Table of Contents

EXECUTIVE SUMMARY

This is a report on the health needs of the lesbian and gay community in New York City. As part of the rich and varied mosaic of the City's communities and neighborhoods, gay men, lesbians, bisexuals, and transgendered individuals represent a community whose needs are in many ways the same as those of other New Yorkers, and in many ways unique and different. This report does not attempt a comprehensive analysis of every health concern affecting gay men and lesbians, but it addresses and reflects current knowledge on some of the most significant health issues in this population. It concludes with a number of recommendations on public health actions that could improve health status and access for lesbians and gay men.

The gay and lesbian community has seen a remarkably rapid social and cultural development over the past two decades. As the social context within which gay men and lesbians live has changed, so, of course, have their health needs and ability to access services. This has been accentuated by the HIV/AIDS epidemic, which in a relatively brief period of 18 years has devastated the gay male community in New York City, and has radically transformed the community's internal institutional structure and the external public profile of the community. Standards of care for HIV treatment and prevention have evolved rapidly over this time, and with them demands on service structures that provide care to the community.

The information used in this report is based upon two sources: published material in the research literature about the health needs of gays and lesbians, and materials provided by (and interviews with representatives of) key organizations serving gays and lesbians in New York City. Where available, the report utilizes New York City-specific research and data. The pool of such data is, however, extremely limited. Therefore, this information was supplemented by research based upon either national samples or other research from elsewhere in the country that could be applied to the New York City gay and lesbian population.

Because of the rapid evolution of the gay community's social environment and the impacts of the HIV epidemic in particular, research on gay and lesbian health needs can rapidly become dated. The authors of this report have attempted, wherever possible, to rely on recent studies and literature to support its analysis. Older studies are used only when more recent information does not exist. In the areas where research data are limited or nonexistent — and there are many — the authors supplemented published information with material provided by a number of organizations within New York City that focus their services on the health, mental health, and substance abuse treatment needs of gays and lesbians, and whose systematic or anecdotal observations about their clients supplemented other available analyses.

This report begins with a description of the lesbian and gay community in New York City, discussing some of the definitional questions about whom the community comprises, and what is known about the community's scope and demographics. It also presents evidence that gay men and lesbians face particular health issues that relate to the social environment in which they live, to the ongoing pervasiveness of homophobia and hostility in many quarters, to unique developmental issues related to discovery and acceptance of a "minority" sexual orientation, and to patterns of sexual behavior and socialization that are different from those in society at large.

This report then focuses on six areas of health concern in which gays and lesbians have the most distinctive patterns of need:

• HIV/AIDS
• Other sexually transmitted diseases (STDs)
• Breast cancer
• Substance abuse
• Mental health
• Violence

The health status of any community is a function of both its health care needs and its ability to have those needs met. This report also looks at the specific health issues of lesbian and gay youth, seniors, immigrants, and transgender people and points out disparities in their health care needs from those of the community as a whole. This report looks at barriers that inhibit access to health care services. Some of these are general to the broader New York City population (e.g., lack of insurance coverage), while others are specific to gays and lesbians as a group (e.g., provider homophobia).

The report concludes with a set of public health policy recommendations based upon its analysis which are intended to provide the basis for a program to address the most significant health problems and access barriers for lesbians and gay men in New York City. These recommendations are:

1. Undertake targeted public health interventions to address the most significant health risks among lesbians and gay men. This report identifies a number of areas in which lesbians and gay men appear to face health risks greater than those among the general public, toward which interventions should be targeted.
2. Provide enhanced support for health agencies serving the gay and lesbian community, particularly those portions of the community that have difficulty accessing mainstream services (especially youth, seniors, immigrants, and transgender individuals). Targeted health services for the gay and lesbian community are critical, particularly for those portions of the community that face barriers in utilizing mainstream health services.
3. Provide training for present and future health care providers on the specific health needs of gay men and lesbians, and on sensitivity issues in working with this population. Even with expanded availability of targeted services, the bulk of health care for lesbians and gay men will (and should) be provided through mainstream programs and facilities who need training in meeting the needs of this community.
4. Conduct research on community-based health needs and access patterns. In the preparation of this report, it became evident that there are few New York City-specific research data on the health needs of the gay and lesbian community -- the largest such community in the country. The limited availability of reliable information on the community whose needs are to be addressed complicates the task of public health planning and service delivery.
5. Develop demonstration models and service protocols for the delivery of health care to gay men and lesbians through mainstream providers, and for the collection of information about services to this population. Gay men and lesbians receive health care in a variety of settings; each of these settings (private physicians' offices, through managed care systems, in hospital and community clinics, and others) poses different issues with respect to appropriate and sensitive gay and lesbian health services.
6. Assess the impact of significant health care delivery or financing changes on the ability of the health care system to meet the needs of lesbians and gay men. Gay men and lesbians tend to be an invisible population, and hence they are rarely considered as changes in health care delivery or financing are made.
7. Expand legal recognition of lesbian and gay relationships and families. The discussion of whether and how to recognize the relationships and families of lesbians and gay men is usually couched in terms of civil rights and social equity. There are, however, strong public health considerations that favor broader recognition of lesbian and gay partnerships.

Introduction

This is a report on the health needs of the lesbian and gay community in New York City. As part of the rich and varied mosaic of the City's communities and neighborhoods, gay men, lesbians, bisexuals, and transgendered individuals, represent communities whose needs are in many ways the same as those of other New Yorkers, and in many ways unique and different. This report attempts to paint a picture of both the ways in which lesbians, gay men, bisexuals and transgendered people reflect the health care needs and access issues of the broader community, as well as how and where their needs diverge.

The topic of this report is an ambitious one, and it remains a work in progress, in that much research is yet to be done on the lesbian and gay community's health issues, and for that matter, on the very definition and scope of the community itself. To produce a document that provides meaningful and useful information for public health planning, it was necessary to narrow the focus of the study to some of the most salient health issues affecting the community. Thus, this report does not attempt a comprehensive analysis of every health concern affecting gays and lesbians. Rather, it addresses and reflects current knowledge on some of the most significant health issues in this population, and makes recommendations on public health actions that could improve health status and access for lesbians and gay men.

The discussion in this report is based upon two sources: published material in the research literature about the health needs of gays and lesbians, and material provided by (and interviews with representatives of) key organizations serving gay and lesbians in New York City. Where available, the report utilizes New York City-specific research and data. The pool of such data is, however, extremely limited. Therefore, this information was supplemented by research based upon either national samples, or other locally-based research from elsewhere in the country that could be applied to the New York City gay and lesbian population.

The gay and lesbian community has seen a remarkably rapid social and cultural evolution over the past two decades, as more people have "come out" and chosen to be public about their sexual orientation, and as public visibility and acceptance of homosexuality has increased. As the social context within which gays and lesbians live has changed, so, of course, have their service needs, and their ability to access services. This has been accentuated by the HIV/AIDS epidemic, which in a relatively brief period of 16 years has devastated the gay male community in New York City, and has radically transformed the community's internal institutional structure and the external public profile of the community. Standards of care for HIV treatment and prevention have evolved rapidly over this time, and with them demands on service structures that provide care to the community.

Because of the rapid evolution of the gay community's social environment, and the impact of the HIV epidemic in particular, research on gay and lesbian health needs can rapidly become dated. The report attempts, wherever possible, to rely on recent studies and literature to support its analysis. Older studies are used only when more recent information does not exist. In the areas where research data are limited or non-existent — and there are many — the report supplements published information with material provided by a number of organizations within New York City that focus their services on the health, mental health, and substance abuse treatment needs of gays and lesbians, and whose systematic or anecdotal observations about their clients supplemented other available analyses.

This report begins with a description of the lesbian and gay community in New York City, beginning with some of the definitional questions about whom the community comprises, and discussing what is known about the community's scope and demographics. It then discusses the evidence that gays and lesbians face particular health issues that relate to the social environment in which they live, to the ongoing pervasiveness of homophobia and hostility in many quarters, to unique developmental issues relating to discovery and acceptance of a "minority" sexual orientation, and to patterns of sexual behavior and socialization that are different from those in society at large. The report focuses on six areas of health concern in which gays and lesbians have the most distinctive patterns of need:

• HIV/AIDS
• Other sexually transmitted diseases (STDs)
• Breast cancer
• Substance abuse
• Mental health
• Violence

The report also looks at the special health issues of lesbian and gay youth, seniors, immigrants, and transgender people, and points out disparities in their health care needs from those of the community as a whole.

The health status of any community is a function of both its health care needs, and its ability to have those needs met. After discussing the needs of the gay and lesbian community and its sub-communities, this report then looks at barriers that inhibit access to health care services. Some of these are general to the broader New York City population (e.g. lack of insurance coverage), while others are specific to gays and lesbians as a group (e.g. provider homophobia).

The report concludes with a set of public health policy recommendations based upon its analysis, and intended to provide the basis for a program to address the most significant health problems and access barriers for lesbians and gay men in New York City.

The Lesbian and Gay Community in New York City

New York City has served as a magnet for lesbians and gay men since the turn of the century, as many of these individuals have left the relative isolation and oppression of their home towns for the possibilities offered by the large and diverse urban culture of New York. New York has provided lesbians and gay men the wide range of business, cultural, and intellectual opportunities of the largest city in the country, combined with the sense of community from the critical mass of lesbians and gay men with the resources and inclination to create gay-identified neighborhoods, businesses, cultural institutions, and public spaces.

Definitions and Identity Issues

The lesbian and gay community in New York City is large and diverse; however, there are significant methodological issues in enumerating just how large. First, there are myriad issues in defining whom one is trying to count. Second, even if consensus could be reached about who was being counted, there is no way to definitively count a hidden and partially invisible population. Therefore, the discussion of gay and lesbian health issues in this report is necessarily descriptive, in the main, rather than quantitative.

Historical and anthropological research shows that people whose primary identity is homosexual have not always existed in every society or historical period. However, research does show that homosexual behavior occurs in virtually every society and historical period. Thus any attempt to assess the size of the homosexual population raises a question about the definition of what is being measured — identities or behavior — since not everyone who engages in homosexual activity self-identifies as a "homosexual".

Results from the largest recent national probability survey on sexual behavior among 3,423 adults demonstrates a disparity between self-identity and sexual behavior. The survey showed that whereas 7.6 percent of white men reported ever having same-sex sexual partners, only 3.0 percent identified as "homosexual" or "bisexual". The corresponding proportions for white women were 4.0 and 1.7 percent; for black men, 5.8 and 1.5 percent; and for black women, 3.5 and 0.6 percent. (Diamond, p. 305) The boundaries of these definitions are clearly quite sketchy and deeply personal.

Furthermore, people claim a range of sexual identities, not simply a dichotomy between homosexual and heterosexual. There are self-identified bisexuals, who may or may not act upon their sexual desires for both genders at any given time or ever in their lives. Transgender people constitute their own continuum, with people of either gender identifying as a person of the opposite gender, taking a range of steps to enact that identity (ranging from cross dressing to hormone therapy to surgery), and with a range of sexual desires expressed differently within different gender identities. If all these variations leave too many clear boundaries, there are also self-identified lesbians and gay men who also have sexual partners of the opposite gender.

Identity issues that complicate the task of defining this community include how to account for changes in sexual identity through time, differences between desire, self-identity and behavior, and the continuum of sexual identity and behavior that is included within the broad rubric of gay, lesbian, bisexual, and transgender. The sexuality researcher, Robert T. Michael describes some of the life cycle issues:

"Does a man who has homosexual sex in prison count as a homosexual? Does a man who left his wife of twenty years for a gay lover count as homosexual or heterosexual? Do you count the number of years he spent with his wife compared to his lover? Does the married woman who had sex with her college roommate a decade ago count? Do you assume that one homosexual experience defines someone as gay for all time?" (Michael et al., p. 172)

While one person might equate desire for another of the same sex with homosexuality, another person might think that one has to act on these desires to be homosexual. And, what about the individual who considers himself a homosexual but has never had sex with another person of the same sex? The more commonly described disparity between self-identity and behavior involves people who self-identify as heterosexual, but have sex with partners of the same sex. Some such people are actually partnered or married to opposite sex partners, while others are not.

In addition to distinctions between self-identity and behavior, there is the largely separate issue of what people choose to reveal to a researcher or on a survey. The existence of homophobia quiets many gay men and lesbians, even in a relatively open city like New York. With national polls spanning 20 years indicating that over 70 percent of Americans believe that homosexuality is morally wrong, many have chosen to keep their sexual orientation undisclosed to the public. (Michael et al., p. 172) Obviously, the numbers who self-disclose depends on the context and the questioner.

Making Epidemiological Comparisons: The Denominator Problem

These complexities of identity have multiple implications for a study of lesbian and gay health. First, for simple epidemiological purposes, a denominator is necessary to make quantitative comparisons. Thus, it is methodologically difficult to support a seemingly simple statement like "Substance abuse is more common in the gay community." This statement implies a comparison between the rate of substance abuse in a gay and (implicitly, comparable) heterosexual group. No such comparison is possible, because while we can count numbers of gay people with substance abuse problems, we have no denominator — we do not know how many gay people there are — to calculate the rate. We are left with the observation that there are many gay people with substance abuse problems, but we have no way of knowing whether it is more prevalent among lesbians and gay men than among the heterosexual population. The absolute magnitude of substance abuse among homosexuals may be a sufficient observation for program planning purposes, but makes true descriptive epidemiology (which is a precursor to searches for correlates and then causes) extremely difficult.

Secondly, to describe gay and lesbian health, issues of identity and behavior are central to multiple health issues. To describe the epidemiology of homosexually-transmitted, sexually transmitted diseases, sexual behavior is clearly more important than sexual identity. However, any program planning to prevent or treat these diseases entails understanding people's self-identification as well as their behavior. Similarly, there are health conditions for which lesbians and gay men appear to be higher risk not because of their sexual behavior or identity, but because of coincidental correlations. For example, lesbians appear to have a higher rate of breast cancer (though the lack of a denominator, described above, makes it difficult to know without comparing large comparable groups of lesbians and straight women). However, this risk of breast cancer is probably not related to being a lesbian, but more likely, to less frequency of childbirth, and possibly also to the greater likelihood of being overweight, greater consumption of alcohol, smoking, and lack of preventative care. A recent study by a distinguished national panel found that lesbians were not at higher risk for any particular health problem by virtue of having a lesbian sexual orientation. The panel recommended further research to determine whether there are health problems for which lesbians are at higher risk, as well as conditions for which protective factors may operate to reduce health risks for lesbians. (Institute of Medicine, 1999).

