Abstract
Bisexual people are at increased risk for sexually transmitted infections (STIs), including HIV. In STI data collection, bisexual people are often miscategorized as or conflated with heterosexual or gay/lesbian people. Such poor data capture practices invisibilize bisexual people and prevent the tailoring of HIV and STI services to cater to bisexual populations. The Center on Halsted (COH) is an LGBTQ community center in Chicago. COH’s HIV & STD Services Department provides HIV testing to people who present for HIV screening services age 12 and older. COH also administers the State of Illinois AIDS, HIV, & STD Hotline. This manuscript reports HIV-related service access patterns of COH clients by sexual identity, with an emphasis on reporting patterns among bisexual and other non-monosexual (e.g., “bi+”) populations in comparison with other sexual minority populations. Among COH’s HIV testing clients who were sexual minorities in fiscal years 2018 and 2019, 15.42% in 2018 and 16.71% in 2019 identified as bisexual, respectively. Among sexual minority hotline callers, approximately one quarter (25.1% in 2018 and 28.8% in 2019) identified as bisexual. Given that bisexual individuals comprise over half of sexual minority populations, these findings indicate that bi+ individuals may be underrepresented in accessing HIV and STI services at COH. These results provide previously unknown insight into the sexual identities of populations accessing HIV- and STD-related services within a LGBTQ community setting. Funders of HIV and STI surveillance services should change reporting requirements to make visible the HIV services access patterns and outcomes of bisexual populations.
Keywords: Bisexual, program evaluation, HIV, sexually transmitted infection, community engaged research
Introduction
Over 4.5% of the population – more than 10 million U.S. adults – identify as lesbian, gay, or bisexual and/or transgender (LGBT) (Newport, 2018). Over 19 million U.S. adults report same-sex behavior in their lifetimes (Chandra et al., 2011; Copen et al., 2016). The proportion of the population identifying as LGBT has been found to be even higher among youth, non-White individuals, women, and people of lower socioeconomic status backgrounds (Gates, 2017; Newport, 2018). Bisexual people comprise the largest segment of sexual minority populations who report sexual minority identity in the United States. A meta-analysis published by the Williams Institute found that among people who identified as lesbian, gay, or bisexual (LGB), over half (52%) identified as bisexual (Gates, 2011). Furthermore, the percentage of the US population that reports a sexual minority identity is increasing over time (Chandra et al., 2011; Copen et al., 2016; Newport, 2018; Phillips et al., 2019). Among youth, the percent of the population identifying with a sexual minority identification is primarily being driven by increases among those who identify as bisexual, especially bisexual female youth (Phillips et al., 2019). Despite the fact that the majority of sexual minority individuals identify as bisexual, comparatively few studies focus on the health and wellbeing of bisexual populations. This lack of study is concerning because compared to both their heterosexual and gay/lesbian peers (e.g., collectively their monosexual peers), bisexual individuals experience wide-ranging health disparities, including disparities in healthcare access, mental health, and substance use, among others (Ward et al., 2014).
In addition to disparities tied to socioeconomic status (SES) and mental and behavioral health, bisexual individuals also experience disparities in sexual health. Work by Agenor et al. (2017) has shown that by sexual identity, bisexual women are more likely to have both viral and bacterial STIs, but are less likely to report obtaining cervical cancer screenings (e.g., a Papanicolaou test) compared to heterosexual women. Both research studies and public health surveillance activities that investigate sexual health and STI diagnoses, however, often do not utilize sexual identity, but instead use sexual behavior to classify sexual minority sub-populations. The majority of studies reporting HIV-related outcomes (e.g., HIV testing, linkage to care, treatment, retention in care, and HIV viral suppression) have been reported among men who have sex with men (MSM). Reports from leading HIV surveillance systems as a rule do not separately report outcomes for men who have sex with men only (MSMO) compared to men who have sex with men and women (MSMW) (Friedman, Stall, et al., 2014). Therefore, given that HIV epidemiologic surveillance reporting also does not typically include sexual identity, HIV-related disparities impacting bisexual and MSMW populations have largely gone unmonitored and unreported. Few if any published studies have reported HIV-related outcomes among cisgender women by sexual identity or sexual behavior. While HIV-related outcomes of transgender populations are increasingly reported, often the sexual identity and sometimes even the sexual behavior of transgender people is missing from these reports. The limited number of studies that have reported HIV-related disparities impacting bisexual male populations have found that although MSMW are less likely to be living with HIV than MSMO, MSMW are more likely to be diagnosed with AIDS at initial HIV diagnosis, and are less likely to be virally suppressed (Friedman, Wei, et al., 2014; Singh et al., 2014). In addition, like MSMO, MSMW experience strikingly higher rates of HIV compared to men who have sex with women only (Friedman, Wei, et al., 2014). Despite these documented disparities, governmental and other public health surveillance agencies continue to invisibilize bisexual people in their reporting systems.
