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The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding 2 Context for LGBT Health Status in the United States The current health status of lesbian, gay, bisexual, and transgender people of all races, ethnicities, ages, and social backgrounds can be understood only in cultural and historical context. To provide this context, this chapter reviews basic definitions and concepts concerning gender identity, gender expression, and sexual orientation; summarizes key historical events that have shaped contemporary LGBT culture and communities; describes the demography of LGBT people in the United States; and examines barriers to accessing health care for LGBT people. The chapter then presents a discussion of the case of HIV/AIDS as it relates to several important themes of this report. The final section summarizes key findings and research opportunities. DEFINING GENDER IDENTITY, GENDER EXPRESSION, AND SEXUAL ORIENTATION To discuss the context surrounding the health of LGBT populations, the committee has adopted working definitions for a number of key terms. Sex is understood here as a biological construct, referring to the genetic, hormonal, anatomical, and physiological characteristics on whose basis one is labeled at birth as either male or female. Gender, on the other hand, denotes the cultural meanings of patterns of behavior, experience, and personality that are labeled masculine or feminine. Gender Identity and Expression Gender identity refers to a person’s basic sense of being a man or boy, a woman or girl, or another gender (e.g., transgender, bigender, or gender
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The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding queer—a rejection of the traditional binary classification of gender). Gender identity can be congruent or incongruent with one’s sex assigned at birth based on the appearance of the external genitalia. Gender expression denotes the manifestation of characteristics in one’s personality, appearance, and behavior that are culturally defined as masculine or feminine. Gender role conformity refers to the extent to which an individual’s gender expression adheres to the cultural norms prescribed for people of his or her sex. Gender dysphoria refers to a discomfort with one’s sex assigned at birth (Fisk, 1974). This dysphoria can manifest itself in a persistent unease with one’s primary and secondary sex characteristics, a sense of inappropriateness in one’s gender role, and a strong and persistent identification with and desire to live in the role of the other sex, which has been classified as gender identity disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 2000). The term transgender has come to be widely used to refer to a diverse group of individuals who cross or transcend culturally defined categories of gender (Bockting, 1999); that is, they depart significantly from traditional gender norms. This group includes transsexuals (who desire or have had hormone therapy and/or surgery to feminize or masculinize their body and may live full time in the cross-gender role); cross-dressers or transvestites (who wear clothes and adopt a presentation associated with the other gender for emotional or sexual gratification, and may live part time in the cross-gender role); transgenderists (who live full time in the cross-gender role, may take hormones, but do not desire surgery); bigender persons (who identify as both man and woman, may take hormones, and may live part time in the cross-gender role); drag queens and kings (who dress in clothes associated with the other gender, adopt a hyperfeminine or hypermasculine presentation, and appear part time in the cross-gender role); and other identities, such as gender queer or two-spirit—a term used by some Native Americans for individuals who possess feminine and masculine qualities (who may or may not desire hormones or surgery, and may or may not live part or full time in the cross-gender role). Definitions of these categories vary and continue to evolve over time. The term transgender is increasingly used to encompass this family of gender-variant identities and expressions, but opinions on the term vary by geographic region and by individual. For example, some transsexual women differentiate themselves from those who self-identify as transgender to underscore that they are not gender variant or nonconforming, but instead identify unambiguously with the other gender. As explained in the previous chapter, a person whose gender identity differs from a male sex assignment at birth is often referred to as a male-to-female transgender woman. A person whose gender identity differs from a female sex assignment at birth is often referred to as a female-to-male