Thirdly, with no complete descriptions of the overall population (all lesbians and gay men in New York City, by any definition), we are left gleaning evidence about health status from various small scale studies and non-representative samples. For example, the STD numbers and rates from the City's STD clinics cannot be generalized to any other population at all, as such clients are, by definition, practicing unsafe sex. Even less obviously biased samples still have their own biases. For example, many surveys are performed on readers of magazines or newspapers. However, magazine readers have higher incomes and economic status, which is one of the biases that has resulted in the myth of the affluent gay community. Thus, all of the following descriptions must be interpreted tentatively, and the information source analyzed for bias before generalizations can be made beyond the specific population described. Larger and more representative studies will be needed before more definitive statements about the health of the community can be made.

The Lesbian and Gay Population of New York City

As the foregoing discussion illustrates, there are, and indeed can be, no reliable data on the numbers of lesbians and gay men in New York City. Estimates range from 750,000 to one million, out of an overall city population of more than seven million. Literature reports on the proportion of the total U.S. population that is homosexual range from 1 percent to 10 percent. This would translate to between 75,000 and 750,000 lesbians and gay men in New York City; however, lesbians and gay men migrate to New York, and thus proportions are likely to be at the highest end of the range for the entire nation.

Laumann et al. showed that men living in the central cities of the twelve largest metropolitan areas report rates of "same-gender sexuality" (identifying as homosexual/bisexual or attracted to members of the same sex) of between 9.2 and 16.7 percent, as compared to rates for all men surveyed of between 2.8 and 7.7 percent. (Laumann et al., 1994) They found a similar, yet not as striking, pattern among women. Regardless of gender, same-gender sexuality appeared to be correlated with the degree of urbanization of the locale of the responders. From this study, New York City would be expected to have a higher percentage of people with same-gender sexuality than the national average.

Nationally, population-based surveys that ask people about their sexuality reveal a population similar to the heterosexual population. The Yankelovich Partners' 1994 Perspective on Gays and Lesbians reports that the gay/lesbian sample in their survey of 2,503 respondents across the country is similar to the heterosexual population in terms of age, gender, ethnicity, occupation and employment, income and formal political affiliation (although gays/lesbians espouse a more liberal viewpoint). (p. 21) Compared to the heterosexual population, the population that identifies as gay or lesbian is more likely to have attended graduate school and be self-employed. They are less likely than the heterosexual population to be Protestant, married, parents (although 50% of the gay male/lesbian population report that they are parents), and live in households where children under 18 are present (although 24% of the gay male/lesbian sample do).

It is, however, not clear whether gay men and lesbians in New York City reflect its age, racial and ethnic, and socioeconomic profile or whether patterns of in- and out-migration have made a profile unique to the lesbian and gay community. The 1990 Census included, for the first time, a question on census forms about unmarried partners living together, providing an opportunity — albeit a limited one — to draw some conclusions about lesbian and gay couples. In New York City, 11,668 same-sex couples identified themselves as unmarried partners, about ten percent of the total number of unmarried couples who answered the question. Some evidence about the demographic distribution of same-sex couples in the City can be gleaned from census respondents: while male couples responding to the Census were disproportionately white (68 percent compared to 40 percent of the citywide population), female couples were slightly more proportionately Hispanic (29 percent versus 24 percent citywide). Approximately two-thirds of responding couples were men.

There is no way to know if same-sex respondents to the unmarried partners question on the Census are representative of gays and lesbians in New York City. First, there is the documented Census undercounting of people of color, especially immigrants. Secondly, the same-sex couple question was asked of a small subsample of Census respondents, with no way to know its representativeness of the people who were not asked. Third, it could only count gays and lesbians who were in couples and living together. Fourth, it seems probable that many people who met all the previous qualifications would be reticent to identify themselves to the federal government. There is currently no way to assess whether, in fact, there are disproportionately more gay white men and Hispanic women, or whether the community's racial and ethnic distribution more closely mirrors the diversity of New York City. For purposes of this report, we will make the assumption that gays and lesbians reflect the underlying racial and ethnic distribution of the City. Clearly, basic community description remains a vital need.

The Socio-Economic Profile of Gay Men and Lesbians

The stereotype of the wealthy and privileged gay community persists, and is constantly fueled by the high-visibility coming out of affluent performers and public figures. The myth of the affluent gay community is kept alive by some as ammunition against gay civil rights protections; they argue that gays, far from being the victims of discrimination, are actually wealthier than their counterparts. Marketers have identified gays as an "untapped" market, drawing attention and visibility to a portion of the community with expendable income. The surveys leading to these conclusions have been drawn from biased samples which are not representative of the entire gay, lesbian and bisexual populations. Among the common biases of such surveys include surveying readers of specific magazines, who are better educated and have higher incomes, and conducting surveys at gay and lesbian events and travel destinations that, by definition, attract people with the disposable income to travel.

The most comprehensive analysis of the nationally representative samples that include both sexual orientation questions and income and occupation questions have been performed by Lee Badgett, as have the analyses of the biases of other studies of lesbian and gay income. (Badgett, 1997; Badgett, Donnelly, and Kibbee, 1992) Badgett concludes that the preponderance of the national data reveals that both gay men and lesbians earn less than their heterosexual counterparts. Household income for a gay male couple is slightly higher, on average, than for a heterosexual couple; household income for a lesbian couple, on the other hand, is lower on average than for a heterosexual couple. This seems to be explained by the lower wages earned by women compared to men.

The Yankelovich Partners' report indicates that a higher percentage of the gay men and lesbians sampled attended any college at all (49% versus 37%) and attended graduate school (14% vs. 7%) compared to the heterosexual population. (p. 23) Usually this can be associated with higher income levels; however, the report indicates that this is not the case for the gay/lesbian population. Whereas 65 percent of the heterosexual men surveyed earned under $25,000, 81 percent of gay men earned at this level. Also, 29 percent of the heterosexual men earned between $25,000 and $49,999 compared to 13 percent of the gay men. The differences were not as outstanding when comparing the lesbian population to the heterosexual women. Other studies, including the General Social Survey, the 1990 Census and Voter News Service survey, consistently found gay and lesbian individuals earning less than their heterosexual counterparts. For example, the General Social Survey conducted from 1988 to 1990 showed that for full-time workers, lesbian/bisexual women earned an average of $15,056, compared to $18,341 for heterosexual women. Gay/bisexual men earned $26,321, compared to $28,312 for heterosexual men.

We have no specific data about the socio-economic status of lesbians and gay men in New York City; however, generalizing from the evidence in national studies, it appears that they may be slightly less well-off than their heterosexual counterparts. In the absence of concrete evidence that the community's distribution of age or occupation is different from the City as a whole, we can assume that gays and lesbians share approximately the same distribution of wealth, and economic condition, as City residents overall. Gathering of better descriptive data is an important future step because, as will be made explicit in the following sections, poverty, hazardous living conditions (closely associated with poverty), and lack of health insurance are strong predictors of health problems and access barriers to health services. Any full assessment of gay and lesbian health status will require more information on the community's socio-economic profile.

Health Issues of the Lesbian and Gay Community

Lesbians and gay men are part of the larger community in New York City, and are affected by the same health issues as the entire community. Thus, for example, gay men who do not die prematurely from HIV/AIDS can be expected to die of heart attacks as old men, just as their heterosexual counterparts do. Similarly, lesbians die in old age of cancer and heart attacks as do other women. It is important to keep the health issues of special concern to the community — either because of excess incidence (like HIV/AIDS and possible breast cancer and substance abuse) or because of need for special services (like health care for adolescents separated from their families, mental health services, and substance abuse treatment) — within the context of the dominant health issues affecting all residents of New York City.

Gay men and lesbians are also unlikely to be immune from the differentials in health status and health care access that negatively impact poor communities, often predominantly communities of color. On the contrary, it seems likely that the gay and lesbian residents of the neighborhoods with high rates of health problems and indicators of health care access barriers will share these problems with their heterosexual neighbors. For lesbians and gay men, there are the additional challenges of finding health care providers who are both culturally competent and sensitive to issues of sexual orientation.

There are, however, a number of areas in which, for reasons having to do with special problems or circumstances faced by members of the lesbian and gay community, the community faces different health concerns (in kind or in degree) than the New York City community as a whole. This section focuses on six of the most significant of these areas: HIV/AIDS, other sexually transmitted diseases, breast cancer, substance abuse, mental health, and violence.

HIV/AIDS

AIDS was first identified within the gay male community, and has remained strongly associated with the gay community, even as the epidemiology of HIV infection has shifted to encompass additional populations. The effect of the epidemic within the gay community has been literally transformative. On the one hand, the epidemic has caused the loss of enormous numbers of leaders, artists, scholars, and a broad cross-section of community members; on the other hand (and hardly offsetting the losses), it has stimulated community mobilization and institution-building on an unprecedented scale. Both effects have ongoing implications for lesbian and gay health.

According to the New York City Department of Health (NYCDOH), New York City AIDS cases represent approximately 16 percent of all U.S. cases reported, in a metropolitan area that has 3 percent of the country's population. This translates into a cumulative total of over 100,000 AIDS cases since the beginning of the epidemic. This cumulative number of cases is greater than the combined total in the next three metropolitan areas most heavily affected by the epidemic: Los Angeles, San Francisco and Miami.

HIV/AIDS Among Racial/Ethnic Minorities

The increasing prevalence of AIDS among men of color who have sex with men, and specifically the Black and Hispanic sub-populations, indicate that initial prevention efforts were not as effectively targeted to these groups. Herek and Cogan report that "the HIV-related problems of African American and Latino gay and bisexual men have often been ignored within their own ethnic and racial communities (in which anti-gay prejudice has contributed to a reluctance to acknowledge the importance of the epidemic), in the larger society (which has tended to focus on primarily health concerns of White heterosexuals), and in the predominantly White gay community (which has tended to ignore the specific needs and concerns of its members who are Latino, African American, Asian/Pacific Islander, Native American, or from other ethnic or racial minority groups)." (p. 3) It is important to note that many gay men of color prefer to frame their HIV care issues in terms of ethnic identity rather than gay or bisexual identification. They would opt to seek care within their communities as they believe this would aid in the delivery of "effective, culturally competent, and prejudice-free services." (USDHHS, 1993, p. 16)

Gay men of color require HIV services characterized by "a combination of racial/ethnic cultural competence and sensitivity to the individual's sexual identity within the individual culture. Many [men of color who have sex with men] do not identify themselves as gay and are alienated by agencies that cater to the gay population. Conversely, many agencies that cater to people of color, but not the gay community, alienate [men of color}." (1997 Supplemental Grant Application, p. 161) Lesbians face many of the same issues as gay men, as well as the additional hurdle of often being unrecognized by providers who confuse individual identity with HIV risk behavior. Many health care providers fail to appreciate that, whatever the source of infection, many lesbians are living with HIV/AIDS and require culturally sensitive services.

Specific cultural hurdles impede access to HIV prevention and treatment among different minority groups. Many African-Americans, for example, have a strong distrust for government programs "based on a legacy of betrayal and tragedies, such as the Tuskegee Syphilis Experiment." (USDHHS, 1993, p. 16) Some also maintain a suspicion that the HIV epidemic may have been intentionally introduced into their populations. This distrust creates particular challenges in promoting access to new, more effective HIV antiviral therapies among African-American communities.

Gay and lesbian Latino/Hispanic people also have specific culturally related needs to be addressed. Their community is extremely diverse, "consisting of documented and undocumented people from the Caribbean, Central America, South America and the Iberian Peninsula. The largest proportion of the Hispanic population in New York City is Puerto Rican, many of who have maintained very strong ties with the island of Puerto Rico." (U. S. Conference of Mayors, p. 55) The cultural and ethnic diversity in the gay and bisexual Latino community in New York City has made it difficult to mount a unified organizational response to the HIV/AIDS epidemic. Since many are either monolingual Spanish or limited bilingual, they require Spanish speaking staff who are knowledgeable about the diverse Latino cultures. Furthermore, members of the Puerto Rican community frequently travel to New York to seek health care services for HIV disease. This has important implications for resource allocation and the continuity of care. (USCM, p. 55)

According to the USCM, there are more than 250,000 adolescent/adult Asian and Pacific Islander males in New York City. As of September 1998, 741 cases of AIDS had been reported among Asian and Pacific Islander men. Of these cases, 389, or about 60%, were among men who have sex with men (including IDUs). (NYCDOH 1998) While this population appears small in comparison to the African American and Latino/Hispanic communities, it is also culturally, linguistically and geographically diverse. Asian and Pacific Islander gay and bisexual men often do not openly identify themselves as gay; many fear that their sexual identities would isolate them from their families and communities, where they find emotional and practical support.

USCM reports that New York City is home to over 27,000 Native Americans, making it the second largest urban Native American population in the United States. Of the 40 cumulative AIDS cases in Native American men as of September 1998, 15 were among MSM (including MSM + IDU). While these numbers also seem small, it is these individuals who are most likely to fall between the cracks in the health service system. According to the Department of Health and Human Services, "there is widespread confusion about who is responsible — the Indian Health Service (IHS), other Federal agencies, or State and local jurisdictions — for delivering HIV services to these populations." (p. 17) However, urban areas such as New York City have very few if any IHS facilities or contract clinics, so seeking care at such facilities would be difficult at best. This community also has specific cultural beliefs and traditions that need to be acknowledged in order for effective outreach to be achieved. For example, it is important to acknowledge its long history of traditional medicines and therapies, and to accept that gay and bisexual men in this population often do not self-identify.

Public Health and HIV Prevention

The early years of the HIV/AIDS epidemic registered dramatic changes in gay male sexual behavior. An early study of a cohort of gay men in New York City (ages 20 to 65) indicated the sexual activity in general declined 78 percent from the time that the individuals studied heard about AIDS. The frequency of sexual episodes involving the exchange of body fluids and mucous membranes contact declined by 70 percent, and condom use during anal intercourse increased from 1.5 to 20 percent in a short period of time (Martin, 1987), with subsequent studies recording much higher rates of condom use.

More recent studies, however, have indicated that the impact of the epidemic on gay male sexual activity has not been consistent over time, particularly among younger gay men. Recent New York City data have shown increases in sexual activity among younger men: "The median number of sexual partners and sexual episodes, and the proportion of men who engaged in receptive anal intercourse, increased" during a two-year study period in the early 1990's. (Dean and Meyer, p. 210) Furthermore, "almost all young gay men engaged in unprotected oral sex," which is considered a risk behavior for HIV transmission, although lower risk than unprotected anal sex. This study concluded that the "increase in risk sexual behavior is an indication that AIDS may proliferate in new generations of gay men in New York City." (Dean and Meyer, p. 210)

Moreover, sustaining behavior change among the older cohort of gay men has also been a challenge for HIV prevention programs. "[M]any first-generation HIV prevention strategies among MSMs were premised on the unspoken assumption that research scientists would develop a cure, effective treatments or a preventive vaccine. In the absence of such a medical breakthrough, prevention educators increasingly recognize the difficulty of effectuating sustained change in sexual behavior." (New York City Prevention Planning Group, p. 12-13)

These disturbing trends in risk behavior have forced a rethinking of HIV prevention strategies for gay and bisexual men. This has included the acknowledgment that the old prescription for everybody to "use a condom every time" was not working over an extended period of time for many, and had almost never worked for some specific population groups. More complex articulations have been integrated into prevention theory including distinctions between the needs and motivations of HIV-positive men, HIV-negative men, or men who do not know their status; the role of desire in sexual practice; the different issues and challenges about sexual practice within the context of unequal power relationships; specific differences related to cultural identity as well as gender identity and sex role; and the complicated relationship between substance use and sexual decision-making.