The pathways that shape HIV-related disparities impacting the health of bisexual and other sexual minority populations are described by minority stress theory (MST). MST theorizes that marginalized populations experience increased levels of stress tied to discrimination and stigmatization (Lick et al., 2013; Meyer, 2003). This excess stress contributes to increases in stress-linked coping behaviors (e.g., increased substance use (Rosario et al., 2014), having multiple barrier-free sex partners (Rendina et al., 2017)), as well as to poor mental health and physical health outcomes and associated population level health disparities (Lick et al., 2013). Specific to minority stressors in bisexual populations, a robust literature describes that bisexual individuals experience “double discrimination”; bisexual people are twice harmed because bisexuality is stigmatized not only in society writ large but also specifically within LGBT communities (Friedman, Dodge, et al., 2014). These stigmatization patterns are uniquely tied to experiences of biphobia and result in social conditions that not only ensure that bisexual people experience the harmful health effects of stigma, but they also are less likely to benefit from the helpful effects of social support that accrue to gay and lesbian individuals by participating in LGBTQ social support clubs and coming out activities (Farmer et al., 2015; Mereish et al., 2017; Ross et al., 2016). For these reasons, more research is needed that specifically assesses the sexual and HIV-related outcomes health of bisexual individuals vis-à-vis their heterosexual and gay and lesbian counterparts. However, the majority of HIV and STI data collection sources miscategorize and invisibilize bisexual people by not allowing individuals to identify themselves as bisexual and/or by combining or conflating MSMW and MSMO as well as gay and bisexual individuals in HIV-related epidemiologic surveillance reporting.
To advance the field of bisexual sexual health research, therefore, it is necessary to identify HIV population health data sources that collect and report more detailed information about sexual behavior, sexual identity, sex at birth, and gender identity (collectively sex, sexual orientation, and gender identity (SSOGI data)) than current standardized HIV and STD public health surveillance and reporting systems allow or disseminate. Though not required by the government-run public health surveillance agencies that commonly fund them, LGBTQ community organizations and AIDS services organizations (ASOs) often independently collect such detailed SSOGI information. Analysis of this information could provide a basis for more inclusive HIV and STD reporting necessary to describe the sexual health of bisexual populations and of people who have sex with people of more than one gender. ASOs and LGBTQ community organizations, however, often lack the monitoring and surveillance capacity to report HIV and STD related outcomes in formats not required by their funders (Beach et al., 2018).Without resources or partnerships in place to analyze and disseminate organizational HIV and STD data in more inclusive ways, such data often remain unanalyzed. The programmatic monitoring and evaluation data collected by LGBTQ community organizations and ASOs can therefore be viewed as an untapped resource that could allow for more in depth reporting of the sexual health of bisexual populations. To address this opportunity, this article describes in depth the sexual identity distribution of individuals accessing HIV and STD services at a LGBTQ community center in Chicago, the Center on Halsted (COH). Specifically, the reasons why individuals called COH’s STI information hotline are reported and compared by sexual identity. Using detailed SSOGI information captured by COH’s client demographics form, this article also reports the numbers and proportions of the sexual identity of COH’s HIV testing clients, including those who identify as bisexual as well as those who identify with bi+ umbrella labels, such as queer and pansexual.
Methods
Description of Center on Halsted
Center on Halsted (COH) is the Midwest’s largest and most comprehensive LGBTQ community center. Located in the heart of Chicago’s LGBTQ neighborhood in the Lakeview community area, COH has been as a staple in the community for over 45 years, originally operating under the name Horizons Community Services.
COH’s services are split between social programs and direct services. Social programs bring community together for art, entertainments, and sports activities as well as activism, community organizing, and racial/gender equity and inclusion programs and events. COH’s direct services include comprehensive youth and senior social services, including housing, workforce readiness, GED services, HIV and Hepatitis C Virus (HCV) testing and support, behavioral health services, and anti-violence programmatic support. COH also provides free HIV testing for anyone ages 12 years and older and HCV testing for people who have ever injected non-prescription drugs. The Department of HIV/AIDS & STD Services houses the Illinois Department of Public Health (IDPH) funded State of Illinois AIDS/HIV & STD Hotline. COH’s HIV/HCV Testing Program as well as the State of Illinois AIDS/HIV & STD Hotline assist thousands of clients per year by providing counseling, testing, and referral services for HIV and HCV testing clients, as well as referrals and emotional support for HIV/STD hotline callers. Of note, while COH makes available this comprehensive list of services to the public with an emphasis on Chicago’s LGBTQ+ communities, COH services and outreach have not historically been tailored to bisexual and bi+ populations.
Data Source
Data in the manuscript were collected by COH’s Department of HIV/AIDS & STD Services, including HIV Testing Data from Fiscal Year 2018 (FY18) from July 1, 2017 – June 30, 2018 and Fiscal Year 2019 (FY19) from July 1, 2018 – June 30, 2019 as well as State of Illinois AIDS/HIV & STD (Hotline) data from FY18 and FY19.
