San Francisco, CA

With acknowledgement to Darren Carter, MD; Jennifer Pittman; Ronald Tierney

Email: rls39@columbia.edu

Email: pdunn@glma.org

Web: http://www.glma.org

I. Introduction/Background *

I. A. Definitions and Scope

This report discusses the health of lesbian, gay male, bisexual and transgender (LGBT) individuals. This grouping includes diverse and varied populations that often share little more than society’s stigma and prejudice. Stigma, however, as well as a range of other social and cultural factors, are forces that impact both the health of LGBT people and the ability of health care providers to care for them in myriad ways.

Like the general United States population, LGBT people are diverse in terms of cultural background, ethnic or racial identity, age, education, income, and place of residence. The degree to which sexual orientation or gender identity is central to one’s self-definition, the level of affiliation with other LGBT people, and the rejection or acceptance of societal stereotypes and prejudice can vary greatly from individual to individual. These differences parallel the diversity among members of other minority groups.

Lesbian, gay, and bisexual (LGB) people are defined by their sexual orientation, a definition that is complex and variable. Throughout history and among cultures the definition of sexual orientation shifts and changes. While sexual orientation is not easily defined, a generally accepted definition is an orientation toward people of the same gender in sexual behavior, affection or attraction, and/or a self-identity as gay/lesbian or bisexual.

Varied definitions of sexual orientation and research methodologies have resulted in differing estimates of the number of lesbians and gay men in the U.S. Many scientists now concur with estimates derived from Laumann et. al.’s (1994) well-designed survey of the U.S. population, though the authors note that these numbers may be low due to the limited ability of survey research to capture sensitive information from sexual minorities. Laumann et. al. used varied definitions of sexual orientation to offer a range for prevalence of homosexuality. Lower-end estimates were derived from reports of those people who self-identified as homosexual, gay, lesbian, or bisexual, while upper-end estimates were derived from those reporting any sexual behavior with a person of the same gender since puberty. Using these definitions, between 1.4% and 4.3% of women and 2.8% and 9.1% of men in the U.S. are classified as lesbian, gay, or bisexual. Because of the concentration of LGB people in larger urban centers, these estimates increase sharply when the 12 largest cities in the U.S. are considered separately. In these areas, estimates of homosexuality or bisexuality range from 2.6% (identity) to 4.6% (sex since puberty) for women, and 9.2% (identity) to 15.8% (sex since puberty) for men.

Definitions and scope of transgender populations are even less adequately researched. Gender is increasingly being understood as having a strong cultural definition in addition to precise biological and extensive psychosocial components. Studies frequently and incorrectly include gender non-conformist individuals under the rubric of gay men or lesbians, in spite of the fact that gender identity is clearly distinct from sexual identity (Israel & Tarver, 1997). Other studies have focused on health concerns of transsexuals alone, while ignoring intersex individuals, androgynes, transvestites, and a range of other individuals whose behavior and identity make them identify as transgender (Cohen, et. al., 1997; Gagne 1997; Israel & Tarver, 1997; Mason-Schrock 1996).

I. B. Stigmatization of LGBT Populations in the U. S.

Despite a steady increase in the acceptance of homosexuality over the past two decades (Herek, 1999), there still is great stigma surrounding homosexuality in the U.S. A recent poll found that the majority of Americans view homosexuality as morally wrong, in the same category as adultery (Ungvarski & Grossman, 1999).

"Homophobic" and "antigay" are terms commonly used in this document and elsewhere to describe negative attitudes toward lesbians and gay men. "Heterosexist" is used to refer to characteristics of an ideological system that denies, denigrates, and stigmatizes any non-heterosexual form of behavior, identity, relationship, or community.

Homophobia and heterosexism play a role in the inadequate assessment, treatment and prevention of lesbian, gay, and bisexual health problems. LGB individuals suffer from discrimination in housing, employment, and basic civil rights. Homosexuality is still criminalized through sodomy laws in 16 states of the U. S., a factor used not only to arrest LGB people, but to deny jobs, child custody, or participation in the political process (Lambda Legal Defense, 1999). Insurance companies, government, hospitals, and health clinics often fail to recognize committed lesbian and gay relationships, and deny gay and lesbian partners the privileges granted to married heterosexual couples (O’Hanlan, Cabaj, et. al., 1997).

Many LGB people, rejected by or uncomfortable with their families of origin, lose traditional social support after disclosure of their sexual identity (Vincke, Bolton, Mak & Blank, 1993). In addition, disproportionate numbers move to large urban centers with concentrated health risks.

Research on the effects of stigma, violence, social attitudes, and gender bias on the lives of transgender individuals is even less available than for LGB populations. Preliminary reports and existing studies suggest that the problems above may be even more severe for transgender individuals. They frequently face marginalization from gay and lesbian communities as well as from heterosexual communities and providers, and in many instances are regarded as pathological or unhealthy per se (Israel & Tarver, 1997).

I. C. Health of Lesbian, Gay, Bisexual, and Transgender Populations

Social conditions impact the health of LGBT populations in a variety of ways. The areas affected can be conceptualized as ranging from the direct impact of stigmatization and prejudice (e.g., exposure to violence, stress, poor access to care) to failure to adequately address special needs of LGBT populations (e.g., gay-specific sexually transmitted disease, fertility challenges, genital reassignment surgery). The diverse public health areas of impact are the substance of this report, though two general themes running throughout include:

1) Research and Evaluation

2) Health Care Delivery and Access to Care

This report covers a wide variety of health concerns of particular relevance for LGBT populations, organized by health topic. It is also important to consider these health outcomes in the context of their social origins. The following table conceptualizes health outcomes and their putative relationship to social/behavioral factors specific to LGBT populations, listing social/behavioral factors (across the top) and health outcomes specific to each (vertically below each factor). While not an exhaustive list of either, the table may serve as a useful heuristic in considering the relationship of social/behavioral factors and LGBT health concerns.

While knowledge of and standards of care for particular conditions prevalent among LGBT populations vary widely, several threshold areas impact LGBT health delivery generally and provide important opportunities to enhance delivery of care to LGBT populations. These topics are summarized in Section II, and include:

• public health infrastructure;
• access to quality health services;
• health communication; and
• educational and community-based programs.

Although there are many common issues affecting LGBT communities, transgender concerns present unique health challenges that merit separate discussion. Subject-specific summaries of leading lesbian, gay, and bisexual health concerns (e.g., cancer, substance abuse, etc.) are found in section III of this document. Section IV provides an overview of some of the complex issues related to transgender individuals.

Central to study of LGBT health concerns are the methodological challenges posed by studies of these populations. Relevant issues include definition and measurement of critically unexamined and socially constructed categories, as well as challenges of sampling rare and hidden populations concerning sensitive topics. These methodological challenges are examined in Section V.

Many topics of concern to the health of LGBT individuals are not addressed here. While this report summarizes existing research findings, clinical and public health research for these populations have been scarce (Bradford & White, 2000). In addition, there is currently no public health infrastructure for funding and supporting research on the health of LGBT communities. Coordination of research into LGBT health, and systemic reform and education toward elimination of anti-gay bias and insensitivities, remains imperative.

While this report is brief, its findings will prove useful if it engenders increased dialogue, understanding, concern, and support for research, education, and training with respect to LGBT health concerns. These are among the steps necessary for increasing knowledge about LGBT health and LGBT access to health services; for improving the health of members of lesbian, gay, bisexual, and transgender communities; for addressing health disparities in the U.S.; and for ensuring the health of all U.S. residents.

Efforts to research and address the health needs of LGBT populations are hampered by a lack of infrastructure to support and direct funded initiatives. Currently there is no identified agency within the Public Health Service with responsibility to oversee and/or coordinate such initiatives. Various agencies have funded competitive research and policy studies, but these efforts have been scattered and without central, overarching guidance relevant to population health. For gay and bisexual men, competitive research grants have been funded primarily in areas related to HIV/AIDS. For lesbians, several grants have been awarded in the areas of substance abuse, health care, and mental health (Solarz, 1999). While useful, these uncoordinated studies do not comprise an organized program of population-based research, nor is it easy to understand how they may mature into such a program without the intentional development of support structures. Research and public health interventions targeted to transgender individuals have lagged even more seriously.

Recent reports on LGBT health, most notably the Institute of Medicine’s landmark report on lesbian health, contain a number of recommendations that will be difficult to implement without significant infrastructure development (Solarz, 1999). Political constraints may limit the feasibility of creating an LGBT-dedicated research organization within the federal bureaucracy. However, alternatives such as cooperative planning and funding of critical population-based research and initiatives may be feasible. The IOM study on lesbian health, supported by funding from two agencies in the federal public health infrastructure – the Office of Research on Women’s Health in the Department of Health and Human Services (DHHS) and the Office of Women’s Health at the Centers for Disease Control and Prevention (CDC) – represents one example of such a collaboration.

Other promising cooperative efforts have followed publication of the IOM report. In September 1999, the National Institute of Mental Health (NIMH) collaborated with the American Psychological Association to present and host a two-day workshop on current research regarding LGBT populations. A current collaboration of DHHS with the Gay and Lesbian Medical Association/Lesbian Health Fund (GLMA/LHF) to implement a March 2000 scientific meeting as follow-up to the IOM report is another related endeavor. Cooperative efforts such as these can help fill gaps in the infrastructure, and can provide a foundation on which to create an enduring structure with appropriate sharing of responsibility among public and private organizations.

II. B. Access to Quality Health Services

LGBT individuals face financial, structural, personal, and cultural barriers as they attempt to access competent, sensitive health care services (Millman, 1993). These barriers and anxiety about facing them prevent LGBT individuals from receiving the screening and prevention services they need, and cause delays in receiving care for acute conditions.

