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. Author manuscript; available in PMC: 2021 May 31.
Published in final edited form as: J Bisex. 2020 Nov 11;20(3):251–272. doi: 10.1080/15299716.2020.1841478

Bi Us, For Us: Articulating foundational principles for research in partnership with bisexual communities

Lauren B Beach 1,2,*, Casey D Xavier Hall 1,2
PMCID: PMC8166211  NIHMSID: NIHMS1695772  PMID: 34075311

Abstract

Bisexual people comprise over half of all adults who identify as sexual minorities within the United States. Increasingly, population level health research has revealed that bisexual people face striking and broad-ranging health disparities compared not only to heterosexual people, but also often compared to their gay and lesbian peers. Despite the fact that bisexual people comprise an ‘invisible majority’ of LGBTQ people and are disproportionately impacted by poor health, the vast majority of funding dedicated to LGBTQ community organizing and to sexual and gender minority health research does not address the needs of bisexual people. Within this three-part article, we first describe how manifestations of systematic biphobia have led to the current situation where bisexual community organizations and bisexual health researchers are not granted adequate resources to address the health and health promotion of bisexual populations. In the second section, we articulate foundational ethical guiding principles and propose Bi Us, For Us, a new model to inform the design, evaluation, and implementation of intersectional bisexual community engaged research to inform the development of structural bisexual-specific health equity interventions. In the last section of this paper, we present the Chicago Bisexual Health Task Force as a case study of the model in action to illustrate a real-life approach that community engaged research and advocacy initiatives can take to promote bisexual health equity. We view this article as an invitation for dialogue about how to develop best practices to advance bisexual health equity and hope that it inspires additional bisexual people, organizers, and researchers to join in these pursuits.

Introduction

Bisexual health research has growing national attention. The Bisexual Health Research Workshop hosted by the National Institutes of Health (NIH) in September 2019 was the first ever convened to identify research opportunities to address the health of bi+1 populations (Health, 2019). The historic one-day workshop brought together 43 in-person attendees and 200 virtual attendees from the NIH, academia, government agencies, non-profit organizations, and community advocacy organizations. Scientific presentations from academic and governmental researchers showcased the increasing breadth and depth of bisexual population health research. Bisexual community stakeholders highlighted how research findings demonstrating the striking health disparities impacting bisexual populations at the intersections of sex, race, ethnicity, and gender identity informed their advocacy work. Throughout the day, however, bisexual community stakeholders emphasized critical flaws in the research infrastructure tied to the systematic marginalization of bisexuality, including the underrepresentation of bisexually identified researchers in science and the lack of bisexual community input throughout the research process. To begin the process of remedying these structural wrongs, bisexual community stakeholders cited a slogan popularized by disability justice movements (Andre, 2013; Charlton, 1998), “Nothing about us without us” (Health, 2019).

The emphasis bisexual community activists placed on prioritizing bisexual representation in health research came from firsthand knowledge that both lived experience and community knowledge are irreplaceable forms of expertise when it comes to creating coalitions to identify research priorities and to translate research into practice and policy. Bisexual stakeholders noted that when bisexual individuals and community stakeholders from diverse backgrounds are included in the design, conduct, interpretation, and dissemination of bisexual health research studies, the potential for positive impact of these studies increases exponentially. Indeed, for decades, bisexual community activists have demanded the meaningful representation of bisexual people and community issues in public health surveillance, research, and policy. From the early contributions of bisexual individuals to fight back against the HIV/AIDS epidemic in the 1980s (Cheltenham, 2015), to the lead role bisexual activists played in organizing the White House Bisexual Community Policy Briefing in 2015 (“Recognizing the Unique Challenges in the Bisexual Community,” 2015), to the development of local government and community coalitions to improve the visibility and health needs of local bisexual populations (“Bi+ Visibility Day,” 2019), bisexual community leaders have always helped to lead the fight to improve the health of bisexual people.

We view the NIH workshop as illustrating the challenges of addressing representation of the expertise of bisexual individuals, bisexual community stakeholders, and researchers of bisexuality within the research process. As individuals who hold more than one of these roles (bisexual+ self-identity, bisexual community stakeholder status, and bisexual health researcher), we are familiar with how such challenges manifest within scientific research enterprises. We have also witnessed how dynamic and complex power differentials tied to these roles/forms of expertise combine with systematic biphobia and intersectional oppression to shape which voices most influence decision-making in sexual and gender minority health research. As an acknowledgment of and response to the interlocking contexts of these challenges, both of us strive to apply community engaged research (CER) methods in our role as bisexual health researchers. From this context, we note that though many prior authors have published thoughtful social-justice informed models of CER, key tenets for effective community-engaged bisexual health research have not been expressly established. Therefore, given the overlapping though sometimes incongruous realities of bisexual community advocacy and bisexual health research, we seek to uplift a dialogue to:

  1. Problematize how biphobia contributes to systemic bi-erasure, lack of accountability to bisexual communities, lack of bisexual-specific funding and resources, and insufficient approaches to engage bisexual communities.

  2. Propose guiding principles and a CER-informed model tailored to bisexual communities to address deficits in bi-focused research.

