The Voices of African Descent Bisexual Women

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Electronic Theses, Treatises and Dissertations The Graduate School

2015 The Voices of African Descent Bisexual Women: Experiences Related to Identity and Disclosure in Social Support Networks and Health Care Settings in the United States and United Kingdom Kristin M. Brown

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COLLEGE OF SOCIAL WORK

THE VOICES OF AFRICAN DESCENT BISEXUAL WOMEN:

EXPERIENCES RELATED TO IDENTITY AND DISCLOSURE

IN SOCIAL SUPPORT NETWORKS AND HEALTH CARE SETTINGS

IN THE UNITED STATES AND UNITED KINGDOM

KRISTIN M. BROWN

A Dissertation submitted to the College of Social Work in partial fulfillment of the requirements for the degree of Doctor of Philosophy.

2015

Kristin M. Brown defended this dissertation on April 20, 2015.

The members of the supervisory committee were:

Neil Abell

Professor Directing Dissertation

Koji Ueno

University Representative

Jean Munn

Committee Member

James Whyte, IV

Committee Member

The Graduate School has verified and approved the above-named committee members, and certifies that the dissertation has been approved in accordance with university requirements.

ACKNOWLEDGMENTS I would like to extend thanks to all those who made this study possible, including Florida State University and the College of Social Work. I would like to acknowledge the Chair and Members of the Dissertation Committee, who committed to my doctoral program and this study over a period of several years. I would like to express gratitude to the women who participated in this study and shared generously from their life experiences, in the US and the UK. I would like to thank all of the organizations, scholars, researchers, and community organizers who supported this study internationally. Your expert review and feedback was constructive. Your publicizing the study opportunity was invaluable. The interview space provided was an important resource. I acknowledge individual and institutional funders who provided grants and scholarships. I would like to thank family and friends for their generous support. I would like to acknowledge forbearers who made these opportunities possible. Throughout this study and my graduate programs, I took strength from the words of Audre Lode i he poe A Lita fo “uial: …Whe e speak e ae afaid ou ods ill ot be heard nor welcomed, but when we are silent we are still afraid. So it is better to speak, remembering we were never meant to survive Lode, .

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TABLE OF CONTENTS

Abstract ...... x

1. INTRODUCTION ...... 1

Statement of the Problem ...... 1 Significance of the Problem ...... 4 African Descent Bisexual Women and Health Care ...... 4 African Descent Bisexual Women and Social Support ...... 5 African Descent Bisexual Women and Resilience ...... 6

2. BACKGROUND AND CONTEXT ...... 8

Conceptual and Empirical Context of the Problem ...... 8 Ethnic and Sexual Minority Women, Health Care and HIV/AIDS ...... 8 Identity, Disclosure, Social Support and Well-being ...... 9 Cross-National Perspective ...... 11 Overview of Health Care Systems in the US and UK ...... 12 Nondiscrimination Policies in the US and UK ...... 13 Definition of Terms ...... 14 Social Support Concepts and Terminology ...... 14 Resilience Terminology ...... 16 Conceptual and Empirical Literature: African Descent Bisexual Women ...... 16 Discussion of Related Research ...... 19 Health care ...... 19 Social support ...... 20 Resilience and well-being ...... 21 Spirituality ...... 22 Expressive arts ...... 22 Relevance to Social Work Research and Practice ...... 23

3. METHODOLOGY ...... 27

Aims of the Research Study ...... 27 Research Questions ...... 27 Research Design ...... 29 Grounded Analysis ...... 29 Settings ...... 30 Sample ...... 30 Race and ethnicity criteria...... 30 Sexual identity and orientation criteria ...... 31 Sexual and gender criteria ...... 31

Recruitment ...... 31 Incentive ...... 34 Protection of Human Subjects ...... 34 Informed consent ...... 34 Confidentiality and data protection ...... 35 Confidentiality ...... 35 Disclosure of HIV status ...... 35 Data protection ...... 35 Data Collection ...... 36 Data Analysis ...... 36 Software ...... 37 Modified grounded analysis ...... 37 Transcription ...... 38 Initial coding ...... 39 Focused coding ...... 40 Memo writing ...... 41 Identifying themes and subthemes ...... 42 Trustworthiness ...... 43 Accuracy during the process of analysis ...... 43 Participant feedback ...... 44 Respecting Participant Priorities ...... 45

4. PRESENTATION OF US DATA AND RESULTS OF THE ANALYSIS ...... 46

Participants ...... 47 Theme 1: Identity ...... 49 Bisexual Identity is Experienced as Non-Binary ...... 50 Identities of Race, Gender, and Sexual Orientation are Intersectional...... 51 Identity Development is Impacted by Stigma and Influenced by Support...... 52 Theme 2: Social Support ...... 54 Experiences and Resources of Social Support Vary ...... 55 Social Networks are Needed that “uppot Oes Idetities ...... 58 Behaviors Constitute Barriers and Facilitators of Disclosure ...... 60 Theme 3: Health Care ...... 62 Experiences and Resources of Health Care Vary ...... 63 Environmental Cues and Behaviors Constitute Barriers and Facilitators of Disclosure ...... 66 Types of information given to the women by providers ...... 71 Specific Changes Can Improve Services for African Descent Bisexual Women...... 77 Recommendations: Environments that welcome diversity ...... 78 Recommendations: Inclusive intake screening and forms...... 79 Recommendations: Health screening and tests...... 82 Recommendations: Time and communication with providers ...... 82 Recommendations: Choice of provider gender ...... 84 Recommendations: LGBTQ practitioners who are openly queer ...... 84

Recommendations: Prevention information for bisexual women of African descent ...... 85 Health information provided by agencies and events ...... 85 Health information shared between peers ...... 86 Communicating with partners ...... 87 Recommendations: Culturally relevant health literature ...... 89 Recommendations: Outreach from agencies ...... 90 Experiences Related to Mental Health Care ...... 92 Need for mental health care ...... 92 Disclosure in mental health care settings ...... 94 Disclosure in mental health care settings: Individual counseling ...... 94 Disclosure in mental health care settings: Group counseling ...... 96 Recommendations for improving mental health care and well-being ...... 97 Improving mental health care: Cultural competence ...... 98 Improving mental health care: Groups for individuals and families ...... 100 Theme 4: Resilience ...... 100 Social Support is a Primary Source for Well-being and Resilience ...... 101 Activism and Self-Nurturing Activities Also Facilitate Resilience ...... 102 Physical and outdoor activities ...... 102 Creativity and self-expression ...... 102 Self-affirmation ...... 103 Media and online bi resources ...... 103 Community involvement ...... 104 Travel ...... 104 Safe spaces ...... 105 Recreation ...... 106 Chapter Summary ...... 106

5. PRESENTATION OF UK DATA AND RESULTS OF THE ANALYSIS...... 109

Participants ...... 110 Theme 1: Identity ...... 112 Bisexual Identity is Experienced as Non-Binary ...... 113 Identities of Race, Gender, and Sexual Orientation are Intersectional...... 114 Identity Development is Impacted by Stigma and Influenced by Support...... 114 Theme 2: Social Support ...... 117 Experiences and Resources of Social Support Vary ...... 118 Social Networks are Needed that “uppot Oes Idetities ...... 121 Behaviors Constitute Barriers and Facilitators of Disclosure ...... 122 Religious and spiritual communities ...... 125 Theme 3: Health Care ...... 126 Experiences and Resources of Health Care Vary ...... 127 Environmental Cues and Behaviors Constitute Barriers and Facilitators of Disclosure ...... 129 Registration and intake processes and disclosure ...... 132 Types of information given to the women by providers ...... 136

Types of information: Sexual and reproductive health testing ...... 137 Types of information: Prevention ...... 137 Specific Changes Can Improve Services for African Descent Bisexual Women...... 141 Recommendations: Medical record confidentiality ...... 142 Recommendations: Environments that welcome diversity ...... 142 Providers should avoid making assumptions ...... 143 Providers should make LGBT inclusion visible ...... 143 Recommendations: Inclusive intake screening and forms...... 143 Acknowledge and affirm bisexual identity ...... 144 Include sexual orientation and identity in general intake ...... 145 Avoid making assumptions on the basis of marital status ...... 146 Recommendations: Health screening and tests...... 146 Recommendations: Time and communication with providers ...... 148 Recommendations: Prevention information for bisexual women of African descent .... 148 Recommendations: Culturally relevant health literature ...... 150 Recommendations: Sexual health product information ...... 150 Recommendations: Communicating with partners ...... 151 Recommendations: Reduce sexual health stigma ...... 152 Experiences Related to Mental Health Care ...... 153 Mental health challenges ...... 153 Accessing mental health care ...... 155 Disclosure in mental health care settings ...... 156 Recommendations for improving mental health care and well-being ...... 158 Improving mental health care: Cultural competence ...... 159 Improving mental health care: Support groups and family counseling ...... 159 Theme 4: Resilience ...... 161 Social Support is a Primary Source for Well-being and Resilience ...... 162 Activism and Self-Nurturing Activities Also Facilitate Resilience ...... 162 Activism ...... 162 Physical and outdoor activities ...... 162 Community involvement, creativity and self-expression...... 163 Cultural heritage and spirituality...... 164 Travel ...... 165 Chapter Summary ...... 165

6. CONCLUSIONS AND IMPLICATIONS ...... 168

Discussion Related to Research Question 1 ...... 169 Theme 1: Identity ...... 169 Bisexual identity is experienced as non-binary ...... 169 Identities of race, gender, and sexual orientation are intersectional ...... 169 Identity development is impacted by stigma and influenced by support ...... 170 Theme 2: Social Support ...... 170 Experiences and resources of social support vary ...... 170

