibbitson, 2017b).
Although the apology had been discussed since the 1980s and two other
countries (Britain and Germany) had both issued apologies by the summer
of 2017 to gay men who had been prosecuted under anti-homosexuality
laws, Canada did not formally issue its apology or accompanying repara-
tions until November 28, 2017 (Ibbitson, 2017b).
The final catalysts for the apology can be partially attributed to the 2016
attack on a gay nightclub in Orlando, in which 49 people were killed, and a
report prepared by the Egale Canada Human Rights Trust, known as Egale
(Ibbitson, 2017b). Egale, describing itself as the “only national charity pro-
moting lesbian, gay, bisexual, and trans human rights,” urged the Canadian
government to apologize to those who had been imprisoned, fired from
jobs, or persecuted because of their sexuality (Egale, 2016). At the time
that Trudeau was nearing his decision to make a formal apology, some
 2 LEGAL STATUS AND CHALLENGES TO HOMOSEXUALITY 41

LGBT individuals were participating in a class action lawsuit that sought

financial compensation and redress for their loss of jobs during the Cana-
dian “gay purge” conducted between 1950 and the early 1990s, which
focused mostly on occupations within national security, the military, and
public service (Egale, 2016). Mr. Trudeau’s apology issued in the House
of Commons was made on behalf of all Canadians to lesbian, gay, bisex-
ual, transgender, and queer individuals who had been imprisoned, fired,
or persecuted in other ways due to their sexuality (Catungal, 2017). The
apology was also accompanied by a promised sum of $145 million dollars,
the largest amount provided by any government to compensate the LGBT
community (Ibbitson, 2017b). The funds will be allotted to individual
compensation and to the cost of a memorial in Ottawa and educational
activities throughout Canada (Ibbitson, 2017b).
Although acknowledging the importance of these various apologies
from several countries, some activists and scholars have emphasized the
need to for continued action and commitment to long term financial and
political support for the LGBT community (Catungal, 2017). Catungal
(2017) further stressed that the inequalities within the LGBT community
necessitate a varied response, with careful attention given its most vul-
nerable members including transgender women and transgender people
of color. Catungal (2017) argued for stronger policies and legislation to
combat the disproportionate violence suffered by transgender individuals
in schools, the workplace, and in the community.

Hate Crimes
A hate crime is defined as a crime (e.g., physical or verbal assault, bully-
ing, harassment) that is motivated by bias or hate directed toward victims
who are members of particular races or social groups including sex, sexual
orientation, gender identity, ethnicity, disability, language, nationality, and
religion (Stotzer, 2007). Incidents that are motivated by hate but classi-
fied as noncriminal are often referred to as bias incidents. As hate crimes
targeting the LGBT community occur throughout the world, in 2014,
the United Nations Human Rights Council passed its first resolution con-
demning violence and discrimination on the basis of sexual orientation and
gender identity (Howard, 2014). The United States strongly supported
the resolution which was sponsored by Uruguay, Columbia, Brazil, and
Chile (Howard, 2014).
42 S. R. NOTARO

Although the term “hate crime” did not become a common part of the
English lexicon in the United States until the 1980s, the term often refers to
events such as the killing of millions of Jewish people during the Holocaust
as well as lynchings of African Americans during reconstruction and the civil
rights movement that occurred well before the term was popularized. Hate
crimes have numerous psychological effects on victims including feelings
of terror, vulnerability, powerlessness, depression, and anxiety. Reasons for
committing hate crimes often overlap. Some motivations for committing
such crimes include seeking excitement and thrills; protecting a community
from perceived threats; retaliating or seeking revenge as in the case after
terrorist attacks; and defending a mission or particular ideology (Burke,
2017).
Hate crime laws are designed to deter crimes based on bias and hatred
by several means including the enhancement of penalties associated with
existing crimes, the classification of some acts as distinct crimes or classes
of civil actions, and the collection of hate crime statistics (Stotzer, 2007).
In 1968 in the United States a federal statute was included in the Civil
Rights Act which codified the first modern hate crime legislation aimed at
protecting victims who were targeted based on race, color, religion, and
national origin. The U.S. Supreme Court has upheld hate crime laws as
long as the crimes are associated with threats of injury or death.
In the United States, 20 states and the District of Columbia address
hate or bias crimes based on sexual orientation and gender identity while
11 states have laws against hate or bias crimes based on sexual orientation
only. Fifteen states have laws addressing hate or bias crimes but do not
include protections based on sexual orientation or gender identity. Finally,
three states have no laws concerning hate crimes based on sexual orientation
or gender identity, but do collect data on such crimes.
In 2009, the Matthew Shepard and James Byrd, Jr. Hate Crimes Preven-
tion Act augmented the federal definition of hate crimes by adding actual
or perceived gender, gender identity, sexual orientation, and disability. The
Act also removed the prerequisite that the victim had to be engaging in
federally protected activity such as attending school, using public accom-
modations, applying for employment, serving as a juror, or voting (Human
Rights Campaign, 2010). Although this expanded version of hate crimes
legislation was introduced in the United States House of Representatives
and Senate in 1997, it was not until 12 years later that the bill was passed
and signed into law by President Barack Obama (Human Rights Campaign,
2010). The Act assigned the United States Justice Department jurisdiction
 2 LEGAL STATUS AND CHALLENGES TO HOMOSEXUALITY 43

over the investigation and prosecution of hate crimes and also provided
funding and technical assistance for the local and state investigation and
prosecution of hate crimes.
The Mathew Shepard and James Byrd, Jr. Hate Crimes Prevention Act
was named to honor the victims of two especially heinous and gruesome
murders. On October 9, 1998, near Laramie, Wyoming, Matthew Shep-
ard, a college student, was brutally beaten, burned, and tied to a fence
where he was found 18 hours later. He subsequently died after five days
in the hospital. The prosecution provided evidence that Matthew’s killers
murdered him because he was gay (Human Rights Campaign, 2010). On
June 7, 1998, in Jasper, Texas, James Byrd Jr., an African American man,
was murdered by three white men because of their hatred against African
Americans. Of the three convicted assailants, two were members of white
supremacist groups called the Aryan Nations and Confederate Knights of
America, an offshoot of the Ku Klux Klan. James Byrd was kidnapped,
driven to a wooded area, beaten, and chained by the ankles to the back
of one of the assailant’s truck. His severed head, neck, and right arm were
discovered about one mile from where his torso was eventually dumped
(Human Rights Campaign, 2010). According to the Federal Bureau of
Investigation, hate crimes in the United States increased 4.6% from 2015
to 2016 and 17% between 2016 and 2017 (Federal Bureau of Investigation,
2017).

Hate Crimes and Discrimination Globally

While data regarding hate crimes, discrimination, and harassment of LGBT
individuals has not been consistently collected throughout the globe, some
information on this matter is available from surveys conducted by the Euro-
pean Union Agency for Fundamental Rights or FRA. As depicted in Fig. 2.3
twenty-eight member states located primarily in Europe comprise the Euro-
pean Union (EU), a political and economic entity whose goals are to sup-
port an internal single financial market and common policies regarding
trade, development, and laws.
Since 2008 the FRA has conducted research examining intolerant atti-
tudes and behaviors including verbal and physical attacks suffered by the
LGBT community throughout the EU. Within the EU, sexual orientation-
based discrimination is prohibited by law only in the realm of employment
while gender identity is also protected if the discrimination is related to
gender reassignment (FRA, 2019).
44 S. R. NOTARO

Fig. 2.3 European Union map (Courtesy of the US Central Intelligence Agency
Library)

In 2012 the FRA conducted the EU LBGT online survey with 93,079
persons aged 18 years or over living in the EU or Croatia who self-identified
as lesbian, gay, bisexual, or transgender. The FRA acknowledges that the
survey was not representative of all LGBT persons living in the EU; how-
ever, at the time the survey was the largest of its kind providing a view
into experiences of the LGBT community. The anonymous online survey
focused on self-reported discrimination, violence and harassment of LGBT
 2 LEGAL STATUS AND CHALLENGES TO HOMOSEXUALITY 45

people living in the EU in the domains of employment, education, health-

care, housing and other services (FRA, 2019).
A consistent finding across all countries surveyed was the relationship
between perceptions about the level of offensive language about LGBT
people by politicians and self-reports of feeling personally discriminated
against or harassed based on sexual orientation (FRA, 2019). Specifically,
results demonstrated that in 14 out of the 17 countries in which fewer
than half of the respondents reported discrimination or harassment based
on sexual orientation in the year before the survey, the majority of respon-
dents reported that offensive language about LGBT people by politicians
was rare. The survey revealed differences by age, gender identity, and gen-
der. The youngest age group (18–24 years) were the least likely to have
disclosed their sexual orientation and the most likely to report being vic-
tims of violence or discrimination based on sexual orientation. Respondents
who self-identified as transgender reported a more hostile environment and
more discrimination in employment and healthcare than that experienced
by lesbian, gay and bisexual respondents (FRA, 2019). Respondents iden-
tifying as women were much more likely than men respondents to report
that the most recent attack that they experienced in the 12 months prior
to the survey was sexual in nature.
Given the results of this survey, the FRA published several recommen-
dations designed to bolster responses to and reductions in discrimination
targeting the LGBT community living within the EU. For example, the
FRA encouraged the EU to develop and execute plans to increase respect
for LGBT people by integrating their needs into national human rights
plans and strategies. As the results pointed to harsher environments and
higher incidences of self-reported discrimination based on age and gen-
der identity, the FRA urged special focus on the youngest respondents and
those self-identifying as transgender. Finally, FRA encouraged EU member
states to facilitate dialogue among social and political institutions regard-
ing LGBT rights and protections while increasing funding for national level
research regarding discrimination targeting LGBT individuals.

Summary
This chapter illuminated the current legal status of LGBT persons both in
the United States and across the globe. One area of progress within the
United States and some countries worldwide is the legalization of same-sex
marriage and adoption, which afforded all of the legal benefits enjoyed by
46 S. R. NOTARO

opposite-sex couples to same-sex couples. Despite this positive outcome,

this chapter provided ample evidence that discrimination, bias, and the
denial of legal rights continue to plague the LGBT community as they
attempt to access employment, housing, education, public accommoda-
tions, military service opportunities, refugee protections, and remedies for
hate crimes based on sexual orientation and gender identity. Although no
federal laws exist to protect the LGBT community from discrimination,
some progress has occurred as individual states have passed laws prohibit-
ing discrimination based on sexual orientation and gender identity. Sexual
and gender minority refugees have been assisted by some countries includ-
ing Canada, who recently took action to secretly evacuate gay men who
were being attacked from the Russian Federation republic of Chechnya
into Canada. Further progress for some homosexuals who had been per-
secuted and often jailed for homosexuality prior to the decriminalization
of homosexuality came by way of recent apologies and in some cases repa-
rations from several European countries. The Mathew Shepard and James
Byrd, Jr. Crimes Prevention Act provided additional legal remedies for
federal hate crimes by adding actual or perceived gender, gender identity,
sexual orientation, and disability and removing the stipulation that the vic-
tim had to be engaging in federally protected activity such as attending
school, using public accommodations, applying for employment, serving
as a juror, or voting (Human Rights Campaign, 2010). Globally, discrim-
ination in employment based on sexual orientation is prohibited within
the European Union; however, a recent online survey reveals experiences
of discrimination, bias, and violence within the EU’s LGBT community.
Overall, this chapter demonstrated that, at best, progress in gaining equal-
ity in the legal treatment and status of the LGBT community is mixed and
in need of sustained efforts within the United States and globally.

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50 S. R. NOTARO

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 CHAPTER 3

Access to Health Care

Culturally Competent Health Care

This chapter will discuss the significance of access to health care for LGBT
persons, with a focus on the impact of health care reform which was codified
into law via the Affordable Care Act (ACA) and attempts to repeal it.

Nancy Pelosi says the angry opposition to health care reform is like the angry
opposition to gay rights that led to Harvey Milk being shot. (P. J. O’Rourke,
comedian and entertainer, n.d.)

The concept of culturally competent health care is the first area of impor-
tance in understanding health care outcomes for marginalized communi-
ties. Culturally competent health care is defined as the ability of providers
and organizations to effectively deliver health care services that meet the
social, cultural, and linguistic needs of patients (Butler et al., 2016). Educat-
ing providers to deliver culturally competent health care to LGBT patients
has the potential to improve health outcomes and quality of care while elim-
inating health disparities among this community. While most health care
providers do not receive specific training in LGBT health, protocols, and
recommendations (Butler et al., 2016), there have been attempts to pro-
vide culturally competent LGBT health care training (Butler et al., 2016).
Butler et al. (2016) sought to conduct a review of evaluations of such
interventions, but found a paucity of studies that met their criteria which
included only studies designed to better inform the average, nonspecialized
© The Author(s) 2020 53
S. R. Notaro, Marginality and Global LGBT Communities,
Neighborhoods, Communities, and Urban Marginality,
https://doi.org/10.1007/978-3-030-22415-8_3
54 S. R. NOTARO

provider and health care system of appropriate ways and strategies to

improve the health of LGBT individuals. This approach explicitly excluded
providers embedded in the so-called “parallel” system (e.g., public health,
specialized LGBT clinics, and AIDS service organizations or ASOs) as the
authors’ goal was to evaluate efforts of providers who do not typically
receive specialized training or have caseloads consisting mostly of LGBT
individuals (Butler et al., 2016).
Butler et al. (2016) reviewed 11 studies, including 5 randomized con-
trolled trials conducted from 2002 to 2013. The interventions provided
culturally competent LGBT health care training in several areas targeting
providers and patients, in inpatient, outpatient, and community settings
(Butler et al., 2016). Intermediate outcomes included provider competen-
cies, knowledge, changes in attitude, behaviors such as decision-making,
and beliefs such as stereotypes; improved access to health services, utiliza-
tion of health services, patient experience and satisfaction, patient health
behaviors, and use of preventive services and other access to care (Butler
et al., 2016). Final outcomes included the patient’s physical and mental
health outcomes (Butler et al., 2016).
One of the randomized control trials attempted to use culturally com-
petent counseling to increase rates of breast self-examination and mam-
mography among women who self-identified as lesbian or bisexual (e.g.,
Bowen, Powers, & Greenlee, 2006; Butler et al., 2016). The culturally
competent approach included concordance between the patient and the
provider such that participants were informed that all scientists, staff, and
counselors involved with the study were self-identified as sexual minority
women (e.g., Bowen et al., 2006; Butler et al., 2016). While the authors
reported significant increases in both breast self-examination and mam-
mography and significant decreases in perceived risk and cancer worry as
compared to a waitlisted control group, they did not include a control
group of providers whose sexual identity was not explicitly identified as
lesbian or bisexual (e.g., Bowen et al., 2006; Butler et al., 2016).
Overall, Butler et al. (2016) concluded that research evaluating ways to
reduce LGBT health disparities through cultural competency interventions
are sparse and limited in terms of non-randomized designs, low sample size
and response rates, and lack of tests of statistical significance (Butler et al.,
2016). A much larger body of research has examined ways to deliver cultur-
ally competent HIV prevention for the LGBT population, and specifically
to men who have sex with men (MSM), as compared to non-specialized
 3 ACCESS TO HEALTH CARE 55

systems of care (Butler et al., 2016). Butler et al. (2016) argue for a main-
stream approach to delivering culturally competent care to LGBT individ-
uals, ensuring that patients have the choice of where to obtain care that
is not driven by stigma or lack of skill. Further, research into other areas
of LGBT health disparities beyond HIV/AIDS, including obesity, men-
tal health, substance abuse, and suicide, while also ensuring the inclusion
of intersectional identities including sexual minority women, transgender
people, and LGBT youth would be beneficial (Butler et al., 2016). Finally,
more research focusing on the effectiveness of culturally tailored interven-
tions versus patient-centered or individualized interventions would add to
our understanding of the impact of these related approaches (Butler et al.,
2016).

Access to Health Insurance

In addition to the need for culturally competent care, LGBT individuals are
seeking expanded access to health insurance. In response, recent United
States Supreme Court decisions have expanded pathways to health insur-
ance for the LGBT community (Kates, Ranji, Beamesderfer, Salganicoff,
& Dawson, 2017). As discussed in Chapter 2 of this volume, perhaps the
most influential of these decisions was the 2015 Obergefell v. Hodges ruling
in which the United States Supreme Court cited both the Due Process
Clause and the Equal Protection Clause of the Fourteenth Amendment in
its recognition of same-sex marriages nationwide. Although the decision
was not unanimous, former Justice Anthony Kennedy eloquently stated
the majority opinion’s reasoning for recognizing the legality of same-sex
marriage:

In forming a marital union, two people become something greater than once
they were. As some of the petitioners in these cases demonstrate, marriage
embodies a love that may endure even past death. It would misunderstand
these men and women to say they disrespect the idea of marriage. Their
plea is that they do respect it, respect it so deeply that they seek to find
its fulfillment for themselves. Their hope is not to be condemned to live in
loneliness, excluded from one of civilization’s oldest institutions. They ask
for equal dignity in the eyes of the law. The Constitution grants them that
right. (Justice Anthony Kennedy, Obergefell v. Hodges , A. Soergel, 2015)
56 S. R. NOTARO

The Kaiser Family Foundation details a variety of outcomes stemming

from the 2015 Obergefell ruling including changes in federal and state tax
regulations that ended tax penalties levied upon same-sex married couples
who utilize dependent spousal coverage (Kates et al., 2017). In terms of
military and veteran benefits, the Obergefell decision led to the Department
of Veterans Affairs recognizing all same-sex marriages and extending bene-
fits to all same-sex spouses of veterans, including health coverage, survivor
compensation, and burial benefits (Kates et al., 2017). Similarly, federal,
state, and local employees and contract employees are all eligible for same-
sex spousal coverage (Kates et al., 2017).
In terms of private employers, the Obergefell decision does not require
such employers to offer same-sex spousal coverage; however, an April
2017 federal appeals court ruling (Zarda vs. Altitude Express, Inc.) has
extended Title VII of the Civil Rights Act’s anti-discrimination protections
in employment discrimination to sexual orientation (Kates et al., 2017).
This ruling, although technically applying only to the states of Illinois,
Minnesota, and Wisconsin, has implications for same-sex spousal coverage
nationwide in that employers who offer health benefits to only opposite-
sex spouses but not to same-sex spouses would likely be in violation of
Title VII’s anti-discrimination provision (Fensholt, 2017). The Obergefell
decision is in line with the Equal Employment Opportunity Commission’s
(EEOC) regulation which found Title VII’s prohibition on sex discrimina-
tion to extend to sexual orientation (Fensholt, 2017). Further, the EEOC
found that private and public sector employees may bring potential Title
VII same-sex spousal discrimination cases for its review (Kates et al., 2017).
Employers who provide only opposite-sex spousal coverage may also be in
violation of state non-discrimination laws (Kates et al., 2017). Discrim-
ination in private health insurance based on sexual orientation and gen-
der identity (SOGI) is prohibited in twelve states (California, Colorado,
Delaware, Hawaii, Illinois, Maine, Minnesota, Nevada, New York, Ore-
gon, Rhode Island, Vermont, and West Virginia) as well as the District of
Columbia (Kates et al., 2017).
The Obergefell decision did clarify that private group health plans may
extend some benefits to married same-sex couples offered under the
Department of Labor’s Employment Retirement Income Security Act of
1974 which sets minimum standards for pension and health plans (Kates
et al., 2017). Specifically, with Obergefell ’s recognition of same-sex cou-
ples nationwide, private group health plans may extend both the Consol-
idated Omnibus Budget Reconciliation Act (COBRA), the law offering
 3 ACCESS TO HEALTH CARE 57

employees and their families a temporary extension of group health cover-

age after a job loss or other qualifying events, as well as special enrollments
rights for newly-married spouses, to same-sex married couples (Kates et al.,
2017).
The Kaiser Family Foundation provides an overview of the access to
employer-sponsored health coverage for same-sex spouses and domestic
partners based on a telephone survey of 2137 randomly selected non-
federal public and private employers with three or more workers (Dawson,
Kates, & Rae, 2017). Survey results, based on a 33% response rate, revealed
that overall in 2017 approximately 57% of firms offering health insurance
coverage to opposite-sex spouses also provided same-sex spousal coverage
while 11% did not provide such benefits (Dawson et al., 2017). Results
showed that among firms that offer opposite-sex spousal coverage, 88% of
large firms (those with 200 or more employees) were more likely to also
offer this coverage to same-sex spouses as compared to 56% of smaller firms
(Dawson et al., 2017). In terms of the largest employers (those with more
than 1000 workers), 92% of them provided health insurance benefits to
same-sex spouses as contrasted with 56% of the smallest employers (those
with 3–199 workers) (Dawson et al., 2017). Most of the employees in the
United States work at larger firms (200 or more employees) and 71% of
such firms offer same-sex spousal health insurance benefits as compared to
97% of the largest firms (those with 1000 or more workers) (Dawson et al.,
2017).
In terms of domestic partner (unmarried couples) benefits, some ques-
tions had arisen about whether or not the Obergefell decision recogniz-
ing same-sex marriage would decrease the number of employers offering
domestic partner benefits (Dawson et al., 2017). Survey data comparing
domestic partner benefits before and after the Obergefell decision indicate
no statistically significant difference between the percentage of employers
offering same-sex domestic partner health coverage in 2017 as compared
to 2012 (Dawson et al., 2017). Further, 52% of large firms who provided
same-sex spousal benefits also provided same-sex domestic partner benefits
(Dawson et al., 2017).
In addition to examining the impact of recent court rulings on the
access to health care and insurance within the LGBT community as a
whole, research from the 2013 National Health Interview Survey specif-
ically examined health care service utilization and health care access by
self-reported sexual orientation. Results indicated that for some measures,
including access to care, bisexuals have less access to care as compared
58 S. R. NOTARO

to heterosexuals, while lesbian and gay people have access comparable

to heterosexuals (Ward, Dahlhamer, Galinsky, & Joestl, 2014) Further,
the data revealed that while the uninsured rate did not differ by sexual ori-
entation, bisexual adults reported having a usual place to go for medical
care less often and going without medical care due to cost more frequently
than lesbian or gay people (Ward et al., 2014). As is common with most
state and national health surveys, the National Health Interview Study did
not include questions regarding gender identity, thus leaving the possibility
of differences in health care access among transgender individuals an open
question (Kates et al., 2017).
In terms of coverage, Baker, Cray, and Gates (2013) explore changes
in access to both Medicare and Medicaid for LGBT persons. Medicare is
a federal program providing health coverage for those persons aged 65 or
older or under 65 if they have a disability, regardless of income. Medicaid
is a combined state and federal program providing health coverage for low
income families and individuals as well as other groups such as pregnant
women and those with disabilities. Baker et al. (2013) estimated that the
expansion of Medicaid (which made Medicaid available to adults with no
children and based eligibility on income) by states who chose to expand
made it possible for 390,000 LGBT people to qualify for Medicaid and
for approximately 1.12 million uninsured LGBT people to receive federal
subsidies to defray the costs of coverage in insurance marketplaces. Due to
the legalization of same-sex marriages nationwide, some Medicare benefits
that had previously been available only to opposite-sex married couples
(e.g., free Medicare Part A hospital premiums, spouses receiving care at
the same skilled nursing facility) were extended for the first time to same-
sex married couples (Kates et al., 2017).
Two additional areas of expansion in access to health care have resulted
from the legalization of same-sex marriages—the Affordable Health Care
Act (ACA) and the Children’s Health Insurance Program (CHIP). The
Affordable Care Act (ACA or “Obamacare”) is a signature piece of leg-
islation signed into law in 2010 by President Barack Obama as a major
restructuring of the U.S. health care system with the overall goal of reduc-
ing the amount of uncompensated care incurred by the average U.S. family
by requiring everyone to have health insurance or pay a tax penalty. The
Children’s Health Insurance Plan (CHIP), offered by each state in coop-
eration with Medicaid programs, provides affordable health coverage to
children living in families whose income is above the eligibility for Medi-
caid. The eligibility for assistance in the ACA health insurance marketplaces
 3 ACCESS TO HEALTH CARE 59

and for coverage under Medicaid and CHIP must now take into account
same-sex marriages (Kates et al., 2017).
One development that may reverse some of the gains in the expansion
of health care coverage to lower and middle income LGBT individuals is
U.S. President Donald Trump and his administration’s recent decision to
end reimbursements to insurers for reducing the deductibles and co-pays of
lower-income ACA enrollees (Luhby, 2017). Under the ACA, insurers are
required to continue the discounts although they will not be reimbursed by
the federal government. This reduction in federal funding was anticipated
by some carriers who adjusted in several ways—either by announcing sub-
stantial rate increases for 2018, contemplating the raising of rates in the near
future, or withdrawing altogether from the health care exchanges (Luhby,
2017). Enrollees, including LGBT individuals, will continue to receive the
subsidies and will not pay much more for their health care in the exchanges,
but they may be forced to change plans to keep their rates steady and those
who earn too much to qualify for the subsidies may face much higher rates
(Luhby, 2017). Given these changes, although insurers must continue pro-
viding cost-sharing discounts under the ACA, the Trump administration’s
decision to end the reimbursements could halt some of the increases in
access to care that were starting to accrue to lower and middle income
LGBT individuals under the ACA (Luhby, 2017).

ACA Nondiscrimination Protections

Recent policy changes stemming from the ACA have expanded health
insurance coverage for LGBT individuals and their families while also pro-
viding protections based on gender identity and sexual orientation (USD-
HHS, 2015). For example, in 2015, the Centers for Medicaid and Medicare
(CMS) issued guidance clarifying that preventive services under the ACA
are available for all patients, regardless of gender identity, sex assigned
at birth, or recorded birth (USDHHS, 2015). Such guidance combats
some of the discrimination that transgender individuals have suffered in
the health care system related to the fact that the majority of states will not
allow the recorded sex at birth to be changed. Some transgender individu-
als have then reported problems with providers refusing to provide certain
health-related services that do not “match” the gender of the person’s birth
certificate (Grant et al., 2011).
The ACAs’ nondiscrimination protections also included a prohibition
against denying health insurance due to a preexisting medical condi-
60 S. R. NOTARO

tion, including HIV, mental illness, and transgender-related health services

which disproportionately affected LGBT individuals (Kates et al., 2017).
More specifically, Section 1557 of the ACA prohibits certain entities (e.g.,
insurers and health care providers) who receive federal payments through
the Department of Health and Human Services (DHHS) from denying
health care or health coverage based on sex, pregnancy, gender identity, and
sex stereotyping (Kates et al., 2017). The 2013 Urban Institute’s Health
Reform Monitoring Survey demonstrated that the percentage of under-
insured LGB adults decreased significantly between 2013 and 2015 (just
before the first open enrollment period of the ACA and just after the close
of the second open enrollment period) from 21.7 to 11.1%, representing
a larger reduction than that reported by heterosexual adults (Karpman,
Skopec, & Long, 2015).
The ACA addresses several other discriminatory practices in health
care. Under Section 1557 of the ACA, insurance companies must
consider transition-related care for transgender individuals and cannot
automatically exclude a specific procedure or therapy that it covers for non-
transgender individuals (National Center for Transgender Equality, 2017).
For example, if an insurance company covers breast reconstruction for can-
cer treatment, postmenopausal hormone replacement, or genital surgery
repairs after accidents, it cannot deny these treatments for gender dyspho-
ria, a DSM-5 recognized diagnosis for transgender individuals discussed in
Chapter 2 of this volume (e.g., National Center for Transgender Equality,
2017; Parekh, 2016).
Due to a recent decision by a federal trial court in August 2017, por-
tions of the ACA Section 1557 that prohibit discrimination on the basis of
gender identity and termination of pregnancy have been suspended (“ACA
Issues Persist,” 2017). The challenge to this portion of Section 1557 of
the ACA asserts that these nondiscrimination rules exceed the authority
of the DHHS and infringe upon the exercise of religion (“ACA Issues
Persist,” 2017). While offering no timeframe for its review, the DHHS
has requested that the court stay the proceedings while DHHS completes
a review of these rules, resulting in a lack of enforcement of these rules
nationwide (“ACA Issues Persist,” 2017).
In what is becoming a familiar shift, the Trump administration has
made changes in DHHS and the Office of Civil Rights (OCR) that
may erode several of the ACA’s nondiscrimination protections (McGraw,
2018). For example, in May 2017, President Trump signed an executive
order related to free speech and religious liberty focused on enforcing
 3 ACCESS TO HEALTH CARE 61

existing federal protections for religious freedom and withdrawing the

ACA’s requirement that employer-sponsored health insurance cover con-
traception (McGraw, 2018). In October 2017, the Trump administration
officially allowed employers to cite religious or moral objections to justify
employers’ discontinuation of coverage for birth control (McGraw, 2018).
In January 2018 the Trump administration announced the establishment
of a new division within the DHHS focused on conscience and religious
freedom (McGraw, 2018). This new division is supported by faith-based
and religious freedom groups who have urged the Trump administration to
strictly enforce anti-abortion conscience laws including the 1973 Church
amendment requiring federally funded health care facilities to allow health
care providers to refuse to perform abortions, sterilization, or other proce-
dures based on religious or moral grounds; the 1996 Coats-Snow amend-
ment extending those protections to medical students and residents; and
the 2004 Weldon amendment extending the conscience exemptions (or the
refusal to provide care based on religious objections) to a broader range of
so-called health entities (Posner, 2018).
The OCR, charged with enforcing anti-discrimination laws, health pri-
vacy laws, and conscience laws, is now operated by Trump appointees whose
priority is the enforcement of conscience protection laws and religious free-
dom as opposed to the protection of women’s reproduction choices and
health care access for transgender people (Posner, 2018). President Trump
appointed Roger Severino as director of the (OCR), which is the office
charged with enforcing anti-discrimination laws (Posner, 2018). Mr. Sev-
erino, formerly headed the Devos Center for Religion and Civil Society at
the conservative Heritage Foundation (Posner, 2018). While serving in his
role at the Heritage Foundation, Severino criticized the Obama administra-
tion’s regulation that offers protection to transgender people as a threat to
the religious conscience of some for health care providers (Posner, 2018).
Shortly after Severino’s appointment as director of the OCR, 12 Demo-
cratic U.S. senators sent a letter to then secretary of Health and Human
Services Tom Price expressing their concern over Severino’s history of state-
ments that were unsupportive of LGBT individuals and women’s access to
health care services (Posner, 2018). Mr. Severino has hired several staff
members into the OCR who have previously demonstrated in their work
at Christian rights organizations their support for religious protections
for individuals who oppose abortion and LBTQ rights (Posner, 2018).
As an example, Mandi Ancalle, who now serves as a contract worker for the
OCR, is considered a highly-experienced activist with detailed knowledge
62 S. R. NOTARO

of the desires of the Christian right’s policy goals for the Trump adminis-
tration, including reviving former President George W. Bush’s conscience
rule which exempted health care workers from treating women, LGBTQ
individuals, and others based on religious objections (Posner, 2018).
To provide perspective on the new focus on conscience violations, Mr.
Severino announced at the January 18, 2018 ceremony celebrating the
creation of the new Conscience and Religious Freedom Division at OCR
that while the Obama administration had only received 10 complaints of
conscience violations, the Trump administration had already received 34
(Posner, 2018). Such a steep increase in complaints is most likely due to
the deliberate strategy of Christian rights advocacy groups taking advan-
tage of Mr. Severino’s focus on the enforcement of conscience laws (Pos-
ner, 2018). For example, the Family Research Council, a Christian rights
advocacy group, sent a communication to its constituents on January 9,
2018 urging them to file conscience violation complaints with the OCR
and offering a tutorial on how to do so (Posner, 2018). The regulations
of the new Conscience Division extend beyond the Weldon, Church, and
Coats-Snow amendments in their scope and reach, pledging to provide
conscience and religious freedom enforcement and technical assistant to
federal staff, health care providers, religious organizations, nonprofits, and
state and local governments (Posner, 2018).
Susan Berke Fogel, the director of the National Health Law Program,
a reproductive rights advocacy group, criticizes the new regulations as an
attack on women and LGBT health, citing that the regulations seem to
allow anyone to refuse to provide health care for any reason which may
well undermine people’s health and dignity (Posner, 2018). Fogel points
out that the new Conscience Division’s decisions regarding conscience vio-
lations will most likely be litigated in court; however, she cautions that
successful litigation will probably increase such complaints while unsuc-
cessful litigation will serve as evidence that Congress should pass more
vigorous conscience laws beyond Church and Weldon (Posner, 2018).
Former House Speaker Paul Ryan had signaled his approval of increas-
ing conscience protections as shown by of his support of a bill, the Con-
science Protection Act, introduced in 2016 and again in 2017, that would
allow health care providers to sue for damages, including from a govern-
ment provider (Posner, 2018). This bill extends the remedies of filing a
complaint with OCR or seeking a court injunction to placing conscience
complaints on the same legal level as those in protected classes, who may
sue over discrimination for damages and attorney’s fees (Posner, 2018).
 3 ACCESS TO HEALTH CARE 63

As of May 2, 2019, the Department of Health and Human Services

(HHS) issued its final rules governing the religious rights of health care
providers and religious institutions. These rules, which represent an expan-
sion of existing protections, allow health care workers or any workers even
tangentially connected to medical procedures and who have a religious or
conscience objection to the procedure (e.g., birth control, abortion, ster-
ilization, insemination) to refuse to provide such services all together or to
certain individuals such as LGBT persons (Kodjak, 2019). To affirm the
shift in focus of the OCR from ensuring equal access to health care services
provided by HHS to protecting religious freedom, the DHHS changed its
mission statement to clearly affirm its priority of protecting religious beliefs
and “moral convictions” of individuals and institutions (Kodjak, 2019).

Expanded Data Collection

Changes in data collection and monitoring of health disparities is another
major component of the ACA designed to recognize and include LGBT
populations (Kates et al., 2017). The ACA requires national health care
surveys to include SOGI questions in the near future, providing for the
opportunity to conduct analyses related to SOGI (Kates et al., 2017).
At the national level, as of 2013, the National Health Interview Survey
includes a question on sexual orientation while at the state level, the Cen-
ter for Disease Control and Prevention has approved SOGI questions
for inclusion on the Behavioral Risk Factor Surveillance System surveys
(Kates et al., 2017). In terms of individual clinicians, some groups have
urged health care providers to collect patient data regarding SOGI to bet-
ter inform patients’ needs (Kates et al., 2017). These efforts have met with
some resistance from clinicians who express uncertainty and a lack of knowl-
edge regarding the appropriate methods for collecting potentially sensitive
information (Kates et al., 2017). Best practices in soliciting SOGI infor-
mation include offering patients the reasons for collecting the information,
ensuring confidentiality, providing an opt-out option, and posing several
questions to more accurately assess SOGI (Kates et al., 2017). Advocates
further advocate that electronic medical records serve as the repository for
this data (Kates et al., 2017). A 2016 decision by the National Institutes
of Health to designate sexual and gender minorities as a health disparity
population further support the collection of SOGI information at all levels
of health care (Kates et al., 2017).
64 S. R. NOTARO

While the addition of questionnaire items related to SOGI is a posi-

tive step toward a further understanding of health disparities and access
to health care among these populations, several researchers who focus
on LGBTQ communities are advocating for a transparent examination
of terms, definitions, and possible sources of error in such research (e.g.,
Cimpian, 2017; Mayo, 2017). Mayo (2017) asserts that LGBTQ issues are
approached differently depending on the discipline, potentially leading to
different interpretations of outcomes. For example, not only does the ter-
minology designating sexual and gender minorities vary within education
and humanities research, but also the concept of quantitative methods and
fixed-time designations of SOGI within fields such as education and public
health are often in sharp contrast with qualitative methods and deliberately
fluid and nontemporal designations of SOGI within the fields such as the
humanities (Mayo, 2017). Mayo (2017) further asserts that SOGI data
must also take into account and query intersection categories including
age, race, class, and ethnicity. Including an emphasis on intersectionality
has traditionally been more common in the humanities’ study of LGBTQ-
related issues potentially leading to a more complex yet richer understand-
ing of context and contingency (Mayo, 2017). Mayo (2017) argues for
the importance of both approaches, in that qualitative research focusing on
complexity and instability may help inform the conceptual frameworks of
quantitative research. Similarly, humanities-based queer studies may bolster
their arguments with empirical data from disciplines such as public health
(Mayo, 2017).
Cimpian (2017) echoes some of the same concerns as Mayo (2017)
in terms of the need to account for a continuum of sexuality that recog-
nizes instability, intersectionality, and complexity among sexual minorities.
Cimpian (2017) is further concerned with measurement errors that may
misclassify sexual minorities, and in particular sexual minority youths who
are asked to identify on questionnaires as lesbian, gay, bisexual queer, or
questioning. Cimpian (2017) does not include gender minorities (e.g.,
transgender, intersex, agender, gender-queer) in his examination of mea-
surement error as he asserts that the research regarding gender minorities
in general and classification errors related to gender minorities in particular
is less well-developed. According to Cimpian (2017), the potential for mis-
classification of sexual minority youth gathered through population-based
self-administered questionnaires can lead to errors and incorrect impres-
sions about health disparities in these communities.
 3 ACCESS TO HEALTH CARE 65

Cimpian (2017) delineates seven sources of error including fluidity, mis-

chievousness, inclusivity, nondisclosure, misunderstanding of terminology,
random reporting, and thresholds for categorization. Depending on the
source of error in questionnaires, inaccurate data may over or underesti-
mate both the population of sexual minorities as well as health dispari-
ties among this community (Cimpian, 2017). Cimpian (2017) and several
other researchers (e.g., Diamond, 2008; Diamond, Bonner, & Dickenson,
2015) have argued that sexual orientation can be quite fluid, flexible, and
situational with greater variation than can be captured by a cross-sectional
survey administered at one point in time. Cimpian (2017) illustrates the
impact of fluidity error in the following example wherein an individual
reports same-sex only attraction at one time point but then reports only
opposite-sex attraction at another time point. This reporting pattern results
in the likelihood that this respondent may not be included among the sex-
ual minority population at the second time point. The impact of such a
fluidity error on health disparity estimates is unclear, cannot be predicted
a priori, and depends upon the values of the outcomes measured at each
time point (Cimpian, 2017). Cimpian (2017) points out several ways to
decrease fluidity error including cross-sectional research that queries past
experiences in addition to current experiences and longitudinal research
that assesses sexual orientation over time without the risk of recall errors.
Additionally, questionnaire items that include categories that are less rigid
and more developmental such as “transition to LGB attraction” (Needham,
2012) or “heteroflexible” (Fish & Pasley, 2015) may decrease fluidity error.
The next source of error discussed is that of mischievous responding
(e.g., Cimpian, 2017; Robinson-Cimpian, 2014; Savin-Williams & Joyner,
2014) in which youth respond with extreme answers viewed as humorous,
out of the ordinary, or stigmatizing. Such responses typically over esti-
mate both the population of sexual minority youth and health disparities,
as their untruthful answers apply to sexual orientation as well as outcome
measures (Cimpian, 2017). One caveat to this source of error, is that mis-
chievous responding is just as possible among non-heterosexual youth or
sexual minority youth as it is among heterosexual youth (Cimpian, 2017).
Thus, mischievous reporting of membership in a very small minority group
(e.g., sexual minority youth) may create substantially biased estimates of
health disparities whereas mischievous reporting of membership in a very
large group (e.g., heterosexual youth) may have less impact on estimates of
health disparities (Cimpian, 2017). The research that has addressed ways
to mitigate the impact of mischievous responding all rely on the gathering
66 S. R. NOTARO

of additional data, either from parents (e.g., RanjiFan et al., 2006) or from
the respondents regarding truthfulness of responses or items unrelated to
sexual minority status such as extreme height and weight (e.g., Cornell,
Klein, Konold, & Huang, 2012; Robinson-Cimpian, 2014).
Cimpian (2017) refers to the third source of measurement error as
inclusivity of dimensions which describes the inconsistent use of various
dimensions (e.g., identity, romantic and sexual attraction, and behavior)
to categorize sexual orientation. Some critiques of earlier research inves-
tigating sexual minority adolescents assert that the focus on sexual orien-
tation identity versus items related to attraction and behavior may have
underestimated the prevalence of sexual minority youth, given that, devel-
opmentally, adolescents may have a less clear sense of their sexual iden-
tity relative to attraction (e.g., Savin-Williams, 2001). Including questions
about all dimensions of sexual orientation may identify distinct categories
that are related to specific outcomes and disparities (e.g., Fish & Pasley,
2015). Cimpian (2017) recommends a broad approach to measuring sex-
ual orientation that includes all three dimensions, as some youth who do
not identify as a sexual minority but who may experience romantic and/or
sexual attraction could still report experiences of stigma and bias.
The fourth source of error, nondisclosure of actual group status, may
lead to an underestimation of sexual minority youth; however, it is unclear
whether or not the outcomes or disparities differ for youth who disclose
their sexual orientation versus those who do not (Cimpian, 2017). Sev-
eral options for reducing this source of measurement include ensuring
respondents that the research is confidential, and perhaps anonymous,
offering self-administered questionnaires, and embedding sexual minority
status among a list of nonsensitive items, referred to as the veiled response
technique (e.g., Badgett & Goldberg, 2009; Cimpian, 2017). Misunder-
standing the survey items is a fifth source of error, affecting many identi-
fication statuses including sexual minority, race/ethnicity, and social class
(Cimpian, 2017). It is unclear as to how the misunderstanding of sur-
vey items impacts the reporting of disparities; furthermore, it is difficult
to measure a respondent’s level of misunderstanding (Cimpian, 2017).
Some prior research has attempted to reduce misunderstanding by using
a cognitive processing method, commonly referred to as “think aloud”
(Austin, Conron, Patel, & Feedner, 2007). Respondents who are similar
to the population of those who will ultimately complete the questionnaire
are asked to read and respond to the survey items while verbalizing their
thought process, allowing the researchers to refine survey items to increase
 3 ACCESS TO HEALTH CARE 67

accurate understanding of the final survey instrument (Cimpian, 2017).