Provider attitudes, communication difficulties, and systemic obstacles pose major impediments for sexual minorities to access care. LGBT persons, despite generally higher educational levels, have a lower socioeconomic status than their heterosexual counterparts. Many are self-employed, work as artists or craftspersons, or work part-time; consequently, many have few or no health insurance benefits (Badgett, 1998; Bradford, 1988).

An analysis of data from the National Lesbian Health Care Survey (NLHCS) (Bradford, in press) suggests that subgroups of lesbians may be at particularly high risk of negative health consequences due to lack of insurance coverage. Within the NLHCS sample, lack of health insurance was significantly correlated with being younger, unemployed, in school, of lower income, and African-American. Mental health issues were more prominent among uninsured respondents, many of whom reported significantly higher levels of anxiety and suicide ideation. Uninsured respondents are also more likely to have experienced physical and/or sexual abuse and reported much greater concern about sometimes feeling unable to meet their routine responsibilities. Certain physical health conditions were also more prominent, including ulcers and other intestinal disorders, substance abuse, and eating disorders. There was a statistically significant correlation for this sample between not having health insurance and believing that being lesbian affected their access to health care.

Both gay men and lesbians in committed relationships are at a disadvantage compared to married heterosexuals because many insurance companies and employers deny spousal benefits to unmarried partners (Denenberg, 1995; Stevens, 1995). Systemic bias in favor of heterosexuals is also found in regulations allowing one member of a married heterosexual couple to retain a jointly owned house without jeopardizing the other’s right to Medicaid coverage. Moreover, married heterosexuals receive a spouse’s Social Security payments following his or her death. While some 30 states have passed constitutional amendments barring recognition of gay marriage even if found legal by their courts, a recent ruling in Vermont provides a promising model. The State’s highest court has instructed legislators to recognize gay marriage or to structure domestic partnership regulations affording committed gay and lesbian couples benefits equivalent to those of heterosexual spouses. A number of local municipalities and private corporations have also widened insurance coverage for their employees to include unmarrieddomestic partners, both homosexual and heterosexual

LGBT populations may also find it difficult to access other publicly-supported programs. While many localities offer critical low cost or free health care and screening to women who are seeking birth control, lesbians who do not need birth control find it hard to locate affordable health care services. Men, already less likely to seek out such services than women, may be further impeded by reluctance to reveal their sexual practices or fear of homophobia in medical settings.

Additionally, same-sex partners are denied rights granted to married heterosexuals in hospitals and clinics. Unless a gay or lesbian couple has signed legal papers (e.g., durable power of attorney, health proxy, etc.) authorizing mutual medical decision making, blood relatives – including those who know less about the patient’s ethical, medical or religious preferences – can override decisions by a homosexual partner. Some health care settings also limit visits or participation in medical consultations to legally recognized spouses or blood relatives, a practice particularly damaging to the many LGBT people who prioritize families of choice over families of origin (O’Hanlan, Cabaj, et. al., 1997).

Even those LGBT individuals who have individual private insurance may be reluctant to use it to access care. The vast majority of U.S. employers who have more than 1,000 employees now self-insure, which means they have access to employee health care records and claims (Wolfe, in press). For some LGBT persons, disclosure of information about sexual orientation or gender identity would be an unacceptable consequence of seeking care. Similar confidentiality concerns may impede LGBT individuals from seeking counseling or support, or care for stigmatized conditions such as HIV, through HMOs which often require detailed justifications to ensure continuation of benefits.

In response to poor access to the health care system, during the past two decades LGBT communities have begun building elements of their own system. Systemic reform and the elimination of anti-gay bias in health care and social service settings remain essential goals for the health of LGBT communities. These goals are critical both to address medical concerns with unique effects for LGBT populations ¾ detailed in the pages that follow ¾ and to address general medical concerns shared with Americans at large.

II. C. Health Communication

In addition to difficulties in accessing health care, lesbian, gay, bisexual, and transgender individuals face significant obstacles in communication with health care providers. First and most challenging are negative attitudes toward homosexual, bisexual, and transgender persons held by many providers. Forty percent of physicians in one study were sometimes or often uncomfortable providing care to lesbian or gay patients (Matthews, Booth, and Turner, 1986). In a nonrandom survey of members of the Gay and Lesbian Medical Association (GLMA), 67% of respondents believed they had seen gay or lesbian patients receiving "substandard" care because of their sexual orientation (Schatz & O’Hanlan, 1994). Many lesbians and gay men have reported that their doctors are not sensitive to or knowledgeable about their particular health risks and needs, and do not disclose pertinent information about treatments or prevention (Smith, Johnson, & Guenther, 1985; Trippet & Bain, 1992; Schatz & O’Hanlan, 1994).

Whether patients disclose their sexuality and sexual practices to providers may depend in part on where patients are in their coming out process. For example, gay and lesbian adolescents ¾ who often lack structural supports such as financial independence and social networks that can sustain older gay men and lesbians (Allen, Glicken, Beach, et. al., 1998; D’Augelli & Hershberger, 1993; Newman & Muzzonigro, 1993) ¾ are likely to delay disclosure of sexuality to clinicians. Homosexually active men and women who identify as heterosexual, or those who are at the early stages of the distinct developmental processes theorists have associated with coming out (Brady & Busse, 1994) may also choose not to disclose their sexual histories to a health care provider.

Still, even individuals who enjoy significant social support as openly gay men and lesbians may find it difficult or imprudent to reveal their sexuality in a doctor’s office. Intake forms covering sexual history rarely include the option for providing information on same-gender sexual partners. Physicians and researchers routinely ask heterosexually-biased questions, such as: "Are you married, single, widowed or divorced?" or "What kind of birth control do you use?" Consequently, disclosure of sexual orientation in a health care setting remains infrequent for the majority of gay men and lesbians (Robertson, 1998; White & Dull, 1997; Allen, et. al., 1998; Cochoran & Mays, 1988; Siegel, Krauss & Karus, 1994). In a survey of lesbians in Michigan, 61% felt unable to disclose their sexual orientation to their providers (Bybee, 1990). Some 9% of respondents reported that their health providers had not allowed their female partners to stay with them during treatment or see them in a treatment facility; 9% also said that providers had not included their partners in discussion about treatment (Bybee, 1990).

The medical educational system has failed to educate providers and researchers regarding the unique aspects of lesbian and gay health (Wallik, 1992), including examination techniques, taking of patient histories, and preventive recommendations. Although homosexuality has been removed from the list of diagnoses in the diagnostic manual of the American Psychiatric Association, the relationship between homosexuality and sickness has proved more enduring in the minds of many providers. A variety of studies describe provider hostility (Hayward & Weissfeld, 1993; Gerber, Maguire, Bleeker, et. al., 1991) or instances of gay men or lesbians being described as "deserving" of illness or unworthy of treatment (Schatz & O’Hanlan, 1994). Tellingly, stigma can be most pronounced in those instances where sensitive treatment is needed. A number of respondents to the GLMA survey, for example, said they had seen doctors performing "rough" or "violent" digital rectal exams on patients after discovering that they were gay (Schatz & O’Hanlan, 1994).

Many clinicians sympathetic to gay men or lesbians may lack a repertoire of questions about social and sexual history appropriate to homosexuals, or be unaware of why they might be necessary. Among physicians interviewed for a cancer screening project conducted by the Mautner Project for Lesbians with Cancer, approximately half stated that they assumed lesbians were in their practices, but did not see any reason to address this in a direct way (Bradford & Dye, unpublished manuscript). These providers expressed an eagerness to learn more about the needs of lesbians and stated emphatically that they would make changes when they had information about what steps would be appropriate (Bradford & Dye).

Physicians are not alone among health providers in facing difficulties in communication with gay and lesbian patients. In a random sample survey of Virginia mental health providers, respondents acknowledged having lesbians in their practices, yet had little or no training about the special needs of these clients (Ryan, Bradford, & Honnold, 1999). Some mental health practitioners continue to practice "reparative" therapy for homosexuality (Berger, 1994), to use inadequate or inappropriate definitions for lesbians and gay men, and/or state that they do not think the concerns of gay or lesbian clients are different from those of heterosexuals (Robertson, 1998; Ryan, Bradford, & Honnold, 1999). Findings were similar in a California study of physicians dealing with lesbians and gay men (Mathews, et. al., 1986).

Barriers to communication about the needs and realities of gay and lesbian life are manifested at the systemic as well as individual level. In hospitals, emergency room>

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Finally, gay men and lesbians themselves, when faced with an uncomfortable interaction with a clinician, may lack the skills or self-efficacy to defend against negative experiences. They may feel unable to change physicians’ conduct, to resolve an uncomfortable situation, or to speak openly with a clinician about their discomfort. This may stem from a history of discrimination and the power imbalance traditionally experienced between clinician and patient, and/or from past memories of difficult experiences.

Disclosure of sexual orientation in the health care setting is crucial to the provision of appropriate, sensitive, and individualized care. Failure to establish rapport and communication between physicians and patients is associated with decreased levels of adherence to physician advice and treatment plans, and decreased rates of satisfaction (Inui & Carter, 1989). Additionally, clinicians unaware of their patients’ sexual orientation may fail to accurately diagnose, treat, or recommend appropriate preventive measures for a range of conditions.

While more research is needed on the effects of communication related to sexual orientation and medical care, small surveys suggest that successful communication and ease of sexual orientation disclosure may positively affect health risks and screenings. In a study of lesbians in Oregon (White & Dull, 1997), 90% disclosed their sexual orientation to providers, and of these, 92% raised the issue themselves (White & Dull, 1998). Communication style of the provider was rated by respondents as the most important characteristic in determining ease of discussion about difficult issues. The lesbians who disclosed their sexual orientation were more likely to seek health and preventive care, to have a Pap test, to be non-smokers, and to report comfort in communication with providers. By contrast, difficulty communicating with the primary care provider was associated with delay in seeking health care (White & Dull, 1998).