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The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding transgender man. For research purposes, transsexuals are more often the focus of study than other transgender groups since they are more likely to seek clinical intervention, making data on this subgroup more accessible (Rosser et al., 2007). Transgender people may be sexually oriented toward men, women, other transgender people, or any combination of these groups. There is no consensus in the research literature as to whether, when describing a transgender person’s sexual orientation, sexual orientation labels should be based on the person’s sex at birth or gender identity. However, transgender people themselves, especially those who live full time in the cross-gender role, more often than not anchor their sexual orientation on gender identity (e.g., a male-to-female transsexual woman who is attracted primarily to women is most likely to refer to herself as lesbian rather than heterosexual or straight) (Amercian Psychological Association, 2009a,b). Sexual Orientation The committee’s working definition of sexual orientation incorporates three core ideas. First, sexual orientation is about intimate human relationships—sexual, romantic, or both. These relationships can be actualized through behavior or can remain simply an object of desire. Second, the focus of sexual orientation is the biological sex of a person’s actual or potential relationship partners—that is, people of the same sex as the individual, people of the other sex, or people of either sex. Third, sexual orientation is about enduring patterns of experience and behavior. A single instance of sexual desire or a single sexual act generally is not regarded as defining an individual’s sexual orientation. Based on these considerations, the committee adopted the following working definition: sexual orientation refers to an enduring pattern of or disposition to experience sexual or romantic desires for, and relationships with, people of one’s same sex, the other sex, or both sexes. As this definition makes clear, sexual orientation is inherently a relational construct. Whether a sexual act or romantic attraction is characterized as homosexual or heterosexual depends on the biological sex of the individuals involved, relative to each other. One’s sexual orientation defines the population of individuals with whom one can potentially create satisfying and fulfilling sexual or romantic relationships. Such relationships help to meet basic human needs for love, attachment, and intimacy and are, for many people, an essential aspect of the self (Herek, 2006; Peplau and Garnets, 2000). This working definition encompasses attraction, behavior, and identity. As explained in Chapter 3, most researchers studying sexual orientation have defined it operationally in terms of one or more of these three components. Defined in terms of attraction (or desire), sexual orientation is
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The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding an enduring pattern of experiencing sexual or romantic feelings for men, women, transgender persons, or some combination of these groups. Defined in terms of behavior, sexual orientation refers to an enduring pattern of sexual or romantic activity with men, women, transgender persons, or some combination of these groups. Sexual orientation identity encompasses both personal identity and social identity. Defined in terms of personal identity, sexual orientation refers to a conception of the self based on one’s enduring pattern of sexual and romantic attractions and behaviors toward men, women, or both sexes. Defined in terms of social (or collective) identity, it refers to a sense of membership in a social group based on a shared sexual orientation and a linkage of one’s self-esteem to that group. Although sexual attractions and behaviors are generally understood as ranging along a continuum from exclusively heterosexual to exclusively homosexual (Kinsey et al., 1948, 1953), sexual orientation is often discussed according to three main categories, especially when it is defined in terms of identity: (1) heterosexuality (for individuals who identify as, for example, “straight” or whose sexual or romantic attractions and behaviors focus exclusively or mainly on members of the other sex); (2) homosexuality (for individuals who identify as, for example, “gay,” “lesbian,” or “homosexual” or whose attractions and behaviors focus exclusively or mainly on members of the same sex); and (3) bisexuality (for individuals who identify as, for example, “bisexual” or whose sexual or romantic attractions and behaviors are directed at members of both sexes to a significant degree). Which of these categories is used in a particular study or health intervention will depend on the research or treatment goals. Individuals may also have a specific attraction toward transgender persons (Coan et al., 2005; Operario et al., 2008; Weinberg and Williams, 2010). Some research suggests that within the subgroup of individuals identifying as bisexual, there exists considerable variability in self-identified orientation and identity groups. While some bisexual individuals exhibit approximately equal attraction to males and females, others exhibit varying levels of preference for one sex or another (Herek et al., 2010). Similarly, bisexual individuals may exhibit differing degrees of heterosexual, homosexual, or bisexual identity, identifying with all groups equally or more strongly with one than the others (Weinrich and Klein, 2002; Worthington and Reynolds, 2009). Individuals vary in the extent to which their behavioral history and patterns of sexual attraction fit neatly within one of the three main sexual orientation categories. As explained in Chapter 3, most adults exhibit consistency across the three categories (e.g., they are exclusively heterosexual or homosexual in their attractions, sexual behavior, and self-labeled identity), but some do not. Moreover, the ways in which people use identity labels—such as gay and bisexual—often vary among cultural, racial, ethnic,