Finally, some researchers have used technology that embeds definitions in
computer-administered questionnaires to clarify survey items (Andrews,
Nonnecke, & Preece, 2003).
Random error is a sixth source of measurement error, resulting from
respondents answering survey items in a random way. The impact of ran-
dom responses is variable, possibly inflating estimates of sexual minor-
ity status and decreasing estimates of health disparities (Cimpian, 2017).
Reducing survey fatigue (e.g., by moving survey items pertaining to sexual
orientation and other demographics earlier in the survey) is one possi-
ble mechanism of reducing the impact of random error (Cimpian, 2017).
Attempting to mitigate survey fatigue does not address, however, the pos-
sibility of biased random reporting of health disparities, as such outcome
measures are likely to appear later in the survey (Cimpian, 2017). A final
source of error is the issue of researchers choosing the thresholds or cut-off
points for the categorization of sexual minority status (Cimpian, 2017). As
sexuality has been viewed on a continuum (e.g., exclusively heterosexual to
exclusively homosexual) by many researchers since the 1940s (e.g., Kinsey,
Pomeroy, & Martin, 1948), the problem of reducing this continuum to
a categorical measure has created several forms of error (Cimpian, 2017).
For example, researchers’ choice of where to place the threshold of het-
erosexual versus homosexual can decease the likelihood of replicating find-
ings in other studies that may define thresholds differently; furthermore,
if researchers’ thresholds define some non-sexual minority individuals as
sexual minorities, then the results will overestimate the sexual minority
population and likely underestimate health disparities (Cimpian, 2017).
The reverse would be in effect if researchers’ thresholds define some sexual
minority individuals as non-sexual minorities, as results will underestimate
the sexual minority population and likely overestimate health disparities
(Cimpian, 2017). Cimpian (2017) concludes his investigation of measure-
ment error in research concerning sexual minority youth with the hopes
that future research will more accurately measure sexuality on a continu-
ous spectrum and separate the “latent” or underlying construct of sexual
orientation from the aforementioned sources of classification error.
68 S. R. NOTARO

Attempts to Repeal the ACA: Impact on LGBT Health

The ACA’s provisions that expanded the health care access of all Americans,
added nondiscrimination protections, and expanded data collection would
have been diminished if the attempt to repeal and replace the ACA in 2017
had been successful (GovTrack.US, H.R. 1628: American Health Care Act
[AHCA] of 2017). The American Health Care Act of 2017 (AHCA) was
championed by a group of United States House of Representative and Sen-
ate Republicans as a way to replace the ACA through budget reconciliation
which allows Congress to pass a bill with a simple majority in the Senate
rather than the 60 votes needed to block a filibuster (GovTrack.US, 2017).
Passing a bill in this manner with a simple majority in the Senate requires the
bill to only make changes that would impact the federal budget as opposed
to changes such as the ACA’s ban on insurance companies denying cov-
erage to people with preexisting health conditions (GovTrack.US, 2017).
The AHCA sought to retain some components of the ACA including the
health care exchanges administered by the states and the federal govern-
ment which sold individual and small business health insurance plans; the
requirement that dependents may continue to be covered by their parents’
plan until age 26; the federal government’s payment of subsidies for premi-
ums based on income; and a revised version of the individual mandate which
would impose a penalty for individuals who do not obtain health insurance
(The Henry J. Kaiser Family Foundation, 2017). The AHCA would have
repealed several features of the ACA including the expansion of Medicaid
eligibility to low income individuals who are not disabled or parents of
dependent children; the expansion of Medicaid coverage of mental health
and addiction services; the elimination of fines for large employers who do
not offer health insurance coverage; small business tax credits; and limits
on the health insurance premiums paid by older individuals as opposed to
younger individuals (The Henry J. Kaiser Family Foundation, 2017).
Several provisions of the AHCA were projected to have a specific and
negative impact on LGBT individual’s access to health care (The Fenway
Institute, 2017). By 2020, the AHCA’s stipulation that Medicaid eligibility
be contingent on income, disability, or parental status, would require peo-
ple living with HIV who seek coverage from Medicaid for health insurance
and life-saving HIV medication to meet the definition of disabled—that
their disease has progressed to AIDS (The Fenway Institute, 2017). Fear
of not being able to re-enroll in Medicaid in case of a job loss might deter
 3 ACCESS TO HEALTH CARE 69

individuals with HIV from seeking a higher paying job with private insur-
ance (The Fenway Institute, 2017). The AHCA’s revised version of the
individual mandate, which would replace the ACA’s flat yearly penalty
for lack of coverage with a 30% insurance surcharge for individuals who
have a lapse in coverage of more than 63 days, would force individuals
with HIV who lose their coverage and are unable to replace it within the
required timeframe to pay the 30% surcharge (The Fenway Institute, 2017).
The AHCA’s prohibition of Medicaid reimbursements for Planned Parent-
hood’s reproductive health, maternal health, and child health services could
disproportionately and negatively impact the LGBT community, and more
specifically Black and Latino men who have sex with men and transgen-
der women of color, who are burdened by disproportionately higher rates
of HIV, other sexually transmitted infections, and unwanted pregnancies
(The Fenway Institute, 2017).
On May 4, 2017, the United States House of Representatives voted in
favor of passing the AHCA and repealing the Patient Protection and ACA
with a vote of 217 in favor and 213 opposed (Kaplan & Pear, 2017). The
House’s narrow passage of the bill revealed stark disagreements within the
Republican party regarding essential health benefits, protections for those
with preexisting conditions, and higher insurance rates for older versus
younger enrollees (Doran, 2017). In response to the passage of the House’s
version of the AHCA, the Senate developed several amendments or bills,
including the Health Care Freedom Act also known as “skinny repeal” of
the ACA (Klein, 2017). The Health Care Freedom Act would have left the
ACA’s Medicaid expansion intact, but would have repealed the individual
mandate to have health coverage and the requirement of large employers
to cover their employers, resulting in an estimated 15 million Americans
without health insurance and premium increases of 20%; however, none of
the amendments received enough votes to pass, leading to a 49–51 defeat
of the bill in the Senate (Klein, 2017).
In September 2017, Republicans made one last attempt to repeal Oba-
macare via the Graham-Cassidy plan which would have provided funds to
states to operate their own health care programs while reducing Medi-
caid funding as well as ending both subsidies to help individuals purchase
health insurance policies and the reimbursements provided to insurance
companies offering price reductions on copayments and deductibles to low
income individuals (Kodjak, 2017). The Graham-Cassidy plan failed to gain
enough support to put the bill to a vote on the Senate floor, with several
Republicans refusing to support the bill due to its attempts to decrease
70 S. R. NOTARO

Medicaid funding and to weaken protections for people with preexisting

conditions (Cornwell, 2017). After seven years, the Republican effort to
repeal Obamacare failed (Cornwell, 2017).
While the ACA is currently the law of the land and continues to pro-
vide health insurance for an estimated 20 million Americans, including low
income, ethnic minority, and LGBT individuals, on December 14, 2018,
Judge Reed O’Conner, a federal district court judge in Texas, responded to
a lawsuit brought by Republican attorneys general from 20 states challeng-
ing the constitutionality of the ACA’s individual mandate (Hadar, 2018).
Judge O’Connor ruled that because a recent Trump administration tax
reform bill set the individual mandate’s tax to zero, then Congress could
no longer constitutionally impose a tax or penalty on those individuals who
did not obtain health insurance (Hadar, 2018). Judge O’Connor ruled
that without the individual mandate, the rest of the ACA should not stand
(Hadar, 2018). As the judge did not issue an injunction, the ACA contin-
ues during the appeal process which will likely land at the U.S. Supreme
Court (Hadar, 2018).

Summary
This chapter focused on culturally competent health care, access to health
insurance, and the Affordable Care Act’s impact on LGBT health and
well-being. Butler et al.’s (2016) review of attempts to provide culturally
competent LGBT health care training concluded with a call for a main-
stream approach to delivering culturally competent care to LGBT individ-
uals, ensuring that patients have the choice of where to obtain care that is
not driven by stigma or lack of skill. Next, the chapter explained recent legal
and policy changes that have led to expanded access to health insurance for
LGBT individuals, including the legalization of same-sex marriage and the
expansion of many coverage and anti-discriminatory provisions of the ACA.
The chapter also discussed several attempts to erode the ACA’s provisions
that expanded the health care access of all Americans, added nondiscrim-
ination protections, and expanded data collection. In sum, the access to
health care for LGBT persons faces renewed challenges under the Trump
administration. It is likely that the U.S. Supreme Court will again weigh
in on the overall legality of the ACA with possible negative consequences
and impacts on health disparities experienced by marginalized populations
such as the LGBT community. Chapter 4 of this volume will discuss the
 3 ACCESS TO HEALTH CARE 71

history and evolution of HIV/AIDS within the LGBT community as well

as some promising avenues for prevention and intervention.

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cent self-report surveys. Field Methods, 18, 223–244.
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chievous responders: Several suggestions to assess conclusions. Educational
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of Research on Adolescence, 24, 5–13.
Savin-Williams, R., & Joyner, K. (2014). The dubious assessment of gay, les-
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opinions.
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HIV/AIDS, LGBT Health. (2017, March). The American Health Care Act
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nhsr/nhsr077.pdf.
 CHAPTER 4

HIV/AIDS

This chapter will discuss disparities in sexually transmitted infections,

including the human immunodeficiency virus (HIV), that exist among
some of the most stigmatized members of the LGBT community.

Because of the lack of education on AIDS, discrimination, fear, panic, and

lies surrounded me. (Ryan White, hemophiliac who died from AIDS in 1990
at the age of 19)

These life-threatening disparities illustrate how silence, bias, and isolation

that were also present in the pre and immediate Stonewall era can lead to
unequal treatment, victimization, and poor health outcomes. Furthermore,
such health disparities have devastating consequences for men who have sex
with men (MSM) and transgender women in particular with MSM account-
ing for approximately 2% of the population but nearly 70% (26,200) of new
HIV infections as of 2014 (U.S. DHHS, 2018). Further, as of 2015 more
than 600,000 gay and bisexual men were living with HIV in the United
States and were estimated to account for 55% (10,047) of people who
received an AIDS diagnosis (U.S. DHHS, 2018). Disparities within this
population are apparent, as racial minorities are overrepresented in those
gay and bisexual men with an AIDS diagnosis—39% African American, 31%
White, and 24% Hispanic/Latino (U.S. DHHS, 2018). As 1 in 6 or approx-
imately 17% of gay and bisexual men living with HIV are unaware of their

© The Author(s) 2020 75

S. R. Notaro, Marginality and Global LGBT Communities,
Neighborhoods, Communities, and Urban Marginality,
https://doi.org/10.1007/978-3-030-22415-8_4
76 S. R. NOTARO

infection, they are less likely to seek drug therapy and to engage in behav-
iors that would prevent transmitting HIV to partners (U.S. DHHS, 2018).
Gay and bisexual men also report higher rates of other sexually transmitted
infections including syphilis, gonorrhea, and chlamydia. Moreover, men
who have sex with men (MSM) are more likely to exhibit antimicrobial
resistant strains of gonorrhea, resulting in decreased effectiveness of drugs
designed to fight infection (U.S. DHHS, 2017).

History of HIV/AIDS
Before examining the current state of the transmission, prevention, and
intervention of HIV infections, and ways in which an understanding of
the Stonewall resistance (discussed in Chapter 1 of this volume) might
prove empowering, it is important to trace the history of HIV/AIDS. In
the 1970s, after experiencing an uplifting sense of belonging spurred by
Stonewall riots, the LGBT community began to openly explore sexuality,
enjoying the same sexual freedoms as heterosexuals (Bausum, 2015). And
then, in 1981, the symptoms of AIDS (Acquired Immunodeficiency Syn-
drome) were first identified—skin lesions, pneumonia, night sweats, throat
infections—that did not respond to treatment. All of those affected, mostly
young men who had been healthy prior to these symptoms, died, often
within months (Bausum, 2015). As the crisis was identified with homo-
sexual men, staunch political conservatives such as Patrick J. Buchanan
declared that AIDS was God’s will and served as a punishment for immoral
behavior:

The poor homosexuals. They have declared war upon nature, and now nature
is exacting an awful retribution. (Patrick Buchanan, 1983, New York Post )

Some other conservative politicians urged that persons infected with

AIDS should be branded and quarantined (Bausum, 2015). During the
presidency of Ronald Reagan, the AIDS crisis was largely ignored, with
President Reagan finally mentioning it publicly for the first time near the
end of his term in 1987 (Bausum, 2015). By the end of 1987 more than
50,000 cases of AIDS, mostly among gay men, had been diagnosed, result-
ing in extremely high mortality (Bausum, 2015). As in the pre-Stonewall
era, silence and stigma were rampant as the U.S. government failed to pro-
vide funding or support for this devastating new disease (Bausum, 2015).
Beliefs among some gay men that their lifestyles were under attack while
 4 HIV/AIDS 77

receiving no support from the government created a deadly environment

associated with more infections and mortality (Bausum, 2015).
Just when it seemed that the momentum from the Stonewall resistance
was permanently squelched by the dire AIDS crisis, a new era of activism
formed to demand federal funding and political action to combat AIDS.
In 1987, the AIDS Quilt was first displayed with panels honoring almost
50,000 Americans who had died of AIDS (Bausum, 2015). During the
same year, gay persons and straight supporters formed ACT UP or the
AIDS Coalition to Unleash Power, which helped to unite gay men and
lesbians in the fight against AIDS (Bausum, 2015). The tactics and strate-
gies employed by ACT UP harkened back to those of earlier gay rights
groups that had emerged in the immediate months and years after the
Stonewall riots—zaps, theater, and civil disobedience (Bausum, 2015).
ACT UP targeted several key institutions who could do more for the AIDS
crisis including the Food and Drug Administration and the National Insti-
tutes of Health. Notably, the White House, under George H.W. Bush’s
presidency, was the target of a 1992 protest in which ashes of AIDS victims
were tossed on the White House lawn (Bausum, 2015).
AIDS continued to ravage not only the gay male community, but also
persons who injected drugs (PWID) and those who underwent drug trans-
fusions. This dire situation changed, however, when President Bill Clin-
ton provided hundreds of millions of federal dollars for AIDS research
(Bausum, 2015). Three years into his first term, the National Institutes of
Health formulated a powerful and effective antiretroviral “cocktail” that
prevented the progression of AIDS. Although not a cure, this discovery
ended the death sentence for those who could access the cocktail. AIDS
deaths in the United States reached a peak of nearly 50,000 in 1995 but
then declined. Additionally, the new funding for awareness and prevention
greatly decreased the number of new infections.
In response to evidence that the HIV/AIDS epidemic was especially
critical in sub-Saharan Africa and low and middle income communities,
President George W. Bush created the President’s Emergency Plan for
AIDS Relief (PEPFAR) in 2004 (Peng, 2015). Funding for antiretro-
viral treatment (ART) was the main focus of PEPFAR. Evidence from
the Joint United Nations Programme on HIV/AIDS (UNAIDS) demon-
strated that, from 1995 to 2013, antiretroviral drugs provided by PEPFAR
and other agencies such as the Global Fund to Fight AIDS, Tuberculo-
sis, and Malaria have averted an estimated 7.6 million AIDS-related deaths
78 S. R. NOTARO

globally, including 4.8 million deaths in sub-Saharan Africa (UNAIDS,

2014).
In 2010 President Barack Obama launched the first National
HIV/AIDS strategy and updated it in 2015 (“Fact Sheet,” 2015). The
four goals of the initiative remain the same—to reduce the number of
new HIV infections, to increase access to health care and improve health
outcomes for people living with HIV, to reduce HIV-related disparities
and health inequities, and to achieve a more coordinated national response
(“Fact Sheet,” 2015).
Although considerable progress has been made in the AIDS epidemic,
including marked reductions in new HIV infections and AIDS-related
deaths, Table 4.1 provides evidence that HIV remains a significant global
public health problem (UNAIDS, 2017). According to 2017 global esti-
mates from UNAIDS, 36.9 million people were living with HIV, 1.8 mil-
lion people were newly infected with HIV, and 940,000 persons died from
AIDS-related deaths (UNAIDS, 2017). In terms of the United States,
2017 estimates found that 1.1 million people were living with HIV, 38,
739 people were newly infected with HIV, and 15, 807 persons died from
AIDS (CDC, 2019).
While earlier diagnosis and treatment would prevent HIV transmission,
as of 2017, 59% of the 36.9 million people living with HIV were receiving

Table 4.1 2017

Worldwide United States
estimates of HIV/AIDS
worldwide and in the 36.9 million living with 1.1 million living with
United States HIV HIV
1.8 million new HIV 38,739 new HIV
infections infections
940,000 AIDS-related 15,807 AIDS-related
deaths deaths

Note Author created using information adapted from UNAIDS

(2017). UNAIDS Fact Sheet, World AIDS Day 2018. Joint
United Nations Programme on HIV/AIDS. UNAIDS Data 2017.
Retrieved from https://www.unaids.org/sites/default/files/media_
asset/UNAIDS_FactSheet_en.pdf
Author created using information adapted from Centers for Disease
Control and Prevention. Estimated HIV incidence and prevalence
in the United States, 2010–2016. HIV Surveillance Supplemental
Report 2019, 24 (1). Published February 2019. Retrieved from
https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-
hiv-surveillance-supplemental-report-vol-24-1.pdf
 4 HIV/AIDS 79

ART (UNAIDS, 2017). The United Nations has adopted a new target
that by 2020, 90% of all people living with HIV will know their status, 90%
of those diagnosed will have sustained access to ART, and 90% of those
on ART will be virally suppressed (UNAIDS, 2014). Achieving this goal
requires coordinated and effective strategies at the urban, rural, regional,
and national levels (Granich et al., 2015).
As mentioned earlier in this chapter, recent data demonstrates that men
who have sex with men (MSM), many of whom identify as gay, bisex-
ual, and transgender, are the group most at risk for new HIV infections
in the United States and globally (U.S. DHHS, 2018; Vermund, 2014).
Even more specific models examining age and racial/ethnic differences
within MSM suggest that the highest rates of continued transmission in
the United States and globally exist among young African American and
Latino MSM (Vermund, 2014). In Africa estimates suggest that transmis-
sion would likely continue among the most at risk populations even if
incidence were to decrease in the general population. These vulnerable
groups include men who have sex with men, persons who inject drugs
(PWID), female sex workers, and migrant men employed by the trucking
and mining industries who often have multiple and concurrent partners
(Vermund, 2014). Similar high transmission among MSM is found in Asia,
South America, the Caribbean, and Europe (Vermund, 2014).
These trends are alarming in many ways including data indicating that
nearly 75% of young men of color who have sex with men (YMCSM) in
the United States are not reached by current prevention efforts (Finlayson,
2011; Patel, Masyukova, Sutton, & Horvath, 2016). Patel et al. (2016)
suggest that traditional intervention efforts may be less likely to reach this
population because these individuals may be less likely to label themselves
as gay or bisexual and/or may be unlikely to visit or access LGBT or HIV
agencies and services.
These findings also place into context the evidence of global declines
in AIDS-related deaths which peaked worldwide in 2004 and have since
declined by more than 51% (UNAIDS, 2017). In 2017, 940,000 persons
died from AIDS-related illnesses worldwide, compared to 1.4 million in
2010 and 1.9 million in 2004 (UNAIDS, 2017). While such declines are
a positive sign in the fight against HIV, the progress is robust only where
prevention strategies have been widely implemented and embraced by the
affected population (Vermund, 2014). While prevention strategies have
increased significantly over time, they rely on behavior change and uptake
by affected populations (Vermund, 2014). The most widely employed
80 S. R. NOTARO

behaviorally based prevention strategies (e.g., male condoms, antiretro-

viral drugs to kill the virus near the time of exposure or at early infection
and to prevent the transmission of the virus from mother to infant, male
circumcision, and needle exchange), all face potentially daunting barriers to
success—awareness, availability, acceptability, affordability, and adherence
(Vermund, 2014). It is important to emphasize that these approaches must
be understood in the context of the social determinants of health such as
external and societal biases that impact access to and quality of health care
for those most vulnerable to HIV/AIDS.

HIV Transmission and Risky Sexual Behaviors

Understanding what may produce behavior change, and what may impede
it, are critical factors in the transmission of HIV. Diaz, Ayala, and Bein
(2004) tested a multivariate mediation model of predictors of sexually
risky behaviors among a sample of gay (including MSM) Latino men in
three large U.S. cities. The first component of the mediation model tested
whether social oppression (including homophobia, racism, and poverty)
was positively associated with higher levels of participation in sexually risky
behaviors (e.g., failure to consistently use condoms) by producing high lev-
els of psychological distress. The second component of the model examined
whether individuals who experience higher levels of social oppression and
psychological distress are more likely to participate in “difficult” sexual sit-
uations (e.g., having sex to relieve depression and loneliness; sex under
the influence of drugs). The third component of the model hypothesized
that participation in difficult sexual situations mediates the impact of social
oppression and psychological distress on sexual risk behavior.
Results indicated that a substantial number of Latino gay men in the
United States reported social oppression related to being poor, Latino,
and gay, multiple instances of verbal and physical abuse during childhood,
and discrimination in adulthood related to their sexual orientation and eth-
nicity. Racial discrimination was experienced within the gay community as
participants reported being objectified as sexually exotic in mostly white
gay communities (Diaz et al., 2004). Participants also reported high lev-
els of financial distress in the last twelve months, which was strongly and
positively related to psychological distress in the last 6 months.
Diaz et al. (2004) found support for their mediational model which
illuminates the continued ethnic disparities that exist in HIV/AIDS preva-
lence and incidence among MSM. First, social oppression related to
 4 HIV/AIDS 81

race/ethnicity, class, and sexual orientation was strongly and positively cor-
related with sexual behaviors that led to higher levels of risk for HIV trans-
mission. Second, social oppression and psychological distress predicted par-
ticipation in risky sexual behaviors. Third, social oppression affected sexual
risk by increasing the likelihood that individuals would participate in situa-
tions that make it difficult to practice safer sex. For example, men who expe-
rienced more discrimination and psychological distress were more likely to
engage in sex under the influence of drugs or alcohol or to use sex as a way of
alleviating anxiety and stress. Participating in difficult sexual situations then
mediated the impact of social oppression on risky sexual behavior. Models
that emphasize the impact of contextual, external, and situational factors
shed light on why MSM, and particularly those of color, continue to bear
such a heavy HIV burden. Prior work by Diaz and Ayala (2001) demon-
strated that social isolation and low self-esteem among Latino gay men
can be alleviated by resiliency and strength-based approaches (e.g., family
acceptance of sexual orientation, community involvement and activism in
support of gay and Latino rights).
These findings demonstrating that community involvement and activism
can create a sense of empowerment and enhance self-esteem among Latino
gay men resonate strongly with testimonials from gay men and women
who participated in, witnessed, and learned about the Stonewall Inn riots
(Carter, 2004). To further bolster prevention efforts, we must understand
how to most effectively decrease the continued social isolation, discrim-
ination, and bias that can foster risky sexual behaviors, less adherence to
other prevention strategies, as well as less access to high-quality, culturally
competent health care.

The Minority Stress Model

As introduced in Chapter 1 of this volume, the minority stress model
(e.g., Meyer, 2003) offers a framework for understanding and examin-
ing the impact of bias, discrimination, homophobia, and marginality on
the unequal and poor health outcomes of lesbian, gay, bisexual, and trans-
gender individuals. The model explores the variability within sexual minor-
ity communities by explicitly investigating the intersectional and overlap-
ping identifies within the LGBTQ community—e.g., LGBTQ individuals
of color who hold unified identities as racial/ethnic minorities as well as
sexual minorities. Research has demonstrated that, at least in the United
82 S. R. NOTARO

States, LGBT individuals of color have a long and rich history of involve-
ment in the “mainstream” gay rights movement (e.g., Stonewall), as well
as within LGBT communities of color (Meyer, 2010). These communities
of support may serve as protective factors or buffers against homopho-
bia, harassment, and discrimination and in turn, lower the risk of health
disparities (Meyer, 2010).
Jeffries, Marks, Lauby, Murrill, and Millett (2013) investigated the
premise of the minority stress model in their examination of the impact
of homophobic events on the odds of black MSM engaging in risky sex-
ual behaviors (e.g., unprotected anal intercourse) and on whether social
integration factors (e.g., social support, closeness with family and friends,
attachment to black gay and religious communities, MSM social network
size) ameliorated these associations. Jeffries et al. (2013) identified homo-
phobia as one possible societal factor that may increase HIV risk infection
among MSM given prior evidence that HIV disparities within this sub-
population are not fully explained by individual-level risk behaviors. For
example, Black MSM often report less HIV risk behaviors (e.g., drug use,
unprotected sex) than non-black MSM (Feldman, 2010; Millet, Flores,
Peterson, & Bakeman, 2007). Jeffries et al. (2013) hypothesized that black
MSM who had been diagnosed with HIV infection as well as those who
had not been diagnosed and who had experienced homophobia (hostil-
ity solely based on their sexual orientation) would have increased odds of
participating in unprotected anal intercourse (UAI). Jeffries et al. (2013)
tested their hypothesis by analyzing data from the Brothers y Hermanos
cross-sectional study that investigated correlates of HIV risk behavior and
HIV infection among 1154 black MSM residing in New York City and
Philadelphia.
Participants were recruited from community-based organizations and
other venues frequented by black MSMs using respondent-driven sam-
pling whereby program staff initially recruited core subjects who then each
recruited additional participants (Jeffries et al., 2013). Each participant
completed an audio computer-assisted self-interview (ACASI) and, with
the exception of those who reported that they had been previously diag-
nosed with HIV, received a rapid oral fluid HIV antibody test (Jeffries
et al., 2013). The ACASI assessed demographic, behavioral, and psychoso-
cial variables including UAI, five perceived homophobic events and six
social integration constructs. Participants were asked to report events that
occurred because of perceptions that they were homosexual or not mascu-
 4 HIV/AIDS 83

line enough. The five negative, homophobic events were categorized into
none; low (respondent had to act more manly than usual to be accepted or
felt uncomfortable among heterosexuals at least once); medium (respon-
dents had been treated rudely, made fun of, or called names at least once);
and high (respondents were hit or beaten, at least once, irrespective of other
homophobic experiences) (Jeffries et al., 2013). Results indicated that the
prevalence of each type of homophobic event were similar for respondents
who were previously and not previously diagnosed with HIV. Over the
past 12 months, approximately 9–13% were beaten, 34–39% were treated
rudely, and 36–41% felt uncomfortable among heterosexual black people
(Jeffries et al., 2013).
Jeffries et al. (2013) assessed six social integration concepts including
social support, closeness with family members, closeness with gay and het-
erosexual friends, attachment to the black and religious communities, and
size of MSM social network (Jeffries et al., 2013). Approximately 17%
of the respondents who were not previously diagnosed with HIV tested
positive for the virus via a rapid oral fluid antibody test and a confirming
Western blot blood test and were subsequently referred to medical treat-
ment facilities for follow-up care (Jeffries et al., 2013). MSM who were
not previously diagnosed with HIV infection and who reported a medium
level of homophobic events were significantly more likely to engage in UAI
as compared to MSM who reported no homophobic events. In compar-
ison, MSM who were previously diagnosed with HIV infection and who
reported low, medium, or high levels of homophobic events were signifi-
cantly more likely to engage in UAI as compared to MSM who reported
no homophobic events.
The correlations between the severity of homophobic experiences and
UAI for both groups of MSM were not buffered by participants’ social
support, closeness with family or friends, or attachment to black gay and
religious communities, or MSM social network size (Jeffries et al., 2013).
Jeffries et al. (2013) postulate that the fact that all levels of homophobic
events were associated positively and significantly with UAI among MSM
previously diagnosed with HIV, but not among those with no diagno-
sis, may result from the psychological trauma of managing HIV stigma.
Indeed, prior research has demonstrated that homophobic experiences
negatively affect levels of self-esteem, anxiety, depression, and internalized
homophobia among MSM which may then influence MSMs to seek com-
fort and intimacy through unprotected anal intercourse (e.g., Diaz, Ayala,
84 S. R. NOTARO

Bein, Henne, & Marin, 2001; Stokes & Peterson, 1998). The authors
caution that their results, including no evidence that social integration
buffers or dampens the association between homophobic experiences and
unprotected anal intercourse, should be interpreted with caution and not
generalized beyond this cross-sectional, non-randomized, sample of black
MSM living in two U.S. cities (Jeffries et al., 2013). The authors suggest
partnerships with communities, academic units, and government agencies
as possible interventions that may reduce the experience of homophobic
events that target black MSM and potentially result in increased risk for
HIV infection (Jeffries et al., 2013).
Balaji, Bowles, Hess, Smith, and Paz-Bailey (2017) build on the work of
Jeffries et al. (2013) by examining the relationship between sexual minor-
ity stigma or “enacted stigma” and sexually risky behaviors in a nationally
representative sample. Balaji et al. (2017) hypothesize that enacted stigma
related to sexual minority status may mediate the relationship between the
individual and HIV risky sexual behaviors (Balaji et al., 2017). To exam-
ine their hypothesis, the authors analyzed survey data from 9819 MSM
from the 2011 national HIV Behavioral Surveillance System. The mean
age of the sample was 34.6 years with 40% identifying as non-Hispanic
White, 27% as non-Hispanic Black, 25% as Hispanic, and 7% as other or
multiple race groups. In terms of education, income, and health insurance,
94% completed at least high school, one third reported earning less than
$20,000 annually, and 30% had no health insurance (Balaji et al., 2017).
Regarding sexual orientation and HIV infection status, 81% identified as
gay or homosexual, 93% had disclosed their sexual orientation to at least
one person, and 14% self-reported being HIV-positive. All respondents,
regardless of self-reported HIV infection status, were offered anonymous
HIV testing.
Enacted stigma was conceptualized with three variables including verbal
harassment (being called names), discrimination (receiving poorer services
in businesses, restaurants, schools, at work, in health care setting,), and
physical assault (being physically attacked). During the past 12 months,
59% of respondents reported no enacted stigma while 32% reported verbal
harassment, 23% reported discrimination, and 8% reported physical assault.
Results of multivariable analyses indicated that younger age, identification
as gay/bisexual, and disclosure of sexual identity were associated with a
greater risk of experiencing enacted stigma (Balaji et al., 2017). Balaji et al.
(2017) posit that asking subjects whether or not they experienced stigma
 4 HIV/AIDS 85

due to others knowing about their homosexuality instead of others know-

ing that they were HIV positive may have led to their unexpected finding
of no association between self-reported HIV status and enacted stigma.
Those respondents who reported enacted stigma related to sexual minor-
ity status in the past 12 months were more likely to report unprotected
anal intercourse at last sex with a HIV discordant (when one partner is
infected with HIV and the other is not) male and past 12 month unpro-
tected anal intercourse with a male partner; four or more male sex partners;
and exchange sex (e.g., sex in exchange for money or drugs). Thus, Balaji
et al. (2017) provide evidence consistent with prior research that experi-
encing stigma related to sexual minority status may put these individuals at
risk for acquiring and transmitting HIV.
Balaji et al. (2017) call for future research that explores whether MSM
who experience enacted stigma feel less empowered, have lower self-
efficacy, and have internalized feelings of shame and guilt that negatively
impact their agency to protect themselves with condoms during anal inter-
course (Balaji et al., 2017). Further, they emphasize that individual expe-
riences of enacted stigma are associated with numerous forms of societal
stigma present in communities, institutions, and laws that also negatively
impact HIV risk behaviors (Balaji et al., 2017). For example, a 2014 study
found that U.S. states with laws that criminalize various aspects of HIV such
as nondisclosure of HIV status to sexual partners have a higher incidence
and prevalence rate of HIV infection, possibly stemming from the increased
stigma associated with the criminalization of HIV (National Alliance of
State and Territorial AIDS Directors and National Coalition of STD Direc-
tors, 2014).
Balaji et al. (2017) acknowledge several limitations of their analyses
including the fact that their sample of 20 U.S. cities with high prevalence
of AIDS may not be representative of all MSM. Further, no rural MSM
were included, despite the evidence that sexual minority stigma may be
experienced to a larger extent in rural as compared to urban cities (Bal-
aji et al., 2017). Additional limitations include self-reported data, a lack
of sampling weights to account for complex sampling methods, possible
inaccurate attributions of stigma to sexual minority status, and data being
collected in 2011 prior to nationwide recognition of same-sex marriage,
which could have decreased stigma for MSM (Balaji et al., 2017). The
authors further acknowledge that their analyses did not include possible
mediating factors including mental health, stress, internalized homopho-
bia, or social support that might mitigate the impact of enacted stigma on
86 S. R. NOTARO

HIV risk behaviors (Balaji et al., 2017). Balaji et al. (2017) stress that any
HIV prevention efforts must function synergistically in biomedical, behav-
ioral, and structural domains while addressing the intersections of racial,
ethnic, socioeconomic, and sexual identities among MSM.

