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But the interplay of these factors in the formation of LGBT identities in the United States has origins in the mid th Century [ 16 ].

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Prior to adopting more consolidated identities of lesbian, gay, bisexual, and transgender, unorganized and isolated individuals first sought to identify and connect with each other in the politically and socially hostile climate following World War II [ 20 ]. The Mattachine Society [ 20 ] and the Daughters of Bilitis [ 21 ].

These moves toward self-acceptance and identity development would ultimately encourage public advocacy for the rights and social acceptance of a broader community. Concurrent with this early mobilization were several other pivotal developments that helped the increasingly organized groups of LGBT people challenge the illness model of homosexuality. Early forms of activism among LGBT people leveraged these studies in order to dismantle the definition of homosexuality as a psychological disorder. In , the first transgender-specific magazine in the United States, Transvestia , was published [ 26 ].

It also argued against the criminalization of gender non-conforming dress and promoted early ideas of transgender people as a minority community [ 26 ]. Transgender people continued to organize throughout the s, developing community and activist organizations and promoting research into medical gender confirmation procedures [ 26 , 27 ].

These efforts were vital in pushing back against anti-homosexual political action that prevailed following s McCarthyism. The rise of consumerism, a growing working class of women, and feminist and civil rights critiques following World War II resulted in many sexual and gender norms being dissolved or reconfigured. LGBT people were sought out, arrested, and exposed under the guise of protecting the social order. In such a hostile climate, new forms of political and social organizing and advocacy were needed [ 28 ]. The Stonewall riots of represent a significant turning point for LGBT people, who not only protested against the frequent police raids in New York City but also organized a nationwide, grassroots liberation movement [ 16 ].

Though not by any means the first form of public protest from LGBT people [ 29 ], it served as a very visible and forceful catalyst to national organizing as sexual minorities began identifying services they could not adequately receive elsewhere and providing for themselves [ 5 , 16 ]. Transgender people were then systematically excluded from LGB groups, who wanted to distance themselves from notions of deviance and medical pathology that transgender people now carried the burden of [ 32 ]. Likewise, feminist groups resisted the inclusion of transgender people, leaving them with few social and political allies throughout the s and s [ 26 ].

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Medical, legal, and psychotherapeutic professionals working with transgender people continued to provide healthcare, conduct research, and develop standards of care via professional organizations like the World Professional Association for Transgender Health WPATH; formerly the Harry Benjamin International Gender Dysphoria Association, founded in [ 26 , 33 ]. Such organizations were among the few resources that remained to transgender people through the s. With homosexuality no longer included in the DSM, large numbers of LGB people were able to create visible communities in urban hubs [ 4 ].

Though these communities by no means flourished in all areas, the rapid growth of LGB organizations throughout the country enabled the once disparate people to share information across communities and better serve their local needs. It was soon recognized that many LGB people were stigmatized when accessing services in general healthcare settings, and as a result many LGB organizations took it upon themselves to offer an alternative source of care [ 3 , 6 , 34 ].

The infrastructure for community-based health services was being established with the proliferation of LGB community centers throughout the country.

LGB community centers and activists began to consider the possibility of unique health issues and disparities in need of specialized attention. These programmatic shifts are visible within both emerging and pre-established community centers of the s. Fenway Community Health, founded in in Boston, Massachusetts, was not initially established as an LGB community health center, but became the first community health center to develop expertise in LGB health services in response to the demographic needs of its own staff and clients [ 37 ].

By the mids, the National Gay Task Force listed over clinics and medical service programs and over counseling and mental health programs, with services ranging from testing and treatment for sexually transmitted infection to counseling and care for substance users, that were openly LGBT friendly and accepting [ 5 ]. Meetings held by these groups disseminated the latest HIV research and prevention strategies, developed often radical and militant strategies for social and political advocacy, and identified and organized social and healthcare services for men with HIV and AIDS who were unable to receive adequate services elsewhere [ 2 , 3 ].

LGB organizations rapidly responded by offering emotional and practical support to those affected by HIV, counseling, sex education, home-based hospice care, housing and other social services [ 1 , 2 ]. The action taken at the community level resulted in increased public awareness of HIV and AIDS and initiated action at the federal level.