Lesbian, gay, bisexual, and transgender communities and their allies began to promote LGBT health concerns in the U.S. in the 1950s when educational, health-care, and other government and private systems proved inadequate. Organizing began with efforts to have homosexuality declassified as a medical illness. These efforts extended through the 1960s and intensified in the 1970s, with successful advocacy to remove homosexuality from the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM) (Bayer, 1981). In related early efforts, LGBT communities created a variety of professional and volunteer health care initiatives to offer non-judgmental treatment and education about sexually transmitted diseases (STDs) and mental health issues related to coming out and stigmatization. Lesbian health initiatives included the creation of "lesbian health nights" at women’s health clinics (Plumb, 1998). Gay counseling sessions, peer education groups, and STD screenings at ordinarily non-gay community health facilities were also organized. Then, as the gay community faced the HIV epidemic, work ensued to expand the focus of mainstream organizations, and to create new and powerful lesbian and gay-focused health education, treatment, and advocacy organizations (Deyton & Lear, 1988; Andriote, 1999).

Today, a variety of LGBT organizations – some of which are now celebrating their 25^th anniversary – deal in a comprehensive manner with HIV/AIDS, mental health, cancer, violence, and other issues. Clinics and volunteer initiatives providing community-based primary health care services directly to LGBT communities are found throughout the U.S. Among the largest and most notable of these are the Callen-Lorde Community Health Center in New York, the Whitman-Walker Clinic in Washington D.C., and the Howard Brown Memorial Clinic in Chicago, whose services include: screening, testing and care for HIV, breast cancer, and STDs; mental health services; family planning services, including artificial insemination and adoption; and support services related to violence and coming out.

Lesbian and gay community centers, of which there are over 100 in 33 states, may provide similar or additional services to those offered by health care clinics. These community centers include the modest Up the Stairs Community Center in Fort Wayne, Indiana and the Panhandle Gay & Lesbian Support Services in Scottsbluff, Nebraska, to the much larger centers serving the gay and lesbian communities of Los Angeles, Chicago, and New York. Many of these offer counseling and support for people in crisis, youth, the elderly, people living with HIV and AIDS, people struggling with substance abuse, and survivors of anti-gay violence. For example, the Los Angeles Gay and Lesbian Center ¾ founded in 1971 as the nation’s first lesbian and gay community services center and now the nation’s largest – offers primary care counseling; addiction recovery groups; testing and treatment for sexually transmitted diseases; and shelter for homeless youth (Burns & Rofes, 1988). Others, such as the New York Lesbian and Gay Community Services Center, serve as focal points for hundreds of support groups, and host cultural events and political advocacy efforts centered around LGBT health issues. New York’s community services center is home to the nationally recognized Gender Identity Project, providing counseling, advocacy, social support and training for transgender individuals and their providers. Many community centers provide a "safe space" to diminish the sense of isolation and self-judgement that are among the particular stresses of minority sexual orientation.

Not surprisingly, in the 1980s and 1990s, the HIV/AIDS epidemic forced a restructuring of existing educational and community-based programs in LGBT communities, and the creation of new LGBT health-focused organizations (Altman, 1994; Drucker, 1994; Jonsen & Stryker, 1993; Van Vugt, 1994). The first of these new organizations and prototype for many others was Gay Men’s Health Crisis (GMHC), founded in New York in 1982. Formed by a group of gay men before there was a name for AIDS, GMHC was a community effort to educate and care for itself as a growing number of its members became ill and died (Reinfeld, 1994). GMHC and many other AIDS organizations have grown from all-volunteer efforts to professionally-staffed, non-profit organizations that provide services such as support and advocacy, primary and secondary risk reduction, and community education. Other leading AIDS organizations include AIDS Project Los Angles, San Francisco AIDS Foundation, and AIDS Action Committee in Boston. Gay men and lesbians have also played prominent roles in the organizations formed to advocate for particular needs and concerns of people of color with HIV, including for example the National Minority AIDS Council, the National Latino/a Lesbian and Gay Organization, the National Native American AIDS Prevention Center, the Latino Commission on AIDS, the Black Leadership Commission on AIDS, Us Helping Us, African American AIDS Support Services and Survival Institute, the Minority AIDS Project, Bienestar, the Asian and Pacific Islander Wellness Center, the Asian Pacific Islander AIDS Intervention Team, and the Asian and Pacific Islander Coalition on HIV/AIDS.

HIV/AIDS strengthened the gay health movement’s emphasis on patient self-determination, and broadened its focus to include the previously ignored arena of clinical trials and medical research. The Community Consortium (CC) in San Francisco and the Community Research Initiative (CRI) of the People with AIDS Coalition in New York were created in the 1980s to increase community involvement in the testing of HIV drugs (Andriote, 1999). The AIDS Coalition to Unleash Power (ACT-UP), with chapters across the country, focused its early efforts on increased scrutiny of governmental agencies and privately-held companies perceived to be impeding the development of or access to potentially lifesaving AIDS medications. While tactics differed, CRI and CC helped establish a network of community clinical trials sites, and ACT-UP used public education and civil disobedience to achieve greater scientific accountability and patient involvement in research. Advocates for a range of illnesses have since adopted similar approaches and goals.

Efforts to foster health as well as combat illness have expanded to address the needs of LGBT individuals across the lifespan. For example, the Gay, Lesbian, and Straight Education Network (GLSEN) works to create a safe learning environment for lesbian and gay students in K-12 schools. GLSEN currently has a network of 85 chapters whose members work to educate school officials about non-discrimination policies. They also train teachers to prevent anti-gay attacks and create non-hostile environments. Other organizations working to protect and advocate for LGBT youth are the Hetrick-Martin Institute in New York City and Horizons Community Services Center in Chicago (Ryan & Futterman, 1998). For older gay men and lesbians, a number of organizations – many of which participate in a network organized by Senior Action in a Gay Environment (SAGE) – now provide support groups, social support, provider education, and advocacy.

LGBT professional organizations, or committees and working groups within larger professional organizations, serve as important resources for health care provision and social support efforts. Both the American Psychological Association and the American Society on Aging have committees or working groups focused on gay and lesbian concerns. LGBT professional organizations include the Gay and Lesbian Medical Association (GLMA), the Association for Gay, Lesbian, and Bisexual Issues in Counseling, and the National Association of Lesbian and Gay Addiction Professionals. The mission of GLMA, for example, is: "to combat homophobia within the medical profession and in society at large, to promote quality health care for LGBT and HIV-positive people, to foster a professional climate in which our diverse members can achieve their full potential, and to support members challenged by discrimination on the basis of sexual orientation (GLMA, 1999)."

In some locations, governmental entities have been created to promote the health of LGBT people beyond concerns of HIV/AIDS. For example, New York City established the Office of Gay and Lesbian Health Concerns (OGLHC) in 1983 in response to the AIDS crisis and redefined it in 1985 to address all lesbian and gay health concerns. The OGLHC has addressed the lack of health-care services for lesbian and bisexual women, anti-gay and lesbian violence, gay and lesbian suicide, and chemical dependency and substance abuse among gays and lesbians. Similarly, in San Francisco a Coordinator of Lesbian and Gay Health Services was created in the early 1980s (Vachon, 1988).

Other governmental agencies extended their reach to LGBT people by collaborating with existing community organizations. In 1996 the Massachusetts Department of Public Health, in conjunction with the Justice Resource Institute, the Medical Foundation, and the JSI Research and Training Institute, created the Gay, Lesbian, Bisexual and Transgender Health Access Project (GLBTHAP). The project works "to strengthen the Massachusetts Department of Public Health’s ability to foster the development of comprehensive, culturally appropriate health promotion policies and health care services for gay, lesbian, bisexual and transgender people through a variety of venues including community awareness, policy development, advocacy, direct service and prevention strategies (GLBTHAP, 1999)."

In conclusion, while some governmental agencies, professional organizations and mainstream health care entities have begun to address and respond to the concerns of lesbian, gay male, bisexual, and transgender individuals, LGBT people still largely depend upon self-created community-based and professional organizations to address their special health care needs. In addition, no federal infrastructure exists to facilitate the creation of LGBT health initiatives or research.

While definitive studies are lacking, preliminary data lends credence to the suggestion that gay men and lesbians are at increased risk for certain cancers, and that more research is needed to understand the natural history of disease in LGB populations. Innovative studies in psychoneuroimmunology further suggest a direct association between psychological phenomena, reduced immunity, and tumor growth; thus, gay men and lesbians who do not disclose their sexual orientation may be at increased risk for melanoma or other cancers due to psychogenic suppression of the immune response (Cole, Kemeny, Taylor, et. al., 1996).

Breast cancer is probably the most researched topic in lesbian health. Several investigators have hypothesized that lesbians are at higher risk for breast cancer than are heterosexual women due to higher rates of risk factors such as obesity, alcohol consumption, nulliparity, and lower rates of breast cancer screening (Haynes, 1994; Denenberg, 1994). While definitive studies in this area have yet to be completed, data on prevalence of each of the risk factors confirms the plausibility of this hypothesis (Dibble, et. al., 1997; Valanis, Bowen, et. al., in press). Lesbians also receive less frequent gynecologic care than do heterosexual women (Robertson, et. al., 1981) and therefore might also be at greater risk for mortality and morbidity from gynecological cancers. Both of these risks are likely compounded by the difficulties many lesbians experience in communicating with or receiving standard clinical care from physicians and health care systems (Trippet, et. al., 1992). Little is known about prevalence and incidence of other cancers among lesbians.

