Annotated Bib, post 10

Blair, Janet M., Jennifer L. Fagan, Emma L. Frazier, Ann Do, Heather Bradley, Eduardo E. Valverde, A. D. McNaghten, et al. “Behavioral and Clinical Characteristics of Persons Receiving Medical Care for HIV Infection — Medical Monitoring Project, United States, 2009.” MMWR Surveillance Summaries 63, no. 5 (June 20, 2014): 1–28.
At the end of 2009, about 864,748 persons in the U.S. (including District of Columbia and the 6 dependent areas) were living with human immunodeficiency virus (HIV). In 2005, the CDC implemented the Medical Monitoring Project (MMP) to represent data for those living with HIV.
23 areas were funded to collect data from the MMP.  Two versions of the same questionnaire were given (in English and Spanish): a standard and short version. The short questionnaire was only given if someone spoke a language other than Spanish or they were too ill for the longer interview.
603 eligible facilities in the aforementioned 23 project areas yielded 461 locations that participated in MMP. 9,338 patients were sampled from the participating facilities, but only 4,217 patients had medical record abstractions and completed the standard questionnaire. The sample of 4,217 patients is used to represent the 421,186 adults with HIV who received outpatient care during January to April of 2009. The source then refers to the 421,186 as patients.
71.2% of patients were male, 27.2% were female, and 1.6% were transgender.
Sexual orientation
Surprisingly, 50.3% were self-identified as heterosexual, following 41.4% identifying as homosexual (gay or lesbian), and 8.3% were bisexual.
41.4% of the patients were black, 34.6% were white, and 19.1% were Hispanic or Latino.
50.6% of the patients had more than a high school education.
81.1% had health coverage, between Medicaid, private health insurance, and Medicare.
9% of patients were homeless. 82.7% were born in the U.S. 43.8% of the patients’ household incomes were “at or below federal poverty guidelines.”
Depression and Substance Use
12.4% of patients had major depression, and 23.7% of patients had moderate or severe depression. Additionally, approximately 42.4% of the population smoked at the time. The estimated prevalence of alcohol use was 66.4% amongst patients. As discussed in other sources, there was a percentage of those that drank alcohol before sex: 24%.
The source indicates that depression can lead to treatment non-adherence, which can lead to death and HIV transmission risks. An HIV-infected patient with depression may also use substances, leading to risky behaviors and the probability of HIV transmission.
Sexual Behavior
47.1% of patients were men who have sex with men (MSM). 24.7% of all patients engaged in unprotected sex. About 31.8% of MSM had unprotected anal intercourse, with 13.7% having unprotected sex with a parter who’s HIV status is negative or unknown.
The source states that the prevalence of remaining risky sexual behaviors demonstrates the need to implement HIV prevention in patients’ medical care.
Met and Unmet Need for Support Services
Approximately 57.7% of patients received “HIV case management services”, but only 42% of patients received counseling on preventing the spread of HIV.
Prevention Activities
About 44.8% of patients received counseling on prevention of HIV and STDs from a healthcare provider. 54.8% of patients also received free condoms from a variety of organizations.
Those given free condoms exhibit a higher percentage of usage in condoms.
The source states that HIV-infected persons are more likely to be homosexual black men, that are also less likely to have access to promotional healthcare.
The source urges that programs and policies relating to HIV consider the multiple needs of those with HIV, because many cannot afford health coverage. The less-than-half percentage of patients counseled on prevention reveals the missed opportunities to educate more patients.
 Final Thoughts
As discussed by numerous other sources, there is a large gap of research for LGBT service members in the U.S. military. Many sources examine the information on civilian counterparts, which gave me the idea to examine the behavioral and clinical characteristics of a civilian. This source also relates to source 9, which discusses the races and factors that may play a part in infection and/or receiving care, including access to and use of health care. It also relates to previous sources in that it discusses unmet needs for supportive service. This source, like others, considers the mental and sexual health of those infected, along with drug and alcohol use.
The source does well with admitting bias and limitations, including a face-to-face interview, which can cause social response bias. Additionally, patients in the MMP have “a usual source of HIV care and are receiving medical care.” However, the source, though putting the statistics in numerical versions, had a tendency to overestimate or underestimate certain information.

Annotated Bib, post 9

Johnson, Erica N., Mollie P. Roediger, Michael L. Landrum, Nancy F. Crum-Cianflone, Amy C. Weintrob, Anuradha Ganesan, Jason F. Okulicz, Grace E. Macalino, and Brian K. Agan. “Race/Ethnicity and HAART Initiation in a Military HIV Infected Cohort.” AIDS Research & Therapy 11 (February 2014): 1.

HIV has become a treatable illness in the era of highly active antiretroviral therapy (HAART), and HAART is associated with a reduction in morbidity and mortality among those with severe immunosuppression.

Certain groups still seem more vulnerable to issues, and those issues have persisted over time. In a U.S. study, 3 or more months of delay between the diagnosis and an initial specialty encounter happened more with African Americans, Latinos, and those who lacked access to diagnosis. Disparities are likely highly complex and multifactorial. They have been hypothesized from previous studies to include lack of education or health literacy (as we saw in source 8), lack of health insurance, or, as mentioned in other sources, aspects in the physician-provider relationship.