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The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding socioeconomic, and age groups. They may also vary from one situation to another and change over time. In addition, new labels and identities emerge over time in conjunction with societal changes. Since the 1960s, for example, “gay” has become a more widely used identity label than terms such as “homosexual” and “homophile.” More recently, some individuals have adopted the term “queer”—long a derogatory epithet used for gay, lesbian, and bisexual individuals—as a positive self-label. In addition, adolescents and young adults have coined a variety of alternative labels, such as “boi-dyke” and “omnisexual.” Nevertheless, the labels “gay,” “lesbian,” and “bisexual” remain widely used by both adolescents (Russell et al., 2009) and adults (Herek et al., 2010). Variations in Sexual Orientation Empirical research shows that men and women overlap considerably in their experiences of sexual desire and behavior. In some aspects of sexuality, however, the experiences of men and women may be more likely to differ, and these areas may have implications for health. Three examples are highlighted here. First, on average, men tend to show greater interest in sex and express a desire to engage in sex more frequently than women; these patterns appear to occur in both heterosexual and homosexual populations (for a review, see Baumeister et al., 2001). In self-reports, for example, the frequency of solitary masturbation, which is a useful indicator of sexual interest insofar as it is not constrained by the availability of a partner, is generally higher among men than women (Oliver and Hyde, 1993), and this pattern appears among nonheterosexual as well as heterosexual individuals (Laumann et al., 1994a,b). Second, on average, sexual-minority men and women may differ in their early experiences of their sexuality. Overall, lesbians appear to display greater variability than gay men in the age at which they recall reaching various developmental “milestones,” such as awareness of same-sex attractions, experience of same-sex fantasies, and first pursuit of same-sex sexual contact (for a review, see Diamond, 2008). Data from a 2005 national probability sample reveal that gay men (n = 241) recalled recognizing their homosexual orientation at a significantly earlier average age than lesbians (n = 152) or bisexual women (n = 159), while the average age for bisexual men (n = 110) was between that of women and gay men (Herek et al., 2010). Third, compared with that of men, women’s sexuality may be more likely to be shaped and altered by cultural, social, and situational influences over time (Baumeister, 2000). As a group, women may exhibit greater
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The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding fluidity in their sexuality than men; that is, they may be more likely to experience changes over the life span in their patterns of sexual attraction. As Diamond (2008, p. 3) notes, “This flexibility makes it possible for some women to experience desires for either men or women under certain circumstances, regardless of their overall sexual orientation … women of all orientations may experience variation in their erotic and affectional feelings as they encounter different situations, relationships, and life stages.” These examples of gender-linked patterns suggest that, on average, men and women may experience some aspects of their sexuality differently. As noted above, however, the sexes overlap considerably on these dimensions. The extent to which patterns of same-sex sexual behavior differ across racial and ethnic groups is not clear. Using data from the General Social Survey, Turner and colleagues (2005) found that different racial groups did not differ in the extent to which they reported having engaged in same-sex sexual activity since age 18. Using data from the 2002 National Survey of Family Growth, however, Jeffries (2009) found that non-Mexican Latino men were significantly more likely than non-Latino white men to ever have had anal sex with a male partner and were significantly more likely than non-Latino black men to have had oral sex with a male partner. These relationships remained significant after controlling for age, education, and foreign birth. Chae and Ayala (2010) examined data from the National Latino