Among gay men, high rates of Kaposi’s sarcoma (KS) were some of the first described indicators of AIDS (CDC, 1981). Estimated risk for KS among gay and bisexual men was thousands of times higher than in the general population prior to approval of highly active antiretroviral therapies (Koblin, et. al., 1996). This was a by-product both of HIV’s weakening of the immune system and of the sexually transmitted nature of the herpes virus (HHV-8) now thought to cause the cancer (Martin et. al., 1998). The risk for AIDS-related non-Hodgkin’s lymphoma is also elevated among gay men, although at lower magnitudes (Koblin, et. al., 1996). Between 1973 and 1987 non-Hodgkin’s lymphoma incidence increased ten-fold and Kaposi’s sarcoma incidence increased over 5,000-fold in single San Francisco men ages 20 to 49 (Rabkin, Biggar, & Horn, 1991). While highly active antiretroviral therapies have significantly reduced KS rates (Buchbinder et. al., 1999), non-Hodgkins lymphoma remains among the AIDS-related malignancies that continue to occur at sharply higher rates among HIV-positive individuals. An increase in the incidence of Hodgkin’s disease has also been observed, but its association with HIV/AIDS is equivocal and the disease is not included in the AIDS case definition (Koblin, et. al., 1996).

In a cohort design, using studies of records in New York and California cancer registries and the National Death Index, Koblin and colleagues (1996) found gay and bisexual men to be at excess risk for anal cancer (standardized incidence ratio [SIR] = 24.2), non-Hodgkin’s lymphoma (SIR = 12.7) and Hodgkin’s disease (SIR = 2.5). These accounted for an increased risk for all cancers in this population (SIR = 1.6). The authors found no difference in the incidence of cancers in any other site, including lip, oral cavity and pharynx; digestive system and peritoneum; respiratory; bone and connective tissues; skin; genitourinary; multiple myeloma; leukemia; or other and unspecified sites. While Koblin and colleagues determined that the increase in risk for both non-Hodgkin’s lymphoma and Hodgkin’s disease was related to increased incidence of HIV/AIDS among homosexual men, they found the increased risk for anal cancer was unrelated to HIV/AIDS.

Evidence increasingly suggests that gay men are at increased risk for anal cancer. Higher risk for anal cancer among gay and bisexual men was demonstrated by Daling et. al. (1987) in a case-control study of anal cancer. Daling et. al. (1987) found that history of anal intercourse was associated with anal cancer (RR = 33.1) in men. History of STDs was also a risk factor for the disease.

Research suggests that risk factors for the excess incidence of anal cancer among homosexual men included increased rates of Human Papillomavirus (HPV) and anal squamous intraepithelial lesions (ASIL), both putative anal cancer precursors (Beckman, et. al., 1989; Breese, Judson, Penley & Douglas, 1995; Daling, et. al., 1987; Melbye, Palefsky, Gonzales, et. al., 1990; Palefsky, Holly, Ralston, & Jay, 1998). HPV has been found in both HIV-positive and HIV-negative men, but prevalence of infection is higher among HIV-positive men, with highest prevalence associated with latest stages of HIV disease (Breese, Judson, Penley, & Douglas, 1995; Melbye, Palefsky, Gonzales, et. al., 1990). In a study of HIV-positive and HIV-negative gay and bisexual men, Palefsky et. al. found high prevalence of HPV (93% and 61%, respectively), most of subtype HPV-16. Infection with multiple HPV types was found in 73% of HIV-positive and 23% of HIV-negative men. Higher risk for HPV has been related to a history of receptive anal intercourse, rectal administration of recreational drugs (Palefsky, Holly, Ralston, & Jay, 1998), and a higher number of lifetime sexual partners (Breese, Judson, Penley, & Douglas, 1995). In addition to sexual behavior, smoking – prevalence of which is sharply higher among gay men – increases risk of anal cancer (Daling, et. al., 1987).

Survival time among gay men with cancer may also be lower than the general population. Koblin (et. al., 1996) found five-year survival rates for non-Hodgkin’s lymphoma (9.8%) and Hodgkin’s disease (32.8%), much shorter then the expected national rates (50.2% and 75.7%, respectively). The shorter-than-expected survival rate is probably related to HIV/AIDS comorbidity. Additional reasons for the lower survival rate may include delay in detection and treatment, possibly related to barriers in accessing care or communication with health care providers. The disparity in survival rate "highlights the need for rapid identification of such patients, and more effective approaches to detection and treatment of malignancies (Koblin, et. al., 1996)." The use of rectal pap smear for detection of HPV infections has been suggested (e.g., Palefsky, et. al., 1998) as one such intervention, although further research needs to assess the association of HPV subtypes and anal cancer and the efficacy of pap smear in detection.

Finally, difficulty in assessing sexual orientation in the general population may lead to bias in studies of gay/bisexual men and cancers. Available studies typically use urban, highly sexually active men, usually of midlife age. It is not known to what extent the results are applicable to less sexually active, older, or younger populations of gay and bisexual men.

Fear of discrimination – particularly among lesbian and gay parents, who may face loss of child custody or visitation rights as a result of their sexual orientation – has made it difficult for researchers to produce reliable figures on how many lesbians or gay men are currently raising children (Patterson, 1996; Havemann, 1997). Estimates of the number of children being raised by lesbian or gay parents in the U.S. range from six to 14 million (Patterson, 1996; Havemann, 1997).

At one time most children parented by lesbians or gay men were conceived during a previous heterosexual relationship. That is now changing. The newly-coined phrase "lesbian baby boom" describes the increasing numbers of lesbians who are now choosing to have children after coming out, a pattern also reported to a lesser extent among gay men (Patterson, 1996). In 1990, it was estimated that five to ten thousand lesbians had chosen to have children after coming out (Patterson, 1996) and the phenomena has only continued to grow. In addition to the donor inseminations that make up the majority of such pregnancies among lesbians, increasing numbers of gay men and lesbians are exploring other routes to parenthood, including foster care, adoption, and co-parenting (Patterson, 1999; Cowan & Cowan, 1999).

Gay and lesbian parents have been routinely threatened by courts as being unfit per se, simply by virtue of their sexual orientation. Perhaps this explains why much of the limited research on lesbian and gay parenting is focused on the question of whether there are adverse effects to children of gay and lesbian parents. The literature does not show any negative outcomes for children raised by lesbian or gay parents (Patterson, 1995; Allen & Burrell, 1996), nor does it demonstrate that those children are more likely to become gay or lesbian themselves (Patterson, 1996). Golombok’s research showed that lesbian families had a greater mother-child interaction than heterosexual families in the sample, and greater psychological wellbeing in families where there was no genetic link to the child (Golombok, Tasker & Murray, 1997). National organizations that have policy statements supporting gay and lesbian parents include the American Academy of Matrimonial Lawyers, American Psychological Association, American Academy of Child and Adolescent Psychiatrists, and the National Association of Social Workers (Patterson, 1996).

Gay and lesbian families have few if any legal protections. The courts rule frequently in favor of biological parents and against the interests of the non-biological parent in custody cases (Editors of the Harvard Law Review, 1990; Polikoff, 1990). Agreements between known sperm donors and lesbian mothers, too, are rarely recognized as legally binding; courts fail to recognize any role for known donors except that of parent, an interpretation which is often unsatisfactory to both the donor and the mothers raising the child (Bernstein, 1998). Gay and lesbian families, particularly non-biological parents, face a range of systemic impediments to care and custody of children, including exclusion from a spouse’s health insurance coverage and hostility in school systems and health care settings. Some states expressly prohibit gay men and lesbians from adopting or serving as foster parents, and other agencies advise gay men and lesbians to pursue those options as single parents rather than introducing the subject of sexual orientation (Patterson, 1996; Martin, 1993).

Little research has addressed the effects of stress produced by such institutionalized discrimination, or the ways in which gay and lesbian families must struggle with many psychosocial factors related to their alternative status. Factors include whether the non-biological parent will be recognized by others as a parent, how the extended families will react to the new family structure, how to deal with a surrogate mother or a known-donor father, whether to choose a sperm donor who allows himself to be known later in the child’s life, how to provide the children with peers who have similar families, and what and when to tell children about donors.

In addition, evidence suggests that communication difficulties between lesbians and health care providers may impede screening and care commonly delivered through family planning clinics or by ob-gyn physicians. In the National Lesbian Health Care Survey, 27% of respondents said their current providers had assumed they were heterosexual, 16% felt they could not come out to their providers, and 11% said providers had "forced" birth control on them. One in seven of these lesbians (14%) said they had difficulty talking to their ob-gyn providers (Bradford, 1988).

In 1981, reports of unusual cancers and pneumonias among gay males were the first hint of the HIV pandemic to come (CDC, 1981). Researchers looked to the number of sexual partners, recreational drug use, and other factors to identify the cause of what was originally known as GRID, or gay-related immunodeficiency. However, it was anal sex, a common sexual practice among men who have sex with men, that proved to be the most common means of transmitting the virus that caused the symptoms now known as AIDS. The history and future of LGBT communities will forever be shaped by the decimation experienced as a result of HIV.

Since 1981, it is estimated that more than 702,000 Americans have been diagnosed with AIDS (CDC (2), 1999). Of those, 54% are reported to be men who have sex with men (MSM) (CDC (2), 1999). While the popular image of a person with AIDS remains that of the white gay man, African-American and Latino men now constitute the majority of AIDS cases among MSM since 1998 (CDC, 2000). In the states that report HIV infection, men who have sex with men (including those cross-listed as MSM and injecting drug users) constitute 38% of all newly reported cases (CDC (2), 1999), with African American and Latino MSM becoming infected in greater numbers, and at a younger age, than white men (CDC, 2000).