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“oial etoks ae eeded that suppot oes idetities ...... 171 Behaviors constitute barriers and facilitators of disclosure ...... 172 Theme 3: Health Care ...... 173 Experiences and resources of health care vary...... 173 Disclosure ...... 173 Mental health ...... 176 Prevention ...... 176 Prevention and testing ...... 177 Environmental cues and behaviors constitute barriers and facilitators of disclosure .... 179 Discussion Related to Research Question 2 ...... 181 Theme 3: Health Care (Continued) ...... 181 Specific changes can improve services for African descent bisexual women ...... 181 Discussion Related to Research Question 3 ...... 184 Theme 4: Resilience ...... 185 Social support is a primary source for well-being and resilience ...... 185 Activism and self-nurturing activities also facilitate resilience ...... 185 Barriers and facilitators of resilience practices ...... 185 Implications for Practice and Policy ...... 186 Provider Education ...... 187 Limitations ...... 190 Diversity and Inclusion in Research ...... 190 Women living with HIV ...... 190 Socioeconomic background ...... 190 Delimitations ...... 190 Methodology ...... 192 Recommendations for Future Research ...... 192

APPENDICES ...... 197

A. ORIGINAL INTERVIEW GUIDE ...... 197 B. REVISED INTERVIEW GUIDE ...... 199 C. PARTICIPANT COMMENT FORM ...... 201 D. DEMOGRAPHIC QUESTIONNAIRE FOR US PARTICIPANTS ...... 202 E. REVISED DEMOGRAPHIC QUESTIONNAIRE FOR UK PARTICIPANTS ...... 206 F. INSTITUTIONAL REVIEW BOARD APPROVALS ...... 210 G. REVISED LETTER OR EMAIL MESSAGE TEMPLATE FOR ORGANIZATION, PROFESSIONAL, OR ORGANIZER ...... 215 H. REVISED US LETTER OR EMAIL MESSAGE TO ORGANIZATION, PROFESSIONAL, OR ORGANIZER ...... 216 I. REVISED UK LETTER OR EMAIL MESSAGE TO ORGANIZATION, PROFESSIONAL, OR ORGANIZER ...... 217 J. REVISED US BRIEF RECRUITMENT FLYER ...... 218 K. REVISED UK BRIEF RECRUITMENT FLYER ...... 219 L. REVISED US DETAILED RECRUITMENT FLYER ...... 220

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M. REVISED UK DETAILED RECRUITMENT FLYER ...... 221 N. SCREENING SCRIPT ...... 222 O. PARTICIPANT CONTACT INFORMATION ...... 224 P. CODE LIST WITH CASE NUMBER AND PARTICIPANT INITIALS ...... 225 Q. CODE LIST WITH CASE NUMBER AND PARTICIPANT PSEUDONYM ...... 226 R. REVISED US RESEARCH STUDY CONSENT INFORMATION ...... 227 S. REVISED UK RESEARCH STUDY CONSENT INFORMATION ...... 230

References ...... 233

Biographical Sketch ...... 248

ABSTRACT

The overall focus of this study is the well-being of cisgender African descent bisexual women (ABW), within three interrelated main areas of inquiry: social support, health care, and resources for resilience. Due to the history of the dispersal of African people, compounded by marginalization of African descent bisexual women, this united cross-national research strategy was intended to transcend histoial diides ad ig oe attetio to these oes concerns. The cross-national design was also intended to highlight similarities and contrast differences in countries with different health care systems, toward increasing understandings of the woes epeiees.

The qualitative research method of grounded analysis guided this study. The researcher completed individual face-to-face semi-structured in-depth interviews with six self-identified

ABW in the US in 2013, and with eight women in the UK in 2014. The eseahes oigial intention was to implement a study inclusive of women living with HIV (WLWHA). However, without WLWHA participants, information on their life experiences was not able to be gathered during this study.

The researcher gathered and analyzed information about ABW life experiences related to resources and quality of social support and health care when bisexual identity is and is not disclosed. The women were also asked about resources that sustain them and support resiliency. Eleven subthemes emerged from the data, related to four main themes.

The participants spoke of their intersectional identities, and needs for affirming social support and culturally competent health care. The participants made recommendations toward creating more inclusive and supportive environments for delivery of health and social care. The

oes eeds ilude: Aess to ualit phsial ad etal health ae; odisiiatio policies posted in agency settings that are inclusive of lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI) people; more LGBTQI-identified providers; universal HIV and STD screening; information about healthy relationships, especially on how to communicate assertively about sexual health with a female partner; and inclusive social services that acknowledge the families of sexual minority women. Participants also shared about activities of resilience, including their writing and activism for socioeconomic justice. The findings are intended to increase diversity awareness and sensitivity among health and social care providers.

CHAPTER 1

INTRODUCTION

Statement of the Problem

The overall focus of this study is the well-being of cisgender African descent bisexual women (ABW), with three interrelated main areas of inquiry: health care, social support, and resources for resilience. The population of focus comprised cisgender women of Black African descent who self-identify as bisexual (i.e. able to feel attraction for another person regardless of gender). These women face unique challenges related to invisibility, disclosure and treatment in health care settings and social networks due to stigma (Barker, 2007; Bowleg et al., 2008; Cochran & Mays, 1988) and a history of oppression and socioeconomic disadvantage

(Cole, 2009; Gómez, 2011; Melton, 2011). Fear of prejudice and discrimination can make it difficult for these women to acknowledge, accept, and disclose all of their own diversity, particularly related to bisexual orientation. Bisexual women are more likely to experience stereotyping and discrimination by others (Brewster, 2010; Herek, 2002; Israel & Mohr, 2004).

Women of African descent comprise over 60% of women living with the Human

Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) in the US and

UK (Centers for Disease Control (CDC), 2011; CDC, 2012; Health Protection Agency, 2011).

Health care and social service providers, family, friends and colleagues may not be able to share culturally competent information and resources, especially he a oas sexual orientation and HIV status is unknown and/or individuals lack knowledge of how best to provide effective support.

For this study, the complex life experiences of these women who are both racial/ethnic and sexual minorities was researched with an intersectional perspective. Intersectionality provides a framework within which to simultaneously consider complex experiences of those with multiple minority statuses (Cole, 2009; Monro & Richardson, 2012; Moore, 2010;

Steinhouse, 2001). The impact of multiple minority status is not additive, related to gender, race/ethnicity, class, sexual orientation and ability; the impacts can be exponential (Cole, 2009).

The experiences of African descent bisexual women related to sexual orientation/identity cannot be considered nor understood separately from race, ethnicity, gender, and socioeconomic context. Generational ongoing socioeconomic disadvantage and lack of opportunities continue to perpetuate health disparities, impacting well-being and quality of life for these women (Gómez, 2011; Melton, 2011).

For the dissertation study, I gathered and analyzed detailed information about the

oes epeiees of health ae ad soial suppot, elated to dislosue ad o- disclosure of sexual orientation, in the US and UK. Efforts were made to reach women living with HIV/AIDS (WLWHA) to participate in the study because of 1) lack of attention to HIV research, prevention and services with African descent bisexual women, and 2) the invisibility of and lack of social support for African descent bisexual women living with HIV/AIDS. However, participants in this study had either not yet taken an HIV test, or had received a negative test result; no participant reported having received a positive test result. Health care settings the participants mentioned included primary care, health departments, clinics, and HIV/AIDS agencies. Social support networks the participants spoke of included relatives, partners, significant others, friends, community members and fellow workers.

The oes epeiees elated to dislosue ad o-disclosure of bisexuality in both health care and social settings were studied because of relationships between disclosure, social support, health and well-being (Moore, 2010; Potoczniak, Aldea, DeBlaere, 2007; Szymanski &

Kashubeck-West,2008). Marginal acceptance is related to being treated as an inferior out-group due to differences in race, ethnicity, gender, class, sexual orientation, ability, and/or age.

Minority stress, related to experiences of oppression, is considered to be a contributing factor in negative health outcomes. Social support is a mediator that can reduce the negative impact of minority stress (Meyer, 2003; Szymanski & Kashubeck-West, 2008). Bisexual women have additional disclosure considerations and potentially different experiences with acceptance and affirmation in social networks (Bradford, 2006), including within African descent communities

(Bowleg et al., 2008; Moore, 2010). Women living with HIV/AIDS (WLWHA) have even greater challenges related to stigma, disclosure and social support (Anderson & Doyal, 2004; Logie,

James, Tharao & Loutfy, 2011; Teti & Bowleg, 2011).

It may not be possible to affect meaningful change in the treatment of ABW and

WLWHA in society, social networks and health care settings in the near term. Efforts for socioeconomic change can take time. In the context of the difficulties that may be experienced by ABW and WLWHA who are multiple minorities and may feel affected by many forms of oppression, the third main area of inquiry for this study is in regard to the kinds of self- nurturing activities these women are utilizing to sustain themselves and support resiliency (i.e. a sense of strength) in their day-to-day lives.

This study builds upon years of ground work in the public administration and social work graduate programs, during which I conducted interviews with health care agencies, HIV/AIDS

workers, and African descent sexual minorities in the US and UK. The dissertation study included data collection from within both the US and UK.

Significance of the Problem

African Descent Bisexual Women and Health Care

When health care providers lack elements of clinically relevant information about their clients, they may not be able to provide the best health related information and care. The limited empirical information available indicates that among some African American sexual minority women only about 50% have disclosed their sexual orientation in health care settings

(Bowleg et al., 2008). An earlier study indicated that only one third of African American sexual minority women had disclosed in health care settings (Cochran & Mays, 1988). In the UK, 50% of sexual minority women surveyed had not disclosed their sexual orientation in health care settings (Hunt & Fish, 2008). Attempts have been made to examine the effects of stigma and bias upon marginalized and vulnerable populations, and ways that health and social care professionals can avoid perpetuating harmful beliefs and actions against those who are already disadvantaged (Rutledge & Abell, 2005).

HIV/AIDS research, prevention and services thus far tend to focus with African descent heterosexual or straight women and overlook bisexual women (Teti & Bowleg, 2011), although many bisexual women have biological children and may be affected by HIV/AIDS risk (Battle,

Cohen, Warren, Fergerson & Audam, 2000). Nearly 30 years after the discovery of HIV, a prevention intervention developed specifically for use with bisexual women has not yet been made available through the US Centers for Disease Control (CDC) Diffusion of Effective

Behavioral Interventions (DEBI) program which provides interventions for men of all sexual orientations, heterosexual women, and transgender women (Effective Interventions, 2012).

