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Ecological Analysis of Bisexual Identity and Health Access

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Ecological Analysis of Bisexual Identity and Health Access ECOLOGICAL ANALYSIS OF BISEXUAL IDENTITY AND HEALTH ACCESS: AN INTERPRETIVE CRITICAL INQUIRY A Dissertation by CARLOS PAVAO Submitted to the Office of Graduate and Professional Studies of Texas A&M University in partial fulfillment of the requirements for the degree of DOCTOR OF PUBLIC HEALTH Chair of Committee, Kenneth R. McLeroy Co-Chair of Committee, Yvonna S. Lincoln Committee Members, James N. Burdine Eric Wright Head of Department, John Spengler May 2019 Major Subject: Health Promotion and Community Health Sciences Copyright 2019 Carlos Alberto Oliveira Pavao ABSTRACT Ecological Analysis of Bisexual Identity and Health Access: An Interpretive Critical Inquiry (May 2019) This interpretive critical inquiry was aimed at coming to understand the experiences of self-identified bisexuals, and how bisexual health disparities occur due to misunderstandings of bisexual identity and institutional barriers that foster biphobia. This study was carried out in the metropolitan Atlanta area. Purposive sampling was used to select 36 self-identified bisexuals as study participants. The data collection included participant observations ethnographic interviews, focus groups, and document analyses and occurred over a 19-month period between January 2017 and July 2018. The focus groups and interviews were audio recorded, transcribed, and analyzed using Lincoln and Guba’s approach to content analysis. Based on the themes and subthemes that emerged, the experiences of bisexual healthcare experiences seemed to yield positive self-image that is complicated by how society construes their sexuality. Overall, participants did experience different obstacles in accessing healthcare, there is a lack of bisexual social spaces to socialize, and face discrimination from both the heterosexual and homosexual communities. One key theme is how bisexual identity is often collapsed with other identities such as men who have sex with men (MSM) or women who have sex with women (WSW). Typically, within the academic literature bisexuality as an identity is synonymous with gay or lesbian identities. This folding of bisexuals into broader categories (MSM, gay, etc.) is based on sexual behavior rather than one’s sexual chosen identity. The majority of the participants appeared to be resilient and have a positive self-image of bisexuality. Many said their bisexuality is an important aspect of their social identity. Results ii indicate that when bisexuals seek medical care there is considerable variation in how they receive medical care. The conclusion includes implications for public health planning, community practitioners, and, state systems; recommendations for future research; and three working hypotheses. iii DEDICATION I dedicate this dissertation to my immigrant family who came from a country under military dictatorship for fifty years with four suitcases filled with hope, anticipation, eagerness and a wavering sense of how to navigate American institutions. iv ACKNOWLEDGEMENTS First and foremost, I would like to thank my faculty advisor and committee chair, Dr. Ken McLeroy, who provided incredible guidance, support, kindness, leadership, and insight throughout my dissertation process. His intellectual curiosity is the central reason why I ask the academic questions that I do. He is my intellectual father. In the same way that I was influenced by Dr. McLeroy, I was fortunate to also be taught by Dr. Yvonna Lincoln, my intellectual mother. She taught me to see the beauty and depth of methodological inquiry. My teaching and research is highly influenced by her axiological views of the need for social justice frames within social science research. They both have truly influenced the way I look at the world and the way I approach my work. A most sincere thank you also goes to Dr. Jim Burdine and Dr. Eric Wright, my committee members, who provided their support, feedback, and unique perspective throughout the process. Dr. Burdine instilled in me hope that someone of my age and professional experience has value to contribute during an academic career. Dr. Burdine is the person I go to get advice on professional development since he can understand what it means to be older and start a new career in academia. Dr. Wright exemplifies who I hope I can become as an LGBT focused researcher, and I hope that he can be a future mentor. I see his career path and use his model for how to become a LGBT researcher. I am exceedingly grateful for all of the family, friends, classmates, colleagues, and other faculty who have provided their support, understanding, encouragement, guidance, advice, and patience. A special thank you to Zina Age, Aniz, Inc for their continual support and encouragement over the years. Last but certainly not least, to my family, I will be forever thankful for their enduring support over the past years. My mom, Maria, and little brother, Milesio, are my rocks. We have v gone through much in this country. I thank them for offering continual encouragement and giving me much needed life perspective. A special thanks to my nephew Tyler who inspires me as to why we as an immigrant family have the desire to succeed. A thanks to my husband, James H. Doster, for his laughter, encouragement, patience, and love. Our hardships have made us stronger. A special thanks to my fur-babies William and Abby our dogs, and four cats Blake, Soren, Simon, and little Sonia. We lost William during my first year of the doctoral program and I was not there in Georgia for him. I truly miss him. Abby has and will always be the baby girl. Blake is our Texas cat who purrs boisterously even during a vet appointment. During my dissertating phase, three feral small kittens appeared in my back deck in the middle of a chilly Georgia winter. After the tender domestication phase, they have brought life back into the house with their crazy playful antics. I could not have made it through then many hours of writing without my fur babies interrupting me and chewing on draft chapters and computer cords. vi CONTRIBUTORS AND FUNDING SOURCES This dissertation was the result of a community-based project examining health access barriers for bisexual individuals. This project, “Acknowledging the Silence: Addressing the Health Disparities Access Issues for the Bisexual Population”, was funded by the Atlanta Clinical Translational Science Institute (ACTSI) Community Engagement Research Program (CERP) 2015 Community Academic Research Partnerships Grants Program award in the amount of $10,000. The community agency that hosted the study was Aniz, Inc. I was hired as an evaluation consultant to oversee methodological approaches. In addition to Aniz, this study was a collaborative partnership with Physicians for Reproductive Health with the end goal to develop cultural competency training for medical providers to provide clinical services for bisexuals. This study has been approved by two IRBs. One was to conduct the community project by Morehouse School of Medicine, (IRB 906342-4 IRB protocol). For the dissertation phase, a second IRB approval was secured (IRB 2018-0026M) entitled, “Resilience and Sexual Identity Construction of Bisexual Identifying Individuals: a socioecological assessment and health policy case study”. The data analyzed for Chapter II and III was provided by the Aniz community project. vii NOMENCLATURE LGBT Lesbian, Gay, Bisexual, Transgender LGT Lesbian, Gay, Transgender CLAS National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (The National CLAS Standards) viii TABLE OF CONTENTS Page ABSTRACT .............................................................................................................................. ii DEDICATION .......................................................................................................................... iv ACKNOWLEDGEMENTS ....................................................................................................... v CONTRIBUTORS AND FUNDING SOURCES ................................................................... vii NOMENCLATURE .............................................................................................................. viii TABLE OF CONTENTS ......................................................................................................... ix LIST OF TABLES ................................................................................................................. xiii CHAPTER I INTRODUCTION ............................................................................................... 1 Framing of sexual identity ............................................................................................. 4 CLAS Standards: healthcare policy implementation ..................................................... 8 National LGBT health disparities priorities ................................................................ 10 Problem Statement ....................................................................................................... 12 Purpose of the Study .................................................................................................... 13 Research Questions ...................................................................................................... 13 Definition of Terms ..................................................................................................... 14 Significance of the Study ............................................................................................. 14 Organization
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