and Asian American study, a national probability household sample of Latino and Asian adults over 18 years of age residing in the United States (n = 2,095 Asian and 2,554 Latino respondents, including 101 Asians and 111 Latinos reporting same-sex behavior during the previous 12 months). They found that 6.2 percent of Asian respondents reported any same-sex behavior during the previous 12 months, compared with 3.9 percent of Latino respondents. Because the authors reported no confidence intervals, however, comparison across the groups is difficult. As highlighted by the concept of intersectionality, the experience of being a sexual minority is influenced by an individual’s other identities. Thus, the experience of being lesbian, gay, or bisexual appears to vary according to the racial or ethnic group with which one identifies. Chae and Ayala (2010) compared Latino and Asian American respondents who were “LGB-identified” (i.e., self-labeled as homosexual, lesbian, gay, or bisexual) and “non-LGB-identified” (i.e., reporting same-sex behavior during the previous year but not self-labeling as homosexual, lesbian, gay, or bisexual). They found considerable heterogeneity between Asian and Latino respondents, with most participants identified as sexual minorities within the sample not self-identifying as LGB. Furthermore, they found an association between identifying as a sexual minority and psychological distress. There were variations within the two ethnic groups, with participants of
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The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding Chinese ancestry more likely than members of other Asian ethnic groups to identify as LGB, and participants of Mexican ancestry less likely than other Latino respondents to identify as LGB. In addition, socioeconomic status was associated with LGB identification: LGB-identified respondents of Asian ancestry were more likely to be employed than their non-LGB-identified counterparts, and non-LGB-identified Latinos had lower levels of education than LGB-identified Latinos (Chae and Ayala, 2010). Another study, conducted in Houston, Texas, with a nonprobability sample of 1,494 black, Latino, Asian, and white men and women, found that concordance rates between sexual behavior and identity varied across racial and ethnic groups (Ross et al., 2003). Other data indicate that black men who have sex with men are less likely than white men who have sex with men to self-identify as gay (Chu et al., 1992; Doll et al., 1992; Goldbaum et al., 1998; Kramer et al., 1980; McKirnan et al., 1995, 2001; Montgomery et al., 2003; O’Leary et al., 2007; Torian et al., 2002) and are more likely to engage in sexual behavior with both males and females (Flores et al., 2009). Among adults who self-identify as lesbian, gay, or bisexual, self-identified bisexual men appear to be more likely than others to be black or Latino. A 2005 survey with a national probability sample of self-identified lesbian, gay, and bisexual adults found that only 43 percent of the bisexual men were non-Latino white, compared with more than 70 percent of the gay men, lesbians, and bisexual women. Whereas the racial and ethnic characteristics of the lesbian subsample generally corresponded to those of the U.S. adult population, the proportion of non-Latino whites was higher among self-labeled bisexual women than in the national population (Herek et al., 2010). Consistent with this pattern, black lesbian, gay, and bisexual adults appear to be less likely than those of other races to disclose their sexual orientation in the workplace (Herek et al., 2010). Black men who have sex with men are less likely than other men who have sex with men to join gay-related organizations (Kennamer et al., 2000; Stokes and McKirnan, 1996). Black men who have sex with men also appear less likely than their counterparts of other races to disclose their same-sex behavior or sexual orientation identity to others (CDC, 2003; Kennamer et al., 2000; McKirnan et al., 1995; Stokes and McKirnan, 1996). Another study found that as education increased, white men who have sex with men were more likely to disclose their sexual identity, but black men who have sex with men were substantially less likely to do so (Kennamer et al., 2000). Research with black lesbian and bisexual women suggests that disclosure of sexual orientation varies according to several factors, including whether one’s sexual orientation identity is considered more important than one’s racial identity (Bowleg et al., 2008). In a convenience sample of New York City youths recruited from community organizations and local colleges