Mental health service providers may also lack professional skills of cultural competence for working with bisexual women (Page, 2004), including those who are women of color

(Brooks, Inman, Klinger, Malouf & Kaduvettoor, 2010). Cultural competence is considered important by the social work profession. Regarding cultural competence, the National

Assoiatio of “oial Wokes states, “oial okes should otai eduatio about and seek to understand the nature of social diversity and oppression with respect to race, ethnicity,

atioal oigi, …se, seual oietatio, …ad phsial disailit NA“W, , p. . In order to fulfill this standard, providers may need more awareness and training.

African Descent Bisexual Women and Social Support

Social support is necessary in order to thrive physically (Lubben & Gironda, 2004), psychologically (Fung, Carstensen & Lang, 2001; Shaw, Krause, Liang, & Bennett, 2007), and spiritually (Canda & Furman, 2009). Social support is most beneficial when disclosure of true self is epeieed ouetl ith aeptae ad affiatio fo people i oes soial network (Bradford, 2006) . Disclosure is related to the quality and strength of socioemotional social support relationships. Disclosure, experienced with acceptance and affirmation, results in greater perceived positive social support and an increased sense of well-being (Beals, Peplau, &

Gable, 2009). Social support inclusive of women living with HIV/AIDS (WLWHA) is important and beneficial for these women (Belgrave, Corneille, Hood, Foster-Woodson & Fitzgerald, 2010;

Wingood & DiClemente, 2000).

African descent sexual minority women may focus on self-protective behaviors, and thus may not disclose their sexual orientation within immediate social support networks

(Bowleg et al., 2008; Morris, Waldo, Rothblum, 2001). These women often live with a degree of isolation as there are few organized ethnically diverse bisexual communities (Barker, Richards,

Jones, Bowes-Catton, Plowman, Yockney, & Morgan, 2012; Bradford, 2006; The San Francisco

Human Rights Commission, 2010). These women may also feel marginalized within their own ethnic communities, in African descent lesbian communities, and in predominantly White sexual minority communities (Moore, 2010).

African Descent Bisexual Women and Resilience

African descent bisexual women, including those living with HIV, are affected by marginalization and oppression. Quality of life and well-being include but are not limited to socioeconomic conditions, and physical and psychosocial aspects of health (Keyes & Waterman,

2003). In social work, we strive to have a strengths-based perspective with the goal of empowerment (Saleebey, 2002).

The researcher invited the women to share about resources they draw upon to maintain and increase their energy, sense of optimism, strength and well-being in their day-to-day lives.

Health care and social support can be resources for well-being and resilience. Spirituality is another resource for resilience and self-nurturance used by women of color (Cervantes &

Parham, 2005; Musgrave, Allen & Allen, 2002), and by women living with HIV/AIDS (WLWHA) in the UK and US (Anderson & Doyal, 2004; Braxton, Lang, Sales, Wingood & DiClemente, 2007). In light of the socioeconomic disadvantages seen in the African descent community, it can be adaptive for these people to value human beings based upon their humanness, rather than

their material resources (Nobles, Goddard & Gilbert, 2009; Townsend & Belgrave, 2009). The expressive arts have also been beneficial resources for African descent women (DiClemente &

Wingood, 1995), bisexual people (Bowes-Catton, Barker, Richards, 2011), and WLWHA (Bartlett

& Finkbeiner, 2006; Wingood & DiClemente, 2000; Wingood, DiClemente, Mikhail, Lang,

McCree, Davies, Hardin, Hook & Saag, 2004). Though this poess, people a…. discover insights about themselves, increase their sense of well-being, enrich their daily lives through

eatie epessio, o epeiee pesoal tasfoatio Malhiodi, , pp. 21-22).

In Chapter 2, more in-depth information will be provided, elaborating on the larger context related to the research problem. Literature searches will be detailed, with a discussion of the literature related to the main areas of inquiry. The main areas of inquiry are African deset iseual oes epeiees i health ae settigs ad soial suppot etoks, mainly related to identity and disclosure of sexual orientation and HIV status, and resources for resiliency, within their socioeconomic and political contexts.

CHAPTER 2

BACKGROUND AND CONTEXT

Conceptual and Empirical Context of the Problem

The life experiences and needs of sexual minority women should not be overlooked in health care and social services, including social work and HIV/AIDS prevention and services.

Research focusing on the experiences of bisexual people is important due to lack of information and inadequate cultural competency in health care and social service settings (Barker, et. al.,

2012; Fredriksen-Goldsen et al., 2011; Mays, Cochran, & Roeder, 2003; Mays, Yancey, Cochran,

Weber, Fielding, 2002; Miller, André, Ebin, Bessonova, 2007; The San Francisco Human Rights

Commission, 2010). Biseual ad lesia oes epeiees ad eeds should e eseahed separately, due to differences between the populations (Miller et al., 2007).

Ethnic and Sexual Minority Women, Health Care and HIV/AIDS

In the US and in the UK, women of Black African descent comprise the majority of women living with HIV/AIDS (Centers for Disease Control (CDC), 2011; CDC, 2012; Health

Protection Agency, 2011). Blak oe i geeal, iludig iseual oe, ae ieasigl at risk fo tasissio of HIV Battle et al., 2000, p. 27). However, there have been few studies regarding HIV/AIDS and lesbian and bisexual women (Champion, Wilford, Shain & Piper,

2005; Teti & Bowleg, 2011; Teti, Bowleg, Rubinstein, Lloyd, Berhane, & Gold, 2008). A significant number of lesbian and bisexual women of African descent have biological children conceived with a male partner (Battle, et al., 2000, p. 27; Ramsey, Hill, & Kellam, 2010). Since unprotected intercourse is one of the main ways that HIV is spread, these women may face

some risk of contracting HIV. Same-sex transmission of HIV between women has also been documented (Kwakwa & Ghobrial, 2003)

Socioeconomic factors contributing to HIV/AIDS risk for African descent and sexual minority women include gender-based inequalities, lack of education and employment opportunities (Wingood, Camp, Dunkle, Cooper, & DiClemente, 2009; Wingood & DiClemente,

2000), lack of access to affordable and safe housing (Melton, 2011; Wenzel, Tucker, Elliott &

Hambarsoomians, 2007; Whyte, 2006), transactional sex and sex work (Gómez, 2011), intimate partner violence (Josephs & Abel, 2009; Maman, Campbell, Sweat & Gielen, 2000). The intersections of HIV and violence: directions for future research and interventions. Social science & medicine, 50(4), 459-478.), domestic violence (Lichtenstein, 2005), sexual abuse

(Austin, Roberts, Corliss & Molnar, 2008), sexual assault (Long, Ullman, Long, Mason &

Starzynski, 2007), intravenous drug use (Young, Friedman & Case; 2005), and alcohol and other substance use (Lehavot & Simoni, 2011). Barriers in accessing affordable culturally competent physical health care (Hughes & Evans, 2003; Mays, et al., 2002; Powers, 2001) and mental health care (Page, 2004) including preventive care, are also factors affecting HIV/AIDS risk for

African descent and sexual minority women.

Identity, Disclosure, Social Support and Well-being

The term bisexual refers to a sexual identity and orientation, as do the terms heterosexual or straight, gay male, and lesbian (Human Rights Campaign, 2011-2012). The bisexual person is able to feel attraction for another person regardless of gender, with the potential for an intimate relationship. The bisexual person may have had no intimate relationships, or may have had partner(s) of only one gender. Some bisexual people do have

relationships with more than one sex/gender of persons in their lifetime, however not all people identify as bisexual who have been intimate with partners of different sexes or genders.

According to surveys, approximately half of the 5.2 to 9.5 million sexual minority people in the US state they are bisexual (Gates, 2014). African American people comprise approximately 13% of the US population (US Census Bureau, 2012), although it is not known what percentage of the bisexual population is African American. African Americans who are sexual minorities may be somewhat more likely to identify as bisexual, rather than as lesbian or gay, especially if they have biological children (Henderson, 2009). African descent people comprise 5.8% of the UK population (Office for National Statistics, 2012). The Bisexuality Report published in the United Kingdom cites US statistics as well as providing their own estimates; due to stigma, people may be less likely to identify as bisexual with the census in the UK

(Barker, et al., 2012). Regardless of population estimates, ensuring full human and civil rights is important, including socioeconomic equality and culturally competent health care.

Bisexual people are at risk of invisibility because assumptions are sometimes made about their sexual orientation based on the sex/gender of their partner. For example, a bisexual person in a same sex relationship may be mistaken by a health care provider as being a gay or lesbian person, and a bisexual person in a different sex relationship may be mistaken for being a heterosexual person. As mentioned in Chapter 1, African descent sexual minority women do not always disclose their sexual orientation to everyone within social support networks (Bowleg et al., 2008; Morris, Waldo, Rothblum, 2001). And only about 50% have reported disclosing their sexual orientation in health care settings (Bowleg, et al., 2008). In the UK, 50% of 6000 sexual minority women surveyed had not disclosed their sexual orientation in health care

settings (Hunt & Fish, 2008). It is ipotat fo a pesos sese of ell-being to be accepted for who they are and treated well in their social networks and in health care settings (Brooks et al., 2010; Fox, 2006; Greene, Miville, Ferguson, 2007; Potoczniak et al., 2007; UK AIDS and

Human Rights Project, 2005).

Cross-National Perspective

Due to the history of the dispersal of African people, compounded by marginalization of

African descent bisexual women, this united cross-national research strategy was intended to tased histoial diides ad ig oe attetio to these oes oes. The cross- national study was also designed to highlight similarities and contrast differences toward ieasig udestadigs of the oes epeiees. Because of the low profile of African descent bisexual women, the cross-national research design was intended to illuminate the experiences of a purposive sample of such women, illustrating their experiences of health care and social support related to disclosure of sexual orientation, in both the US and UK. A cross- national study was designed to highlight similarities and contrast differences that may increase udestadigs i the U“ ad UK egadig the oes epeiees elated to dislosue ad non-disclosure of sexual orientation in health care settings and social support networks -- within the context of the cultures, and corresponding human, civil rights and health care policies, with which they live. A cross-national study may potentially generate more interest among health care providers, social workers, and policy makers, rather than a one country study with this marginalized population. To conduct this study within only one country would not produce the same opportunities to highlight and contrast how the cultures within which

the women live may be influencing their experiences of health care and social support related to disclosure of sexual orientation.