Growing understanding of HIV transmission has underscored the importance of distinguishing between sexual identity and sexual behavior. As indicated by the category "men who have sex with men," those at risk for HIV infection through homosexual sex include men who describe themselves as gay, bisexual, and heterosexual, and those who reject such categories altogether. Cultural differences in assessing sexuality, differences in homophobia levels within cultural and ethnic groups, and conflicts between racial and sexual identity may also contribute to reluctance to identify as gay, particularly for African American and Latino men (Diaz, Stall, Hoff et. al, 1996; Stokes & Peterson, 1998; Johnsen & Stryker, 1993; Icard, 1986). One recent study of more than 8,000 MSM of color with HIV found that as many as 24% of homosexually active African American men with HIV identified themselves as heterosexual (CDC, 2000). Some 15% of Latino men who had contracted HIV through homosexual sex identified themselves as heterosexual (CDC, 2000). The threat of HIV, or actual infection with the virus, may itself complicate the process of disclosure of sexual identity and identification with a gay community. This situation can increase an individual’s belief in negative stereotypes about gay men, binding attachment and intimacy to fears of illness, death, and loss of self and others (Saddul, 1996).

Many HIV research and prevention materials for homosexually active men have focused on men who identify as gay or bisexual, or have grouped bisexual and homosexual men together as a single group (Heckman, et. al., 1995). In fact, this elision may have most serious consequences precisely in those men of color at highest sexual risk for HIV. Studies of bisexual behavior in men have found it to be correlated with lower intention to use condoms, knowing fewer HIV-positive people, weaker perceived norms for safer sex (Heckman, et. al., 1995), and higher rates of sex that is high-risk for HIV (Doll & Beeker, 1996).

In addition, several studies have found that bisexually active men are often unlikely to disclose their bisexuality to female partners (Kalichman, Roffman, Picciano, & Bolan, 1998; Weatherburn, et. al., 1998). It is difficult to tell how many heterosexual female exposures are a result of sex with undisclosed bisexual males. Community planners have identified the role that "survival" behaviors – including convenience sex, sex for drugs, or sex for food – all play in the transmission patterns of the pandemic. These factors underscore the need for greater research and educational materials aimed at homosexually active men who do not identify as gay. In addition, some bisexual men, if infected with HIV, may encounter difficulties in accessing care, because the ability to identify with the gay community has been a proven predictor of supportive social relationships and subsequent health benefits in coping with HIV (Chapple, Kippax, & Smith, 1998; Jonsen & Stryker, 1993).

Behavioral interventions to reduce risk for HIV/AIDS are currently the only effective way of slowing the spread of HIV infection (NIH Consensus Statement, 1997). Gay communities have pioneered strategies to successfully lower risk of HIV exposure through community-based education (Coates & Collins, 1998; Kalichman et. al., 1997; Jonsen & Stryker, 1993; Saddul, 1996). In the aggregate, research has shown that while most gay men have protected sex all or most of the time, a significant percentage of MSMs – as many as one in three – have some incidence of unprotected anal sex (Hickson, et. al., 1996; Meyer & Dean, 1995). Reasons for and context of this unprotected sex, and perceived risk for HIV involved in it, vary widely. Studies show some gay men to engage in selective risk reduction strategies such as unprotected sex only or primarily with partners they believe to be of the same serostatus (both HIV positive or both HIV negative) (Kippax, et. al., 1997; Elford, Bolding, Maguire, & Sherr, 1999). In addition, a wide and sometimes contradictory range of other pyschosocial factors have been shown to influence sexual risk-taking, among them: self-esteem, social supports or lack thereof, mood prior to sexual encounter, optimism, fatalism, age, education, and alcohol or drug use (Hospers & Kok, 1995). A growing body of literature suggests the importance of moving beyond informational prevention education to consideration of mental health models and support in the service of effective HIV prevention.

Health implications of the HIV epidemic for gay men are myriad, ranging from life-threatening opportunistic infections and malignancies to mental health challenges noted above and elsewhere in this document. While the advent of highly active anti-retroviral treatments (HAART) has sharply reduced AIDS deaths and opportunistic infections (CDC (3), 1999), long-term effects of the combination anti-HIV drug regimens are unknown. Recent years have seen increasing reports of high cholesterol, diabetes, and redistribution of body fat known as lipodystrophy (Kaul, et. al., 1999), raising questions about the treatment’s long-term viability.

Gay men may also face particular obstacles in accessing health care, or in achieving the communication with health care providers that is critical to adherence to treatment regimens. The implications of failure to adhere, as well as of saturation in some gay communities of earlier, less effective treatment regimens, are only now beginning to be gauged by research. Studies have already documented passage of a drug-resistant virus from one gay man to another, and one recent study among newly infected gay men found that as many as 16% had HIV that was somewhat resistant to one or more AIDS drugs (Boden, et. al., 1999).

HAART’s efficacy may also impact HIV prevention efforts and other health supports for homosexually active men. Fueling the perception that AIDS has become a manageable, chronic infection, advent of HAART has been accompanied by reports of sharp drops in funding for community based AIDS prevention and service organizations serving gay men and increases in high-risk behavior. One study, for example, found that 18% of HIV-positive gay men were now practicing safe sex less often because of treatment advances (Kelly et. al., 1998).

While the long-term treatment effects of HAART are not fully understood, neither are its effects on HIV transmissibility. Some research points to a reduction of HIV in seminal fluid associated with a reduction in viral load (Gupta, et. al., 1997). Based on the CDC's retrospective case-control study of HIV-exposed health workers, and extrapolation from the use of antiretrovirals to interrupt perinatal transmission, a number of urban centers have begun offering gay men and others post-exposure prophylaxis in an effort to contain viral replication for those thought to have experienced recent exposure (Kowng, et. al, 1999). While these findings and efforts are preliminary and inconclusive, they suggest possibilities for future HIV prevention strategies.

Youth represent a subgroup of all MSM who are particularly likely to engage in high-risk behavior, and so are particularly at risk for HIV. Adolescents and young adults (ages 13-24) are the single most likely group to contract an STD (CDC, 1998). Among this same group, the rate of HIV infections is growing particularly rapidly, with 31% of all new infections being reported as MSM. In a sample of young MSMs (ages 15-22) in six urban counties, between 5 and 9 % were found to be infected with HIV – with a significantly higher percentage of African American youth and Latino youth being infected than white youth (CDC (1), 1999). Other studies have shown that adolescent MSMs show markedly higher rates of unprotected receptive anal sex than do older MSMs and that sex with older people is highly correlated with exposure to HIV (Morris, Zavisca, & Dean, 1995). One study of inner-city youth attending a gay community center program reported consistent condom use in only 13% of adolescent MSMs, while one quarter engaged in prostitution, and all reported sexual activity (Rotheram-Borus, et. al., 1992).

The impact of HIV on the lesbian community, and the risks of female-female HIV transmission, remain underresearched. Since people with HIV are categorized by the highest risk group to which they belong, lesbians with HIV who have had any heterosexual contact or injection drug use history are usually classed as heterosexual or injectors, regardless of their personal sexual identification or history (Cohen et. al., 1993). While small studies among serodiscordant lesbians have found no evidence of female-to-female HIV transmission (Raiteri et. al., 1994), numerous health advocates have urged for greater research, as well as consideration of broader assessment of HIV risk for lesbians; in 2000, the Centers for Disease Control will fund a 200-participant study of lesbians and HIV with cohorts in Washington, D.C., San Francisco and New York (Smith, 2000). Fears of elevated risk for HIV among some lesbians is not restricted to their sexual contact with women: HIV-positive women reporting female sexual partners in one San Francisco study, for example, were twice as likely to have used drugs and significantly more likely to have engaged in anal intercourse with a man than those not reporting female sexual partners (Young, Weissman, & Cohen, 1992).

Vaccination recommendations for gay and lesbian people do not differ significantly from those for the general population, with two notable exceptions. Both exceptions are for the prevention of viral hepatitis, for which gay and bisexual men are at increased risk of transmission. . Immunization against hepatitis B virus (HBV) for all homosexually active men has been recommended since the 1980s, and vaccination against hepatitis A virus (HAV) was recommended in 1996 by the Advisory Committee on Immunization Practices (ACIP) for gay and bisexual men, as well as for certain other high-risk groups (CDC, 1997).

Although HAV and HBV vaccination is recommended for gay and bisexual men, national prevalence rates for these vaccinations are currently unknown, hampering efforts to assess the successful implementation of vaccination campaigns for these men. However, available data suggest that rates of vaccination for men who have sex with men are low. In 1996, the Centers for Disease Control found that only 3% of the sample of young MSM were vaccinated against HBV (CDC, 1996). The CDC analyzed serologic data from the 1992-1993 Young Men's Survey (YMS) conducted by the San Francisco Department of Public Health to estimate hepatitis B vaccination coverage among young MSM. The survey used a targeted sampling method to enroll MSM aged 17-22 years at selected public venues in San Francisco and Berkeley, California. Of the 385 young MSM eligible for the study, 20% had evidence of previous or current HBV infection, while an additional 3% were positive for anti-HBs alone, suggestive of hepatitis B vaccination. Of the remaining 77% who lacked evidence of vaccination or infection, 80% reported having had anal sex or having injected drugs during the preceding 6 months. Of these, 86% reported receiving one or more types of health-care (CDC, 1996).

See also III. C., HIV, III. G., Substance Use, and III. I., Violence and Sexual Assault

Most studies of mental disorders among gay, lesbian, or bisexual people in the 1960s and 70s addressed issues related to the status of homosexuality as a mental disorder (Bayer, 1981; Gonsiorek, 1991; Morin, 1977). Such studies helped lead to the declassification of homosexuality as a mental disorder in 1973 and the removal of "ego-dystonic homosexuality" from the 1986 Diagnostic and Statistical Manual of Mental Disorders (DSM-III). Epidemiological advances of the past two decades, including the recognition of the importance of population surveys (rather than clinical studies) of mental disorders, the introduction of an improved psychiatric classification system, and the development of measurement tools and techniques for epidemiological research, have made earlier research on mental health among LGBT populations virtually obsolete.