Description of Forms and Measures
HIV/HCV testing session data are captured using the Illinois Department of Public Health (IDPH) HIV Counseling, Testing, and Referrals (CTR) form. The IDPH form captures “gender at birth” (response options: male, female, declined), “current gender” (response options: male, female, trans – male to female (MTF), trans – FTM (female to male), declined), “gender of sexual partners” (response options: male, female, MTF, FTM), and race/ethnicity (response options: Black/African American, White, Alaskan Native, Asian, Native American, Native Hawaiian, Pacific Islander, Declined, Don’t Know). In addition to the IDPH CTR Form, COH clients accessing HIV/HCV testing services also complete a COH Client Information Sheet. The COH form asks clients for their “self-reported gender identity” (response options: cis male, cis female, intersex, trans woman, trans man, queer, questioning, gender non-conforming, gender queer, non-binary, agender, unknown/unreported), to describe their sexual partners using a check all that apply approach (response options: cis men, cis women, trans women, trans men, declined, unknown/unreported), as well as for their “self-reported sexual orientation” (gay, lesbian, bisexual, heterosexual, questioning, queer, asexual, declined, demisexual, pansexual, same gender loving, unknown/unreported, other).
Data collection for the COH HIV/STD Hotline (including sexual orientation data) is coded using the State of Illinois AIDS/HIV & STD Hotline Data Entry Codes. The Hotline Data Entry Codes form includes 6 options for “orientation,” including lesbian (women who have sex with women (WSW)/transgender people who have sex with women (TSW)), gay (MSM/TWM (transgender people who have sex with men)), bisexual (MSMW, women who have sex with men and women (WSMW), transgender people who have sex with men and women (TSMW)), heterosexual (men who have sex with women (MSW), women who have sex with men (WSM), TSM, TSW), questioning, and queer; callers whose sexual orientation was not disclosed are listed as “unknown” by hotline staff. In addition, within the listed STD risk factors, the form includes a category of “bisexual behavior.” The form includes 11 categories for “ethnicity,” including African American, Arab/Middle Eastern, Asian/Pacific Islander, Puerto Rican, Mexican, Other Hispanic, Multiracial, American Indian, Other, European American, and Unknown.
Following call completion, in addition to coding sexual orientation, a COH HIV/STD hotline staff member codes the main purpose of the call as falling under one unique Illinois hotline data entry code. The top 12 most common Illinois hotline data entry codes for FY18 and FY19 (see Tables 3 and 4) are included in analyses in this manuscript. Table 2 includes a listing of these top 12 codes and example calls that fell within the content of each code. In total, 15% and 13% of calls in FY18 and FY19, respectively, were classified using codes outside of the top 12. Due to small sample sizes, these calls were not analyzed within this manuscript.
Table 3:
HIV/STD Hotline Call Coding by Sexual Identity, Fiscal Year 2018
| Bisexual | Heterosexual | Gay | Othera | Total | Chi-squared test | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
|
| |||||||||||
| Hotline Call Reason | No. | Prop. | No. | Prop. | No. | Prop. | No. | Prop. | No. | Prop. | Adjusted significanceb |
| HIV Transmission | 88 | 0.32 | 573 | 0.24 | 180 | 0.24 | 13 | 0.16 | 854 | 0.24 | b* |
| HIV Symptoms/ Medical Info | 54 | 0.20 | 335 | 0.14 | 121 | 0.16 | 4 | 0.05 | 514 | 0.15 | c* |
| STD Info | 52 | 0.19 | 501 | 0.21 | 91 | 0.12 | 7 | 0.09 | 651 | 0.19 | d*** |
| PrEP | 23 | 0.08 | 30 | 0.01 | 29 | 0.04 | 1 | 0.01 | 83 | 0.02 | a*; b***; d*** |
| Information about HIV/STD Testing | 13 | 0.05 | 233 | 0.10 | 50 | 0.07 | 3 | 0.04 | 299 | 0.09 | |
| Emotional Support | 13 | 0.05 | 396 | 0.16 | 20 | 0.03 | 3 | 0.04 | 432 | 0.12 | b***; d***; f* |
| Safer Sex | 7 | 0.03 | 12 | 0.00 | 14 | 0.02 | 1 | 0.01 | 34 | 0.01 | b**, d** |
| Linkage to Care Services (ADAP) | 2 | 0.01 | 17 | 0.01 | 16 | 0.02 | 1 | 0.01 | 36 | 0.01 | b**d** |
| HIV/STD Referrals | 11 | 0.04 | 156 | 0.06 | 53 | 0.07 | 10 | 0.13 | 230 | 0.07 | |
| PEP | 3 | 0.01 | 5 | 0.00 | 35 | 0.05 | 0 | 0.00 | 43 | 0.01 | d*** |
| Statistical Info /Literature | 1 | 0.00 | 7 | 0.00 | 0 | 0.00 | 1 | 0.01 | 9 | 0.00 | Too small to test |
| Undisclosed | 9 | 0.03 | 140 | 0.06 | 133 | 0.18 | 36 | 0.45 | 318 | 0.09 | a***; c***; d***; e***; f*** |
| Total | 276 | 1.00 | 2405 | 1.00 | 742 | 1.00 | 80 | 1.00 | 3503 | 1.00 | |
Note. “Other” includes queer, lesbian, undisclosed, questioning, and any other sexual identity named by the client.