The US and UK were selected for a cross-national study because of similar recent history, cultures, official government language, and the differences and developing similarities of their health care systems. The context for this study is within the policy areas of health care, socioeconomic justice, and human and civil rights.

Overview of Health Care Systems in the US and UK

The US health care system is becoming more similar to the UK system, expanding what has been fee-for-service health care coverage (HealthCare.gov, 2012), while the UK is scaling back a comprehensive system of nationalized health care (Ham, 2009). Many in the US still do not have health insurance (HealthCare.gov, 2012; Jonas, 2003), and many in the UK are concerned about reductions in funding for medical staffing and services (National AIDS Trust,

2012; Hughes & McGuire, 1992). The structure of the National Health Service (NHS) is becoming more similar to Health Maintenance Organizations (HMO) in the US (Ham, 2009; Webster,

2002). In general, low income women in the UK have better access to health care and better health outcomes than low income women in the US.

In the US, the Patient Protection and Affordable Care Act (PPACA) was passed in 2010 and amended the same year by the Health Care and Education Reconciliation Act of 2010. The

PPACA included measures to prevent discrimination against sexual and gender minorities. For eaple, hospitals eeiig fedeal fudig ae euied to eogize patiets sae-sex partners. Implementation of health care reform is continuing.

In the UK, the Welfare Reform Act was passed in 2012, involving budget and policy changes that will affect health coverage and disability benefits. Concerns included that people living with HIV will be affected adversely by eligibility criteria that do not consider all HIV/ AIDS complications and symptoms (National AIDS Trust, 2012). The Department of Health coordinated development of policy briefings for staff in both NHS health and social care for the purpose of education and training to address the needs of sexual and gender minorities (Fish,

2007).

Nondiscrimination Policies in the US and UK

The human and civil rights policies of each country were expected to provide a useful

otast i fidigs of the oes life epeiees. The oe ho participated in the study share historic experiences of oppression, and face current challenges related to ethnicity/race, gender, class, and sexual orientation. An important aspect of the context in which ABW live is the existence of these historically connected African diaspora communities (Nobles, Goddard &

Gilbert, 2009). The US and UK cultural similarities and ethnic/racial diversity are related to transatlantic slavery, and colonial and migrant histories. During the times of African enslavement during which the ancestors of many of these women lived, not everyone survived the tremendous stressors caused by institutionalized human rights violations and injustice.

However, many did survive long enough for slavery in that form to end, and for some of their descendants to have better access to resources and opportunities in life. Significant numbers of

African descent people live in both the US and UK today, including those who emigrated from the Caribbean region. Each country has had similarities and differences in opposing and facilitating the human and civil rights of African descent people.

The Uited Natios Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) has been signed and ratified by most countries including the UK.

While the US has signed CEDAW and President Barack Obama supported it, this international treaty has not been ratified due to opposition by conservative members of the Senate (CEDAW,

2011). The social work professional codes of ethics, for both countries, each state that social workers should undertake efforts toward ending all forms of oppression including that against sexual minorities (British Association of Social Workers, 2012; National Association of Social

Workers, 2012).

The UK has more consistently observed international human rights policies. The UK also has more consistent LGBTQ non-discrimination policies in place uniformly throughout their countries, whereas in the US LGBTQ nondiscrimination policies vary by state and local governments and by organization. Over recent decades, gains have been made in understanding and ensuring the human rights of persons who are gay or lesbian, in the US and

UK. Over the same period of time, lesser gains have been made toward understanding bisexual people and reducing prejudice and stigma for this population (Barker et al., 2012; The San

Francisco Human Rights Commission, 2010).

Definition of Terms

Social Support Concepts and Terminology

Definitions of social support can vary. Social support can be defined as "verbal and nonverbal communication between recipients and providers that reduces uncertainty about the situation, the self, and the other, or the relationship, and functions to enhance a perception of personal control in one's life experience" (Albrecht & Adelman, 1987 as described in Denton,

1990, p. 19). Three dimensions of social support identified through qualitative methods are primarily soial opaioship, task help, ad suppotieess, in a sample of 71 African

American professional women (Denton, 1990, p. 447). Mutual supportiveness that includes commitment and emotional support was found to be the most beneficial form of social support for well-being.

Social support can be considered the degee to hih a pesos asic social needs are gatified though iteatio ith othes Kapla et al., as described in Thoits, 1982 p.

. Basi soial eeds ilude affetio, estee o appoal, elogig, idetit, ad seuit p. . Structural properties of social support are etok idiatos of size, density, accessibility, kinship-eliae, feue of otat, ad stailit p. . Functional properties of social support are peeied aout ad adeua of socioemotional and istuetal aid eeied fo the suppot sste p. . Socioemotional aid involves

affetio, spath ad udestadig, aeptae, ad estee fo sigifiat othes p.

147).

Peeied soial suppot is defied as the etet to hih a participant feels cared aout ad ell egaded people i he soial etok ho ko he tue self Bo &

Abell, 2009). Concepts inherent in the definition of perceived social support include disclosure, acceptance and affirmation. Disclosure is the extent to which a person has shared about their true self with others. True self refers to authentic self, including aspects of the individual such as sexual identity and orientation (Meyer & Ouellette, 2009). Aeptae is the etet to which a participant feels her true self is considered to be normal and okay by herself and people in her soial etok Bo & Aell, . Affiatio is the etet to hih a

participant feels her true self is supported through the words and actions of people in her social

etok Bo & Aell, . Social support in the current study is understood to refer to the positive or beneficial instrumental and socioemotional resources that have been available to a research participant through social networks, recognizing that her experiences in social networks may have been negative and/or positive.

Resilience Terminology

For the purposes of this study, resilience is related to resources in addition to social support and health care that foster a sense of well-being (Wheaton, 1985), specifically self- nurturing activities. ‘esiliee is thus oeied as … [a] podut of uffeig poesses that do not eliminate risks and adverse conditions in life but allow the individual to deal with them effetiel Rutter, 1987 as summarized in Werner & Smith, 2001, p. 3). The term well-being includes but is not limited to socioeconomic conditions, and physical and psychosocial aspects of health (Keyes & Waterman, 2003).

The concept of integration is of particular relevance to the multiple minority female who experiences non-acceptance of different aspects of her being such as race/ethnicity, sexual orientation, and HIV status. Integration refers to acceptance of aspects of oneself in a way that facilitates a sense of wholeness as a human being (Cole, 2009).

Conceptual and Empirical Literature: African Descent Bisexual Women

Research is an important way of providing accurate and helpful information about people, including ethnic and sexual minorities such as the women who participated in this study. The meaning of grounded analysis is that findings will be grounded in the data from the research study. In using the qualitative method approach of grounded analysis, the study does

not necessarily begin with an extensive review of extant theory. In discussing the findings of this dissertation study, the researcher describes similarities and dissimilarities in relation to existing theories and scholarship regarding identity, intersectionality, marginalization, empowerment, disclosure, and social support [Please see Chapter 6].

Although searches for scholarly literature were conducted by the researcher in earlier years, the most recent search was completed at the beginning of 2015. In online searches for scholarly works related to African descent bisexual women, the following databases were searched through ProQuest: AIDS and Cancer Research Abstracts, Applied Social Sciences Index and Abstracts (ASSIA), BioOne Abstracts & Indexes, ERIC, Ethnic NewsWatch, GenderWatch,

Health & Safety Science Abstracts, Immunology Abstracts, MEDLINE®, National Technical

Information Service Database (NTIS), Public Affairs Information Service International (PAIS),

Published International Literature On Traumatic Stress (PILOTS), ProQuest Deep Indexing:

Biological Sciences, PsycINFO, Social Services Abstracts, Sociological Abstracts, and Virology and

AIDS Abstracts. Searches were limited to English language materials with dates of 2000 through

2015, and include mostly US but also UK authors.

Literature searches were used to locate peer-reviewed journal articles as well as dissertations focusing with sexual minority women. Regarding inclusion criteria, there are few published articles that provide information specifically about African descent bisexual women.

Therefore, the articles included for the purposes of this study are those that most closely relate to ABW and/or relate to issues of identity, disclosure, social support and health care including

HIV/AIDS.

The first search used the terms bisexual and lesbian in the title, and woman or women in the title. This search returned 248 non-duplicated articles. The second search used the terms bisexual in the title, and woman or women in the title, specifying not lesbian in the title, locating 103 non-duplicate articles focusing mainly with bisexual women. Separate searches with the same terms and limits were also completed in ProQuest Dissertations &

Theses (PQDT). Returns for the first search included 28 dissertations related to both bisexual and lesbian women, and the second search returned 16 dissertations related mainly to bisexual women. A third search used the terms bisexual in the abstract, and woman or women in the title, returning 360 articles several of which referred to the women as sexual minorities or women who have sex with women (WSW), and /or focused on sexually transmitted infections

“TIs.

Of the publications and dissertations available regarding lesbian and bisexual women, many studies have predominantly Caucasian participants (such as Young, 2011; and Beaber,

2008). Fewer published studies are available that focus on lesbian women of African descent

(such as Bowleg, Huang, Brooks, Black, & Burkholder, 2003), and even fewer that focus jointly on African descent lesbian and bisexual women (such as Bowleg, et al., 2008; Teti & Bowleg,

2011; and Wekker, 1993).

Only two articles were located that focus exclusively with African descent bisexual women. One earlier qualitative study inquired about sexual health with a clinical sample of 23

ABW (Champion et al., 2005). A second published article, focusing exclusively with ABW, reports findings from interviews with two bisexual women conducted during an earlier dissertation study in which most participants were lesbian-identified women (Bates, 2012); this

author recommended further research with a larger more geographically diverse sample of

African descent bisexual women (Bates, 2012).

Discussion of Related Research

Health care.

Bisexual women are less likely to receive preventive health care than heterosexual women in the US (Mays, et al., 2002), and in the UK (Hunt & Fish, 2008). Intravenous drug use and unprotected sexual intercourse with those who are biologically and genetically male are the main risk factors implicated in HIV infection for lesbian and bisexual women (Bailey,

Farquhar, Owen & Mangtani, 2004). Sexual minority intravenous drug users (IDU) are four times more likely to become HIV-positive than heterosexual IDU females (Young, et al. 2005).