The population of the study came from an ethnically diverse group of early-diagnosed HIV patients in the U.S. military. This group may offer less confounding due to the same free healthcare and medications, high school education, and a stable and similar income.
In the first analysis, participants were in the study from 1998-2009, did not have HAART before 1998, had HIV before going into service, and had a definite indication for HAART. To have a definite indication, patients had to have a CD4 cell (a type of white blood cell, to fight infection) count under 200, AIDS event, or severe symptoms.
Screening occurred at least every 6 months, as required by military policy. Those with more advanced HIV are evaluated more frequently (at least every 3-4 months).
1262 participants were included, 94% being male. The average age was 33.8 years. 40% were white, 46% were black, 10% were Hispanic, and 5% was from other ethnic groups. The source says race/ethnicity and other demographics were not significantly associated with the timing of HAART. In the first group, there was no difference in the timing of HAART when one had an AIDS-defining condition, compared to those that had a low CD4 cell count.
The source states that a better understanding of psychosocial and systems-based factors might help with the elimination of treatment barriers and enable healthcare providers to give the best care to HIV patients. The lack of significant statistical difference is likely due to the similar factors in free healthcare and income, however, in the third group, which started HAART at higher CD4 cell counts without any indication, African Americans had a lower odds of starting. The source said that in other studies, differences in initiating HAART could be attributed to differences in healthcare access, racial discordance with the physician, feeling known by the provider, health literacy, and attitudes towards health. Previous sources I’ve reviewed discuss similar issues, especially involving the provider (in what was an extremely homophobic environment at one point) and, as described in source 8, health literacy and attitudes towards health.
Final Thoughts
This source discusses the different races and ethnicities involved in the military that are also infected with HIV. The memorialized veteran in my AIDS Quilt panel was likely a white male, and this source gives a better insight on the differences of diagnoses and health statistics between each race in the military. However, being in the military means having access to free healthcare, which, along with a similar and stable income, seemed to have removed disparities. The authors do admit their study’s limitations: a broad timeframe and research across five research sites can cause variation in practices. There is also limited data on the participants’ substance use, though, being in the military, it is assumed to be low. I chose this source to further explore healthcare in the military for those infected with HIV. This source attempted to examine differences in race/ethnicity of military members infected with HIV. This relates to other sources in acknowledging the similar factors that create delays or issues with receiving proper healthcare.

Annotated Bib, post 8

Russak, Simcha M., Daniel J. Ortiz, Frank H. Galvan, and Eric G. Bing. “Protecting Our Militaries: A Systematic Literature Review of Military Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome Prevention Programs Worldwide.” Military Medicine 170, no. 10 (October 2005): 886–97.
Through the usage of eight electronic databases, dating from 1983 to February 2005, and manual searching, evaluative studies of HIV/AIDS prevention interventions for military service members.
Five hundred eighty-four abstracts were found, but only 8 met “formal acceptance criteria.” Qualifications included:
  1. published in English in peer reviewed journal
  2. included specific HIV/AIDS intervention applied to the military
  3. included outcomes

Five studies were done with U.S. soldiers and the remaining three were conducted with Thai Royal Military soldiers. They were assessed by one of four HIV prevention intervention methods: “clinic-based, educational, risk-reduction program, a cognitive-behavioral skills-building intervention known as the Sexually Transmitted Diseases/HIV Intervention Program (SHIP), a behavioral intervention targeting change at the individual, group, and institutional levels, and Thailand’s mass media campaign”  (100% Condom Program).


Single Approach/Single Session

One study was done at a U.S. military STI clinic. Soldiers were given a pre-evaluation and a post-evaluation to compare those with standard clinic care to those that received the same care and one of three intervention methods:

  1. Review of the patient’s HIV/STI risk assessment and problem-focused counseling
  2.  Viewing of an interactive video that intends to promote self-evaluation of risk behaviors
  3.  Targeted, situational, behavioral interventions where patients are put through an individual scenario with high-risk and encouraged to find alternatives

Interactive videos were significantly greater in creating sexual abstinence. Those that received a form of intervention were more likely to be willing to change to a “less risky sex partner” than those without any intervention. The groups did not, however, show much change in their conjunction of alcohol and sex.

Single Approach/Multiple Sessions

One study did a group-based, cognitive-behavioral intervention/prevention program called SHIP. It involved four 2-hour sessions that were interactive. These were given to U.S. Marines on ships before liberty visits. The control group was U.S. Marines over a span of three ships, assigned to be trained in cardiopulmonary resuscitation training.

This study assessed sexual activity and risk of HIV/STIs by a 3-point categorical index. Those with the intervention were less likely to be at a “low” or “high” sexual risk than the control group. The intervention group was also less likely to consider their partner a “stranger”, but there was no difference between the groups in whether their most recent partner was “regular” or “casual.” Additionally, the authors of this particular study saw no difference in the number of sexual partners and the length of time knowing their most recent sexual partner. There is, however, a reported difference in condom usage. The intervention group was more likely to use condoms, and to use it likely 100% of the time, compared to the control group.

In one of the studies, the intervention group was found more likely to be “non-drinkers” than not, but another study found no difference in consumption 1 year after. However, the latter study found that after a year, the intervention group was less likely to have sex after consuming alcohol. The length of the sessions did not seem to cause a significant difference, but those exposed to SHIP were more knowledgeable on HIV/STI.

Multiple Approaches/Multiple Sessions

One study, done on Thai conscripts, was a 15-month intervention with 3 approaches towards high-risk sexual behavior. The source states that they were nonrandomly assigned to one of 3 groups: intervention, diffusion (on the same base but without intervention), and control (different base, no intervention). Perhaps they are “nonrandomly” assigned because the study cannot have control on where soldiers are stationed, but the source doesn’t say. Mixed results were found in differences in sexual activity. The intervention group had notably fewer instances of commercial sex workers (CSWs) alone, but an increase in visits to CSWs. Alcohol use and condom use didn’t differ between the intervention group and the other groups. The authors concluded that, though HIV/STI indicators were lower in the intervention group, the reduction was not due to the intervention.