However, the narrow focus on HIV over the course of the s and s re-associated homosexuality with illness after long-fought struggles to disassociate from the medical field [ 41 , 42 ]. Though large amounts of federal funding were made available to research HIV among gay men, little attention was given to other health issues among either gay men or LGBs in general [ 3 ]. At the same time, transgender people re-emerged to advocate for their own uniquely transgender health issues, including issues related to HIV and gender confirmation [ 43 , 44 ].

Little has been written on the political, social, and historical milestones for transgender people during the s. On the other hand, the s saw a burst of activity that sparked an increase in activism. Ongoing debates within feminist studies and theory resulted in the development of a queer theory that legitimized transgender identities. Once again advocating for issues as a collective, LGBT people together produced a large body of research pointing to diverse and complex health disparities [ 45 — 49 ].

Formerly LGB organizations began re-branding themselves as inclusive of transgender individuals, and a focus on LGBT health took shape at both community and national levels [ 3 ]. The collective efforts of LGBT community centers, activists, and professionals culminated in a variety of events that aided LGBT people in gaining national recognition as an underserved population in health.

These include: In it, they synthesized decades of research on LGBT health in order to summarize what was known about the disproportionate burden of disease among LGBT people and areas for future research. Anxiety; access and other barriers to quality care; depression; suicide and suicidal ideation; eating disorders; adolescent pregnancy; obesity; HIV and other sexually transmitted infections; breast cancer; anal cancer; cervical cancer; bullying and harassment; erectile dysfunction; substance abuse including cigarettes, alcohol, and other drugs ; cardiovascular disease; and elevated rates of other cancers possibly associated with hormone treatments for transgender individuals [ 57 ].

Each of these can be recognized as relevant health concerns for LGBT populations, but researchers and community members have questioned how disproportionate health burdens could or should translate to concrete health service [ 5 , 57 ]. Guided by this review of the literature, we now turn to assess the scope of LGBT health services in the United States today. We then discuss how the LGBT health movement has shaped the contemporary landscape of LGBT health services, current gaps in service, and consider how social and political changes may influence the LGBT health service landscape moving forward.

To generate an asset map of the contemporary landscape of LGBT health services, several key constructs required operationalization. These definitions and criteria ensured that all organizations and service sites identified during data collection were appropriately categorized and, if necessary, excluded from analyses. Definitions and criteria are included in Table 1. FQHCs are also included in Table 1 in order to contrast our own definition of and criteria for LGBT community health centers with the stringent criteria that must be met in order to be recognized federally as a community health center.

Although FQHCs are able to provide much more comprehensive care than the LGBT community health centers we define here, many LGBT community health centers operate in smaller capacities and provide a variety of health services to their local community members. Initial records for LGBT organizations and their respective service sites were created using the lists of CenterLink member organizations and respondents to their biannual LGBT community center survey [ 7 , 61 ]. These lists were not mutually exclusive, and not all respondents to the biannual survey were CenterLink members, resulting in an initial list of organizations and service sites.

We then searched public records for each organization using GuideStar, a database of IRS-registered non-profit organizations, to confirm non-profit status.

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Any new organizations that was identified via the GuideStar search were added to the list. In the event that any of the criteria for LGBT community health centers was unavailable on an organizational website, organizations were contacted by telephone to confirm the missing data. Organizations that did not meet the criteria for LGBT community centers, or for which the criteria could not be confirmed via online search or telephone call, were excluded.

Data collection occurred between September—December, Ten new organizations were included that had not been otherwise identified, of which two met the criteria for an LGBT community center. Neither met the criteria for an LGBT community health center. Additional categories were created for organizations whose health services did not fit within the above categories. LGBT community centers that operated a physical health clinic were also identified, and were defined as clinical spaces operated by trained and licensed healthcare personnel.

These include but are not limited to primary care clinics in that health clinics may specialize in specific services e. Community health centers that offer health services in the absence of a trained and licensed professional e. In all, records were created during the search for LGBT community health centers.