In 1999, the Diffusion of Effective Behavioral Interventions project was started, providing support for development and implementation of HIV prevention interventions

(Effective Interventions, 2012. “ie the s, a HIV iteetios hae ee eseahed, however very few have been developed for use with African American women (DiClemente &

Wingood, 1995; El-Bassel, Caldeira, Ruglass, & Gilbert, 2009; Wingood, et al. 2004). No interventions researched specifically for use with lesbian and bisexual women have been approved or disseminated at the federal level in the US by the Department of Health and

Human Services Centers for Disease Control (Effective Interventions, 2012).

It is emphasized that bisexual women need information on safer sex and risk reduction practices (Champion et al., 2005; Tao, 2008), including with same-sex partners (Marrazzo,

Coffey & Bingham, 2005). The comprehensive socioeconomic needs of African descent bisexual women living with HIV/AIDS also need to be considered (Teti & Bowleg, 2011).

Social support.

Social support is beneficial for African descent women in order to counteract the stress experienced as a result of marginalization related to multiple minority statuses (Denton, 1990;

Warren, 1997). Socioemotional social support is strongly correlated with heterosexual and lesia oes etal health Waet & Peplau, . Community and individual social suppot a ediate the egatie effects of social prejudice on mental health for lesbian, gay and bisexual (LGB) populations (Meyer, 2003, p. 679). For social support to be effective, the social interactions need to be positive and affirming (Lincoln, 2000). Social support is directly benefiial he it ioles a pesos degee of itegatio i a lage soial etok Cohen &

Wills, 1985, p. 310).

African American LGB women may experience challenges in maintaining social support in a predominantly Caucasian society, and in predominantly heterosexual African American communities (Thomas, 2005). Racism, sexism, and rejection related to non-heterosexual status

esult i tiple jeopad Geee, , and increased difficulties in developing and maintaining networks of social support. Connecting with supportive resources can be particularly difficult for African descent sexual minority and HIV-positive women who live in rural areas and small towns and cities.

Social work counseling can provide formal support, and assist the LGB client in engaging in a thoughtful process regarding to whom she should and should not disclose her sexual oietatio, usuall teed oig out Clees, 04; Thomas, 2005; Woitke, 2002). The goal is to maintain and increase social support. Losing the support of family and community can be detrimental. Skillful discretion is important in order for the client to have the privacy to work

on their own self-acceptance, and establish relationships with accepting others, while avoiding unnecessary disclosures and consequences. It is contraindicated for social workers to encourage their sexual minority clients to disclose their non-heterosexual identity with all people and networks. Because many sources of social support usually available to African

American women such as family, church, and ethnic community may not be as supportive of openly lesbian, gay or bisexual women, it is important in the field of social work to identify additional resources for support (Thomas, 2005). Social support is also important for women living with HIV/AIDS, and support groups can help fill this need (Belgrave et al., 2010;

Cooperman, Simoni, & Lockhart, 2003; Willinger, 2003; Wingood & DiClemente, 2000).

Resilience and well-being.

The areas of focus for this study included experiences related to social support, health care, and resources for resilience. African descent bisexual women live with many sources of historical oppression, yet survive. It is known that health disparities exist for minority women, including disproportionate risk for HIV/AIDS. It is known as well that these women are more likely than heterosexual women to fear disclosure of sexual orientation and identity within social networks and health care settings. In addition to physical and psychological health disparities, ABW face greater challenges accessing supportive relationships and communities that accept both their race/ethnicity and bisexual orientation/identity. This study gathered information about the oes atiities of self-nurturance, in addition to how they maximize beneficial social support and health care for well-being. Discussed next is literature on resources for resilience.

Spirituality.

Spirituality is recognized in social work as an important resource for many people

(Canda and Furman, 2009). Spirituality can help with coping, and a sense of purpose and meaningfulness in life, for sexual minorities (Tan, 2005), including for African descent sexual minorities (Jeffries, Dodge, & Sandfort, 2008). Practitioners can address spirituality with those they are working with who consider this to be a helpful resource. Related to spirituality is creativity (McGrady & McDonnell, 2006) which is discussed next.

Expressive arts.

The expressive arts can serve many therapeutic purposes, including poetry therapy

(Mazza, 2004), and visual art (Piccirillo, 1999). The arts have been used in facilitating participant self-expression in working with sexual minorities (Newman, 2010, pp. 139-153), and people living with HIV/AIDS (PLWHA) (Piccirillo, 1999; Willinger, 2003). The expressive arts have been used with African descent women in the context of HIV prevention group interventions (Nobles,

Goddard & Gilbert, 2009), including women living with HIV/AIDS (Wingood & DiClemente,

2000). The purposes of creative self-expression include providing opportunities for self- awareness and growth, experiences of liberation from silencing stigma and oppression, and empowerment through claiming parts of the self that have been rejected in society, hence facilitating personal and social integration and empowerment.

Collage art in particular may have special applications with multiple minorities as it provides the opportunity to arrange and manifest all aspects of oneself, consistent and discordant, as one whole. A collage art activity facilitates the arrangement of any combination of images and/or words (Moon, 2010, pp. 18-19), thus potentially being especially compatible

for the purpose of supporting expression of culturally specific life experiences of African descent bisexual women. The AIDS Memorial Quilt is a well-known creative and artistic national collaborative project conveying humanizing messages through collage (Junge, 1999), with a special outreach program for African American participation (The Names Project Foundation,

1987-2011). Collage art as a means to assemble disparate parts as a whole, can be a useful way to work with parts of self that are treated with stigma and shunned, to facilitate integration and empowerment. This relates to the intersectional perspective in that African descent bisexual women can be placed in the position of being asked to choose between or prioritize differently race/ethnicity and sexual orientation/identity. For optimal well-being, the women need to experience integration and wholeness.

Relevance to Social Work Research and Practice

Despite efforts to improve health and social care for sexual and gender minorities, much is still needed in the US and UK in order to ensure culturally competent service delivery. These women can still experience exclusion in many settings. Of concern is potential HIV risk

oied ith iadeuate esoues to addess the oes soioeooi eeds, hee considerable vulnerability related to low social support and barriers accessing health and social care.

All persons are deserving of culturally appropriate social support, health care and social services as they go through life stages and experiences. African descent bisexual women are as much in need of affirming social support networks and culturally competent health care as other people (Scott, 2006). Hopefully, with an increase in empirical information, society and particularly health care providers will be more comfortable with bisexual people, and with

social change come to better value multiple minorities, and in turn the women may feel more comfortable to disclose about their lives.

The findings of this study are intended to contribute to guidance for social workers and health care providers in working with African descent women, of known or unknown sexual orientation who may be bisexual, particularly steps that can be taken to avoid contributing to invisibility for these women. Health care providers can be more effective in serving clients, with an expanded knowledge base regarding some of the life experiences and accompanying concerns and needs of these minority women. The information is intended to be helpful for social workers in working with these women more effectively, with increased knowledge regarding needs and special issues related to developing and strengthening social support networks. Information about resources for resiliency is intended to be useful for social workers and health professionals, toward encouraging the women to engage in self-nurturing activities.

Ideally, the findings will increase diversity awareness and sensitivity among social workers and health care providers, and lead to modifications in agency culture and services toward advocacy and inclusion, especially in HIV/AIDS services. Unfortunately, changes at these levels alone may not have an adequate impact on the quality of life, HIV/AIDS risk, and opportunities for socioeconomic well-being for these women without greater change overall in global policies and practices impacting economic and social justice (Gómez, 2011; Melton, 2011).

Next, in Chapter 3 the methodology for this study will be described in detail, including the design, research questions and data analysis. The research questions are based upon the concepts explained above, related to socioeconomic and political conditions, identity, disclosure, social support, health care, resilience and well-being.

To summarize, these women face unique challenges related to invisibility, disclosure and treatment in health care settings and social networks due to stigma (Barker, 2007; Bowleg et al., 2008; Cochran & Mays, 1988) and a history of oppression and socioeconomic disadvantage (Cole, 2009; Gómez, ; Melto, . The oes epeiees elated to disclosure and non-disclosure of bisexuality in both health care and social settings were studied because of relationships between disclosure, social support, health and well-being (Moore,

2010; Potoczniak et al., 2007; Szymanski & Kashubeck-West, 2008). Marginal acceptance is related to being treated as an inferior out-group due to differences in race, ethnicity, gender, class, sexual orientation, ability, and/or age. Minority stress, related to experiences of oppression, is considered to be a contributing factor in negative health outcomes. Social support is a mediator that can reduce the negative impact of minority stress (Meyer, 2003;

Szymanski & Kashubeck-West, . It is ipotat fo a pesos sese of ell-being to be accepted for who they are and treated well in their social networks and in health care settings

(Brooks et al., 2010; Fox, 2006; Greene et al., 2007; Potoczniak et al., 2007; UK AIDS and Human

Rights Project, 2005).

The framework for the interview questions of this research study are based upon the concepts in the literature reviewed in this chapter. As detailed next in Chapter 3, the participants were asked about 1) how they came to identify as bisexual; 2) their experiences related to social support, including disclosure and non-disclosure of sexual orientation in their social networks; 3) their experiences related to health care, including disclosure and non- disclosure of sexual orientation in health care settings; 4) information they had received about

HIV/AID“, “TDs ad elated testig; esoues that suppot thei esilie; ad oe life experiences and/or concerns they would like to share for this research study.

CHAPTER 3

METHODOLOGY

Aims of the Research Study

The principles and techniques of grounded analysis guided the methods of this qualitative research study (Glaser & Strauss, 1999). The review of the literature indicates that

African descent bisexual women are affected by inadequate resources for their specific needs, available information is limited, and further study is warranted. The researcher gathered and analyzed data reflecting the women's life experiences related to resources and quality of social support and health care when sexual orientation/identity is and is not disclosed. The researcher also gathered data about self-nurturing activities the women practice in their day-to-day lives, to sustain themselves and aid their resiliency.