Mass Media

Mass media geared towards improving the sexual activity, condom use, illicit injected drug use, and STI indicators showed a significant reduction. There was a reduction in sex with CSWs, but there was an increase in the report of condom usage with CSWs. However, one study did not find the same reduction, regarding “less inconsistent condom use with girlfriends.” Both studies saw a reduction in incidences of STI/HIVs, but one study found an increase in drug use over the years.


Explanation for and Consequences of Few Published Studies

Only 8 studies were found that assessed the HIV/AIDS prevention for militaries in the world, but of the 62 responding countries, 98% had some HIV/AIDS prevention education. It’s possible that there’s a lack of studies because of financial constraints, or there are studies that are conducted but not published because they’re classified. Combined with the stigmas of homosexuality, other countries may deem militaries with homosexuals as weak.

“Regardless of the reason, the dearth of studies highlights the urgent need for governments to exercise a greater willingness to conduct, monitor, and share the efficacy of HIV/AIDS prevention programs. Otherwise, the large number of countries either coping with or soon to have an HIV/AIDS epidemic are left vulnerable because of needing to “reinvent the wheel” of prevention. Indeed, without such information, the socioeconomic, political, and global security of the entire world is being jeopardized.”

The source basically states that many countries are vulnerable and need to conduct and share the efficiency of their prevention programs and studies.


Final Thoughts

The source seems very detailed in the studies it discussed, however, it may have some ambiguity in some descriptions. Because the source is rewording studies done in the past, some things may be altered or misinterpreted. The source, did, however, acknowledge the significant variety in each study and noted the varying success in different topics. The variations included time, follow-up, session amount, and methods. The authors of the present source also recognize the English publications as an issue and admit to trying to minimize it, and the authors admit to publication bias: many authors self-reported the data, meaning they could alter it in any way they wanted the studies to have been portrayed.

This source gives me a perspective on the actual prevention methods that are occurring, as I was curious about what has been done to help the situation involving LGBT service members. Whether it be laws, prevention, or healthcare to the infected, I wanted to learn more about it. This source gave a more global spectrum of the case I was interested in, but it allows me to see the relations in militaries and see other perspectives. This source related to many others in acknowledging the lack of research in the field of military men that have sex with men.




Annotated Bib, post 7

Yano, Elizabeth M., Steven M. Asch, Barbara Phillips, Henry Anaya, Candice Bowman, Sophia Chang, and Samuel Bozzette. “Organization and Management of Care for Military Veterans with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome in Department of Veterans Affairs Medical Centers.” Military Medicine 170, no. 11 (November 2005): 952–59.
The Department of Veterans Affairs (VA), being the largest provider for HIV health care services, has launched a national quality improvement program. The source aims to assess the care for HIV infected veterans was conducted. Surveys in 118 VA facilities with senior HIV clinicians were given discussing staffing, approaches, and delivery of HIV health services. Selection was made by a census of all VA medical centers (VAMC) that cared for one or more HIV-infected patients during the 1999 fiscal year. Senior clinicians were asked to participate as the informants for the surveys, which had adapted measures of multiple aspects to HIV care.
Of 165 VAMCs that reported serving one or more HIV patients, 27 informed the surveyors that they redirect their patients to a larger VAMC. Of the remaining 138, 118 responded. Most patients received care through a specialty clinic, with a smaller portion getting care from a primary care provider and HIV expert. Most VAMCs managed HIV patients with some joint care involving an expert, but only one VAMC reported their facility had a dedicated HIV/AIDS inpatient ward.
Staffing could range from 1 to 50 in HIV providing for each facility. Notably, providers generally had greater than 10 years of experience in treating HIV patients. 53% of the facilities reported having HIV experts available 24 hours a week.
Only a few VAMCs wrote any HIV-related directives, policies, or programs for treatment adherence. Commonly, programs were inventions to influence patient behavior (38%), followed by courses for HIV providers (23%). 17% of facilities had reminder systems that prompted clinicians to ask about their patients’ adherence. Only 47% of VAMCs adopted HIV practice guidelines.
The source states that the costs and processes to treat HIV in the medical field will continuously accelerate. Consequently, understanding the environment and its organization in the health care services is important to improve quality and must be done routinely.
Final Thoughts
This source discusses multiple VAMCs and how well equipped they are for HIV-related patients. This source, written in Military Medicine in 2005, may be a little outdated, but gave statistics relevant to its time and is a good starting point for future/current VAMCs clinicians to compare for improvement. Being where this article was published, there might be some reason to believe that the studies were biased, but the statistics seem honest enough to demonstrate otherwise. I chose this source because I was curious about how the VA was dealing with HIV/AIDS in more current times because other sources mentioned the lack of care for LGBT service members.