  3. Describe a case study of the proposed guiding principles and model in practice in the city of Chicago.

Problematizing Current Practices: Etiologies and Manifestations of Biphobia in Bisexual Health Research

In the first part of this article, we articulate three intersecting problems that plague prevailing approaches to bisexual health research – especially when bisexual health research projects are centered in the larger context of LGBTQ community health research: systemic bi-erasure, a lack of accountability to bisexual communities, and the lack of bisexual-specific funding in research. In the last section, we reiterate not only how biphobia exacerbates general problems impacting health research, but also how biphobia shapes the engagement of bisexual communities in bisexual health research.

Systemic bi-erasure

A common prevailing problem that undermines successful bisexual health initiatives is the systemic erasure of bisexuality by both lesbian, gay, bisexual, transgender, queer (LGBTQ) organizers, and health researchers (Beach et al., 2018; M. R. Friedman et al., 2014; Kaestle & Ivory, 2012; Roberts, Horne, & Hoyt, 2015; Walters, 2013; Yoshino, 2000). The erasure of bisexuality or “bi-erasure” refers to the process by which bisexual people are rendered socio-politically invisible through the action and inaction of surrounding communities that uphold a prevailing view of sexual identity as binary (Yoshino, 2009). Bi-erasure is present in both LGBTQ organizing as well as health research practices in what legal scholar Kenji Yoshino has referred to as “the epistemic contract of bisexual erasure” (Yoshino, 2009). In the article, Yoshino highlights that bi-erasure exists across monosexual2 communities (whether heterosexual or gay/lesbian communities) and upholds values of monosexual communities that are perceived to be threatened by bisexuality (e.g. monogamy) (Yoshino, 2009).

Undergirding bi-erasure is the common viewpoint that bisexuality is not an integrated, whole, unique sexual identity, but rather an amalgamation of gay and straight identities (Beach et al., 2018; Roberts et al., 2015). This viewpoint forces bisexuality into an existence where the identity is defined by its proximity to existing monosexual identities (e.g. gay or straight) positing that bisexuality is to occupy one of these two social spaces at any given time. This is in opposition to “the third option” as Dr. Fritz Klein classically said or the understanding of bisexuality as a unique identity and experience (Beach et al., 2018; M. R. Friedman et al., 2014; Roberts et al., 2015). Not only does this erasure have implications for the recognition of identity, but also for understandings of power within LGBTQ communities.

The notion that bisexual people are some amalgamation of gay or straight contributes to the false idea that all people who occupy sexual minority communities are impacted by stigma and oppression in a uniform way in the form of homophobia. By positioning bisexual identity as “part oppressor and part oppressed” this understanding at best recognizes the homophobic stigma that bisexual people experience (at the exclusion of unique forms of biphobic stigma which are well documented (Beach et al., 2018; M. R. Friedman et al., 2014; Mulick & Wright, 2002; Obradors-Campos, 2011; Roberts et al., 2015)). At worst, this view presumes bisexual identity has a closer proximity to heterosexuality and therefore perpetuates the dangerous assumption that bisexual people do not have any unique policy issues that are pressing to be specifically addressed in LGBTQ political movements. This is further reified by the misappropriation of a concept adapted from Critical Race Theory known as “centering at the margins” (Ford & Airhihenbuwa, 2010), which in misapplication argues that homosexuality is more socio-politically marginalized than bisexuality and therefore should be prioritized in LGBTQ advocacy. In its original intent, centering at the margins was developed by Critical Race Theorists as an articulation of the need to uplift and center voices of marginalized Black individuals and communities in discourse, research, and community advocacy (Ford & Airhihenbuwa, 2010). The misappropriation of this concept not only ignores the experience of homophobia by bisexual people, but evidently ignores documentation of unique forms of stigma faced by bisexual individuals often referred to as “biphobia” and “monosexism” (Beach et al., 2018; M. R. Friedman et al., 2014; Mulick & Wright, 2002; Obradors-Campos, 2011; Roberts et al., 2015). Indeed, it has been documented that bisexual people and communities face various forms of stigma and discrimination which contribute to the unique health and socio-political needs of bisexual populations (Beach et al., 2018; Dyar & Feinstein, 2018; Feinstein & Dyar, 2017; M. R. Friedman et al., 2014; Mulick & Wright, 2002; Obradors-Campos, 2011; Roberts et al., 2015; Ross et al., 2018).

Bi-erasure and the subsuming of bisexuality under homosexuality is frequently replicated in health research. This often includes the use of sexual identity classifications such as the combined category of “gay and bisexual” or overarching behavioral categories such as “men who have sex with men” or “women who have sex with women” (M. R. Friedman, & Dodge, B.M., 2016; Holmes & Beach, 2020). A consequence of this replication is that unique bisexual experiences or bisexual health disparities may be obscured by incorporating bisexuality underneath these broader categories (Holmes & Beach, 2020; G. Phillips et al., 2018; Singh, Hu, Wheeler, & Hall, 2014). Health research that differentiates sexual identity by more than two categories has documented that bisexual people experience health disparities not only compared to heterosexual individuals but also in comparison to their gay and lesbian counterparts such as in the case of mental health concerns (Feinstein & Dyar, 2017; Ross et al., 2018), substance use (Feinstein & Dyar, 2017), and intimate partner violence (Walters, 2013), etc.