Social Media and HIV/AIDS Risk

To more fully understand the impact of social media use on the sexual risk
behaviors among urban, low income, young men of color who have sex
with men (YMCSM) and young transgender women, Patel et al. (2016)
conducted a formative study in New York City with a convenience sam-
ple of 102 individuals. Participants were recruited from community-based
organizations serving LGBT youth, bars frequented by minority gay self-
identified youth, and one dance competition. Demographic information
revealed that over 90% of respondents were under 30 years of age; mostly
Hispanic or Black (85.3%); male (80.4%); self-identified as gay or bisexual
(85.2%); had seen a doctor in the previous 12 months (85.2%), and used
condoms at last sexual intercourse (87.3%). In terms of HIV and sexually
transmitted infections (STIs), approximately 15% reported a STI in the
prior 12 months and 11% reported a positive HIV status. The majority of
respondents (67.6%) reported accessing the Internet and social media via
cell phones or other mobile devices. All of the individuals had at least one
social media profile while the vast majority (83.3%) had multiple profiles
and accessed the Internet and social media sites multiple times per day
(87.3%). In terms of sexual risk behavior and social media use, the major-
ity of respondents (56.7%) used social media to seek sexual partners while
approximately 20% used it to exchange sex for money and clothes or drugs
(10%).
Several limitations of Patel et al.’s (2016) study, including its cross-
sectional design and small convenience sample, preclude broader gener-
alizations of the findings; however, the overall results demonstrated that
among their sample, social media access and use were universal and fre-
quently used to engage in risky sexual behaviors. Further, the type of sites
used for finding sexual partners varied (e.g., general sites versus more spe-
cific sexual networking sites) and such variations in social media platforms
were sometimes associated with “exchange” sex. These findings point to
the need to tailor prevention efforts using social media in targeted and
specific ways to address the different areas of risk (Patel et al., 2016).
 4 HIV/AIDS 87

This sample also self-reported high prevalence of HIV and STIs; how-
ever, high levels of self-reported condom use at last sexual encounter, ever
being tested for HIV, and having seen a doctor in the last 12 months, are
encouraging signs suggesting that the positive health behaviors occurring
among this vulnerable population could be increased through effective use
of social media platforms (Patel et al., 2016). This possibility is bolstered
in that social media platforms are in line with Vermund’s (2014) assertion
that effective prevention strategies must have high awareness, availability,
acceptability, affordability, and adherence. Patel et al. (2016) further argue
for the use of social media in reaching this vulnerable population in that
online social networks can disseminate information “virally,” bolster social
support, and change norms.
Garett, Smith, Chiu, and Young (2016) investigated HIV/AIDS stigma
among a sample of Latino and African American MSM who resided in Los
Angeles, California and who reported using social media or social network-
ing sites. Garett et al. (2016) focused on HIV stigma and minority MSM
given prior evidence that HIV/AIDS stigma is a major negative influence
in the prevention of HIV infection. HIV/AIDS stigma has been associated
with a lower likelihood of disclosing HIV/AIDS status, a higher likelihood
of engaging in high-risk sexual behaviors, and decreased access to HIV care
(e.g., Brooks, Etzel, Hinojos, Henry, and Periez, 2005). Additionally, the
investigation of the use of social media among this population is warranted
given prior evidence that while 58% of the general population reported
accessing social networking sites, 80% of LGBT adults reported such use
(Pew Research Center, 2013). Garett et al. (2016) surveyed 112 respon-
dents who were recruited from online websites, venues frequented by gay
men, and respondent referrals who met the criteria for their study (e.g.,
African American and Latino males; English-speaking; registered Face-
book users; at least 18 years old; engaged in sex with men in the past
12 months). The respondents completed a questionnaire to measure sev-
eral items including HIV/AIDS stigma as well as type and frequency of
use of social, sexual, and/or general social networking sites (Garett et al.,
2016).
The mean age of respondents was 22 with most participants identifying
as homosexual (76%) and Latino (60%) or African American (30%). 75%
of respondents reported spending one or more hours per day in social net-
working sites in the past three months. The mean HIV/AIDS stigma com-
posite score for the entire sample was 22.2, with a range of 15–45. Approxi-
mately 4% of respondents reported a positive HIV status while another 13%
88 S. R. NOTARO

reported that they were unaware of their status. T-tests revealed no signifi-
cant difference between stigma scores for HIV-negative and HIV-positive
respondents. The HIV/AIDS stigma composite score was positively and
significantly associated with increased time spent on social networking sites
(Garett et al., 2016). The low HIV/AIDS stigma composite score is sur-
prising in this sample of minority MSM, as prior research has indicated
high stigma levels among this population (e.g., Brooks et al., 2005). The
authors point out that given some differences between minority MSM and
minority communities in regard to HIV stigma, future research should
explore differences in stigma between minority MSM who use social net-
working sites and minority MSM who do not use social networking sites
(Garett et al., 2016). Several limitations of this study limit the general-
izability of the findings and preclude any claims of causation, including
the cross-sectional design; small sample size; the individual-level measure-
ment of HIV/AIDS stigma as opposed to broader community, policy, and
institutional stigma; and the possibility that assessing Internet use with
time intervals as opposed to open-ended questions may have skewed the
responses (Garett et al., 2016).

HIV Prevention and Intervention in the United

States
In the United States, HIV/AIDS prevention/intervention efforts include
community-based participatory research programs (CBPR), community-
based organizations, biomedical approaches, and informational campaigns
(U.S. DHHS, 2018). The less common and more complicated approach,
CBPR, involves the community as equal copartners (rather than sub-
jects or respondents) in the design, execution, and evaluation of interven-
tions (Rhodes et al., 2014). CBPR involves a partnership between outside
experts including university-based scientists and researchers and lay com-
munity members and representatives from community-based organizations
(Rhodes et al., 2013). This approach involves action and change at multi-
ple intersections, including at the individual, group, community, policy, and
societal levels (Rhodes et al., 2013). Building such partnerships between
the community and scientists may produce interventions and programs that
are more relevant and culturally appropriate, more precise in terms of mea-
surement, analysis and interpretation of results, more likely to be adopted,
sustained, and disseminated, and more likely to attract robust participation
rates (Rhodes et al., 2013). Finally, the process of CBPR has the potential
 4 HIV/AIDS 89

to strengthen the community’s sense of its problem-solving capacity and

engagement in research to make changes in the community (Rhodes et al.,
2013).
Rhodes et al. (2013) developed the HOLA (Hombres Ofreciendo Lid-
erazgo Y Ayuda or Men Offering Leadership and Help) as a response
to Latino MSM who requested an HIV prevention intervention during
the initial implementation of the CBPR intervention, HoMBReS (Hom-
bres Manteniendo Bienstar y Relaciones Saludables or Men Maintaining
Well-Being and Healthy Relationships). While the original intervention,
HoMBRES, focused on HIV prevention for heterosexual Spanish-speaking
Latino men, the adapted intervention, HOLA, focused on Spanish-
speaking, less acculturated, Latino MSM (Rhodes et al., 2013). To ensure
that the partnership met the needs and priorities of the community, the
researchers employed an 11 step process to develop the HOLA interven-
tion (Rhodes et al., 2013). The academic researchers established a sub-
group of their new intervention team that included Latino MSM, repre-
sentatives from local community-based organizations, and local business
owners (Rhodes et al., 2013). As an initial step, the researchers reviewed
published and unpublished reports and briefs on the sexual health of Lati-
nos residing in the United States and on sexual health interventions for
Latino MSM in the United States Next a needs assessment was conducted
by interviewing 21 Latino MSM, aged 18 to 45 years old and administer-
ing a questionnaire to a respondent-driven sample of 190 Latino MSM.
Results of these ethnographic interviews and the survey indicated several
priorities among Latino MSM including the need for accurate informa-
tion about HIV and STD transmission, prevention, and treatment, and the
negative impact of internalized homophobia and traditional associations of
masculinity and manhood with risky sexual behaviors.
The researchers finalized the intervention priorities and goals through
close consultation with community forums, each attended by local Latino
MSM and community-based organization representatives. The interven-
tion priorities focused on increasing awareness of the prevalence of HIV
and STD infections as well as on transmission and symptoms; disseminating
information on access to and eligibility for health care services including
HIV/STD testing; enhancing skills in correct condom use; decreasing risky
health behaviors; changing norms of masculinity, maleness, and sexuality
that may compromise health; and building advocacy and supportive rela-
tionships to empower the community (Rhodes et al., 2013). The HOLA
researchers trained community members to serve as lay health advisors or
90 S. R. NOTARO

navigators (navegantes ) to build on the social support structures already

in place in the community including the help that Latino MSM were pro-
viding to each other in terms of transportation, housing, and jobs (Rhodes
et al., 2013). Utilizing Latino MSM instead of non-Latino MSM to deliver
the intervention was conceptualized as a more effective way to minimize the
stigma related to immigration and same-sex orientation within the Latino
community. The intervention team designed training modules for the nav-
igators using both social cognitive theory (Bandura, 1986) and empower-
ment education (Freire, 1973) to frame their intervention and understand
the processes involved in changing knowledge, attitudes, and behaviors
(Rhodes et al., 2013). The intervention materials included wallet-sized
cards that reinforced the navigators’ support model of “pay attention, ask
questions, offer advice, and together organize next steps” (Rhodes et al.,
2013). The navigators utilized additional materials including role-playing
scripts, data collection forms, and DVDs to illustrate self-efficacy and com-
munication skills surrounding condom use, HIV testing, and living with
HIV (Rhodes et al., 2013).
The navigators executed the HOLA intervention in one-on-one ses-
sions and group discussions, meeting monthly to debrief, share successes
and challenges, and provide social support to one another. Rhodes et al.
(2014) describe the challenges in the HOLA intervention as common
to most CBPR efforts. First, it can be difficult to define who represents
the community and to ensure that a variety of voices and viewpoints are
represented in the intervention planning, implementation, and evaluation
efforts. Next, the community’s desire to exercise some flexibility in adjust-
ing the research agenda to accommodate for changing priorities and needs
can conflict with the need to secure and maintain funding from agencies
with proscribed funding-criteria. On a related note, intense competition
among community-based organizations for HIV prevention funds can neg-
atively impact CBPR collaborations. Another challenge that surfaced in
the HOLA project was the focus of community-based organizations on
tasks, processes, and the maintenance of partnerships versus the attention
toward outcomes that is the traditional standard for researchers and scien-
tists. Finally, changes in leadership and staffing among CBPR partners that
are often associated with decreases in skills and capacity can lead to gaps
in the ability to achieve the interventions’ goals. Given these challenges,
all CBPR members must be fully committed and accept the realities of this
approach, recognizing that although the process can be more difficult and
 4 HIV/AIDS 91

time-consuming than a traditional researcher-driven project, the results can

be more authentic, effective, and sustainable (Rhodes et al., 2014).
Currently, there are few effective HIV programs targeting MSM and
Latino MSM in particular (Rhodes et al., 2013). The HOLA interven-
tion helped to fill that gap with a CBPR approach designed for immi-
grant Spanish-speaking Latino MSM, most of whom recently arrived in
the United States who had not participated in HIV prevention programs
in their countries of origin. Given that the burden of HIV among Latino
MSM continues to rise, HOLA’s structure that built upon the founda-
tion of existing community strengths, natural helpers, and social support
is especially crucial and potentially impactful in the efforts to assist Latino
MSM in their fight against HIV/AIDS. HOLA developed skills among
the navigators and other community partners including public speaking,
leadership, and mobilization of resources that will help the community at
large build capacity to surmount other health challenges (Rhodes et al.,
2013).
Given the growth in studies examining the use of social media and tech-
nology by Latino MSM (e.g., Meadowbrooke, Veinot, Loveluck, Hickok,
& Bauermeister, 2014), researchers analyzed baseline survey data from
167 respondents who participated in the HOLA intervention cited above
to examine differences between Latino MSM and transgender persons liv-
ing in the U.S. south who used sexual and social networking websites and
applications (apps) and those who did not (Sun, Reboussin, Mann, Garcia,
& Rhodes, 2016). Increasingly, websites and global positioning system
or GPS-based mobile applications target MSM with some (e.g., Grindr)
claiming to have five million male users in nearly 200 countries (Sun et al.,
2016). These platforms enable users to identify other MSM by displaying
profiles and photographs organized by geographic distance to the user and
subsequently to arrange in-person meetings (Sun et al., 2016). As users
may be interested in locating friends and social support, as well as sex-
ual partners, the researchers assert that social networking platforms can be
viewed as positive and affirming (Sun et al., 2016).
On average the respondents were 30 years old having lived in the United
States for approximately 10 years with three quarters reporting Mexico as
their country of origin (Sun et al., 2016). Approximately 28% of respon-
dents reported using social or sexual networking websites or applications to
find sexual partners at least once per month while 70% of the sample using
the Internet daily and 85% owned a cellular telephone (Sun et al., 2016).
Multivariate analyses demonstrated that respondents who reported using
92 S. R. NOTARO

social or sexual websites or applications at least monthly were more likely

to be younger and to report more male sex partners in the past 6 months
and a history of STD diagnosis and illegal drug use other than marijuana
in the past 6 months (Sun et al., 2016). Sun et al. (2016) caution that
due to several limitations of their study (e.g., cross-sectional design, small
non-probability sample), their findings do not support the premise that
the increase in number of male sex partners and rates of STD diagnosis are
caused by the use of social and sexual networking websites and applications
(Sun et al., 2016). Despite this lack of causality, given the vulnerability of
young minority MSM to HIV infection and the increasing popularity of
social and sexual networking sites among this community, more research is
needed to explore the efficacy of social media-based HIV interventions as
well as future and more advanced networking technology in this population
(Sun et al., 2016).

Centers for Disease Control and Prevention

The United States Department of Health and Human Services’ Cen-
ters for Disease Control and Prevention (CDC) is one of the main fed-
eral agencies involved in the efforts to decrease the spread of HIV in
the United States. The CDC’s approach to prevention and intervention
is three-pronged, including the funding of community-based organiza-
tions (CBOs), antiretroviral drugs, and information campaigns and part-
nerships (U.S. DHHS, 2018). Within the CDC, the National Center for
HIV/AIDS, Viral Hepatitis, STD, and TB Prevention follow the National
HIV/AIDS Strategy, launched in 2010 during the Obama administration
to address HIV in the United States (U.S. DHHS, 2014). This national
strategy specifies three goals designed to diagnose HIV early, provide effec-
tive care, and decrease transmission. The goals include increasing the num-
ber of HIV-positive persons who know their status to 90%; increasing the
proportion of newly diagnosed persons who are linked to care within three
months to 85%; and increasing the proportion of HIV-diagnosed individ-
uals with suppressed viral loads with an emphasis on the most vulnerable
communities of African Americans, Latinos, and gay and bisexual men of
all races (U.S. DHHS, 2014).
To evaluate the progress toward achieving these national goals and
inform resource allocation for HIV prevention efforts, the CDC mon-
itors the national HIV Care Continuum, which was launched in 2013
under the Obama administration (U.S. DHHS, 2014). Specifically, the
 4 HIV/AIDS 93

HIV care continuum details the steps from the time a person is diagnosed
with HIV through successful treatment of HIV with medications (U.S.
DHHS, 2014). The ultimate goal of the Continuum is to achieve viral sup-
pression to the point where the HIV virus is present in very low amounts or
undetectable (U.S. DHHS, 2014). This approach is designed to help peo-
ple with HIV live longer and reduce the likelihood of transmitting HIV to
others. Careful monitoring of those infected with HIV enables the CDC to
make progress in its goal of achieving viral suppression. The CDC monitors
the proportion of people with HIV who are in different stages of infection,
including those who have been diagnosed, linked to care with a health care
provider within three months of learning their status, received medical care
for HIV infection, prescribed antiretroviral drugs, and virally suppressed to
a very low level of HIV in the blood. The HIV Continuum can sometimes
move in different directions, as is the case when a virally suppressed indi-
vidual stops taking antiretroviral drugs (U.S. DHHS, 2014).
To monitor the HIV Continuum, the CDC uses two surveillance sys-
tems that provide complimentary information. The National HIV Surveil-
lance System (NHSS) provides data (including race/ethnicity, route of
transmissions, age) from every U.S. state and territory and the District
of Columbia on people who are diagnosed or who have died with HIV
(U.S. DHHS, 2014). The Medical Monitoring Project (MMP) provides
information (e.g., outcomes of treatment, number receiving care, number
prescribed antiretroviral therapy, and number of those who are virally sup-
pressed) from a weighted sample of people in U.S. states, cities, and Puerto
Rico who are living with HIV and who have been diagnosed (U.S. DHHS,
2014). The MMP data can be examined by race/ethnicity and sexual orien-
tation (e.g., young black MSM). The federal, state, and local government
track the movement along the HIV Care Continuum to identify areas of
need and a blueprint to improve outcomes.
The CDC spearheads many efforts to improve outcomes along the HIV
Care Continuum, including the funding of community-based organiza-
tions (CBOs). In 2017, the CDC provided approximately $11 million per
year for five years to 30 CBOs to provide HIV testing to young gay and
bisexual men of color and young transgender persons of color to decrease
numbers of undiagnosed HIV infections and increase linkages to care and
prevention services (U.S. DHHS, 2018). In 2015 the CDC began fund-
ing Project PrIDE (PreP, Data2Care, Implementation, Data, Evaluation),
a multipronged intervention program that targets MSM and transgender
persons by attempting to reduce the number of new infections and increase
94 S. R. NOTARO

access to care for those persons living with HIV. The main components
of Project PrIDE (e.g., PrEP and Data2Care) are three-year demonstra-
tion projects that support 12 health departments in distributing PrEP, an
antiretroviral drug that can be taken by an HIV negative person before
potential exposure to HIV to reduce risk of infection, and in expanding
or enhancing the linkage, retention, and reengagement in HIV care (U.S.
DHHS, 2015). A final and complimentary component of the CDC’s efforts
to decrease HIV infection is through national information campaigns and
partnerships that provide culturally appropriate messages about HIV test-
ing, prevention, and engagement in care to gay and bisexual men (U.S.
DHHS, 2015).

HIV Prevention and Intervention Globally

The international response to the HIV/AIDS epidemic has generated rec-
ommendations for the design and implementation of HIV programs at the
country level (Silva-Santisteban, Eng, Iglesia, Falistocco, & Mazin, 2016).
One group that has put forth recommendations includes the Investment
Framework for the Global Response to HIV—developed by a group repre-
senting a variety of organizations including UNAIDS, World Health Orga-
nization (WHO), PEPFAR, the World Bank, and the Global Fund. The rec-
ommendations include evidence-based interventions for prevention, treat-
ment, and support for people with HIV/AIDS in general. At the individual
level, recommendations emphasize condom distribution along with volun-
tary testing and counseling. At the societal level, recommendations focus on
enacting laws to protect vulnerable populations, and to reduce stigma and
poverty while increasing access to education and jobs (Silva-Santisteban
et al., 2016). In 2016 the WHO published updated guidelines for HIV
prevention and care for key populations, including the dissemination of
pre-exposure antiretroviral drugs (e.g., PrEP) as well as early antiretroviral
treatment following HIV diagnosis (e.g., PEP), increased access to testing,
and strengthening protective laws (WHO, 2016).

Latin America
In Latin America (the continent of South America in addition to Mexico,
Central America, and the islands of the Caribbean whose inhabitants speak a
Romance language) and the Caribbean (Cuba, Dominican Republic, Haiti,
Guadeloupe, Martinique, Puerto Rico, Saint-Barthelemy, Saint-Martin),
 4 HIV/AIDS 95

nearly 2 million people are estimated to be living with HIV with men who
have sex with men, transgender women, and sex workers at highest risk
(UNAIDS, 2017). Data specific to transgender women as a subpopulation
of MSM is often missing from global examinations of the HIV response
(Baral et al., 2013). Baral et al. (2013) conducted a meta-analysis using data
from the United States, six Asia-Pacific countries, five Latin American coun-
tries, and three European countries that estimated that transgender women
were nearly 50 times more likely to become infected with HIV than the
general adult population of reproductive age. Given that, globally, some of
the highest HIV prevalence rates are found in transgender women in Latin
America (e.g., 18–48%), Silva-Santisteban et al. (2016) conducted a review
of HIV prevention efforts in 17 Latin American countries that monitor
HIV rates of transgender women separately from MSM. Silva-Santisteban
et al. (2016) were interested in examining the multitude of intersectional
factors (e.g., individual, interpersonal, and structural) that contribute to
the vulnerability of transgender women’s risk for HIV infection in Latin
America. At the individual level, some of the most impactful risk factors
include unprotected receptive anal sex, substance use, high numbers of
sexual partners, and a high number of sex workers (Silva-Santisteban et al.,
2016). At the interpersonal level, low levels of condom negotiation skills
with partners and sex work-clients and high-risk partner pools are signif-
icant risk factors for transgender women, while structural factors include
social exclusion, violence, discrimination, bias, poverty, limited employ-
ment, and a lack of legal recognition of gender identity (Silva-Santisteban
et al., 2016).
The UNAIDS Fast Track Strategy has been adapted by Latin American
countries with the goal of ending AIDS as a public health threat by 2030
by achieving “90-90-90” targets such that 90% of people living with AIDS
know their HIV status, 90% of people diagnosed with HIV are receiving
treatment, and 90% of people on treatment have achieved viral suppres-
sion (Silva-Santisteban et al., 2016). The National Strategic Plans (NPSs)
comprise the outlines by which governments track and report their progress
toward achieving the “90-90-90” targets within the Global AIDS Response
Progress Reporting or GARPR (Silva-Santisteban et al., 2016). GARPR
maintains the official documents that track the progress of national goals
to reduce HIV infection and transmission—a process that requires the coor-
dination of stakeholders to assess HIV prevalence and incidence, as well as
the social context and identification of the most vulnerable populations,
96 S. R. NOTARO

strategies and protocols for the allocation of resources (Silva-Santisteban

et al., 2016).
Silva-Santisteban et al.’s (2016) review assessed the ways in which 17
Latin American countries design and implement prevention programs
for transgender women and the extent and impact of these programs,
along with the ways in which these responses support international rec-
ommendations on HIV prevention efforts among vulnerable populations.
Their review included several South American countries (e.g., Argentina,
Bolivia, Brazil, Chile, Colombia, Ecuador, Paraguay, Peru, Uruguay, and
Venezuela) as well as the Central American countries of Costa Rica, El
Salvador, Guatemala, Honduras, Nicaragua, Panama, and Mexico (Silva-
Santisteban et al., 2016). Their review focused on several areas including
legal rights of transgender people, design and implementation of programs,
access to and coverage of prevention services, use of new technologies,
alignment with international recommendations, community participation,
and best practices. Prior to the desk review of documents that were submit-
ted within GARPR, along with public reports, health surveys, and needs
assessment, Silva-Santisteban et al. (2016) conducted 12 key informant
interviews with representatives of United Nations (U.N.) agencies (e.g.,
UNAIDS, Pan American Health Organization) and a focus group with
transgender women to guide their document review. The 12 key informant
interviews, which were conducted via telephone, required the respondents
to identify key HIV prevention strategies for transgender women in Latin
American countries.
Silva-Santisteban et al. (2016) analyzed the data by country and by the
main elements of the intervention approach. The first element reviewed
included protective laws and social environments for transgender women.
Of the 17 south and central American countries reviewed, only Argentina,
Uruguay, and Mexico have passed gender identity laws allowing transgen-
der persons to change their legal identity by altering their name and sex
on identity documents. In Columbia and Panama, judicial processes have
been established to facilitate the change in legal identity. The data revealed
that of the 10 South American countries reviewed, all (with the exception
of Peru and Paraguay) have passed laws prohibiting discrimination on the
basis of sexual orientation and gender identity. As for Central America,
its laws are considered conservative in terms of LGBT populations. For
example, Costa Rica, Guatemala, Peru, and Mexico have identified certain
groups as opposing laws that protect LGBT rights and programs aimed at
providing sexual education, condom distribution, and intravenous drug use
 4 HIV/AIDS 97

harm reduction strategies to LGBT populations (Silva-Santisteban et al.,

2016). Although every Latin American country in this review identified
transgender women as a key population in their HIV progress reports,
only four countries (Argentina, Brazil, Mexico, and Uruguay) have put
into place interventions targeting transgender women and thus recogniz-
ing their specific health needs as distinct from MSM. The other countries
include transgender women with MSM in terms of data analysis, interven-
tion design and implementation.
The most common HIV prevention strategies include information and
education; condom distribution; diagnosis and treatment of sexually trans-
mitted infections (STIs); voluntary HIV counseling and testing; and peer
education. Most prevention services focus on STI and HIV diagnosis, treat-
ment and counseling and are provided in primary care facilities including
general hospitals (Silva-Santisteban et al., 2016). A few countries also offer
outreach efforts including education and testing at social and sex work loca-
tions while several of the largest clinics in Mexico also provide antiretroviral
treatment along with oral and mental health. The key informant interviews
with transgender women revealed that Bolivia, El Salvador, and Panama
do not distribute enough condoms to meet the demand of the popula-
tion, especially given the prevalence of sex work among poor, transgender
women. Based on the review of progress reports, Silva-Santisteban et al.
(2016) estimate that in the majority of Latin American countries, less than
50% of MSM and transgender women have been tested for HIV in the
last 12 months, resulting in a gap in the HIV Continuum of Care. The
use of antiretroviral HIV drugs before exposure (e.g., PrEP) and post-
exposure (e.g., PEP) is not yet widespread in Latin American countries, as
this practice is currently implemented by only three countries (e.g., Brazil,
Argentina, Mexico).
In the conclusion of their review, Silva-Santisteban et al. (2016) note a
lack of prevention services that move beyond individual-level risk reduc-
tion (e.g., condom use, HIV testing and counseling) and a disease control
approach to a more comprehensive rights-based perspective that address
the social determinants of the HIV epidemic. Most of the HIV preven-
tion efforts in Latin American countries are hampered by limited commu-
nity involvement, a weak public health system, limited human resources,
poor integration of referral and treatment services, and a high level of dis-
crimination against and mistrust among transgender women. Additionally,
Silva-Santisteban et al. (2016) identified inconsistencies in the strategies
outlined in some countries’ planning documents and the actual prevention
98 S. R. NOTARO

efforts that were implemented. Ecuador is a prime example of this situa-

tion in that its NSP or HIV planning document emphasized a human rights
approach to HIV prevention along with an acknowledgment of health as
a right and the continued marginalization of transgender women. Despite
this rights-based approach detailed in Ecuador’s NSP, the actual imple-
mentation of prevention efforts focused on individual risk amelioration
including condom distribution and HIV testing. The countries identified
as most thoroughly executing a comprehensive rights-based approach tar-
geting transgender women that is consistent with its NSP or national HIV
strategy include Argentina, Brazil, Mexico, and Uruguay (Silva-Santisteban
et al., 2016).
Both Argentina and Uruguay address HIV and other related health
issues of the LGBT population through a social inclusion and rights-
based model bolstered by the implementation of employment and poverty-
reduction programs. Brazil and Mexico prioritize HIV treatment for vul-
nerable populations including transgender women and intravenous drug
users, regardless of viral load or CD4 count. Brazil is credited with the
most comprehensive use of PEP, the post-exposure antiretroviral drug,
and with the assessment of PrEP, the pre-exposure antiretroviral drug, as
an integrated public health strategy. Silva-Santisteban et al. (2016) summa-
rize their review by emphasizing that despite the recognition of transgender
women as a key population for HIV in official strategic plans and progress
reports, very few of the intervention programs focus specifically on this
population. Further, HIV prevention is predominantly aimed at reduc-
ing individual risk through testing and condom distribution, rather than
employing a rights-based and disease control combination. Data collected
on the response to HIV mostly categorize MSM and transgender women
together, thereby impeding the planning, implementation, and monitor-
ing of approaches specifically targeted toward transgender women; fur-
thermore, the extreme paucity of data concerning transgender men results
in a gap in the understanding of the impact of HIV on this subgroup.
Final recommendations include adopting a multipronged approach based
on human rights; considering social determinants such as discrimination,
stigma, unemployment, and poverty; strengthening of public health and
community systems with adequate human resources for testing, retesting,
and treatment; and integrating transgender-specific health needs in the HIV
care continuum (Silva-Santisteban et al., 2016).
 4 HIV/AIDS 99

Africa
The HIV epidemic as well as the progress in HIV intervention and pre-
vention varies by region within the continent of Africa, with the highest
prevalence of HIV existing in East and Southern Africa (e.g., Botswana,
Kenya, Lesotho, Malawi, South Africa, Swaziland, Tanzania, Uganda, Zam-
bia, and Zimbabwe) (UNAIDS, 2017). This region accounts for only 6.2%
of the global population but over half of the total number of people living
with HIV (19.4 million) (UNAIDS, 2017). Table 4.2 demonstrates the
state of the HIV epidemic in West and Central Africa (e.g., Benin, Burk-
ina Faso, Cameroon, Central African Republic, Chad, Congo-Brazzaville,
Cote d’Ivoire, Gabon, Guinea, Mali, Mauritania, Niger, Senegal, Togo,
The Gambia, Ghana, Liberia, Nigeria, Sierra Leone, Cabo Verde, Guinea-
Bissau, Sao Tome & Principe, & Equatorial Guinea) as compared to East
and Southern Africa as well as the challenges faced throughout the region
in providing antiretroviral treatment (UNAIDS, 2017).
In terms of HIV intervention in East and Southern Africa, some coun-
tries including South Africa and Kenya have recently increased the political
and financial resources for prevention, treatment, and care, while most
other countries in the region rely heavily on external donations to fund
their HIV response (UNAIDS, 2017). The most impacted populations
within East and Southern Africa are men who have sex with men or MSM,
transgender people, young women, sex workers, prisoners, and people who

Table 4.2 2016

West and Central Africa East and Southern Africa
regional HIV and AIDS
data for Africa 6.1 million people living 19.4 million people living
with HIV with HIV
2% adult HIV prevalence 7% adult HIV prevalence
370,000 new HIV 790,000 new HIV
infections infections
310,000 AIDS-related 420,000 AIDS-related
deaths deaths
36% adults on 61% adults on
antiretroviral treatment antiretroviral treatment
22% children on 51% children on
antiretroviral treatment antiretroviral treatment

Note Author created using information adapted from UNAIDS

(2017). Joint United Nations Programme on HIV/AIDS. UNAIDS
Data 2017. Retrieved from http://www.unaids.org/en/resources/
documents/2017/2017_data_book
100 S. R. NOTARO

inject drugs or PWID (UNAIDS, 2017). Positive developments include

data demonstrating that the UNAIDS targets of 90-90-90, described pre-
viously in this chapter, are well within sight, given that in 2016, 76% of
people living with HIV were aware of their status, 79% were in treatment,
and 83% of those receiving treatment were virally suppressed (UNAIDS,
2017).
Barriers to HIV care and prevention include historical cultural, struc-
tural, and legal barriers including stigma, discrimination, and bias which
disproportionately and negatively impact HIV risk among key populations.
For example, in 2016 HIV prevalence among young women (aged 15–24)
in the region was twice that of young men (3.4% versus 1.6%) (UNAIDS,
2017). High levels of sex work, young women marrying much older men,
lack of educational opportunities, and intimate partner violence all con-
tribute to an increased HIV risk for young women (UNAIDS, 2016). In
2013 regional ministers of health and education in Eastern and South-
ern Africa began in earnest to fund programs designed to address many
of these barriers with a focus on keeping young girls in school, providing
sex education and targeted reproductive services, reducing sexual violence
and female genital mutilation, and increasing political power (UNAIDS,
2016). One example of a successful intervention is the DREAMS interven-
tion project designed to reduce HIV infections among adolescent girls and
young women by 40% in Kenya, Lesotho, Malawi, Mozambique, South
Africa, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe (USAID,
2016). Intervention components focus on decreasing social isolation, dis-
crimination, stigma, and gender-based violence while increasing access to
education and economic opportunities (USAID, 2016). Results of the
intervention are forthcoming, but preliminary data reveal that more than
1 million adolescent girls and young women received services associated
with DREAMS in 2016 (PEPFAR, 2017).
Attempts to reduce HIV transmission among people who inject intra-
venous drugs (PWID) in East and Southern Africa are expanding but cur-
rently exist on a small scale. The most prevalent “harm reduction” strategies
for PWID include needle and syringe programs, education on safe injecting
practices, and opioid substitution therapy. Kenya serves as a best practice
nation in this region for their implementation of harm reduction strate-
gies as Kenya has provided such services since 2012 resulting in a marked
increase in reports of using a clean syringe at last injection among PWID
from 2012 to 2015 (51.6% compared to 90%) (Hyde, 2016).
 4 HIV/AIDS 101

Overall, many challenges to HIV intervention and prevention remain

entrenched in East and Southern Africa which act as barriers to achieving
the UNAIDS 90-90-90 targets. At the individual and interpersonal level,
the use of both PrEP and PEP must be scaled up, along with sex and
reproductive education, voluntary medical male circumcision, condom and
lubricant distribution, and harm reduction for PWID. At a structural level,
funding must increase for community-based clinics and health services,
as well as programs targeting HIV-related stigma, discrimination, and bias
which disproportionately affects the populations most vulnerable to HIV—
MSM, sex workers, transgender people, and PWID.
Although HIV prevalence is lower in West and Central Africa in com-
parison to East and Southern Africa (see Table 4.2), less than half of those
living with HIV in West and Central Africa are aware of their HIV status,
resulting in a very low uptake of antiretroviral drug treatment (UNAIDS,
2017). This lack of treatment is the most impactful influence on this region
being home to the most AIDS-related deaths globally (UNAIDS, 2017). In
terms of specific key populations impacted by HIV, four out of ten children
aged 0–14 who die of AIDS once lived in this region (UNAIDS, 2017).
Women are also a key population disproportionately impacted by HIV in
this region, with adolescent girls and young women aged 15–24 more likely
to acquire HIV than their male counterparts of the same age (UNAIDS,
2016). Many of the same factors impact the HIV epidemic for children
and women in this region, including the failure to diagnose and administer
antiretroviral therapy to pregnant women and to the estimated 540,000
children living with HIV in this region, as well as high levels of underaged
child and forced marriage, domestic violence, and rape (UNAIDS, 2017).
One example of a successful HIV intervention targeting young women is
MTV Shuga, a campaign that delivers original content focused on HIV
and sexual and reproductive health messaging (MTV Staying Alive, 2017).
Originating in Kenya in 2009, MTV Shuga has now been shown in Nige-
ria and several other countries in the region (MTV Staying Alive, 2017). A
2016 study funded by the World Bank in Nigeria revealed a 35% increase
in HIV testing for Nigerian youth who reported watching MTV Shuga for
up to six months and over half for those who watched the series for longer
periods of time (The World Bank, 2016).
In addition to children and young women, key affected populations in
this region include sex workers, PWID, and men who have sex with men, all
of whom are negatively impacted by stigma, discrimination, and legal barri-
ers such as the criminalization of sex work, drug use, and same-sex relations
102 S. R. NOTARO

that prevent access to HIV counseling, therapy and treatment (UNAIDS,

2017). For example, Northern Nigeria and Mauritania impose the death
penalty for MSM while homosexuality is also illegal in Cameroon, Gambia,
Ghana, Guinea, Senegal, Sierra Leone, and Togo (Amnesty International,
2017). Overall, the response to the HIV epidemic in West and Central
Africa requires enhanced and sustainable local and international funding,
as well as a more integrated public health system to effectively imple-
ment voluntary medical male circumcision, harm reduction for PWID, and
antiretroviral treatment (both PrEP which is not yet available in this region
and PEP) (UNAIDS, 2017).

Asia and the Pacific

The HIV epidemic, as well as the progress in HIV intervention and preven-
tion, in Asia and the Pacific varies greatly within the region and by country.
Asia and the Pacific is generally considered to include countries near the
Western Pacific Ocean and typically includes East Asia, South Asia, South-
east Asia, and Oceania. The region as a whole accounts for the second
highest HIV prevalence in the world with 5.1 million people living with
HIV, while India has the third largest HIV epidemic in the world with 2.1
million people living with HIV (UNAIDS, 2017). Table 4.3 demonstrates

Table 4.3 2016

Asia and the Pacific India
regional HIV and AIDS
data for Asia and the 5.1 million people living 2.1 million people living
Pacific and India with HIV with HIV
0.2% adult HIV prevalence 0.3% adult HIV prevalence
270,000 new HIV 80,000 new HIV
infections infections
170,000 AIDS-related 62,000 AIDS-related
deaths deaths
47% adults on 50% adults on
antiretroviral treatment antiretroviral treatment
40% children on 33% children on
antiretroviral treatment antiretroviral treatment

Note Author created using information adapted from UNAIDS

(2017). Joint United Nations Programme on HIV/AIDS. UNAIDS
Data 2017. Retrieved from http://www.unaids.org/en/resources/
documents/2017/2017_data_book
 4 HIV/AIDS 103

the state of the HIV epidemic in Asia and the Pacific as a whole as well com-
pared with India, as well as the challenges faced throughout the region in
providing antiretroviral treatment (UNAIDS, 2017).
In terms of HIV intervention in Asia and the Pacific, some countries
have made significant progress in the HIV epidemic, with some prevention
programs estimated to have decreased new HIV infections by 13% since
2013 (UNAIDS, 2017). Despite these positive developments, late diag-
nosis of HIV is a major concern across the region. Similarly to Africa, in
Asia and the Pacific, the populations most impacted by HIV are men who
have sex with men or MSM, transgender people, sex workers, prisoners,
and people who inject drugs or PWID (UNAIDS, 2017). MSM residing
in urban areas (e.g., Bangkok, Thailand, Yangon, and Yogyakarta) are par-
ticularly affected by HIV with prevalence rates ranging from 20 to 29%
overall and incidence or new infections especially high among young MSM
aged 18–21 as compared with MSM over the age of 30 (UNAIDS, 2017).
The rate of new infections among young MSM in this region (including
high income countries such as Australia) is even more alarming given sur-
vey results indicating that young MSM have less access to HIV prevention
and testing services and engage in less condom use as compared to older
MSM (UNAIDS, 2017). Often referred to as a subpopulation of MSM,
transgender women in some urban areas (e.g., Delhi, Mumbai, and Phnom
Penh) have been found to have a higher HIV prevalence as compared with
MSM (Asia Pacific Coalition on Male Sexual Health, 2013). The extreme
isolation and discrimination faced by transgender people as well as a lack of
legal recognition of transgender identity and rights throughout Asia and
the Pacific are barriers to accessing HIV prevention and services and formu-
lating effective policies and programs for this key population (Asia Pacific
Coalition on Male Sexual Health, 2013).
In terms of injection drug use, over one third of people throughout the
globe who inject drugs (PWID) reside in Asia and the Pacific where HIV
prevalence and incidence among this population varies among countries.
For example, in 2015 20–65% of new adult HIV infections were found
among PWID in the three countries of Vietnam, Pakistan, and Myanmar
(UNAIDS, 2017). Several factors drive the high HIV prevalence among
PWID in this region including high incarceration rates combined with
limited harm reduction in the form of opioid substitution therapy and nee-
dle exchange programs within prisons (UNAIDS, 2017). Outside of the
prison environment, harm reduction programs for PWID vary considerably
among countries with Malaysia leading the way by increasing its needle and
104 S. R. NOTARO

syringe program sites from 297 in 2012 to 729 in 2013, and thereby con-
tributing to the finding of 93% of PWID in Malaysia reporting having used
a clean needle at their last injection (UNAIDS, 2017). To increase the
proportion of PWID who know their HIV status and who access antiretro-
viral treatment, Vietnam has taken the lead by enhancing the coordina-
tion of opioid substitution therapy along with HIV counseling and testing
resulting in larger numbers of PWID who reside in Vietnam accessing and
remaining in care as compared to those PWID who do not receive these
comprehensive services (Harm Reduction International, 2014).
Overall, Asia and the Pacific will need to drastically increase HIV services
and treatment to obtain the 2020 UNAIDS 90-90-90 target that 90% of all
people living with HIV will know their status, 90% of all those diagnosed
with AIDS will receive antiretroviral therapy (ART), and 90% of all people
receiving ART will have viral suppression (UNAIDS, 2017). Variations in
funding and national responses to the HIV epidemic are demonstrated in
2016 data revealing the access to ART in Thailand (69%) as compared to
Pakistan (5.9%) (UNAIDS, 2017). The most entrenched barriers to scaling
up access to HIV treatment and counseling throughout the region include
stigma, discrimination, and legal barriers (UNAIDS, 2017). For exam-
ple, 11 countries in the region including Malaysia and Papua New Guinea
impose HIV restriction laws regarding entry, stay, travel, and residence
of people living with HIV while same-sex activities are criminalized in 18
countries including Pakistan, Bangladesh, and Malaysia (Global Commis-
sion on HIV and the Law, 2013). Although some progress has been made
(e.g., India and Pakistan have formally recognized transgender as a “third”
gender since 2009 and 2010), stigma and discrimination faced by people
living with HIV throughout Asia and the Pacific are deeply entrenched and
ubiquitous. A final necessary improvement is increased national funding for
the HIV response, beyond the global expenditures of countries including
the United States. While a few countries including Thailand, China, and
Malaysia fund 90–99% of their HIV responses, most of the remaining coun-
tries in the region need to drastically increase their internal spending on
the fight against HIV (UNAIDS, 2017).