Research Questions

The main areas of focus of the research questions pertain to the oes life experiences related to disclosure of sexual orientation/identity in social support networks and health care settings, and resources that support their resiliency. 1) What are the experiences of these women related to identity and disclosure in social support networks and health care settings? 2) What recommendations do they have regarding their needs in order to feel safer to disclose and ways service provision can be improved for women like them? 3) What resources are the women accessing and utilizing in their day-to-day lives to support their well-being and resiliency? The conceptual foundations of the research questions were discussed in Chapter 2.

The following topics were used as a guideline for the interview questions. During data collection, the women were asked questions about 1) how they came to identify as bisexual; 2)

their experiences related to social support, including disclosure and non-disclosure of sexual orientation in their social networks; 3) their experiences related to health care, including disclosure and non-disclosure of sexual orientation in health care settings; 4) information they hae eeied aout HIV/AID“, “TDs ad elated testig; esoues that suppot their resiliency; and 6) more life experiences and/or concerns they would like to share for this research study. Each numbered question was followed by probes that could be used to encourage the participant to share more about their life experiences. Questions and prompts pertaining to HIV status were not used during the study, as no participant who had tested had received a positive HIV test result.

The emphasis of the interview guide evolved according to the information emerging from the data as interviews proceeded. [Please see the original and revised interview guides in

Appendices A and B]. The qualitative approach of using semi-structured interviews does not require using all of the same questions for each interview. Participants naturally shared more in areas of greater interest or familiarity to them; each participant varied in the extent to which they spoke on each topic area. With the process of grounded analysis, once an adequate amount of information was gathered in a topic area, the researcher focused on obtaining more details in other areas. For this study, once an ample amount of information had been shared on identity and social support, the researcher sought to obtain as much detail as possible

egadig the oes epeiees as ABW i health ae settigs. A comment form was also created. [Please see the participant comment form in Appendix C].

Demographic information was collected via a questionnaire. [Please see the US and UK demographic questionnaires in Appendices D and E]. Each participant filled out the

demographic questionnaire. The researcher specified that each participant need answer only those questions they were comfortable to provide a response for. The researcher provided any requested clarification.

Research Design

The qualitative research method of grounded analysis guided this study, in gathering and analyzing information about the women's life experiences related to resilience, as well as the nature of health care and social support when sexual orientation is and is not disclosed

(Glaser & Strauss, 1999). This initial study with African descent bisexual women (ABW) was exploratory in nature, and therefore best suited for a methodology that permitted responses that are not too narrowly confined the way a quantitative study may require. Qualitative methods comprised the primary approach for this dissertation research study also for the following reasons. There is an absence of application of theory with these women in the literature. Furthermore, due to invisibility and lack of empirical research, not enough was known about how bisexual women of African descent view the specified issues.

Grounded Analysis

The data was comprised of semi-structured interviews, notes, and demographic information. As described above, the interviews were completed during data collection, using open ended questions. Each interview was transcribed and analyzed, using methods of grounded analysis which are differentiated from Grounded Theory Method (Glaser & Strauss,

1999) and further explained in the section on data analysis below. The findings are detailed for each country separately, in Chapters 4 and 5, describing 1) barriers and facilitators of disclosure in social networks and health care settings, 2) recommendations for improvements, and 3)

activities of self-nurturance supporting resilience. Differences and similarities between US and

UK findings are discussed in Chapter 6.

Settings

Implementation of the research study began, following approval by the Human Subjects

Committee (Institutional Review Board) of the Florida State University (FSU) Office of Research.

The study recruitment and interviewing with two separate samples was completed in the US from July through December 2013, and in the UK from January through March 2014. Several international scholars and community organizers, as well as institutions, agencies and organizations in each country, supported the study with guidance, information, referrals, publicity, recruitment, and work space.

Sample

The sample for the study was a purposive sample. In the US, six women completed interviews. In the UK, eight women completed interviews. Every woman who scheduled an interview kept her appointment. Participant characteristics are detailed in Chapters 4 and 5.

The researcher conducted the voluntary interviews with participants who self-identified according to the following race/ethnicity, sex/gender, and sexual identity/orientation criteria.

These criteria were used in determining eligibility to participate in the study.

Race and ethnicity criteria.

African descent is defined as Black persons born in Africa or descended from Black persons born in Africa. Black is defined as African ethnicity/origin that is not exclusively Asian or

Hispanic ethnicity. (For example, a British woman whose parents are originally from Uganda

would not be eligible for the study if the ethnicity of her biological parents is exclusively of southeast Asian ancestry).

Sexual identity and orientation criteria.

Bisexuality, for the purposes of this study, is considered to be the combination of identity, orientation, and life experiences contributing to a woman identifying as bisexual

(Brewster & Moradi, 2010). Bisexual orientation, for the purposes of this study, is defined as considering oneself able to experience attraction to another person regardless of their male or female sex/gender, although one may have had no sexual partners or have had a sexual partner(s) of only one sex/gender (Human Rights Campaign, 2011-2012).

Sex and gender criteria.

This study focused on bringing awareness to issues affecting bisexual-identified cisgender females. The life experiences of transgender bisexual women were not included within the scope of this preliminary study. Quantitative studies with large samples may benefit from heterogeneity within a sample, but qualitative studies generally need to focus with a relatively homogenous population in order to have meaningful conclusions. Differing hardships and risks experienced by transgender women have been reported (Battle, et al., 2000; Poteat,

2012). The discrimination and risks affecting African descent transgender women are severe; and although their experiences are not represented within the scope of this study, more research is needed.

Recruitment

In 2006, communication with agencies began in the US. In 2008, networking with US and

UK sexual minority researchers began. In 2010, the researcher first met with agencies in the UK.

In 2012, women in the UK expressed interest to participate in the study. Following approval by the FSU Office of Research Institutional Review Board, US interviews were scheduled in 2013.

[Please see the IRB approval letters in Appendix F]. In 2014, UK interviews were scheduled. In

2013 and 2014, every potential participant who scheduled an interview, completed the interview on the scheduled day.

In the US and UK, several health care and LGBTQ community organizations and agencies supported the study through consultation, guidance, referrals, posting the recruitment flyers, and providing interview rooms. Also, scholars and community organizers were contacted with requests to share information about the study; several posted the study on their listservs and online sites, and shared information about the study with individual women in the US and UK who were known to them and had disclosed that they identify as African descent bisexual women. Most participants learned of the study through scholarly and community networks and referrals. [Please see the recruitment messages and letters for agencies, organizations, professionals and organizers, beginning in Appendix G. Please also see the US and UK recruitment flyers beginning in Appendix J].

Direct recruitment was not used by the researcher. The snowballing method, encouraging participants to share information about the study with additional women who may meet criteria for participation, was largely not utilized, as many participants stated they knew of no other ABW in their social networks.

A screening script was used when contacted by potential participants. [Please see the screening script in Appendix N]. A participant contact information form was used at the time of scheduling. [Please see the participant contact information form in Appendix O]. At the request

of one of the health care agencies, two separate participant code lists were created; one with the case number and participant initials, and another with the case number and pseudonym.

The agency requested the researcher keep these lists in case the agency was contacted by a participant; however, the agency was not contacted by any participant following an interview.

[Please see the participant code lists in Appendices P and Q].

Older women and women living with HIV were encouraged to participate, but were not reached for this study. One HIV/AIDS service agency in the US stated they believed in the importance of research but had no staff to review studies for participation. An HIV/AIDS service agency in the US and UK respectively stated that the ABW multiple minority population would

e ti i ue, ad the fe eligile potetial patiipats a ot e iteested to participate. Patiipatig ageies told e thee is fatigue aogst okes i the seto.

Several HIV/AIDS service agencies had limited time to respond to messages, nor time for additional projects such as research. One HIV/AIDS service agency in the UK serving African clients placed phone calls the same day the researcher met with an agency worker; however, the HIV-positive sexual minority clients contacted stated that they identified as lesbian and not bisexual. Another UK HIV/AIDS service agency stated that they are inundated with requests to participate in research; the executive director stated that they prefer studies that will benefit women living with HIV/AIDS (WLWHA), in which the WLWHA are fully involved in the study conception and design, and requested a focus on a priority area of violence against women and

WLWHA. Most HIV/AIDS service agencies contacted in the US and the UK did post flyers in their agencies and on listservs, with policies that protect their clients by not sending direct emails about research opportunities. Overall, HIV/AIDS service agencies were very generous with their

time, and also provided space for interviews. Especially in the UK, HIV/AIDS service agencies expressed that they valued research that would make available more information about the needs of African descent bisexual women.

Incentive.

The researcher offered each participant an incentive of a gift card at the beginning of the interview appointment. The amount of each gift card was $25 USD or 25 GBP in the US and

UK respectively. The specified amounts in USD and GBP were considered to be comparable in reference to the cost of living in each country. Each participant was informed that the incentive was theirs to keep, even if they changed their mind and did not complete the interview. This was intended to ensure interviews were voluntary. Each participant scheduled did choose to complete their interview.

Protection of Human Subjects

Informed consent.

I introduced myself to potential participants as the Principal Investigator and a PhD candidate in the FSU College of Social Work. I verbally explained the information in the informed consent document about the study, and provide a copy of the document for them to read, to ensure disclosure and make possible informed consent. [Please see the research study consent information documents in Appendices R and S]. The FSU Office of Research waived obtaining a signed consent form from requirements. Each participant stated at the beginning of the audio recorded interview that she understood the informed consent information and was agreeing to participate in the study. Each research participant was invited to provide a first

name pseudonym for the study, that was different from their real or legal name, and is also different from any nick name they usually used.

Confidentiality and data protection.

Confidentiality.

The audio recorded interviews were confidential. As stated earlier, the FSU Office of

Research waived obtaining a signed consent form from requirements. Each research participant was invited to provide a first name pseudonym for the study, that was different from their real or legal name, and is also different from any nick name they usually used. Although statements from the transcribed interviews are included in the written dissertation every effort was made to ensure this information is presented in a way that should not reveal a patiipats identity.

Disclosure of HIV status.

Women living with HIV/AIDS were encouraged to participate. The demographic form that was administered prior to the interview provided the option of disclosing HIV status, though study participants were not required to respond to all questions or disclose their HIV status to the researcher. [Please see the research study consent information documents in

Appendices R and S]. All participants in the study who stated they had tested, reported receiving a negative HIV test result.

Data protection.