Annotated Bib, post 6

Ramirez, M. Heliana, and Paul R. Sterzing. “Coming out in Camouflage: A Queer Theory Perspective on the Strength, Resilience, and Resistance of Lesbian, Gay, Bisexual, and Transgender Service Members and Veterans.” Journal of Gay & Lesbian Social Services 29, no. 1 (January 2017): 68–86.
There have been centuries of official and unofficial anti-LBGT laws in the military, labeling them as criminals and mentally ill (thus making them unfit to serve). Because of this, their contributions have been erased. Service members (SM) that weren’t heterosexual were sent to psychiatric hospitals or to the military incarceration facilities. About 100,000 LGBT SMs were discharged between 1941 and 1980, and 13,369 were discharged between 1993 and 2010 under the Don’t Ask, Don’t Tell (DADT) policy.
Just between 2004 and 2009, replacing LGBT SMs who were discharged under DADT costed $193.3 million. LGBT veterans that served under such discriminatory policies had higher rates of depression, substance abuse, suicidality, and PTSD, compared to non-LGBT counterparts.
The source states that queer theory provides many ways that LGBT SM/Vs showed resistance everyday. Contrary to the attitudes of the general military, LGBT SMs exhibited their true selves by performing soldier shows in drag, using “gay culture” lines, and creating the opportunity to meet other LGBT members. Additionally, they’ve used strategic timing of coming out or keeping their sexuality concealed. The source says these are examples of their everyday strengths and resistance.
Anti-LGBT military policies
The source discusses multiple policies made throughout history
  1. Articles of War of 1916, “punishing sexual assault between men” (revised in 1919 to specify consensual and forced sex)
  2. 1940s/1950s Senate Subcommittee on Expenditures report deemed gay soldiers a “security risk” and likely to commit treason
  3. Navy’s 1957 Crittenden Report, stating gays didn’t pose any risk, sexual identity had no negative effect on service, and LGB SMs were successful (military denied existence of this until its release in 1976 by Freedom of Information Act)
  4. 1973 Diagnostic and Statistical Manual of Mental Disorders removed homosexuality from the list (caused the military to start banning based on conduct instead of mental charges)
  5. 1994 DADT, allowing LGBT SM to serve under the premise that they conceal their orientation (repealed in 2010)
LGBT military minority stressors
  • LBGT-related military investigations, including coercive tactics and health/religious providers violating confidentiality
  • Military sexual trauma, MST, including rape and other forms of sexual assault, which goes unspoken, even for decades
  • Criminalization of HIV/AIDS, AIDS was treated as a “homosexual problem” instead of a medical problem, causing gay SMs to avoid their military doctors and be discharged on the assumption of sodomy  (as discussed in a previous annotation)
  • Discrimination, including pastors quoting homosexual damnation passages from the bible, people refusing to share elevators, or refusing to bring homosexual patients food


Strategies of strength and resistance by LGBT service members

Queering military trainings/spaces, as aforementioned, subverting the marriage quarters systems (reserved for heterosexual SMs), and creating a more relaxed environment of their HIV/AIDS ward in hospitals

Strategic use of “the closet”, calling other LGBT SMs “family” and using retirement parties to come out. Contrarily, LGBT SMs were hiding their sexual orientation to put their patriotism and other benefits first, or they were in a higher position that had to enforce anti-LGBT policies (and they wanted to protect their LGBT family).

Creating underground LGBT military support networks, such as the Coalition of Gay Servicepeople (CGS)
With all the policies that remain enacted and the ones that have been repealed, LGBT veterans or current members of the U.S. Military will be working more towards fixing the issues. The stigmas surrounding the LGBT SM must be unlearned and their identity should be supported. The source urges that the mental and behavioral health of LGBT SM/Vs should be blended with their daily strength and resilience.
Final Thoughts
The source discusses LGBT policies in the U.S. military and stressors for LGBT SMs, but the source also delves into the strengths and examples of resilience in LGBT SMs. It is a change of pace on the topic, examining ways that LGBT SMs worked around the homophobic system and discussing their strengths. The source is probably the most recent sources. There is a contradiction that should be noted: this source talks about higher rates of depression, substance abuse, and PTSD, whereas a previous source says the resiliency of LGBT SMs is an explanation for why their rates are lower. Ultimately, the source relates to the political aspect of other sources with its policies and considers a response to the homophobic environment and stigmas placed on homosexual SMs: they are successful, beneficial, and did not pose any risks.

Annotated Bib, post 5

Campbell, Wesley R., Mojgan Jahan, Mary F. Bavaro, and Robert J. Carpenter. “Primary Care of Men Who Have Sex With Men in the U.S. Military in the Post-Don’t Ask, Don’t Tell Era: A Review of Recent Progress, Health Needs, and Challenges.” Military Medicine 182, no. 3/4 (April 3, 2017): e1603–11.

With the repeal of Don’t Ask, Don’t Tell (DADT) in 2011 and the passing of the Defense of Marriage Act (DOMA) in 2013, military members of the lesbian, gay, and bisexual (LGB) orientation can openly serve the country and provide the usual benefits for their same-sex spouses as heterosexual service members could for their spouses. Before the repeal of DADT, MSM in the military was at 2.2%, compared to the civilian counterparts’ 3.2%.
This source urges that MSM continue to be at higher risk for disparities involving mental and sexual health. Only recently have MSM been included in national health surveys, making it difficult to compare their previous health patterns and statistics.
Mental Health Disorders
Syndemic factors (a set of linked health problems involving two or more inflictions) including “depression, childhood sexual abuse,” and polysubstance abuse generally lead to higher likelihood of health problems, such as HIV.  Studies show MSM have higher rates of IPV. Those with IPV were more likely to be depressed, have HIV, and participate in risky sexual behavior. This source also addresses the fact that there is little information on the mental health of homosexual servicemen. Fortunately, a study found an association between depression and the concealment of sexual orientation in the military.
Since the repeal of DADT, communication between MSM patients and their providers has been easier. Disclosure of sexual orientation has been documented, in a U.S. military study, as increasing amongst SMs. The source states that there has been an “early adoption of enhanced STI and anal cancer screening”, which recognizes the value of mental health resources to build resiliency. The healthcare focus for MSM is shifting to expand over social and mental health, as opposed to the original focus of just sexual health. The authors make their final statements, urging that providers must be prepared to discuss MSM’s health respectfully and without any judgement.
Final Thoughts
The source advises providers aware of the connections between mental health and sexual preference to screen their patients’ behavioral health.
This source is a more up-to-date document, written in 2017, which gives the research a current standpoint on the situation at hand involving MSM in the U.S. military after the DODT policy. This source also explores the health needs, sexually and mentally, and remaining issues, relating to the previous annotations in the overarching theme of health challenges for MSM and AIDS in servicemen. As discussed in other sources, there is a lack of studies on MSM or gay/bisexual men in the military, and there are still problems concerning their sexual and mental health that needs to be fixed.
With the source using 110 other sources, it seems like the authors have a credible background in writing this, however, whether there is an issue with this being published in Military Medicine or not, I am uncertain. On one hand, this could present an idea of bias because the publishers may only want to hear a positive progression in healthcare. On the other hand, this may just make the source more credible in its knowledge and reports on the information given.