A recent surge of activism about HIV in the gay community has returned to the first issue raised by the emergence of a sexually transmitted virus: methods for modifying sexual behavior and the impacts on the community of utilizing them. As sexual transmission became clear early in the epidemic, gay men developed personal and community strategies to lower the risk of transmission. The community developed norms and standards of "safe sex" that included condom use (especially for anal intercourse). A now-prevailing consensus developed that focused on eroticizing safer sex as a risk reduction technique, to encourage gay men to engage in sexual practices that minimized the risk of HIV transmission. This was seen, in part, as important to maintaining the social definition and liberation gained by the gay community in the 1970s. The community strategy repulsed efforts to separate people who were HIV-positive from those who were HIV-negative, and as testing for the virus became available, the community fought successfully for its voluntary and confidential use. This political and social strategy had political benefits, but some (for example, Odets, 1996) would argue, costs in the effectiveness of HIV prevention. Odets has argued that HIV prevention issues for HIV-positive and HIV-negative gay men are different, and that moving from a blanket social norm which people do not always follow ("use a condom every time") to a more effective individual harm reduction strategy requires making differentiations in the message to audiences of different HIV antibody status.

Recently, two prominent gay journalists in New York City (Gabriel Rotello and Michelangelo Signorile), as well as others, have argued that the community has more responsibility to police itself, and that public sex venues condoning unsafe behavior should be closed. Both published books in 1997 that argue that the gay community's continued self- definition in terms of sexual activity is deadly. Both Rotello and Signorile argue that with community survival potentially at stake, compliance with safer sex practices should be policed more closely, and that the community may need to relinquish some individual autonomy for the public good.

Other members of the gay community have differed strongly with Rotello and Signorile, arguing that the gay community's suppression of its own sexual expression only contributes to people's own feelings of marginalization and isolation, and that the internal policing strategy dovetails with other efforts to suppress gay sexuality across the country. Furthermore, they argue that sexual choices and decision-making are more complex than adherence to a set of community norms, and that at this point effective HIV prevention has more to do with disentangling the complex series of costs and benefits associated with each sexual act than with being stigmatized for failing to follow a community prescription. The vitality of the conflict suggests that the sexual issues raised by the epidemic remain one of its most profound and ongoing effects.

HIV and Health Care Services

In general, the HIV-related service needs of gay men are "similar to those of all persons with HIV/AIDS: prevention and education, counseling and support groups, other mental health services, primary health are transportation, housing, outreach and case management." (NYCDOH 1997 Supplemental Grant Application, p. 193) However, "[t]here are a number of ways in which unique needs of gay men or men who have sex with men are seldom recognized by service providers. Prejudice, lack of experience and/or skill in openly serving MSM, insensitivity to cultural mores of MSM, fear and ignorance — all contribute to ineffective service delivery and account for a general lack of outreach by mainstream providers." (NYCDOH 1997 Supplemental Grant Application, p. 157)

While gay men and lesbians receive services through a wide range of mainstream and neighborhood-based providers, HIV-related services targeted to lesbians and gay men in New York City are extremely few. A single organization in the city, the Callen-Lorde Community Health Center, offers health care strictly targeted to a clientele of gay and lesbian patients, including HIV-related medical services. The city's largest HIV support organization, Gay Men's Health Crisis, makes its services available to the entire HIV population citywide, although a large proportion of its clients are gay men or lesbians. Of GMHC's mid-1999 client base of 7,505, 59.4% identify as gay or bisexual men, and 3.0% identify as lesbian or bisexual women. (Gay Men's Health Crisis, 1999). Other organizations that specifically serve gay men and lesbians "are generally small and usually not the beneficiaries of government funding" for HIV services (NYCDOH 1997 Supplemental Grant Application, p. 158), although some provide government-funded HIV prevention programming. While mainstream HIV services throughout New York City are, of course, available to gay men and lesbians, there has been no systematic assessment of the degree to which the needs of gay and lesbian patients/clients are being met through the general network of HIV services.

Lesbians and HIV

While gay men have been the foremost infected and affected population for much of the epidemic, lesbians have tended to be a forgotten population. While strongly affected because of their relationships with gay men and the transformations wrought upon the gay community, much controversy has ensued about whether, how, and how many lesbians are themselves infected with HIV. Initial attention and controversy centered on whether HIV could be transmitted through sexual activity between women. Public discussion then moved on to how lesbians with AIDS were being counted, and has finally landed upon the realization that many women who partner with women also have significant extrinsic risks for the transmission of HIV (including injecting drug use and unprotected sex with men at increased risk for HIV) and therefore have specialized prevention and service needs.

The biological possibility of sexual transmission of HIV via female-to-female sex exists, since HIV is present in cervical and vaginal secretions, including menstrual blood. It is unknown whether cunnilingus or female-to-female sexual acts pose significant risks for HIV transmission; however, there are reported cases of such transmission. Study of this question has been partially impeded because "accurate and comprehensive data is hindered by definitions of 'lesbian' used to track AIDS incidence." Rankow explains:

CDC surveillance data count lesbians as women reporting sexual relations exclusively with other women since 1977. Such definitions do not describe the majority of women who partner with women, or even the majority of women who self-define as lesbian. (Rankow, p. 488)

New York and national studies do support the thesis that many women who partner with women are at risk for and infected with HIV. Bevier et al.'s study of the HIV seroprevalence and risk behaviors of New York City women at a sexually transmitted disease clinic who reported same-sex contact showed that women who reported same-sex contact had more HIV risk behaviors and were more often HIV seropositive than women who had sex only with men. (Bevier et al., 1995) The former were predominantly bisexual women who had likely acquired HIV through injected drug use and heterosexual contact.

In a national study of 1,122 women with HIV/AIDS in nine states, it was clear that many women who have sex with women (WSW) engage in behaviors that put them at risk for HIV infection. These behaviors include unprotected sex with men, unprotected sex or sharing of sex toys with women and injection drug use. Interviews provided data in support of this:

"Of the 65 (5.8 percent) of women who reported sexual contact with women in the past five years, 55 (85 percent) also reported sexual contact with men in the same time period. Of these 55 behaviorally bisexual women, 33 (60 percent) reported a history of sexually transmitted disease (STD), 31 (56 percent) reported exchanging sex with men for money or drugs, 28 (51 percent) reported injection drug use and 20 (36 percent) reported crack or cocaine use. Of the 10 women who reported sexual contact with other women only in the past five years, 8 (80 percent) reported injection drug use, one received a transfusion and one woman was a possible case of female-to-female transmission. The latter woman reported sexual contact (including oral sex and use of sex toys) with a number of high-risk female partners, including female partners who may have injected drugs and a female partner who was diagnosed with AIDS." (Kennedy et al., p. 103)

In New York City, while there is no count of the number of lesbians with HIV, providers of services to these women describe a specific set of service issues, prevention questions and issues, and political, advocacy, and identity issues as these women attempt to fit themselves into models of women's services that assume heterosexuality, or alternatively, into gay-identified services that are designed for men.

Sexually Transmitted Diseases

Gay and bisexual men tend to be at greater risk for many sexually transmitted diseases (STDs) than heterosexual men. Prior to dramatic changes in gay male sexual behavior in the early years of the AIDS epidemic, gay men generally experienced higher rates of syphilis, gonorrhea, hepatitis, and other enteric diseases. (Remafedi, 1986) According to NYCDOH STD surveillance, however, reported anorectal gonorrhea in all New York City men has decreased 98 percent over the past 16 years, suggesting an adjustment by the gay community to the AIDS epidemic. The 1990s have seen a stabilization at a low level for such cases. In 1992, 29 cases were reported; in 1993, 33 cases; in 1994, 50 cases; in 1995, 32 cases; in 1996, 29 cases; and in 1997, 61 cases. While these extremely low numbers of cases almost certainly reflect some under reporting, the trend has been dramatic.

A study of a cohort of men who have sex with men (MSM) at New York City STD clinics suggests some changes in STD patterns. Between 1988 and 1993, the proportion of MSM diagnosed with gonorrhea dropped from 24% to 11%. During the same period, however, diagnoses of genital ulcer disease rose from 8.4% to 14.1%. The latter trend "stands in contrast to the experience among non-MSM STD clinic clients," in whom GUD rates were stable at 7% over that period. (Torian, p. 189) Moreover, while HIV seroprevalence dropped substantially (from 53% to 34%) in this population over the study period, HIV seroprevalence remained high and stable in patents with gonorrhea (58% seroprevalence) and GUD (52%). This suggests that these STDs are markers of unsafe sexual behavior that is also a risk factor for HIV transmission.

Symptomology of STD infections among gay men may also be different, posing challenges for providers not experienced in treating that patient population. "Although gay men are subject to the entire spectrum of sexually transmitted diseases (STDs) that are found among heterosexual men.....certain manifestations of these infections.....are more common in gay men." These may include anogenital warts attributable to human papillomaviruses (HPV), proctitis due to many causes, gastrointestinal symptoms due to bacterial and parasitic causes, urethritis and pharyngitis. (O'Neill and Shalit, pp. 195-97)

"Hepatitis A, hepatitis B, non-A non-B hepatitis [Hepatitis C], and delta hepatitis are, to varying degrees, health concerns of gay men," all of which can be sexually transmitted and some of which are endemic in the gay community. (O'Neill and Shalit, p. 198) A study in the 1980s projected that more than 50 percent of adult gay males would contract hepatitis Type B during their lifetime. (Gibson, 1989) Furthermore, one out of five gay men infected with hepatitis B is at risk for developing chronic hepatitis which requires ongoing monitoring and care. Ryan and Bogard report that "one out of twenty will go on to develop chronic active hepatitis which can become life threatening in later years, leading to chronic liver disease, cirrhosis, liver cancer and premature death." (Ryan and Bogard, p. 11) Both Hepatitis A and Hepatitis B can be prevented with vaccines; however, patient education is poor and vaccination rates have remained relatively low. NYCDOH provides Hepatitis B vaccination at some clinic sites, and has recently supported a campaign to vaccinate gay and bisexual men for Hepatitis A, and provided free hepatitis A vaccine through public and private sites in Chelsea.

Recent New York City surveillance data suggest an increase in Hepatitis A infection rates among gay men. In the United Hospital Fund neighborhood of Chelsea/Clinton, for example, the rate of reported Hepatitis A cases among men ages 20 to 59 rose from 88 per 100,000 in 1996 to 227 per 100,000 in 1997, in relation to a 1997 citywide rate of 27 per 100,000 among men in that age group. In other neighborhoods with a substantial presence of gay men, case rates were similarly high: 60 per 100,000 on the Upper West Side, 142 per 100,000 in Greenwich Village/Soho, 88 per 100,000 in Union Square/Lower East Side, and 48 per 100,000 in Downtown Brooklyn Heights/Park Slope. In these neighborhoods, case rates generally doubled from 1996 to 1997, suggesting the possibility of changes in sexual behavior leading to increased transmission of this disease, although rates dropped somewhat in 1998. Reported rates of Hepatitis B among men 20 to 59 in these neighborhoods were also substantially higher than the citywide average in 1997, although the absolute number of reported cases is small. (NYCDOH Surveillance data, 1998)

Lesbians are also at risk for many STDs. "Clinical experience demonstrates that infecting agents such as vaginal candida, Gardnerella vaginalis, trichomonas, Chlamydia, and hepatitis A can be passed between female partners." Also, herpes simplex virus and HPV may be spread by direct contact with the lesions. (Rankow, p. 488) While under reporting of STDs may be indicated in the MSM population, it is also extremely problematic in the lesbian population. Some sources report that lesbians are unlikely to present to the physician with an STD. (Remafedi, 1986) This may be for one of a number of reasons. First, there may be no reason for a lesbian who has an STD to self-identify as a lesbian, particularly in light of provider homophobia (see Barriers to Health Care). There is also the possibility that the lesbian contracted the STD from a man, and therefore, again may not identify herself as a lesbian. Moreover, when a women does self-identify as a lesbian, there is a possibility that her physician would not perform a routine screening for STDs simply because he or she presumes that lesbians are not at risk.

Breast Cancer

Epidemiologic data suggest that lesbians are at elevated risk for breast cancer, but the reasons for this have been widely misunderstood. While being a lesbian in itself has not been shown to be a risk factor for breast cancer, there are nevertheless some reasons why breast cancer is a particular health concern for lesbians. The 1985 National Lesbian Health Care Survey, a survey of a non-representative sample of 2,000 lesbians, showed that 40 percent of whose over age 50 were cigarette smokers, 21 percent over 50 were heavy drinkers, and 34 percent over 55 reported weight problems. (Rounds, 1993) Using these data, the National Cancer Institute concluded that lesbians have a "two to three-fold" higher risk than non-lesbian women of getting breast cancer based upon these risk factors, not their status as lesbians.

The major factor that may put lesbians at a greater risk for breast cancer is the fact that a large percentage of lesbians (70 percent, according to the Survey) do not give birth, a factor that "increases the risk of breast cancer by 80 percent — and puts lesbians in the same risk profile as nuns." However, barring other risk factors, "a lesbian who never is pregnant is at no higher risk of developing breast cancer than a straight woman who never is pregnant.....Both are equally at higher risk for developing breast cancer than a lesbian who has a child at a young age." (Rounds, p. 45)

Studies also show that there is an excess risk of developing breast cancer among women with high body-mass indexes, and there is a weak suggestion of a higher proportion of weight problems in the older lesbian population than in the general population of women. (Rounds, 1993) Research shows that excess consumption of alcohol does increase breast cancer risk, but smoking has not been conclusively shown to have an impact on the development of breast cancer. It is not known whether rates of any of these activities among lesbians have changed in the more than 10 years since the Survey was done.

Another reason for enhanced risk is that lesbians often avoid regular gynecological exams, which means some may miss early detection and therefore be at greater risk of dying from breast cancer. In a large national study, 35-45 percent of lesbians lacked regular gynecological care. (Ryan and Bogard, p. 9) One reason is that very few lesbians seek birth control, which is what usually brings heterosexual women to the gynecologist. (Rounds, 1993) Lesbians also receive fewer mammograms and are less likely to perform regular breast self-examinations. (Rankow, 1995) Lack of access to gynecological care may also be due to actual or perceived provider homophobia or insensitivity, which deters lesbians from seeking care. Finally, many lesbians are estranged from their family due to their sexual orientation, and thus may lack information regarding family history of breast cancer that could motivate them to seek regular screening.