The data consisted of interview audio recordings, transcripts and data files. Each confidential research interview was audio recorded digitally, and by cassette tape as a back-up recording. The digital audio recordings were downloaded to a password protected computer from the recording device. Any identifying details were removed from the transcripts. The

audio files and transcripts were stored on a password protected computer, and a secure online storage location (or an external storage device). The tapes, printed transcripts, and any external storage device were stored in a locked storage compartment when not in use.

The audio recordings from the digital recorder would be erased once the audio file on the password protected computer was verified for completeness and clarity. The audio files would be deleted once the transcripts had been analyzed, no longer than one year from the date of the interview. Any tape recordings and printed transcripts would also be destroyed once analysis was complete.

Data Collection

Interviews were conducted on the FSU main campus in Tallahassee, and the FSU Study

Centre in London, England. Interviews were also conducted at LGBTQ organizations in the US and UK, and at an HIV/AIDS agency in London, England. All interviews were face-to-face and completed in person by the researcher. The duration of each confidential audio recorded in- depth semi-structured interview, was ranged from an estimated 1 to 3 hours. Demographic information was collected. Each participant was provided with a resource list of organizations intended for information and support. The researcher wrote post-interview reflections regarding the completed interview, making note of issues to attend to as the next interviews proceeded.

Data Analysis

The steps used during data analysis are described in this section. The primary strategies of grounded analysis used were coding and memo writing (Charmaz, 2006).

Software.

The researcher managed the data within Microsoft Word files through all phases of analysis. The US and UK data were analyzed within separate Word files. A methodologist on the committee suggested Microsoft Word for analysis of data with a smaller sample. Although qualitative software can be utilized to assist in managing and analyzing data, the researcher preferred to manage the data manually for optimal control of analytical processes particularly during categorization of data. Microsoft Word permitted a large viewing window, including the ability to view multiple pages of transcript on the wide-screen monitor at the same time, which the researcher preferred to the typically more restricted viewing window of qualitative analysis software. Microsoft Word also permitted working in side-by-side documents on the wide- screen monitor, which facilitated categorizing data. Microsoft Word also facilitated viewing codes in comment balloons in the margins and memos in footnote fields while simultaneously working within the document during coding and analysis, whereas in qualitative software viewing memos can require additional steps. However, for a large number of interview transcripts, the researcher would consider utilizing qualitative software to manage the data.

Modified grounded analysis.

Modified techniques of grounded analysis were used during data collection and analysis of the interviews, including coding, memo writing, and constant comparison (Charmaz, 2006;

Glaser & Strauss, 1999). The analytic goal remained the use of Grounded Theory Method (GTM) principles (Glaser & Strauss, 1999), although for this study there was no requirement that theoretical saturation be reached.

Guided by GTM principles for the research process, each interview was conducted with consideration of information from previous interviews, as described here. During the initial three interviews in the US, it became evident that the interview would proceed more effectively if the order of some of the questions was changed. The order of the interview questions can be seen in the original and revised interview guides. [Please see the original and revised interview guides in Appendices A and B]. The post-interview reflective notes, mentioned in the section on data collection, assisted the researcher in tracking the extent to which the interview processes and data obtained were meeting the goals of the study to address the research questions. As the interviews proceeded, once adequate information had been gathered overall in one topic area such as social support, the researcher then focused on pertinent areas for which more data was needed such as health care provider communication of prevention information for bisexual women. For example, when the pattern became clear that the women are usually provided standard prevention information that might be provided to heterosexual female clients, the researcher asked more specifically about whether the women obtained information on healthy same-sex relationships from providers or other sources such as their social networks.

Transcription.

The Grounded Theory Method usually involves transcribing and analyzing each interview before proceeding with the next interview. When the researcher was collecting data through conducting interviews in different cities in the US and/or UK, it was not always feasible to complete transcription and analysis between each interview before proceeding to the next.

The modified process is described as follows.

The first three interviews in the US were fully transcribed verbatim by the researcher before proceeding with additional interviews. These transcripts were read and the data was carefully considered before proceeding with additional interviews. In reviewing the transcripts, the researcher sought to determine the extent to which the information sought for the study was being effectively obtained, as described in the section above with the subheading

Modified gouded analysis. The last three interviews in the US were conducted close to the departure to the UK. After the researcher returned to the US, a graduate assistant transcribed verbatim the last three US interviews and all eight of the UK interviews. Confidentiality of the data was reviewed with the graduate student assistant.

Transcripts were identified by the case number and by the pseudonym selected by each participant. Identifying information was removed from all transcripts. Any italicized words were the emphasis of the participant.

Initial coding.

The researcher read and re-read each individual interview transcript line-by-line, considering the ideas and experiences described by the participant. An a priori coding guide was set up, based upon the main categories specified in the research questions and interview questions. Although coding is usually conducted with at least two coders, for this study the researcher was the main coder in consultation with a methodologist with expertise in GTM.

Based on the data in each transcript, basic concepts were identified related to the research questions on identity, disclosure, social support, health care and resilience. Codes were added that emerged from the transcript data, primarily reflecting in vivo the words of the participants.

The four main categories of the coding guide were identity, social support, health care, and resilience. Each category of codes had subcategories; for example, subcategories under social support included general social support, family, parents, siblings, friends and co-workers.

Subcategories also denoted negative experiences (barriers) and positive experiences

(facilitators) related to identity and disclosure within social networks and health care settings.

Subcategories of codes pertaining to resilience also arose from the data (i.e. activities of resilience such as writing and exercise). A specific count of the codes was not essential to analysis, as not all coded data pertained to the research questions of this study. Some of the data extended beyond the focus of the current study. For example, data on additional socioeconomic concerns were coded and categorized, though not included in the results and findings within the scope of the dissertation.

Focused coding.

Main categories and subcategories, related to identity, social support, health care and resilience concepts, were obseed ithi eah patiipats tasipt. The researcher also considered the data within each transcript for relationships between concepts, for example potential relationships between disclosure in social networks versus health care settings by each participant. Memos or notes were used to document relationships between concepts, as well as to document similarities and differences across cases. Barriers and facilitators of disclosure were also noted.

To fully compare responses across cases, the researcher next combined the data from transcripts one case at a time, grouping similar concepts from the cases into categories under main headings and subheadings in a separate master Microsoft Word file. Viewing documents

side by side on a wide-screen monitor, the researcher moved quotes pertaining to identified concepts from each transcript into categories in the separate master file. The researcher used two separate master files for categorization of the data from US and UK transcripts.

Reflecting the description of the coding guide in the section on initial coding, the main headings of categories were Idetit, “oial “uppot, Health Cae, ad ‘esilience, based on the research questions of the study. Subheadings arose from the data, depending on the information provided by participants. For example, statements a participant made regarding disclosure and family social support were placed in a main category for “oial “uppot under a subheading for Fail social support. Statements made about HIV testing were placed in a main category for Health Cae ude a suheadig fo Testing. Most categories were similar for the US and UK data, except the UK had a more standardized intake process for their health care system which comprised a category with its own subheading ‘egistatio ad itake processes.

A methodologist advised that one occurrence could be included for coding purposes, as each participant comprised more than 10% of the sample. However, I sought to include what repetitively emerged at least twice or more frequently across participants.

Memo writing.

The researcher made memos or notes about meanings emerging from the data

(Charmaz, 2006). Memos were generated and added throughout the process, noting ideas about relationships between concepts and categories within and across cases, using the constant comparative method (Charmaz, 2006). For example, the researcher noted that most participants in both the US and the UK were provided only prevention information pertaining to

a male partner even if she had disclosed bisexual identity to the medical provider, with few exceptions.

The researcher used memos to note latent content that was not explicitly stated because the women themselves may have been unaware of the connections. For example, the researcher sought to piece together data that indicated some participants had difficulty in transferring prevention information from school and college health education to their health- related behaviors as adults. Though communicable diseases were taught about in school and college, some participants did not know how to transfer that knowledge to STD and HIV testing as adults. At least one participant speculated that providers did not discuss prevention more due to believing the women had already received the information through school curriculum.

Identifying themes and subthemes.

Because developing theory was not a goal of this study, selective coding was not used.

Although advanced steps of grounded analysis can be used to develop theory, the initial steps of the method can be used to arrive at themes illustrating the data as was done for this study.

In order to address the goals of this study to make available information for practitioners and policy makers toward improving resources for African descent bisexual women, the study was

ot desiged to deelop theo ut to ake lea the oes epeiences and their recommendations for improvements.

Overarching themes were identified based on the categories formed during analysis of participant responses, as relate to the research questions. The main categories are based on the research questions, and the subcategories emerged from the data. In considering the data within all of the categories and subcategories, subthemes for experiences related to the main

themes of Idetit, “oial “uppot, Health Cae, ad ‘esiliee, were identified that were most pertinent to the focus of the study, as detailed in Table 1. The subthemes describe the oes epeiees of idetit, the atue of thei soial suppot and health care related to disclosure, approaches that facilitate more effective health care delivery related to disclosure, and resources and activities that support resilience.

Trustworthiness.

The current study was guided by criteria established regarding trustworthiness of qualitative analyses. The criteria utilized for this study are 1) credibility, 2) transferability, and 3) confirmability (Lincoln & Guba, 1985; Shenton, 2004). The process of developing codes and themes was for the purpose of credibility. Discussing the findings in relation to extant liteatue, o thik desiptio, as for the purpose of transferability. Describing in detail the research methods and findings was for the purpose of confirmability. Additional steps are described below.

Accuracy during the process of analysis.

Transcribed interviews were checked with the digital recordings for accuracy. A great effot as ade to ode i io, piail usig the ods ad tes of the patiipats themselves. Printed hard copies of transcripts were read and re-read. Memos were written manually and transferred to electronic files, regarding meanings and relationships of information within individual transcripts. No categorization combining information across cases commenced until within-case meanings and relationships had been fully noted. For example, the researcher strove to assess a potetial elatioships etee a idiidual patiipats experiences of social support and consequent health care experiences, prior to grouping

patiipats stateets i ategoies of Idetit, “oial “uppot, Health Cae, ad

‘esiliee, across cases.

