Brian Cozart’s panel in the AIDS Quilt and its many qualities brings about the sense of an individual and makes him come to life. Brian like many others, loved Mickey Mouse. Brian was an accepting individual that enjoyed Godiva and, assumably, had a favorite shirt. Brian was like many of us in a number of ways, however, his honor and courage exceeds those of the average citizen.
Brian Cozart was one of the nearly 225,000 individuals in the U.S. military to die after developing HIV/AIDS. This unique individual’s small memorial in the AIDS Quilt was the initial spark of my curiosity for HIV/AIDS infected U.S. service members (SMs). How was the military handling HIV/AIDS, a disease stigmatized as an indicator of homosexuality, in an environment that is socially and politically homophobic and discriminatory? The policies and stigmas shaped the original attitude towards HIV/AIDS SMs, creating a gap in the research, and, consequently, made care for the infected SMs more difficult.
I will first discuss the policies and environment in the military, specifically, the Department of Defense policy “Don’t Ask, Don’t Tell” (DADT) and the effects of this policy before, during, and after its establishment. Simultaneously, the homophobic environment created in the military, through social expectations and policies, will be explored. For this essay, the focus will be on Lesbian, Gay, and Bisexual (LGB) SMs, but mostly those of the gay sexual orientation, as they are more prone to HIV/AIDS. Following that, I will discuss the lack of research available for homosexual service members’ health, why it is this way, and the little we know about their health. 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.
Prior to written and enforced laws, the U.S. military had an environment against homosexuality and male femininity, deeming them to make service members weak. Those that were homosexual during entry would not be allowed to enlist because homosexuality was considered an illness. Any service member that wasn’t heterosexual were sent to psychiatric hospitals or to the military incarceration facilities. The U.S. military has had its series of anti-LGB military policies or outside documents that justified the attitudes towards LGB, according to Ramirez and Sterzing in “Coming out in Camouflage: A Queer Theory Perspective on the Strength, Resilience, and Resistance of Lesbian, Gay, Bisexual, and Transgender Service Members and Veterans”:
- Articles of War of 1916
- This punished “sexual assault between men”. It was revised in 1919 to specify consensual and forced sex, establishing that gay SMs could be punished.
- 1940s/1950s Senate Subcommittee on Expenditures report
- This report deemed gay soldiers a “security risk” and deducted gay soldiers were likely to commit treason against the U.S.
- Navy’s 1957 Crittenden Report
- A review of policies regarding homosexuality, this report found that gays in the military didn’t pose any risks to security, gays sexual identity had no negative effect on service, and LGB SMs were successful in serving their country.
- The military denied the existence of this report until its release in 1976 by the Freedom of Information Act.
- 1973 Diagnostic and Statistical Manual of Mental Disorders
- This updated manual removed homosexuality from the list of mental disorders.
- Consequently, the military had to start banning based on conduct instead of on the basis of mental disorders.
- 1982 Department of Defense (DOD) directive 1332.14
- This stated explicitly that homosexuals were to be excluded from military service solely based on their sexual orientation (Delgado et al.).
- 1994 Don’t Ask, Don’t Tell (DADT)
- This policy allowed LGBT SMs to serve under the premise that they conceal their orientation
- It was later amended and renamed “Don’t Ask, Don’t Tell, Don’t Pursue, Don’t Harass” to protect those affected by this policy from harassment and violence.
- In the recent year of 2010, this policy was repealed.
With the history of policies serving their purpose to keep homosexuals out of the military, it is understandable that the environment itself was very homophobic. Soldiers were trained that homosexuality was weak, and jokes labeling one as gay were taken as insults. Studies like “The Effect of Discrimination and Stress on Sexual and Behavioral Health among Sexual Minority Servicemen” by Delgado, Gordon, and Schnarrs suggest that this lingering, even after DADT’s repeal, can possibly indicate the military’s heternormative culture. (Delgado et al.).
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 (“Homosexuals in the Military.”, 2010). 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. (Goldbach et al.).
This poster expresses one of the responses of Americans after DADT.
It became policy that statements of homosexuality were grounds for investigation and, if proven true, discharge. The law permits the discharge of a SM if “(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” (“Homosexuals in the Military.”, 2010).
Additionally, the term “orientation” is subject to various interpretations. Critics hypothesized that Clinton strategized implementing a muddled regulation. 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. (“Homosexuals in the Military.”, 2010).
Available Research on Healthcare
According to numerous authors, there is a lack of studies on men who have sex with men (MSM) in the military, and there are still problems concerning their sexual and mental health that needs to be fixed. 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. Ethical dilemmas in providing care to LGB service members caused medical professionals to avoid documentation of the LGB SMs’ identities and medical history. (Delgado et al.). Of course this is one of the effects of DADT, but the limited research available on LGB SMs can be contributed to a few other hypotheses:
- LBGT-related military investigations, including coercive tactics and health/religious providers violating confidentiality (Ramirez et al.).
- Regarding personal views of mental health care providers, the belief held by many that LGBT SMs should be allowed to serve (Goldbach et al.).
- Discomfort at VA services due to a lack of trust in some staff questioning sexual orientation (Delgado et al.). Only 70% stated comfort with discussing their sexual orientation, while only 56.7% believe the military cares for their health regardless of sexual orientation. (Goldbach et al.).