Lack of accountability to bisexual community

Given the history of bi-erasure in LGBTQ social movements and existing health research, there exists a discrepancy with regard to who can speak for and who is accountable to bisexual communities (Obradors-Campos, 2011; Weiss, 2003; Welzer-Lang, 2008). For example, obscuring the unique struggles of bisexual communities fuels the idea that if the political aims of mainstream LGBTQ movements were to be successfully addressed, that bisexual people would attain full social equity alongside their gay and lesbian peers. Ironically, this implication is made while simultaneously dismissing the existence of biphobic stigma or unique needs of bisexual communities by LGBTQ-focused initiatives – including sometimes by bisexual people themselves who are organizing within LGBTQ movements. Defining bisexual health research by metrics established by broader LGBTQ movements may mislead researchers into thinking that research programs aimed at addressing LGBTQ community objectives inherently and sufficiently address the distinct priorities of bisexual communities, when they frequently do not.

In addition to the discrepancy between research and advocacy priorities of broader LGBTQ and bisexual communities is the possible discrepancy between research outcomes and tangible benefits to bisexual communities. Many community-engaged models for research tend to articulate the goals of community-engaged research in ways that align more closely with metrics of research productivity (such as publication, or dissemination of published materials), whereas community organizations are likely to prioritize the immediate services to their constituents (Mikesell, Bromley, & Khodyakov, 2013; Sieber, 2008). Realistically, this conflict in priorities may set up the researcher to prioritize academic research productivity more so than immediate tangible outcomes such as implemented programming, policy recommendations, or structural change (Sieber, 2008). This may set up bisexual community stakeholders to experience disappointment through what may feel like—or truly be—broken promises made by the research team and ultimately damage the reputation of the researchers among bisexual communities. Bisexual stakeholders have expressed frustration that without bisexual people at the table throughout the entire research process – whether conceptualized and conducted in academia or in LGBTQ advocacy and think tank organizations – bisexual health research studies have asked and answered questions that were often irrelevant at best and damaging at worst to the health of bisexual populations, such as studies investigating whether or not bisexual men “exist” (Jabbour et al., 2020).

Lack of bisexual-specific funding and resources

The aforementioned biphobic/monosexist views commonly held within LGBTQ movements are often presented in a way that misrepresents these phenomena as consistent with the values of social justice movements. As previously mentioned, this often takes the form of a misguided application of the concept from Critical Race Theory known as “centering in the margins” (Ford & Airhihenbuwa, 2010). In their misapplication of this concept, LGBTQ movement organizers will suggest that lesbian/gay people and communities are deeply marginalized whereas bisexual people are not—a notion which has been refuted and disproved in community spaces as well as research. As a result, biphobia disguised as social justice advocacy insidiously permeates not only the work of gay and lesbian LGBTQ movement organizer spaces, but also the work of many bisexual activists who are leaders in LGBTQ movement work. These damaging biphobia-fueled false social justice narratives ultimately contribute to the lack of funding for bisexual-specific community projects and bisexual-specific research initiatives. After all, if bisexual people don’t have any unique issues to address, why should LGBTQ or sexual and gender minority funding initiatives dedicate resources to providing services or developing systematic interventions for change to benefit bisexual and bi+ populations? In addition to the challenges of deeply-rooted biphobia described above, especially within research structures, current LGBTQ funding norms don’t account for the needs of well-applied community-engaged research which typically requires a significant investment in community development as well as relationship building, and privileges community priorities over the research priorities of funders (Giese-Davis, 2008; Mikesell et al., 2013). Funding agencies also don’t always prioritize budgets that incorporate adequate funds to sustain the efforts of community partners (Mikesell et al., 2013).

Compounding this challenge is the systematic lack of funding for bi-focused work (Commission, 2011; Issues, 2017). In their 2008 report on bisexual invisibility, the San Francisco Human Rights Commission LGBT Advisory Committee reported that while overall funding for LGBT issues had increased, that bisexual-specific funding had decreased (Commission, 2011). This has not changed much in recent years. In their latest report, Funders for LGBTQ Issues show that while there have been modest gains, bisexual-specific funding by US-based foundations represents <1% of total LGBTQ grant dollars (compared to 73% allocated to the broader LGBTQ community, 17% allocated to transgender people, 6% being allocated to gay/queer men, 3% allocated to lesbians/queer women, and 1% allocated to intersex people) (Issues, 2017). This means despite bisexual people comprising the largest group within the LGBTQ umbrella, that projects addressing the needs of bisexual populations are the least-funded (Herbenick et al., 2010; Issues, 2017). This is problematic given that bi-erasure is the norm. This erasure contributes to a near complete absence of bi-specific programming and initiatives being funded by “broader LGBTQ funding” allocations. Lack of funding also forces bisexual individuals and bisexual community organizations to self-fund bisexual-specific initiatives – a ‘solution’ that is also limited in scope given known income disparities impacting bisexual populations (Ross et al., 2016). Effective community partnerships with bisexual communities will require funding to be allocated to projects that specifically center bisexual people and communities.