Alcohol and Substance Use

Studies from the 1970s and early 1980s gave rise to the notion that rates of alcoholism and alcohol abuse within the gay community are much higher than within the general population. These studies reported problematic alcohol use among gay men and lesbians in several disparate communities to cluster around a prevalence rate of 30 percent — much greater than the figure of 10 percent usually ascribed to the general population. (Paul et al., 1991) However, these studies had serious methodological limitations. For example, they generally employed opportunistic sampling techniques such as use of gay bars as a significant source for recruitment of samples, thus risking an overestimation of the prevalence of alcohol and other drug abuse among homosexual and bisexual men and women. Furthermore, many of the earlier studies had predominantly white and middle class sample populations, thereby limiting the knowledge of the drinking practices of ethnic minority gay men and women.

More recent studies have been designed to produce a more accurate picture of the prevalence of substance use in the gay and lesbian populations. For example, Stall and Wiley compared the alcohol and other drug patterns of self-identified gay and heterosexual men who lived in the 19 census tracts of San Francisco. Their results indicated that the rate of heavy drinking among gay men in their sample was 19 percent, compared with 11 percent among heterosexual men in the sample. Gay men in this sample were approximately twice as likely to be frequent/heavy drinkers or abstainers as heterosexual men. (Stall and Wiley, 1988) Few other differences were found between the drinking habits of the sample's gay men and heterosexual men.

In 1990, Martin found that only 5 to 6 percent of sampled self-identified gay New York City men throughout the four years of his study could be categorized as frequent/heavy drinkers. This is in contrast to the 19 percent of the San Francisco sample, and provides evidence that high rates of excessive drinking or alcoholism do not exist in this community sample of New York City gay men. He also found considerable consistency over a 4-year period in the typical alcohol consumption patterns of the subjects in his study, with averages of about five drinks per week.

A 1988 Chicago study, comparing survey responses of a local gay newspaper to those of a national general population sample, found "rates of abstention from alcohol among gay men and lesbians in Chicago to be lower than those found in the general population (14 percent versus 29 percent). Rates of heavy drinking among gay men and lesbians were comparable to those found in the general population (15 percent versus 14 percent), although rates of reported alcohol problems were higher in the gay sample (23 percent versus 12 percent)." (Paul et al., p. 152) In general, they concluded that significantly more homosexuals use alcohol or drugs than in the general population, but that this does not translate into substantially higher rates or more frequent use. (McKirnan and Peterson, 1989)

The 1988 Chicago study is one of the few studies to measure alcohol-related problems among lesbians. It showed that rates of heavy drinking among Chicago lesbians were comparable with those of the general population (9 percent versus 7 percent). "However, the rate of alcohol-related problems among these urban lesbians — 23 percent — appears to be higher than the rate estimated for heterosexual women (8 percent) in a national sample of both urban and rural women." (Paul et al., p. 152) Additionally, a large national study showed that one out of five middle-age lesbians sought care for alcohol and drug related problems. (Ryan and Bogard, 1994) The typical pattern in the general population — that women consume less drugs and alcohol than do men, and that substance use declines substantially with age — has not been found in the gay population. As a result, higher overall rates of substance abuse exist in the gay community, and there is less disparity between men and women. (McKirnan and Peterson, 1989)

Use of other drugs, particularly so-called "designer drugs," can fluctuate tremendously over time, as different drugs become fashionable or widely available. In general, use of drugs appears to be significantly higher among urban gay men than in the general community. Of 72 participants in a substance use counseling and education program at GMHC, 19 (26%) reported use of one drug only and 10 (14%) reported usage of multiple drugs. Of those reporting use of one drug only, the most common single use drug was alcohol, with 10 of the 19 respondents reporting use. Five of the respondents reported use of cocaine. Of the 10 individuals reporting usage of multiple drugs, the combination of alcohol and cocaine was most common. Other combinations reported included that of alcohol with marijuana; alcohol with marijuana and ecstasy; crystal and methadone; ecstasy and cocaine; and alcohol with prescription drugs.

Stall and Wiley believe "it is more difficult to make precise statements regarding drug use among gay men except to note that the prevalence of use of particular drugs within this sample of an urban gay community is quite high...The finding that a sizeable proportion of gay men use many different types of drugs raises the possibility that concurrent drug use is relatively common among gay men." (pp. 70-71) They showed that homosexual men in their sample were more likely to use a set of different drugs (marijuana, poppers, MDA, psychedelics, barbiturates, ethyl chloride and amphetamines) and to use a greater variety of drugs than their heterosexual counterparts. Again, the frequency of use was not suggestive of dependence or addiction. Gay men, they concluded, use a wide variety of drugs but do not frequently use specific drugs.

What would cause alcohol and drug abuse to be prominent in the gay community to begin with? First, the three factors that, according to Fifield and her colleagues, contribute to alcoholism in any culture can be applied to the gay community. These are: (1) the degree of stress and inner tension that a culture produces, (2) the culture's attitudes toward alcohol abuse, and (3) the degree to which the culture offers alternative means of satisfaction and coping with anxiety. (Paul et al., 1991) The obvious stresses of gay life (such as the social stigmatization of homosexuality, discrimination, and internalized feelings of isolation, inadequacy and alienation) can manifest themselves as discomfort with one's sexual orientation or internalized homophobia. (Paul et al., 1991) Numerous studies have indicated such reasons for alcohol and drug use. For example, the 1988 Chicago study demonstrated that "subjects reporting more negative affectivity than others were more likely to see alcohol as a means of reducing tension and were more likely to use bars as a primary social setting." (Paul et al., p. 154) The researchers concluded that "alcohol abuse among those who used bars as a social resource was significantly related to experienced discrimination and to personal stress of low self-esteem, alienation and depression." (Paul et al., p. 154)

High rates of substance use among lesbians and gay men are often attributed to psychosocial factors. Gays not only face stigmatization, but also lack many mainstream coping and support resources, and many use bars as a significant social focus. (McKirnan and Peterson, 1989) "Bars or similar settings have traditionally been an important social focus in homosexual culture, due to a history of exclusion or discrimination in other 'mainstream' social settings. This may contribute to substance abuse through simple exposure and/or through cultural norms that sanction alcohol or drug use as a component of social interaction. The vulnerability induced by the cultural importance of bars may be exacerbated by the stress many homosexuals feel as stigmatized members of a sexual minority, and, more recently, the AIDS crisis." (McKirnan and Peterson, p. 545)

It has been suggested that substance abuse can lead to a range of high-risk behaviors, including those that put lesbians and gay men at increased risk of HIV infection. Martin concludes that "there appear to be too few heavy drinkers in the New York sample to support the idea that homosexual men have experienced a disproportionate amount of AIDS because of the pervasiveness of excessive alcohol use in that population. A more parsimonious explanation of the epidemiologic distribution of AIDS and HIV in the U.S. population can be found in patterns of sexual behaviors and drug injecting behavior." (Martin, p. 33)

A number of reports have suggested that both alcohol and drug abuse have declined overall in the gay male community, possibly as a repercussion of the AIDS epidemic. Reasons commonly given by men who had stopped abusing alcohol or other drugs after the onset of the AIDS epidemic included "...non-HIV-related health problems, changes in other risky behaviors that led to a reduction in alcohol or other drug use, and a general change in norms within the gay community regarding the use of these substances. Delaying the onset of clinical AIDS symptoms was a reason commonly mentioned among HIV seropositive gay men. Only a small minority of the men in this sample attributed ending their alcohol and other drug abuse to treatment." (Remien, 1992)

Conversely, however, more recent evidence suggests that the AIDS epidemic may have the paradoxical effect of contributing to substance abuse for some gay men. The existence of AIDS as an omnipresent factor in gay men's lives may lead to substance abuse as a way of dealing with the overwhelming pain and loss associated with the epidemic. For other men, the constant dangers associated with sexual activity may make it difficult to have sex at all, except under the influence of drugs or alcohol. In some cases, psychologists have suggested, gay men may need to "get high" in order to have sex, or even to release inhibitions against risky sexual practices. (Odets, p. 219)

Mental Health

Lesbian and gay men have a wide range of mental health needs. While there is no intrinsic relationship between sexual orientation and psychopathology, the effects of homophobia and prejudice have adversely affected many gay and lesbian individuals. Thus, while many mental health issues for lesbians and gay men parallel those in the heterosexual community, others relate to their distinctive experiences: estrangement from families, the challenge of adjusting to a minority sexual orientation, the hostility or abuse that many lesbians and gay men experience throughout their lives, the lack of social support for gay relationships or family structures, or other factors.

Gonsiorek explains that while homosexual individuals present a full spectrum of psychological adjustment from the well adjusted to the severely disturbed, the effects of homophobia and prejudice have adversely affected many gay and lesbian individuals. (Gonsiorek 1988) He describes one of the greatest impediments to the mental health of gay and lesbian individuals as "internalized homophobia." Internalized homophobia refers to negative feelings one incorporates into one's self-image as the result of being raised with culturally sanctioned anti-homosexual biases. Gonsiorek states that symptoms may range from a tendency toward self-doubt in the face of prejudice to unmistakable, overt self hatred. (Gonsiorek, 1988)

Internalized homophobia has various expressions. The overt type presents in persons who consciously accuse themselves of being evil, second class or inferior because of their homosexuality. They may abuse substances or engage in other self-destructive abusive behaviors.....Covert forms of internalized homophobia are the most common. Affected individuals appear to accept themselves, yet sabotage their own efforts in a variety of subtle ways. For example, homophobic gay and lesbian individuals may abandon career or educational goals with the excuse that external bigotry will keep them from their objectives. Internalized homophobia may take the form of tolerating discriminatory or abusive treatment from others. (Gonsiorek, p. 117)

Internalized homophobia can be considered one of the major stressors for gay men and lesbians. It is compounded by both stigma, which relates to expectations of rejection and discrimination, and by actual experiences of discrimination and violence. These three factors have been shown to have a significant independent association with a variety of mental health measures. (Meyer, 1995) Meyer also suggests that psychological distress increases internalized homophobia, perceptions of stigma and reports of prejudice events. A recent finding from a national survey indicated how pervasive the stress in the lives of homosexuals is: it reported that 98 percent of homosexuals, compared to 89 percent of heterosexuals, consider themselves under stress. (Dean, 1995)

While Meyer's study involved 741 gay men in New York City, he believes that similar stressors play an important role in the mental health of lesbians as well. However, he warns that "generalizations from gay men to lesbians should be made with some caution. This is primarily because lesbians are subjected to social stress and oppression related to both the homosexual and gender aspects of their identity." (Meyer, p. 52) There has been no New York City-based cohort study of lesbians, but other studies suggest significant mental health issues among lesbians as well. "Surveys of adult lesbians reveal that 40% have considered suicide at some point in their lives, with 18% actually attempting suicide. (Rankow, p. 489)

The multiple stigmas facing gay men and lesbians of color can be associated with higher rates of mental health problems. Research indicates higher crude prevalence rates of psychological distress in community-drawn samples of African American subjects than in white subjects, and also higher rates in women than in men. (Cochran and Mays, 1994) The results of a national study by Cochran and Mays showed "homosexually active black women to be as distressed as HIV-infected gay black men." (Cochran and Mays, p. 524) Their findings indicated higher levels of depressive distress for both homosexually active men and women than would be expected based on their ethnic background, gender, or sexual orientation alone. Furthermore, when the CES-D Scale scores of their subjects were compared with previous research on predominantly heterosexual African-Americans, their subjects clearly reported greater depressive distress. Specifically:

"In earlier community drawn studies, approximately 23 percent of black men (presumably predominantly heterosexual) scored above 15 percent on the CES-D Scale, but in the current study, 33 percent of the black men did. Earlier community studies of black women suggest that approximately 26 percent scored in the depressed range, but in our study, 38 percent scored in the higher range." (Cochran and Mays, p. 527)

A previous study examining ethnic differences in CES-D Scale scores among gay and bisexual men showed that being African-American was a significant predictor of higher scores on one of the four CES-D Scale subscales. Other large community surveys, unselected for sexual orientation, indicate higher crude prevalence rates of depressive distress among African- Americans in general than among whites. (Cochran and Mays, 1994) Also, HIV-infected black gay men have been found to have more difficulty than white men in coping with AIDS-related stressors. "It may be that homosexually active African Americans are subjected to a larger number of negative life events than their white counterparts and/or have fewer resources to use in coping with them." (Cochran and Mays, p. 528) Cochran and Mays therefore speculate that their findings may, in part, "be a function of the interactive nature of stigmatization for being homosexual, for being a racial/ethnic minority, and in the case of the women, for being female." (Cochran and Mays, p. 528)

The AIDS epidemic has contributed enormously to mental health problems within the lesbian and gay community. AIDS-related mental health issues generally stem from two factors: dealing with one's own HIV status, and with widespread illness and death among one's friends and community:

Since the onset of the epidemic, urban gay men who were sexually active in the late 1970s and early 1980s have faced the realistic fears and practical concerns of their own premature mortality. But gay men have endured more than the fear of learning their health status and preparing for severe illness and death. Two other formidable stressors have menaced the gay community during this time: the rampant and irretrievable loss of friends and lovers due to AIDS and uncontrolled acts of anti-gay violence and discrimination. Acts of bias and prejudice against gay people are not new with AIDS, however, these events may be more painful now, occurring as background noise to the dirge of the epidemic. (Dean, p. 136)

Numerous studies have explored the possible psychiatric morbidity associated with HIV infection among gay and bisexual men:

Several of these studies used the Center for Epidemiologic Studies Depression Scale (CES-D Scale), a brief screening instrument for depressive symptoms in non-psychiatric populations. Results showed that depressive distress scores in homosexually active men seemed to be higher than U.S. population norms for males, even among men who were not HIV infected. This suggests that gay men experience somewhat elevated levels of depressive distress, though still averaging below the standard CES-D Scale cutoff score used to identify individuals at higher risk for clinical depression. Whether this heightened distress is a result of HIV-associated street or reflects somewhat higher distress levels found in pre-AIDS studies is indeterminable. However, symptomatic HIV men reported greater distress than asymptomatic or uninfected men. (Cochran and Mays, p. 524)

"Knowing one is HIV positive or having symptoms of AIDS represents the strongest, most consistent correlate of psychological distress we have found to date." (Martin and Dean, p. 102) For many men, particularly older men, this stress is compounded by multiple losses from AIDS. From Dean's seven year panel study of 746 gay men in New York City, the evidence for such stress is clear. Nearly two-thirds of the panel had experienced at least one-major AIDS-related death — described by Dean as "merely one experience in what is typically a series of stressful events that includes the burdens associated with care-giving. Most men learned of their friend's illness a year or two before he died, and many witnessed a long and debilitating illness that may have been emotionally more difficult than the actual death." (Dean, p. 147) Also, "bereavement of a close friend of lover who dies of AIDS results in significant psychological distress involving one or more of the following types of symptoms: depression, traumatic stress, sedative use, and suicidal ideation." (Martin and Dean, p. 102)