Summary
This chapter delineated long-standing and entrenched barriers to HIV care
and prevention including historical cultural, structural, and legal systems
 4 HIV/AIDS 105

that have fueled the stigma, discrimination, and bias faced by key popu-
lations who are disproportionately impacted by HIV. These challenges to
HIV intervention and prevention in the United States and globally make
the goal of achieving the UNAIDS 90-90-90 targets by 2020 unlikely.
At the individual and interpersonal level, the use of antiretroviral medica-
tions including both PrEP and PEP must be scaled up, along with sex and
reproductive education, voluntary medical male circumcision, condom and
lubricant distribution, and harm reduction for PWID. At a structural level,
domestic and global funding must increase for community-based clinics
and health services, as well as integrated, comprehensive programs target-
ing HIV-related stigma, discrimination, and societal and legal bias which
disproportionately affect the populations most vulnerable to HIV—MSM,
sex workers, transgender people, and PWID.
Promising areas of intervention and prevention include social media and
other rapidly developing technological approaches to HIV/AIDS preven-
tion among young men of color MSM and transgender women. Future
research examining the impact of social media along with the Stonewall
legacy’s historical and empowerment-based message of resistance could
prove impactful in the search for effective HIV/AIDS interventions. One
aspect of intervention research could explore whether or not today’s pop-
ulations who are most vulnerable to HIV (e.g., of young minority MSM
and transgender women) could be inspired and learn lessons from those
who came before them in the Stonewall movement and who share a com-
mon experience of discrimination, bias, victimization, poverty, and racism.
Understanding how to infuse this message into social media interventions
could lead to promising and effective new ways to decrease the numbers
of new HIV infections impacting these communities.
Despite these challenges, historically LGBT communities also possess a
great deal of resilience, support, and strengths based on sub-communities
and cultural currency that may be harnessed to bolster effective HIV inter-
ventions. Research should examine whether prevention efforts that honor
and build upon the legacy of the Stonewall resistance that was discussed
in Chapter 1 of this volume. The Stonewall Inn riots saw the most vul-
nerable members of the LGBT community join together to demand equal
treatment, respect, and dignity—a strategy that might be effective in stem-
ming the disparities in HIV among MSM and transgender women. While
the aftermath of this rallying cry led to gains in civil and political rights
that still pay dividends decades after the Stonewall riots, the new challenge
is to explore whether harnessing this history, relaying it to those most at
106 S. R. NOTARO

risk in the LGBT community, and infusing it in multipronged prevention

strategies is an effective and feasible prevention strategy.
Going forward, those impacted the most by HIV/AIDS, young minor-
ity MSM and transgender women, must receive reinforcement that HIV
is not related to a moral deficiency—as some ultraconservative politicians
claimed when AIDS was first discovered—but rather the risk of HIV is influ-
enced by situations, personal interactions, and social determinants or exter-
nal societal factors that perpetuate HIV among their community (Adams,
2012; Diaz et al., 2004; Friedman, Cooper, & Osborne, 2009; Hallfors,
Iritani, Miller, & Bauer, 2007). Research should explore whether fostering
a sense of community among those most vulnerable to HIV based on a
connection to past Stonewall activism could lead individuals to make life-
saving choices and to demand changes in the structural and external societal
factors that perpetuate HIV/AIDs in their communities, including access
to high-quality health care and culturally competent providers.

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 CHAPTER 5

Substance Use and Abuse

Discrimination and Substance Abuse Among

the LGBT Community in the United States
This chapter will discuss the impact of discrimination and bias on the sub-
stance use and abuse of the LGBT community.

Jeremy and I are 34. In our lifetime, the gay community has made more
progress on legal and social acceptance than any other demographic group
in history. As recently as my own adolescence, gay marriage was a distant
aspiration, something newspapers still put in scare quotes. Now, it’s been
enshrined in law by the Supreme Court. Public support for gay marriage
has climbed from 27 percent in 1996 to 61 percent in 2016. In pop culture,
we’ve gone from “Cruising” to “Queer Eye” to “Moonlight.” Gay characters
these days are so commonplace they’re even allowed to have flaws. Still, even
as we celebrate the scale and speed of this change, the rates of depression,
loneliness and substance abuse in the gay community remain stuck in the same
place they’ve been for decades. (Michael Hobbes, 2017, Together Alone: The
Epidemic of Gay Loneliness. Highline)

Prior research has demonstrated that substance use (e.g., alcohol, other
drugs, and smoking) are serious public health concerns for the general
population in the United States (e.g., Substance Abuse and Mental Health
Services Administration [SAMHSA], 2012). Additionally, the rates of sub-
stance use disorder diagnoses among LGBT and MSM (men who have sex

© The Author(s) 2020 111

S. R. Notaro, Marginality and Global LGBT Communities,
Neighborhoods, Communities, and Urban Marginality,
https://doi.org/10.1007/978-3-030-22415-8_5
112 S. R. NOTARO

with men, who may or may not identify as bisexual or homosexual) individ-
uals are disproportionately high as compared with heterosexual individuals
(e.g., Parsons, Grov, & Golub, 2012). These elevated rates of substance
use disorders combined with higher rates of HIV and some STIs (sexually
transmitted infections) among those who identify as lesbian, gay, bisexual,
and MSM suggests that substance use and problems related to such use
are more highly correlated with HIV or STIs among LGBT individuals as
compared with heterosexuals (e.g., Parsons et al., 2012; Wray, Pantalone,
Kahler, Monti, & Mayer, 2016).
Importantly, this chapter will provide data to further shed light on the
lived experience of individuals such as “Kristina,” a transgender woman
seeking treatment for substance abuse whose challenges were exacerbated
by discrimination, isolation, and lack of family support. Kristina supported
her drug habit by working as a prostitute and selling drugs before she began
performing in transgender clubs.

My 12-Step group has been my life support system. No one in my family

has spoken to me for over 15 years, since I came out as queer. The members
of my group are my family, my friends, my lifeline. Going to meetings isn’t
just how I stay sober, it’s how I stay connected to people who care. Straight
folks, even gay folks, don’t really understand how cut off we are in the trans
community. (Kristina, personal interview, Desert Hope, American Addiction
Centers, 2019)

Alcohol Abuse in the United States

Previous studies have shown that MSM living with HIV report higher rates
of binge drinking (five or more drinks at one time period) as compared to
women and men who have sex only with women (e.g., Vellozzi et al., 2009).
Skeer et al. (2012) found that 20% of HIV-positive MSM in their sample
reported binge drinking at least once per week. Wray et al. (2016) point
out that binge drinking can have alarming and serious health consequences
for people living with HIV (e.g., higher risk for liver toxicity, poor response
to antiretroviral therapy, increased cognitive difficulties). To date, there is
a lack of research focused on determining the contributing factors of heavy
alcohol drinking among MSM (Wray et al., 2016). Prior studies examining
discrimination and the minority stress model have demonstrated that MSM
of color living with HIV who experience racial discrimination are more
likely to have lower CD4 counts (the number of white blood cells in a
 5 SUBSTANCE USE AND ABUSE 113

cubic millimeter of blood that fight infection) and to have a detectable HIV
viral load and less likely to adhere to antiretroviral therapy (e.g., Bogart,
Landrine, Galvan, Wagner, & Klein, 2013).
Past research exploring motivations for heavy drinking among the LGBT
community have found that drinking heavily to cope with or avoid nega-
tive emotions stemming from discrimination may play a role in these neg-
ative health behaviors (e.g., Hatzenbuehler, Corbin, & Fromme, 2011).
Additional motivating factors for heavy drinking among LGBT individu-
als include drinking to have more fun, to enhance positive emotions, and
to enhance sexual experiences (e.g., Wray et al., 2016). There is a dearth
of research which explores both direct and indirect mechanisms by which
these various motives for heavy drinking impact the likelihood of experi-
encing alcohol-related problems, especially among MSM with HIV who
often report multiple forms of discrimination related to their sexual orien-
tation and HIV status (Wray et al., 2016). To expand upon prior research,
in two analogous studies, Wray et al. (2016) examined direct and indi-
rect relationships among discrimination based on sexual orientation and
HIV status, heavy drinking, alcohol-related problems, and reasons to drink.
The motivations to drink included coping (e.g., “To forget your worries”);
enhancement (e.g., “Because you like the feeling”); social facilitation (e.g.,
“To be sociable”), and sexual (e.g., “To be more confident in approaching
sex partners”). In Study One, which focused on MSM, HIV-negative indi-
viduals recruited in the northeast via online social media advertisements,
flyers, and contact at LGBT events, alcohol use was assessed in the past
thirty days with three items related to frequency and quantity of drinking
while alcohol-related problems (e.g., getting in trouble at work because of
drinking) in the past six months were assessed with 13 yes/no items from
the Short Michigan Alcoholism Screening Test (SMAST). A total of 171
participants (mean age  27.2, 86% white; 12% Black or African American;
17% Hispanic or Latino) completed linked online surveys.
Wray et al. (2016) hypothesized that drinking to cope would be pos-
itively associated with problems with drinking while other motives for
drinking would indirectly impact problems with drinking through alcohol
use. Results of the path models in Study One indicated that MSM, HIV-
negative individuals who reported more perceived discrimination based on
sexual orientation also drank more heavily for several reasons including to
cope with negative emotions, to enhance mood, and to facilitate sex. Only
alcohol use and coping motives were directly and positively associated with
alcohol-related problems. There was a significant and indirect effect of
114 S. R. NOTARO

perceived discrimination on alcohol problems through coping motives;

however, perceived discrimination did not significantly and indirectly
impact alcohol problems through drinking to enhance mood. Drinking
to enhance mood was positively associated with alcohol use, which in turn,
was positively associated with alcohol-related problems. Study One revealed
that heavy-drinking MSM who are HIV negative and who also experience
more discrimination and who drink to cope with negative emotions were
directly at risk for alcohol-related problems over and above their alcohol
use compared to those individuals who drank for other reasons including
to enhance their mood or to facilitate sex (Wray et al., 2016). For HIV-
negative MSM who drank heavily, drinking to enhance positive emotions
are associated with higher levels of alcohol use, which in turn leads to more
alcohol problems, regardless of discrimination (Wray et al., 2016).
Study Two focused on heavy-drinking MSM HIV-positive individuals
enrolled in a randomized controlled trial to test an intervention for heavy
drinking. A total of 185 participants (mean age  42.2, 73% white; 22%
Black or African American; 17% Hispanic or Latino) were recruited from an
urban community health center in the northeast that provides sexual and
gender minority health services. The measures for discrimination, drinking
motives, and sexual motives for drinking were identical to those in Study
One; however, the measures of alcohol use and alcohol problems differed.
Study Two used a technique to help cue the memory of drinking on each
day over the past 30 days and a different measure of alcohol problems, the
Short Inventory of Problems or the SIP which assesses 15 negative conse-
quences of alcohol use over 3 months (Wray et al., 2016). The survey data
was collected via trained interviewers or through audio computer assisted
self-interview technology (ACASI).
In Study Two, 50% of participants experienced discrimination based on
HIV-status (e.g., ignored by potential sexual partners) while 65% experi-
enced discrimination based on HIV status or sexual orientation (Wray et al.,
2016). The results of Study Two were consistent with Study One in that
reporting more discrimination based on HIV status or sexual orientation
was significantly and directly associated with drinking to cope with nega-
tive emotions, which was then positively and significantly related to alco-
hol problems. Results of both studies demonstrated that MSM individuals,
whether HIV positive or HIV negative, who reported more discrimina-
tion also reported drinking more frequently for sexual reasons; however,
in Study Two, more discrimination was not associated with drinking to
enhance positive mood as it was in Study One. Social motives were also
 5 SUBSTANCE USE AND ABUSE 115

directly and negatively associated with alcohol problems, but not alcohol
use, among MSM living with HIV in Study Two, whereas social motives
were not associated with drinking or problems in Study One. While these
results could suggest that HIV-positive MSM who drink for social reasons
are at lower risk for alcohol problems, Wray et al. (2016) urge caution in
the interpretation of these findings given the high probability of multi-
collinearity and the association between social and enhancement motives.
These strong associations among these two variables may have led to the
result of HIV-positive MSM who drink for social reasons being at lower risk
for alcohol related problems. Additionally, the authors present evidence of
multicollinearity in the results of a stepwise regression analysis showing that
social motives were positively associated with alcohol use unless enhance-
ment motives were included in the model.
Study Two also found that for HIV-positive MSM, frequent drinking for
sexual reasons were associated with heavier drinking and in turn, alcohol-
related problems. These findings for HIV-positive MSM differ from those
for HIV-negative MSM in Study One. MSM HIV-positive individuals
may feel that drinking excessively may lessen their inhibitions about being
rejected by potential sexual partners. Additionally, the difference in results
could be attributed to age and alcohol use factors in that participants in
Study Two were substantially older and drank more heavily than partici-
pants in Study One.
Overall, taken together, Study One and Study Two demonstrated that
discrimination based on sexual orientation and HIV status is a risk factor
for alcohol problems among MSM who are both HIV negative and HIV
positive. Drinking to cope with negative emotions was a mediating factor
between discrimination and alcohol problems in both studies. No other
motivating factor acted as a mediator in the relationship between discrimi-
nation and alcohol problems. Interventions may need to focus on discrim-
ination as a major factor in heavy drinking among MSM as well as more
effective coping strategies. Given that across both studies drinking to have
a better time socially was associated with more alcohol problems through
heavier patterns of use, interventions should also target the motivating fac-
tor of drinking to have a good time. For HIV-positive MSM who drink
heavily, interventions may need to specifically address the motivation of
drinking to increase confidence in approaching sexual partners by building
skills related to approaching sexual partners without excessive drinking.
Wray et al. (2016) acknowledge several limitations of their work. First,
the small sample size of minority MSM prevented the exploration of
116 S. R. NOTARO

these relationships within racial minorities. Second, Wray et al. (2016) the
authors of the study did not use the same measures of alcohol use or alcohol
problems in Study One and Study Two. Third, there were substantially dif-
ferent ages in Study Two (mean age  42.2) versus Study One (mean age 
27.8) and drinking (number of binge drinking days in the past 30 days  7.6
in Sudy Two versus 3.3 in Study One). These differences in measurement,
age, and heavy drinking could account for the observed differences in the
associations across studies. These findings of HIV-positive MSM being on
average older and heavier drinkers than HIV negative MSM are consistent
with some prior research reporting similar differences in age and drink-
ing patterns in these populations (e.g., Skeer et al., 2012). Fourth, these
samples consisted mostly of heavy drinking MSM, so the results may not
be generalizable to MSM who drink more moderately. On a related note,
Study Two participants were willing to participate in a drinking interven-
tion which may further limit the generalizability of the findings. Finally,
the results are cross-sectional and thus cannot provide evidence for causal-
ity in the relationships among discrimination, drinking motives, alcohol
use, and alcohol problems. Wray et al. (2016) advocate for longitudinal
studies to examine discrimination experienced in adolescence and young
adulthood in MSM populations with both positive and negative HIV status
as predictors of later reasons to drink and associated drinking problems.

Smoking in the United States

Related to alcohol use is a concern about disparate smoking behaviors
among LGBT individuals, especially given the Center for Disease Con-
trol and Prevention’s assertion that smoking remains one of the most
preventable causes of early death in the United States (United States
Department of Health and Human Services, 2014). Results have shown
that the smoking prevalence among LGBT individuals or “sexual minori-
ties” is approximately twice that of heterosexual individuals (e.g., Balsam,
Beadnell, & Riggs, 2012; Gruskin, Greenwood, Matevia, Pollack, & Bye,
2007); however, less research has focused on the smoking prevalence of
gender minorities including individuals identifying as transgender and on
possible effects of transgender-based discrimination on smoking behaviors
(Gamarel et al., 2016). Indeed, prior research has examined associations
between discrimination and smoking among LGBT communities in a
minority stress framework but little research has focused on transgender
 5 SUBSTANCE USE AND ABUSE 117

women (gender minorities) in terms of the impact of minority stress on

smoking behavior and cessation attempts (Gamarel et al., 2016).
Research is also needed that examines the barriers to smoking cessa-
tion among transgender women because this population experiences a high
prevalence of other negative health outcomes including depression, sub-
stance use, and HIV risk (e.g., Gamarel, Reisner, Laurenceau, Nemoto, &
Operario, 2014; Hotton, Garofalo, Kuhns, & Johnson, 2013). Some lim-
ited data on smoking prevalence among transgender women in California
found that transgender women smoked at twice the rate of other Califor-
nians (Bye, Gruskin, Greenwood, Albright, & Krotki, 2005). Additionally,
smoking while also ingesting cross-sex hormones (e.g., estrogen in a male
body) can increase the risk of heart disease and smoking may slow down the
recovery from surgery that some transgender women choose (e.g., Mueck
& Seeger, 2005; Silverstein, 1992).
In a minority stress framework, discrimination based on transgender sta-
tus can exacerbate and increase the risk of smoking, as smoking may serve as
a mechanism to cope with the discrimination that manifests in name-calling
and violence experienced by some transgender individuals (e.g., Hendricks
& Testa, 2012). More research is needed to test the relationships among
discrimination, gender-identity bias, and smoking in transgender women.
To that end, Gamarel et al. (2016) conducted a study to examine the associ-
ation between discrimination and smoking patterns in transgender women
and to identify barriers to smoking cessation in transgender women who
smoked. The study included two urban locations—San Francisco, CA, and
Oakland, CA and focused recruitment efforts on venues known to attract
transgender women including community-based organizations, bars, and
nightclubs. All participants were at least 18 years of age, self-identified as
transgender women (pre- or post-operative), provided informed consent,
and were compensated with $50.00 as well as safe-sex kits and brochures
with resources listing local community-based organizations specializing in
transgender needs.
The cross-sectional study administered a one-time survey via ACASI
to 241 transgender women between August 2004 and July 2006. Self-
reported data included age, race, socioeconomic status, HIV status (pos-
itive, negative, unknown), hormone use, and engagement in sex work.
Depression was measured via the Center for Epidemiological Studies or
the CES-D while discrimination was measured with an 11 item scale that
included the frequency of harmful experiences related to being transgender
or transitioning to become a woman. A sample question asked respondents
118 S. R. NOTARO

to rate on a 5-point Likert scale “How often were you made fun of for being
transgender” with responses ranging from never to almost daily. The trans-
gender discrimination scores ranged from 11 to 45 (M  26.63, SD 
7.83), where higher scores indicate greater levels of discrimination. Partic-
ipants who indicated ever smoking were further asked to report the number
of cigarettes smoked per day resulting in the categories of current smok-
ers, no smoking history, and not current smoker. Respondents were also
asked about smoking cessation attempts resulting in the three categories of
successful cessation, unsuccessful attempt, and never attempted.
The demographics demonstrated that the respondents’ ages ranged from
18 to 65 years (M  36.52, SD  10.5) with all respondents identifying
as either African American (n  123, 51%) or White (n  118, 49%).
The majority of participants reported less than a high school education
(n  161, 66.8%) and annual incomes of less than $1000 per month (n
 154, 63.9%). The majority of participants self-reported a HIV-positive
serostatus as well as engagement in sex work in the past 6 months (n 
124, 51.9%), and lifetime use of hormones (n  169, 70.1%). In terms of
smoking, the vast majority of respondents reported having smoked in their
lifetime (n  174, 72%) with about 40% smoking a pack or more per day,
26% smoking 10–19 cigarettes a day, 25% smoking 1–9 cigarettes per day,
and 9% smoking a few cigarettes per week. The average age of smoking
initiation was 14.77 (SD  5.16) while 82% of lifetime smokers (n  119)
indicated a previous attempt to quit.
In terms of racial/ethnicity differences, white respondents were signifi-
cantly less likely to report never smoking and were four times more likely to
report current smoking as compared to African American respondents. In
terms of other substance use, participants who reported alcohol use were
significantly more likely to report daily and intermittent smoking as com-
pared to those who reported no alcohol use in the past thirty days. Those
who reported daily smoking had significantly higher discrimination scores
as compared to those who never smoked. Participants who reported an
HIV seropositive status were 49% less likely to be current smokers as com-
pared to participants who reported an HIV negative or unknown status.
Higher levels of transgender-based discrimination were positively associ-
ated with an increase in the odds of being a current smoker and with
unsuccessful attempts to quit smoking when compared to those who had
successfully quit smoking. Further, higher levels of discrimination were
associated with greater odds of reporting no attempt to quit as compared
to those who reported a successful or unsuccessful attempt to quit smoking.
 5 SUBSTANCE USE AND ABUSE 119

Gamarel et al. (2016) used logistic regression to examine the relationship

between study variables, smoking, and smoking cessation attempts in cur-
rent smokers versus non-smokers. Given the small number of intermittent
smokers, the smoking categories of intermittent and daily smokers were
collapsed into current smokers.
In the sample, over 69% reported being a current smoker. Smokers
reported a significantly higher frequency of discrimination experiences as
compared to transgender women who did not currently smoke. These find-
ings are similar to those in sexual minority (LGB) populations in the United
States (McCabe, Boyd, Hughes, & d’Arcy, 2003). Whereas over 60% of the
sample had attempted to quit smoking at some point in their lives, only
17% reported successful cessation. Higher discrimination was associated
with unsuccessful cessation attempts or never having tried to quit smok-
ing. Given these findings, interventions should target discrimination as a
barrier to smoking cessation in transgender women who smoke. This study
also found that alcohol use was a barrier to smoking cessation in that drink-
ing alcohol in the past 30 days was associated with an increased odds ratio
of never attempting to quit smoking as compared to unsuccessful attempts.
Complex racial differences emerged in that white transgender women
who lived in San Francisco were more likely to report current, daily, or prior
smoking as compared with African American women who lived in Oakland.
Further white women were more likely to have attempted to stop smoking
as compared to Black women in the study. Gamarel et al. (2016) theorize
that these racial differences may be related to geographical resource differ-
ences in that San Francisco (where the majority of the white respondents
resided) may have more resources related to smoking cessation programs
than Oakland, CA where the majority of African American respondents
lived.
Gamarel et al. (2016) identified several limitations of their study. First,
their sample was one of convenience with no random selection and focused
on a high-risk population of sex workers. Gamarel et al. (2016) point out
that this limitation is common among gender minority research because of
the lack of inclusion of gender minorities in representative population sur-
veys. A second limitation is related to the geographical differences between
the tolerance for gender minorities in San Francisco versus Oakland in that
gender-based discrimination may not be as prevalent in San Francisco in
comparison to Oakland, CA or other parts of the country. Next, the self-
report which could lead to social desirability bias and the cross-sectional
design cannot support temporal or causal claims. In terms of measurement,
120 S. R. NOTARO

the study did not capture the dates of quit attempts or the numbers of quit
attempts, so comparisons between those respondents who attempted to
quit recently or who had several quit attempts to those who attempted to
quit in the past were not possible. As alcohol was assessed with a single item
measure and did not account for frequency or quantity, it was not possi-
ble to assess whether different levels of alcohol consumption were related
to smoking cessation. Gamarel et al. (2016) advocate for future research
within a more heterogeneous sample of gender minorities to inform smok-
ing cessation interventions through the further exploration of differences
in race, ethnicity, socioeconomic status, sexual identity, and discrimination.

Prescription Drug Misuse and Illicit Drug Use

Among Young MSM in the United States
In addition to illicit drug use, research focusing on substance use among
young adults has demonstrated that 31.4% of young adults aged 18–29
report prescription drug misuse at least once in their lifetime (SAMHSA,
2010). Recent research has focused on the prescription drug misuse of
young MSMs or young men who have sex with men (e.g., Kecojevic, Wong,
Corliss, & Lankenau, 2015). According to SAMHSA (2010), prescription
drug misuse is defined as the use of opioids, tranquilizes, and stimulants
when not prescribed by a doctor or when taken only for the effect caused.
Given prior research that found a greater likelihood of high-risk behav-
iors including substance use and prescription drug misuse among young
men who have sex with men (YMSM) who also reported maltreatment or
abuse during childhood, Kecojevic et al. (2015) hypothesized that experi-
ences of stress, discrimination, bias, and stigma could increase the risk of
prescription drug misuse and illicit drug use among YMSM. The authors
sought to understand whether or not the further stress of racism placed
minority YMSM at an even greater risk of adopting negative coping behav-
iors including prescription drug misuse. Kecojevic et al. (2015) examined
the association between childhood abuse, minority stress (including homo-
phobia, discrimination, bias, and racism) and mental health distress. They
also investigated whether or not perceptions of general stress are associated
with these psychosocial stressors and mental health concerns. The authors
hypothesized that YMSM who self-reported high levels of childhood abuse
and minority stress would report increased levels of mental health distress
and general stress which would in turn lead to a greater likelihood of pre-
scription drug misuse and illicit drug use.
 5 SUBSTANCE USE AND ABUSE 121

This cross-sectional study collected data from 2012 to 2013 in a sam-

ple of 18–29 year-old men who reported misusing a prescription drug
(e.g., opioid, tranquilizer, stimulant) in the prior 6 months; engaging in
sex with a male partner in the prior 6 months; speaking English; and liv-
ing in Philadelphia, PA (Kecojevic et al., 2015). The authors employed a
variety of strategies to locate 18–29 year old males who met the study cri-
teria including targeted and “chain-referral” sampling, recruitment from
parks, streets, gay bars and clubs, and community-based organizations.
A total of 191 participants provided verbal informed consent and com-
pleted face-to-face interviews lasting approximately one hour administered
via portable computers (Kecojevic et al., 2015). The participants received
$25.00 in compensation as well as resources including HIV testing infor-
mation. Demographic information collected included age, race (e.g., White
or non-White), and sexual orientation (e.g., bisexual, heterosexual, other).
The frequency of several forms of childhood abuse (e.g., emotional,
physical, sexual) was assessed via a Childhood Trauma Questionnaire (Bern-
stein et al., 1994). Measures of discrimination in the form of lifetime expe-
riences with homophobia and racism were adopted from Diaz, Ayala, Bein,
Jenne, and Marin (2001) and Wong, Schrager, Holloway, Meyer, and Kipke
(2014). Racism (e.g., lifetime experiences of verbal and physical threats and
attacks, police harassment due to race or ethnicity) was measured via a 4
item Likert composite scale ranging from never to many times. Homo-
phobia was measured with a 4 item Likert composite scale ranging from
never to many times regarding lifetime experiences of verbal and physical
threats and attacks, police harassment, friends and family teasing other gay
people, and needing to move to avoid harassment based on sexual orien-
tation. Social racism and homophobia were measured with a composite 4
item scale ranging from strongly disagree to strongly agree assessing the
extent to which the respondent felt uncomfortable in “gay” spaces or online
and whether they were rejected as a potential sexual partner due to their
race/ethnicity. Internalized homophobia (e.g., the extent to which partic-
ipants disliked themselves for their sexual attraction to men, wished they
were not sexually attracted to men, felt guilty for having sex with men, and
felt stress or conflict from having sex with men) was measured with the
short version of Ross and Rosser’s (1996) 4 item Likert scale ranging from
strongly disagree to strongly agree. Psychological distress (e.g., depression,
anxiety, somatization or perceptions of bodily dysfunction) experienced in
the prior week was measured with the Brief Symptom Inventory (BSI-
18) (Derogatis, 2000). General stress appraisal (e.g., frequency of feeling
122 S. R. NOTARO

upset because of an unexpected event) was measured via the 10 item Per-
ceived Stress Scale (PSS) (Cohen, Kamarck, & Mermelstein, 1983), with
responses ranging from never to very often.
Misuse of prescription drugs was assessed with a question asking respon-
dents whether or not they had misused (pills taken that were not pre-
scribed or taken just for the feeling) any of the three most commonly
abused prescription drugs (e.g., tranquilizers, opioids, and stimulants) in
the past 6 months as well as the amount of pills taken in the past 6 months.
Respondents were asked the same questions concerning illicit drugs includ-
ing ecstasy, heroin, cocaine, crack, and crystal methamphetamine.
The demographic analyses revealed an average age of 23.7 (SD  3.3)
with one-third of the sample identifying as White (n  64) and two thirds
as non-White (n  71). Nearly 60% (n  109) of respondents identified as
gay or homosexual while approximately 42% identified as bisexual, hetero-
sexual, or other. Childhood abuse (e.g., emotional, physical, and sexual)
was reported at levels considered above standardized thresholds. Depres-
sion, anxiety, somatization, and perceived general stress were reported at
higher levels than in previous research with YMSM populations (Kecojevic
et al., 2015).
While some participants infrequently misused prescription drugs, some
subjects misused prescription drugs frequently, especially opioids (78%)
and tranquilizers (80%), with stimulants misused to a lesser extent (52%).
Reports of childhood abuse and discrimination were positively and sig-
nificantly correlated with each other and with mental health distress and
general stress. Higher levels of childhood abuse were significantly and pos-
itively correlated with a higher prevalence of substance use as compared to
those who did not report child sexual abuse. Specifically, of the three forms
of child abuse included in this study, reports of physical child abuse were
significantly and positively correlated with heavy misuse of opioids. Opioid
misuse could serve as a coping mechanism for the pain and anxiety resulting
from childhood physical abuse (e.g., Dube et al., 2003; Kecojevic et al.,
2015). These findings are also consistent with prior research demonstrat-
ing that social discrimination can be associated with discomfort with one’s
sexual identity as well as psychosocial stress which may in turn increase the
risk of substance use disorders (e.g., McCabe, Bostwick, Hughes, West, &
Boyd, 2010).
Higher levels of social discrimination were positively and significantly
related to increased stimulant use whereas reports of racism were posi-
tively correlated with increased levels of opioid and tranquilizer misuse.
 5 SUBSTANCE USE AND ABUSE 123

Experiences of somatization or distress from perceptions of bodily dysfunc-

tion were significantly and positively associated with increased stimulant
misuse and with illicit drug use. The authors hypothesize that their finding
of the association of self-reported depressive symptoms with higher stim-
ulant misuse, but less opioid misuse, is in line with the effect of stimulants
as a mood enhancer. Taken together, these findings suggest that YMSM
may rely on different types of drugs to achieve, enhance, or avoid specific
effects (Kecojevic et al., 2015). In terms of age effects, older YMSM were
more likely to misuse opioids as compared to other ages, leading Kecojevic
et al. (2015) to hypothesize that older YMSM have easier access to opioids.
Bisexual, heterosexual, and “other” YMSM were at higher risk for misuse
of all three class of prescription drugs as compared to gay and homosexual
YMSM. Kecojevic et al. (2015) hypothesize that individuals who do not
self-identify as gay, but who have sex with men, may experience a conflict
between their sexual actions and their sexual identities, possibly leading to
drug misuse as a coping mechanism (Kecojevic et al., 2015). Racial minor-
ity YMSM were less likely to misuse tranquilizers and stimulants or illicit
drugs as compared to White YMSM.
Overall, the study findings support prior research (e.g., Wong et al.,
2014) that demonstrated correlations between stress and substance use in
YMSM. YMSM who expressed childhood abuse, discrimination, or mental
health distress may experience a greater risk for prescription drug misuse
as a way to cope with or alleviate negative feelings (Kecojevic et al., 2015).
This study found no differential effects of risk factors between subtypes
of prescription drug misuse. Kecojevic et al. (2015) call for more research
examining prescription drug misuse within this population including lon-
gitudinal studies designed to explore causal paths and more qualitative
studies to identify additional risk factors including sensation-seeking and
impulsivity. The findings of the current study suggest that health providers
should take into account the full mental health and psychosocial history of
patients, recognizing childhood abuse in all of its forms as potential risk fac-
tors for substance abuse and prescription drug misuse in YMSM. Further,
clinicians working with YMSM should consider substance abuse treatment
that incorporates strategies for coping with negative life experiences.
Kecojevic et al. (2015) identified several limitations of their study includ-
ing the self-report data that could be impacted by social desirability and
recall bias, especially in terms of respondents accurately recalling the num-
ber of pills taken in the prior 6 months. The cross-sectional design of the
study precludes the formation of causal inferences and the sample may not
124 S. R. NOTARO

generalize to YMSM who do not engage in substance abuse or who reside

in locations other than Philadelphia. Finally, no adjustments were made for
potential peer influences on respondents’ social networks.

Comorbidity of Mental Health and Substance Use

Disorders
While substance use disorders and prescription drug misuse among sexual
minorities including individuals who identify as transgender women and
MSM pose serious public health concerns, comorbidity or co-occurrence
of mental health disorders may precede substance abuse problems and may
complicate and negatively impact substance abuse treatment (e.g., Grella,
Hser, Joshi, & Rounds-Bryant, 2001). Further, lesbian, gay, and bisex-
ual individuals report provider and institutional discrimination and bias as
substantial barriers to accessing mental, physical, and substance use treat-
ment (e.g., Buchmueller & Carpenter, 2010). Fluente, Livington, Roley,
and Sorensen (2015) investigated whether mental and physical health needs
and treatment utilization of LGB individuals differ from heterosexuals seek-
ing substance abuse treatment in one publicly funded health system in the
County of San Francisco. Data was collected from all substance abuse treat-
ment facilities in the County that received any government funding. Treat-
ment records of residential, detoxification, and outpatient services received
from 2007 to 2009 resulted in 107,470 total treatment episodes experi-
enced by 13,211 individuals with an average age of 38.10 years (SD 
13.48).
In this sample, gay and bisexual men were more likely to report white
ethnicity and higher levels of education. Analyses revealed that sexual ori-
entation is predictive of mental and physical health status as individuals
identifying as LGB reported higher rates of prior mental health diagnoses
and a higher likelihood of taking psychiatric medications at the time of
treatment for substance use (Fluente et al., 2015). Specifically, lesbian and
bisexual women had two times greater odds of prior mental health diag-
noses as compared to heterosexual women whereas gay and bisexual men
had 3.5–4 times greater odds of prior mental health diagnoses as compared
to heterosexual men. Further, gay and bisexual men and bisexual women
were more likely to report current treatment for psychiatric disorders at
the time of admission for substance use treatment as compared to hetero-
sexual individuals. These findings demonstrate comorbidity of psychiatric
and substance abuse disorders among the LGB individuals in this sample,
 5 SUBSTANCE USE AND ABUSE 125

suggesting the need for continuity and coordination of health care (Fluente
et al., 2015).
Fluente et al. (2015) discuss several implications for health care service
and delivery that emerged from this study. First, they point to a need for
additional screening and coordination of care for LGB individuals given the
experience of comorbidity of mental and substance use disorders reported
in their sample. Fluente et al. (2015) encourage providers to first seek train-
ing in working with LGB populations and then to inquire about sexual
orientation respectfully during office visits as a way to aid in risk assess-
ment and screening of mental, physical, and substance abuse concerns and
to ensure the coordination of psychiatric medications being taken at the
time of substance use treatment. The integration and coordination of care
for LGB individuals in the electronic health record presents several advan-
tages including the prevention of LGB clients from repeatedly disclosing
their sexual orientation to new providers, decreasing drug interactions,
and increasing treatment compliance (Fluente et al., 2015). Fluente et al.
(2015) acknowledge several limitations including the cross-sectional design
which included only one urban area of San Francisco, California. Also, while
the minority stress model (e.g., Meyer, 2003) was supported, its effects may
have been attenuated due to the progressive social and cultural milieu of
the sample. Finally, this self-report data may not generalize to LGB indi-
viduals in general as it may only be relevant to LGB individuals seeking
treatment for substance use.