Current approaches to community-engaged research are insufficient

Approaches to engaging bisexual community through research are embedded in a broader framework of community-based research, which faces considerable ethical and logistic challenges (Mikesell et al., 2013). Researchers often cite the Belmont Report when considering ethical principles of research (American College of Dentists, 2014). This report was created by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research and published in 1979 (American College of Dentists, 2014). The report articulates three ethical principles as they pertain to individual research participants: (1) respect for persons aims to protect the autonomy of individuals and allow for informed consent; (2) beneficence refers to “do no harm” and maximizing benefits to research participants; and (3) justice aims to fairly distribute the costs and benefits of research to all potential research participants in an equitable manner (American College of Dentists, 2014). Many fields of research, particularly social and public health research, are working with populations and communities beyond the individual (American College of Dentists, 2014). However, these ethical principles are largely framed for individual participants, which has sparked critique and community-based research methods have in-part been developed and applied as a means to address ambiguities in these commonly applied ethical principles in research by defining approaches to further engage community ethically and hold deeper accountability to communities that are researched (American College of Dentists, 2014; Mikesell et al., 2013; Shore, 2006). Community-based research approaches attempt to extend these principles to populations and communities.

A notable example is Community-Based Participatory Action Research, which is considered an ethical standard for community engaged research (CER) by many, because its principles are deeply embedded in community and it incorporates strategies to share decision-making processes between research teams and communities (Mikesell et al., 2013). Though Community-Based Participatory Research and other CER models are largely regarded as a more ethical alternatives to more standard “ivory tower” research traditions, we have identified above a range of ethical and logistic challenges that are particularly relevant to bisexual communities including issues of systemic bi-erasure, accountability to bisexual community, and the lack of bisexual-specific funding. As a complement to other CER methods, our proposed model builds particularly upon two of the Belmont Report principles: (1) beneficence in outlining ways to better reduce harm when conducting research that directly relates to bisexual communities and (2) justice by outlining the ways that the outputs of research can be more strategically generated and distributed to benefit bisexual communities. The existence of these concerns speaks to the need to articulate a set of guiding principles and a model that centers the perspectives of bisexual+ individuals and communities using a CER approach. In the next section, therefore, we describe such principles and highlight how they apply in a model of CER tailored to the community contexts in which bisexual health research occurs.

Articulating Guiding Principles to Inform a Bisexual Community Engaged Research Model – “Bi Us, For Us”

In response to the aforementioned challenges to community-engaged bisexual health research we propose five guiding principles which are requisite for effective bisexual health research (summarized in Table 1): (1) bi-affirmation, (2) centering in the margins, (3) power sharing with bisexual community, (4) accountability to bisexual community, and (5) allocation of bisexual-specific resources. First, the foundational principle of the proposed model is bi-affirmation, which seeks to actively counteract bi-erasure through the explicit prioritization of bisexual experience and efforts to dismantle biphobia. Second, researchers may also learn from an earnest application of the key tenant of Critical Race Theory which calls researchers to “center in the margins,” meaning that it is important to center the experience of the most marginalized groups in organizing, discourse, and research (Ford & Airhihenbuwa, 2010). To effectively address bisexual communities’ needs it is not sufficient to simply “include” bisexual individuals, but rather it is necessary to center bisexual communities in these endeavors (T. Israel, 2018). This includes centering members of bisexual communities who are further marginalized due to racism, ethnocentrism, sexism, abelism, transphobia, sizeism, or other overlapping stigmas (Bowleg, 2012). The importance of this tenant is further emphasized by the understanding that a growing proportion of bisexually identified youth in the U.S. are Black adolescent female youth (Gregory Phillips et al., 2019). Monosexism and biphobia cannot be dismantled in isolation from other interlocking forms of oppression. Third, successful research addressing the needs of bisexual communities should be willing to share control of the research agenda with bisexual communities, including defining the ultimate products of the research (B. A. Israel, 2013). Community-engaged research agendas in bisexual communities must prioritize mutually determined outcomes that benefit bisexual communities as much as they benefit academic researchers. Fourth, organizations and researchers seeking to further bisexual health should establish systemic accountability to bisexual community meaning explicit commitment, strategies, and allocations of resources to bisexual-focused initiatives. Finally, effective community-engaged research with bisexual communities requires resources that are designed to address the health of bisexual communities. This includes: 1) funding structures that allow for extended relationship building (such as grants that last over the course of years); 2) funding priorities that are flexible enough to prioritize the concerns and interests of community partners rather than national agendas; 3) funding that is earmarked for bisexual health concerns, and 4) adequate compensation to support and sustain the efforts of community partners (Giese-Davis, 2008; Issues, 2017; Mikesell et al., 2013). These principles both directly address the aforementioned challenges to bisexual health research and inform the activities and strategies outlined in the proposed model.

Table 1.

