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.
- published in English in peer reviewed journal
- included specific HIV/AIDS intervention applied to the military
- 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:
- Review of the patient’s HIV/STI risk assessment and problem-focused counseling
- Viewing of an interactive video that intends to promote self-evaluation of risk behaviors
- 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 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.
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.
- Articles of War of 1916, “punishing sexual assault between men” (revised in 1919 to specify consensual and forced sex)
- 1940s/1950s Senate Subcommittee on Expenditures report deemed gay soldiers a “security risk” and likely to commit treason
- 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)
- 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)
- 1994 DADT, allowing LGBT SM to serve under the premise that they conceal their orientation (repealed in 2010)
- 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).
For my primary source analysis, I aim to discuss the lack of research for homosexual servicemen and the problems that remain with the providing of healthcare in the U.S. military. Issues on homosexual servicemen include mental and sexual health. The issues involving the concealment of sexual orientation in the military, due to the pre-existing laws and the homophobic environment, create a problem of minimal research for the healthcare of these gay servicemen. With minimal research and a lasting judgment on homosexuals, it is difficult to provide appropriate health care or HIV/AIDS prevention programs for homosexual servicemen.
First I will talk about how my AIDS Quilt panel initiated my research journey. I then will discuss the Department of Defense policy “Don’t Ask, Don’t Tell” and the effects of this policy before, during, and after it’s establishment. While investigating this, the homophobic environment created in the military will be explored. Following that, I will discuss the lack of research available for homosexual service members and why there is a lack of research. Sequently, the issues involving a lack of HIV/AIDS prevention programs for those at higher risk and the mental health of homosexual servicemen will be investigated, along with appropriate statistics.
My panel does not answer the questions proposed, but it does create the initial curiosity. The panel shows that this individual was in the military at some point, but it doesn’t address the healthcare or lack thereof in the military for homosexuals. The panel does, however, address that this memorialized man was more than just a service member of the U.S. Army.
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. https://doi.org/10.7205/MILMED-D-16-00255.
“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.
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.
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. https://doi.org/10.1080/09540121.2016.1260086.
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.
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.
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. https://doi.org/10.1007/s11920-016-0695-0.
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.
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.