Annotated Bib, post 4

“Homosexuals in the Military.” Congressional Digest 89, no. 4 (April 2010): 103.




Bill Clinton, in 1992, commented that he would “lift the ban” on homosexuals serving in the military if elected. Under this policy, “Don’t Ask, Don’t Tell”, the Department of Defense (DOD) wouldn’t ask questions about the sexual orientation of prospective members of the military. Individuals were required, however, to keep their sexual orientation to themselves or be discharged or denied enlistment if they were not already active duty. On July 19, 1993, President Clinton announced this policy.

It became that statements of homosexuality were grounds for investigation and, if proven true, discharge. Critics hypothesized that Clinton strategized implementing a muddled regulation and poorly defended the policy. Additionally, the term “orientation” is subject to various interpretations.

“The law codified the grounds for discharge as follows: (1) the member has engaged in, attempted to engage in, or solicited another to engage in a homosexual act or acts; (2) the member states that he or she is a homosexual or bisexual; or (3) the member has  married or attempted to marry someone of the same sex.”

The elusiveness of “orientation” has created many issues in its ambiguity, as the actions of homosexuality were illegal, but acknowledging one’s “orientation” was not committing an act of homosexuality. The law’s wording focuses on the homosexual conduct, not the homosexual preferences.

Final Thoughts

This source talks further on the Don’t Ask, Don’t Tell and the ambiguity of it, which helps clarify what the other sources didn’t go into much depth on, hence, why I chose it. This source explores the complications of the policy and thus, the consequences and maltreatment that was given to homosexuals and bisexuals, which were more commonly infected with AIDS/HIV than their heterosexual counterparts. The source seems to include many references, but the PDF itself did not include a notes page. It can be possible that this source is credible by it’s seemingly knowledgeable and various references, but there is no physical citations or a bibliography to really deem this source as ‘credible’ which is a major flaw in the source. Overall, the source gives the historical background, in sequence, of the Department of Defense’s Don’t Ask, Don’t Tell policy and connects to the other sources to give light on the uncertainty of the policy and how homosexual/bisexual servicemen and prospects had to tread. Though unstated, this uncertainty of the policy’s solid rules can add to the anxiety a homosexual/bisexual might have already experienced in an unaccepting workplace, and the discrimination that surrounded any sexual minority can be assumed to negatively affect their mental health (i.e. depression, stress, anxiety), relating to the first annotation.



Annotated Bib, post 3

Hannah, William N., Shilpa Hakre, Peter Dawson, Hao Wu, Sheila A. Peel, Nelson L. Michael, Paul T. Scott, and Jason F. Okulicz. “Clinical Indicators Associated with HIV Acquisition in the United States Air Force.” AIDS Care 29, no. 6 (June 2017): 724–28.





Development of a successful HIV-1 prevention program depends on the identification of HIV risk factors and testing of at-risk individuals to reduce HIV acquisition and sharing. The United States Air Force (USAF) has mandated HIV testing for active duty members about every 2 days. About one-third of those infected with HIV are unaware of their harboring of the virus. Early detection can be difficult because there are several risk factors, such as intravenous drug use (IDU) and illicit substance abuse. By mandated screening, about 75% of incident cases in the USAF allow disruption in forward HIV transmission.


The USAF conducts HIV screenings every 2 years and for peri-deployment. In this source’s study, the study population consisted of active duty USAF members at any time during January 1996 and December 2011 with available demographic information. All persons with a new HIV diagnosis during the study were considered cases. Individuals were matched into controls by age, length of service, sex, race, branch, service component (active duty, National Guard, or Reserve), and HIV test collection date.


462 total cases of HIV were identified among USAF personnel that served actively during January 1996 and December 2011. Because of the small numbers, the 10 female cases were removed. In unadjusted analyses within the last two years before HIV diagnosis, having clinical signs and symptoms of HIV infection, having a clinical syndrome consistent with HIV clinical history of a mental health disorder, or history of a STI had significantly higher odds of HIV infection. Five indicators had notably higher odds of HIV infection: having signs of HIV infection, clinical syndrome consistent with HIV infection, a clinical syndrome consistent with HIV, more frequent medical encounters, clinical history of a mental health disorder and history of a STI. This source recommends that the USAF screen those with HIV indicators more than the mandated screenings. Numerous studies have proven that the association “between HIV infection and serious mental health illness, and the prevalence rate of HIV infection in patients with serious mental illness is higher than expected in the general population for the same demographic area.” Severe mental illness in the military, however, undergoes an in-depth evaluation that ultimately leads to discharge. “The results of this study suggest that less debilitating forms of mental illness, such as depression, adjustment reactions, and anxiety may also play a contributory role in HIV acquisition in the active duty population.” This source also suggests that those with mental illness are likely to have riskier sexual behavior (including lack of condom with the same sex) and alcohol and drug use.