These combined AIDS-related effects have led to a number of mental health problems, including increased levels of depressive symptomatology involving demoralization, sleep problems, guilt and suicidal ideation. However, these effects may have declined more recently, as was seen in the New York City cohort of gay men. (Martin, 1989; Martin and Dean, 1993) "Data from the first 5 years of the AIDS epidemic suggested that gay men were not adapting well to multiple personal losses and that there was a direct relation between the number of bereavements and the level of psychological distress. However, after 7 additional years of the AIDS epidemic and the continuation of close losses, adaptation may be improving." (Martin and Dean, p. 94)

Martin and Dean suggest that these diminishing bereavement effects may be the result of concern over one's own health status replacing AIDS losses as the primary determinant of psychological distress. (Martin and Dean, 1993) "This is not to say that bereavement is a nonevent for gay men but that it can now be viewed as the context or background against which other types of events occur and take on salience." (Martin and Dean, 1993) Even for those individuals who have remained HIV-negative or without symptoms of AIDS throughout the course of the study, bereavement distress has decreased, probably because they have become habituated to the experience of AIDS-related losses. In general, men who are HIV positive (both those who are bereaved and those who are not) continue to experience higher levels of distress. (Martin and Dean, 1993)

Violence

Gay males and lesbians are routinely the victims of violence. A survey of nearly 2,100 lesbians and gay men nationwide by the National Gay Task Force found that more than 90 percent had been victims of verbal and physical assault because of their sexual orientation. (Gibson, 1989) Indeed, a report on bias crime sponsored by the National Institute of Justice found that 'homosexuals are probably the most frequent victims.' In a nine-city study of anti-gay violence, "nearly half of lesbians and gay men had been threatened with violence and modified their lives to reduce the likelihood of attack. Two out of three feared for their safety." (Ryan and Bogard, p. 6) In anti-gay street crimes, the weapons of choice are usually crowbars, clubs and chains. And, attackers are "almost always armed, outnumbering their victims and taking them by surprise." (Cotton, p. 2999)

According to Ryan and Bogard, one out of every two lesbian and gay Americans will be victimized during their lifetime because of their sexual orientation. "The most frequent targets of anti-gay violence are those persons who are most open, particularly lesbian and gay youth and young adults." (Ryan and Bogard, p. 8) Lesbians and gay men of color are also more frequent victims than white individuals. Since the advent of AIDS, violence against lesbians and gay men has steadily increased.

A 1999 report by the National Coalition of Anti-Violence Programs (NCAVP) found that hate crimes committed against lesbians, gay men, bisexual and transgender people (LGBT) continue to rise throughout the United States, despite reported decrease in crime generally. There were 2,552 incidents reported in 1998 within the NCAVP's multi-site national tracking program. In New York City, 616 anti-gay incidents were reported to the NCAVP, with 761 victims involved in these incidents. Sixty-one incidents resulted in serious injury, and complaints to police increased by 22%. The reported 1998 incidents in New York City included 10 murders, twice the number in the prior year. The weapons most commonly used in anti-gay incidents nationally were firearms; vehicles; bats, clubs and blunt objects; and knives and other sharp objects.

These figures probably represent only a fraction of the actual crimes committed, as studies of gay men and lesbians victims indicate that there is vast underreporting of hate crimes. In one study of 226 lesbians who had experienced victimization, only 15 percent reported the incident to the police. Other surveys of gay men and lesbians indicated that 89 percent and 73 percent, respectively, declined to report an incident to the police. (Berrill and Herick, 1992) "Victims are often unwilling to report the nature of the attack to police." (Cotton, p. 2999) "Secondary victimization," or negative response to a crime survivor because of his or her homosexual orientation, shapes the way lesbian and gay male survivors respond to primary victimization of hate crimes. (Berrill and Herek, 1992)

To literally add insult to injury, "physicians tend to be especially insensitive to gay men and lesbians in cases of sexual assault. There's an unwillingness to believe that a man, especially a gay man, can be sexually assaulted." (Cotton, p. 2999) Lesbian victims of sexual assault may have compounded problems. "When a rape is a lesbian's first sexual contact of any kind with a man, it 'can create a lot of psychological problems beyond what other women who have been raped would face.'" (Cotton, p. 3000)

Not only physical, but also mental health can be affected by an environment in which anti-gay and anti-lesbian violence is endemic. Ryan and Bogard describe the effects of sustained violence as being extensive:

Hate crimes create a climate of fear that pressures lesbians and gay men to hide, to maintain vigilance and to monitor their routine interactions with others — how they walk, talk, what they say. Violence can result in psychological trauma with long term effect on ability to function. Typically, depression, anxiety, fear, low self-esteem and self-blame follow victimization, togther with a range of somatic symptoms. (Ryan and Bogard, p. 6)

Gay men and lesbians also experience domestic violence, as in heterosexual relationships. One 1991 study reported that between 350,000 and 650,000 gay men in the United States are victims of domestic violence perpetrated by their lovers. And, "according to Women Inc., a San Francisco-based organization serving battered women, domestic violence occurs in 1 in 4 lesbian relationships — roughly the same percentage as in heterosexual relationships." (Singer and Decamps, p. 40)

The problem of domestic violence is exacerbated by the unavailability or inaccessibility of support services. As Rankow explains, "battered women's shelters may not provide a safe haven, as a female perpetrator would have the same access to the shelter as her partner." (p. 490) A 1991 study estimated that a total of not more than 20 professionals scattered in four American cities were adequately experienced or trained to deal effectively with lesbian and gay victims of domestic violence. (Singer and Decamps, p. 40)

Special Health Issues

In addition to the issues that affect a broad cross-section of the lesbian and gay community, there are particular issues that affect certain special groups within the community. This section looks at specific issues for:

• youth
• older lesbians and gay men
• immigrants
• transgender individuals

Youth

Adolescence is a challenging period of life for everyone, but for lesbian and gay teenagers, it can be especially difficult. (Remafedi, 1987) The physical, emotional and intellectual changes that take place, as well as sexual development, provoke anxiety for many, and there are "few guidelines for helping youth resolve the problems they face, often for the first time, and making the transition to adulthood." (Gibson, p. 12) Recognition of different sexual feelings can lead to a sense of peculiarity and isolation from one's peers and positive gay role models may not be readily available to offset the frequently negative messages young people receive about homosexuality:

Growing up lesbian and gay in America can be a health hazard. Unlike their heterosexual peers, lesbian and gay youth have no built-in support system, no assurances that their friends and family will not reject them if they share their deepest secret. They must learn to accept themselves despite a stigmatized identity, to find positive role models in a society that perpetuates negative stereotypes of lesbian and gay lives. The must learn to protect themselves against ridicule, verbal and physical abuse and exposure. And generally, they must do this alone. (Ryan and Bogard, p. 7)

Although adolescent homosexual activity has frequently been considered an experimentation with sexuality for individuals who will eventually adopt a heterosexual identity, primary adolescent homosexuality is far more prevalent than often believed. Remafedi's study demonstrates that homosexuality is a well-established preference for many adolescents, rather than a passing phase on the road to adult heterosexuality. (Remafedi, 1987) Studies have found a significant amount of homosexual behavior among adolescents, with one showing that 28 percent of the males and 17 percent of the females reported least one homosexual experience. (Remafedi, 1987) These high percentages suggest that a great number of New York City youth are forced to face the complex duality of adolescence and homosexuality alone.

Gay youth must attempt to develop a positive identity as a lesbian, gay male or bisexual in what is frequently a hostile and condemning environment. Consequently, they may be more susceptible to external pressures leading to unhealthy behaviors and impaired psychosocial development. "[H]aving to cope with a disparaging and oppressive society creates unique stresses and developmental variations in identity development, especially in adolescence and young adulthood, that are cofactors for HIV infection and disease." (Grossman, p. 39) "Lesbian, gay and bisexual adolescents face tremendous challenges to growing up physically and mentally healthy in a culture that is almost uniformly anti-homosexual. Often these youth face an increased risk of medical and psychosocial problems, caused not by their sexual orientation, but by society's extremely negative reaction to it." (Center for Population Options, 1992) Gay, lesbian, and bisexual youth face rejection, isolation, verbal harassment and physical violence in numerous settings from both family and peers.

The extreme isolation and lack of support for this population is identified by many researchers:

Lesbian and gay youth are the most invisible and outcast group of young people with whom you will come into contact. If open about who they are, they may feel some sense of security within themselves but face tremendous external conflicts with family and peers. If closed about who they are, they may be able to 'pass' as 'straight' in their communities while facing a tremendous internal struggle to understand and accept themselves. Many gay youth choose to maintain a facade and hide their true feelings and identity, leading to a double life, rather than confront situations too painful for them. They live in constant fear of being found out and recognized as gay. (Gibson, p. 112)

The majority of gay and lesbian adolescents, given the opportunity to develop within a supportive and informed environment with access to gay role models that counter dominant stereotypes, present no more serious mental health problems than the general adolescent population. Thus it is those individuals who are not given such a supportive and informed environment, as well as those who have psychologic concerns superimposed on their struggles with sexual orientation and those who have been particularly traumatized by their experiences as sexual minority members, who will experience mental health problems. (Gonsiorek, 1988)

Many of the problems that are experienced by gay and lesbian youth appear to be psychologic or intrapsychic in nature, but actually stem from external stress and lack of support. In response to the external pressure and isolation they often face, lesbians and gay youth are more vulnerable than others to psychosocial problems including substance abuse, chronic depression, school failure, early relationship conflicts, being forced to leave their families and having to survive on their own prematurely. (Gibson, 1989) They often remain unrecognized and unsupported by health care professionals: "[D]espite the mental and physical health risks faced by gay, lesbian and bisexual youth, many physicians do not discuss homosexuality with adolescent patients. Some feel it is outside their realm; others fear that discussing it may upset teenage patients or their parents. Many feel too uninformed or uncomfortable to be helpful." (Center for Population Options, 1992)

Parental and Peer Rejection

Parental rejection is a legitimate fear for many gay youth, while for others it proves a harsh reality. According to one study, one in four gay or bisexual males is forced out of the parental home prematurely due to issues surrounding sexual orientation. (Center for Population Options, 1992) Another found that half of all lesbians and gay youth interviewed report that their parent rejected them in some way due to their sexual orientation. (Remafedi, 1987) Many families are unable to reconcile their child's sexual identity with moral or religious values. (Gibson, p. 112) It is important to recognize that "gay youth are the only group of adolescents that can face total rejection from their family unit with the prospect of no ongoing support." (Gibson, p. 112)

As a consequence of estrangement from their families, gay male, lesbian, bisexual and transsexual youth comprise as many as 25 percent of all youth living on the streets in this country. (Gibson, p. 114) Living on the streets, without an adequate education or vocational training, many gay youths are forced to become involved in some sort of prostitution in order to survive. "They face physical and sexual assaults on a daily basis and constant exposure to STDs including AIDS." (Gibson, p. 114)

Verbal and physical abuse from peers, whether experienced directly or simply observed, is also a significant stressor for gay youth. Fifty-four percent of 289 school counselors surveyed strongly agreed that students are very degrading toward fellow students whom they discover are homosexual, and 67 percent strongly agreed that homosexual students are more likely than most students to feel isolated and rejected. (Price and Telljohann, p. 433) Conflict with family members regarding sexual orientation is another major external stressor. Many adolescents who disclose their sexual orientation to their family are rejected, mistreated, or become the focus of the family's dysfunction.

Drugs

Substance use is a common coping mechanism used by gay youth, who face two risk factors: adolescence itself, and coping with developing a gay identity:

"Substance use often begins in early adolescence when youth first experience conflicts around their sexual orientation. It initially serves the functional purposes of (1) reducing the pain and anxiety of external conflicts and (2) reducing the internal inhibitions of homosexual feelings and behavior." (Gibson, p. 113)

One study concluded that there may be a higher rate of substance abuse among gay youth than among gay adults. (Gibson, 1989) In a small study of gay or bisexual male adolescents ages 15-19, 58 percent regularly abused substances. (Center for Population Options, 1992) In a study of gay and lesbian adolescents in New York City, 68 percent of young gay men reported alcohol use (with 26 percent using alcohol once or more per week), and 44 percent reported drug use (with 8 percent considering themselves drug dependent). Among young lesbians, 83 percent had used alcohol, 56 percent had used drugs and 11 percent had used crack or cocaine in the three months preceding the study. (Rosario, 1992) Another study of Hispanic and Black gay and bisexual males in New York City showed lifetime alcohol (76 percent), marijuana (42 percent) and cocaine/crack (25 percent) use; none reported intravenous drug use. Furthermore, current alcohol and drug use was significantly related to sexual risk acts. Substance use in this study was higher than among male adolescents in a 1991 national household survey. The greater use may reflect the high stress reported by gay and bisexual male youths, particularly stressors associated with their sexual orientation. (Rotheram-Borus, 1991) As one would predict, gay youth forced to live on the streets experienced more severe drug problems.

