At the time of the 1973 declassification of homosexuality as a mental illness, people joked that never in history had so many "sick" people been cured so quickly.
Forty years later, health researchers across the U.S. are still assessing the ongoing fallout of discrimination on LGBT health. Today's Supreme Court decisions striking down the Defense of Marriage Act and Proposition Eight are among the factors that continue to shape the slowly fading stigma, and build on the positive gains toward equality that are important to public health. While we are learning that most members of the LGBT community cope remarkably well, considering what many have lived through, there's also promise in several health movements that are developing evidence-based interventions to further optimize resilience.
Dr. Gregory M. Herek is a professor of psychology at the University of California at Davis and an authority on prejudice against gay men and lesbians, hate crimes, and AIDS stigma. Under the George W. Bush administration, Herek was part of the so-called "hit list" of researchers working on LGBT issues who were allegedly blacklisted by those overseeing federal funding for scientific research.
One challenge researchers face in studying LGBT people is the sheer lack of even basic data.
In marked contrast, by 2011 Herek was asked to serve on a panel for the Institute of Medicine (IOM), part of the National Academy of Sciences, which produced a groundbreaking report on LGBT health. The report, "The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding," said that a challenge in studying LGBT health is the sheer lack of even basic data: Who are they? Where do they live? What is their socioeconomic status? The IOM recommended including data on sexual and gender minorities in electronic health records as well as in the demographic information collected in federally funded surveys, just as race and ethnicity data are collected.
Merely collecting data on LGBT people represented a radical change for the federal government. "Having government-level research acknowledge the existence of sexual minorities has been incredibly controversial," said Herek. He recalled that the earliest attempt to include data on LGBT citizens, in the 1990 Hate Crimes Statistics Act, was "vehemently opposed" by rabidly anti-gay Senator Jesse Helms and his counterpart in the House, Rep. William Dannemayer. "They didn't want the numbers used by the 'gay agenda' to promote the size of the LGBT population," said Herek. "They didn't want the groups to be able to say 'here's how many of us there are.'"
A follow-up report released in January 2013 by the National Institutes of Health (NIH) LGBT Research Coordinating Committee revealed exceptionally thin NIH resources committed to investigating the well-documented health disparities among LGBT Americans -- including higher rates of alcoholism, cancer, depression, smoking, suicide, and violence.
The NIH report found that in fiscal 2010 (the most recent year for which data were available at the time of analysis) only 5 percent of the institutes' LGBT health projects were focused on alcoholism; 7.7 percent on cancer; 2.7 percent on depression; 1.4 percent on smoking and health; 1.4 percent on suicide; and 6.3 percent on violence. The overwhelming majority of projects -- 81.5 percent -- dealt with gay men and HIV/AIDS, particularly on ways to reduce HIV transmission.
The emphasis on gay men isn't entirely surprising because the HIV/AIDS epidemic, more than anything else, shined a spotlight and directed limited resources at gay men's health and the disparities that contribute to their risk for HIV. "One important thing the epidemic did," said Herek, "is actually force much of society, and the federal and state governments, to acknowledge the existence of people who are homosexual, especially gay men."
By the time effective combination drug treatment for HIV became available, starting in 1996, Boston's Fenway Community Health Center (known today as Fenway Health) had become one of the nation's leading LGBT health organizations. Its services of necessity skewed heavily to caring for gay men with HIV/AIDS. Finally in a less reactive mode to the epidemic, Dr. Kenneth H. Mayer, a Harvard professor and medical research director of the Fenway Institute, said Fenway was able to focus more resources on women's health and the medical challenges of an aging population.
Now they could work to develop interventions aimed at countering the harmful upstream psychosocial impacts of anti-gay stigma -- such as depression and substance abuse -- that can contribute to harmful downstream behavior such as unsafe sex or not adhering to HIV treatment. Such interventions, said Dr. Mayer, are particularly important for young people. "If we can identify programs that engage youth so they feel good about themselves," he said, "there will be fewer problems down the road."
Even though HIV can largely be managed by medication, and even though gay men are at heightened risk for other health challenges -- including NIH's under-investigated issues -- newer research aimed at gay men still mainly addresses HIV risk.
John A. Schneider, MD, MPH, an assistant epidemiology professor at the University of Chicago, researches networks and how to use them to create change. "After 30 years," he told me, "we are moving away from individualized behavioral interventions toward things that can integrate those components. We are looking at networks and structural things that can drive HIV." His clinical work, with largely young African-American gay men at the Grand Boulevard Clinic on Chicago's South Side, is yielding intriguing findings about how best to support those at greatest risk.
The progress that's been made in supporting gay men's health against HIV/AIDS has put the LGBT health movement back on track after the epidemic hijacked it.
For example, Dr. Schneider said, "The more men who were involved [in a young man's life], straight or gay, and in particular male kin -- fathers, brothers, male cousins -- the more protective." In another intervention, clients list the five people closest to them. Then, said Schneider, "We have engaged one, or more than one, to help the individual maintain their clinic appointments, take their medicine, and keep them engaged in their care."