Guiding principles for the “Bi Us, For Us” Model of Bi-Affirming Community Engaged Research

Problem Addressed
Bi-affirmation This model defines bisexual affirmation or “bi-affirmation” as the explicit recognition of the unique experiences of people who identify as bi+ (bisexual, pansexual, queer, fluid, etc.) as well as active participation in dismantling biphobia and bi-erasure in interpersonal interactions, research, and organizing practices. Systemic bi-erasure
Centering in the margins Inspired by the seminal work in Critical Race Theory, this model defines centering the margins as centering bisexual community, individuals, and experience in research and intervention enterprises. In this application this explicitly includes emphasizing the overlap of other marginalized identities and experiences including but not limited to race, ethnicity, national origin, disability, etc. More specifically, Black bisexual voices should be centered in discourse, research, and community advocacy surrounding bisexual health.
Accountability to bisexual community Bisexual and non-bisexual researchers and organizations that serve bisexual individuals and bisexual community should be accountable to bisexual community in regard to mission, allocation of resources, and strategy. This includes the explicit statement of bi-affirmation in mission statements and/or guiding documents, explicit allocation of funds and labor to bisexual-focused initiatives, explicit solidarity with bisexual communities in monosexual leadership, and the use of research and organizing strategies that support bisexual communities. Lack of accountability to bisexual community
Power sharing with bisexual community28 Inspired by the seminal work in CBPR, this model proposes that power sharing should be made explicit in bisexual health research to ensure that bisexual leaders and bisexual community organizations have shared influence with researchers over the vision of research practices and outputs.
Allocation of bisexual-specific resources Given the unique experiences of bisexual individuals and documented bisexual health disparities (Feinstein & Dyar, 2017; Ross et al., 2018), organizations that seek to further health (such as the National Institutes of Health and Centers for Disease Control and Prevention), as well as LGBTQ advocacy organizations should allocate funding and resources to: (1) extended relationship building with bisexual community and bisexual community organizations, (2) flexible funding that is responsive to bisexual community needs, (3) grants that are earmarked specifically for bisexual health, and (4) funding streams that sustain and support the efforts of community organizations. Lack of bisexual-specific funding and resources
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“Bi Us, For Us”: A Bisexual Community Engaged Research Model

In order to visualize what an evidence-informed, community-led approach to combat bi-erasure and biphobia to promote health equity in bisexual communities could look like in practice, we developed a bi-specific CER-informed conceptual model. The “Bi Us, For Us” model (see Figure 1) depicts the roles that bisexual individuals, bisexual community stakeholders, and researchers of bisexual health can play to create community-led systematic change using a “bi in all policies” approach to improve health outcomes for bisexual people.

Figure 1.

Figure 1.

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The Bi Us, For Us model depicts how bisexual individuals, community stakeholders, and researchers collectively contribute to the knowledge base to advance bisexual health equity by facilitating the translation, implementation, and dissemination of community engaged, evidence informed policies, initiatives, and structural change efforts.

Capturing Bisexual Community Reality

The first part of the model depicts how people from different backgrounds contribute to the production of knowledge about bisexual health. Within the model, bisexual people, bisexual community stakeholders, and researchers all contribute to the knowledge base required to create change. For the purposes of the model, the term “bisexual people” is defined as people who identify as bisexual, but who are not necessarily involved in bisexual community organizing work and/or who are not necessarily researchers. “Researchers of bisexuality” includes people who are located in the academy, in think tanks, in government agencies, or in other contexts where they spend time designing, analyzing, or disseminating research on bisexual health in a variety of contexts, such as within the scientific literature, in white papers, or to the mainstream media. Finally, the term “bisexual community stakeholders” is defined as individuals who are part of leading and organizing bisexual and bi+ specific organizations. It is particularly important to note that these three general groups are not mutually exclusive and that an individual may play all three roles at different times or in different contexts.

For reasons outlined above, the definition of “bisexual community stakeholders” does not automatically include leaders of LGBTQ organizations. This is true even if the LGBTQ leaders themselves identify as bisexual. Even if LGBTQ organizational leaders do happen to identify as bisexual, the politics of LGBTQ movements often demand that LGBTQ community leaders endorse and adopt expressly biphobic value systems disguised in the language of social justice to guide the operations of their organizations. Furthermore, bi-affirming leadership is a crucial component to effective bisexual community research. It is important to promote leaders who are bisexual and have a bisexual community consciousness3, while recognizing that most bisexual people have experienced some form of discrimination or harassment in the work place and may have internalized biphobia (EC, 2017; T. Israel, 2018). A bisexual community consciousness is important in part because bisexual leaders may be processing internalized stigma against their bisexual identity, which can sometimes lead to inadvertent participation in bi-erasure or other forms of biphobic stigma. Moreover, in environments that are not bi-affirming, bisexual people may put themselves or their jobs at risk for standing up for the needs of bisexual communities. Therefore, bi-affirmation in organizing also necessitates non-bisexual leadership who are committed to work in solidarity with bisexual communities.