Of these records, Of those, Same-sex households, identified using census data, is used in this study as a proxy for local LGBT population density. Doing so associated United States counties within the electronic map shapefile with their relative number of same-sex households. The county shapefile was then overlaid above a United States shapefile displaying the state and national boundaries of the United States.

Next, county areas were filled by graduated colors representing the relative proportion of same-sex households to all households per county. Finally, LGBT community health centers were geocoded, or linked to a specific geographic location within the United States map, in order to display their location relative to the local same-sex population density.

A mile buffer was created around each LGBT community health center to represent the geographic coverage area for each center. The 60 miles radius was chosen to approximate a one-hour drive from each center. Centroid locations, or the most central point of each county polygon, were calculated using ArcGIS in order to determine approximate distances between each county center and its nearest LGBT community health center.

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Linear regression was run to determine whether the local LGBT population density was significantly associated with the distance to the nearest LGBT community health center. Clusters of LGBT community health centers are located on both coasts of the continental United States, with fewer or no health centers located in the center, Alaska, or Hawaii. Fig 4 displays community health centers offering transgender services, specifically, which further reduced the number of centers to only 21, which are available in only 9 states California, Connecticut, Florida, Georgia, Pennsylvania, Illinois, Massachusetts, New York, Texas and the District of Columbia.

Both general health clinics and health clinics that specialize in transgender health are concentrated in the northeastern United States. Fig 5 displays the type of services provided across all LGBT community health centers. Early efforts to protect LGBT people against societal stigma and prejudice motivated LGBT communities to provide themselves with better health services than they could not obtain in general population settings.

In their earliest form these health services consisted predominantly of general medical, mental health, and sexual health services at LGBT organizations operating small health clinics [ 5 , 37 , 38 ]. These organizations soon included such specialized services as hospice, grief counseling, cancer prevention, peer support groups, and step programs in the era of HIV, the stigma from which left many without access to care in the general population healthcare settings [ 1 , 2 ].

LGBT health services have continued to evolve and expand in accordance with social change and medical advances. For example, hospice care services have presumably diminished within LGBT community health centers as HIV-related morbidity and mortality decreased, while counseling services remain common and have expanded in the types of counseling services available.


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The expansion of services over time demonstrates that, whether offering highly technical and specialized medical care or preventative and wellness services, a majority of LGBT community organizations have made health a priority. The high prevalence of wellness services suggests that even organizations with limited resources may be able to engage with health promotion and prevention efforts in their communities.

This study highlights a number of challenges with regard to accessing LGBT health services. First, as Fig 2 demonstrates, while significant proportions of LGBT people living on either coast live within miles of an LGBT community health center, the central states are largely under-served. Thirteen states are devoid of LGBT community health centers altogether.

And while we used a mile radius as an indicator of proximity, even a mile radius may not represent accessibility in the dense urban and coastal hubs. Moreover, proximity to any one LGBT community health center does not necessarily mean access to comprehensive LGBT health services given that each LGBT community health center provides a different combination of health services.

At the same time, we should not assume that a lack of LGBT community health centers equates to a lack of culturally competent health services. The purpose of this study is not to definitively determine all the places LGBT people can and do access culturally competent care. With that said, our own findings suggest that CenterLink and MAP have likely greatly under-reported the number of LGBT people served in , as their estimate of , people served is based upon data reported by only 62 organizations [ 8 ]. LGBT community health centers continue to be a valuable resource to LGBT people, and how these resources are invested in going forward is a matter of great concern.

The research conducted as a part of this study is limited in a few ways. First, we cannot claim to represent all LGBT community health centers. Although we had criteria for defining and categorized organizations during data collection, there was nonetheless room for error. Information available online was assumed to be accurate, particularly including information regarding the services provided.

However, if an organization had recently added or removed services without updating the website than their classification as an LGBT health center or not may be inaccurate. Also, our findings represent an overall snapshot of the LGBT community health centers and services provided between September—December of The nature of studying or working with community-based organizations requires some allowances for imperfections in the data collected.

One consequence of being a small, new, or under-resourced LGBT community health center—as many of the organizations included in our study are [ 8 ]—is that the services they provide may change over time or even cease to exist. This may be the result of organizations merging together, shifting the services provided according to the demands, the availability of new funding opportunities, the withdrawal of funding, and changes in personnel. Finally, our findings only describe the availability of services offered by LGBT community health centers, not on the quality of services or even the extent to which any services are utilized.