Final Thoughts

The goal of the study was to “identify and assess clinical indicators associated with HIV infection in the USAF.” It also suggests, based on findings, that the USAF should consider an increase of HIV testing for persons at risk, which would be GB men, relating this back to the first annotation. This source offered a different, more specific side of the HIV scenario in the military. This source focuses on the USAF, but it also surprised me that this branch had mandatory HIV screenings.


The source identifies its own limitations, indicating that the study included exclusive use of ICD-9 diagnosis codes which weren’t available the entire study period. Many of the diagnoses also lacked specificity. Politically, this testing of HIV is mandated through the USAF, but socially this source provides a glimpse at the indicators that relate to higher odds of HIV acquisition.



Annotated Bib, post 2

Goldbach, Jeremy T, and Carl Andrew Castro. “Lesbian, Gay, Bisexual, and Transgender (LGBT) Service Members: Life After Don’t Ask, Don’t Tell.” Current Psychiatry Reports 18, no. 6 (June 2016): 56–56.




71,000 military personnel identify as lesbian, gay, or bisexual with many others identified as transsexual. Though homosexual behavior has always been prohibited, being of gay or lesbian sexual orientation was not explicitly stated as being banned from the military until 1942. Over time, the list of objections to allow homosexuals join the service grew, including higher health care costs (primarily because of AIDS), erosion of military morale, violation of privacy/modesty rights of non-lesbian and gay service members, and violation of the Uniformed Code of Military Justice’s prohibition against sodomy. Though the intention DADT was to protect LGB members in the service, it did little to protect them from discrimination and may have actually made it easier to be identified and separated as a LGB service member.

Because LGB service members were prohibited, studies on them aren’t available, however, we see in this source like we did in “The Effect of Discrimination and Stress on Sexual and Behavioral Health among Sexual Minority Servicemen”, that there have been studies on LGB veterans and civilians. Civilian LGBT studies show increased amounts of stress and psychological vulnerability, specifically depression, anxiety, PTSD, and substance abuse.


Contrary to we saw from the small study in “The Effect of Discrimination and Stress on Sexual and Behavioral Health among Sexual Minority Servicemen” (but was also the belief based on civilian and veteran GB studies) LGBT civilians have increased risks for a variety of illnesses and diseases. Lesbians, tending to smoke more, have STIs, and lack screening, are at greater risks for cervical and breast cancer. Gays are at higher risk for HIV and anal cancer. In civilian literature, health issues are usually attributed to LGBT-unique individuals, called minority stress, which states that major life events can cause one to be less equipped to adapt and tolerate life stressors. This can lead to poor physical and mental health.


Before the repeal of DADT, members could be discharged for disclosing their homosexuality. Even after the repeal, this distrust remains. Only 70% stated comfort with discussing their sexual orientation, while only 56.7% believe the military cares for their health regardless of sexual orientation. We saw similar information in “The Effect of Discrimination and Stress on Sexual and Behavioral Health among Sexual Minority Servicemen.”


The lack of military health care providers’ knowledge on LGBT health issues is a large issue discussed in the source, considering that with the repealing of DADT occurring in 2011, any provider trained before this would have limited exposure to LGBT health considerations.


The last issue regarding personal views of mental health care providers regarding LGBT service members in that many in the military do not believe LGBT should be allowed to serve. While everyone is entitled to have their own views, it can cause concern for LGBT service members knowing that their healthcare providers may treat them with discrimination.


Final Thoughts

This source discusses the repeal of DADT and the effects following it, along with issues that still need to be dealt with, such as knowledge gaps on healthcare and discrimination in the medical field and in the service throughout. This source argues also that there needs to be more research on active duty service members and discusses about the issues before and after DADT concerning healthcare and discrimination, connecting it to the other annotations. This source is a recent, concise article that has numerous resources for evidence, making it credible. There isn’t any reporting of new evidence in this source, so it would have to be assumed that this article used credible sources itself.


Annotated Bib, post 1

Delgado, Adolph Joseph, Danielle Gordon, and Phillip Schnarrs. “The Effect of Discrimination and Stress on Sexual and Behavioral Health among Sexual Minority Servicemen.” Journal of Gay & Lesbian Mental Health 20, no. 3 (July 2016): 258–79. doi:10.1080/19359705.2016.1141344.





Don’t Ask Don’t Tell (DADT)

The military is estimated to have 37,071 gay and bisexual men serving, either actively or in the reserves, totaling about 1.5% of all servicemen. Further, there is estimated to be 12,965 gay and bisexual men that are retired from the reserves. However, this number is likely significantly underrepresentation due to an old military policy, DADT, that forced lesbians, gays, and bisexuals to mask their sexuality. Fortunately, these numbers no longer have to be estimates, as DADT has been repealed as of September 20, 2011. However, the repeal of DADT has not removed heteronormative roles caused by long time discrimination against homosexuals.