Relatedly, underlying the ability of the model to be successfully applied in practice is an understanding of the power dynamics among people who hold one or more roles within the context of developing the evidence-basis to create change to empower bisexual people and communities to improve bisexual equity. Within these power dynamics, bisexual community stakeholders can be viewed as playing the largest role of making sure that efforts to generate the knowledge base that would be used to develop ‘evidence informed’ interventions to dismantle biphobia and promote bisexual political equality and health equity. It is also important that efforts to dismantle biphobia and promote equity include bisexual people who are not researchers and who are not in positions of power within bisexual and bi+ community organizations. Bringing together bisexual and bi+ individuals from across diverse backgrounds to help decide what research questions are asked and how interventions are designed is critically important to apply in practice the social justice value of “nothing about us without us.”

Thinking across the different roles listed in the model, it is particularly important for people who do inhabit more than one of these roles to critically reflect about what ‘hats’ they are wearing when engaging in the design or implementation of research studies and/or interventions to dismantle biphobia to promote bisexual health equity. In community settings, people who are both researchers of bisexuality and community stakeholders can (un)intentionally silence other bisexual community leaders by adopting a “research hat” perspective. It is important in this context for researchers of bisexuality to learn when to step up and when to step back in community stakeholder discussions. Furthermore, in such discussions, it is crucial for people who do not identify as bisexual or bi+ to step back to ensure the voices of people who do identify as bisexual – whatever other roles they may or may not hold – are centered and also are given priority in decision-making processes. It is also important that regardless of role(s) held in the model, bisexual people leading health equity efforts also apply ‘centering on the margins’ to ensure that the voices of bisexual Black, Indigenous, and other People of Color (BIPOC) individuals, bisexual transgender and non-binary individuals, and bisexual individuals from a variety of additional marginalized backgrounds are centered in these efforts.

The need to consider and interrogate these same power dynamics that are present in efforts to set research agendas and conduct research become all the more amplified when the focus of the model shifts to operationalizing change to translate research findings to the generation of systems-wide advocacy tools. Compared to bisexual community funding efforts, academic funding for bisexual health research has become more readily available. Therefore, researchers of bisexuality are much more readily situated to help drive forward intervention development efforts – which are a key driver of change to promote bisexual health equity. This reality, however, means that the inherent inequalities discussed above between researchers and community stakeholders become more acute. Researchers of bisexuality should strive to find creative solutions to incorporate bisexual community leaders. Such solutions may include paying bisexual community stakeholders as Co-Investigators within their research project proposals or generously funding community advisory boards and other related opportunities to obtain input from individuals who identify as bisexual and bi+ in their research implementation. To the greatest extent possible, to avoid perceptions that researchers of bisexuality do not value the expertise of bisexual community stakeholders or bisexual people, community advisory boards should be maintained over multiple projects, not convened on a “one-off” basis for each project. Researchers convening community advisory boards should ask members what the researchers can offer in addition to meals and stipends that would compensate them for their expertise. Taking into account the roles and power dynamics described in the first part of the model, the second part of the model focuses on how to center the voices of bisexual people, researchers, and community stakeholders when developing structural interventions to improve bisexual health equity.

Translating research to practice through the development of bi-affirming health interventions, advocacy tools, and “bi in all policies”

Reflecting on the need to be accountable to bisexual people and communities, as alluded above, the second part of the model suggests that the ability to impact bi-inclusive policy change should be an integral part of developing research agendas to benefit the health of bisexual communities. Bisexual populations are affected not only by bi-specific policies, but rather by all policies that have the potential to impact the lives of bisexual community members. For this reason, we here introduce the idea of “bi in all policies” based on the concept of “Health in All Policies.”

The concept of “Health in All Policies” has been articulated as a national agenda to mutually integrate public health with the goals of other sectors through broad stakeholder engagement, and development of policies that promote mutual benefit between public health and other sectors such as economic, environmental, and educational policies (Rudolph L). These strategies include the creation of health-specific policies and embedding health considerations into policies pertaining to other sectors, such that health considerations in policy become ubiquitous (Rudolph L). Similarly, a conceptualization of “Bi in all Policies” would recognize: 1) that all policies regardless of sector have the potential to further or detract from bi-affirmation; 2) bi-affirmation can be achieved through both bi-specific policies, as well as bi-specific considerations within other sectors; and 3) research projects should aim to inform policy impact on bisexual communities. We propose that “Bi in All Policies” can be achieved through mutually beneficial community engagement that centers bisexual communities, bi-affirming leadership, and bi-affirming policy recommendations. Not only do policies need to directly address bisexual-specific needs, but all policies need to avoid bi-erasure for the sake of “simplifying the message” such as earlier campaigns for same-sex marriage that used the term “gay marriage” (Marcus, 2015). “Simplified” messages may inadvertently lead to the exclusion of bisexual-specific needs being met through the proposed policy change and create barriers to mobilizing bisexual communities (Marcus, 2015). Just the simple act of considering how each policy may impact bisexual people in itself would revolutionize bi-affirmation.