Mental Health Issues

The concept of internalized homophobia as discussed in the context of the mental health of the general gay and lesbian population has particular implications for adolescents:

"Children who will eventually be bisexual or homosexual often develop an awareness of being different at an early point in their lives. They may not understand the sexual nature or the precise meaning of their differentness, but they quickly learn that it is negatively regarded. As these young people develop and mature, they reach a fuller understanding of the nature of their differentness and the negative societal reaction to it....Negative feelings about a part of one's self (i.e. sexual orientation) may be overgeneralized to encompass the entire self. (Gonsiorek, p. 117)

Furthermore, "youth who have a growing awareness of gay or lesbian orientation become painfully aware that they do not fit the 'social script'. They see the hostility directed toward homosexuals by others and hear taunts of 'dyke' and 'faggot' used indiscriminately by peers." (Gonsiorek, p. 117) As the adolescent becomes more aware of his or her homosexuality and the stigma associated with it, he can choose to deny his orientation, hide his orientation or accept his orientation. Each choice has significant mental health consequences. For the individuals who choose to hide a gay or lesbian identity, usually in response to witnessing or being subjected to negative treatment of homosexuality by their peers, the "pain and loneliness of hiding often causes.....serious harm to their mental health and social development." (Gibson, p. 119) "More often than other adolescents, they feel totally alone, often suffering from chronic depression, despairing of life that will always be as painful and hard as the present one." (Gibson, p. 113) These youths often suffer their fears in silence:

They are unknown victims of scapegoating with every homophobic assault or remark they witness. They live in perpetual fear that their secret will be discovered. Gay youth become increasingly afraid to associate with others and withdrawn socially in an effort to avoid what they perceive as a growing number of dangerous situations. (Gibson, p. 119)

"Consequently, many gay and lesbian youth may avoid the normal interpersonal experimentation that is so much a part of adolescence...The suppression and repression of same-sex desires and interests is often accomplished at the expense of normal adolescent interpersonal skill development." (Gonsiorek, p. 118) The result of rejection and abuse in all areas of their lives is devastating for these lesbian and gay youth. "When you have been told that you are sick, bad and wrong for being who you are, you begin to believe it." (Gibson, p. 113)

Suicide

Many experts believe that suicide is the leading cause of death among gay male and lesbian youth. (Gibson, 1989; Center for Population Options, 1992) They are two to three times more likely to attempt suicide than their heterosexual peers and may comprise as many as 30 percent of suicides among youth annually. In a study of 137 gay and bisexual males, ages 14-21, 29 percent reported a suicide attempt; half of those reported multiple attempts. Almost one-third made their first suicide attempt in the same year that they identified themselves as bisexual or homosexual. One survey found that 58 percent of gay males and 33 percent of lesbians surveyed believed their suicide attempts involved their homosexuality. Another survey supports these figures, finding that 58 percent of gay males and 39 percent of lesbians felt their first suicide attempts were related to the fact that they were homosexuals. (Gibson, 1989) Two-thirds of randomly sampled U.S. psychiatrists believed that the suicidal acts of homosexual adolescents were more serious and more lethal than those of their heterosexual peers." (Center for Population Options, 1992)

The risk factors predisposing gay youth to suicide have been extensively researched and warrant discussion. Social attitudes are themselves perhaps the greatest risk factor in youth suicide: "Gay and lesbian youth are strongly affected by the negative attitudes and hostile responses of society to homosexuality. The resulting poor self-esteem, depression, and fear can be a fatal blow to a fragile identity." (Gibson, p. 126) Rosario et al. (1994) found that 29% of gay and bisexual male youth in two non-psychiatric cohorts reported having attempted suicide. Another factor that predisposes gay youth to suicide is poor self-esteem, particularly in those who have "internalized a harshly negative image of being bad and wrong from society, religion, family and peers." (Gibson, p. 126) Family rejection is an extremely significant factor in youth suicide. An anticipated negative reaction from one's family by those individuals who have hidden their homosexuality often precipitates a suicide attempt. (Hammelman, 1993) A survey conducted at the Hetrick-Martin Institute in New York City found that among those youth rejected by their families, 44% had suicidal ideation, and that 41% of the young lesbians and 34% of the young men had attempted suicide. (Hunter, 1990) Religion acts as another possible risk factor, because of the depiction of homosexuality as a sin in many religious traditions and the reliance of many families on the church for understanding homosexuality. School may also act as a risk factor; gay and lesbian youth (like others) have a compulsory obligation to attend, but they also have an inability to defend themselves against assaults and are often not protected by staff. Social isolation, as previously described, is a particularly important risk factor for lesbians and gay men, who often report a total lack of contact with others like themselves during high school. Finally, substance abuse has also been correlated to suicide attempts among gay young people.

A suicide attempt can be a final cry for help by gay youth in their home community. (Gibson, 1989) If the attempt goes ignored or is received with hostility, the youth may prepare to leave that community and venture into larger cities in hopes of finding more accepting friends and families. In actuality, living on the streets enters the youth into further outcast status that increases the risk of suicide. The struggle for survival on the streets becomes the "fulfillment of a 'suicidal script' which sees them engaging in increasingly self-destructive behaviors including unsafe sexual activity and intravenous drug use. Overwhelmed by the complexities of street life and feeling they have reached the 'wrong end of the rainbow,' a suicide attempt may result." (Gibson, p. 114)

Violence

In a study conducted by the National Gay and Lesbian Task Force, 45 percent of the gay men and 20 percent of the lesbians surveyed had been victims of verbal and physical assaults in secondary school because of their sexual orientation. Twenty-eight per cent of these youths were forced to drop out of school because of harassment resulting from their sexual orientation. Another study of 500 New York City youths showed that 40 percent had experienced a violent physical attack. Forty-six percent of those reporting physical assaults believed that the assault was gay-related. Case reports from this study demonstrate that societal attitudes and discriminatory practices are at the root of violence toward lesbians and gay males. (Hunter, 1990) This violence is not limited to schools or the street; sixty-one percent of the gay related violence occurred in the family. (Center for Population Options, 1992)

Increased Risk for HIV

AIDS is the sixth leading cause of death among 15 to 24 year olds in the United States. Among young men, HIV is particularly concentrated among those who have sex with men, whether or not they identify as gay; the MSM transmission route accounts for nearly 75% of infections among young men. (Rosenberg, 1995, National Cancer Institute, 1995)

The NYCDOH AIDS Surveillance report shows that as of December 31, 1996, 23 percent of the cumulative adolescent (ages 13-19) AIDS cases in New York City were among men who had sex with other men, some of whom were also injection drug users. Previous studies have linked homosexual/bisexual behavior to 38 percent of all AIDS cases among adolescents. (Rotheram-Borus 1991) One agency serving gay youths in New York City, estimated that approximately 10 percent to 15 percent of the youth had tested seropositive, and another study found that 45 percent of young gay males interviewed had a history of STDs.

A recent study, mentioned above, looked at HIV seroprevalence among a sample of 15 to 22 year old New York City men who have sex with men who frequent a range of gay-identified public venues. This study found an overall seroprevalence rate of 12 percent among this group. Seroprevalence was higher among men of color: 18 percent of African American men in the study were HIV-infected, as were 9 percent of the Latino men, compared to 3 percent of the white men. The study found high rates of unprotected anal sex, and also found that 2/3 of the men studied reported having also had sex with women. (NYCDOH, January 1999).

Gay and lesbian adolescents are at great risk for acquiring STDs and HIV for a variety of reasons. First, not only is this age a period of sexual exploration and experimentation, but it is also a time when the individual may feel invincible and thus more likely to take risks. Risk-taking may embrace both unsafe sex and substance abuse, both of which put one at a greater risk for STDs and HIV transmission. Low self-esteem often makes negotiating safer sex more difficult. For those who are living on the streets, having to exchange sex for money is a way of life and a means to survival. Denial of their sexual identity may also cause youth to take risks. The sexual partners of gay male adolescents include adult homosexual men, a group with a high prevalence of HIV infection. Young adult gay men are more likely to engage in risky sexual behaviors than are older gay men.

There is a growing racial disparity in the AIDS epidemic among youth both on the national level as well as locally. Male African American and Latino youths who have engaged in homosexual activity are at even greater risk for HIV infection than their white peers. (Collins, 1997) A study examining lifetime and current sexual and substance use behaviors among 131 predominantly Hispanic and Black gay and bisexual males in New York City showed that 80% of these youth engaged in anal sex with other men, and 22 percent bartered sex for money or drugs. Condoms with male partners were never or inconsistently used by 52 percent of youths. (Rotheram-Borus, 1991)

Legal Barriers to Health Care

Lesbian and gay youth who are estranged from their families, or are living independently for other reasons, often encounter legal barriers to the receipt of benefits and entitlements, or to the provision of health care. New York State law has provided that youth over the age of 16 who live separate and apart from their parents, and are not in receipt of or need for foster care, are legally eligible for income support through the Home Relief program (now replaced by new State welfare programs), and for the Medicaid coverage that accompanies such eligibility (N.Y. Code of Rules and Regulations, Title 18, Section 370.2(d)(1)). In practice, however, providers report that youth under age 18 are often denied income benefits and Medicaid. Because most youth 16 to 18 are assumed to be either living with their families or in foster care under the custody of the Administration for Children's Services, the income maintenance program is often reluctant to acknowledge those youth (a disproportionate number of whom are lesbian or gay) who do not fall into either category. New York State law, unlike that of some other states, does not provide a specific procedure for establishing "emancipated minor" status, that would clarify an adolescent's independent right to receive benefits and services. Under recent welfare changes, an adolescent girl with a child cannot get family support unless she is living with her parent.

A related problem has to do with access to medical care in general. Some medical providers are reported to be reluctant to treat adolescents under 18, because of uncertainty about whether patients of this age have the legal right to consent to health care on their own behalf. New York State law provides that individuals under 18 may consent to their own health care only if the physician treating them believes that an emergency exists creating an immediate need for care, and risk to the patient's life or health if treatment is delayed. (N.Y. Public Health Law Section 2504) Providers faced with making this determination, or unaware of the details of this legal provision, may therefore fear opening themselves to liability for providing care to a patient under 18 without parental consent.

With the overall increase in incarceration in the U.S. there are growing numbers of gay, lesbian, bisexual and transgender youth in the justice system. There is little data kept on the specific issues, needs, demographics, recidivism rates and rehabilitation activities of gay, lesbian, or transgendered youth in the justice system. Organizations like the Anti-Violence Project, or homeless youth programs like Safespace, Inc., have anecdotal information indicating a broad range of complex issues, involving employment, disease transmission, basic health, substance use and community involvement.

Older Lesbians and Gay Men

Estimates of the number of older gay men and lesbians range from 3 to 10 percent of the elderly population. (Peterson, 1996) This would translate into approximately 28,000 and 94,000 gay men and lesbians over the age of 65 in New York City, probably an unduly low range given the higher proportion of gay men and lesbians in the City than throughout the country as a whole. "Less is know about their needs and concerns than any other population of lesbians and gay men." (Ryan and Brodman, p. 14) Because many older gay men and lesbians fear disclosure and thus choose to conceal their identity, it is difficult to assess the needs of this population. However, like gay youth, they have less access to lesbian and gay services, often encountering discrimination when they seek health and long-term care services, and are often assumed to be heterosexual by providers. (Peterson, 1996)

Isolation and lack of mobility can be problems for all senior citizens. Since so many lesbians and gay men have migrated to New York City from hometowns elsewhere, they often find themselves aging without the traditional support of family and community. Many gay seniors do not have children to visit them or to transport them to social activities, doctor's appointments, shopping and other necessary activities. And those who have lived their lives as closeted individuals in more repressive times may find themselves isolated later in life, lacking the other networks of friends and acquaintances that many people acquire through their work, participation in community organizations, and the like. For those individuals who have been open about their sexuality, many still have experienced prior oppression and thus find it difficult to seek out trusting individuals in the medical and psychiatric fields.

Isolation and concomitant depression are thus major issues for lesbian and gay seniors, but they often go unrecognized. Many lesbians and gay seniors do not feel comfortable utilizing mainstream services or programs for seniors, and when they do, many do not disclose their sexual orientation. Older gay men and lesbians (particularly those who are closeted) are at a greater risk for social isolation when their peer group or partners die. Nevertheless, as a group they report high level of life satisfaction and are less likely to use mental health services than younger lesbians and gay men. (Ryan and Brodman, p. 14)

Like other seniors, lesbians and gay men will see a reduction in income upon retirement and thus possible reduction in access to care. "For older lesbians and gay men who have lifelong income disadvantages including lack of employee or survivor benefits, tax or inheritance rights, and who may have worked in marginalized lower income jobs, ability to pay for care is a primary concern." (Ryan and Brodman, p. 14) Older Americans in general are the heaviest users of health services: four out of five people over age 65 have at least one chronic condition that requires care; many, particularly women, have more than one. Gay and lesbian seniors are no exception. They remain a subset of the older population and are thus at greater risk for heart attacks, cancer and strokes. Unlike other older individuals, however, gay and lesbians fear discrimination in health care, housing and long term care. "[F]ew services even consider that clients might be lesbian and gay, much less have a life partner of 40 or 50 years." (Ryan and Brodman, p. 15)

Older gay men and lesbians are particularly confronted with the need to take legal precautionary measures to assure that their partners are included in decision making in the case of medical emergencies, and to assure that any property and financial assets are properly distributed in the event of their death.

Immigrants

Approximately 2.2 million New York City residents are foreign-born, according to New York City's Department of City Planning. Most of the immigrants in the City hail from the Caribbean, Latin America and Asia. As a proxy indicator of the countries of origin of gay men in New York City, we can look at the country of origin of MSM AIDS cases in the City. NYCDOH reports that as of December 31, 1996, there were 4,248 cumulative non-US born adult AIDS cases who were MSM, or MSM and IDU. The following countries had significant representation among these diagnosed AIDS cases: Cuba (10.6%), Colombia (7.8%), Dominican Republic (6.3%), Jamaica (4.4%), Haiti (4.1%), Ecuador (4.1%), Brazil (3.7%), Mexico (3.2%), Trinidad and Tobago (2.6%), Argentina (2.1%), Panama (2.0%), Germany (1.7%), Guyana (1.6%), Philippines (1.6%), Honduras (1.5%).

Immigrants are confronted with both legal and cultural barriers to accessing needed health services, regardless of their sexual orientation. Men and women who are gay or lesbian have these problems compounded by the possibility of closely-knit, family-centered immigrant networks that may not be accepting of their sexual orientation, coupled with lack of connection with gay or lesbian community services.

Specific legal challenges in receiving services include barriers to legal employment (with associated health insurance benefits), barriers to obtaining citizenship or other legal status due to HIV infection, and barriers to eligibility for public benefits for some immigrants under the new immigration and welfare laws. Federal legislation implemented in 1988 requires all employers to document proof of citizenship or other legal immigration status before employment may be offered. This requirement has served as a barrier to any possibility that undocumented people will have employment-based health insurance.

The legal barrier that most directly affects access to benefits and services for many immigrant men who have sex with men is the HIV exclusion in United States immigration law. Immigration law generally bars individuals who are HIV-infected from becoming permanent residents, citizens, or otherwise upgrading their immigration status. As a consequence, many HIV-infected immigrants are unable to obtain legal status, and must remain undocumented and with limited access to benefits and health care. "Those immigrants who become HIV infected after [they] acquire permanent residency status may not seek help because they fear it will affect their applications for citizenship. The undocumented who are HIV infected may not seek help because they know that their serostatus excludes them from obtaining permanent residency." (Interim HIV/AIDS Strategic Plan, pp. 85-86)

The cultural barriers to accessing health services for gay and lesbian immigrants are often nationality-specific, but several generalizations are possible. Language differences represent significant barriers to learning where services are available and to communicating with health care providers. Particularly for smaller ethnic groups, these barriers are addressed by community use of one or two providers located within an immigrant neighborhood who either speak the language or, often, employ staff members who do and who may serve as interpreters. Another common solution is an informal (usually self-appointed) community interpreter who accompanies people to appointments. However, these solutions pose significant problems for anyone interested in maintaining privacy in the health care setting. Obviously, such communication arrangements are inconsistent, complicating the task of discussing sensitive subjects like sexual orientation, sexually transmitted diseases, substance use, domestic (or other violence) or mental health issues.