Few recent studies have used these advances to focus needed research on gay men, lesbians, or bisexuals. For example, no information on LGB individuals has been provided by either of two recent large-scale, national psychiatric epidemiological surveys conducted in the U.S.–the Epidemiological Catchment Area study (Robins & Regier, 1991) and the National Comorbidity Survey (Kessler, McGonagle, Zhao, et. al., 1994). LGB populations may be at increased risk for mental distress, mental disorders, substance use, and suicide because of exposure to stressors related to societal antigay attitudes. Known social stressors include prejudice, stigmatization, and antigay violence (Meyer, 1995; Rosario, Rotheram-Borus, & Reid, 1996; Gonsiorek & Rudolph, 1991). Internalization of negative social attitudes (internalized homophobia) in particular has been related to intimacy and sexual problems and other adjustment difficulties (Meyer & Dean, 1998), as well as high HIV risk-taking behaviors among young gay and bisexual men (Meyer & Dean, 1995). Understanding patterns of and risk factors for mental disorders in LGB individuals is important for tailoring proper mental health treatment and for designing effective public health intervention and prevention programs (Council on Scientific Affairs, American Medical Association, 1996).

As noted above, methodologically sound studies of mental disorders in LGB populations are lacking. Many studies have used symptom scales in which the relationship to psychopathology is unclear (Bradford, Ryan, & Rothblum, 1994; Cochran & Mays, 1994; Gonsiorek, 1991); have included no comparison group (Bradford, et. al., 1994; Tross, et. al., 1987; Williams, et. al., 1987; Martin, 1990); have employed convenience samples unlikely to be representative of LGBT populations (Saghir & Robins, 1973; Pillard, 1988; Atkinson, 1988); or have expressed potential bias in their definition or detection of homosexuality (Fergusson, et. al., 1999; Cochran, et. al., in press). Most studies fail to distinguish between findings on gay or lesbian individuals and those on bisexuals, making comparisons of gay men and lesbians with bisexual men and women difficult.

A number of studies have used criteria-based case diagnoses to study mental illness among gay men, and used a comparison group to assess differences between gay and heterosexual men. Pillard (1988) found elevated rates of bipolar disorders among gay men; Atkinson (1988) found elevated rates for most mental disorders among gay men; and Cochran et. al. (in press) found homosexual men to have higher rates of major depression disorder than heterosexuals. Fergusson et. al. (1999) found lesbians, bisexuals and gay men to have higher rates of major depression disorder, generalized anxiety disorder, and conduct disorders than a heterosexual sample, though the author did not disaggregate data by gender. Other studies using case diagnoses included no explicit comparison group. Compared with estimates of U.S. rates of disorder reported by the Epidemiologic Catchment Area study (ECA, Robins & Regier, 1991), Williams et. al. (1991) found high lifetime prevalence of affective disorders, but no elevated prevalence of current disorders; Tross et. al. (1987) found a slightly elevated prevalence for current major depressive disorder; and Martin (1990) found no increased prevalence of alcohol abuse/dependence among gay and bisexual men.

Mental health among lesbians, too, has gone largely unstudied or been inadequately researched. As recently as 1990, the Women and Depression Task Force Report of the American Psychological Association (McGrath, Keita, Strickland, & Russo) reviewed several hundred studies on women and depression, none of which focused on lesbians. The largest and most comprehensive survey of lesbian mental health to date is the National Lesbian Health Care Survey (NLHCS) (Bradford, Ryan, & Rothblum, 1994) of a sample of 1,925 lesbians. Symptoms of depression in the study were roughly equivalent to those in studies among heterosexual women (McGrath, Keita, Strickland, & Russo). Similarly, Cochran and Mays (1994), reported similar levels of depressive symptoms among African American lesbians and gay men as those found in studies of African Americans in the general population.

While homosexuality has been removed from the American Psychiatric Association’s diagnostic manual, GID remains. As defined in the DSM, GID is "strong and persistent cross-gender identification, which is the desire to be, or the insistence that one is, of the other sex," and "persistent discomfort about one’s assigned sex or a sense of inappropriateness in the gender role of that sex (American Psychiatric Association, 1994)."

While not necessarily involving sexual attraction to the same gender, a GID diagnosis is seen by some gay and lesbian health professionals as reinforcement for normative gender standards that are hostile to feminist or gay-affirmative values (Corbett, 1999). A child or adult who perceives that he or she is attracted to a person of the same sex may experience some gender identity "confusion" because by definition their sexuality deviates from assigned gender roles. For example, a boy who feels same-sex attraction, having internalized societal values, may feel that he is girl-like in that attraction. This may indicate nothing but the beginning of a process of questioning social norms, but can be labeled a disorder according to the DSM’s categories. Similarly, the diagnosis may "punish" innovators who challenge existing gender roles (e.g., a girl who wants to be on a football team, a boy who wants to grow up to be a mom) by stigmatizing them.

Sensitive to critiques of diagnosis as a means of social control, authors of the DSM-IV make "clinically significant distress or impairment in social, occupational, or other important functioning" a requirement for GID diagnosis. However, distress is subjective, and widely defined. For example, subjective distress could simply be the interpersonal problems one has with parents because of one’s nonconforming behavior. It is hard to imagine any person who is somewhat different not experiencing some distress, at least related to others’ reactions to his or her non-normative behavior. A child who is taunted for being a "sissy," or who is socially isolated because she is "masculine," will clearly experience subjective distress, but the source of the distress is oppression and intolerance – not an inherent disorder. This is analogous to ethnically based taunting.

Small, non-random studies of boys with childhood GID have indicated that 75% of boys with GID may grow up to be homosexual men (DSM-IV). This may heighten concerns that parents and physicians will see GID as a precursor, or even a "risk factor," for homosexuality, and – if seen as a problem – may seek to treat it aggressively. All these have been discussed as reasons for the declassification of GID as a mental disorder. Against this, some transgender advocates argue for maintaining the classification, suggesting that the inclusion of GID in the DSM-IV may allow for insurance reimbursement and treatment for transgender people seeking psychiatric therapy or hormonal treatment. Investigation is needed to determine how such third-party payments can be appropriately authorized without unnecessarily stigmatizing children and adults for gender roles that do not fit the dominant norm.

Stress and mental health raise important practical public health issues related to HIV risk taking behavior, particularly as prevention research has begun to move from purely cognitive explanatory models of risk taking behavior to the consideration of affective and non-rational processes among gay men (McKirnan, Ostrow, & Hope, 1996; Kelly, Murphy, Sikkema, & Kalichman, 1993; NIMH, 1999. Mental health problems, including substance use and personality and psychological constructs (e.g., low self-esteem, sensation seeking) have been associated with HIV-related risk taking behavior (Bartholow, Doll, Joy, et. al., 1994; Graham, Kirscht, Kessler, & Graham, 1998; Strathdee, Hogg, Martindale, et. al., 1998; Hays, Paul, Ekstrand, Kegeles, et. al., 1997; Kalichman, Kelly, & Rompa, 1997; Diaz, Stall, Hoff, et. al., 1996; Kalichman, Heckman, & Kelly, 1996; Kalichman, Kelly, Morgan, & Rompa, 1997; Chesney, Barrett, Stall, 1998; Leviton, 1989; National Institutes of Health, 1997). Research has also described high-risk behavior as an emotion-focused coping strategy to reduce stress (Folkman, Chesney, Pollack, & Phillips, 1992).

Alcohol and drug use, in combination with emotion-focused coping, serve a disinhibiting function leading to more risk taking (Folkman, Chesney, Pollack, & Phillips, 1992; Meyer & Dean, 1995, 1998). The convergence of internalized homophobia, drug problems, and AIDS-related traumatic stress response are related to increased risk taking (Meyer & Dean, 1998). In addition, in the context of reports of increased risk for suicide among gay and bisexual men, the relationship of mental health and HIV risk taking is of particular concern. Some researchers have suggested that high-risk sexual behavior among young gay and bisexual men may be related to a sense of hopelessness and suicidal tendencies (Frances, Wikstrom, & Alcena, 1985; Odets, 1994; Flavin, Franklin, & Frances, 1986).

Whether gay/bisexual men and lesbians have higher rates of suicidal behavior has been widely debated in recent years, and research evidence is mixed (Muehrer, 1995). Studies of suicide ideation and attempts found elevated lifetime prevalences for gay/bisexual men and lesbians (e.g., D’Augelli & Hershberger, 1993; Kurks, 1991; Remafedi, Farrow, & Deisher, 1991; Schneider, Farberow, & Kurks, 1989; Pillard 1988; Bell & Weinberg, 1978; Saghir & Robins, 1973), but studies of completed suicides found no evidence for elevated rates (e.g., Rich, Fowler, Young, & Blenkush, 1986; Shaffer, Fisher, Hicks, Parides & Gould, 1995). Results of the NLHCS found that more than half the sample had had thoughts about suicide at some time, and 18% had attempted suicide (Bradford, et. al., 1994). This compares with 33% and 4%, respectively, for women in the U.S. as reported in the ECA studies (Robins & Regier, 1991; Moscicki, 1994). Several recent studies of gay youth populations continue to report alarmingly high rates of suicide ideation and attempts among gay and bisexual youth. For example, Faulkner and Cranston (1998), Remafedi et. al. (1998), and Fergusson et. al. (1999) found that rates of various measures of suicide ideation and attempts were three to seven times higher among gay and lesbian youth compared with heterosexual youth.

Both types of studies – of completed suicides and of suicide ideation and attempts – have severe methodological limitations. The former uses samples biased toward underestimating rates of completed suicides because of difficulties in post-mortem classification of sexual orientation; the latter uses samples biased toward over-reporting of suicide ideation and attempts because more vulnerable gay youth may be identified at younger ages. These problems have led members of a workgroup convened by the NIMH and the CDC to recommend epidemiological study of mental disorders and suicide as an important priority (Working Groups, Workshop on Suicide and Sexual Orientation, 1995).