Note. a=Bisexual vs. Gay; b=bisexual vs. heterosexual; c=bisexual vs. other; d=gay vs. heterosexual; e=gay vs. other; f=heterosexual vs. other
p<0.05
p<0,01
p<0.0001
Table 4:
HIV/STD Hotline Call Coding by Sexual Identity, Fiscal Year 2019
| Bisexual | Heterosexual | Gay | Othera | Total | Chi-squared test | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
|
| |||||||||||
| Hotline Call Reason | No. | Prop. | No. | Prop. | No. | Prop. | No. | Prop. | No. | Prop. | Adjusted significanceb |
| HIV Transmission | 91 | 0.25 | 547 | 0.17 | 170 | 0.20 | 14 | 0.19 | 822 | 0.18 | b** |
| HIV Symptoms/ Medical Info | 38 | 0.10 | 531 | 0.17 | 170 | 0.20 | 10 | 0.14 | 749 | 0.17 | a***; b*** |
| STD Info | 61 | 0.16 | 534 | 0.17 | 119 | 0.14 | 16 | 0.22 | 730 | 0.16 | Omnibus test ns |
| PrEP | 3 | 0.01 | 9 | 0.00 | 34 | 0.04 | 0 | 0.00 | 46 | 0.01 | a*; d*** |
| Information about HIV/STD Testing | 27 | 0.07 | 305 | 0.10 | 54 | 0.06 | 4 | 0.06 | 390 | 0.09 | d* |
| Emotional Support | 68 | 0.18 | 812 | 0.26 | 72 | 0.09 | 8 | 0.11 | 960 | 0.22 | a***; b*; d***;f* |
| Safer Sex | 14 | 0.04 | 53 | 0.02 | 25 | 0.03 | 3 | 0.04 | 95 | 0.02 | |
| Linkage to Care Services (ADAP) | 1 | 0.00 | 14 | 0.00 | 15 | 0.02 | 1 | 0.01 | 31 | 0.01 | |
| HIV/STD Referrals | 23 | 0.06 | 145 | 0.05 | 51 | 0.06 | 2 | 0.03 | 221 | 0.05 | Omnibus test ns |
| PEP | 6 | 0.02 | 26 | 0.01 | 38 | 0.04 | 1 | 0.01 | 71 | 0.02 | d*** |
| Statistical Info /Literature | 4 | 0.01 | 4 | 0.00 | 2 | 0.00 | 0 | 0.00 | 10 | 0.00 | Too small to test |
| Undisclosed | 35 | 0.09 | 181 | 0.06 | 97 | 0.11 | 13 | 0.18 | 326 | 0.07 | b*; d***; f** |
| Total | 371 | 1.00 | 3161 | 1.00 | 847 | 1.00 | 72 | 1.00 | 4451 | 1.00 | |
Note. “Other” includes queer, lesbian, undisclosed, questioning, and any other sexual identity named by the client.
Note. a=Bisexual vs. Gay; b=bisexual vs. heterosexual; c=bisexual vs. other; d=gay vs. heterosexual; e=gay vs. other; f=heterosexual vs. other
p<0.05
p<0,01
p<0.0001
Table 2:
Examples of Call Topics by HIV/STD Hotline Call Codes
| Hotline Call Reason | Example Calls |
|---|---|
| HIV Transmission | Did I contract HIV from ________? |
| HIV Symptoms/Medical Information | Is _______ a symptom of HIV? If I were to test positive, what would taking medication look like? |
| STD Info | What are the symptoms of chlamydia? |
| Pre-exposure Prophylaxis (PrEP) | I want to get on PrEP |
| Information about HIV/STD Testing | What is the window period for fourth generation HIV Testing? |
| Emotional Support | I’m incredibly upset about my test results |
| Safer Sex | How do I protect myself from contracting HPV? |
| Linkage to Care Services (e.g., ADAP) | I need the Illinois ADAP Hotline |
| HIV/STD Referrals | I need an HIV test |
| Post-Exposure Prophylaxis (PEP) | I had condomless anal sex this weekend, and I need to get on PEP |
| Statistical Information/Literature | What is the likelihood of me contracting herpes from oral sex? |
Statistical Analyses
Descriptive statistics (numbers, proportions, percentages) were used to characterize the demographic distributions of clients engaging with the COH HIV/HCV testing and HIV/STD hotline services. Chi-square tests were conducted using R 3.6.3 to determine if the proportion of client calls classified according to the top 12 most popular HIV/STD hotline codes differed by sexual identity in FY18 and FY19, respectively. The integrated stats package in R was used to conduct omnibus chi-squared testing, while the R packages Rcompanion and gmodels were used to conduct multiple comparison testing and generate Bonferroni adjusted p-values.