Impact of Sexual Orientation and Gender

Influences on Alcohol Use Globally
Hughes, Wilsnack, and Kantor (2016) identify a lack of funding for research
focusing on sexual minorities, with the exception of HIV/AIDS, in both
the United States and globally. This issue extends to studies of alcohol
use among sexual minorities and sexual minority women in particular as
evidenced by a review of studies funded by the National Institute of Health
between 1989 and 2011 (Coulter, Kenst, Bowen, & Scout, 2014). Coulter
et al.’s (2014) review determined that excluding HIV/AIDS, only .1% of
all NIH-funded studies focused on sexual minorities and of those studies,
only 13.5% focused on sexual minority women; moreover, only 13% of all
funded sexual minority studies focused on alcohol use.
Available research estimates that alcohol use varies according to country
with global estimates ranging from a low of 3% for women and 37% for men
126 S. R. NOTARO

in the Indian state of Karnataka to a high of 94% for women and 97% for
men in Denmark (e.g., Wilsnack, Wilsnack, Kristjanson, Vogeltanz-Holm,
& Gmel, 2009). In the United States and globally, rates of alcohol use are
typically higher for men as compared with women (e.g., SAMHSA, 2013;
Wilsnack et al., 2009). Furthermore, data from the global Gender, Alcohol,
and Culture: An International Study (GENACIS), demonstrated that men
are more likely than women to drink frequently (e.g., drinking on 5 or
more days per week) and to drink more heavily and women as compared to
men were more likely to be classified as never drinkers or former drinkers
(e.g., Wilsnack et al., 2009).
Turning to data focusing on sexual minorities and gender influences
on alcohol use identifies an interesting gender paradox (Hughes et al.,
2016). In studies in both the United States and globally, sexual minority
women (e.g., those women identifying as lesbian or bisexual) reported sig-
nificantly higher levels of high-risk drinking as compared to heterosexual
women whereas sexual minority men reported higher levels high-risk drink-
ing as compared to heterosexual men, but to a much lesser extent or not at
all (e.g., Bloomfield, Wicki, Wilsnack, Hughes, & Gmel, 2011; McCabe,
Hughes, Bostwick, West, & Boyd, 2009; Talley, Hughes, Aranda, Birkett,
& Marshal, 2014; Van Griensven et al., 2004). Hughes et al. (2016) refer to
these findings as a gender paradox given that heterosexual men on average
drink more than heterosexual women whereas the reverse is true among
sexual minority men and women.
While Hughes et al. (2016) acknowledge that minority stress (e.g.,
internalized homophobia, discrimination, bias) experienced by many sexual
minorities is associated with an increased risk of problem drinking among
this population, they point out that the rejection of traditional gender roles
would indeed predict larger increases in drinking among sexual minority
women than in sexual minority men (e.g., Meyer, 2003). Furthermore,
Hughes et al. (2016) assert that sexual and gender influences have dis-
tinct differences whereby sexual differences encompass biological variations
between male and female bodies that on average result in females reaching
higher blood alcohol levels more quickly than men, given the same amount
of alcohol consumption (e.g., Holmila & Raitasalo, 2005). The impact of
gender on alcohol use and misuse is a function of socially constructed views
and norms attributed to women and men in a particular society; moreover,
gender differences in alcohol use are most pronounced in countries with
the largest differences in gender roles (e.g., Hughes et al., 2016; Wilsnack
et al., 2009).
 5 SUBSTANCE USE AND ABUSE 127

Hughes et al. (2016) speculate that countries who conceptualize the

male gender as masculine and aggressive may perceive men’s consumption
of alcohol as a mechanism to demonstrate and amplify these attributes. This
hypothesis is supported by research demonstrating that in national U.S.
samples, risk-taking is correlated with heavy drinking among men but not
among women; moreover, women are more likely to report risk-reduction
strategies when drinking (e.g., Iwamoto, Cheng, Lee, Takamatsu, & Gor-
don, 2011; Nguyen, Walters, Wyatt, & DeJong, 2011). Hughes et al.
(2016) point to additional examples of societally-based gender differences
in alcohol use including a greater degree of acceptance of males participat-
ing in public drinking and drinking to a state of intoxication, which could
support male superiority and authority over women. On a contrasting note,
the traditional view of women as caretakers of children who also discour-
age excessive drinking of their male partners are potential factors leading to
less drinking among women in these societies (e.g., Holmila & Raitasalo,
2005; Kuntsche, Knibbe, Kuntsche, & Gmel, 2011).
Despite these historical findings, some research exploring birth cohorts
and alcohol use globally have identified high rates of heavy drinking among
women in younger cohorts in the United States and Europe, suggesting
changes in “traditional” societal roles and perceptions of women’s drinking
(e.g., Keyes, Li, & Hasin, 2011). On a related note, Makela, Tigerstedt,
and Mustonen (2012) report findings from a Finnish survey which demon-
strated disproportionate increases in drinking amounts and frequency as
well as intoxication among women over a forty-year time span as compared
to among men.
In addition to the experience of minority stress, research conducted
globally has identified several other factors which impact problem drinking
among sexual minorities. For example, in a review of data from 12 coun-
tries, sexual orientation, gender expression, and gender appearance were
associated with peer victimization, which in turn impacted alcohol and
other drug use (Collier, van Beuskekom, Bos, & Sandfort, 2013). Societal
attitudes and organizational policies are also powerful influences on the
health and well-being of sexual minorities. For example, the World Health
Organization had debated for many years whether or not to include sex-
ual minority health and discrimination in health care in its agenda (e.g.,
Daulaire, 2014). Despite strong opposition from some African and Middle
Eastern countries, progress has been made in that the Pan American Health
Organization (PAHO), the subregion of WHO representing the Ameri-
cas, passed the first United Nations resolution to address sexual minority
128 S. R. NOTARO

health and discrimination in health care (e.g., Daulaire, 2014; Pan Ameri-
can Health Organization [PAHO], 2013).
Given the findings of the impact of gender roles on drinking behav-
ior, Hughes et al. (2016) advocate for prevention and intervention efforts
that encourage greater gender role flexibility which may prove beneficial
and effective in reducing alcohol use among both heterosexuals and sexual
minorities. Clinical interventions focusing specifically on challenges experi-
enced by sexual minorities (e.g., discrimination, victimization, internalized
homophobia) may also prove impactful. Their ultimate recommendation
involves much more complex and broad interventions that address social
determinants of health (e.g., economic resources, workplace acceptance)
that often serve as barriers to opportunity and equity in marginalized pop-
ulations. Finally, Hughes et al. (2016) argue for more research examining
and harnessing the power of resilience and protective factors (e.g., commu-
nity, family) among sexual minorities as compared to disease and deviance
as well as a shift away from the view of sexual minorities as one homogenous
population.

Prescription Drug Misuse Use Among Adolescents

and Sexual Identity
Disparities in substance abuse among sexual minority adolescents represent
a global health problem as supported by research demonstrating higher lev-
els of self-reported substance abuse among sexual minority adolescents as
compared with their heterosexual peers (e.g., Goldberg, Strutz, Herring,
& Halpern, 2013; Homma, Chen, Poon, & Saewyc, 2012; Li et al., 2018).
Due to the availability and popularity of prescription drugs among adoles-
cents coupled with the experience of minority stress, recent studies have
focused on the misuse of prescription drugs among sexual minority adoles-
cents, with most available data emanating from the United States (e.g., Li
et al., 2018; Meyer, 2003). As discussed earlier in this chapter, according
to SAMHSA (2010), prescription drug misuse is defined as the use of opi-
oids, tranquilizes, and stimulants when not prescribed by a doctor or when
taken only for the effect caused. A 2016 nationally representative study
of substance use among 12th grade high school students in the United
States found lifetime (18%), annual (12%) and 30-day (5.4%) prevalence
of misuse of prescription drugs (Johnston, O’Malley, Miech, Bachman, &
Schulenberg, 2017). The growth in the popularity of misusing prescription
drugs can be attributed to several factors including the ease of obtaining
 5 SUBSTANCE USE AND ABUSE 129

prescription drugs from family and peers (e.g., McCabe & Boyd, 2005); as
well as a false sense of safety in using prescription drugs as compared with
illegal drugs (e.g., Fleary, Heffer, & McKyer, 2013).
U.S. studies of adolescent sexual minorities have reported a higher preva-
lence of the misuse of prescription drugs and earlier initiation of misuse as
compared to heterosexual peers (e.g., Corliss, Rosario, Wypij, Frazier, &
Austin, 2010; Kecojevic et al., 2012). The fact that the misuse of prescrip-
tion drugs can lead to dependence and addiction in the same ways as illegal
drugs necessitates more research examining the factors which influence the
misuse of prescription drugs (e.g., Li et al., 2018; McCabe, West, Morales,
Cranford, & Boy, 2007).
There has been sparse research examining the relationship between sex-
ual orientation and prescription drug misuse in Asian countries including
China. Furthermore, prior research has not regularly included adolescents
who reported their sexual orientation as “unsure,” although these adoles-
cents may experience sexual minority stress from bullying and discrimina-
tion that can in turn lead to mental health problems (e.g., Birkett, Russell,
& Corliss, 2014; Coulter et al., 2016). To better understand the risk factors
associated with prescription drug misuse among adolescents who report
“unsure” sexual orientation as well as those adolescents who consider them-
selves sexual minorities or heterosexual, Li et al. (2018) examined prescrip-
tion drug misuse and sexual orientation in a school-based nationally repre-
sentative sample in 7 Chinese provinces (Guangdong, Liaoning, Shandong,
Hunan, Shanxi, Chongqing, and Guizhou). The analyses were drawn from
data collected in the 2015 School-based Chinese Adolescents Health Sur-
vey (SCAHS), a large-scale cross-sectional study of health behaviors among
7th to 12th grade Chinese adolescents that has collected data every two
years since 2007 (Guo et al., 2015; Li et al., 2018; Wang et al., 2014). The
2015 data collection effort resulted in a response rate of 95.3% and 150,822
self-administered questionnaires completed anonymously. Sexual orienta-
tion was measured by asking students about their sexual attractions to the
opposite sex, same-sex, both opposite and same-sex, and unsure. Respon-
dents who indicated same-sex or both opposite and same-sex were classified
as sexual minorities. Prescription drug misuse was defined as the nonmed-
ical use of prescription drugs (NMUPD)—opioids and sedatives—the two
most commonly used prescription drugs among adolescents in China.
Results indicated that 8.8, 4.4, and 2.2% of the students reported life-
time, past-year, and past-month NMUPD, respectively. Compared with
heterosexual students (8.2%), sexual minority and unsure students were
130 S. R. NOTARO

more likely to report lifetime NMUPD (14.4 and 10.0%, respectively; χ 2 

244.34, P < 0.001). Sexual minority and unsure adolescents were also more
likely to report past-year and past-month use of NMUPD after adjusting for
several covariates including social demographics (e.g., sex, age, household
socioeconomic status); lifestyle (e.g., parental marital status); interpersonal
relationships (e.g., peer relationships); smoking; and alcohol use.
Li et al. (2018) assert that their findings regarding the increased likeli-
hood of NMUPD among sexual minority adolescents and unsure adoles-
cents as compared to their heterosexual counterparts may be explained by
chronic and repeated exposure to sexual minority stress (e.g., Meyer, 2003).
Li et al.’s assertions are in line with prior research demonstrating that expo-
sure to chronic stress from bullying increases the risk of the initiation and
escalation of substance use among adolescents (e.g., Tharp-Taylor, Havi-
land, & D’Amico, 2009). Further, chronic stress could negatively impact
brain reward pathways that increase the vulnerability to substance use (e.g.,
Frank, Watkins, & Maier, 2011; Saal, Dong, Bonci, & Malenka, 2003).
Finally, Li et al. (2018) point out that in their sample, the most common
reason cited for NMUPD was to relieve stress.
Based on their findings, Li et al. (2018) recommend several areas for
intervention in the misuse of prescription drugs among sexual minority
and unsure adolescents. First, anti-bullying and anti-discrimination policies
should be created by the Department of Education to reduce the experi-
ence of minority stress in the school-setting. Second, families should be
encouraged and provided with resources to better support sexual minority
adolescents including the appropriate management and control of prescrip-
tion drugs located within the home. Finally, sexual minority adolescents
suffering from drug addiction should be provided with tools and resources
including psychological counseling to combat pervasive and chronic sex-
ual minority stress. Li et al. (2018) summarize the strengths of their study
as using a large-scale randomized sample that allowed for robust analysis
of between group differences and the inclusion of “unsure” adolescents
who are not commonly included in studies of sexual minority adolescent
mental health. Limitations of the study include the cross-sectional design
which precludes causal inferences; the use of sexual attraction to measure
sexual orientation as opposed to other indicators such as sexual behaviors;
the possible impact of missing data from students who had dropped out of
school or were absent on the day of survey administration; and the inclusion
of only two types of prescription drugs—opioids and sedatives (Li et al.,
2018).
 5 SUBSTANCE USE AND ABUSE 131

Summary
This chapter explored the association among discrimination and substance
use (e.g., alcohol, cigarettes, and prescription drugs) and sexual orientation
in the United States and globally. In terms of alcohol use, two studies
conducted by Wray et al. (2016) demonstrated that discrimination based
on sexual orientation and HIV status is a risk factor for alcohol problems
among men who have sex with men (MSM) who are both HIV negative
and HIV positive. Possible interventions should explore ways to reduce
discrimination experienced by MSM while also equipping them with ways
to cope with negative emotions that were shown to mediate the relationship
between discrimination and alcohol misuse.
In terms of smoking, this chapter provided an overview of the find-
ings of several studies which demonstrated that lesbian, gay, bisexual, and
transgender women smokers reported a significantly higher frequency of
discrimination experiences as compared to heterosexual women and trans-
gender women who did not currently smoke (e.g., Gamarel et al., 2016;
McCabe et al., 2003). As higher discrimination was also associated with
unsuccessful cessation attempts or never having tried to quit smoking, inter-
ventions should target discrimination as a barrier to smoking cessation in
LGB and transgender women who smoke.
The misuse of prescription drugs among MSM was discussed in a review
of Kecojevic et al.’s (2015) study which found that reports of childhood
abuse and discrimination were positively and significantly correlated with
each other and with mental health distress and general stress. Given these
findings, Kecojevic et al. (2015) advocate for additional research examin-
ing prescription drug misuse within this population including longitudinal
studies designed to explore causal paths and more qualitative studies to
identify additional risk factors including sensation-seeking and impulsivity.
In terms of comorbidity or the co-occurrence of mental health disorders,
Fluente et al.’s (2015) study was informative as it demonstrated comor-
bidity of psychiatric and substance abuse disorders among LGB individu-
als, suggesting interventions that increase continuity and coordination of
health care. This chapter next discussed data focusing on sexual minori-
ties and gender influences on alcohol use. Overall, findings suggested that
several factors impact problem drinking among sexual minorities, includ-
ing the experience of minority stress, societal attitudes concerning gender
expression and gender appearance, and organizational policies (e.g., Collier
et al., 2013). Possible interventions should address the social determinants
132 S. R. NOTARO

of health (e.g., economic resources, workplace discrimination) that often

impede opportunity for marginalized populations (e.g., Hughes et al.,
2016).
Lastly, given the popularity and accessibility of prescription drugs among
adolescents coupled with the experience of minority stress, this chapter dis-
cussed recent studies that have focused on the misuse of prescription drugs
among sexual minority adolescents (e.g., Li et al., 2018; Meyer, 2003). In
both the United States and globally, the increased misuse of prescription
drugs among adolescents can be attributed to several factors including the
ease of obtaining prescription drugs from family and peers (e.g., McCabe
& Boyd, 2005), as well as to a false sense of safety in using prescription
drugs as compared with illegal drugs (e.g., Fleary et al., 2013). Li et al.
(2018) identified possible interventions targeting the reduction of prescrip-
tion drug misuse among sexual minority adolescents in several arenas that
focused on the school setting (e.g., anti-bullying initiatives); the family unit
(e.g., increased family support and closer supervision of prescription drugs
within the home); and external supports (e.g., psychological counseling).

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 CHAPTER 6

Mental Health

Psychological Distress
This chapter will discuss the mental health of the LGBT community in the
context of psychological distress, suicide, homelessness, reparative thera-
pies, and resiliency and protective factors.

The thing is, in many cases, mental illness and being queer go hand in hand.
It’s an uncomfortable but important reality that LGBT youth are four times
more likely to kill themselves than their heterosexual counterparts. More
than half of individuals who identify as transgender experience depression
or anxiety. Even among Stonewall’s own staff, people who dedicate them-
selves to the betterment and improved health of our community, 86% have
experienced mental health issues first-hand. It’s a morbid point to make, but
it makes perfect sense that we, as a community, struggle disproportionately.
(Alexander Leon, 2017, Opinion Web Log, The Guardian)

Prior research by Hatzenbuehler (2009) found a relationship between the

stigma experienced by young adult men who identify as Black, gay, and
bisexual (GBM) and health-related problems including poor mental health
in the form of higher rates of psychological distress as compared to the
general population (e.g., Hatzenbuehler, 2009). Boone, Cook, and Wilson
(2016) identify one key source of psychological distress for gay and bisexual
men as internalized homophobia, wherein an individual who self-identifies
as gay may internalize society’s negative attitudes toward homosexuals,

© The Author(s) 2020 139

S. R. Notaro, Marginality and Global LGBT Communities,
Neighborhoods, Communities, and Urban Marginality,
https://doi.org/10.1007/978-3-030-22415-8_6
140 S. R. NOTARO

same-sex attraction, and same-sex sexual behavior. Further, the internal-

ization of these negative attitudes may begin at an early age (e.g., Boone
et al., 2016; Herek, 2009). Young black gay and bisexual men (GBM) may
experience additional psychological distress resulting from their negotiating
of two identities—sexual and racial. Specifically, GBM may feel simultane-
ously ostracized and rejected by the black community due to their sexual
identity, and by the gay community due to their racial identity (e.g., Boone
et al., 2016; Choi, Han, Paul, & Ayala, 2011).
Millett, Malebranche, Mason, and Spides (2005) conducted research
which further investigated issues and concerns that are more closely aligned
with bisexual black men as compared with gay black men. For example,
bisexual black men face stereotypes that label them as HIV positive indi-
viduals who spread HIV into the heterosexual black community (Millet
et al., 2005). In response to these stereotypes, some bisexual black men
may conceal their sexual identity which may lead to mental distress and
physical health risk (e.g., Wilson, 2008). In contrast to bisexual black men,
gay-identified black men may face more direct forms of stigma due to their
sexual orientation as they may less able to hide their sexual identity or may
choose not to do so (e.g., Malebranche, 2008).
Boone et al. (2016) noted that few prior studies have examined both
the impact of internalized homophobia as well as the internalization
of HIV/AIDS stigma on psychological distress. Indeed, people with
HIV have frequently been the target of discrimination, prejudice, and
violence, which can then lead to psychological distress (Boone et al.,
2016). Thus, Boone et al. (2016) investigated the relationship of sexual
identity to internalized homophobia and HIV/AIDS stigma and the ensu-
ing impact of these stressors on the psychological distress of GBM. A con-
venience sample of 227 Black gay or bisexual men (GBM) were recruited
for this study in New York City (Boone et al., 2016). Participants were
included who identified as Black, as being between the ages of 18–35 years
old, as gay or bisexual, and as someone who had engaged in oral or anal
intercourse with another man in the two months prior to the study. Partici-
pants were recruited in a variety of ways including outreach to community-
based organizations, social media, flyers, and snowball sampling (Boone
et al., 2016). Demographic information indicated that the participants had
a mean age of 23.9 years (SD  4.2 years, range 18–34 years). Self-reported
HIV status revealed that approximately 25% of the sample was HIV pos-
itive while approximately 75% reported HIV-negative status. In terms of
 6 MENTAL HEALTH 141

sexual identity, nearly 75% of participants identified as gay or homosexual

while the other 25% of the participants identified as bisexual.
Boone et al. (2016) assessed several constructs including internalized
homophobia, HIV/AIDS stigma, and psychological distress. The Internal-
ized Homophobia Scale (IHP) included 9 items designed to measure inter-
nalized homophobia in men with same-sex sexual attractions and behaviors
(Meyer, 1995). A sample item included in the IHP was “I feel alienated
from myself because of being gay or bisexual.” Respondents were asked to
rate how often they felt this way on a Likert scale with responses ranging
from 1 (often) to 4 (never). Boone et al. (2016) reported a Cronbach’s
alpha of .88 for the IHP in this sample. The HIV/AIDS stigma scale was
used to measure stigma against HIV and AIDS in men who have sex with
men (Diaz, 2006). Two versions of the scales were used—one for HIV-
positive men and one for HIV-negative and HIV-status unknown men.
Both scales were scored with a 4-point Likert scale. Boone et al. (2016)
reported Cronbach alphas of .71 for HIV-positive participants and .77 for
HIV-negative and unknown status participants.
Psychological distress was measured via the Kessler Screening Scale of
Non-Specific Psychological Distress or the K10 (Kessler et al., 2002). The
K10 measures cognitive, affective, and behavioral symptoms of psychologi-
cal distress. Participants were asked to rate how often they had experienced
feelings and emotions (e.g., “I felt hopeless”) in the past thirty days with
a 4 point Likert scale. Boone et al. (2016) reported a Cronbach’s alpha of
.92 for the K10 in this sample. Psychological distress was also assessed in
this study with the 53 item Brief Symptom Inventory or BSI (Derogatis &
Spencer, 1993). Participants rated the severity of the overall incidence of
psychological distress along with five subscales focusing on depression, anx-
iety, interpersonal sensitivity, somatization, and hostility that they had expe-
rienced over the 14 days prior to the study. Boone et al. (2016) reported
a Cronbach’s alpha of .97 for the global severity index and coefficients of
.88, .83, .80, .79, and .79, respectively for the five subscales.
Boone et al. (2016) performed multiple linear regression analyses which
revealed that internalized homophobia was significantly and positively
related to psychological distress. Further analyses revealed an interaction
between sexual identity and internalized homophobia such that internal-
ized homophobia was positively and significantly related to psychological
distress only for gay/homosexual participants, but not for bisexual partic-
ipants. Analyses regarding the subscales of the BSI indicated that internal-
ized homophobia was significantly related to four subscales—depression,
142 S. R. NOTARO

anxiety, interpersonal sensitivity, and somatization. No interaction was

found between sexual orientation and internalized homophobia on any
of the BSI subscales.
Boone et al. (2016) extended prior findings that demonstrated a rela-
tionship between “enacted” stigma, including discrimination and psycho-
logical distress in gay men to include internalized homophobia as an
important influence on psychological distress in young Black gay men.
These relationships between internalized homophobia and psychological
distress were only significant for gay men and not bisexual men. Boone
et al. (2016) hypothesize that bisexual men may use relationships with
women as a way to decrease the salience or attention paid to their same-
sex sexual behavior in their community. In turn, with less focus on their
same-sex sexual behaviors, Black bisexual men may then access protective
factors including the seeking of support and coping resources that mitigate
internalized homophobia.
As for HIV/AIDS and psychological distress, no significant main
effects were found between HIV/AIDS stigma and psychological dis-
tress; however, there was a significant interaction between HIV status and
HIV/AIDS stigma wherein the relationship between psychological distress
and HIV/AIDS stigma was significant for HIV-positive men, but not for
HIV negative men. Higher levels of HIV/AIDS stigma were related to
higher levels of psychological distress in HIV-positive men.
Boone et al.’s (2016) finding of a relationship between HIV/AIDS
stigma and psychological distress for HIV-positive men but not for HIV-
negative or unsure status men contradicted their hypothesis that this rela-
tionship would hold for HIV-negative and unsure status men as well. This
hypothesis was based on the evidence that society associates HIV and AIDS
with sexual identities and behaviors of young gay black men, even if they
are HIV negative. Boone et al. (2016) provide several possible explanations
for the lack of association between HIV/AIDS stigma and psychological
distress for HIV-negative and unsure status men. First, young black gay
and bisexual men in this particular community may not perceive a soci-
etal bias that associates sexual identity with HIV. Thus, these men may
not experience psychological distress from stigma directed at HIV-positive
individuals. Second, it is possible that even if HIV/AIDS stigma has a
small negative impact on psychological well-being of gay Black men, these
HIV-negative men utilized personal and community resources to reduce its
impact. These protective factors are contrasted with the experience of HIV-
positive gay black men whose HIV positive status is negatively evaluated by
 6 MENTAL HEALTH 143

society and whose internalization of HIV/AIDS stigma is associated with

psychological distress.
Boone et al. (2016) acknowledged several limitations of their study
including the small convenience sample that is not generalizable to the
general population. They called for future research that would include
black men who identify as both heterosexual and as MSM (men who have
sex with men) to allow for comparisons of the experience of HIV/AIDS
stigma. Finally, the findings that HIV/AIDS stigma impacted the psycho-
logical distress of HIV-positive GBM men establishes targets for public
health intervention.

Suicide
Suicide attempts are four times more likely among LGBT youth as com-
pared with their heterosexual peers and “questioning” youth or those who
are not sure about their sexual identity, are three times more likely to
attempt suicide as compared with their heterosexual peers (e.g., Centers
for Disease Control and Prevention [CDC], 2011). Specifically, the CDC
(2011) reported that for nine states (Delaware, Maine, Massachusetts,
Rhode Island, Vermont, Boston, Chicago, New York City, and San Fran-
cisco) that assessed attempted suicide one or more times during the
12 months prior to administering the Youth Risk Behavior Surveys, the
prevalence of attempted suicide ranged from 3.8 to 9.6% (median: 6.4%)
among heterosexual students, from 15.1 to 34.3% (median: 25.8%) among
gay or lesbian students, from 20.6 to 32.0% (median: 28.0%) among bisex-
ual students, and from 13.0 to 26.7% (median: 18.5%) among unsure stu-
dents. Another layer of health disparities is demonstrated by data indicating
that racial minority LGBT youth (African American and Latino) attempt
suicide at twice the rate of nonminority LGBT youth (CDC, 2011). As
death records do not typically record sexual orientation, these findings may
actually underestimate mortality among LGBT youth (Sidaros, 2017). In
addition to suicide, suicidal ideation or thinking about suicide is almost
twice as prevalent among LGBT individuals of all ages as compared with
their heterosexual peers (e.g., King et al., 2008).
Data suggests that the risk for suicide among LGBT individuals is related
to a greater extent to sexual identity than to sexual behavior, given that
mood and anxiety disorders—common correlates of suicidal behavior—are
more strongly associated with LGBT identity than with same-sex sexual
behaviors (e.g., Bostwick, Boyd, & Hughes, 2010; Sidaros, 2017). Zhao,
144 S. R. NOTARO

Montoro, Igartua, and Thombs (2010) provided further corroboration

of these findings in their study which demonstrated that adolescents who
experience same-sex attraction or same-sex sexual behaviors, but who iden-
tify as heterosexual, do not demonstrate an elevated risk of suicidal behavior
as compared to their peers. In terms of chronological age as a risk factor
for suicide among the LGBT community, some data suggests that suicide
may be more evenly distributed across the lifespan and associated with age
of sexual orientation disclosure or “coming out” as compared to the gen-
eral population wherein suicide is more common in adolescents and young
adults (e.g., De Graaf, Sandfort, & Ten, 2006; Paul et al., 2002).
While data consistently demonstrates an association between suicide
attempts in LGBT individuals and major depression, generalized anxiety
disorder, and substance use, these comorbid psychiatric diagnoses do not
fully account for two to three-fold increase in the risk of suicidal behav-
ior in the LGBT population (e.g., Fergusson, Horwood, & Ridder, 2005;
Sidaros, 2017). Sidaros (2017) posited that the elevated risk of suicide
among LGBT individuals is partially accounted for by bias, discrimination,
and prejudice discussed in the minority stress literature (e.g., Meyer, 2007),
which identifies stressors that may negatively impact the mental health of
LGBT individuals. The minority stress literature investigates both objective
or external stressors (e.g., family rejection, housing and job discrimination)
and subjective or internal stressors (e.g., internalized homophobia) and
corresponding interventions that may alleviate such stressors (e.g., policy
changes and cognitive appraisal of stress techniques). Some research has
demonstrated that LGBT young adults who experience frequent family
rejection are 8 times more likely to attempt suicide as compared to those
LGBT young adults who report parental acceptance (e.g., Ryan, Huebner,
Diaz, & Sanchez, 2009; Sidaros, 2017). Parental rejection is also associated
with homelessness—a health disparity experienced by an estimated 40% of
LGBT adolescents in the United States (e.g., Durso & Gates, 2012). An
estimated 50% of transgender individuals report job-related discrimination
in terms of promotions, hiring, and firing due to their transgender identities
with transgender people of color reporting even higher levels of employ-
ment discrimination (e.g., Sidaros, 2017).
In terms of interventions, Sidaros (2017) described several foundations
and organizations designed to reduce suicide risk among LGBT individ-
uals. These entities attempt to offer culturally appropriate and tailored
mental health services. For example, the Trevor Project, the only national
crisis and suicide prevention hotline created especially for LGBT and
 6 MENTAL HEALTH 145

questioning youth, provides in-school workshops, online resources, and

advocacy to reduce LGBT stigma (Sidaros, 2017). Several organizations
focus on LGBT individuals and their families such as GLSEN (Gay,
Lesbian, and Straight Education Network), SAGE (Services and Advocacy
for Gay, Lesbian, Bisexual, and Transgender Elders), and PFLAG (Parents,
Families, and Friends of Lesbian, Gay, Bisexual and Transgender People).
In addition to national organizations, Sidaros (2017) identified a need
for culturally sensitive, knowledgeable physicians and therapists with
high-level skills in screening, diagnosis, treatment, and self-awareness of
potential bias to help LGBT individuals cope with suicidal risk and psychi-
atric comorbidities. While training to manage psychiatric morbidities and
suicidal risk in LGBT patients has not typically been offered to psychiatric
residents, the Group for the Advancement of Psychiatry focuses on LGBT
mental health by training psychiatric residents to take sexual histories
in LGBT patients, prioritize ethical psychotherapy, and learn about the
history of psychiatry and homosexuality (Sidaros, 2017). Finally, the
Association of American Medical Colleges (AAMC) (2014) and the Gay
and Lesbian Medical Association (GLMA) (2013) have created online
resources to improve the health care and increase inclusivity for LGBT
patients as well as for LGBT students and health professionals.

Homelessness
According to the United States Department of Housing and Urban Devel-
opment (USDHUD) (2014), 33% of homeless individuals as of January
2014 identified as children, youth, and young adults (aged 18–24). About
one-quarter of these individuals who are younger than 25 years of age
reported having no adult, relative, or caregiver to provide them with shel-
ter (USDHUD, 2014). Of the population of runaway and homeless youth
(RHY), LGBTQ individuals are overrepresented at 20–40%, a much higher
percentage than either heterosexual or cisgender (individuals whose gender
identity matches the sex that they were assigned at birth) peers (e.g., Durso
& Gates, 2012). Although these data may be an underrepresentation of
sexual orientation and gender identity within the homeless population, the
USDHUD (2014) conservative estimate of 20% of LGBTQ homeless and
unaccompanied individuals under the age of 25 results in 18,082 LGBT
individuals out of a total of 45,205 individuals (e.g., Corliss, Goodenow,
Nichols, & Austin, 2011; Cray, Miller, & Durso, 2013).
146 S. R. NOTARO

A review of service organizations focused on RHY suggest that these

agencies may not adequately meet the needs of LGBTQ RHY due to a lack
of knowledge and resources to appropriately assist these individuals with a
host of specialized needs (e.g., Maccio & Ferguson, 2016; Shelton, 2015).
Agencies focusing on heterosexual and cisgender RHY may not realize that
the origins of health disparities within the LGBTQ RHY population may
differ according to sexual orientation and gender identity (e.g., Maccio &
Ferguson, 2016; Snapp, Hoenig, Fields, & Russell, 2015). Maccio & Fer-
guson (2016) advocate for services that affirm youth’s sexual and gender
identity by recognizing bias, discrimination, and other stressors that may
influence their homelessness and lack of family support. Maccio and Fer-
guson (2016) conducted an inventory of LGBTQ RHY resources offered
by 19 agencies across the United States. The authors sought to gather
information related to existing services and gaps with the hopes of offer-
ing suggestions for more customized approaches and policies for LGBTQ
RHY. Maccio and Ferguson (2016) employed several strategies to iden-
tify the 19 LGBTQ RHY organization and 24 staff for their investigation,
including internet searches, snowball sampling or referrals from participat-
ing agencies, and resource guide reviews (e.g., Child Welfare League of
America, 2012).
Using the above methods, Maccio and Ferguson (2016) identified 32
organizations offering LGBTQ RHY services—either exclusively or as part
of general services. Of the 32 agencies identified, 19 agreed to participate
in the study (response rate  59.4%). Of the 19 organizations, 6 served
LBGTQ RHY and their allies (considered as LGBTQ-supportive hetero-
sexual individuals); 13 served LGBTQ RHY in general while also offering
specific programs for LGBTQ RHY; all 19 agencies provided LGBTQ-
affirming versus accepting environments. Maccio and Ferguson (2016)
defined LGBTQ-affirming environments as displaying LGBTQ symbols
including the gay pride flag, welcome signs and bulletin boards with diver-
sity messages, and workplace non-discrimination policies. Most of the agen-
cies were located in large cities (14/19) with populations greater than
100,000 while more than half of the agencies were located in cities with
populations of 1 million or more. All regions in the U.S. were represented
with 5 agencies in the Northeast and 5 in the West. The 24 staff who par-
ticipated in the study either served as executive directors or their designees
(e.g., clinicians) and provided oral informed consent. Maccio and Ferguson
(2016) conducted one-hour telephone interviews in 2012 with staff. Inter-
view notes were transcribed and coded using template analysis (e.g., King,
 6 MENTAL HEALTH 147

1998). Template analysis is a qualitative method which identifies themes by

arranging them in a hierarchy wherein broader themes (e.g., educational
services) are described by more specific themes (e.g., college preparation)
(e.g., King, 1998; Maccio & Ferguson, 2016).
The template analysis resulted in 7 main themes with more specific
subthemes illustrating service gaps in LGBTQ RHY agencies. The first
theme, housing services, revealed the need for more beds at crisis shelters
for LGBTQ RHY. Some staff advocated for completely separate beds for
these youth while some stressed the need to avoid isolating or segregating
based on sexual and gender identity. The consensus across agencies was
that transgender youth should be housed with the gender with which they
identified (e.g., Maccio & Ferguson, 2016; Yu, 2010). Maccio and Fer-
guson (2016) recommend the establishment of more permanent housing
designed to serve LGBTQ RHY beyond the age of 18 such as the True
Colors Residence in New York City. This facility, containing 30 units for
LGBTQ youth aged 18–24, may be the first permanent housing residence
for LGBTQ youth in the United States (e.g., Corporation for Support-
ive Housing, 2011; Maccio & Ferguson, 2016). Housing options such as
True Colors are especially relevant for youth who are considered too old
for foster care, which is the case for the 28 states that did not pass the 2014
federal legislation, Fostering Connections to Success and Increasing Adop-
tion Act, that extended the foster care age to 21 (National Conference of
State Legislatures, 2014). In general, youth who remain in foster care for
one additional year to age 19 have additional access to education, health,
and mental health services that may increase physical and psychological
well-being and financial stability (e.g., Courtney et al., 2005; Maccio &
Ferguson, 2016).
The second theme, educational services, suggested the need for alterna-
tive educational programming including General Education Development
or GED preparation for LGBTQ youth who have dropped out of high
school or are at risk for dropping out due to psychological distress associ-
ated with bullying and school violence (Maccio & Ferguson, 2016). The
analyses identified the additional educational services of college preparation
as well as college housing and dining for LGBT RHY. Maccio and Fergu-
son (2016) argue for increased research examining the college experiences
of the overlapping and intersecting populations of college youth who are
LGBT, homeless, first generation/and or foster care involved.
Enhanced employment services were identified as the third theme, with
one program described as a possible model for LGBTQ RHY clients.
148 S. R. NOTARO

The Green Chimneys program in New York City requires 20 hours work
per week among its LGBTQ clients in exchange for assistance with resumes,
interviewing, and executing job roles in a professional manner (e.g., Maccio
& Ferguson, 2016; Nolan, 2006). According to Nolan (2006), nearly 60%
of the youth who left the Green Chimneys shelter had secured a job with
that percentage increasing to nearly 70% of the clients who remained at the
shelter for more than 6 months. A specialized component of employment
services for the LGBTQ RHY population includes youth with criminal
backgrounds and substance use problems, as prior research has demon-
strated that longer periods of homelessness are positively correlated with
unemployment and criminality. Maccio and Ferguson (2016) point out that
job training may help youth with these concerns avoid criminal behavior
and end homelessness. Some services identified as part of the employment
theme focused on community-based economic development or opportuni-
ties outside of shelters and housing services such as connecting employers
with LGBT youth (Maccio & Feguson, 2016). Finally, within the employ-
ment services theme, Maccio and Ferguson (2016) discuss workplace dis-
crimination and harassment, with a special focus on transgender RHY. To
combat discrimination aimed at transgender youth in the workplace, agen-
cies recommended the promotion and support of legislation that protects
the employment rights of individuals based on sexual orientation and gen-
der identity (e.g., Pizer, Sears, Mallory, & Hunter, 2012).
Increased services focused on families were identified as the fourth
theme. Gattis (2013) recommended family therapy for LGBTQ youth who
are homeless or at risk of being rejected from their home. One example of
such therapy is San Francisco State University’s Family Acceptance Project
(FAP) which is designed to help families support LGBT children’s well-
being, and minimize their rejection from family (e.g., Ryan, 2010). Within
this theme of family services, Maccio and Ferguson emphasized the need
for an assessment of bicultural and multicultural interventions that tailor
services according to unique cultural aspects including religion, language,
and ethnicity.
The fifth theme related to LGBTQ-affirming services including pro-
grams commonly offered in shelters and drop-in centers. One such service
identified was the Sylvia Rivera Law Project based in New York City which
aids low income, transgender, and gender variant people with issues of
discrimination, violence, homelessness, unemployment, and arrests (e.g.,
Maccio & Ferguson, 2016; Shepard, 2013). Other programs mentioned
were based in public libraries and offered LGBTQ RHY the opportunity
 6 MENTAL HEALTH 149

to take temporary shelter and to search for online resources with minimal
engagement with library staff (e.g., Shelton & Winkelstein, 2014). Medical
services tailored to LGBTQ youth in general were also identified, including
a need for nurses, doctors, and other clinicians to use gender-neutral and
nonjudgmental language during patient care. One resource mentioned for
LGBTQ RHY seeking appropriate and sensitive medical treatments and
standard screenings for a host of health concerns (e.g., mood disorders,
PTSD, trauma, and substance use) included the referral lists published and
curated by the GLMA (e.g., Coker, Austin, & Schuster, 2010; Keuroghlian,
Shtasel, & Bassuk, 2014). Relatedly, the need for more services tailored to
LGBTQ youth living with HIV or at risk for HIV was identified along with
the services (e.g., case management, mental health services, HIV testing,
hormone treatment) provided by Health and Education Alternatives for
Teens (HEAT) located in Brooklyn, New York (e.g., Lolai, 2015; Maccio
& Ferguson, 2016).
The last two themes—cultural competency and advocacy—have been
interspersed throughout the prior themes. Agencies called for increased
education on the culture, terminology, and context of LGBTQ youth
among homeless shelters and the adoption of policy recommendations put
forth by the National Gay and Lesbian Task Force including requirements
of cultural competence and LGBTQ awareness for all federally funded
agencies, social service workers, and child welfare, and juvenile justice staff
(Maccio & Ferguson, 2016). An increase in integration and connections
between LGBTQ and heterosexual and cisgender RHY was also encour-
aged for shelters and agencies that are not specifically tailored to LGBTQ
RHY (e.g., Maccio & Ferguson, 2016). The final theme identified the
need for advocacy and organizing, especially in smaller and more rural
communities with fewer LGBTQ resources. More research examining the
experiences of LGBTQ RHY in these environments is warranted, given
the lack of shelters located in small, rural communities (e.g., Maccio &
Ferguson, 2016).
Maccio and Ferguson (2016) delineated several limitations of their
study including its small, nonrepresentative sample size which may have
excluded newer organizations, or agencies in rural communities, and those
with no websites. Information should be gathered from nonresponders
to increase the validity of these findings. Finally, the study did not gather
specific data regarding the funding sources for organizations as some of the
respondents served as direct and frontline workers who may have lacked
knowledge of funding information. This lack of information prevented the
150 S. R. NOTARO

authors from considering the impact of funding on service gaps (Maccio

& Ferguson, 2016).
In an urban community sample in Chicago, Illinois, researchers Bruce,
Stall, Fata, and Campbell (2014) examined the relationships among sex-
ual minority stress variables (e.g., experiencing sexual orientation stigma,
internalizing sexual orientation stigma), homelessness, current depression,
and substance use in young men (age range 16–24) who have sex with
men (YMSM). Overall, Bruce et al. (2014) found that experiencing sexual
orientation-related stigma (e.g., being rejected by a friend because of sex-
ual orientation) directly and significant affected major depressive symptoms
and indirectly impacted these symptoms through internalized homopho-
bia (e.g., feeling ashamed of one’s sexual orientation) and being homeless
in the past twelve months. Additionally, being forced out of one’s home
mediated the impact of experiencing sexual orientation-related stigma on
daily marijuana use (Bruce et al., 2014). Bruce et al. (2014) identified sev-
eral promising avenues of intervention that focus on the family, school, and
social media contexts. Helping families accept adolescent and young-adult
sexual orientation, providing training and development to bolster support
for sexual minorities among teachers and staff in schools, and designing
social networking sites that promote positive identity development may
help to ameliorate the impact of both the experiences of and internaliza-
tion of stigma on young adults who have sex with men and other sexual
minorities (Bruce et al., 2014).

