HIV/AIDS in the U.S. Military

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.

Policies

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”:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.).
  6. 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.
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. LGB veterans that served under such discriminatory policies had higher rates of depression, substance abuse, suicidality, and post-traumatic stress disorder (PTSD), compared to non-LGBT counterparts. (Ramirez et al.).

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.).

Study 1

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.

Sexual Behavior

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 source states that the prevalence of remaining risky sexual behaviors demonstrates the need to implement HIV prevention in patients’ medical care.
Looking at the data provided in a study of HIV-infected civilians reveals the statistics in alcohol use, mental health, and sexual health and complications that could occur or ongoing issues from such indications. With such available research, it is possible that predictions can be made about HIV-infected SMs. If depression rates are high in HIV-infected civilians and depression leads to treatment non-adherence, those under such circumstances are likely to die. Almost half of the infected patients were MSM. This is an alerting percentage that, if applied to the military, would cause an epidemic in the armed forces.

 

Study 2

“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.).

Stress

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.).

Discrimination

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:

  1. The sample’s majority included GB servicemen that were enlisted during DADT, thus, they experienced the discriminatory policies before and during DADT.
  2. 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.
  3. 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.)

Study 3

Only recently have MSM been included in national health surveys, making it difficult to compare their previous health patterns and statistics.

Mental Health Disorders
According to Campbell et al. in “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,” 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.  MSM have higher rates of intimate partner violence (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. However, study found an association between depression and the concealment of sexual orientation in the military. (Campbell et al.).
Substance Abuse
As seen earlier in this essay, many studies involving illegal and legal substance abuse is focused on nonmilitary MSM. In a study with civilian MSM, 57% binge drank alcohol in the past 30 days, that is, had an occurrence where they drank 5 drinks in a 2-hour period.
In a survey of 226 LGB SMs, 63% were male and exhibited a higher rate of depression, anxiety, and PTSD rates when they showed alcohol dependence. Generally, MSM demonstrated higher tobacco use than non-sexual minorities by roughly 11.9%. According to the LGBT “National Tobacco Control Network, the LGBT community is approximately 50% to 100% more likely to be addicted to tobacco” (Campbell, et al.).
This study shines light on the small information we have on LGB SMs and their mental, physical, and sexual health. All aspects of sexual minority SMs seem to be at a risk of a list of complications, however, some of these statistics for sexual minority SMs must be based on the only applicable research available: LGB civilians. With such limitations, it is possible that these numbers may not apply to the SMs because of numerous different circumstances between civilian and armed forces, but it is also likely that there are similar patterns in such negative health behaviors and risks.

Study 4

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.).

Results

Five indicators had notably higher odds of HIV infection:

  1. having signs of HIV infection
  2. clinical syndrome consistent with HIV infection
  3. a clinical syndrome consistent with HIV
  4. more frequent medical encounters
  5. clinical history of a mental health disorder
  6. 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.

Prevention

With increasing numbers of LGB SMs enlisting into the military, there leads a fear of a HIV/AIDS spike in the community. The potential increase in costs for HIV treatment frightens many militaries into working towards effective HIV prevention in hopes of a lower rate of infection.
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 (Hannah et al.). As the U.S. military has expanded its policies for sexual minorities, it has increased the need to employ effective prevention methods. However, the extent of the efficiency is usually unspoken of.

Study 1

Summary
The Department of Veterans Affairs (VA), being the largest provider for HIV health care services, launched a national quality improvement program to be assess their facilities (Yano et al.). 118 VA facilities with senior HIV clinicians were given surveys discussing staffing, approaches, and delivery of HIV health services. The 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 (Yano et al.).
Results
The background for gathering the data and other collected information can be summarized briefly here. Only a few VAMCs wrote any HIV-related directives, policies, or programs for treatment adherence. Commonly, programs were interventions 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 (Yano et al.).
It is assumed that the costs and processes to treat HIV in the medical field will continuously accelerate (Yano et al.). Consequently, understanding the environment and its organization in the health care services is important to improve quality and must be done routinely.
Yano et al’s study denotes the VA’s initiative towards HIV treatment and prevention. From the numbers, it appears that there is still much improvement to be made in these components of healthcare. Patient behavior reappears, but in this case it is involved in the treatment of HIV, rather than the information for HIV negative MSM. The connection between behavior and HIV/AIDS begins to be clearer because of this. Much of the focus on this study is on the treatment of HIV, rather than the prevention of it, but the low percentages give hints that HIV needs to be viewed with higher regard in VAMCs.

Study 2

“Protecting Our Militaries: A Systematic Literature Review of Military Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome Prevention Programs Worldwide” is one publication that explores the limited journals about specific HIV/AIDS intervention applied to the military. A more detailed description of the study and its variance in forms (multiple sessions/approaches, single session/approach, mass media, etc.) of HIV/AIDS prevention can be found here.
Results
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.
This source gives a hopeful global view beyond the U.S. military, featuring a nearly perfect percentage of prevention education in the participating countries. This indicates that throughout the nations, HIV/AIDS is known and most militaries are putting forth effort to educate their soldiers. Multiple attempts with variations have been attempted as time has gone by, also exhibiting various militaries’ work towards prevention. Unfortunately, it has still been difficult to determine the most effective prevention method for soldiers. With time, it is predicted that HIV prevention will become common practice amongst soldiers.

Study 3

About 44.8% of 4,217 civilian patients discussed in an aforementioned study, “Behavioral and Clinical Characteristics of Persons Receiving Medical Care for HIV Infection — Medical Monitoring Project, United States, 2009”  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 (Blair et al.).
Though this study is based on civilians, it examines another method of prevention that could be applied to soldiers. However, this prevention applies to the stoppage of HIV-infection spread. Even under the circumstance that someone may already be HIV-positive, medical facilities can positively intervene with the continuation of HIV-infection spread by incentivizing patients with free condoms.
Prevention for HIV remains imperative in the cessation of HIV sharing. Whether the prevention takes place before or after infection, the efforts must consistently be applied. Before infection, those with clinical indicators should be targeted, in a non-discriminatory manner, and tested frequently. Different methods may work with certain individuals, if the variance is dependent on country. Globally, there are numerous nations that are working on HIV prevention. HIV can potentially be eradicated if the initial HIV infection can be prevented and paired with, like Blair et al’s study, infected persons practice healthy sexual behavior.

Conclusion

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.

Works Cited

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.

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.

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.

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.

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 Care29, no. 6 (June 2017): 724–28. https://doi.org/10.1080/09540121.2016.1260086.

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

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.

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. https://doi.org/10.1080/10538720.2016.1263983.

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. https://doi.org/10.7205/MILMED.170.10.886.

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.

 

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