In practice, an application of the “bi in all policies” approach would leverage the evidence base of knowledge about bisexual health cultivated by bisexual people, community stakeholders, and researchers of bisexuality to inform generation of a set of tools and resources to combat biphobia and promote bisexual health equity at the structural level. As discussed within the case study below, events should be convened to get feedback from bisexual people, bisexual community stakeholders, and researchers of bisexuality about the types of tools that should be developed. Given the marginalized position of bisexual people, communities, and movements, this set of resources should include the development of structural and foundational support systems to advance bisexual health equity. Such structural supports should center initiatives to fill critical gaps in bisexual community infrastructure, including potential efforts such as 1) launching a bisexual community-led funding organization that supports the sustainable capacity building of bisexual community organizations, 2) co-creating culturally and linguistically appropriate standards (CLAS standards) that address how to provide culturally competent care to bisexual patients, 3) developing training materials and building capacity to train LGBTQ and mainstream healthcare organizations alike in best practices to provide inclusive bisexual healthcare, and 4) creating an advocacy toolkit that contains materials that explain how to encourage local political stakeholders to adopt a “bi in all policies” approach to designing health policy interventions, regulations, and laws. Efforts to advance bisexual health equity, however, cannot stop at the creation of change-making tools, they must be evaluated, implemented, and disseminated at scale in ways that benefit bisexual populations.

Evaluation, Implementation, and Dissemination of Bisexual Health Equity Interventions

The third part of the model focuses on applying in practice the tools and interventions described in the second part of the model. As shown in earlier parts of the model, the prioritization of which interventions and tools to evaluate, implement, and disseminate should be influenced by input from people from all of the noted roles (e.g., bisexual individuals, bisexual community stakeholders, and researchers of bisexuality). These implementation efforts should also benefit people who hold each of these roles. In practice, this means that research studies and implementation of interventions to promote bisexual health equity should be disseminated not only within peer-reviewed scientific journals, but also within bisexual community organizations and to LGBTQ and mainstream media organizations and to other outlets and in other formats requested by bisexual community stakeholders and individuals. Implementation efforts should be structured to ensure that bisexual individuals, community stakeholders and researchers are all compensated as part of community-led efforts to promote bisexual health equity change efforts. Finally, any effort to implement a structural level bisexual health intervention should contain within it an evaluation plan. The evaluation plan should seek to determine if the effects of the intervention not only benefit the health of bisexual populations writ large, but if they confer at a minimum equal benefit to bisexual individuals who hold multiple marginalized identities.

A Case Study of “Bi Us, For Us” in Action: The Chicago Bisexual Health Task Force

In this third and final section of the manuscript, we provide an in-depth case study of the Bi Us, For Us model in action. In the introduction to this special issue, Feinstein (this issue) describes the founding of the Chicago Bisexual Health Task Force (CBHTF) – the organization serving as the primary case study of the model. Since 2017, CBHTF has brought bisexual researchers, community stakeholders, and bi+ self-identified people and their allies together in Chicago, IL to organize research and advocacy for bisexual communities. CBHTF has led many local events and initiatives by leveraging partnerships between researchers, community organizers, and local organizations. In alignment with the Bi Us, For Us model, CBHTF has sought to “capture bisexual reality” by including individuals who identify as bisexual, bisexual community stakeholders, and researchers of bisexuality within the leadership and membership of the group. People who hold multiple roles in the group at one time (e.g., both researcher of bisexuality and bisexual community stakeholder) are encouraged to engage in self-reflection during CBHTF meetings to note what ‘hat’ they were wearing when they share comments. While people who do not identify as bisexual hold leadership roles within CBHTF, these individuals have committed to center the voices of bisexual people when setting the agenda for the types of initiatives and partnerships CBHTF would pursue (Pickett & Tucker, 2020). CBHTF leadership also applies a ‘centering on the margins’ approach to the design of all group events: the voices of bisexual BIPOC, bisexual transgender and gender non-conforming individuals, and bisexual disabled people have been intentionally centered in the design of CBHTF programming.

Further, the partnerships and collaborations that have evolved from CBHTF have led to the operationalization of change and translation of research to practice to benefit bisexual health equity in myriad ways. Events co-sponsored by CBHTF have included community forums to identify the health needs of bi+ populations, workshops addressing relevant topics (such as racism and violence in bisexual communities), a bisexual health summit (a symposium of bisexual health research and community advocacy), and partnering with Chicago mayors to proclaim International Day of Bisexual Visibility in Chicago (Simonette, 2019). At CBHTF events, organizers have highlighted the importance of a “bi in all policies” approach to promote bisexual health equity. For example, at the CBHTF October 2019 Domestic Violence Policy Panel and Community Forum, local Chicago organizers, service providers, researchers, and community members discussed the implications of considering bisexual populations in internal policies at health service providers as well as at the city level (Chicago Bisexual Health Task Force, 2019).

Also central to the application of the model in practice, to organize and host these events, researchers of bisexuality in CBHTF partnered with local bisexual community organizations such as the Bi Queer Alliance Chicago (BQAC) and local LGBTQ health networks and community centers such as Howard Brown Health (HBH) and the Center on Halsted. These partnerships led to the generation of new bi-specific health initiatives, like the evaluation of Center on Halsted’s inclusion of bisexual people within HIV and STI-related health services (Holmes & Beach, 2020) and the creation of HBH’s Bisexual Health Working Group (BHWG) in 2019.