Service members experience more stressful situations than civilians. This source refers to other studies to prove that service members have increased risks of mental distress, such as anxiety or depression, negative health behaviors, such as alcohol consumption, and risky sexual behavior, such as unprotected sex. In addition to the likely aforementioned issues, sexual minorities in the military also experience social isolation, stigmatization, and discrimination. This source recognizes that DADT has limited the research that could have been done on active duty sexual minorities. This source wants to focus on the effect of discrimination and mental distress on negative health behaviors for sexual minority servicemen. The source acknowledges, however, that there has been research conducted on sexual minority civilians and sexual minority veterans.


Discrimination against homosexual and bisexual service members has been documented as far back as World War I (WWI). Sodomy became illegal; thus, numerous sexual minority service members were discharged. During World War II (WWII), the American Psychiatric Association classified homosexuality as a mental illness, labeling any homosexual or bisexual service member as unfit for the military. In 1982, the U.S. military wrote the Department of Defense (DOD) directive 1332.14 stating explicitly that homosexuals were to be excluded from military service solely based on their sexual orientation. DADT, however, passed in 1993 by Congress, allowed homosexuals to serve.

This source recognizes a handful of studies have reported negative outcomes of discrimination among LGB service members, and references a study of 71,570 service members. 39% of 71,455 active duty respondents reported being aware of harassments based on sexual identity. The referenced study also found a negative correlation between rank, education, and training on awareness of harassment: that is, the higher rank, education, and training, thw lower their awareness of harassment was.

This source references another study, conducted in 2013, in which, 38 lesbian, gay, bisexual, and transgender (LGBT) veterans and current service members felt much relief when meeting others. They also described their discomfort at VA services due to a lack of trust in some staff questioning sexual orientation. Many veterans keep their sexual orientation hidden after being discharged due to “a heteronormative culture that rejected their true identity.”

Risky sexual behavior

Sexually transmitted infections (STIs) are a globally common cause of illness that affects economic, health, and social aspects of one’s life. STI prevention, such as usage of a condom, are important in preventing HIV. Knowledge-based programs in STD clinics have not shown to be an effective prevention intervention. Understanding specific risk behaviors have greater potential to yield behavior changes with effective intervention.

The U.S. has underscored the importance of STD care and prevention. Military service members tend to have higher STD rates than their civilian counterparts, notably during deployment or wartime. The military also tries to do a knowledge-based approach, rather than changing risk behavior or focus on persons at risk for increased HIV infection. The Centers for Disease Control and Prevention (CDC) stated that STIs have been increasing for men who have sex with men (MSM). MSM are 17 times more likely to develop anal cancer than heterosexual men, which is likely caused by HPV.

Because of the military’s historically negative view on homosexuality, there is a large chunk of information on the sexual health of LGB service members that is missing. Many LGB service members sought out civilian medical practitioners. Because of ethical dilemmas in providing care to LGB service members, medical professionals avoided documentation of the LGB’s identities and medical history.

Negative health behavior

This source gives a paragraph of information on the nation’s statistics for alcohol and drug substances. Heavy drinking can lead to cardiovascular disease, high blood pressure, strokes, and liver disease, along with psychological ailments such as depression, anxiety, antisocial personality disorder, and sociopathy.

This source states that the policy makers over the U.S. military underscore prevention in heavy drinking and tobacco use, and argues that it contradicts the DOD’s goal to maintain military readiness. The DOD desires to “prevent and minimize the effects of heavy alcohol, other drug, and tobacco use on military performance and promote behaviors that contribute to health and fitness.” However, norms tended to encourage alcohol and tobacco usage. Alcohol is used in many ways: to prove masculinity, celebrate, reward, let loose, etc. Similarly, tobacco is used as a way of unwinding and socializing. Both of these detrimental substances are available to the military at reduced prices.

In 1986 the DOD pushed for health promotion. Smoking programs used social support to discourage tobacco use, in addition to prohibited smoking areas. Knowledge-based presentations on tobacco became required for incoming personnel, whereas alcohol, and other drugs had counseling and education for at-risk populations. The DOD directive included nongovernmental agencies, education, and drug urinalyses. There is a gap, as aforementioned, on the health of LGB service members, but there are numerous studies on drug and alcohol usage of LGB civilians.

Numerous studies have shown that sexual minorities have higher risk of smoking tobacco and marijuana than heterosexuals. This source again acknowledges the lack of research in current military climates after DADT’s repeal, and that hypotheses were generated based on literature on discrimination for LGBT civilians and reports from LGBT veterans.

The purpose of this study is to increase the knowledge about sexual and behavioral health of gay and bisexual servicemen, investigating if these individuals experienced discrimination and psychological stress. Further, to see if discrimination and stress would affect negative health behaviors (tobacco and/or alcohol usage) and risky sexual behavior (having casual sexual partners). This source claims that the data is an important first step to see if heteronormative roles still exist in the military. The source defines the possibilities of sexual minorities experiencing discrimination or not, engaging in more negative behaviors or not, and engaging in more risky sexual behavior or not.



85 males, ranging from 20 to 68 (with a median of 32.17) volunteered to participate. Participants were recruited either by email or web postings on social media, which then directed them to a questionnaire survey entitled, “The Effects of Discrimination and Stress on Sexual & Behavioral Health among Sexual Minority Servicemen.” 51 (60%) respondents were heterosexual, 25 (29%) were gay, and 9 (11%) were bisexual. Majority of respondents were white, followed by 24% Hispanic, 7% Black, 5% Asian, and 2% classified as “other.” Nearly two-thirds of respondents were veterans. 40% were Army, followed by 13% Air Force, 12% Marine Corps, 11% Navy, and 2% each for Coast Guard and National Guard. More than half had some college or associates degree, were currently enrolled, or had a four-year degree.

