By Brian Mustanski, Ph.D.
Director, Institute for Sexual and Gender Minority Health and Wellbeing
Co-Director, Third Coast Center for AIDS Research
Co-Director, Center for Prevention Implementation Methodology
Professor, Department of Medical Social Sciences
Member, National Advisory Council on Minority Health and Health Disparities
In June 1969, the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community led historic riots against discriminatory police raids of the Stonewall Inn, a gay bar in Greenwich Village. The Stonewall riots galvanized the LGBTQ community to come together in a nationwide movement in pursuit of equality.
Growing up as a young gay man in Minnesota, I had no knowledge of Stonewall. With the Internet still in its infancy, there were limited resources to learn about the LGBTQ community. I resorted to secretly reading my high school encyclopedia’s entry on “homosexuality,” which that edition still described as a psychiatric disorder. Media coverage of homosexuality was dominated by the emerging AIDS crisis. I often heard people say, “AIDS is God’s punishment.” With no access to alternative information, it was hard to reject these messages.
Years later, I began pursuing a career in science. My undergraduate faculty mentor warned me not to “come out,” as it could hurt my chances of graduate admission. Evidence is just emerging on how sexual and gender minority (SGM) people experience structural and interpersonal barriers to STEM careers.1
In graduate school, I was heavily impacted by a report showing that the majority of SGM teens came out online before they did in the “real world.”2 This information emerged alongside evidence of alarmingly high HIV prevalence among young gay and bisexual men.3 It was then that I realized that the Internet might be the only way to reach this group with resources and education at a critical point: before they may be at risk of HIV.
e-Health approaches to HIV prevention have continued to be a major focus of my research—particularly with young gay and bisexual men, among whom HIV diagnoses continue to increase.4 In 2018, my team published the first study to show significant effects of an e-Health HIV prevention program on a biomedical outcome (sexually transmitted infections),5 and we’re studying implementation of the program nationally.6 With support from NIMHD, my team is studying a package of developmentally adapted e-Health HIV prevention programs for teenage gay/bisexual boys.6 Both projects are simultaneously studying implementation and effectiveness to quickly move evidence into practice.7
HIV research on gay/bisexual men represents the majority of NIH funding for SGM health.8 But research on the entire SGM community is critical if we are going to remediate health disparities. For example, despite being at increased risk, lesbian and bisexual women are less likely to receive cancer screenings.9 Transgender people are more likely to be uninsured, experience rampant discrimination in health care settings, and delay care as a result of that stigma.10
These aren’t just disturbing statistics—they are devastating realities. At the root of this inequity is the same discrimination that the Stonewall activists rioted against 50 years ago. We are only beginning to uncover how prejudice and discrimination “get under the skin,”11 with toxic effects on SGM health.
That’s not to say we haven’t seen progress. SGM representation in STEM disciplines is becoming more of a priority. My academic home, Northwestern University, appointed me as director of the first university wide institute focused exclusively on SGM health and well-being (ISGMH). In 2016, through the leadership of NIMHD Director Dr. Pérez-Stable, the National Institutes of Health formally recognized our community as a health disparity population for research purposes, opening up new doors for research funding.
But movement often feels like two steps forward and one step back. SGM-focused data collection, which is critical to understanding the health needs of our community, may be discontinued from federal surveys. Our online outreach is increasingly met with hateful messages (e.g., “You deserve extermination”) that we have never seen at this frequency before.
The Healthy People 2020 report ended on a powerful conclusion—that “understanding LGBT health starts with understanding the history of oppression and discrimination that these communities have faced.” This Pride Month, 50 years after Stonewall, we’ll reflect on that history and celebrate our resilience. We’ll also continue to push forward and commit to continuing to advance SGM health equity.
1 Freeman, J. (2018). LGBTQ scientists are still left out. Nature, 559(7712), 27–28. doi:10.1038/d41586-018-05587-y.
2 Kryzan, C., Walsh, J., !OutProud!, The National Coalition for Gay, Lesbian, Bisexual, and Transgender Youth, & Oasis Magazine. (1998). !OutProud!/Oasis Internet Survey of Queer and Questioning Youth, August to October 1997.
3 Valleroy, L. A., MacKellar, D. A., Karon, J. M., Rosen, D. H., McFarland, W., Shehan, D. A., . . . Janssen, R. S. (2000). HIV prevalence and associated risks in young men who have sex with men. Young Men’s Survey Study Group. JAMA, 284(2), 198–204. doi:10.1001/jama.284.2.198.
4 Centers for Disease Control and Prevention. (2018). Estimated HIV incidence and prevalence in the United States, 2010-2015. HIV Surveillance Supplemental Report, 23(No. 1).
5 Mustanski, B., Parsons, J. T., Sullivan, P. S., Madkins, K., Rosenberg, E., & Swann, G. (2018). Biomedical and behavioral outcomes of Keep It Up!: An eHealth HIV prevention program RCT. American Journal of Preventive Medicine, 55(2), 151–158. doi:10.1016/j.amepre.2018.04.026.
6 Institute for Sexual and Gender Minority Health and Wellbeing (ISGMH). (n.d.). Keep It Up!
7 Curran, G. M., Bauer, M., Mittman, B., Pyne, J. M., & Stetler, C. (2012). Effectiveness-implementation hybrid designs: Combining elements of clinical effectiveness and implementation research to enhance public health impact. Medical Care, 50(3), 217–226. doi:10.1097/MLR.0b013e3182408812.
8 National Institutes of Health. (2018). Sexual & gender minority research portfolio analysis (FY 2016).
9 American Cancer Society. Cancer facts for lesbians and bisexual women. (2018).
10 Centers for Disease Control and Prevention. (2018). Patient-centered care for transgender people: Recommended practices for health care settings.
11 Hatzenbuehler, M. L. (2009). How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychological Bulletin, 135(5), 707–730. doi:10.1037/a0016441.