CBHTF’s partnership with HBH and the BHWG in particular can be viewed as an in-depth application of the Bi Us, For Us model. The CBHTF/HBH partnership demonstrates how input from not only bi+ communities and researchers of bisexuality but also from bi+ patient populations and staff from healthcare institutions who serve bi+ patient populations (many of whom identify as bi+ themselves) can be used to identify research priorities and opportunities for intervention. The ultimate goal of the BHWG is to improve the quality of care received by bisexual patient populations at the patient-provider and health systems levels at HBH. Prior to the development of the BHWG, since its founding in 1974, HBH had never undertaken a bi-specific health improvement project in the history of the organization. Since the start of the BHWG, the authors of this manuscript have worked with HBH clinicians, research staff, community outreach staff, and leadership team to identify bi+ research and quality improvement priorities.

In November 2019, in collaboration with Northwestern University, the HBH BHWG received its first small research grant from the Third Coast Center for AIDS Research as part of the Ending the HIV Epidemic (EHE) initiative. The pilot funding provided for a data pull from HBH’s electronic medical records (EMR) warehouse that allowed for the characterization of pre-exposure prophylaxis (PrEP) and HIV care cascades of HBH patient populations at the intersections of sexual identity, sexual behavior, race, ethnicity, sex assigned at birth, gender identity, and socioeconomic status. These analyses revealed that bi+ patient populations – despite being equally eligible for PrEP - experienced disparities in PrEP uptake. They also revealed that compared to cisgender gay male patient populations, cisgender bi+ male patient populations were less likely to have an undetectable viral load. These findings were shared at two events: 1) With bi+ community members via a virtual panel and 2) With healthcare providers and research staff at HBH via a virtual grand rounds presentation. In September 2020, HBH also launched an infographic on social media to disseminate findings from the grant, thereby increasing reach of the study findings to include bisexual people at large who may not have a connection to bisexual community organizations.

In March 2020, in partnership with the authors of this manuscript, Dr. Cori Blum at HBH, and Jessie Miller, President of the Bisexual Queer Alliance Chicago, the BHWG applied for a second pilot grant that was funded in September 2020 to elicit feedback from both bisexual community members and HBH patients living on the West, South, and North sides of Chicago about how to improve the primary care experiences of bisexual+ populations. Feedback gathered from bisexual+ community stakeholders and individuals throughout the city of Chicago from the grant will be used to generate a quantitative survey to gather information to understand how to improve the quality of care bi+ patients receive from primary care providers. Moving forward, HBH plans to incorporate ongoing input from CBTHF, the Bi Queer Alliance Chicago, and the BHWG as well as findings from the previously mentioned research activities to design health systems interventions to eliminate health disparities and promote the health equity of bi+ patient populations. Similar to the findings from the November 2019 grant, findings from these studies will be shared widely within the scientific literature, in bisexual community organizations, and within LGBTQ and mainstream media outlets.

The efforts of CBHTF overall and the BHWG at HBH in particular illustrate the Bi Us, For Us model’s systematic approach to design and implement a multi-component systemic intervention to improve bisexual health equity. Embedded within the core values of the application of the model in practice is an ethical analysis that dynamically recognizes the value of different types of expertise and how these should be treated within efforts to design and implement interventions to dismantle biphobia and promote bisexual equity. Within CBHTF and the BHWG initiatives, people are encouraged to think critically about the expertise they hold and the role(s) they are playing at any given time when designing or implementing efforts for systems change. Such thoughtful reflection is required to build effective bisexual CER partnerships and networks that - through community action - can translate research findings into policy and practice to dismantle biphobia and promote bisexual health equity at a systems level.

Conclusion

This manuscript presents the Bi Us, For Us model - a model that can be applied by researchers and bisexual community organizers alike to guide efforts to build community-first initiatives to dismantle biphobia and promote bisexual health equity. The model responds to the shortcomings of bisexual health research initiatives with a set of proposed guiding principles as well as a framework for organizing bisexual health research initiatives. In order to further refine the model, future work should continue to describe and evaluate case studies of applying the model in practice, including systematically collecting additional perspectives from bisexual communities and bisexual stakeholders who are organizing for bisexual health. Future work should also describe in more depth theoretically and conceptually how the model is compatible with intersectional frameworks and can be pragmatically applied on the ground to address racial and gender equity to bring greater application of the concept of Centering in the Margins within bisexual+ movements. In articulating these foundational principles, we hope that bisexual health researchers, bisexual community advocates, and bisexual community members will apply and improve upon this framework through fruitful multi-sector collaborations that result in direct benefit to bisexual communities as well as further articulation of principles for the engagement of bisexual communities.

Footnotes

1

Bi+ refers to a variety of identities that refer to romantic or sexual attraction to multiple genders such as but not limited to bisexual, pansexual, fluid, queer, bi-romantic, etc.

2

Monosexual refers to identities that are meant to represent a romantic or sexual attraction to a single gender such as heterosexual, gay, or lesbian.

3

Bisexual community consciousness refers to an awareness of the systemic oppression faced by bisexual communities including but not limited to biphobia and bi-erasure.

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