Results
Sexual Identity of COH HIV Testing Clients
During FY18, 4,127 clients ranging from 14 years to 78 years in age received HIV testing at COH. The numbers and percentages of COH HIV testing clients by sexual identity can be found in Table 1. Among COH’s HIV testing clients who were sexual minorities in FY18, 15.42% identified as bisexual, while 0.29% identified as pansexual and 3.42% identified as queer. Overall in FY18, among HIV testing clients reporting a sexual identity other than heterosexual, a total of 19.13% identified using sexual identity labels that would potentially (e.g., queer) or definitively (e.g., bisexual or pansexual) classify them as having a non-monosexual identity.
Table 1:
Sexual identity of clients who received HIV testing at COH in FY18 and FY19
| Data Year | FY 18 | FY 19 | ||
|---|---|---|---|---|
|
| ||||
| Sexual Identity | Number | Percent | Number | Percent |
| Bisexual | 483 | 11.70% | 458 | 11.49% |
| Pansexual | 9 | 0.22% | 31 | 0.78% |
| Queer | 107 | 2.59% | 122 | 3.06% |
| Heterosexual | 995 | 24.11% | 1246 | 31.25% |
| Gay | 2423 | 58.71% | 2047 | 51.34% |
| Lesbian | 24 | 0.58% | 26 | 0.65% |
| Questioning | 13 | 0.31% | 18 | 0.45% |
| Same Gender Loving | 1 | 0.024% | 1 | 0.025% |
| Demisexual | 0 | 0% | 3 | 0.075% |
| Asexual | 0 | 0% | 1 | 0.025% |
| Other | 2 | 0.048% | 15 | 0.38% |
| Unknown/Unreported | 31 | 0.75% | 5 | 0.13% |
| Refused to Disclose | 39 | 0.94% | 14 | 0.35% |
| Total | 4127 | 100.00% | 3987 | 100.00% |
During FY19, 3,987 clients age 14 to 79 years received HIV testing at COH. In FY19, among COH’s HIV testing clients who were sexual minorities, 16.71% identified as bisexual, while 1.13% identified as pansexual and 4.45% identified as queer. In total in FY19, among HIV testing clients reporting a sexual identity other than heterosexual, 22.29% identified using sexual identity labels that would potentially (e.g., queer) or definitively (e.g., bisexual or pansexual) classify them as having a non-monosexual identity.
Demographics of Clients Accessing HIV/STD Hotline and HIV/HCV Testing at COH
During FY18, the COH HIV/STD Hotline received 6,282 calls. Once nuisance calls (hang-ups, pranks, and wrong numbers) and calls falling outside the top 12 hotline codes were removed, 3,503 calls remained. Callers ranged from 14 to 88 years in age. In total, 7.87% of callers identified as bisexual, while 68.66% of callers identified as heterosexual, 0.17% of callers identified as queer, 21.18% of callers identified as gay, 0.31% of callers identified as lesbian, 0.14% of callers reported questioning their sexual orientation, and 1.66% of callers did not report their sexual orientation. Among bisexual callers, 103 of 276 callers (37.31%) reported “bisexual activity,” indicating they had reported sexual activity with partners of more than one gender. There were 9 callers (3.26%) who identified as bisexual women, 266 callers (96.37%) who identified as bisexual men, and one bisexual person who did not disclose gender (0.36%). By race/ethnicity, 131 (47.46%) bisexual callers were White, 53 (19.20%) were Black, 59 (21.37%) were Mexican, 2 (0.72%) were Puerto Rican, 9 (3.26%) were of a Hispanic (Latinx) identity other than Mexican or Puerto Rican, 8 (2.90%) were Asian, 7 (2.53%) were Multi-Racial, 1 (0.36%) identified as from the Near East, and 3 (1.09%) did not disclose race.
During FY19, the COH HIV/STD Hotline received 7,752 calls. Once the nuisance calls and calls falling outside the top 12 hotline codes were removed, 4,451 calls remained and comprised the analytic sample. In FY19, callers ranged from 14 to 85 years in age. In total, 8.34% of callers identified as bisexual (38% of whom reported sexual activity with people of more than one gender), while 71.01% identified as heterosexual, 19% identified as gay, 0.88% identified as lesbian, 0.05% identified as queer, 0.25% reported questioning their orientation, and 0.45% of callers did not report a sexual orientation. By gender, 5 (1.35%) bisexual callers identified as transgender, 36 (9.7%) identified as women, and 329 (88.68%) identified as men. By race/ethnicity, 166 (44.74%) of COH’s bisexual callers were White, 111 (29.91%) were Black, 33 (8.89%) were of a Hispanic (Latinx) identity other than Mexican or Puerto Rican, 24 (6.47%) were Mexican, 10 (2.70%) were Puerto Rican, 9 (2.43%) were Asian, 9 (2.43%) were multi-racial, and 3 (0.81%) were from the Near East.