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The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding (n = 156 youths aged 14–21), black participants reported less disclosure of their identity than white participants (Rosario et al., 1996). A study examining gender identity affirmation among 571 male-to-female transgender persons focused on gender disclosure in six relationships—with parents, siblings, friends, fellow students, work colleagues, and sexual partners. The authors found that, compared with non-Latino whites, nonwhites had fewer relationships in which they were able to disclose their transgender identity, yet in the relationships available to them, they were more likely to disclose and to receive affirmation of their transgender identity (Nuttbrock et al., 2009). HISTORICAL PERSPECTIVE Contemporary health disparities based on sexual orientation and gender identity are rooted in and reflect the historical stigmatization of LGBT people. Most LGBT people encounter stigma from an early age, and this experience shapes how they perceive and interact with all aspects of society, including health-related institutions. Likewise, heterosexual people (including many health care professionals) have been socialized in a society that stigmatizes sexual and gender minorities, and this context inevitably affects their knowledge and perceptions of LGBT people. And institutions and systems that affect the health of LGBT people have evolved within a society that has historically stigmatized those populations, and this has important implications for their ability to address the needs of sexual and gender minorities. Although an extensive discussion of the history of LGBT populations is beyond the scope of this report, this section highlights some key historical themes relevant to the current health status of LGBT individuals. Specifically, this section describes how LGBT individuals have been marginalized through the law and through psychiatric diagnoses, how they have been affected by the AIDS epidemic, and how their current legal status has evolved. In addition, this section notes some ways in which LGBT individuals’ responses to their differential treatment and stigmatized status have implications for their health. Insofar as contemporary notions of sexual orientation and gender identity have their origins in the beginning of the twentieth century, this historical review focuses mainly on the past 100 years. Lesbian, Gay, and Bisexual History Inversion, Homosexuality, and the Origins of Contemporary Notions of Sexual Orientation Although heterosexual and homosexual behaviors and attractions are ubiquitous across human societies, the idea that individuals can be mean-
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The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding ingfully defined or categorized in terms of their patterns of sexual attraction and behavior emerged in science and medicine only in the nineteenth century. When this discourse emerged, its initial focus was on individuals who were perceived as deviating from cultural definitions of gender and sexual “normalcy.” The category of “the sexual invert” historically preceded that of “the homosexual” as a target for medical and scientific scrutiny. During the 1860s, Ulrichs proposed that male inverts, or “Urnings,” should be understood as “individuals who are born with the sexual drive of women and who have male bodies” (Ulrichs, 1994b, vol. 1, p. 35). Hirschfeld supported this argument and later posited that inverts represented an intermediate sex, reflecting both male and female qualities (Hirschfeld, 2000). Sexual inversion originally described the individual in totality, with sexual conduct being only one of various aspects (Chauncey, 1982–1983). Male inverts were believed to possess “feminine” qualities, including passivity, weakness, and sexual attraction to “masculine” males. Female inverts were believed to manifest “masculine” qualities, including an active interest in sexuality—an abnormal quality in the eyes of a society that believed femininity was inherently passive (Chauncey, 1982–1983). The modern notion of sexual orientation—defined in terms of whether one’s sexual attractions and interest are directed toward men or women—is usually traced to Sigmund Freud (Freud, 1953). He introduced a distinction between the sexual aim (i.e., preferences for particular types of sexual activity) and the object toward which that aim is directed. Freud’s theory and clinical practice focused on the sexual object, with “homosexuals” and “heterosexuals” being understood entirely in terms of their sexual object (respectively, a person of the same or the other sex). The construct of “the invert,” which focused on the individual’s sexual aim (passive sexuality among male inverts, active sexuality among females), fell into disuse (Chauncey, 1982–1983; Freud, 1953). However, the modern construct of “transgender” has similarities to the notion of sexual inversion insofar as both involve crossing socially defined boundaries of gender.1 Homosexual Conduct as a Crime, Homosexuality as a Diagnosis Throughout much of the twentieth century, consensual same-sex sexual behavior was illegal, and homosexuality was considered a form of mental illness. This dual stigma historically attached to homosexual behaviors and persons has, as noted earlier, shaped the experiences of many people living today and has influenced many contemporary institutions that affect health. 1 Personal communication, J. D’Emilio, University of Illinois, Chicago, October 22, 2010.