Social stressors may impact body image and eating patterns among gay and lesbian adolescents. Significant literature suggests that adolescence, and the social stress that accompanies it, may place gay men in particular at increased risk for body dissatisfaction and problem eating behaviors whose onset commonly occurs during this period.

In addition to this social stress hypothesis, other research suggests a sociocultural hypothesis linking body image dissatisfaction and eating disorders with the cultural valuation of a thin body (Silberstein, Mishkind, Streigel-Moore, et. al., 1989; Hefferman, 1994). According to this view, emphasis on thinness normally placed on feminine bodies may also influence gay men, who are more likely to demonstrate atypical gender role behavior (Fichter & Daser, 1987), and may place greater cultural emphasis on appearance (Herzog, Newman, & Warshaw, 1991; Siever, 1994). In contrast, a decreased emphasis on physical appearance among lesbians may be protective against the development of weight concern, body dissatisfaction, and disordered eating behavior (Siever, 1994; Beren, Hayden, Wilfley, & Grilo, 1996).

Clinical samples assessing whether homosexuality is overrepresented among patients with eating disorders has found sexual orientation to be a significant predictor of eating disorders among men, though not among women. A study of the 135 men treated for eating disorders at Massachusetts General Hospital from 1980 to 1994 showed 27% of all men reported homosexual orientation and 42% of bulimic patients identified as homosexual or bisexual (Calat, Camargo, & Herzog, 1997). These results are consistent with other smaller studies, which found association between male homosexuality and eating disorders, showing that a higher proportion of men who were anorectic or bulimic were gay than would be expected. (Herzog, Norman, Gordon, & Pepose, 1984; Schneider, & Agras, 1987; Robinson & Holden, 1986; Fichter & Daser, 1987).

Nevertheless, it is difficult to assess the validity and generalizability of these conclusions. With an overall prevalence of less than 1% for bulimia and 3% for anorexia (APA, 1994; Hall, Dalahunt, & Ellis, 1985), eating disorders are rare, and men account for less than 10% of total cases (APA, 1994; Carlat & Camargo, 1991). In addition, research on the association of eating disorders and homosexuality has used varying definitions of both eating disorders and homosexual tendencies, sometimes equating lack of heterosexual experience or atypical gender behavior with homosexuality (Fichter & Daser, 1987). The effect of comorbid psychiatric disorders (e.g., depression) is largely ignored in these studies. Differences by gender in reporting of eating habits may also bias results. For example, women are more likely than men to label eating a large amount of food as a "binge" (Calat & Camargo, 1991). To the extent that this bias in reporting style is also characteristic of gay men, it may lead to over-reporting and increased detection of anorexia and bulimia among gay men as compared with heterosexual men. Heterosexual men may be more reluctant than homosexual men to seek help for eating disorders because the disorders are perceived, and thus stigmatized, as "feminine" (Calat & Camargo, 1991). Finally, while many clinical studies report an association with male homosexuality, several found no such association (Turnbull, Freeman, Barry, et. al., 1987; Pope, Hudson, & Jonas, 1986; Herzog, Newman, & Warshaw, 1991).

Community studies – which have typically sampled college students or participants in gay and lesbian organizations – have often found significant association between sexual orientation and negative body image among gay men (Silberstein, Mishkind, Striegel-Moore, et. al., 1989; Beren, Hayden, Wilfley, & Grilo, 1996; Herzog, Newman, & Warshaw, 1991), but it is impossible to draw clear conclusions from them. These studies typically used small samples of easily recruited subjects, and their generalizability to the general gay population is questionable. Also, some studies show that heterosexual men with eating disorders have similar problems in body image, exercise, and dieting behavior (Olivardia, Pope, Magweth, & Hudson, 1995). Among women, while being female was related to concerns about dieting and being fat, lesbians were less likely to be preoccupied with weight and body image than heterosexual women (Siever, 1994; Brand, Rothblum & Solomon, 1992).

The Minnesota Adolescent Health Survey (Neumark-Sztainer, Story, Resnick, & Blum, 1998), a survey of more than 30,000 Minnesota students (grades 7 — 12), was the only one to use a random community sample. In that study, homosexual boys were more likely than heterosexual boys to report a poor body image (28% vs. 12%), frequent dieting (9% vs. 6%), binge eating (25% vs. 11%), and purging behaviors (e.g., vomiting: 12% vs. 4%) (French, Story, Remafedi, Resnick, & Blum, 1996). Homosexual girls, by contrast, were more likely than heterosexual girls to report a positive body image (42% vs. 21%), though no less likely to report disordered eating behaviors such as binge eating or purging. (Rogers, Resnick, Mitchell, & Blum, 1997). While random, the sample did identify adolescents of high school age or younger. Because many gay men and lesbians do not know or disclose their sexual orientation until older, it may be difficult to generalize the results to gay men and lesbians more broadly.

It is important to note that significant gender differences related to eating problems hold true for gay and lesbian populations (Saewyc, Bearinger, Heinz, et. al., 1998). Young boys (15%) in the Minnesota sample were less likely than young girls (27%) to rate themselves low on body image. A greater proportion of older females (38%) than males (22%) considered themselves to be overweight. In each group more girls than boys reported dieting in the last year, at all levels of frequency. Despite increased risk among homosexual men compared with heterosexual men, women (both lesbian and heterosexual) are at greater risk for body dissatisfaction and disordered eating.

Like members of other minority groups, LGBT populations are not passive recipients of stigma and discrimination but engage in active coping to counter the ill effects of negative social stressors. Such positive coping has been shown to be beneficial to members of minority groups (Shade, 1990). Minority status is related not only to stigma and discrimination (stress) but also to structural resources, such as group solidarity and cohesiveness, that protect minority members from the adverse mental health effects of social stress (Crocker & Major, 1989; Kessler, et. al., 1985). Even exposure to antigay violence, while creating a crisis with potential adverse mental health outcomes, also presents "opportunities for subsequent growth" (Garnets, et. al., 1990). Jones and colleagues (1984) described two functions of minority-related coping, cohesiveness and support: 1) to allow stigmatized persons to experience social environments in which they are not stigmatized by others; and 2) to provide support against the negative evaluation of the stigmatized minority group. Social evaluation theory suggests another plausible mechanism for minority coping. In-group support can provide a reappraisal (Lazarus & Folkman, 1984) of the stressful environment, yielding it less injurious to psychological well being. Through reappraisal, the minority group validates its experiences (Thoits, 1985; Crocker & Major, 1989).

Oetjen and Rothblum (in press) used a standardized measure to examine the effect among lesbians of factors consistently cited in the women and depression literature (relationship status, relationship satisfaction, social support from friends, and social support from family), and two unique factors (outness and relationship status satisfaction), to determine their ability to predict depression among lesbians. Perceived social support from friends, relationship status satisfaction, and perceived social support from family were found to be significant predictors, accounting for 17.8% of the variance in depression. Among those lesbians in committed relationships, social support from friends was the only predictor, accounting for 5.8% of the variance in depression. A similarly designed study among Canadian lesbians found lower depression rates among women in relationships, lesbians who had more social support from friends and family, and those who were more open about their sexual orientation. Some 38% of the variance in depression scores could be predicted from the four variables (Ayala & Coleman, in press).

In addition to HIV, men who have sex with men (MSM) are at increased risk of certain sexually transmitted diseases relative to their heterosexual counterparts (Council on Scientific Affairs, 1996; Harrison & Silenzio, 1996; Ungvarski & Gorssman, 1999). The stigma associated with sexually transmitted infections in general and with homosexual acts make accurate estimates of the prevalence rates for these conditions in MSM almost completely unavailable. STDs for which homosexually active men are at risk include urethritis, proctitis, pharyngitis, prostatitis, hepatitis A (HAV) and B (HBV), syphilis, gonorrhea, chlamydia, herpes, genital warts, and HIV infection. MSM are believed to be at generally increased risk for these infections, although additional data on patterns of infection and definitive prevalence data are needed. In addition, high rates of HIV infection among MSM put them at danger for chronic or life threatening complications from sexually transmitted infections that are harmless or self-limiting in HIV-negative individuals, including cytomegalovirus, herpes, and anal cancer associated with strains of the Human Papillomavirus. In spite of availability of vaccines to prevent hepatitis A and B, and recommendations calling for vaccination of sexually active MSM against these viral infections, rates of vaccination for these diseases remain low.

After sustained declines in rates of STDs in gay and bisexual men since the beginning of prevention programs aimed at HIV/AIDS, recent data from many U.S. and international cities indicate that rates of unprotected anal sex and STDs may be increasing (Centers for Disease Control (6), 1999, Community Disease Report Weekly, 1999). STD clinics and public health departments report increases in rectal gonorrhea rates among MSM in San Francisco (CDC, 1999), as well as increases in syphilis rates among MSM in Seattle. Community-based clinics reported epidemic rates of HAV in 1998 and 1999 among gay men in New York, Boston, Atlanta, and various cities outside the U.S. (Wolfe, in press). These increased STD rates are coincident with the decline in the number of MSM reporting that they "always used condoms," and an increased proportion of MSM reporting unprotected anal sex. This points to a clear need for renewed efforts to reduce the rates of STD and HIV transmission among MSM, as well as the development of new surveillance techniques to assess the efficacy of these efforts.

No known gynecological problems are unique to women who have sex with women, and none are believed to occur more often in lesbians than in bisexual or heterosexual women. STDs appear to be less common in women who identify as lesbian and in women who are sexually active only with women than in either heterosexual women or gay men. This may be due in part to a relative epidemiological isolation of this group from men and the lack of penile-vaginal intercourse.