COH HIV/STD Hotline Call Codes by Sexual Identity
In FY18, out of 276 bisexual callers, 32% were coded as calling about HIV transmission, 20% called about HIV symptoms/medical information, 4% called for HIV/STD referrals, 8% called about PrEP, 5% called about HIV/STD test information, 1% called for linkage to care services (including AIDS Drug Assistance Program [ADAP] information), 1% called for PEP referrals, 5% called for emotional support, 19% called about STD information, 3% called about safer sex, 0.27% called for statistical information, and 3% called for undisclosed reasons. The numbers and proportions of callers of all sexual identities for FY18 are included in Table 3.
Out of the 371 bisexual callers in FY 19, 25% called about HIV transmission, 7% called about information for HIV/STD testing, 10% called about HIV symptoms and medical information, 6% called about HIV/STD referrals, 0.27% called about linkage to care/ADAP, 2% called about PrEP, 2% called about PEP, 18% called about emotional support, 16% called about STD information, 4% called about safer sex, and 1% called about statistics and literature. The numbers and percentages of callers of all sexual identities for FY19 are included in Table 4.
Sexual Identity Comparisons of HIV/STD Hotline Call Codes
In both FY18 and FY19, compared to callers of all other sexual identities, bisexual individuals had the highest proportion of calls coded as primarily focusing on HIV transmission, though only the comparison between bisexual vs. heterosexual callers was significant. Similarly, in FY 18, the highest proportion of callers calling about HIV symptoms was found among bisexual individuals; this proportion was significantly higher among bisexual individuals compared to “other” individuals. In FY19, however, compared to bisexual individuals, both heterosexual and gay callers were significantly more likely to call about HIV symptoms. In FY18, bisexual individuals were significantly more likely to call about PrEP than gay callers. In FY19, however, this trend was reversed; a significantly lower proportion of bisexual callers vs. gay callers called about PrEP. Of note, in both years, a significantly higher proportion of gay callers compared to heterosexual callers called about PrEP; this comparison was not significant among bisexual vs. heterosexual callers. In FY18, compared to the proportion of heterosexual callers, significantly lower proportions of gay and bisexual callers called about safer sex, while significantly higher proportions called about HIV linkage to care services. No significant sexual identity differences for these call codes were observed in FY19. In both FY18 and FY19, a significantly higher proportion of gay vs. heterosexual clients called about post-exposure prophylaxis (PEP) referrals; no significant differences were detected between bisexual and heterosexual or bisexual and gay callers. A comprehensive listing of all comparisons is listed in Tables 3 and 4; comparisons that do not appear in the tables were tested, but were not found to be significant.
Discussion
Centering the findings of bi+ individuals, this manuscripts presents by sexual orientation a description of the scope of HIV and STI-related services clients accessed during a 2-year period at a large Midwestern LGBTQ community center, Center on Halsted (COH). These findings demonstrate the contribution that analysis of detailed SSOGI data collected by LGBTQ community organizations can make to disseminate much needed information about the engagement of bi+ populations with community-based sexual health providers. Especially given the increasingly documented sexual health disparities bisexual populations face compared not only to heterosexual populations (Friedman, Stall, et al., 2014) but also often to sexual minority populations (Agenor et al., 2019; Lindley, Kerby, et al., 2007; Lindley, Walsemann & Carter, 2013), such findings are crucially important to generating an evidence base to improve the sexual health of bi+ populations in an evidence-informed fashion. In this regard, public health surveillance funding agencies should follow the lead of their grantees such as COH. It is time for public health epidemiologic surveillance reporting systems to be updated to document the sexual health of bi+, transgender, and other diverse sexual and gender minority populations often already being collected by their LGBTQ grantee organizations.
The analyses reported in this manuscript can also be viewed as a form of bi+ tailored program evaluation and quality improvement assessment of the HIV/STD-related services offered by COH – a LGBTQ community organization that has a variety of peer organizations throughout the United States. Given the known disparities in both healthcare access and in the burden of HIV and STDs impacting bisexual populations (Agenor et al., 2019; Gonzales & Henning-Smith, 2017; Gonzales et al., 2016; Singh et al., 2014), the ability to access free sexual health information and HIV screening services at a LGBTQ-tailored community organization may represent an important intervention point to improve the sexual health of bi+ populations. Biphobia, however, which operates not only in ‘mainstream’ societies, but also within LGBTQ community spaces (Friedman, Dodge, et al., 2014), has often limited the implementation of such interventions.