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The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding Long before Freud articulated his theory of sexuality, theological doctrine and secular law sought to regulate sexual behaviors and attached punishments to a variety of sex acts that were nonprocreative or occurred outside of marriage. Proscribed sexual behaviors were often referred to collectively as sodomy, a term that was not clearly defined in most religious and legal texts but included homosexual behavior as well as other nonprocreative and extramarital sexual acts (Jordan, 1997). U.S. sodomy laws, which existed in all of the states until 1961, when Illinois eliminated its statute, were the legacy of these prohibitions. Their language varied from state to state, and they outlawed various types of sexual behavior, including some forms of homosexual behavior. The main effect of sodomy laws was not prosecution for homosexual acts—such prosecutions were relatively infrequent. However, the laws were regularly used to justify differential treatment of sexual minorities in a variety of arenas, including employment, child custody, and immigration (Leslie, 2000). The expansion of discourse about sexuality from the domains of law and theology into medicine, psychiatry, and psychology was considered a sign of progress by many at the time because it offered the hope of treatment and cure (rather than punishment) for phenomena that society generally regarded as problematic. Nevertheless, after Freud, the division of people into “heterosexuals” and “homosexuals” involved stigmatization of the latter. Many early physicians and sexologists regarded homosexuality as a pathology, in contrast to “normal” heterosexuality (e.g., Krafft-Ebing, 1900), although this view was not unanimous (e.g., Ellis, 1901; Ulrichs, 1994a). Freud himself believed that homosexuality represented a less than optimal outcome for psychosexual development, but did not believe it should be classified as an illness (Freud, 1951). In the 1940s, however, American psychoanalysts broke with Freud, and the view that homosexuality was an illness soon became the dominant position in American psychoanalysis and psychiatry (Bayer, 1987). Thus by the beginning of World War II, sodomy laws continued to criminalize same-sex sexual behavior, even when it occurred in a private setting between consenting adults, while psychiatry and psychology generally regarded homosexuality as an illness. Around this time, the illness model became part of government personnel policies when the U.S. military incorporated psychiatric screening into its induction process and developed formal procedures for rejecting homosexual recruits. Whereas same-sex sexual behavior previously had been classified as a criminal offense under military regulations prohibiting sodomy, the armed services now sought to bar homosexual persons from their ranks (Berube, 1990). However, the screening process was often superficial, especially during the early years of the war when troops were desperately needed. Indeed, many lesbians and gay men served successfully in the military, often with the knowledge
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The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding of their heterosexual comrades (e.g., Berube, 1990; Black et al., 2000; Menninger, 1948). When the need for recruits diminished during the war’s waning years, however, policies prohibiting homosexual personnel were more vigorously enforced, and many gay men and lesbians received undesirable discharges as sexual psychopaths (Berube, 1990). Such discharges had severely negative consequences. Denied benefits under the GI Bill of Rights and socially ostracized in civilian life, gay and lesbian veterans with undesirable discharges often could not secure employment. As Berube (1990, p. 229) notes, “Sometimes their lives became so unbearable as exposed homosexuals that they had to leave home or tried to kill themselves.” Ironically, the mass courts martial and discharges may have contributed to the development of modern lesbian and gay communities in U.S. urban centers. D’Emilio (1983) observed that, rather than returning to their hometowns after the war, many men and women chose to settle in major port cities and centers of war industry, such as Los Angeles, San Francisco, and New York. Still others later migrated to these cities to join the growing communities. Thus, large gay communities began to emerge in many American cities after World War II ended. Although gay and lesbian civilians often found some degree of tolerance in the relative anonymity of these large cities, they nevertheless experienced negative consequences related to stigma. Because of the criminalization of homosexual acts and the stigmatization of homosexual identity, local police generally had the freedom to harass and pursue gay men and lesbians at will. Sexual minorities risked arrest when they gathered, even in private homes. Gay bars provided a venue for gay men and lesbians to socialize openly, but they also served as targets for harassment. Police raids were common, with bar patrons routinely being charged with offenses such as disorderly conduct, vagrancy, public lewdness, and solicitation (Boyd, 2003; Johnson, 2004). At the national level, a U.S. Senate committee issued a 1950 report concluding that homosexuals were not qualified for federal employment and that they represented a security risk because they could be blackmailed about their sexuality (Subcommittee on Investigations of the Senate Committee on Expenditures in the Executive Departments, 1950). In response to this report, President Eisenhower issued an executive order dismissing all homosexuals from federal employment, both civilian and military. Reporting on the government’s campaigns against gay, lesbian, and bisexual employees by daily newspapers across the country reinforced the anxiety experienced by sexual minorities (D’Emilio, 1983). In 1952, the newly created DSM listed homosexuality as a sociopathic personality disturbance, along with substance abuse and sexual disorders (American Psychiatric Association, 1952; Bayer, 1987). This classification of homosexuality was used as the basis for laws and regulations that denied
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