Immigrants who seek health care services outside of their ethnic communities can be confronted with lack of cultural understanding or sensitivity, leading to discomfort about disrobing in front of practitioners of the opposite sex and physical examinations, and misunderstandings about the meanings of diagnoses and prescribed regimens. Therefore, leaving the neighborhood to seek lesbian or gay-sensitive services requires immigrants to confront agencies and providers who may lack cultural understanding or competency.

Transgender Individuals

The transgender community has long historical associations with the lesbian and gay communities, particularly around the shared concern with gender expectations and norms. Transgender is an umbrella term used to refer to a range of people who dress and/or live in a gender different than the one assigned at birth. The trans community includes transsexuals, drag people, cross dressers, and gender variants.(Namasti, 1995) However, within that identity, members of the trans community are widely diverse with regard to gender expression, identity, and lifestyle. And, as Roz Blumenstein, director of the Gender Identity Project, explained in a June 25, 1997 interview, "The trans community is a spectrum, and many of us are not at all gay in our sexual orientation. I'll be marching in the gay pride parade with a sign reading 'queer straight woman.'" Barbara Warren, Director of Project Connect, the major provider of mental health and substance use services for the trans community in New York City, emphasizes that there is enormous variation within these identities, and that they include people whose birth gender is male, female, and inter-sexed; people whose sexual orientation is gay, straight, or bi-; and some people who seek to alter their bodies surgically and others who do not.

Transsexuals feel they were born into bodies that do not match their internal gender identity. Some choose to live as their true gender without altering their bodies, and others make alterations ranging from reversible hormone therapy to plastic surgery and sex reassignment surgery. Health issues particular to this group surround access to body altering treatments for which third party coverage is frequently not available, and which many providers are reluctant to offer. (Namasti, 1995)

People who "do drag" include pre-operative transsexuals, gay men and lesbians, straight men and women, and people who do drag as theater or for inclusion in the complex house social scene. Cross dressers are typically heterosexual, and frequently are middle class married men. Gender variants include the most diverse people, ranging from people who were born inter-sexed to people who consider themselves bi-gendered or gender neutral.

The salient health issues affecting members of the trans community are caused directly or indirectly by alienation and lack of acceptance by either "straight" society or the lesbian and gay community. Obviously, this lack of acceptance also makes the identification of appropriate services very difficult. Based on descriptions of service providers offering primary health care, substance abuse and mental health services to the trans population, as well as a national study of transgender violence (GenderPAC, 1997), major health issues for members of the trans community include violence; mental health and substance use issues; difficulties accessing sexual reassignment surgery,hormone therapy, and plastic surgery; HIV and other STDs; and the need for basic primary health care. According to Barbara Warren, another major health issue is the employment discrimination that makes survival challenging for members of the trans community, and leaves many of its members dependent on sex work for income.

Until recently, violence against transgendered people has been anecdotally reported and occasionally headlined following sensational murders. In 1997, GenderPAC, a group of transgendered people, released the results of a national survey on violence. The report was based on a national survey distributed through networks and conferences of the trans community and on the Internet; its authors acknowledge that its sample is neither representative nor random. However, its stark findings lend support to its authors' arguments for further study of transgender violence, for inclusion of transgender violence on state and federal hate crimes registries, and for further training for health care providers and law enforcement officials on violence against members of the transgender community.

Almost sixty percent of the 402 survey respondents report having been a victim of harassment or violence over the course of their lifetime. One quarter of these incidents resulted in injury, and while only 30% of these ended in medical attention, the health care implications go far beyond this number. (GenderPAC, p.23) First, for one-third of the approximately 100 violent incidents resulting in injury, the report states that health care was "needed but not received." This suggests access barriers to needed health services. Secondly, the study found a systematic relationship between being poor and experiencing economic discrimination and experiencing violence. This suggests that the access barriers are partly economic. Third, frequent incidents of harassment and violence are just one expression of what members of the trans community see as patterns of discrimination and non-acceptance by the rest of society. Such ubiquitous condemnation takes its toll in other ways.

Warren (1997) reports that among the clients attending the Gender Identity Project in New York City, there are high rates of substance abuse: 20% report alcohol abuse; 45% report other drug abuse; and 10% report injection of heroin or cocaine. In addition, this project reports that many clients seek mental health counseling services, but most therapists continue to view many expressions of transgender behavior in terms of psychopathology. Despite need for both substance abuse treatment services and mental health services, Warren reported that there are only two community-based providers and a small number of therapists in private practice with whom members of the transgender community feel comfortable.

Members of the transgender community report barriers to accessing body altering drugs and procedures. Both public and private payors view all such procedures as "elective" and do not reimburse for them. A limited number of providers are willing to prescribe them. In addition, clients described providers' refusal to provide either hormones or surgery to people with HIV, even when there is no reason to believe they are medically contra-indicated. As a result of these barriers, clients report extensive use of "black market" hormones, with attendant risks of poor quality or contamination, lack of appropriate dosing, lack of medical oversight, and use of shared needles (and of transmission of blood borne diseases, including HIV and hepatitis).

Some members of the trans community are at particular risk for HIV, as has been documented in non-New York studies (Galli et al, 1991; Gattari et al, 1992, cited in Warren, 1997) Reasons for this heightened risk posited by Warren and Blumenstein include frequent involvement in sex work, both because economic discrimination precludes other employment and to raise money for non-reimbursed treatments; complex patterns of sexual behavior that may include sexual activities in dissociative states that make condom use difficult; and ambivalent relationship to male genitalia impeding condom use.

Barrier's to Health Care

Many New Yorkers, gay men and lesbians included, confront challenges in obtaining the health care they need, challenges such as lack of insurance, underfinanced health care infrastructure in many poorer neighborhoods, and insensitivity of providers or health care delivery systems to their particular health care needs. In addition to patterns of morbidity and mortality that are at variance with those of the general population, lesbians, gay men, bisexuals and transgendered individuals often face access barriers to health care that are distinct from those faced by other New Yorkers. This section discusses the factors that make it particularly difficult for lesbians and gay men to receive appropriate, adequate, or culturally-sensitive health care.

Societal Homophobia

Many Americans have historically disapproved of same-sex relationships, and homophobia remains omnipresent today. Defined by Communication Technologies as "the most common way of describing the cluster of stereotypical beliefs, prejudicial attitudes, animosity, and discomfort held by most heterosexuals in our society in reference to gay men, lesbians and bisexuals," American society has internalized homophobia at a variety of levels. It can manifest itself through outright discrimination in employment, housing or services; in opposition to legal protections for the equality of gays and lesbians; in fear of gays in the workplace; in the widespread view (particularly earlier in the epidemic) that AIDS was a "gay man's disease"; or even in violence. The literature review conducted by Herek and Cogan describes homophobia as being "pervasive throughout American society, observable in personal attitudes and public and private institutions, and reinforced by legal statutes." (p. 6) This is supported by Public Media Center's findings that "three different nationwide polls conducted in 1993 and 1994 showed roughly one-half to two-thirds of all Americans still condemn homosexuality or homosexual behavior as morally wrong or a sin, and that only one-third of adults view homosexuality as an acceptable lifestyle." (p. 29)

Despite increased visibility and attention to the gay and lesbian populations, it is not clear how much homophobic attitudes have waned over the last decade. The Public Media Center reports that "a growing number of Americans disapprove of laws that legalize homosexual relations between consenting adults, with 48% of respondents to a 1993 poll stating that they did not approve of such legalization, versus only 39% who had disapproved of decriminalization in 1982." (p. 29) Furthermore, "twenty-five percent of respondents to one nationwide survey said that they would 'strongly object' to having people who are homosexual at their workplace, and another 27% stated that they would prefer not to have them there." (p. 29)

Unlike racial and religious minorities, discrimination and intolerance are "officially condoned by government, religious and social institutions." (Ryan and Bogard, 1994) And, it is not simply laypeople or the uneducated who have internalized homophobia. Until 1973, the medical profession considered homosexuality a mental disorder; it was listed as such in the American Psychiatric Association's Diagnostic and Statistic Manual of Mental Disorders (DSM).

The results of Krieger and Sidney's study on the prevalence and health implications of anti-gay discrimination experienced by black and white men and women participating in a multisite longitudinal study of cardiovascular risk factors demonstrate the pervasiveness of homophobia and its impact. Of the 204 participants in Kreiger and Sidney's study indicating that they have had at least one same-sex partner, approximately one-third of the black men and women and more than one-half of the white men and women reported having experienced discrimination based on sexual orientation. (Krieger and Sidney, 1997)

Lack of Appropriate Providers

There are very few health care providers who target their services to gay and lesbian populations in New York City. In fact, only a single agency, the Callen-Lorde Community Health Center, is "dedicated to meeting the specific primary health care needs of lesbians and gays," and Callen-Lorde reports that it is the only Article 28 (state-licensed) facility of that type. According to Callen-Lorde, "[I]n the absence of accessible primary and preventive health care services, the sexual minority community find itself confronted, more often than other minority populations, with medical problems such as STDs, HIV/AIDS, hepatitis A, B, and C, chemical dependency, stress and related illnesses caused by discrimination, psychologic pathologies, increased incidence of suicide, and elevated incidence of later stage cancers of the breast, cervix, endometria, ovaries and colon." (Callen-Lorde Community Health Center, CON Application, Sec. 5)

The New York State Lesbian and Gay Health and Human Services Network was recently formed to represent health and social service agencies throughout New York State that (1) target their services to the gay and lesbian community, and (2) receive public funding to support their work. Of the Network's 23 members, 14 are organizations located in New York City. The majority of these organizations provide social support services, rather than licensed mental health, substance abuse or primary care services. Only one member agency — Callen-Lorde, located in Manhattan — provides primary care services. Two agencies provide substance abuse services, primarily in the form of counseling. Three agencies offer some form of mental health services. (Empire State Pride Agenda Foundation, 1996)

A primary reason for the paucity of services in the lesbian and gay community is a simple lack of targeted funding. Much of the public and private funding that has gone to organizations serving the lesbian and gay community has been targeted to HIV/AIDS programs, admittedly a critical need. In 1996, the Empire State Pride Agenda Foundation, which conducts research and public policy on gay and lesbian issues in New York State, surveyed the funding profiles of gay and lesbian service organizations throughout the State. It concluded: "Public funding . . . for the few community services programs that do exist around the state has been virtually non-existent." (Empire State Pride Agenda Foundation, p. 1) In the 1997-98 State budget, funding for gay and lesbian services was specifically provided for the first time. Limited State funding has been supplemented by financial support from New York City for a range of gay and lesbian service organizations. However, there has not yet been a systematic assessment to determine whether existing funding is adequate and appropriately targeted to meet the needs of the community.

Private funding has been similarly limited. Foundations have been slow to incorporate gay and lesbian services into their grantmaking. Of 6,334 foundations listed in the 1993 nationwide Foundation Directory, only 13 reported having given grants to lesbian and gay projects. (Working Group on Funding Lesbian and Gay Issues 1994, p. 5) The 1993 directory of the New York Regional Association of Grantmakers listed only seven foundations for which lesbian and gay issues are a funding priority. "Lesbian and gay organizations also receive very little corporate foundation support." (Carlson, p. 8). The demands of the AIDS epidemic have also limited the ability of individual donors to support non-AIDS related gay service organizations.

The lack of gay-oriented and experienced providers has tangible consequences for health care access. A striking example relates to receipt of Papanicolaou (Pap) smears by lesbians. The Pap smear is a routine, preventative measure used in the early detection of cervical cancer. Statistics invariably show that lesbians have a significantly longer interval between screenings, if they have the test performed at all. "The interval varies with the subpopulation studied and has been reported to average 21 to 34 months for lesbians, compared with an average of 8 to 9 months for heterosexuals. Twenty-three percent of lesbians in one sample had not had a Pap smear in more than 5 years, and 8 percent had never had one." (Rankow, p. 487) According to the largest national study of lesbian health concerns, one out of 20 lesbians over age 55 has never had a Pap smear. Rates were higher among African-American lesbians than among whites. (Ryan and Bogard, p. 11) Fifty percent of women seeking care at CHP's Lesbian Health Project report not having had a Pap smear in over 5 years. (Callen-Lorde Community Health Center CON Application, Sec. 4)

Rankow reports that some lesbians have been told, upon disclosing their sexual orientation to health care providers, that they do not need pelvic examinations or cytological screening because they are not at risk for STDs or cervical cancer. The risk factors for cervical cancer include early age of first coitus, multiple sex partners, history of STDs, and infection with certain strains of human papilloma virus. "In fact, 75 percent to 90 percent of lesbians report having had heterosexual activity, and many report a history of multiple male partners. Most commonly, this activity has occurred during younger years and thus conveys more significant risk." (Rankow, p. 488)

Even when services are theoretically available, they are often either culturally inappropriate or are provided by staff who lack knowledge and education about the group most in need of services. In a city-wide survey of health and social service agencies (including medical centers) that serve the elderly, Ryan and Brodman found that not one provided specialized services or outreach or had staff with knowledge or sensitivity to the needs of lesbians and gay men. (Ryan and Brodman, p. 15) The Community Health Project has noted that many facilities "tend to ignore or are hostile toward the very real needs and concerns of this population. These are needs and concerns which go directly to the core of the patient-provider relationship — concerns over trust, privacy and open communication — whose absence often results in non-compliance, improper diagnosis or treatment, or patients lost to follow-up." (Callen-Lorde Community Health Center DOH Application, p. 2) Clearly, access is even more problematic for gay and lesbian members of minority communities, who must also face biases based upon race, class, gender and age, as well as language barriers.

Mainstream service providers may be unable to properly diagnose or respond to the emotional problems experienced by gay seniors, or to create an atmosphere in which issues relating to lesbian or gay self-identity can be disclosed and discussed. And, because older individuals in general are not seen as sexual, these individuals are often not questioned about their sexual orientation or activity. Instead, "older lesbians are likely to be 'invisible,' assumed to be widows of heterosexual marriages or 'old maids.'" (Rankow, p. 490) Also, some researchers believe there is a widespread lack of knowledge regarding the issues faced by lesbian and gay youth. (Peterson, pp. 10-11) Most providers assume that adolescents are heterosexual and treat them as such. Warren emphasized the need for primary health care for the transgendered community that is sensitive to their needs and issues. The Center and Positive Health Project each offer such services, but there are none located outside of lower Manhattan, and trans people report extreme discomfort in either "mainstream" or most gay and lesbian health care settings.

The bulk of programs and services available for gays and lesbians are centered in lower Manhattan; few exist in other boroughs or even in certain Manhattan neighborhoods. More than half of those in Manhattan are located in the Greenwich Village-Soho and Chelsea-Clinton neighborhoods. While lower Manhattan neighborhoods have significant concentrations of gay residents, the Census data cited above indicated that lesbians and gay men live in all parts of the city's five boroughs. Particularly for individuals with mobility impairments or limited financial resources, geographic barriers make it difficult or impossible for them to connect with other members of the community or receive services that they need.