Reparative Therapies
While evidence-based and culturally sensitive interventions designed to
increase coping among LGBT individuals are appropriate and necessary,
so-called “reparative therapies” have been found to cause physical and
emotional harm to those receiving such therapy (e.g., Shidlo & Schroeder,
2002). Therapists attempting to “repair” homosexual orientation practice
various forms of reparative therapies (e.g., psychotherapy, electric shock,
hypnosis) based on the assumption that homosexual orientation results
from a deficiency in personal development and does not represent a nor-
mal variant of human sexuality in contrast to the view espoused by the
American Psychological Association (APA) (2012). To increase the under-
standing of specific variables that may be associated with the development
of a reparative attitude or therapeutic approach to homosexuality, Lin-
gardi, Nardelli, and Tripoldi (2015) surveyed over 28,000 psychologists
 6 MENTAL HEALTH 151

who were members of the Italian Psychological Association. Lingardi et al.

(2015) chose to examine these attitudes in Italy based on several factors.
First, many members of the general population in Italy hold negative views
of homosexuality (Lingardi et al., 2015). Second, the location of the Vat-
ican in Italy may support negative perceptions of homosexuality in that
the Roman Catholic Church officially views homosexuality as weakening
the traditional family unit (Lingardi et al., 2015). Third, there is a lack
of civil rights and legal protections for same-sex couples and those victim-
ized by homophobic-related hate crimes in Italy (Lingardi et al., 2015).
The authors contrast Italy with Spain and Portugal, both countries whose
inhabitants also hold negative views of homosexuality, but which do extend
civil and political rights for LGBT individuals including the recognition of
marriage among same-sex couples (Lingardi et al., 2015).
Through a partnership with the Italian Psychological Association, Lin-
gardi et al. (2015) distributed an online, password-protected survey to
28,477 Italian psychologists to collect demographic information as well
as attitudes toward homosexuality, lesbians, and gay men. The response
rate of 11% represented 3135 completed questionnaires. The demographic
items on the questionnaire included age, gender, and sexual orientation.
Sociocultural items included political orientation (e.g., more conservative
to more progressive); religious education (e.g., none to fully); and religious
commitment (nonbeliever to believing in God and attending religious ser-
vices). Professional attributes related to sexual minority clients were mea-
sured in terms of the amount and nature of clinical experience with sexual
minority clients and self-evaluation of preparation for working with such
clients. Assumptions about the origins of homosexuality were measured in
terms of the extent of agreement with theories connecting homosexuality
with pathology or troubled family interactions as contrasted with the most
current and widely accepted view within international health organizations
that homosexuality is a normal variation of human sexuality (Lingardi et al.,
2015). Another key measure was reparative attitude or whether or not the
clinician self-reported having a professional treatment plan that included
“repairing” or altering a sexual minority orientation for clients who sought
help for distress related to sexual orientation. Responses ranged from no
attempt to repair homosexual orientation to only if requested by the client
to always attempting to repair homosexual orientation. Finally, the procliv-
ity of clinicians to respond in socially desirable ways was assessed via the
short form of the Marlow-Crowne Social Desirability Scale developed by
Reynolds (1982).
152 S. R. NOTARO

The survey respondents were overwhelmingly female (86%) with an age

range of 25–83 years (M  38.61; SD  10.11). Respondents resided in
northern, central, and southern Italy and 89% identified as exclusively het-
erosexual. The vast majority had received religious education while about
38% believed in God, but did not attend religious services. About 16% of
respondents reported no political orientation, while the other responses
on this item ranged from most conservative to most progressive (5–40%).
Of the respondents, 41% were licensed psychotherapists with 65% hav-
ing received psychotherapy treatment. In terms of the respondents’ beliefs
about the origins of homosexuality, 76% reported that homosexuality is a
normal variant of human sexuality; however, some respondents expressed
some combination of views that homosexual orientation is pathological or a
deviation from normal sexuality. For example, 3% of respondents reported
that homosexuality is a pathology; nearly 10% believed that homosexual
orientation stems from an arrested psychological development; and nearly
24% believed that homosexuality results from troubled family interactions.
While approximately 76% of respondents viewed homosexuality as a nor-
mal variant of human sexuality, more than half held a reparative attitude
toward homosexuality. Lingardi et al. (2015) point out that such views are
consistent with those held in the general Italian population according to
data from the 2011 National Institute of Statistics. This general popula-
tion survey (N  44,000) found that 74.8% of respondents did not view
homosexuality as an illness, but only 43.9% approved of legalizing same-
sex marriage and 19% approved of adoption by same-sex couples (National
Institute of Statistics, 2012).
Responses regarding the preparation to effectively work with homosex-
ual clients who express anxiety regarding their sexual orientation revealed
that most respondents believed that they lacked the appropriate knowl-
edge about the theoretical and clinical issues surrounding homosexuality;
indeed, of the 30% of respondents who reported having clients who were
worried about their homosexuality, only 15% of them felt adequately pre-
pared to assist with clinical issues related to homosexuality. In terms of ther-
apeutic attitude, 58% of the sample would intervene to change or repair
a client’s sexual orientation, and of these, 56% would do so only at the
request of the client while 2% would pursue a reparative treatment plan
even if the client did not request it.
Responses regarding the correlates of holding a reparative attitude
toward homosexuality demonstrated that the strongest predictor was the
respondent reporting a heterosexual orientation (Lingardi et al., 2015).
 6 MENTAL HEALTH 153

Furthermore, some lesbian and gay identified psychologists also hold repar-
ative attitudes, suggesting that these psychologists may be struggling with
similar issues of internalized homophobia that impact their clients. Addi-
tional correlates of reparative attitude include age, which was a small, sig-
nificant predictor with older age more associated with reparative attitude,
possibly reflecting attitudes of older people in the general population who
are more likely to express homophobia. Older psychologists also may have
received training during the time when homosexuality was viewed as a
mental disorder (Lingardi et al., 2015).

Resiliency and Protective Factors

The literature examining mental health and psychological well-being of sex-
ual minorities often focuses on deficits and maladaptive processes with less
attention and research aimed at understanding the developmental context
of the family’s impact on healthy sexual identity formation (e.g., Zimmer-
man, Darnell, Rhew, Lee, & Kaysen, 2015). Zimmerman et al. (2015)
posited that the minority stress theory, which investigates the burden of
societal discrimination and bias experienced by sexual minorities, could
be bolstered by a more comprehensive and developmental examination
of the interdependence of overlapping microsystems of individual, fam-
ily, and society. Specifically, Zimmerman et al. (2015) implored a social-
ecological development model to explore the interplay of these systems
in the formation of normative sexual minority development and resilience
in young adult sexual minority women (SMW). Their study investigated
family rejection of SWM as a stressor that potentially interacts with sexual
identity development and “outness” or the status of having revealed one’s
sexual minority status to family, to predict community connectedness and
collective self-esteem over a 12-month period.
Zimmerman et al.’s (2015) strengths-based approach and focus on
resilience is informed by prior research demonstrating that most SMW
women do not show symptoms of mental disorders, despite experiencing
societal discrimination and bias; furthermore, most SMW develop a lesbian
or bisexual identity during adolescence and young adulthood. SMW typi-
cally disclose their identity to family, form connections with sexual minor-
ity communities, and develop collective, affiliation-based lesbian or bisex-
ual self-esteem or group pride (e.g., Calzo, Antonucci, Mays, & Cochran,
2011; Savin-Williams & Ream, 2003). Healthy sexual identity formation
and family acceptance can then buffer or decrease identity risk factors
154 S. R. NOTARO

including self-stigma, internalized homophobia, and motivations to con-

ceal sexual identity (e.g., Zimmerman et al., 2015). Parental acceptance
and positive responses to SMW’s identity disclosure predict health and
well-being as they reduce depression and increase self-esteem (e.g., Legate,
Ryan, & Weinstein, 2012; Rosario, Schrimshaw, & Hunter, 2011).
Despite prior findings of mostly healthy sexual minority identity devel-
opment among SMW, some research has focused on SMW’s experiences
of family rejection, which is associated with poorer mental health in terms
of increased risk for suicide, depression, and substance abuse (Ryan et al.,
2009). In a small number of cases, SMW experience severe family rejec-
tion, including verbal and physical abuse and attacks (e.g., Zimmerman
et al., 2015). Familial rejection may exacerbate societal risks of bias and
discrimination as evidenced by research indicating that poor mental health
among sexual minorities was accounted for by both perceived societal
discrimination, hate crime, and victimization, as well as by family rejection
(e.g., Frisell, Lichtenstein, Rahman, & Langstrom, 2009). SMW who
are rejected by their families may demonstrate resilience, which is not
observed directly, but rather is inferred by responses and adaptations in
the context of risk factors and stressors (e.g., Dohrenwend, 2000; Masten,
2001; Zimmerman et al., 2015). Rejected SMW who develop greater
community connectedness and collective self-esteem than is typical among
non-rejected SMW provide evidence of resiliency and positive coping
(e.g., Zimmerman et al., 2015).
Zimmerman et al.’s (2015) conceptual framework is one of protective-
enhancing resilience wherein these resilience processes are defined by the
interaction between high-risk stressors and adaptations to such stressors.
As risk increases, so does the possibility of resilience. Under this model,
Zimmerman et al. (2015) expected that resilient young adult (YA) SWM
who have a strong sense of sexual identity and identity disclosure or “out-
ness” to family and who are also rejected by family would be even more
likely to seek out community resources than would be typical for SMW
who are not rejected by their families. Rejected SMW would then demon-
strate resilience by adapting to fill their needs for socialization within the
community rather than in the family.
Zimmerman et al. (2015) investigated whether sexual identity forma-
tion and outness to family predicted sense of community and collective
self-esteem over a 12-month period for all SMW or whether an interaction
existed such that relationships between individual and community pro-
tective factors were moderated by family rejection. The authors recruited
 6 MENTAL HEALTH 155

a large national sample of SMW through online advertisements featured

on Facebook and Craigslist between 2010 and 2011. The final sample
consisted of 873 SMW which was comprised of 21% of the SMW who
expressed interest in completing the screening tool, who met the study
criteria, and who participated in the study at both baseline and at 12-
month follow-up. The study retained 77% of its original sample from
initial interview to baseline follow-up with eligible participants residing
in the United States, possessing a valid email address, self-reporting ages
between 18 and 25 (M  21.4, SD  2.1), and sexual identity as lesbian
or bisexual based on their response to one item asking them to describe
their sexual identity. According to one-way ANOVA analyses, there were
no differences in respondents who remained in the study at 12 months
versus those who dropped out of the study in terms of demographics and
study variables (Zimmerman et al., 2015).
The respondents self-reported their sexual identity as bisexual (57%)
and lesbian (43%). Approximately 10% of respondents reported a Latina
or Hispanic ethnicity, with racial identity reported as White (54.2%), mul-
tiracial (16.6%), African American (9.6%), and Asian (3.1%). The majority
of respondents lived in a large urban area (31%), with the remainder living
in medium-sized cities (26%), smaller cities and towns (29%), suburban
areas (9%), and rural areas (5%). Zimmerman et al. (2015) examined sev-
eral measures that have been previously validated in racially diverse samples
of SMW. The age at which individuals disclosed their sexual identity was
measured via the Age of Coming Out Questionnaire (e.g., Rosario et al.,
2011). Identity risk was assessed at baseline (Cronbach alpha  .80) and at
12 months (Cronbach alpha  .84) via the 27-item Lesbian, Gay, & Bisex-
ual Identity Scale (Mohr & Fassinger, 2000) which focused on 6 identity
risk factors (e.g., stigma, concealment of sexual identity, identity uncer-
tainty, internalized homophobia, difficulty with identity development, and
identity superiority or denigration of heterosexual identity). Changes in
identity risk were assessed over time, with time one scores subtracted from
time two scores. Positive values indicated an increase in overall identity risk
across the 6 factors.
Family rejection was assessed with 6 items from the Daily Heterosex-
ual Experiences Questionnaire (DHEQ) (Balsam, Beadnell, & Molina,
2012) at baseline (Cronbach alpha  .81) and at 12 months (Cron-
bach alpha  .82). Specifically, Zimmerman et al. (2015) assessed the
family’s acceptance of partners, avoidance of discussions related to sexual
identity, and rejection by mother, father, siblings, or extended family due to
156 S. R. NOTARO

sexual identity. Reponses ranged from never to almost every day with higher
scores indicating higher levels of rejection. Disclosure of sexual identity or
“outness” was measured via the Outness Inventory (Mohr & Fassinger,
2000) at baseline (Cronbach alpha  .85) and at 12 months (Cronbach
alpha  .85). Zimmerman et al. (2015) used 4 items from this inventory
to specifically investigate identity disclosure to mother, father, siblings, and
extended family to create an “outness to family” measure ranging from
no knowledge of the respondent’s sexual orientation to openly talking
about the respondent’s sexual orientation. Changes in outness to family
was assessed over the 12 month study period with a score of 0 indicat-
ing stable outness relationships and positive values indicating increases in
overall outness across relationships.
Connections to the LGBTQ community were assessed with 8 items via
the Connectedness to LGBTQ Community Scale (Frost & Meyer, 2012) at
baseline (Cronbach alpha  .87) and at 12 months (Cronbach alpha  .90).
The 8 items included items measuring community belonging (e.g., “I feel I
a m a part of the LGBTQ community”) with higher scores indicating higher
connectedness. A related measure to LGBTQ connectivity, Collective Self-
Esteem, assessed positive self-esteem related to membership in the LGBTQ
community with 4 subscales at baseline (Cronbach alpha  .93) and at
12 months (Cronbach alpha  .93). Higher scores reflected higher levels
of collective self-esteem.
In this sample, the most frequent response to family rejection items was
“never” (range 59–82%), which is consistent with prior findings demon-
strating the positive family relationships and family resources to cope with
societal bias among young adult SMW (Zimmerman et al., 2015). Despite
these mostly positive findings, a subset of respondents (range 10–24%)
reported daily family rejection related to sexual minority identity. These
individuals’ experience of family rejection worsened societal stress related
to sexual minority identity. As hypothesized, despite high levels of family
rejection, coming out to family was associated with increasing community
protective factors 12 months later. This finding of increased community
protective factors being associated with coming out to family, despite high
levels of family rejection, demonstrates protective-enhancing resilience.
This resilience process is inferred from the finding that rejected SMW
reported community connectedness that exceeded non-rejected peers
(Zimmerman et al., 2015). Despite this resilience, family rejection also
increased self-stigma, identity-confusion, internalized homophobia, and
other identity risk factors that lowered collective self-esteem. Zimmerman
 6 MENTAL HEALTH 157

et al. (2015) discussed the importance of connections to the LGBTQ

community for young adult SMW in helping them to reduce risks of sui-
cide, homelessness, and violence. For example, the GLBT National Help
Center provides young adult peer support via text messages, telephone,
and online referrals to LGBTQ centers and resources. Other resources
include PFLAG (Parents and Friends of Lesbians, and Gays), Substance
Abuse and Mental Health Services Administration (SAMHSA), both of
which provide guidelines for helping families support LGBT children,
including information on the impact of family rejecting behaviors on
substance abuse (e.g., SAMHSA, 2014).
Zimmerman et al. (2015) reported no significant differences in eth-
nicity, but did find an impact of race such that those respondents who
self-identified as multiracial, African American, and Asian American also
reported lower community connectedness as compared to those who iden-
tified as White. Zimmerman et al. (2015) provided three possible explana-
tions for this finding, based on prior research. First, developing connections
with sexual minority communities may be of lower importance for racial
minority young adult SMW. Second, racial differences in sexual minority
community connectedness may be associated with the salience of sexual
minority identity as compared to racial minority identity. Racial minority
young adult SMW may not experience similar levels of belonging in the
LGBTQ community as compared to their White peers. Zimmerman et al.
(2015) pointed out that, as race was not a significant covariate in the col-
lective self-esteem models, racial minority SMW may use strategies that
they learned to cope with racial minority discrimination to also ameliorate
stresses related to their sexual minority identity (e.g., Neblett, Rivas-Drake,
& Umana-Taylor, 2012).
Zimmerman et al. (2015) acknowledged several limitations including
possible sampling bias due to recruitment via social network web sites and
online data collection. Their findings may generalize less to SMW who
do not self-identify an interest in women on their social media profiles.
Second, the study collected only self-report data of family rejection from
SMW. While this data could be validated by also collecting it from family
members, such a strategy might cause additional stress for rejected SMW
(Zimmerman et al., 2015). Future research extending the data collection
beyond 12 months could help inform an understanding of whether these
relationships continue after young adulthood or decrease over time.
Zimmerman et al. (2015) concluded with several strengths includ-
ing their robust sample size which encompassed a large portion of U.S.
158 S. R. NOTARO

geographical regions and ethnic and racial backgrounds. The authors pro-
vided evidence of the resilience process in that the rejected SMW who
increased outness to family also reported more community connectedness
and collective self-esteem. Such findings add to the small body of research
focusing on SMW strengths and resiliency while identifying implications for
intervention. Specifically, Zimmerman et al. (2015) suggested that young
adult SMW who report internalized homophobia and who conceal their
sexual orientation could be at greatest risk for poor mental and physical
health—especially in high-rejecting families.

Summary
This chapter explored relationships among mental health, discrimination,
stigma, suicide, homelessness, reparative therapies, and resiliency within the
LGBT community. For example, Boone et al. (2016) identified internalized
homophobia as a key factor in the psychological distress of young black gay
and bisexual men due to the internalization of societal negative attitudes
toward homosexuals, same-sex attraction, and same-sex sexual behavior.
Next, the chapter identified suicide as a health disparity given that suicide
attempts are four times more likely among LGBT youth as compared with
their heterosexual peers and “questioning” youth (CDC, 2011), and that
racial minority LGBT youth (African American and Latino) attempt sui-
cide at twice the rate of nonminority LGBT youth (CDC, 2011). Research
findings indicating that the elevated risk of suicide among LGBT individ-
uals is partially accounted for by bias, discrimination, and prejudice as well
as from family rejection were reviewed (e.g., Ryan et al., 2009; Sidaros,
2017). Possible interventions designed to reduce suicide risk among LGBT
individuals, such as the Trevor Project, the only national crisis and suicide
prevention hotline created especially for LGBT and questioning youth,
were discussed.
The chapter also focused on homelessness given that the population of
RHY is comprised of a 20–40% overrepresentation of LGBTQ individuals,
a much higher percentage than either heterosexual or cisgender (indi-
viduals whose gender identity matches the sex that they were assigned at
birth) peers (e.g., Durso & Gates, 2012). A review of service organizations
providing support to RHY suggest that the most effective agencies affirm
youth’s sexual and gender identity by recognizing bias, discrimination, and
other stressors that may influence their homelessness and lack of family
support (e.g., Maccio & Ferguson, 2016; Shelton, 2015). An inventory of
 6 MENTAL HEALTH 159

LGBTQ RHY resources offered by 19 agencies across the United States

identified seven areas for improvement, including housing, education,
employment, family, LGBTQ-affirming services, cultural competency, and
advocacy (Maccio & Ferguson, 2016).
This chapter also reviewed research focused on the harmful approach of
“reparative therapies,” designed to repair or change homosexual orienta-
tion to heterosexual. In terms of the correlates of clinicians holding a repar-
ative attitude toward homosexuality, one study found that the strongest
predictor was the respondent reporting a heterosexual orientation (Lin-
gardi et al., 2015). Furthermore, internalized homophobia among some
lesbian and gay identified psychologists may be a factor in their embracing
reparative therapies for homosexuality (Lingardi et al., 2015). Finally, the
concepts of resiliency and protective factors were reviewed as Zimmerman
et al. (2015) discussed the importance of connections to the LGBTQ com-
munity for young adult SMW in helping them to reduce risks of suicide,
homelessness, and violence.

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 CHAPTER 7

Violence

Incarceration: Violence and Sexual Abuse

in the United States
This chapter will discuss violence inflicted upon the LGBT community,
with a focus on the vulnerable populations of incarcerated individuals and
young abused boys in Afghanistan. Examining violence within U.S. prisons
necessitates a discussion of the Prison Rape Elimination Act (PREA), fed-
eral legislation which was sponsored by former U.S. Attorney General Jeff
Sessions and unanimously passed by both chambers of Congress in 2003.

In prison, it’s hard. But being gay in prison makes it ten times harder. (G.
Guzman, personal interview, Johnson, 2017, Inmates Tell of Abuse, Use of
Solitary)

PREA sought to identify and analyze the incidence and prevalence of prison
rape in federal, state, and local prisons and jails throughout the United
Sates, and to provide information, recommendations, and funding to elim-
inate prison rape (National PREA Resource Center, 2018). PREA provided
a mandate and requisite funding for research conducted by the United
States Bureau of Justice Statistics through the National Institute of Jus-
tice. PREA also created the National Prison Rape Elimination Commis-
sion whose charge was to draft standards for the elimination of prison rape.
A subset of those standards, which were finalized by the Department of
Justice on August 20, 2012, mandated that prison officials must screen
© The Author(s) 2020 165
S. R. Notaro, Marginality and Global LGBT Communities,
Neighborhoods, Communities, and Urban Marginality,
https://doi.org/10.1007/978-3-030-22415-8_7
166 S. R. NOTARO

all inmates upon admission and transfer to assess their risk for experienc-
ing sexual abuse in the facility (National PREA Resource Center, 2018).
The rules were put in place to protect transgender inmates and specifi-
cally required that “genital status” not be used to determine a transgender
inmate’s housing in a men’s or women’s prison; rather, PREA required the
determination of a housing decision be made on a case-by-case basis, tak-
ing into account the preferences of transgender inmates (National PREA
Resource Center, 2018).
The National Inmate Survey-3 or the NIS-3 was administered by the
Research Triangle Park, North Carolina between February 2011 and May
2012 in 233 state and federal prisons, 358 jails, and 15 facilities operated
by Immigration and Customs Enforcement (ICE), the U.S. military, and
Indian reservations (Beck, Berzofsky, Caspar, & Krebs, 2013). The surveys
were collected from 91,177 adult prison and jail inmates and 1738 juveniles
aged 16–17 incarcerated in adult prisons and jails via computer-assisted
self-interview (ACASI), which involved a touch screen to interact with
the computer-assisted questionnaire. Allegations of sexual victimization
and other forms of violence were confidential and anonymous to increase
response rates; however, Beck et al. (2013) cautioned that both under-and
over-reporting may have occurred as there was no independent review to
substantiate abuse. Results of the survey, which used weights to provide
national and facility level estimates, indicated that 4.0% of prison inmates
reported experiencing one or more incidents of sexual victimization in the
past 12 months or since admission into the facility if less than 12 months
(Beck et al., 2013). As indicated in Table 7.1, results demonstrated large
and statistically significant (p < 0.05) differences in sexual victimization
among inmates based on their sexual orientation whereby prison inmates
identifying as lesbian, gay, bisexual, and transgender reported higher rates
of inmate-on-inmate sexual victimization as well as abuse from prison staff
as compared with heterosexual inmates (e.g., Beck et al., 2013).
The data in Table 7.1 provide evidence that transgender prisoners may
be most at risk of sexual victimization during incarceration, when com-
pared with individuals identifying as heterosexual, lesbian, gay, and other.
Indeed, reports of abuse suffered by transgender inmates abound, such as
the case of Jules Williams, a transgender woman who reported multiple
instances of sexual and physical assault and harassment while incarcerated
in the Allegheny County Jail in Pittsburgh, Pennsylvania between 2015
and 2017. While Williams is recognized by the state of Pennsylvania on
her identification card as a woman, she was incarcerated with men; fur-
 7 VIOLENCE 167

Table 7.1 Percent of

Source of
adult prison inmates victimization
reporting sexual inmate-on-
victimization in the Sexual inmate Staff sexual
United States orientation (%) misconduct (%)

Heterosexual 1.2 2.1

Lesbian, gay, 12.2 5.4
other
Transgender 33.2 15.2

Note Author created using information adapted from Table 8, preva-

lence of sexual victimization, by type of incident and inmate sexual
characteristics, National Inmate Survey, 2011–2012, Beck et al. (2013)
and Table 2, prevalence of sexual victimization among transgender
adult inmates, by type of victimization, National Inmate Survey, 2007,
2008–2009, and 2011–2012, Beck (2015)

thermore, although the jail’s policy requires transgender prisoners to be

housed in single cells, this policy was violated when the jail officials placed
Williams and other transgender women in holding cells with 10–15 men
for up to 72 hours while waiting to transfer these inmates to the main areas
of the jail (Cowart, 2017).
In September 2015, Williams was arrested and incarcerated in Allegheny
County Jail where she was placed in a holding cell with male prisoners.
After reporting harassment from male prisoners and corrections officers,
Ms. Williams requested protective custody which typically translates to soli-
tary confinement. Instead of granting her request, jail officials transferred
Williams to a cell with one male prisoner whom Williams alleges raped
her repeatedly for four days, while guards ignored her pleas and screams
for help. Williams also alleges that guards referred to her in derogatory
terms such as “faggot” and forced her to shower and change clothes in the
presence of mail prisoners. The assignment of Williams to a male prison
violates PREA’s (2003) mandate that transgender prisoners be assigned to
men’s or women’s correctional facilities on a case-by-case basis that consid-
ers the prisoners’ beliefs of where they will be safest. On behalf of Williams,
the American Civil Liberties Union (ACLU) of Pennsylvania and a private
attorney sued Allegheny County for trauma and abuse that she suffered in
jail after guards refused to house her with other female inmates (Cowart,
2017). The litigation is ongoing.
168 S. R. NOTARO

In a similar case of alleged sexual violence within prisons, Deon “Straw-

berry” Hampton, a transgender woman serving a 10-year sentence in
Illinois for burglary, filed a lawsuit in March 2017 against the Illinois
Department of Correction (IDOC) requesting a transfer to the woman’s
prison in Lincoln, Illinois. Hampton was quoted as saying “I feel inhu-
man” after reporting denial of her ability to represent herself as a female,
numerous sexual assaults, verbal and physical harassment, and beatings in
two Illinois men’s prisons (Brady-Lunny, 2018). According to IDOC, 80
inmates who are incarcerated in Illinois prisons have self-identified as trans-
gender women (Brady-Lunny, 2018). In response to Hampton’s lawsuit,
which is based upon violations of PREA, U.S. district court judge Nancy
Rosenstengel ordered the state of Illinois to submit a training plan regard-
ing the appropriate treatment of transgender prisoners within 14 days for
its correction officers. The decision of whether to grant Hamptons’ request
for a transfer to a women’s prison will be made by IDOC’s Transgender
Care Review Committee based on evidence both for and against the trans-
fer (Brady-Lunny, 2018).
The judge further ordered that Hampton be permitted to attend a
transgender support group within the men’s prison—a privilege she had
been denied due to her housing in segregation or solitary confinement.
The judge’s ruling noted that although three of Hampton’s sexual com-
plaints had been substantiated, the assistant warden of operations at the
men’s prison where she was incarcerated could not provide evidence that
any measures had been implemented to protect Hampton after her claims
were substantiated (Brady-Lunny, 2018). Additionally, the judge’s ruling
referred to her understanding that the IDOC transgender committee had
not met with Hampton nor had they considered her complaints or her per-
sonal sense of safety. In response, IDOC officials maintained that Hamp-
ton’s basic needs were met, that she was housed in a safe environment,
that some of their mental health-focused staff received specialized training
in transgender issues, and that training for all IDOC staff was underway
(Brady-Lunny, 2018).
The debate over transferring transgender women from men’s prisons to
women’s prisons has taken on another layer in countries such as England.
The issue is whether or not transgender women should be permitted to
transfer to women’s prisons if they have been convicted of committing
violent crimes against women and if they have not legally changed their
gender to female (Topping, 2018). According to England’s Ministry of
Justice, 125 transgender prisoners are incarcerated in England and Wales,
 7 VIOLENCE 169

with 60 of these 125 prisoners having been convicted of one or more sexual
offenses (Topping, 2018). The consideration of transfers for transgender
women prisoners to women’s prisons was recently brought to the forefront
in England, when Karen White, a transgender woman prisoner who had
been convicted for multiple rapes and other sexual assaults against women,
was transferred upon her request to New Hall prison for women (Topping,
2018). After the transfer, White was accused of four sexual assaults against
female inmates, which then precipitated a second transfer to a men’s prison
(Topping, 2018).
White subsequently admitted to sexually assaulting two female inmates
while she was incarcerated at the women’s prison. Some women prison’s
advocates, such as Frances Cook, Chief Executive of the Howard League
for Penal Reform, stress that situations in which a transgender woman
prisoner’s prior offending history of violent crimes against women as well
as the decision not to legally change gender to female should disqualify such
prisoners from transferring to a female prison. Cook and other groups who
support her viewpoint on these issues, argue that allowing self-identification
of gender as opposed to legally changing gender, would give a subset of
men posing as transgender access to women in women’s prisons (Topping,
2018).
England’s Ministry of Justice apologized for the decision to transfer
White to a women’s prison, admitting that the typical protocol wherein the
transgender case board considers all previous offending history in the trans-
fer request of a transgender person whose legal gender does not match their
self-identified gender was not followed in White’s case (Topping, 2018).
While Cook acknowledged that the transgender case board does carry out
its review process appropriately in some cases resulting in the denial of
transfer requests from self-identified transgender women with histories of
sexual assault against women, the case of Karen White points out the need
to standardize the transgender case board’s decision-making process (Top-
ping, 2018). The consideration of legal gender and self-identified gender
is further complicated by the fact that legally changing gender in accor-
dance with England’s Gender Recognition Act can take up to 5 years—a
circumstance that has prompted a review and possible reform of this Act to
decrease the time frame and complexity of the process (Topping, 2018).
In another attempt to influence transgender prison policy, some women’s
prison advocacy groups have initiated legal action related to the Labor
Party’s policy of formally including self-identifying transgender women on
female prison short-lists (Topping, 2018).
170 S. R. NOTARO

Turning back to the United States, in light of the importance of PREA

in determining the housing preferences and potential transfer of transgen-
der inmates, many LGBT activists are outraged with the Trump admin-
istration’s May 2018 rollback of the PREA mandate that all transgender
inmates must be screened at admission or upon transfer to determine the
safest environment in which to house them (Burns & Dreier, 2018). The
Trump administration’s new policy encourages all prisoners to be housed
based upon their “biological sex,” which is not a defined legal term, but
is presumed to refer to a prisoner’s assigned sex at birth (Burns & Dreier,
2018). This policy change has been challenged by several advocacy groups
including the National Center for Transgender Equality as well as by 67
members of the United States Congress. These 67 members of Congress
signed a letter drafted by Representative Jerrold Nadler (D-NY), the rank-
ing member of the House Judiciary Committee, and Representative Robert
Scott (D-VA). The letter was addressed to the head of the United States
Bureau of Prisons demanding a return to the PREA policy of consider-
ing the housing of transgender inmates according to self-identified gender
identity (Burns & Dreier, 2018).
Another issue of concern in the treatment of transgender inmates is their
frequent housing in “segregated” or “restrictive” housing which can take
several forms including disciplinary and administrative segregation and soli-
tary confinement within prisons and jails. Data from the U.S. Department
of Justice’s Bureau of Justice Statistics (Beck, 2015) indicates that on an
average day during the calendar year of 2011–2012, up to 4.4% of state and
federal inmates and 2.7% of jail inmates were held in restrictive housing. In
terms of demographic differences in restrictive housing, younger inmates,
those without a high school diploma, and those identifying as LGB were
significantly (p < 0.05) more likely to report time spent in restrictive hous-
ing as compared to older inmates, those with a high school diploma or
more school, and those identifying as heterosexual (Beck, 2015).
Restrictive housing is difficult to measure as there is no uniform defini-
tion or classification system within the prison system and wide variations in
the duration and conditions of restrictive confinement exist (Beck, 2015).
Disciplinary segregation is typically imposed for violating a facility rule as
compared to administrative segregation which is considered non-punitive
and imposed while an inmate is awaiting a transfer or a hearing (Beck,
2015). Solitary confinement, which can keep an inmate in a small cell for
up to 23 hours per day, may be imposed as punishment or for a prisoner’s
protection as is the case with some transgender inmates who report sexual
 7 VIOLENCE 171

assaults in prison; however, in some cases solitary confinement is applied

as harassment and is meted out disproportionately to transgender inmates
(e.g., Brammer, 2017).
Most prison reformers assert that solitary confinement is associated with
emotional distress as well as denial of services and programs (e.g., Brammer,
2017). According to the U.S. Department of Justice’s Bureau of Statistics,
restrictive housing was associated with inmate mental health problems as
evidenced by the estimates that 29% of prison inmates and 22% of jail
inmates who reported current symptoms of serious psychological distress
also reported spending time in restrictive housing over the past 12 months
(Beck, 2015).
Prisons with higher rates of restrictive housing also reported higher levels
of facility “disorder” including self-reported prisoner accounts of fighting
among inmates and between inmates and staff, worry about being assaulted
by other inmates, possession of weapons by other inmates, gang activity,
and theft of possessions by inmates (Beck, 2015). Relatedly, prisons with
higher rates of restrictive housing also housed larger percentages of inmates
who self-reported mental health problems and identified as LGB—note
that gender identity was not assessed (Beck, 2015).
The case of Chelsea Manning, a transgender woman and former Army
soldier convicted of leaking military intelligence information to WikiLeaks,
highlights the toll that solitary confinement can take on an inmate who
is also harassed and abused partly due to a transgender identity. Until
Manning’s sentence was commuted by former President Barack Obama
in January 2017, she was housed in solitary confinement in Kuwait and at
Quantico where she was reportedly stripped naked daily and denied access
to basic essentials including toilet paper (e.g., Brammer, 2017). Eventu-
ally, Manning attempted suicide twice during her incarceration, partially
attributed to her placement in solitary confinement as well as the Army’s
denial of her request for gender-affirmation surgery (e.g., Brammer, 2017).