The study had criteria to ensure that the sample represented only gay, bisexual, and straight servicemen for accurate data. A separate study was done for transgender populations because of their unique experiences. For simplicity, this study focuses on men.

Participant recruitment and data collection

The study used a cross-sectional design, using a convenience sample conducted by aforementioned methods. They were given a consent form to complete before answering the 10-15-minute survey. When the survey was over, participants were shown links to counseling services in the case that they felt uncomfortable.


The demographics of sexual orientation, military status, and ethnicity were assigned numerical values. The survey gathered information on questions about condom use (1 = yes, 2 = no) and behavioral factors, such as “Where you under the influence of alcohol when you last had sex” (1 = yes, 2 = no) and “In the past 3 months, how many casual partner(s) have you engaged in sexual activity with, not counting a main partner?” These questions were to evaluate the risky sexual behavior.

Participants also took The Everyday Discrimination Scale and The Depression Anxiety and Stress Scale (DASS). The negative health behavior levels were measured using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST).

Depression and Anxiety, Alcohol and substance abuse, and Discrimination

DASS includes 3 scales with 4 point measurements to measure the negative emotional states of depression, anxiety, and stress over the participant’s past week. A sum is calculated based on each respondent’s experience and compared to the norms. Scale-level correlations were strongly correlated for each scale.

ASSIST measures substance use, including alcohol, and has a 0-38 rating for a 6 item scale. Higher numbers indicate higher probability of severe health, social, financial, and legal issues.

The Everyday Discrimination Scale, an 11-item scale using 6 points, measures day to day acts of discrimination. Correlation reports that scores are significantly correlated to internalizing and externalizing symptoms.

Discussion and Results

The purpose of the study was to understand if gay and bisexual servicemen had experienced more discrimination and stress compared to heterosexual counterparts. The study also assessed what factors contributed to increased negative health and sexual behaviors. Though the study had limitations, it is the first attempt to gain insight and ignite further research in this topic.

Gay and bisexual (GB) servicemen reported to experience more discrimination than their heterosexual counterparts. 35% of respondents experienced discrimination at their workplace. Even though DADT has been repealed, the source explores 3 possible reasons for this fact. First, the sample’s majority included GB servicemen that were enlisted during DADT, thus, they experienced the discriminatory policies before and during DADT. Second, at the time of this study, DADT had only been repealed for 3 years, so it is likely that those enlisted at the time of the study enlisted before DADT was repealed and experienced discrimination due to the policy. Lastly, this could simply indicate the prominent heteronormative tradition and military culture.

The source says that DOD has taken steps to remove inequality, but some policies still pose a threat toward equality for all sexual orientations. For example, the Uniform Code of Military Justice or the fact that any LGBT is prohibited from donating blood.

Fortunately, there was no difference in stress levels of GB and heterosexual men. This is likely because the military has much standardization in jobs and financials. Previous studies have revealed sexual minorities to experience more discrimination and stress, as this source recognizes, but it did not appear in this study. The source indicates it may be easy to recall a discriminatory event, but not the stress one experienced. It can be interpreted that this similar level of stress shows that the military and VA have done well to make sure service members aren’t under great levels of stress.

Research proved that sexual orientation was a predictor to use alcohol, use tobacco, and have casual sex partners. Contrary to hypotheses based on studies of GB civilians and veterans, GB servicemen had lower likelihoods of all three considerations. Possible explanations include being a GB serviceman reduces the propensity of engaging in such behaviors. Despise the known and displayed negativity towards homosexuality, many GB men still enlisted, indicating initial resilience. This resilience may be an explanation for why GB had lower rates, as they’ve already learned to be resilient in hardships. Another possibility for lower rates could be the consequences if caught. Given that the sample was largely veterans, it’s possible that they’d be careful in their behaviors for the sake of the secrecy of their sexual orientation.

The source recognizes the limitations, included the cross-sectional design that limited the range of respondents, cluster analyses, as this limits the individuals’ specific experiences, and the small size itself makes it hard to generalize. The source also recognizes that it may not be representative considering the recruitment was online and directed towards sites that focused on GB servicemen.

After recognizing the several limitations, the source explains how, to their knowledge at the time, this was one of the first studies to explore “how discrimination and stress affect gay and bisexual servicemen, identify whether discrimination is still prevalent in the military, and de ne how stress affects psychological functioning across servicemen.” These findings will help identify protective factors against discrimination and negative health behaviors in future studies, which will thus help with culturally tailored interventions.

Final Thoughts

I chose this as one of my sources because I found it necessary to consider the mental health of gay and bisexual servicemen when considering the bisexuals and gays in the military and how their treatment and experience has changed over time. This study, which was more detailed and had more evidence than others, included a convenience sample of 85 men in the military that were recruited through social media posts. The data collected showed a strong correlation with sexual orientation and discrimination, but not for negative health  behaviors, physically or psychologically. This is relevant to understand the social and cultural effects in the military for the AIDS/HIV community because a major concern was gay nd bisexual men contracting STIs or STDs. These results push for studies to further explore this and fix the discrimination and negative health behaviors. However, we must recognize that this sample does likely contain bias, since the servicemen studied were volunteers. This resource works in conjunction with research on homosexuals in the military, but this delves deeper into the subject by examining their personal mental and sexual health, or lack thereof, because of certain laws. It also shows how DADT caused such a gap in research and information on GB servicemen and gave many possible explanations for results, such as the fear of consequences. DADT and this source  reveal the political aspect of the AIDS community because of its effect on GB men being discharged or hidden in the military.