Homophobia, Heterosexism, and AIDS Stigma among Health Care Providers

Even when health care is available, the quality of that care can be compromised when health care providers and institutions remain homophobic and carry stigmatized meanings of homosexuality. One set of commentators report that "[d]iscrimination against lesbian and gay patients is a pervasive problem. In a recent national survey of physician attitudes toward lesbian and gay patients conducted by the American Association of Physicians for Human Rights, 9 out of 10 physicians reported observing anti-gay bias. More than two-thirds know of lesbian and gay patients who had received poor care or were denied because of their sexual orientation." (Ryan and Bogard, p. 5) Half of the 711 lesbian, gay, or bisexual physicians and medical students responding to a 1994 national survey reported "actually observing colleagues providing reduced care to patients because of sexual orientation," 88 percent recalled "hearing colleagues making disparaging remarks about lesbian, gay and bisexual patients," and 67 percent knew of "lesbian, gay or bisexual patients who had received substandard care or been denied care because of their sexual orientation." (Krieger and Sidney, 1997)

Typical examples of homophobic provider behavior in the literature include the dismissal by a physician of a gay man experiencing impotency, and of the refusal of a physician to complete the physical exam of a woman who discloses her lesbianism. (Peterson, p. xvii) Provider assumptions of heterosexuality are also quite common. The expectation or reality of such treatment can lead lesbians and gay men to seek health care less frequently, or to withhold pertinent information from the physician or other provider. Not only may misdiagnoses and failure to provide patient education result, but the development of a trusting provider-patient relationship is severely hindered. These attitudes may become extremely problematic: "as a result of negative experiences with providers, many lesbians and gay men delay seeking care until health problems become serious or chronic." (Ryan and Bogard, p. 5)

Many lesbians particularly fear and mistrust a hostile medical environment. The National Lesbian Health Care Survey, completed in 1985, indicated that lack of trust and bad experiences with medical personnel were among the reasons lesbians did not have a physician providing ob-gyn care. (Rounds, 1993) In a San Diego Study in which physicians were given a test that measured their homophobia, gynecologists scored among the worst, with 31 percent testing as homophobic. A particular problem exists for the increasing number of lesbian couples who want to start a family and seek artificial insemination. They may find that "homophobia and heterosexism within the health care system deny the legitimacy of this family form." (Peterson, p. 49)

Individuals searching for assistance with a drug or alcohol problem face the additional obstacle of provider homophobia. When the Weinberg Homophobic Attitudes Scale was used on a sample of 98 alcohol and other drug abuse treatment providers, it found that 9 percent scored "homophobic" and 17 percent scored "marginally homophobic" in attitudes toward homosexuality. This percentages are "likely to be an underestimate of the rates of homophobic attitudes among providers, as some providers declined to participate in the survey and expressed the belief that their personal attitudes toward homosexuality were irrelevant to the quality of care they provided to homosexual clients. Homophobic attitudes among alcohol and other drug abuse counselors reflect a negative bias, lack of expertise, and inappropriate interventions with lesbians and gay men in psychotherapy." (Paul et al., p. 154) As a result, "clients entering treatment are dealing with shame and fear of being rejected, not only for their alcoholism, but also for their homosexuality." (Paul et al., p. 156)

Therapists and counselors are often no exception to this prevalent homophobia, and mental health treatment can be hindered or even rendered counterproductive. "Studies of gay men have indicated that many report a history of nonacceptance, prejudice, and a lack of understanding in their encounters with counselors and psychotherapists." (Paul et al., p. 156) The therapist's values and biases inevitably emerge and influence the process of treatment. (Paul et al., p. 156)

One response to provider homophobia is the incorporation of gay and lesbian issues into the curricula of health care training programs. In 1992, the NYCDOH Office of Gay and Lesbian Health Concerns, surveyed medical, nursing and social work schools in the New York City area. None of the medical schools surveyed offer specialized courses on gay, lesbian or bisexual health issues, although one of the five schools reported requiring that these issues be integrated into the overall curriculum. Two out of four nursing schools, and one of five social work schools, reported specialized courses on gay and lesbian health issues. (NYCDOH Office of Gay and Lesbian Health, pp. 1-4)

Fear of Disclosure of Sexual Orientation

Due to these pervasive heterosexist and homophobic attitudes, many gay men and lesbians fear disclosing their sexual orientation when seeking health care services. About 40 percent of a group of 424 bisexuals and 1,921 lesbians surveyed in the mid-1980s believed that physician knowledge about their sexual preferences would hinder the quality of medical care. Approximately one-third had not disclosed their sexual behavior although they desired to do so. (Smith et al., 1985) Fewer than ten percent of the sample had ever been asked about sexual preference.

A lesbian or gay client seeking services in a health or mental health setting must decide initially whether to reveal his or her sexual orientation or gender identity to program personnel. Intake and assessment forms used by most organizations do not provide opportunities for simple disclosure. The client is faced with determining if is safe to 'come out' to the provider and discuss sexual orientation or gender identity. Whether or not one 'comes out' depends on both a willingness to disclose, and a perception that the environment and the people in it are not homophobic. "Because issues of gender, sexuality and identity are central to one's health and mental health, the failure to reveal accurate facts can negatively affect treatment outcomes...For gay people [who have a] psychiatric illness, participation in a treatment milieu often necessitates the suppression of sexual identity, so that some limited sense of belonging can be experienced." (Lesbian, Gay, Bisexual and Transgender, p. 2)

The reluctance to disclose can be exacerbated for particular groups or in particular situations. Pre- and post-operative transgender individuals will often not attend traditional mental health clinics for fear of being humiliated about their status. (Lesbian, Gay, Bisexual and Transgender, p. 2) Victims of hate crimes often do not tell treating physicians how the injuries occur because they fear secondary victimization. (Cotton, 1992) "Physicians may also convey an insensitivity that will make victims of antigay violence less likely to reveal their sexual orientation...Gay and lesbian patients may worry that physicians will 'treat them badly' because they are homosexual 'or that this may get on their medical chart which could have a lot of negative implications for them in the future.'" (Cotton, p. 2999) Secondary victimization is a common reason that individuals choose not to report hate-crimes to the police. Comstock's 1989 study found that 67 percent of those who had declined to report had experienced or perceived the police to be anti-gay; 14 percent feared abuse from police; and 40 percent feared public disclosure of their sexual orientation. (Berrill and Herek, 1992)

Entering a substance abuse treatment facility takes great courage for anyone and has its own set of stigmas attached to it. To avoid the pain and shame of multiple stigmas, a gay man or lesbian seeking such treatment may feel compelled to hide their sexual identity. "If fear of negative reactions from either treatment staff or other recovering clients does not prevent gay alcoholics from entering treatment, it may pressure them to conceal their sexual orientation." (Paul et al., p. 156) "For example, many individuals entering Pride Institute — a gay-specific, inpatient alcohol and other drug abuse treatment center in Eden Prairie, Minnesota, with patients from across the United States — reported never having talked about issues related to their sexual orientation in prior inpatient treatment."

Lack of Recognition of Relationships

In general, the laws governing health care, property distribution and personal medical decision making reflect distinctions between gay and straight relationships and families that have been characterized as heterosexist. (Peterson, 1996)

Heterosexism is the unwavering assumption that all people are heterosexual and, for purposes of the laws' treatment, share their closest personal bond with either a married spouse, or if there is no spouse, with their parents or adult children. There is no room in a heterosexist ideology for a life partner, a companion, or a close friend. In fact, it is usually assumed that unmarried adults, regardless of age, are always children under the law...An unmarried partner is a legal nonentity. (Peterson, p. 94)

In all states, including New York, lesbians and gay men cannot legally marry, and are thus generally not considered immediate family. If a gay or lesbian individual is incapacitated or otherwise unable to make his or her own medical decisions, a health provider may turn to the patient's "traditional" family members (usually parents or siblings) to determine what the patient might have wanted or what his or her specific needs may be. Generally, this consultation is at the exclusion of gay or lesbian partners. New York law does permit individuals to execute health care proxies, designating a person of their choice to make medical decisions on their behalf, but many people (both heterosexual and homosexual) fail to do so. During health crises, Ryan and Bogard explain, lesbian and gay partners can be excluded from intensive care settings, and later excluded from the care plan, even when they are the primary care-giver at home. (Ryan and Bogard, p. 11) Exclusion of a partner, especially in circumstances requiring family involvement (such as drug treatment or mental health therapy), may cause treatment to be incomplete or unsuccessful.

Lesbians and gay men face other legal barriers that can have health implications. For example, in the event that an individual becomes incapable of taking care of him or herself, a court will generally appoint a blood family member as the individual's guardian or conservator to oversee personal and financial decisions. Again, this could mean that a gay man who has been living with his partner for many years may have no impact on decision-making for health care or other matters. In the case of the death of a partner, "the law does not recognize the right of a surviving domestic partner to inherit the property of a deceased partner unless such a provision is made in the will." (Peterson, p. 104) Also, without a will nominating a domestic partner as guardian, there is less of a probability that a domestic partner will become the legal guardian of any children of the deceased partner.

Some have argued that the lack of recognition of same-sex relationships and families undermines monogamous relationships and contributes to risky sexual practices among gay men. Rotello, for example, argues that in most societies marriage has been central to social and sexual stability, and that "it is overwhelmingly clear from the anthropological record that human sexual relationships that are not recognized and validated by society are nowhere near as durable as those that are." While the argument on behalf of same-sex marriage has rarely been articulated on the basis of HIV prevention, Rotello suggests that "the legalization of same-sex marriage and the right of homosexuals to adopt and raise children would create a solid foundation upon which a sustainable gay culture could arise," a culture in which "people feel socially supported within their identities as gay men to settle down with individual partners for significant periods of time." (emphasis in original) He argues that recognition of gay relationships, for those who opt to participate in them, would likely have the same effect as it does for heterosexuals — that is, creating incentives for "a culture of sexual restraint and responsibility." (Rotello, pp. 255-57)

Lack of Insurance Coverage

Health care services received in the private sector are prohibitively expensive for most people without some form of health insurance — whether private insurance or public insurance (Medicaid or Medicare). In this country, most private health insurance is employment based, with health coverage for individual workers and their families purchased on behalf of employers for their employees. Over time, there has been a reduction in the number of people covered by their employer caused by a shift in the economy from manufacturing jobs (typically providing coverage) to service sector jobs (often without coverage); a shift from full time employees to part time and temporary employees and out sourcing to contractors; and a reduction in family coverage (or an increase in cost sharing for that coverage) as health care costs rise. Despite this trend, close to 90% of current private health insurance coverage remains employment-based. (United Hospital Fund, 1997)

Lesbians and gay men face a number of particular barriers to obtaining employment-based insurance. Most salient among these is lack of recognition of gay and lesbian family structures, meaning that most non-marital partners are not eligible for coverage as domestic partners, and dependent children are only covered if they are the biological offspring or legally adopted by the working person.

When New York City began offering domestic partnership registrations to both heterosexual and homosexual couples in 1993, it was the thirteenth municipal government in the country to do so. Since that date, thousands of couples have registered their domestic partnerships, and roughly 50 percent of these have been gay or lesbian couples. Landmark legislation proposed by Mayor Rudolph W. Giuliani and adopted by the City Council in 1998 treats registered domestic partners equally with marital spouses with regard to numerous benefits (and responsibilities) bestowed under New York City law. This legislation, however, like current practice, confers tangible advantages only upon city employees, whose partners could become eligible for health insurance coverage and other benefits. No legislation makes domestic partnership rights applicable to the city's private sector. While an increasing number of private firms have voluntarily agreed to offer domestic partnership benefits (usually consisting, at a minimum, of health insurance, family and bereavement leave) to their employees, the vast majority still do not. The private firms that attempt to offer domestic partner benefits coverage often discover that insurance companies do not make it available to employers or do so at prohibitive prices.

A second major reason that many lesbians and gay men lack employment-based coverage is that they are employed in jobs that do not provide it. Contrary to popular myths of the "affluent gay," the few studies based on representative samples of gay men and lesbians show that the average household income of gay men is comparable to or slightly lower than that of heterosexual men, and that the average household income of lesbian couples is lower than that of heterosexual couples because women on average earn less than men. (Badgett, 1997) While scientific studies of the distribution of gays and lesbians among occupational categories are only beginning, Badgett and King conducted an analysis of a nationally representative survey called the General Social Survey, which began asking questions on sexual orientation in 1989. Approximately 3% of women and 5% of men in a pool of 2152 surveys reported sex with the same gender. Analysis of the occupational choices of the "behaviorally" lesbian and gay sample reveals women more clustered in service and craft/operative occupations than their heterosexual counterparts. Gay men are more likely to be in professional/managerial jobs, clerical and sales jobs, and service jobs than their heterosexual counterparts. These categorizations are broad, and the reasons for job choices complex . They do not allow linear correlations with health insurance coverage; however, service, sales, and clerical jobs frequently have no or limited health insurance benefits.

While there are no systematic studies of the occupations of lesbians and gay men in New York City, it is the anecdotal experience of service agencies that many have part time or intermittent employment in the theater, arts, and fashion industries that draw people to New York City. So, while no quantification is possible, it is very unlikely that gay men and lesbians are under-represented in the 1.8 million uninsured New Yorkers, and probable that they are over represented.

In terms of access to public insurance, while categorical eligibility categories do not formally recognize lesbians and gay men, they do not tend to discriminate against them. Thus, economically eligible lesbians or gay men raising children qualify for public assistance benefits (formerly ADC, now Family Assistance) and Medicaid with or without a partner in the home, because a unmarried same sex partner is invisible to the eligibility regulations. Problems in public benefits eligibility concern lack of recognition of parenting relationships of partner's children, exclusion of immigrants, and lack of eligibility of adolescents for benefits independent of their families' resources (see Special Health Issues).

Policy Recommendations

Based upon the research and analysis contained in this report, there are numerous steps that could be taken to improve the general health status of lesbians and gay men in New York City, and to overcome barriers to effective health care access for that community. Some of the most significant public health recommendations towards these ends are the following:

Undertake targeted public health interventions to address the most significant health risks among lesbians and gay men.

This report has identified a number of areas in which lesbians and gay men appear to face health risks greater than those among the general public. Targeted public health interventions should be developed to enhance awareness of these issues within the community, and to expand the availability of services to respond to them. Some of the areas to be addressed include:

• Continued and expanded HIV prevention activities for gay and bisexual men, including STD prevention interventions
• Hepatitis A and B vaccination campaigns, including the widespread availability of no-cost or low-cost vaccines for these diseases
• Information campaigns about the importance of regular gynecological care, including Pap smears, for lesbians and bisexual women
• Expanded substance abuse prevention programs for gay men and lesbians
• Campaigns addressing general "wellness" issues, including antismoking, exercise, weight, etc., particularly targeted to reducing breast cancer risk among lesbians