At the Chicago Bisexual Health Task Force (CBHTF) sponsored preconference institute at the National Sexual Health Conference (for a description of the half-day institute, see Feinstein, this issue), Chicago bisexual activists in attendance spoke openly about their historical experiences of biphobia at COH. Such experiences of biphobia should not be viewed as a specific condemnation of COH. Indeed, bisexual people routinely and systematically report biphobic experiences within LGBTQ community settings (Roberts et al., 2015). At the structural level, the presence of biphobic experiences in LGBTQ community organizations is amplified by the fact that these organizations often lack any specific programs or tailored services to address the needs of bi+ people. Strikingly, prior to the start of CBHTF in 2018, with the exception of one bisexual-specific 501(c)(3) non-profit, none of the participating Chicago LGBTQ organizations offered any programs specifically focused on conducting outreach to bi+ populations to recruit them into existing organizational services, let alone stand-alone programs dedicated to serving the needs of bi+ populations. In these ways, both the interpersonal and structural effects of biphobia may contribute to lower than expected attendance rates of bi+ people within LGBTQ community services.
As a source of program evaluation, the data from COH’s HIV/HCV Testing Services and the State of Illinois AIDS/HIV and STD Hotline can be viewed as highlighting this point in practice. As Tables 3 and 4 show, among sexual minority COH HIV/STD hotline callers, approximately one-quarter identify as bisexual, while three-quarters identify as gay or with another monosexual sexual identity. Prior research demonstrates, however, that over half of all sexual minority individuals identify as bisexual (Gates, 2011). Findings from the COH hotline data therefore can be interpreted to indicate that compared to their queer monosexual (e.g., gay and lesbian) counterparts, bisexual individuals are not accessing COH’s LGBTQ-tailored sexual health services at a population proportionate rate. Of note, despite having an HIV prevalence rate over 5 fold higher than heterosexual individuals (Friedman, Wei, et al., 2014), bisexual individuals experience disparities in HIV testing (Agenor et al., 2019). Data from the HIV/HCV testing unit at COH thus provides further concerning evidence that bi+ clients are not accessing COH services at rates in alignment with LGBTQ population demographics, nor arguably within alignment of the disparities inherent in the HIV/AIDS epidemic. In addition to highlighting the lower proportion of bi+ individuals than would have been expected to be attending COH’s sexual health services, the analysis of the coding categories of the hotline data also reveals interesting information about the sexual health needs of bi+ callers. Of note, across both years of data collection, bisexual callers indicated consistently a need for information about HIV transmission. Though the numbers of callers overall for PEP and PrEP were low, analyses indicate that compared to gay callers, bisexual callers may be less likely to ask for information about these topics. These findings may not reflect that bisexual callers have less of a need for these services; instead, they may reflect that bisexual callers are less aware of their existence. Such an interpretation is in alignment with prior studies that have found that compared to men who have sex with men only, men who have sex with men and women were less likely to be aware of PrEP (Friedman et al., 2019).
The completion of this project also had an impact on program operations at COH. Among COH staff, the contextualization of the data included in this manuscript raised awareness about the need to scale up community outreach and recruitment of bisexual and bi+ people to engage in COH’s sexual health services. Internally, the data are being used at COH to educate COH staff about the needs of bisexual+ populations, starting with client-facing COH teams. While this manuscript does not explore the reasons why bi+ people are underrepresented in the groups accessing COH’s sexual health services, one possibility may be that bi+ people fear experiencing biphobia or have experienced biphobia within LGBTQ community spaces such as COH. Given this reality, in addition to educating the COH sexual health teams, in the future, COH plans on prioritizing ongoing education of COH’s Reception Team, Youth Department, Senior Services Team, Anti-Violence Project, and Behavioral Health Team about the unique needs of bi+ populations.
Though this manuscript does not report on the sexual identity of clients accessing services at a LGBTQ community organization beyond sexual health, given the systematic nature of biphobia, the data contained in this manuscript should be viewed as a wake-up call for the need to immediately implement trainings to make sure that staff help bi+ people feel welcome at LGBTQ community organizations more broadly. In addition, it should be viewed as a call to conduct similar service portfolio analyses as described in this manuscript across all teams within these organizations. When developing and administering such trainings and analyses, LGBTQ organizations should take a systemic “360 view” with the organization’s implementation approach. For example, when an individual enters an LGBTQ organization, a receptionist will likely be the first person they will encounter. It is thus critically important that members of reception teams at these organizations are aware of best practices with supporting bi+ clients, to help bi+ people feel welcome in and choose to engage with the space. Relatedly, trainings should be implemented to ensure that youth participants in LGBTQ organizational settings can benefit from early affirmation of their experiences and existence as bi+ people. Such affirming experiences can help to strengthen youths’ sense of being in the world as a bi+ person and thereby potentially improve their mental wellbeing. Reporting the age and sexual identity distributions of clients at LGBTQ organizations accessing senior services can help inform senior services staff of the sexual health needs of bi+ seniors and how to better conceptualize how those sexual health needs may accompany general health issues that often appear as clients accessing LGBTQ community centers age. Such analyses can also help support behavioral health providers in LGBTQ community organizations, who can also benefit from learning about bi+ sexual health needs. For example, information about sexual health services utilization of bi+ seniors at COH may influence the work approach that members of the COH Behavioral Health Team take providing behavioral counseling and supporting the mental health of bi+ clients who may be addressing sexual health issues in their therapy sessions. Notably, having an affirming therapist can help in the promotion of mental wellbeing when mental health clients know that their therapist understands their unique needs as bi+ people.