Incarceration and Government Bias: Violence

and Sexual Abuse Globally
Reports of police and law enforcement’s harassment of LGBT people in
countries around the world demonstrate the ubiquity of the unfair treat-
ment of this community. In Egypt, 57 arrests, primarily for promoting
sexual deviancy, were precipitated in September 2017 when a subset of
concert attendees waived the rainbow LGBT flag in support of the band’s
172 S. R. NOTARO

lead singer, who is one of the few openly gay performers in the Middle
East (e.g., Youssef, 2017). After the initial arrests and subsequent arrests
made after raids on cafes and homes associated with LGBT people, Egypt’s
Supreme Council for Media Regulation issued a statement labeling homo-
sexuality as a disease and banning the discussion of LGBT issues in the
media, except for cases in which the LGBT person showed repentance (e.g.,
Youssef, 2017). These arrests are indicative of the approximately 300 other
arrests that have occurred since 2013 when Abdel Fatah al-Sisi took control
of Egypt’s government and its media (e.g., Youssef, 2017). As homosex-
ual acts in public in Egypt are illegal but homosexuality itself is not, most
of the arrests have been for charges such as debauchery. Some advocates
for LGBTQ rights claim that the Egyptian government’s consideration
of criminalizing homosexuality and imposing a prison sentence of up to
15 years is an attempt to distract the public from the countries’ social and
economic problems (e.g., Youssef, 2017). LGBT people who have been
incarcerated in Egyptian jails report sexual harassment from other inmates
as well as from guards.
In the Indonesian province of Banda Aceh in May 2017, a Sharia Court
sentenced two gay men to 85 public lashes for breaking the Sharia law pro-
hibiting sodomy after members of the public followed them to an apart-
ment, filmed them, and burst into the room while they were engaged in sex
(e.g., Dearden, 2017). The men were arrested by local Sharia police and
sentenced to a public beating based upon the sharia morality code whereby
up to 100 lashes may be imposed for offenses such as adultery, gambling,
women wearing tight clothes, and same-sex sexual behavior for men and
for women (e.g., Dearden, 2017). Sharia law stipulates that members of
the public and sharia police may publicly detain and identify anyone sus-
pected of breaking its rules (e.g., Dearden, 2017). Currently, Banda Aceh
is the only province within Indonesia practicing Sharia law (e.g., Dearden,
2017). The national government agreed to allow Sharia law in this province
to end a war with separatists (e.g., Dearden, 2017). Across Indonesia, the
United Nations and other human rights advocacy groups have reported
a recent increase in police raids, LGBT-activist arrests, and media censor-
ship and bans on broadcasts and information that portray LGBT people as
non-deviant (e.g., Dearden, 2017).
 7 VIOLENCE 173

Brazil
Brazil, a country with the largest gay pride parade in the world and where
gay marriage has been legal since 2013, experienced a sudden, large increase
in violent deaths of LGBT people in 2017 (e.g., Cowie, 2018). The vast
majority of the estimated 445 deaths were attributed to homophobia and
represented a 30% increase in such deaths as compared to 2016 (e.g.,
Cowie, 2018). Even given the reputation of Brazil as a violent country,
this sharp one-year increase in violence directed towards the LGBT com-
munity is alarming. Some victims of anti-gay hate crimes claim that police
often refuse to record these crimes as acts of homophobia and decry the
current lack of training programs designed to educate police officers on
bias and hate crimes and the especially heinous crimes committed against
transgender Brazilians (e.g., Jacobs, 2016). Even when arrested, the per-
petrators of homophobic-fueled violent crimes are often treated leniently,
receiving minimal jail time and paying small fines for crimes as serious as
attempted murder (Jacobs, 2016).
The president of the LGBT rights group Grupo Gay de Bahia in Brazil
asserts that the rise in violence against LGBT people is directly influenced by
the homophobic views of ultraconservative politicians who are supported
by Brazil’s evangelical caucus in the Brazilian congress (e.g., Cowie, 2018).
While the Brazilian population is comprised of approximately 25% evan-
gelical citizens, the Brazilian congress includes more than 60 evangelicals
out of the 513 members of the lower house—a number that has doubled
since 2010 (e.g., Jacobs, 2016). This caucus, referred to as the “B.B.”
or Bullets, Beef, and Bible caucus, is unified and disciplined, voting con-
sistently in a block, as compared to the remaining, fractured legislature
(Jacobs, 2016). The BB caucus is purported to have blocked proposed leg-
islation that would have punished homophobic acts, discrimination, and
hate crimes (e.g., Jacobs, 2016). Several other factors may play into this
rise in violence in Brazil aimed at LGBT people. In September 2017 a
Brazilian judge approved gay conversion therapy, designed to change the
sexual orientation of LGB people to heterosexual (e.g., Jacobs, 2016). The
media and its portrayal of LGBT people is also influenced by the religious
leaders who have purchased hundreds of television and radio stations in
recent years (e.g., Jacobs, 2016).
174 S. R. NOTARO

Papua New Guinea (PNG)

In addition to violence, another health disparity impacting incarcerated
LGBT people is the risk of HIV. One study that focused on HIV risk
and homophobia in incarcerated populations within Papua New Guinea
(PNG) demonstrated the negative impact of violence, discrimination, and
bias on individuals identifying as LGBT and/or as those engaging in male-
to-male and female-to-female sexual behaviors (Kelly-Hanku, Kawage, Val-
lely, Mek, & Mathers, 2015). In 2010, prisons in PNG were identified
as a key cite for increased HIV transmission for incarcerated individu-
als. This focus on the association between increased HIV risk and pris-
ons is widespread among international health organizations including the
World Health Organization (WHO, 2014) as a result of prison-related
activities including consensual sex, rape, intravenous drug use, and tattoo-
ing.
Within PNG, Kelly-Hanku et al. (2015), conducted 116 semi-structured
in person interviews with male (35) and female (21) prisoners and key infor-
mants (36 men, 24 women) in police holding cells and prisons to probe
possible gender differences in HIV-related risks in both types of facili-
ties. Key informants included staff from government and nongovernment
organizations, international donor agencies, and researchers (Kelly-Hanku
et al., 2015). Participants were approached by a third party and informed of
the opportunity to participate in the study. Informed consent was obtained
prior to the interviews which were audio-recorded, transcribed, and trans-
lated from Tok Pisin into English. Data were thematically coded.
Results demonstrated that police holding cells (which had no female
guards and were positioned directly in front of all-male guards) placed
women at more risk of rape as compared to men by police personnel,
although official reports by female victims were rare (Kelly-Hanku et al.,
2015). One woman interviewed about her experience in police holding cells
explained that she was raped repeatedly every night for three consecutive
weeks by a police officer. The study describes the culture surrounding these
types of attacks in prison holding cells as one of victim-blaming wherein
other female inmates refer to female rape victims as “acting like dogs who
get pregnant with bastard children” (Kelly-Hanku et al., 2015).
In contrast to prison holding cells, prisons were associated with higher
HIV risk for men than for women. A number of factors contributed to
this differential risk profile for men versus women, with one of the most
salient being nonconsensual anal sex between male prisoners. The culture
 7 VIOLENCE 175

of denial of such activities, under or no reporting of rape, the fact that

male-to-male sex is illegal in PNG, and a violent culture of exchanging
sex for commodities such as food contributed to the HIV-related risks of
incarcerated individuals. Most of the key informants, including guards and
higher-ranking prison officials, denied that male prisoners engaged in sexual
contact with each other. Some informants suggested that prison rehabilita-
tion practices offering religious fellowship programs to male prisoners were
responsible for the lack of sexual contact between male prisoners (Kelly-
Hanku et al., 2015). Some prisoners also denied the occurrence of sexual
behavior between men, sometimes citing the availability of pornography
via websites as mitigating men’s desire for sex in prison. Despite denials of
sexual acts between men, there were numerous reports of such acts, with
most regarded as nonconsensual and perpetuated by men serving long-
term sentences.
The reporting of non-consensual male-to-male sexual behavior in pris-
ons was uncommon, as victims of rape feared retribution and even death
from the perpetrators. Guards and wardens reiterated these concerns with
one warden stating that “the men who were raped in prison could not
report such crimes, as they would be a dead man” (Kelly-Hanku et al.,
2015, p. 995). One male prisoner who requested to speak with the research
team reported that he had notified an international nongovernmental
agency of his experience of being raped in prison, but had not received any
follow-up communication from the agency. Women in prisons reported
almost no instances of sex with men or rape by men as all men were denied
access to female prisons; however, once women were transferred back to
police holding cells for court appearances, the women again became vul-
nerable to rape.
Despite the prevalence of non-consensual sex in prisons and the endorse-
ment of the availability and distribution of condoms by the Papua New
Guinea Correctional Services HIV/AIDS Policy and Management Guide-
lines, condoms were not actually provided to male or female prisoners.
Only one prison, led by a commander who was a member of the Provincial
AIDS Committee, provided limited access to condoms for male inmates
during weekend release from prison, but not within the prison facility.
Key informants including guards and wardens discussed their refusal to
distribute condoms as upholding the law against sodomy and sexual acts
between men. They viewed condom distribution as condoning illegal sexual
behavior. None of the key informants discussed their reasoning for denying
176 S. R. NOTARO

condoms to female prisoners. A final barrier to condom distribution in pris-

ons within Papua New Guinea is the influence of conservative faith-based
organizations who offer literacy programs and other resources within pris-
ons but who also object to homosexuality and condom use.
HIV and STI testing were not mandatory and did not occur due to
a lack of financial resources and trained personnel, despite the endorse-
ment of several regional commanders at various prisons and the official
policy requiring health screenings upon admission to prisons (Kelly-Hanku
et al., 2015). One commander further stated that the lack of trained health
workers prevented the monthly inspection of prisons by medical officers, as
required by the Corrections Act. Some prisons offered voluntary, confiden-
tial HIV testing, ranging from a stand-alone accredited voluntary counsel-
ing and testing center to mobile units sponsored by faith-based agencies or
hospitals. Several of the prisoners indicated that they had received voluntary
HIV testing and that the prison officials had kept their results confiden-
tial. Several prisoners in two of the prisons were living with HIV and most
of these individuals along with guards and wardens indicated that inmates
with HIV were treated well despite being denied access to nutritional food
including fresh fruit.
Kelly-Hanku et al. (2015) concluded with their assertion that the culture
of violence, homophobia, and gender inequality within the prison system
in Papua New Guinea and other prisons globally exacerbate the risk of
HIV, STIs, and unwanted pregnancies. Their study demonstrated the con-
tinued abuse of power by male police officers. The researchers encouraged
an examination and possible implementation of an intervention practiced
in some U.S. prisons that has demonstrated significantly fewer reported
cases of rape and coerced sexual acts (e.g., D’Alessio, Flexon, & Stolzen-
berg, 2013). Their most urgent recommendations called upon government
agencies who administer the prison system to require the distribution of
condoms to all prisoners, both male and female, to protect against the
transmission of HIV and STIs and to make greater and sustained efforts to
prevent rape and coerced sexual acts within prisons and prison holding cells.
Kelly-Hanku et al. (2015) pointed out that the most pressing challenge in
achieving these changes is the lack of political will and related resources, a
culture that condones sexual violence in prisons and in society, and a failure
to view inmates as patients whose human rights warrant protection.
 7 VIOLENCE 177

Human Trafficking and Pedophilia: Young Boys

in Afghanistan
Similar to the violence experienced by vulnerable members of the LGBT
community, is the common practice of sexual abuse and human trafficking
of young boys by men in Afghanistan, many of whom are members of the
Afghan National Defense and Security Forces (Drury, 2016).

Bacha bazi is pervasive sexual slavery of children, seen widely as a cultural

practice and not a crime. (C. Hogg, personal interview, Chopra, 2016, The
Taliban Is Using Child Sex Slaves to Catch and Kill Afghan Police)

Although this custom referred to as bacha bazi or “boy play” has been
practiced for centuries, it is illegal under Afghan law as it is a violation
of Islam; however, the laws are seldom enforced as the perpetrators are
commonly Afghan military forces and powerful warlords supported by the
United States Department of Defense (DOD) and Department of State
(Nordland, 2018) in the quest to defeat the Taliban and hold territory
(Drury, 2016). An interview with a Grand Mullah, a religious cleric in
Afghanistan, revealed his view of bacha bazi as unacceptable in Islam and
a form of child abuse that continues because the Afghan criminal justice
system is dysfunctional (Qobil, 2010).
This secret culture of abuse revolves around the rape, kidnap, and traf-
ficking of young boys and young men who are also referred to as chai (tea)
boys or bacha bereesh (men without beards) ranging in age from 10 to 17,
before signs of puberty emerge (Goldstein, 2015). Most of these boys, as in
the case with many children in Afghanistan, live in extreme poverty and are
either orphaned, kidnapped, or sold by their desperate families for money
(Drury, 2016). The men who engage in this practice view it as a sign of their
wealth and prestige and often keep several young boys at once as sex slaves,
trading them among their friends who rape the boys after parties (Drury,
2016). Perpetrators of this abuse who do admit to having sex with young
boys and young men insist that the practice is not homosexuality because
they are not in love with the boys, and are therefore not gay. Regardless of
the sexual orientation of the abusers, the sexual violence and forced sexual
enslavement inflicted upon the young, impoverished, vulnerable boys of
Afghanistan, is a health disparity and gross violation of human rights that
has not been adequately addressed (Nordland, 2018).
178 S. R. NOTARO

Bacha bazi was outlawed as punishable by death under Taliban rule

(1996–2001) but resurfaced in 2001 after the U.S.-led invasion ousted
the Taliban (Drury, 2016). The United States military’s quest to defeat
the Taliban was supposedly partly due to the Taliban’s gross violation of
human rights; however, the practice of bacha bazi and sexual abuse of young
boys calls into question the U.S. support of the Afghan’s government and
its military forces who violate the human rights of young boys via sexual
violence and kidnapping (Goldstein, 2015).
One reporter from the BBC World Service spent several months inves-
tigating the practice of bacha bazi in Afghanistan, gaining the trust of sev-
eral abused boys or bacha bereesh and a few of the abusers (Qobil, 2010).
One young boy told the reporter that he started dancing at wedding par-
ties when he was ten-years-old to help support his widowed mother and
his two younger brothers after his father was killed in a landmine explo-
sion. The boy gave his meager earnings from dancing at the parties to his
mother who purchased rice to keep the family just out of reach of starva-
tion (Qobil, 2010). The Independent Human Rights Commission in Kabul
has discussed some of the contributing factors of bacha bazi as secrecy and
shame of the victims as well as their families who rarely accept the boys back
into their homes, even after escape from the abuse, as well as the extreme
poverty of an estimated 65,000 children who work on the streets of Afghan
cities polishing shoes, begging, and reselling plastic bottles (Qobil, 2010).
At a bacha bazi party that took place less than one mile from the Afghan
government’s headquarters, a reporter spoke with a master or bacha baz
who proudly proclaimed to have three dancing boys ranging in age from
15 to 18 years of age. The master discussed paying the boys to dance at
parties in women’s clothing for the entertainment of himself and his friends
and admitted to hugging and kissing the boys; however, he denied having
sexual contact with any of them (Qobil, 2010). He told the reporter that
“some people like dog fighting, some practice cockfighting. Everyone has
their hobby, for me, it’s bacha baze” (Qobil, 2010).
No studies have been conducted to determine how many children are
sexually abused across Afghanistan. In terms of the United States govern-
ment, there are reports from U.S. soldiers that they have been instructed
by their commanding officers to ignore the sexual abuse of young boys
perpetrated by members of the Afghan army (e.g., Goldsten, 2015; Nord-
land, 2018). Some members of the U.S. military even claim to have been
dismissed from service after complaining about the sexual abuse, some
of which is alleged to have occurred on military bases, as they were told
 7 VIOLENCE 179

by officers that such practices were accepted in Afghan culture (Goldstein,

2015). In one instance, former Special Forces captain Dan Quinn claims to
have been relieved of his command and removed from Afghanistan for get-
ting into a fight with an American-backed militia commander (Goldstein,
2015). Captain Quinn and another Marine attacked the Afghan military
commander for allegedly keeping a young boy chained to a bed as a sex
slave and for beating the boy’s mother when she attempted to end the
abuse (Goldstein, 2015). Former Captain Quinn, who has since left the
military, stated that:

The reason we’re here is because we heard the terrible things the Taliban
were doing to people, how they were taking away human rights. But we
were putting people into power who would do things that were worse that
the Taliban did—that was something village elders voiced to me. (Goldstein,
2015, New York Times )

The United States Congress, whose attention to the abuse of young boys
by Afghan military was captured by the 2015 New York Times report detail-
ing former Captain Quinn’s allegations (Goldstein, 2015), requested an
investigation into the practice of bacha bazi by Afghan security forces sup-
ported and funded by the United States military (Nordland, 2018). Since
fiscal year 2002, the United States has provided more than $71.2 billion
in assistance to the Afghan Security Forces Fund (ASFF) (SIGAR, 2018).
The Special Inspector General for Afghanistan Reconstruction (SIGAR)
conducted and published the heavily redacted results of its investigation
in June 2017 and a less redacted version in January 2018 (SIGAR, 2018).
The investigation was particularly focused on determining whether a group
of federal laws commonly referred to as the “Leahy Laws” were being vio-
lated by the practice of bachi bazi. The Leahy Laws prohibit the DOD and
the Department of State (State) from providing funds to a foreign security
force if knowledge exists that the force has committed a gross violation of
human rights (SIGAR, 2018). A complicating matter in the enforcement
of the Leahy Laws is the existence of a clause within the Afghan Security
Forces Fund provision within the Department of Defense’s Appropriations
Act which specifically stipulates that aid to Afghan military forces should
be available “notwithstanding any other provision of law” (SIGAR, 2018).
The SIGAR report asserted that the notwithstanding clause has been used
repeatedly to avoid the cessation of military aid to Afghan security forces,
180 S. R. NOTARO

despite credible allegations of gross human rights abuses, including the

rape of young boys by members of the Afghan forces (SIGAR, 2018).
The SIGAR report also asserted that a number of factors preclude
a full and complete understanding of the extent of child sexual abuse
among Afghan security forces, including the lack of details within incident
reports, the reluctance of individuals with knowledge to provide informa-
tion, and the lack of training and protocol among soldiers related to report-
ing incidents (SIGAR, 2018). Additional impediments in understanding
and addressing this abuse is the lack of coordination and consistency in
investigating alleged abusers among the Afghan government’s Ministry of
Defense and Ministry of Interior, as well as among the United States DOD
and Department of State. Protocols, investigative techniques, training, and
tracking of incidents all vary among both the Afghan and United States gov-
ernment entities charged with addressing allegations of gross violations of
human rights including child rape (SIGAR, 2018). One example of these
inconsistencies in the United States government is the fact that the State
Department considers allegations reported in the New York times as “cred-
ible information” that may be used to launch an investigation, whereas
the DOD requires independent corroboration of the allege incident and
additional details of the facts of the case (SIGAR, 2018).
The SIGAR report included several overarching recommendations.
First, the Special Inspector General urged the United States Congress
to consider prohibiting the DOD from using the notwithstanding clause
to avoid complying with the Leahy Law. Second, the DOD and State
departments should reiterate to all department personnel and contractors
in Afghanistan that gross violations of human rights, including child sexual
assault, are prohibited. Third, both departments should provide transpar-
ent training and guidance on the reporting of these allegations. Fourth, all
existing and future contract clauses must stipulate the mandatory reporting
of such allegations by military contractors to the Leahy Law point of con-
tact. Fifth, both departments should coordinate their activities such that
both units can work with the Afghan Attorney General’s Office on allega-
tions of gross violations of human rights, including child sexual abuse by
Afghan security forces. Sixth, both departments should consistently partic-
ipate in and sustain a Leahy forum specifically established to review com-
pliance with the Leahy Law to allow for the coordination of all relevant
stakeholders. Seventh, the DOD and State departments should collaborate
on a single, accessible tracking system for all allegations of human rights
allegations. Finally, the report recommended the creation or designation of
 7 VIOLENCE 181

a specific position within the DOD charged with overseeing both depart-
ments’ implementation of the Leahy Law in Afghanistan. The DOD and
State Departments provided comments on the SIGAR report, indicating
their overall agreement with the recommendations and plans for imple-
mentation, with the exception of designating a specific position to oversee
the Leahy Law in Afghanistan. The DOD did commit to clarifying the roles
and responsibilities of all DOD units engaged in the implementation of the
recommendations.
The aftermath of bacha bazi is disastrous for most victims of this abuse.
When the dancing boys are no longer valued (e.g., become too old and
show signs of puberty) by their masters or escape despite threats of violence
and murder, they have no place to turn as they are stigmatized and shamed
by Afghan society and labelled as “gay”. This practice of victimizing young
boys is a life sentence, with many of the boys turning to drugs and alco-
hol. Those who manage to keep their past a secret have an opportunity
to marry while others become perpetrators themselves and continue the
cycle of abuse (Drury, 2016) A report on the practice of bacha bazi by the
Independent Human Rights Commission in 2015 (Drury, 2016) attracted
the attention of the ministries of justice and religion who have now insti-
tuted the first law which outlaws bacha bazi and empowers police to make
arrests. It is the goal of the Independent Rights Commission that a home
for the former chi boys be established (Drury, 2016).

Summary
Chapter 6 reviewed violence as a health disparity among the LGBT com-
munity that is exacerbated by discrimination, homophobia, and a disregard
for the lives of children. The chapter began with a discussion of the violence
and sexual abuse experienced by incarcerated LGBT individuals in both the
United States and throughout the globe. The chapter summarized federal
legislation (the Prison Rape Elimination Act or PREA), which provided a
mandate and funding for research conducted by the United States Bureau
of Justice Statistics through the National Institute of Justice. Results of the
National Inmate Survey-3 (NIS-3) revealed that prison inmates identifying
as lesbian, gay, bisexual, and transgender reported statistically significantly
higher rates of inmate-on-inmate sexual victimization as well as abuse from
prison staff as compared with heterosexual inmates (Beck et al., 2013).
This chapter also presented specific examples illustrating the evidence
that transgender prisoners may be most at risk of sexual victimization dur-
ing incarceration, when compared with individuals identifying with sexual
182 S. R. NOTARO

orientations of heterosexual, lesbian, gay, and other. The chapter discussed

the individual cases of several transgender women in the United States who
are pursuing litigation to transfer from a men’s prison to a women’s prison,
given their reports of alleged harassment and physical and sexual abuse suf-
fered at the hands of prison officials and prisoners (e.g., Cowart, 2017;
Brady-Lunny, 2018).
Next, this chapter summarized several global reports of police harass-
ment of LGBT people in countries including Egypt, Indonesia, and Brazil
(e.g., Dearden, 2017; Youssef, 2017). The chapter also examined incarcer-
ation and homophobia as correlates of another health disparity impacting
LGBT—the risk of HIV. A study conducted by Kelly-Hanku, Kawage, Val-
lely, Mek, and Mathers in 2015 focused on HIV risk and homophobia in
incarcerated populations within Papua New Guinea (PNG). Kelly-Hanku
et al. (2015) asserted that the culture of violence, homophobia, and gen-
der inequality within the prison system in Papua New Guinea and other
prisons globally exacerbate the risk of HIV, STIs, and unwanted pregnan-
cies. The researchers urged prison administrators to distribute condoms to
both male and female prisoners to decrease the transmission of HIV and
STIs and to make sustained efforts to prevent rape within all incarcerated
environments.
This chapter ended with a discussion of the common, secret, and illegal
practice of bacha bazi, the sexual abuse and human trafficking of young
boys by men in Afghanistan, many of whom serve in the United States-
supported Afghan National Defense and Security Forces (Drury, 2016).
Most of the victims of bacha bazi are boys and young men who experience
extreme poverty as a result of years of war and violence (Drury, 2016).
Perpetrators of this abuse, who express pride in this practice as it affords
them prestige and power, do not label their sexual behaviors with the young
boys and young men as homosexual. Chapter 6 argues that regardless of the
sexual orientation of the abusers, this rampant and devastating sexual abuse
ruins the lives of countless impoverished and powerless boys of Afghanistan
(Nordland, 2018).
This chapter concluded with an overview of the recent SIGAR report
investigating the practice of bacha bazi and the involvement of the United
States DOD and State Department. The SIGAR report issued several rec-
ommendation, with the overall themes of ending bacha bazi, increasing
accountability for perpetrators, and ensuring coordinated responses from
the DOD and Department of State (SIGAR, 2018). The final note on the
victims of bacha bazi is one of ruin, desperation, and a repetitive cycle of
abuse.
 7 VIOLENCE 183

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 CHAPTER 8

A Framework for the Future

Coinciding with the 50th anniversary of the 1969 Stonewall uprising,

Marginality and Global LGBT Communities: Conflicts, Civil Rights and
Controversy has demonstrated that despite significant gains in LGBT rights,
the purposeful, systematic decisions to withhold equitable civil and political
rights from LGBT individuals in the United States and globally as well as
efforts to reverse gains in such rights will continue to be associated with
bias, stigma, discrimination, and death within this community. The volume
also highlighted the strength, resiliency, and courage of LGBT persons who
have fought for the recognition of their humanity and right to exist (e.g.,
Zimmerman, Darnell, Rhew, Lee, & Kaysen, 2015).

There will not be a magic day when we wake up and it’s now okay to express
ourselves publicly. We make that day by doing things publicly until it’s simply
the way things are. (Tammy Baldwin, First Openly Gay U.S. senator, “Never
Doubt” speech at the Millennium March for Equality, 2000, N. Rivero, 2017,
15 Inspiring Quotes from LGBT Leaders )

Importantly, this volume reviewed research and conceptual models (e.g.,

Meyer, 1995, 2003, 2010) that seek to understand and decrease the dele-
terious impacts of bias, discrimination, and stigma on the health disparities
of the LGBT population. The volume provided a historical and contempo-
rary overview of the tremendous gains that ensued from the Stonewall Inn
riots and the empowerment of a forgotten and hidden community (e.g.,
Carter, 2004).
© The Author(s) 2020 185
S. R. Notaro, Marginality and Global LGBT Communities,
Neighborhoods, Communities, and Urban Marginality,
https://doi.org/10.1007/978-3-030-22415-8_8
186 S. R. NOTARO

Chapter 2 provided ample evidence that the denial of legal rights con-
tinue to plague the LGBT community in the arenas of employment, hous-
ing, education, public accommodations, military service opportunities,
refugee protections, and remedies for hate crimes based on sexual orienta-
tion and gender identity. The continued struggle to simply exist, without
fear of hatred-fueled violence, is expressed by Kirsten Beck, the first openly
transgender former U.S. Navy Seal.

I don’t want you to love me. I don’t want you to like me. But I don’t want
you to beat me up and kill me. You don’t have to like me, I don’t care. But
please don’t kill me. (K. Beck, personal interview, Cooper, 2013)

Chapter 3 shed light on the renewed challenges to accessing health care

for LGBT persons under the Trump administration—challenges that make
it likely that the U.S. Supreme Court will again weigh in on the overall
legality of the Affordable Care Act with possible negative consequences and
impacts on health disparities experienced by marginalized populations such
as the LGBT community. Chapter 4 described historical cultural, structural,
and legal barriers to comprehensive, life-saving HIV/AIDS prevention and
care for persons most vulnerable to HIV. At a structural level, domestic
and global funding must increase for community based clinics and health
services, as well as integrated, comprehensive programs targeting HIV-
related stigma, discrimination, and societal and legal bias.
Although there is only limited research available from which to assess
the rates of LGBT substance abuse as well as the specific treatment needs,
Chapter 5 reviewed the evidence of associations among discrimination and
substance use and abuse (e.g., alcohol, cigarettes, and prescription drugs)
and sexual orientation. Research demonstrated that LGBT status is associ-
ated with minority stress and other prejudices that can lead to drug use as a
coping mechanism and create disincentives to seek drug recovery services.
Chapter 6 explored the importance of connections to the LGBTQ com-
munity, as well as concepts of resiliency and protective factors in reducing
the risk of suicide, homelessness, and damaging reparative therapy practices
that seek to force those who identify as LGBT to adopt heterosexual sexual
orientations.
Chapter 7 provided an overview of the severe and enduring violence that
is so often inflicted among LGBT incarcerated persons as well as the horri-
fying custom of child sex slavery or bacha bazi that is commonly practiced in
some regions of Afghanistan. The chapter concluded with a solemn view of
 8 A FRAMEWORK FOR THE FUTURE 187

the lives of victims of bacha bazi—ruin, desperation, and a repetitive cycle

of abuse. The remainder of this chapter will focus on the foremost ques-
tions that have arisen from the volume’s review of the historical, social, and
political context of the LGBT experience in the United States and globally.
Where will the struggle for LGBT equality go from here? What are the next
phases in the fight for humanity and the struggle to live and love freely?
Perhaps the first step is to acknowledge, celebrate, and encourage more
of the brave voices who have managed to come out of the shadows, to
embrace their identity, and to share their struggles and triumphs with the
world. Charles M. Blow, journalist, commentator, and columnist for the
New York Times is one such individual whose 2014 memoir, Fire Shut Up in
My Bones, formed the foundation of an opera based on his life. Below, Blow
reflected on how identifying himself as bisexual was the beginning of his
escape from the darkness of hiding both his sexual identity and the child-
hood sexual abuse that he suffered. During Pride Month, the celebration
of LGBT communities held annually in June across the globe, Blow shared
words of hope with other queer people who are searching for acceptance,
for community, and for the strength to love themselves:

I had to simply say that I was a bisexual man in order for me to begin to not
only accept that but to celebrate it, to begin to see that my sexual identity
was distinct from my sexual abuse…It is about agony — world-afflicted and
self-imposed — and anger, but also love and beauty. It is about grappling
and wrestling with who and what one is and coming at long last to accept,
embrace and love that person. So, during this Pride Month, I want to say
what countless others have said: ‘It gets better.’ And, I want to say that to
the throngs of people who are not necessarily today’s most celebrated queer
narratives: those who come out late in life, those whose families are not
affirming, those whose identities don’t necessarily adhere to the sexual binary
or may well be fluid, those queer people who still feel out of place even when
they are in the queer community. (Charles M. Blow, It Got Better. That’s My
Testimony, New York Times, Op. Ed., June 16, 2019)

Blow’s affirmative message of hope is a testament to the importance of

self-love in the struggle for basic human rights and to the realization that
marginalization of any group of people is an affront to the rights of all
people.
Going forward, this basic principle of humanity for all people must be
affirmed by institutions and formal structures that hold power over the daily
lives of LGBT persons. Recently during Pride Month progress was made on
188 S. R. NOTARO

this front as the New York City police commissioner, James O’Neill, apol-
ogized for the New York City Police Department’s (NYPD) misconduct
that occurred fifty years ago at the Stonewall Inn uprising:

The actions taken by the NYPD were wrong, plain and simple. The actions
and the laws were discriminatory and oppressive, and for that, I apologize.
(J. McNeil, interview at police headquarters, B. Allyn and D. Matia, 2019,
NYPD Commissioner Apologizes for ‘Oppressive’ 1969 Raid on Stonewall Inn)

O’Neill’s apology was issued under pressure from LGBT activists and local
politicians as New York City prepares to host World Pride on June 30, 2019
in honor of the 50th anniversary of the Stonewall uprising. Despite the
circumstances of the apology, Corey Johnson, a New York City Councilman
who is gay, viewed O’Neill’s statement as “very emotional and moving…It
is a big moment in having further healing and reconciliation.” Other voices
who weighed in on the apology let it be known that the NYPD’s admission
of wrongdoing was long overdue, as was the case with Mark Segal, a gay
journalist who remembers well the Stonewall Inn raid:

It took 50 years to get an apology for this? It’s just amazing. It’s unfathomable
to me. (M. Segal, personal interview, B. Allyn and D. Matia, 2019, NYPD
Commissioner Apologizes for ‘Oppressive’ 1969 Raid on Stonewall Inn)

Segal and other activists pointed out that although the NYPD have pro-
vided security for the annual gay-rights parade commemorating Stonewall,
the lack of a formal apology was still a source of tension between the police
department and the LGBT community. Segal relayed his hope that one
meaningful result of the apology would be to make LGBT youth feel wel-
come and encouraged to consider a career in law enforcement. Segal’s
request that O’Neill appear in person to issue an apology at the June 30,
2019 World Pride parade has so far not been granted, even though in
Segal’s estimation, the personal gesture could inspire police departments
in other cities with a similar fraught relationship with the LGBT commu-
nity to “realize that if the commissioner in New York can make an apology
after 50 years, maybe they can do a little better on their end.”
Similarly, James Fallarino, a staff member and spokesperson for NYC
Pride which organizes the annual parade, expressed his sentiment in a state-
ment that although one apology could not erase years of tense and discrim-
inatory interactions between the NYPD and the LGBT community, that
 8 A FRAMEWORK FOR THE FUTURE 189

moving forward LGBT persons would “continue to demand better treat-

ment by and improving relationships with the NYPD and other branches
of law enforcement…That relationship has reached a turning point, and we
hope that this gesture will allow for even more dialogue moving forward.”
Moving from the more local structures of police departments to the
broader scope and jurisdiction of the courts, brings us to a consideration
of future court cases that will impact the civil rights and daily lives of the
LGBT community both in the United States and globally. First, an exam-
ination of the United States Supreme Court’s possible future stance on
LGBT rights is illuminating and troubling to those concerned with preserv-
ing LGBT rights. President Trump’s recent appointment of conservative
Justice Brett Kavanaugh to the U.S. Supreme Court as the replacement for
former Justice Anthony Kennedy who voted in the majority in the Oberger-
fell v. Hodges decision legalizing gay marriage has left many LGBT activists
nervously anticipating the possible unraveling and overturning of LGBT
protections. Several areas of concern include transgender rights, employ-
ment, religious justifications for discrimination, and even marriage equality
itself.
In terms of transgender anti-discrimination protections in health care
within the United States, Chapter 3 described several provisions in the
Affordable Care Act (ACA or Obamacare) which provided LGBT persons
with protections based on gender identity and sexual orientation includ-
ing that preventive services are available for all patients, regardless of gen-
der identity, sex assigned at birth, or recorded birth. On May 24, 2019,
the Trump administration released its proposed rule that would repeal the
ACA’s discrimination protections for transgender people as well as women
seeking care after abortions (Stern, 2019). This latest erosion of transgen-
der rights extends the conscience rights (also discussed in Chapter 3 of
this volume) of health care providers and insurance companies allowing
them to refuse to treat transgender individuals (Stern, 2019). Transgender
rights groups, who are preparing civil litigation to fight this new rule which
is based on the Trump administration’s definition of “sex” as “biological
sex,” warn that the roll-back in protections will not only increase discrimi-
nation against transgender people within the health care system, but it may
deter them from seeking care in the first place, resulting in possible dire
health consequences (Stern, 2019). The key to the future of protections
for LGBT persons, and especially transgender people, in the United States
lies with the Supreme Court, as the justices will likely soon consider the
question of the definition of “sex” in an analogous sex discrimination case.
190 S. R. NOTARO

The precarious arena of employment protections for LGBT people was

discussed in Chapter 2 of this volume. Federal legislation prohibiting dis-
crimination in employment does not include the categories of sexual ori-
entation or gender identity and fewer than half of the states have added
these classes to their anti-discrimination laws. Given the lack of federal
protections in employment, LGBT activists have argued that the ban on
sex discrimination in Title VII of the Civil Rights Act of 1964 should apply
to those who identify as LGBT. Advocates have made the case that firing
a person for identifying as LGBT is a form of gender discrimination and
punishment for failure to conform to expectations of dress and behavior
associated with their sex assigned at birth. Federal courts, as well as the
Equal Employment Opportunity Commission, have accepted this argu-
ment and currently interpret Title VII’s prohibition of sex discrimination
as forbidding any employment discrimination based on gender identity or
sexual orientation. Despite this history and current interpretation of Title
VII by the EEOC, a conservative ruling in the case of EEOC v. R.G. &
G.R. Harris Funeral Homes could end the EEOC’s protection of LGBT
employment rights. This EEOC case involves Aimee Stephens, a transgen-
der woman who was fired from a Michigan funeral home job after coming
out as a gay woman. In March 2018, the Sixth Circuit ruled that the funeral
homeowners violated Title VII because they fired Stephens for failure to
conform to sex stereotypes. LGBT activists anticipate that this case will
make its way to the U.S. Supreme Court which is now much more likely
to strike down current interpretations of Title VII as extending federal
employment protections to LGBT persons, leaving only individual state
laws to prohibit employment discrimination for this community. Impor-
tantly, LGBT advocates are gearing up for a battle as the justices have
agreed to decide in the near future whether federal civil rights law pro-
tects people from job discrimination because of their sexual orientation or
gender identity.
The issue of religious justifications for discriminating against LGBT per-
sons has been playing out in the arena of wedding services requested by
same-sex couples in several states, including Colorado, Oregon, and Wash-
ington. On July 17, 2019 the U. S. Supreme Court threw out an Oregon
court ruling (Klein, dba Sweet Cakes by Melissa v. Oregon Bureau of Labor
and Industries ) against bakers who refused to make a wedding cake for
a same-sex couple, directing the appellate judges in Oregon to consider
the 2018 U.S. Supreme Court ruling (Masterpiece Cakes v. Colorado Civil
Rights Commission) in favor of a baker from Colorado who cited religion
 8 A FRAMEWORK FOR THE FUTURE 191

reasons for refusing to make a cake for a same-sex wedding. The U.S.
Supreme court’s ruling in the Colorado case was limited in its findings,
leaving open the broader question of religious justifications for refusing
service to same-sex couples. The U.S. Supreme Court is likely to soon take
up the case of Arlene’s Flowers Inc. v. Washington, which involves a florist
from Washington state who refused to create flower arrangements for a
same-sex wedding.
An issue that is related to religious justifications for refusing services
to same-sex couples is that of the equal rights and protections extended
to same-sex married couples under the Supreme Court’s 2015 Obergefell
v. Hodges ruling. Even if Obergefell v. Hodges , which legalized same-sex
marriage nationwide, is upheld in the future, the issue of the granting of the
same rights afforded to married opposite-sex couples as to same-sex couples
may be attacked and eroded. A Texas case (Pidgeon v. Turner) that dealt
with this issue could land in the U.S. Supreme Court in the near future. In
2013, a minister and an accountant from Dallas, Texas successfully sued the
city of Houston over the payment of benefits to same-sex city employees,
arguing that taxpayers should not have to pay for the benefits. Despite
the Obergefell ruling, the Texas Supreme Court ruled that the legalization
of same-sex marriage did not resolve the issue of benefits for same-sex
couples. As of December 2017, the U.S. Supreme Court has refused to hear
the city of Houston’s challenge to the Texas Supreme Court’s decision.
LGBT advocates fear that if this case or a similar one should return to
the U.S. Supreme Court, the justices may decide to permit states to limit
or eliminate benefits for same-sex couples while still technically allowing
same-sex marriage to remain legal—effectively overturning Obergefell in
everything but name only.
Turning a global lens to recent court rulings that have significant con-
sequences for LGBT rights brings us to African nations such as Kenya,
whose punitive laws outlawing homosexually were ushered in my Britain
during the beginning of the colonial period during the late nineteenth
and early twentieth centuries. Indeed, in April 2019 British Prime Minister
Theresa May acquiesced to pressure from U.K. LGBT activists and apol-
ogized for Britain’s introduction of anti-homosexuality laws to its former
colonies and encouraged leaders of now independent nations to repeal such
laws. Although progress continues on this front as evidenced by the legal-
ization of same-sex marriage in South Africa in 2006 and Malta in 2017,
LGBT activists in African countries are fighting to change the culture and
views that homophobia and not homosexuality was introduced to Africa
192 S. R. NOTARO

by British colonizers. If this altered view on homosexuality can be realized,

then advocates hope that the laws will change accordingly.
A setback on this front occurred in May 2019 when Kenya’s High Court
unanimously ruled that the country’s law criminalizing homosexuality or
“unnatural acts,” does not violate the country’s 2010 constitution which
guarantees equal protection to all people, freedom of expression, and free-
dom from discrimination. Charles Kanjama, a lawyer for the Kenya Chris-
tian Professionals Forum, has argued that the majority of Kenyans believe
that homosexuality should remain illegal as they view homosexuality as “a
very moral perversion—a taboo” (Kushner, 2019). The belief that homo-
sexuality is “un-African” and introduced by foreigners is evident in state-
ments from other Kenyans such as Vincent Kidada who support the crim-
inalization of homosexuality:

The devil in the name of foreign agents comes and introduces an alternative
sex. “Foreigners are the people who are nurturing our very locals to this act.”
(Kushner, 2019)

This latest ruling in Kenya is consistent with the fact that other rights
extended to LGBTQ people such as same-sex marriage and same-sex adop-
tion are not even on the agenda of Kenya’s courts. Despite these recent
retrenchments, artists and writers such as Kenyan writer Mukoma Wa
Ngugi have not given up the fight for LGBT rights or the struggle to
reject laws remaining from colonial-era penal codes. At an African litera-
ture festival held in Berlin in 2017, Ngugi said:

The British empire in one sense ended, but its language is now the language
of the world. That’s a sentiment I’ve heard LGBTQ-rights defenders echo
and reframe to criticize not just colonial language, but the morals espoused
through it. (Kushner, 2019)

Expressing a similar sentiment, Kari Mugo, the operations manager

at the National Gay and Lesbian Human Rights Commission of Kenya
said that “we have undo the notion of what culture is, as well as what it
means to be African” (Kushner, 2019). The movement to repeal laws which
criminalize homosexuality is in some ways a reimagining of and reclaiming
of acceptance for LGBT people in Kenya, Uganda, and other former British
colonies that was made impossible by over a century of colonial-imported
homophobia (Kushner, 2019).
 8 A FRAMEWORK FOR THE FUTURE 193

Moving to another region of the globe—Latin America—provides addi-

tional insights into the future of LGBT rights. On June 13, 2019 the
Supreme Federal Court (STF), Brazil’s Supreme Court, voted to criminal-
ize homophobia, or what they label “homotransphobia,” an important sign
of progress for LGBT persons living in one of the most dangerous coun-
tries for sexual minorities in the world. The STF took this action as the
country waits for the Brazilian Congress, which is governed by a conserva-
tive evangelical majority, to pass a law prohibiting discrimination based on
sexual orientation and gender identity. One of the judges who voted for
the new measure, Carmen Luzia, expressed the sentiment of the Court’s
majority opinion:

All prejudice is violence. All discrimination is a cause of suffering. But I

learned that some prejudices cause more suffering than others. (AFP, 2019a)

Although Brazil now joins several other countries (e.g., Argentina,

Colombia, Uruguay, and Ecuador) throughout Latin America that have
passed laws, including same-sex marriage, protecting LGBT rights, Judge
Ricardo Lewandowski expressed the sentiment of all three Brazilian STF
judges who voted against the homotransphobia measure when he said that
only “Congress can pass laws on criminal conduct” (AFP, 2019a). The
STF’s decision faces opposition from conservative members of the Brazil-
ian Congress who fear that church leaders may be penalized for using reli-
gious texts to reject same-sex unions. These fears are entrenched despite
the STF’s explicit assurance that religious freedom will not be curtailed as
a result of criminalizing homotransphobia, as long as churches refrain from
promoting hate speech that incites discrimination, hostility, or violence
based on sexual orientation or gender identity.
Adding to the opposition to the new LGBT protection is none other
than Brazil’s conservative President Jair Bolsonaro who criticized the
Supreme Court’s decision in a statement on Friday, June 14, 2019 claim-
ing that it could “hurt” gays by deterring companies from hiring them.
Bolsonaro argued that employers would “think twice” before hiring a gay
person for fear they could be accused of homophobia (AFP, 2019b). Bol-
sonaro went further by raising again his threat of nominating an evangelical
judge to the STF to help “balance” the bench. LGBT advocates were not
surprised by Bolsonaro’s remarks regarding the new law, as his statements
are in line with prior declarations that he would prefer his son to die than
to be gay. For now, due to the actions of the SFC, the newly defined
194 S. R. NOTARO

crime of homotransphobia carries a penalty in Brazil of one to three years

in prison or a fine, as is the case with the crime of racism. The question
for the future is whether or not changes in the political landscape of the
Brazilian SFC, Congress, or the Presidency will impact the lives of millions
of LGBT Brazilians by either supporting, weakening, or repealing the law
prohibiting homophobia.
In conclusion, this volume provided a foundation and a framework
for considering some of the lived experiences, triumphs, and challenges
of LGBT persons across the globe. Progress in securing LGBT rights is
moving forward; however, society must grapple with and identify ways in
which to continue the struggle for LGBT civil and political rights with a
reduced cost and burden to mental, physical, and emotional well-being.
A deeper understanding of ways to intervene in LGBT health disparities
is sorely needed, being mindful of and harnessing the protective factors
and supports that exist within the diverse LGBT community. Ending the
entrenched societal and structurally based discrimination and bias levied
upon the LGBT community will require the moral and political will of
every nation throughout the world. Going forward, the questions for soci-
ety are twofold. What are the human costs of continued marginalization for
any group of people? Do these costs matter enough to bring about change?

