This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike License. Your use of this
material constitutes acceptance of that license and the conditions of use of materials on this site.
Copyright 2010, The Johns Hopkins University and David Jernigan. All rights reserved. Use of these materials
permitted only in accordance with license rights granted. Materials provided “AS IS”; no representations or
warranties provided. User assumes all responsibility for use, and all liability related thereto, and must independently
review all materials for accuracy and efficacy. May contain materials owned by others. User is responsible for
obtaining permissions for use from third parties as needed.
Sex, sexuality and health
Class overview
  Move from discussion of gender and sex
to discussion of sexuality and health
  View through lens of social stigma,
understand kinds and effects of social
stigma
  Use as an example to illustrate role of
social factors as determinants of health
problems
Case example: HIV
  Public health and sex
  Sexuality and behavior
  Gender socialization plays significant role
  Nexus of gender role inequality
  Communication and conflict resolution
styles
  Boys – more likely to use physical dominance
  Girls – more likely to use verbal persuasion
Case example: HIV
  Risk reduction (using a condom)
  Action by male
  Persuasion by female
  Pleck et al. 1993 – even after controlling for SES and
personal background, boys with traditional attitudes
towards masculinity had







More sexual partners in past year
Less intimate relationship at time of intercourse
Greater belief M-F relationships are adversarial
More negative attitudes towards condom use
Less current use of condoms
Less belief in male responsibility to prevent pregnancy
Greater belief pregnancy validates masculinity
Case example: HIV
  Most research ignores female experience of sex
  Models inclusive of female experience of sex
incorporate understanding of:
  Women’s history and current experience with
presence of threats and violence in relationships
(22% of women polled report assault by intimate
partner at least once)
  Women’s fear – including fear occurring in response
to condom negotiation
  Male attitudes regarding violence and abusive
behaviors towards women
  Male history of threats or violence against women
Source: Amaro 1995
Bridging to sexuality
  Public health and sex
  The personal is political AND has health
implications
  Sexuality is personal
  Sexuality is complex
  Some sexualities are stigmatized
Stigma
  Erving Goffman 1963: Stigma: Notes on the
Management of Spoiled Identity
  Life is role-playing – everyone manages their
identities
  Two kinds of stigma
  Discrediting – immediately visible – we “know the rules” of
the interaction
  Discreditable – not immediately visible – issue less of
managing interaction than of managing information
  Both forms important in thinking about health status of
populations
Three examples
  Homeless
  More likely to be discrediting than
discreditable
  Disabled
  Can be discrediting or discreditable
  GLBTQ
  Mostly discreditable
  “T” issues particularly critical and challenging
GLBTQ
  What is “gay”?
  What kinds of actions provoke gay
oppression?
  What are the social norms at stake in
existence and enforcement of gay
identities?
Source: ILGA, Creative Commons BY-ND
GLBTQ Health:
Areas of concern
(1) areas in which LGBT people are at an
increased risk for disease because of unique
exposures,
(2) areas in which they have high prevalences of
diseases or problems that are not caused by
unique exposures,
(3) areas in which they are not at increased risk for
disease but which nevertheless require
specialized culturally competent approaches.
GLBTQ and Health: Overview
  Research challenge due to disclosure
issues
  Samples often biased
  Self-reporting may be less reliable
  Health risks:
  Violence (external and domestic)
  Mental health issues (arrows of causation?)
  HIV/AIDS
  “MSMs”
GLBTQ and Health
  “MSMs” – what is this category?
  Is HIV the only health problem here?
  Stall et al. 2003: Focus on HIV/AIDS masking
“syndemic” of other psychosocial health conditions
among MSMs:
  Polydrug use
  Depression
  Partner violence
  Childhood sexual abuse
  Conditions mostly in significant relationships with each other
  Accumulation of conditions increases HIV risk
GLBTQ and Health:
Costs of a managed identity
  Mental and physical consequences of nondisclosure
  Gay men with concealed identities at greater risk of:
  Cancer
  Infectious diseases
  Faster progression of HIV infection
  ATOD use
  GB men twice as likely, LB women four times as likely
to have used marijuana in past year
  GB men three times, LB women four times more likely
to have used ecstasy in past year
  GLBQs more likely to smoke than general population
GLBTQ and Health
  Increased risk for CVD
  Lesbians




Higher rates of smoking
Higher body mass on average than heterosexual women
Less likely to report routine Pap smears
Increased risk of lung, cervical, other cancers
  Access to health care as management issue
  Transpersons
  Need help for sex-based problems that are not readiliy apparent
due to visible gender identity
  May be missed in routine screening due to visible gender identity
  Deprivation of social supports in times of health care
crisis
  Lack of legal protections for visitation, decision-making, funeral
preparations, etc.
  SES: denial of fiscal rights, exacerbation of genderbased income differentials
Source for this and preceding slide: Lombardi and Bettcher in Levy and Sidel 2006
GLBTQ and Health
  Societally-imposed definitions of identity
  Medicalization
  Culture-bound interpretations of both gender
and sexual behavior, and interactions of these
with other social categories such as race
  Conflation of sexual orientation and gender
orientation
  Assumptions about relationships between behavior
and identity
  Discomfort with sexuality generally – “don’t ask,
don’t tell”
Populations with discreditable stigma:
common features
  “Wish they would just go away”
  Health status inextricably linked to social
definitions of, assumptions about population
  Access to care influenced by stigma
  Health gains come through social movements
  ACT-UP
  Disability Rights Movement
  Homeless rights and organizing groups
  Health gains come through changes in social
policies