Data from bi+ focused evaluations of sexual health service provision can also help improve the quality of services received by bi+ clients at LGBTQ community centers in other ways. For example, while COH’s testing and hotline services staff are trained to be affirming to people who are bi+, presentation of results from analyses within this manuscript has helped inform how COH’s sexual health teams treat bi+ callers and testing clients. Specifically, these findings encouraged COH’s sexual health staff to use more bi+ inclusive language (e.g., “Can you tell me the gender or genders of your sex partners?”) as well as to address both the client’s sexual identity and their sexual behavior, even if their sexual behavior did not involve sex with people of multiple genders. These findings highlight the importance of collecting and reporting both sexual identity and sexual behavior data as part of providing affirming sexual health services to bi+ clients. When conducting sexual health services program evaluations to improve the quality of services for bi+ clients, LGBTQ organizations can look to the structuring of analyses as reported in this manuscript as a best practice for how to structure such quality initiatives. To help ensure continuous quality improvement in the provision of inclusive sexual health services to bi+ clients, LGBTQ community organizations should as a best practice also consider cultivating meaningful partnerships with bi+ stakeholders and community organizations. Indeed, the inspiration to undertake the bi+ evaluation activities reported in this manuscript stemmed from a partnership COH’s sexual health team founded between COH and CBHTF (see Feinstein, this issue), with a specific goal of improving and tailoring COH’s sexual health services for bi+ people.
This study is not without limitations. COH codes each HIV/STD hotline call only with the main topic discussed during the call. It remains possible that hotline callers discussed multiple topics during their calls; such data would be non-reported in the COH data. In addition, given that no identifying information is collected from callers during the hotline calls, it is not possible to determine if there were repeat callers within the dataset. Therefore, estimates of demographic characteristics of callers may be biased. Despite the more detailed data capture available at COH compared to public health agencies, the COH Client Information Sheet does not include a write-in option for clients who would otherwise report a gender not listed in the current response options. Furthermore, both HIV testing clients and hotline callers were required to select only one option to describe their sexual orientation. In contrast, a strength of this manuscript is that due to COH’s more expansive sexual orientation response options, this manuscript reports the numbers and percentages of COH’s HIV testing clients who identified with bi+ identities beyond identifying as bisexual, including as queer and pansexual.
Overall, this manuscript provides a description of the demographics of clients accessing sexual health services at COH. Future studies should continue to build upon this work by analyzing the programmatic and evaluation data from other COH teams to highlight how they are serving bi+ client populations. Additionally, future studies should investigate the racial/ethnic, gender, age, and socioeconomic status (SES) diversity of bi+ clients accessing services at COH. Patterns that emerge from these analyses should be explored with an aim of optimizing inclusive services that COH provides at the intersections of multiple forms of marginalization. Organizations that offer similar services to LGBTQ+ populations can benefit from analyzing programmatic data from their bi+ clients and disseminating findings internally to improve the quality of service provision to bi+ populations. Analyzing service delivery to bisexual clients within health programs offered by LGBTQ community centers can identify opportunities to tailor marketing and purposeful outreach to bi+ people to expand the number of bi+ people reached by these services. Only by working together with bi+ community stakeholders to design and promote health services to meet the needs of bi+ populations will LGBTQ community organizations help achieve the goal of eliminating bi+ health disparities.
Acknowledgments
We acknowledge the guest editor of this Special Issue of the Journal of Bisexuality, Dr. Brian Feinstein, for his guidance and support throughout the process of creating and submitting the manuscript. We are grateful to the reviewers of this manuscript, whose feedback supported the improved course and content of the manuscript. We also acknowledge the work of the HIV & STI Services Team at Center on Halsted: Jill Dispenza, Director of HIV/STI Services; Erica Gafford (currently Director of HIV Testing/Prevention), serving as Data Specialist Manager in FY18 and FY19; Kristine Chapman (former Hotline Manager); Melvin Laureano (former HIV Services Manager); Javier Arellano (former PrEP navigator, former Chicago Department of Public Health Coordinator), and the FY18 and FY19 Full/Part-Time Health Educator Team, as the data reported in this manuscript could not have been collected without their efforts. We also acknowledge funding received by the Chicago Department of Public Health, Gilead, and the Illinois Department of Public Health – Contract #65700002D. During the course of this study, Dr. Beach was supported by a K12 award (K12 HL143959) funded by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health and administered through the Third Coast Center for AIDS Research (TC CFAR) (P30 AI117943).
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