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 Index

A AIDS Coalition to Unleash Power

Abdel Fatah al-Sisi, 172 (ACT UP), 77
ACC, 32 AIDS Quilt, 77
Acquired Immunodeficiency Syndrome Alcohol, 19, 81, 111–116, 118–120,
(AIDS), 19, 54, 55, 68, 71, 125–128, 130, 131, 181, 186
75–78, 80, 85, 87, 88, 91, 94, Allegheny County Jail, 166, 167
95, 99, 101, 102, 104–106, 125, American Academy of Pediatrics
140–143, 186 (ACP), 30
Activism, 3, 14, 77, 81, 106
American Civil Liberties Union
Administrative segregation, 170 (ACLU), 30–32, 36, 167
Adolescents, 66, 128–130, 132, 144
American Health Care Act (AHCA),
Adoption, 19, 23, 25, 26, 45, 149, 68, 69
152, 192
American Psychiatric Association, 3
Adultery, 172
American Psychological Association
Afghanistan, 25, 165, 177–182, 186
(APA), 3–6, 150
Afghan National Defense and Security
Anal intercourse, 12, 82–85, 140
Forces, 177, 182
Afghan Security Forces Fund (ASFF), Anal sex, 11, 24, 95, 175
179 Ancalle, Mandi, 61
Africa, 8, 79, 99, 103, 191 Andrew, Daniel (Australian Premier),
African American(s), 37, 42, 43, 75, 40
79, 87, 92, 113, 114, 118, 119, Anti-discrimination, 19, 27, 28, 56,
143, 155, 157, 158 61, 130, 189, 190
Agender, 64 Antiretroviral cocktail, 77

© The Editor(s) (if applicable) and The Author(s) 2020 197

S. R. Notaro, Marginality and Global LGBT Communities,
Neighborhoods, Communities, and Urban Marginality,
https://doi.org/10.1007/978-3-030-22415-8
198 INDEX

Antiretroviral treatment (ART), 77, 76, 79, 81, 84, 86, 92–94, 112,
79, 94, 97, 99, 102–104 121–124, 126, 131, 139–143,
Anxiety, 42, 81, 83, 121, 122, 139, 153, 155, 158, 181, 187
141–144, 152 Boissonnault, Randy, 40
Argentina, 96–98, 193 Bolivia, 96, 97
Arlene’s Flowers, Inc. v. Washington, Botswana, 99
191 Brazil, 8, 24, 41, 96–98, 173, 182,
Army, 171, 178 193, 194
Aryan Nations, 43 Brief Symptom Inventory (BSI), 141
Asia, 10, 79, 102–104 Brief Symptom Inventory (BSI-18),
Asia-Pacific, 95 121
Association of American Medical Brothers y Hermanos, 82
Colleges (AAMC), 145 Bullets, Beef, and Bible caucus (B.B.),
Asylum, 27, 37–39 173
Audio computer-assisted self-interview Bureau of Justice Statistics, 165, 170,
(ACASI), 82, 114, 117, 166 181
Australia, 9, 34, 40, 103 Burial benefits, 56
Burkina Faso, 99
Burundi, 39
B
Bacha bazi (boy play), 177–179, 181, Bush, George H.W., 77
182, 186, 187 Bush, George W. (President), 62, 77
Bacha bereesh (men without beards), Butch lesbian, 4
177, 178 Byrd, James Jr., 42, 43, 46
Baker, Gilbert, 17
Banda Aceh, 172
Bangkok, 103 C
Bangladesh, 24, 104 Cabo Verde, 99
Bathroom Bill, 32 Cameroon, 99, 102
BBC World Service, 178 Campaign for Southern Equality v.
Behavioral Risk Factor Surveillance Mississippi Department of Human
System, 63 Services , 25
Benin, 99 Campus Pride, 29
Bias, 2, 9, 10, 15–17, 19, 23, 27, 41, Canada, 34, 38–41, 46
42, 46, 66, 75, 80, 81, 95, 100, Caribbean, 24, 79, 94
101, 105, 111, 117, 119, 120, Case management, 149
123, 124, 126, 142, 144–146, Castration, 12
153, 154, 156–158, 173, 174, CD4 count, 98, 112
185, 186, 194 Center for Epidemiological Studies
Binge drinking, 112, 116 (CES-D), 117
Biological sex, 4, 170, 189 Centers for Disease Control and
Bisexual, 1, 2, 4–6, 10, 18, 19, 29, 40, Prevention (CDC), 92–94, 143,
41, 44, 45, 54, 57, 58, 64, 75, 158
 INDEX 199

Centers for Medicaid and Medicare Community-based organizations

(CMS), 59 (CBOs), 89, 90, 92, 93, 117, 121,
Central Africa, 99, 101, 102 140
Central African Republic, 99 Community based participatory
Central American, 96 research programs (CBPR), 88–91
Chad, 99 Community involvement, 81, 97
Chain-referral sampling, 121 Comorbidity, 124, 125, 131
Chai (tea) boys, 177 Condom negotiation skills, 95
Chechnya, 38, 39, 46 Condoms, 80, 85, 86, 97, 175, 176,
Chelsea Manning, 171 182
Chief Executive of the Howard League Confederate Knights of America, 43
for Penal Reform, 169
Congo-Brazzaville, 99
Childhood abuse, 120–123, 131
Connectedness to LGBTQ Community
Childhood Trauma Questionnaire, 121
Scale, 156
Children’s Health Insurance Program
(CHIP), 58, 59 Conscience and Religious Freedom
Chile, 41, 96 Division, 62
China, 25, 26, 104, 129 Conscience Division, 62
Chlamydia, 76 Conscience Protection Act, 62
Christopher Street, 14 Conscience violations, 62
Christopher Street Liberation Day, 17 Consent decree, 33, 36
Cigarettes, 19, 118, 131, 186 Consolidated Omnibus Budget
Cisgender, 5, 145, 146, 149, 158 Reconciliation Act (COBRA), 56
Civil disobedience, 77 Convenience sample, 86, 140, 143
Civil rights, 1, 4, 16–18, 20, 36, 39, Cook, Frances, 169
40, 42, 56, 151, 189, 190 Cooper, Roy, 33, 36
Civil Rights Act of 1964, 28, 190 Coping, 113–115, 120, 122, 123, 142,
Civil Rights Movement, 42 150, 154, 186
Clinton, Bill (President), 33, 77 Costa Rica, 96
Closet, 15, 17, 23
Cote d’Ivoire, 99
Coats-Snow amendment, 61
Counseling, 54, 94, 97, 102, 104, 130,
Cocaine, 122
132, 176
Collective self-esteem, 153, 154,
Crack, 122
156–158
College, 28, 29, 43, 147 Credible information, 180
Colonization, 8, 11 Criminalization, 85, 101, 192
Color, 2, 3, 27, 28, 41, 42, 69, 81, 82, Cross-sectional, 65, 82, 84, 86, 88, 92,
93, 105, 112, 144, 147 116, 117, 119, 121, 123, 125,
Columbia, 41, 96 130
Coming out, 144, 155, 156, 190 Cross-sex hormones, 117
Commerce Department, 18 Crystal methamphetamine, 122
Communist, 13 Cultural competency, 54, 149, 159
200 INDEX

D Durkan, Jenny, 37
Daily Heterosexual Experiences
Questionnaire (DHEQ), 155
Dakaar, 8 E
Dancing boys, 178, 181 East Africa, 99–101
Data2Care, 93, 94 Ecstasy, 122
Daughters of Bilitis (DOB), 13 Ecuador, 96, 98, 193
Dear Colleague letter, 30 EEOC v. R.G. & G.R. Harris Funeral
Debauchery, 172 Homes , 190
Delhi, 103 Egale, 40, 41
Democratic Republic of Congo, 39 Egale Canada Human Rights Trust, 40
Egypt, 11, 171, 172, 182
Deon “Strawberry” Hampton, 168
Electroshock therapy, 12
Department of Defense’s Appropria-
El Salvador, 96, 97
tions Act, 179
Employment Retirement Income
Department of Defense (DOD),
Security Act, 56
179–182
Empowerment, 81, 185
Department of Health and Human
Empowerment education, 90
Services (DHHS), 9, 60, 61, 63
Enacted stigma, 84, 85
Department of State (State), 179
England, 34, 40, 168, 169
Department of Veterans Affairs, 56
Enhancement, 42, 113, 115
Devos Center for Religion and Civil
Equal Protection Clause, 25, 55
Society, 61
Equatorial Guinea, 99
Diagnostic and Statistical Manual
Ethiopia, 39
(DSM), 3
Europe, 11, 24, 37, 39, 43, 79, 127
Difficult sexual situations, 80, 81 Evangelical, 173, 193
Disability, 28, 41, 42, 46, 58, 68 Exchange sex, 85, 86
Disciplinary segregation, 170 Extortion, 15
Discrimination, 2, 3, 8–10, 13, 15–17,
19, 23, 27–32, 35, 41, 43–46, 56,
59, 60, 62, 75, 80–82, 84, 95–98, F
100, 101, 103–105, 111–124, Facebook, 87, 155
126–129, 131, 132, 140, 142, Facility disorder, 171
144, 146, 148, 153, 154, 157, Faculty, 28, 29
158, 173, 174, 181, 185, 186, Faggot, 167
189, 190, 192–194 Fair Housing Act, 27
District of Columbia, 6, 32, 35, 42, 56, Familial status, 28
93 Family acceptance, 81, 153
“Don’t Ask, Don’t Tell”, 33 Family rejection, 144, 153–158
Drag queen, 4, 16 Family Research Council, 62
DREAMS intervention project, 100 Family therapy, 148
Due Process Clause, 25, 55 Federal Bureau of Investigation (FBI),
Dunford, Joseph (General), 34 13, 43
 INDEX 201

Female genital mutilation, 100 Ghana, 99, 102

Female-to-female sex, 174 GLBT National Help Center, 157
Flame queen, 4 Global AIDS Response Progress
Florida, 28, 37 Reporting (GARPR), 95, 96
Fluidity, 5, 65 Global Fund, 94, 105, 186
Fogel, Susan Berke, 62 Global Fund to Fight AIDS,
Food and Drug Administration, 77 Tuberculosis, and Malaria, 77
Fourteenth Amendment, 25, 55 Global positioning system (GPS), 91
Gloucester High School, 30
Gonorrhea, 76
G GPS-based mobile applications, 91
Gabon, 99 Graham-Cassidy plan, 69
Gambia, 99, 102 Greenwich Village, 12, 14, 15
Gambling, 172 Grimm, Gavin, 30, 31, 36
Gay, 1–6, 8, 10, 12–19, 25, 26, Group for the Advancement of
28, 29, 33, 37–41, 43–46, 53, Psychiatry, 145
58, 64, 75–77, 79–84, 86, 87, Grupo Gay de Bahia, 173
92–94, 111, 112, 121–124, 131, Guatemala, 96
139–143, 151, 153, 155, 158, Guinea, 99, 102
159, 165–167, 172, 173, 177, Guinea-Bissau, 99
181, 182, 188–190, 193
Gay Activists Alliance (GAA), 17
Gay and Lesbian Medical Association H
(GLMA), 145, 149 Harassment, 2, 3, 16, 17, 28, 29,
Gay conversion therapy, 173 41, 43–45, 82, 84, 121, 148,
Gay, Lesbian, and Straight Education 166–168, 171, 172, 182
Network (GLSEN), 145 Harlem, 12
Gay Liberation Front (GLF), 16 Harm reduction strategies, 97, 100
Gay pride, 16, 17, 173 Hate crime, 19, 23, 27, 41–43, 46,
Gay pride flag, 17, 146 151, 154, 173, 186
Gender-affirmation surgery, 171 HB142, 32, 33
Gender, Alcohol, and Culture: An Health and Education Alternatives for
International Study (GENACIS), Teens (HEAT), 149
126 The Health Care Freedom Act, 69
Gender dysphoria, 30, 35, 60 Health insurance, 19, 55–59, 61,
Gender identity, 4, 5, 28, 30, 32, 33, 68–70, 84
36, 41–43, 45, 46, 58–60, 95, 96, Health messaging, 101
103, 145–147, 158, 170, 171, Health Reform Monitoring Survey, 60
189, 190, 193 Heart disease, 117
Gender paradox, 126 Heritage Foundation, 61
Gender-queer, 64 Heroin, 122
Gender Recognition Act, 169 Higher education, 27, 28
General stress appraisal, 121 HIV antibody test, 82
202 INDEX

HIV Behavioral Surveillance System, Illinois, 24, 56, 150, 168

84 Illinois Department of Correction
HIV Care Continuum, 92, 93, 98 (IDOC), 168
HOLA (Hombres Ofreciendo Lider- Immigration and Customs Enforce-
azgo Y Ayuda, Men Offering ment (ICE), 166
Leadership and Help), 89 Immigration and Refugee Board of
HoMBReS (Hombres Manteniendo Canada, 38
Bienstar y Relaciones Saludables or Impulsivity, 123, 131
Men Maintaining Well-Being and Incarceration, 103, 165, 166, 171,
Healthy Relationships), 89 181, 182
Homeless, 145, 147–150 Incidence, 6, 45, 79, 80, 85, 95, 103,
Homophile, 3, 13 141, 165
Homophobia, 2, 3, 80–82, 120, 121, Inclusivity, 5, 65, 66, 145
153, 173, 174, 176, 181, 182, Independent Human Rights Commis-
191–194 sion, 178, 181
Homosexual, 3–5, 8, 10–13, 15, 16, India, 11, 102–104
19, 24–27, 40, 46, 67, 76, 83, Individual mandate, 68–70
84, 87, 112, 122, 123, 139, 141, Indonesia, 172, 182
150–152, 158, 159, 172, 182 Infections, 75–79, 89, 93, 99, 100,
Honduras, 96 102, 103, 105
Honor killings, 38 Informed consent, 117, 121, 146, 174
Host country, 38 Injecting practices, 100
Hostility, 38, 82, 141, 193 Injunction, 31, 62, 70
House Bill 2 (HB2), 32, 33 Insurance market places, 58
House Judiciary Committee, 170
Internalized homophobia, 83, 85, 89,
House of Commons, 41
121, 126, 128, 139–142, 144,
Housing discrimination, 27, 28
150, 153–156, 158, 159
Human immunodeficiency virus
Internalized Homophobia Scale (IHP),
(HIV), 54, 60, 68, 69, 75, 76,
141
78–106, 112–118, 121, 131,
Interpersonal sensitivity, 141, 142
140–142, 149, 174, 176, 182,
Intersectionality, 64
186
Intersex, 5, 64
Human rights, 2, 3, 40, 45, 98, 172,
Intervention, 19, 20, 53–55, 71,
176–180, 187
76, 79, 84, 88–94, 96–103,
Human trafficking, 19, 177, 182
105, 114–116, 119, 120, 128,
Hypnosis, 150
130–132, 143, 144, 148, 150,
158, 176
I Intimate partner violence, 100
Identity, 4–6, 8, 29, 54, 66, 84, Intravenous drug users, 98
96, 120, 122, 140–143, 150, Investment Framework for the Global
153–157, 171, 187 Response to HIV, 94
Illegal drug use, 92 Iran, 11, 25
 INDEX 203

Iraq, 25 Laramie, Wyoming, 43

Islam, 177 Latin America, 8, 94, 95, 193
Israel, 9, 11, 24, 34 Latino, 69, 79–81, 87, 89–92, 113,
Italian Psychological Association, 151 114, 143, 158
Lawrence v. Texas , 24
Leahy Laws, 179–181
J Legal recognition, 95, 103
Jamaica, 24 Lesbian, 1–6, 10, 12, 13, 15–19, 28,
Jasper, Texas, 43 29, 37, 40, 41, 44, 45, 54, 58, 64,
Job discrimination, 144, 190 77, 81, 112, 124, 126, 131, 143,
Johns Committee, 28 151, 153, 155, 157, 159, 166,
Joint Chief of Staffs, 34 167, 181, 182
Joint United Nations Programme on Lesotho, 99, 100
HIV/AIDS (UNAIDS), 77–79, Liberia, 99
94–96, 99–105 Likert scale, 118, 121, 141
Jordan III, Daniel P. (Judge), 25 Limp wrists, 16
Justice Department, 32, 35 Lindsay, John (Mayor), 13, 14
Juveniles, 166 Linear regression, 141
Liver toxicity, 112
Lobotomies, 12
K
Lubricant distribution, 101, 105
Kaiser Family Foundation, 56, 57, 68
Kakuma Refugee camp, 39
Kenya, 39, 99–101, 191, 192
Kessler Screening Scale of Non-Specific M
Psychological Distress (K10), 141 Mafia, 15
Key informant interviews, 96, 97 Malawi, 99, 100
Key informants, 174, 175 Malaysia, 103, 104
Key populations, 94, 100, 101, 105 Male circumcision, 80, 101, 102, 105
Kick lines, 16 Male-to-male sex, 175
Klein, dba Sweet Cakes by Melissa Mali, 99
v. Oregon Bureau of Labor and Marginality, 1, 2, 81
Industries , 190 Marijuana, 92, 150
Kollar-Kotelly, Colleen (Judge), 34, 35 Marine, 179
K-12 school districts, 30 Marlow-Crowne Social Desirability
Ku Klux Klan, 43 Scale, 151
Kuwait, 171 Marriage, 19, 23, 25, 26, 45, 55–59,
70, 85, 101, 111, 151, 152, 173,
189, 191–193
L Masculine, 4, 12, 83, 127
Labor Party, 169 Masterpiece Cakes v. Colorado Civil
Lamba Legal, 32 Rights Commission, 190
Landmine explosion, 178 Mattachine Society, 13, 14, 16
204 INDEX

Matthew Shepard and James Byrd, Jr. N

Hate Crimes Prevention Act, 42, Nadler, Jerrold (Representative), 170
43, 46 National Center for HIV/AIDS,
Mattis, Jim, 33 Viral Hepatitis, STD, and TB
Mauritania, 24, 99, 102 Prevention, 92
McCarthy, Joseph (Senator), 13 National Gay and Lesbian Task Force,
Measurement error, 64, 66, 67 149
Medicaid, 58, 59, 68–70 National Health Interview Survey
Medical Monitoring Project (MMP), (NHIS), 57, 63
93
National Health Law Program, 62
Medicare, 58
National HIV/AIDS Strategy, 78, 92
Mental health, 19, 54, 55, 68, 85, 97,
120, 122–124, 129–131, 139, National HIV Surveillance System
144, 145, 147, 149, 153, 154, (NHSS), 93
158, 171 National Inmate Survey-3 (NIS-3),
Men who have sex with men (MSM), 8, 166, 181
54, 69, 75, 76, 79–93, 95, 97–99, National Institute of Statistics, 152
101–103, 105, 106, 111–116, National Institutes of Health, 63, 77
124, 131, 141, 143 National origin, 27, 28, 42
Mexico, 91, 94, 96–98 National Park System, 18
Microsystem, 153 National Prison Rape Elimination
Middle East, 11, 172 Commission, 165
Military, 13, 19, 23, 27, 33–36, 41,
National Strategic Plans (NPSs), 95
46, 56, 166, 171, 177–179, 186
Navigators (navegantes ), 90
Military contractors, 180
Milk, Harvey, 17, 53 NBA, 32
Ministry of Defense, 180 NCAA, 32
Ministry of Interior, 180 Needle and syringe programs, 100
Ministry of Justice, 168, 169 New Hall prison for women, 169
Minneapolis, 37 New York City, 13–15, 17, 82, 86,
Minnesota, 56 140, 143, 147, 148, 188
Minority stress model, 2, 81, 82, 112, New York Times, 179, 180, 187
125 New Zealand, 9
Mischievousness, 65 Nicaragua, 96
Mississippi, 25
Niger, 99
Misunderstanding of terminology, 65
Nigeria, 24, 99, 101, 102
Mood disorders, 149
Mortality, 76, 77, 143 Night sweats, 76
Mozambique, 100 Nondisclosure, 65, 66
MTV Shuga, 101 Non-discrimination, 56, 146
Mumbai, 103 North Carolina, 32, 33, 36, 166
Myanmar, 24, 103 Notwithstanding clause, 179, 180
 INDEX 205

O Pentagon, 33, 35
Obama, Barack (President), 13, 18, Pentecostal, 39
30–33, 36, 37, 42, 58, 61, 62, 78, PEP, 94, 97, 98, 101, 102, 105
92, 171 Perceived Stress Scale (PSS), 122
Obamacare, 69, 70, 189 Persecuted minorities, 38
Obergefell v. Hodges , 25, 55, 191 Persons who injected drugs (PWID),
O’Conner, Reed (Judge), 70 77, 79, 100–105
Office of Civil Rights (OCR), 60–63 Peru, 96
Office of Fair Housing and Equal Philadelphia, 82, 121, 124
Opportunity, 28 Phnom Penh, 103
Opioid, 120–123, 128–130 Physical abuse, 19, 80, 122, 154
Opioid substitution therapy, 100, 103, Pittsburgh, Pennsylvania, 166
104 Planned Parenthood, 69
Oral sex, 11 Pneumonia, 76
Orlando, 40 Pogrom, 39
Orphaned, 177 Police, 13–16, 172–174, 176, 181,
Ottawa, 41 182, 188, 189
Outness, 153, 154, 156, 158 Police entrapment, 14, 17
Outness Inventory, 156 Police holding cells, 174, 175
Political rights, 2, 18, 19, 30, 105,
P 151, 185, 194
Pacific, 102–104 Portugal, 151
Pakistan, 25, 103, 104 Poverty, 80, 94, 95, 98, 105, 177, 178,
Pan American Health Organization 182
(PAHO), 96, 127, 128 Prejudice, 2, 19, 140, 144, 158, 186,
Panama, 96, 97 193
Papua New Guinea Correctional PrEP, 93, 94, 97, 98, 101, 102, 105
Services HIV/AIDS Policy and Prescription drugs, 19, 122, 123,
Management Guidelines, 175 128–132, 186
Papua New Guinea (PNG), 104, President’s Emergency Plan for AIDS
174–176, 182 Relief (PEPFAR), 77, 94, 100
Paraguay, 96 Prevalence, 6, 66, 80, 83, 85, 87, 89,
Parallel system, 54 95, 97, 99–103, 116, 117, 122,
Parents, Families, and Friends of 128, 129, 143, 165, 167, 175
Lesbian, Gay, Bisexual and Prevention, 19, 20, 54, 63, 71, 76, 77,
Transgender People (PFLAG), 79–81, 86–106, 125, 128, 144,
145, 157 158, 186
Parliament, 40 Preventive services, 54, 59, 189
Patient Protection and Affordable Care Price, Tom, 61
Act (ACA), 69 Prisoner, 167, 169–171, 175
Pedophilia, 177 Prison Rape Elimination Act (PREA),
Peer victimization, 127 165–168, 170, 181
206 INDEX

Project PrIDE, 93, 94 Rodwell, Craig, 16, 17

Propaganda, 39 Roman Catholic Church, 11, 151
Protective factors, 2, 3, 19, 20, 82, Rosenstengel, Nancy, 168
128, 139, 142, 153, 154, 156, Runaway and homeless youth (RHY),
159, 186, 194 145–149, 158, 159
Provincial AIDS Committee, 175 Rural, 12, 79, 85, 149, 155
Psychological distress, 2, 19, 80, 81, Russian Federation, 38, 46
121, 139–143, 147, 158, 171 Russian LGBT Network, 39
PTSD, 149 Ryan, Paul, 62
Public beating, 172
Puerto Rico, 28, 93, 94
Putin (President), 39 S
Safe haven, 37
Same-sex, 4, 8, 10, 14, 25, 26, 56–58,
Q
101, 104, 129, 141, 151, 152,
Quantico, 171
190, 191
Queer, 5, 29, 41, 64, 112, 139, 187
Same-sex sexual behavior, 6, 10, 11,
Questioning, 5, 29, 64, 143, 145, 158
19, 24, 25, 140, 142–144, 158,
Quinn, Dan (Captain), 179
172
Sampling weights, 85
R Sanctuary, 39
Race, 6, 15, 17, 27, 28, 41, 42, 64, 84, San Francisco, 17, 117, 119, 124, 125,
92, 117, 120, 121, 157 143
Racism, 80, 105, 120–122, 194 Sao Tome & Principe, 99
RAND Corporation, 34 Scare queen, 4
Random reporting, 65, 67 Scott, Robert (Representative), 170
Reagan, Ronald, 76 Segregated housing, 170
Refugee, 19, 23, 27, 37–39, 46, 186 Self-efficacy, 85, 90
Religion, 27, 28, 41, 42, 60, 148, 181, Self-esteem, 81, 83, 153, 154, 156
190 Senate Armed Services Committee, 34
Religious communities, 82, 83 Senegal, 99, 102
Reparative therapies, 19, 139, 150, Sengalese, 8
158, 159 Senior Technical Advisor, 18
Research Triangle Park, 166 Sensation-seeking, 123, 131
Reservations, 166 Serostatus, 118
Resettlement, 37, 38 Services and Advocacy for Gay, Lesbian,
Resiliency, 2, 10, 19, 81, 139, 154, Bisexual, and Transgender Elders
158, 159, 185, 186 (SAGE), 145
Respondent-driven sampling, 82 Severino, Roger, 61, 62
Restrictive housing, 170, 171 Sex, 4–8, 13–15, 26–28, 30–32,
Rights-based perspective, 97 36, 41, 46, 56, 59, 60, 79–81,
Risky behaviors, 80, 84 85–87, 92, 95, 96, 99–101, 103,
 INDEX 207

105, 112–114, 119, 121, 123, Social exclusion, 95

129, 130, 145, 150, 158, 170, Social facilitation, 113
172, 174, 175, 177, 179, 186, Social integration, 82–84
189–192 Social media, 86, 87, 91, 105, 113,
Sex assigned at birth, 59, 189, 190 140, 150, 157
Sex trafficking, 177 Social network, 83, 87, 124, 157
Sexually exotic, 80 Social oppression, 80, 81
Sexually transmitted infections (STIs), Social racism, 121
69, 75, 76, 86, 87, 97, 112, 176, Sodomy, 11, 12, 24, 25, 172, 175
182 Solitary confinement, 167, 168, 170,
Sexual minorities, 2, 3, 64, 65, 67, 82, 171
116, 124–129, 131, 150, 153, Somalia, 24, 39
154, 193 Somatization, 121–123, 141, 142
Sexual networking sites, 86, 92 South Africa, 99, 100, 191
Sexual orientation, 3–6, 8–10, 20, South American, 96
26–28, 38, 39, 41, 42, 45, 46, Southern Africa, 99–101
56–59, 63, 65–67, 80–82, 84, South Sudan, 39
93, 113–115, 121, 124, 125, Spain, 11, 151
127, 129–131, 140, 142–144, Special Forces, 179
150–152, 156, 158, 166, 167, The Special Inspector General for
173, 177, 182, 186, 189, 190, Afghanistan Reconstruction
193 (SIGAR), 179–182
Sexual orientation and gender identity Staff, 28, 29, 54, 61, 62, 82, 139, 146,
(SOGI), 5, 28, 33, 36, 41, 42, 46, 147, 149, 150, 166–168, 171,
56, 63, 64, 96, 145, 146, 148, 174, 181, 188
186, 193 State of Higher Education for LGBT
Sex work, 97, 100, 101, 117, 118 People, 29
Sharia Court, 172 Status, 5, 11, 19, 24, 26, 35, 37, 39,
Sharia police, 172 45, 46, 66–68, 79, 84–88, 92, 93,
Shepard, Matthew, 42, 43 95, 100, 101, 104, 113–118, 120,
Short Inventory of Problems (SIP), 124, 130, 131, 140–142, 153,
114 186
Short Michigan Alcoholism Screening Stigma, 3, 8, 19, 55, 66, 70, 76, 83–85,
Test (SMAST), 113 87, 88, 90, 94, 98, 100, 101, 104,
Sierra Leone, 24, 99, 102 105, 120, 139–143, 145, 150,
Simpson, Amanda, 18 155, 158, 185, 186
Skilled nursing facility, 58 Stimulant, 121–123
Skin lesions, 76 Stonewall, 3, 14, 15, 18, 75–77, 82,
Skinny repeal, 69 105, 106, 139, 185, 188
Smoking, 111, 116–120, 130, 131 Stonewall Equity Limited, 18
Snowball sampling, 140, 146 Stonewall Inn, 1, 2, 14–19, 81, 105,
Social cognitive theory, 90 185, 188
208 INDEX

Stonewall National Monument, 18 69, 75, 79, 81, 86, 91, 93, 95–99,
Stonewall riots, 16, 17, 76, 77, 105 101, 103–106, 112, 116–119,
Stress, 2, 19, 81, 85, 86, 116, 117, 124, 131, 139, 144, 147, 148,
120–123, 126–132, 144, 150, 166–171, 173, 181, 182, 186,
153, 156, 157, 169, 186 189, 190
Students, 28–32, 36, 61, 128–130, Transgender Care Review Committee,
143, 145 168
Sub-Saharan Africa, 8, 77, 78 Transmission, 19, 76, 78–81, 89, 92,
Subsidies, 58, 59, 68, 69 93, 95, 100, 174, 176, 182
Substance Abuse and Mental Transvestite, 4
Health Services Administration Trauma, 83, 149, 167
(SAMSHA), 111, 120, 157 Trudeau, Justin, 40, 41
Substance use, 2, 19, 95, 111, 112, Trump, Donald (President), 30–36,
117, 118, 120, 122–125, 128, 59–62, 70, 170, 186, 189
130, 131, 144, 148–150, 186 Twitter, 34
Sudan, 24, 39
Sunday fag follies, 16
Supreme Council for Media Regulation, U
172 Uganda, 24, 39, 99, 100, 192
Survivor compensation, 56 UNAIDS Fast Track Strategy, 95
Swaziland, 99, 100 Unconstitutional, 25
Syphilis, 76 United Nations High Commissioner
For Refugees (UNHCR), 37
T United Nations Human Rights
Tactical Patrol Force (TPF), 16 Council, 41
Taliban, 177–179 United Nations (U.N.), 27, 79, 96,
Tanzania, 24, 99, 100 127, 172
90-90-90 targets, 95, 101, 105 United States Bureau of Prisons, 170
Tattooing, 174 United States Congress, 170, 179, 180
Testimonials, 81 United States Constitution, 25
Testing, 84, 89, 90, 93, 94, 97, 98, United States House of Representa-
101, 103, 104, 121, 149, 176 tives, 42, 69
Thailand, 11, 24, 103, 104 United States Justice Department, 42
Thresholds for categorization, 65 United States Senate, 42, 68, 69
Throat infection, 76 Universities, 28
Title VII, 28, 56, 190 Unsure status, 142
Title IX, 30, 31 Urban Institute, 60
Togo, 99, 102 Uruguay, 41, 96–98, 193
Tok Pisin, 174 U.S. Court of Appeals for the Fourth
Tranquilizer, 121–123 Circuit, 31
Transgender, 1, 2, 5, 6, 10, 12, 18, U.S. Department of Housing and
29–37, 41, 44, 45, 55, 58–61, 64, Urban Development, 28
 INDEX 209

U.S. Department of Justice, 34, 170, Weldon, Church, and Coats -Snow
171 amendments, 62
U.S. District Court, 25, 168 West Africa, 99, 101, 102
U.S. Equal Employment Opportunity Western blot blood test, 83
Commission, 28 Western Europe, 8, 9
U.S. State Department, 180, 182 White, 7, 43, 75, 80, 112–114, 118,
U.S. Supreme Court, 24, 42, 70, 186, 119, 121, 122, 124, 155, 157
189–191 White House, 77
White, Karen, 169
WikiLeaks, 171
V Williams, Jules, 166, 167
Vatican, 151 Wisconsin, 56
Venezuela, 96
World Bank, 94, 101
Verbal abuse, 80, 154
World Health Organization (WHO),
Veterans, 56
94, 127, 174
Vietnam, 103, 104
1964 World’s Fair, 13
The Village Voice, 16
World War I, 12
Violence, 2, 10, 19, 25, 39, 41, 44–46,
95, 100, 101, 117, 140, 147, 148,
157, 159, 165, 166, 168, 173,
Y
174, 176–178, 181, 182, 186,
Yangon, 103
193
Yemen, 11, 25
Viral load, 92, 98, 113
Yogyakarta, 103
Viral suppression, 93, 95, 104
Virginia, 30, 31, 36 Young men of color who have sex with
men (YMCSM), 79, 86
Young men who have sex with men
W (YMSM), 120, 122–124
Wagner, Robert Jr. (Mayor), 13
Wales, 168
Warden, 168, 175, 176 Z
Warlords, 177 Zambia, 99, 100
Washington D.C., 28 Zap, 17
Websites, 87, 91, 92, 149, 175 Zimbabwe, 99, 100