Our goal here was to discuss the broader scope of what LGBT health services look like today, and we believe we have achieved that goal. This study is also limited in its ability to speak to the wide diversity of LGBT experiences. The present study cannot speak to the involvement of these populations in the LGBT health movement in the absence of literature on the subject. Similarly, without assessments of the origins, evolution, and contemporary landscape of LGBT health movements internationally, it is not possible to situate these findings within the broader story of LGBT people globally.

We hope that our research encourages future studies to explore the wide diversity of LGBT people and their experiences within health movements in different regions of the world and over time. One reason being that not all LGBT people have or live with their partners, and another being that not all would feel comfortable identifying themselves as living in a same-sex household. But this approach also fails to capture bisexual and transgender people in opposite-sex households. For example, it may be that bisexual and transgender people are more highly concentrated in distinct areas from lesbians and gay men, but that those communities are not visible within the census data.

In spite of these limitations, this approach using census data remains a useful metric for determining where LGBT people may be more highly concentrated. With no national census data on sexual orientation of individuals, this is the most comprehensive national data currently available for estimating the geographic distribution of the LGBT people.

As acceptance of LGBT people increases [ 66 , 67 ], the need for specialized services may decrease. However, it remains unclear what the path forward will be for LGBT community health centers. It is possible that there will always be a need for LGBT-specific health services no matter what the level of social acceptance becomes.

In this case, we may see continuation of the increase in the numbers of LGBT health centers, their spread into parts of the country where they are now absent, and greater sophistication of their services regarding the needs of diverse subgroups of the LGBT population e. Koester and colleagues [ 9 ] explored this among gay and bisexual men, concluding that gay and bisexual men may come to prefer having both LGBT-specific and general population healthcare services available to them, but would utilize particular kinds of services in each setting. For example, young, HIV-negative gay and bisexual men reported a preference for separating sexual health services, which they sought in LGBT-specific centers, and other general health services, which they sought in general population settings.

So they use bars like these as an outlet for their sexuality. What does that mean exactly? People were more fluid. There are famous stories of samurai having male lovers. Men would have deep emotional relationships with other men. Older scholars, teachers or Buddhist priests would take on young prepubescent students and have sexual relationships with them.

How did you get access to the urisen? Adrian and I were in 2-Chome for 10 months trying to develop relationships with the bars and some of the boys. Why were they there? Some of them ran away from home. The tsunami? After the disaster, there was an influx of people coming to Tokyo to do sex work. Two of the boys in the film who are currently working as urisens came from the disaster area. One of them lost his house in the tsunami. Another lost his job due to the nuclear meltdown. We generally look at that as far as it affects women and small children.

So when a customer enters the urisen bar, what happens? The boys are sitting on little stools behind the counter when no customers are there. They may be on their phone contacting previous customers asking if they want to come in, reading comic books or playing games on their phone. When the customer does come in, they put the comic book or phone down and stand up so they can be viewed.

And they order sexual services off a menu?

Just like all other men, gay, bisexual, and other men who have sex with men need to know how to protect their health throughout their life. For all men, heart disease and cancer are the leading causes of death.

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However, compared to other men, gay, bisexual and other men who have sex with men are additionally affected by:. Some of them are:. These reasons and others may prevent you from seeking testing, prevention and treatment services, and support from friends and family. In fact, gay, bisexual, and other men who have sex with men make up more than half of the people living with HIV in the United States and experience two thirds of all new HIV infections each year.

The large percentage of gay, bisexual, and other men who have sex with men who have HIV and STDs means that, as a group, they have a higher chance of being exposed to these diseases. Most gay, bisexual, and other men who have sex with men get HIV by having anal sex, which is the riskiest type of sex for getting or spreading HIV. However, if you are HIV-negative, bottoming without a condom puts you at much greater risk for getting HIV than topping. Your sexual health is important. All sexually active gay and bisexual men should be tested regularly for STDs.

The only way to know your STD status is to get tested you can search for a testing site.