Because LGB service members were prohibited, studies on their health and healthcare for them are limited. Many studies have turned to civilian LGB studies to understand the differences in their health and supposed that findings apply similarly to LGB SMs.
“The exclusion of LGBT service members from military service meant that understanding the health care needs of LGBT service members was a low priority. Thus, the specific health care needs of LGBT service members remain largely un- known.”
(Goldbach et al.).
Focusing on HIV/AIDS, “Behavioral and Clinical Characteristics of Persons Receiving Medical Care for HIV Infection — Medical Monitoring Project, United States, 2009” discusses a study done on 4,217 adults in the U.S., representing the 421,186 estimated persons in the U.S. with HIV who received outpatient care during January to April of 2009. The source then refers to the 421,186 persons as patients. 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. 71.2% of patients were male and 41.4% of patients identified as homosexual (gay or lesbian), and 8.3% were bisexual.
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.
47.1% of patients were 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 partner who’s HIV status is negative or unknown.
“The Effect of Discrimination and Stress on Sexual and Behavioral Health among Sexual Minority Servicemen” exhibits that there have been efforts to create studies on LGB veterans and SMs. Civilian LGB studies show increased amounts of stress and psychological vulnerability, specifically depression, anxiety, PTSD, and substance abuse.
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.” 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).
51 (60%) respondents were heterosexual, 25 (29%) were gay, and 9 (11%) were bisexual. 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. (Delgado et al.).
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 (Delgado et al.).
39% of 71,455 active duty respondents reported being aware of harassments based on sexual identity. Another finding was a negative correlation between rank, education, and training on awareness of harassment: that is, the higher rank, education, and training, the lower their awareness of harassment was. This source referenced 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. (Delgado et al.).
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. Understanding specific risk behaviors have greater potential to yield behavior changes with effective intervention. 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. (Delgado et al.).
Negative health behavior
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 (Delgado et al.).
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 (Delgado et al.).
Numerous studies have shown that sexual minorities have higher risk of smoking tobacco and marijuana than heterosexuals. Delgado et al acknowledge 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.
Discussion and Results
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:
- The sample’s majority included GB servicemen that were enlisted during DADT, thus, they experienced the discriminatory policies before and during DADT.
- 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.
Delgado et al found there was no difference in stress levels of GB and heterosexual men. They hypothesized that 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, but the same trend 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 taken measures to make sure service members aren’t under great levels of stress.
Previous literature has shown that discrimination was a predictor to use alcohol, use tobacco, and have casual sex partners. Contrary to this, GB servicemen had lower likelihoods of all three considerations. A possible explanation is that being a GB serviceman reduces the propensity of engaging in such behaviors. Despite 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 of negative health behaviors. 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 (Delgado et al.).
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. (Delgado et al.)
Only recently have MSM been included in national health surveys, making it difficult to compare their previous health patterns and statistics.
More recently, the U.S. military has been taking more action in LBG healthcare. “Clinical Indicators Associated with HIV Acquisition in the United States Air Force” by Hannah et al is an example of such initiative by the DOD. This study conducted was within the United States Air Force (USAF) and gives a more specific insight into the LGB SMs data that authors have been yearning for for decades.
The USAF conducts HIV screenings every 2 years and for peri-deployment. 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. By the end of the study in 2011, there was a total of 462 cases of HIV, of which, 452 cases were of males (Hannah et al.).
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
- a history of STIs
The authors suggest 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. 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” (Hannah et al.).
The studies that are available only give a vague scope of the health of LGB SMs. With the information on the policies and attitudes in the U.S. military, the stress produced from a concealed sexual orientation seems like probable cause for many consequent negative behaviors. Though the correlation may not equal causation, there is a sure association between being a LGB SM and negative health (depression, anxiety, alcohol abuse or dependence, tobacco use, etc.). Accordingly, those with mental illnesses are prone to conduct riskier sexual behavior. Risky sexual behavior is the main culprit for HIV transmission, as individuals are not wearing condoms and are generally using substances prior to sexual intercourse. It almost seems as there is a nearly inevitable doom for discriminated LGB SMs’ health, with what information we know. However, as time goes on and acceptance for sexual minorities in the military progresses, the nation’s research on and healthcare for LGB SMs will improve drastically. USAF’s mandated 2 year screenings is a sign of progression in itself for a healthcare improvements.
Militaries have historically been homophobic and heternormative in culture, forcing those SMs of a different sexual orientation to hide in the shadows. Brian Cozart was one of many MSM to serve our country and be affected by HIV/AIDS. Just between 2004 and 2009, replacing LGBT SMs who were discharged under DADT costed $193.3 millions (Ramirez et al.). As the number of LGB SMs increase, methods of prevention for HIV/AIDS must be utilized. In addition to efforts for prevention, VAMCs must be held accountable in being equipped to practice optimal HIV/AIDS healthcare, especially after their acknowledgement of LGBs’ presence in the military. The VAMCs should consider improving their directives, treatment adherence assurances, and prevention methods. They could look at the previously applied methods from other studies and utilize a plethora of methods, such as mass media influence and free condom provision. The U.S. military is not weakened by its variety of sexual orientations, but it can be destroyed by a disease if the necessary action is not taken. As the military’s general mindset changes, the trust between sexual minority SMs and their VA healthcare providers will be greater, creating an environment where prevention and treatment can thrive with confidentiality and acceptance.
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