Human Papillomavirus and bacterial vaginosis have been shown to be transmissible between women and do occur in lesbians (Marrazzo, Koutsky, Stine, et. al., in press; Berger, Kolton, Zenilman, et. al., 1995). Candidiasis and Trichomonas vaginalis infection do occur in lesbians and appear to be transmissible between women (Degen & Waitkevicz, 1982). Women who are sexually active only with women appear to have a lower incidence of syphilis and gonorrhea than any other group except those who have never been sexually active. Infections with chlamydia or herpes virus disease appear to be less common in lesbians who have been sexually active exclusively with women, but all are theoretically transmissible (Johnson, Smith & Guenther, 1987; Robertson & Schachter, 1981; Degen & Waitkevicz, 1982). Hepatitis A, amebiasis, shigellosis, and helminthism also have a low prevalence in these women. Hepatitis B and C occur only when other risk factors are present (Walter & Rector, 1986; William, 1981).

Epidemiologic studies on alcohol and other drug abuse have rarely asked about sexual orientation. Or, if they have, they exhibited serious methodological flaws when focusing on gay and lesbian populations. Early studies, for example, recruited gay and lesbian subjects in bars, a sample which not surprisingly found higher rates of heavy alcohol and drug use than among the general population (Fifield, Lathan & Phillips, 1977; Lohrenz, et. al., 1978, Saghir & Robins, 1973). These and other opportunistic samples have frequently put prevalence of excessive or problem drinking among gay men, lesbians, and bisexuals near 30%, as compared to 10% among the general population (Paul, Stall & Bloomfield, 1991).

Subsequent studies, recruiting subjects via other means, have generally disputed claims that alcoholism among gay men and lesbians reaches 30%. McKirnan and Peterson (1989), surveying readership of a Chicago gay newspaper, found rates of heavy drinking among gay men and lesbians to be comparable to those in the general population. Bloomfield (1993), using random phone surveys in the San Francisco area, reported that there were no significant differences in levels of drinking and bar-going behavior between lesbians and bisexual women and their heterosexual counterparts. Skinner (1994) found higher rates of drinking among lesbians than among women in a geographically matched sample. Stall and Wiley (1988), comparing alcohol use patterns of heterosexual and homosexual males in San Francisco, found no significant differences in quantity and frequency of alcohol consumption overall, though differences at the extreme patterns of use were noted. Gay and bisexual men were approximately twice as likely to be heavy drinkers or abstainers as heterosexual men. Lesbians and bisexual women, too, report higher rates of abstention than heterosexual women in some studies (Bloomfield, 1993).

Sound data about substance use among lesbians is even more scarce, though McKirnan and Peterson (1989) found that rates of marijuana and cocaine use were higher among lesbians than among heterosexual women, and that differences between light and heavy use were smaller than those found in the general population. Skinner and Otis (1996), surveying gay men and lesbians, found few gender differences in substance use, though lesbians in some age groups reported somewhat higher rates of marijuana and cocaine use, as well as higher rates of smoking. Gay men reported higher rates of use of inhalants such as amyl or butyl nitrite ("poppers"), of hallucinogens, and of illicit drug use overall. LGB health researchers and advocates have called for greater research into the effects of recreational drugs common in nightclubs and dance parties (e.g., ketamine, MDMA, etc.), as well as for research into the potential and on-going consequences of chronic pharmacologic manipulation of neurotransmitters (Abrams to Leshner, 1999).

Belief in a direct causal relationship between substance abuse and unsafe sexual behavior has caused the phenomenon of substance use to be better documented among gay men since the advent of HIV (Stall, McKusick, et. al., 1986). Though the assumption that substance use causes unprotected sex has been critically challenged , a wide body of evidence suggests that there is an association between recreational drug use and high-risk sexual behavior, and that gay men use particular drugs more often than their heterosexual counterparts. Stall and Wiley (1988) found gay men significantly more likely to have used marijuana and psychedelics in the last six months, three times as likely to have used barbiturates, five times as likely to have used MDMA, and 58 times more likely to have used "poppers." It is important to note, however, that while this study found gay men more likely to have used more drugs, it did not demonstrate higher levels of dependence or addiction.

Adolescent and young adult gay men and lesbians appear to be especially at risk for substance abuse, and with important health consequences. With the exception of popper use, differences in drug use between heterosexual and homosexual men noted by Stall and Wiley (1988) were largely attributable to higher rates of drug use among the youngest cohort. Data from the 18-to-25-year-old cohort of gay men in the Trilogy Project (Skinner & Otis, 1996) found rates of 87.1%, 78.5%, 31.5%, 57.0%, and 33.3% respectively, for alcohol, marijuana, cocaine, inhalants, and hallucinogens, with an overall rate of 87.1% for any illicit drug use. Young lesbians, too, report overall rates of substance use in excess of 80%. Given the association between substance use and a variety of adverse health consequences for which young gay men and lesbians are at increased risk – including HIV infection and suicide– greater attention is needed to the problem and prevention of substance abuse by young gay men and lesbians.

Finally, though data is not yet conclusive, research suggests that a number of illicit substances may speed replication of HIV or have an immunosuppressive effect, a fact which may impact significantly on the health of the disproportionate number of gay men who are at risk for or are infected with HIV (Seage, 1992; Bagasra & Pomerantz, 1993). Further, adverse interactions have been documented between recreational drugs and other medications. Poppers, for example, cause potentially fatal drops in blood pressure when combined with the common erectile dysfunction medication sildenafil citrate (Viagra). Following the death of a British gay man in 1997, community publications alerted gay men to the possibility that Ritonavir, a common anti-HIV medication, might inhibit the liver’s ability to process the drug MDMA, boosting levels of the recreational drug to potential fatal levels (Wolfe, in press).

Evidence suggests that gay men and lesbians may perceive themselves to be at increased risk for alcoholism and substance abuse, that they have increased need for drug and alcohol treatment, and that they face particular barriers in accessing such treatment. McKirnan and Peterson (1988, 1989) found that while heavy drinking patterns did not differ significantly by sexual orientation, gay men and lesbians reported rates of alcohol problems nearly twice as often as heterosexuals. Drinking rates among gay men and lesbians do not appear to decrease with age as quickly as they do in heterosexual populations (Skinner, 1994, McKirnan & Peterson, 1988; Stall & Wiley, 1988; Bradford & Ryan, 1994). Gay and lesbian Alcoholics Anonymous meetings have become the largest special interest group within the self-help fellowship (Paul, Stall & Bloomfield, 1991). Assessments of alcohol and drug treatment facilities have documented lack of staff training in treatment issues for gay and lesbian alcoholics, and few or no gay staff (Hellman, 1991; Garnets, et. al., 1991), in spite of evidence that gay, lesbian and bisexual clients are more willing to attend treatment programs that address gay issues and less likely to comply with treatment from homophobic mental health providers (Paul, Stall & Bloomfield, 1991; O’Hanlan et. al., 1997)

Effective research into the treatment needs of gay men and lesbians should include enhanced understanding of the role of subcultural factors in forming and influencing patterns of both substance use and sexual behavior. Such factors, including the reliance on bars for socialization, stress caused by discrimination, and targeted advertising by liquor companies in gay and lesbian publications have been documented, but remain inadequately understood (Hughes, 1997; Nardi, 1991).

Adverse health effects of tobacco use among gay and lesbian populations are similar to those among the general population. Evidence suggests, however, that the rates of tobacco use among sexual minority men and women may exceed those of the general population, ultimately leading to increased rates of tobacco-related disease.

As with surveys of alcohol use among gay men, lesbians and bisexuals, studies of tobacco use in these populations tended to use non-random samples, often drawn from bar patrons, and to report rates of tobacco use sharply higher than those of their heterosexual counterparts (Stall et al., 1999). Unlike studies of alcohol use, however, later more representative studies of tobacco use seem to support earlier reports that the prevalence rate is strikingly higher among gay men than in the general male population. Using a household-based sample, Stall, et. al. (1999) found 41.5% of gay adults to be smokers, a rate far in excess of the national rate of tobacco use by men generally (28.6 %) (Centers for Disease Control, 1994). DuRant (1998) found that adolescent males who engage in same-sex sexual behavior also have increased rates of tobacco use relative to their peers, and that higher numbers of male sexual partners correlated with a higher frequency of tobacco use, as well as higher rates of drug use, victimization, and use of violence.

As with alcohol use, representative studies of lesbian tobacco use have yet to be completed. Cardiovascular diseases (e.g., heart, stroke, arteriosclerosis), however, represent the leading causes of death for women in general. Existing non-random studies indicate that lesbians may smoke more and have a higher body mass index than heterosexual women, and thus may be at higher risk for cardiovascular disease and cancers (Bradford, Plumb, White & Ryan, 1994; White & Dull, 1997; Moran, 1996). Because lesbians appear to seek health care less often, they are less likely to receive blood pressure and cholesterol screening, further compounding their risk. In addition, comparisons between young gay men and lesbians (Skinner and Otis, 1996) have found that lesbians actually smoke more than their gay counterparts, furthering concern about their risk and the need for greater research in this area.

A report on the response of the criminal justice system to bias crimes concluded that lesbians and gay men are among the most frequent victims of hate violence in the United States and as a group they "are probably the most frequent victims" (Finn & McNeil, 1987). Acts of aggression, denigration, and violence against LGBT people have been documented in a variety of settings including: schools and colleges, the armed services, jails and prisons, at homes, in work places, and in public places (APA, 1997; Bradford, et. al., 1994; D’Augelli, 1989; Garnets, et. al., 1991; Herek, 1989; Levine & Leonard, 1984; Rothblum, 1994; Wolfe, 1998; Wooden & Parker, 1982).

IV. A. Overview and Definitions

The scientific literature on gend