The process of data analysis was verified by a methodologist with expertise in the

Grounded Theory Method. The coding guide was provided to the methodologist. The methodologist reviewed the process of how units of meaning within the interview transcripts were being identified and analyzed, in relation to the coding guide. The methodologist also reviewed how the categorization of the data across cases was being conducted.

Participant feedback.

While it is advised for qualitative studies that the results, findings, and interpretations be shared with the participants for their feedback regarding accuracy in capturing their intent

(Charmaz, 2006), the current study was designed for no additional contact to participants in order to facilitate their comfort in sharing their information for the study on a one-time basis.

The researcher would like to make clear that although accuracy in data analysis and presentation of results was prioritized, the participants did not have an opportunity to provide review; therefore it is important to emphasize that the findings will not reflect the views of all of the participants nor of bisexual women of African descent generally. The information shared by the participants is valuable, and considerable effort has been made to accurately present the main concerns expressed that they wanted made known in the professional realm. Consistent with ethical practices in research, the findings, results, and discussion will be made available to the participants through distribution to the same agencies, listservs, community organizers and researchers through whom the women learned of the study. The researcher believes it is the right of the participants to disagree with findings they did not have the opportunity to review.

Respecting Participant Priorities

The researcher was aware and had informed participants that the main focus of this study was to obtain information for health and social care providers and policy makers to take into consideration to improve resources and services. In part because nearly all participants were of modest socioeconomic means and live with challenges accessing resources, an understandable and very important priority for the women comprises socioeconomic opportunities and empowerment. Economic well-being and affordable housing are social determinants of health and necessary areas for intervention and sociopolitical change. Several participants in the US and UK were actively involved in community organizing for socioeconomic and political change, and the researcher would like to acknowledge their lifelong commitments and efforts. The researcher could not more fully address these large areas and very important issues within the scope of this study.

The researcher focused data collection and analysis on a salient area which emerged during implementation of the study, which is provider communication with women who have or may have a same-sex partner. When the pattern became evident during the interviews that providers with whom the women had contact were perceived to lack knowledge and/or initiative in communicating and intervening effectively with sexual minority women, the researcher proceeded to focus on this line of inquiry for the study. This appeared to be a key area of which practitioners and policy makers need to be aware, in order to address this gap in health and social care.

CHAPTER 4

PRESENTATION OF US DATA AND RESULTS OF THE ANALYSIS

In this chapter, the data from the US interviews is presented, with results of the analysis related to the main research questions and the interview questions. The format in which these findings are detailed with examples, describes the data in categories of themes and subthemes that emerged from the content, including barriers and facilitators of disclosure, and recommendations for improved health and social care. Subthemes which emerged from the data are listed in Table 1. The subthemes are described below in the sections of the main themes and corresponding research questions. Barriers and facilitators to disclosure, and recommendations, are also detailed.

Because different participants could provide similar content in responding to different interview questions especially within the same main category (identity, social support, health care, or resilience), and even across main categories, their responses are categorized together based on content rather than directly linked to each interview question to avoid redundancy.

To explain further, each topic in the interview usually began with a broader question, followed

oe speifi uestios o poes; patiipats esposes ould hae ee stated comprehensively with the first question, or distributed across the questions. In categorizing similar responses together, overarching themes emerged which are further discussed in

Chapter 6.

Participants

Presented in this section are the characteristics of the participants. To protect the identities of the women, the characteristics are presented in groups and are not presented individually for each participant.

The pseudonyms selected by the participants in the US, not in the order of the interviews completed, are: Jasmine, Dreamadonna, Bobbi, Emerald, Annie and Nikki. Several of the participants seemed to choose a pseudonym somewhat reflective of an aspect of their human experience, such as a gender-neutral name. Two of the women, one in the US and one i the UK, oth seleted Aie fo a pseudo.

Sample size: Six women in the southeastern US participated in the study (N=6).

Age: The participats ages aged fo to eas M=, “D=.

Sex: All si patiipats speified feale.

Gender: Fie of si patiipats speified feale fo gede. Oe patiipat ote, I conform to many aspects of the female gender, but I do not feel especiall feale.

Sexual orientation/identity: Fou of the si patiipats seleted iseual ol, fo seual orientation/identity. One participant selected lesbian and bisexual as sexual orientation/identity. One participant stated that she identifies as queer, but others might

oside he to e iseual; ad she ote I a attated to oth e ad oe, ut the patte of attatio is upeditale.

Ethnicity: To patiipats pefeed to idetif as Blak. Oe patiipat seleted Afia

American and Native American. Oe patiipat hile seletig Afia Aeia ote, I do not identify with a race or ethnicity because I have never felt that it was a good determinant or

idiato of athig speifi aout idiiduals. All U“ patiipants were born in the US, as were their parents.

Faith: Three of the six participants reported Christian faith; two participants reported no

eligious affiliatio; ad oe patiipat ote i Agosti.

Health: Four of six participants reported no disabilities (with one reporting situational depression during the interview, and one reporting situational stress during the interview); one participant reported mental illness; and one participant reported chronic illness (and also reported depression during the interview).

HIV status: Most in US, had tested. Four of the six women stated they had received an HIV- negative test result. Two of the six women stated they had not taken the HIV test, and one

ote i I hae ol gie i.e. doated lood ad hae ot been notified of abnormal fidigs.

Relationship status: Regarding relationship status at the time of the study, four of the six patiipats seleted a status of sigle, oe patiipat seleted that she is datig, ad oe participant selected that she is aied/pateed.

Housing: Three participants lived with roommates, one participant lived with her partner, one participant lived with parents, and one lived alone.

Education: One participant reported some college education. Four of the six women reported holding one college degree; one participant reported more than one college degree.

Employment status: Five of the six women were employed full time. One participant did not have paid employment at the time of the study, and stated her last paid position was over one year prior to the interview.

Profession: The patiipats pofessios ad aoatios iluded teahig, health ad HIV work, peer education, community organizing, and writing. One participant is a mother.

Income: Five participants reported incomes ranging from $11,000 to $38,000, with most reporting incomes below $25,000. One participant reported an income below $20,000. [With monetary conversion at an exchange rate of .67 British Pounds Sterling (GBP) to 1 US Dollar

(USD), this is approximately equivalent to a range of 7000 to 25,500 GBP. $25,000 USD was approximately equivalent to 16,800 GBP. $20,000 USD was approximately equivalent to 13,400

GBP].

Theme 1: Identity

The experiences of the women related to identity are described in this section. The

oes efletios o idetit deelopet ad dislosue ae detailed. The data relates to the fist eseah uestio, What ae the epeiees of these oe elated to identity and disclosure in social support networks.

The eseahe ega eah iteie tellig patiipats, Thee ae a theoies and thoughts about self-identity. The purpose of this interview is to understand life experiences from your perspectie. The ifoatio as sought though askig the oe seeal questions:

Ho did ou oe to ou sese of self, that is ho did ou deteie ho ou ae as a peso?

“What does it ea to ou to idetif as iseual?

What ae soe of the thigs that atte the ost to ou i ou life?

The information in this section on identity is organized under three subthemes that emerged from the data:

. Bisexual identity is experienced as non-binary.

. Identities of race, gender, and sexual orientation are intersectional.

. Identity development is impacted by stigma and influenced by support.

Bisexual Identity is Experienced as Non-Binary

The women were asked to share what it means to them to identify as bisexual. Several indicate a capacity for attraction regardless of gender (male, female, or transgender).

Participants commonly described experiences and meanings of identity as follows.

Nikki explained:

I attated to oth e ad oe, seuall ad non-sexually… ut attated

sexually without actually necessarily having to have sex. (Nikki, US)

Emerald shared:

My bisexuality does not mean that I'm only attracted to people who are cis-male and

cis-female (i.e. cisgender). I would say, I make a distinction between orientation and

identification. Like, I'm attracted to a variety people that might not necessarily fall into

the binary; …ut a lot of iseual people atuall feel that a. (Emerald, US)

Dreamadonna described her understanding of her identity:

I am able to and have experienced attraction for males—biological males—as well as

biological females. Now, I also have experienced and know that I am capable of

experiencing attraction for someone whose gender is not the same as how they were

born, so, you ko, Ie ee i elatioships ith people that ould oside

theseles tasgedeed. “o, he I hea iseual, its like, Oh, ell, tehiall.

I ot sue, ut eause I like gils ad I like os ad that possiilit is thee, eithe

way, I feel like bisexual fits probably better than anything else. (Dreamadonna, US)

Identities of Race, Gender, and Sexual Orientation are Intersectional

As mentioned earlier, Emerald also described a lengthy process of identity development, during which she lacked information and role models.

My exposure into sort of like a queer world was White,… ale-idetified,… ad ga….

But the idea of bisexual, I mean I knew aout iseual, ut I didt know any bisexuals,

I as self…. “o I ae out as a ga iseual…. Coig out ad haig a sese of

myself as a bisexual was just kinda shaky. As a woman, up until that point,

I have a feminist sense of myself, but I didn't have that when I came out.

I have a sense of myself as a Black woman, but I didn't have that about myself at 20.

I as dealig ith ais,….

At times during those developmental years, she had had the support of African American female counselors on her college campus. Emerald further described her evolution to a healthier sense of identity.

The Black identity that I have now is e delieate. Ad its oe afte eas of

asiall just sot of like, Oka, so hat's goig o? I do't feel ofotale ith

African-Aeia eessaily. I guess I feel like being old shool saig “a it loud, I'

Blak ad I' poud!…. But o, I' just sot of like, eah I'll take Blak. Blak

sees to hae a it of poe, I like Blak poe; You do't eall hea Afia-

Aeia poe. I like Blak iseual oa, the alliteatio…. But as fa as like

idetit, o hoestl as fa as like ofidetl eig This is ho I am, is oe of a

recent phenomenon. (Emerald, US)

Identity Development is Impacted by Stigma and Influenced by Support

A pattern described by participants regarding their processes of identity development is detailed in this section. Early experiences of stigma are depicted in these descriptions, followed by later experiences of success in gaining support and affirmation. The women described barriers and facilitators of their identity development as bisexual women of African descent.

Prejudiced attitudes and stigma were barriers. Leaving their families of origin, when they moved away, was a facilitator. Having supportive people around them also facilitated identity development.

Annie was amongst participants who referenced leaving their hometown for college as formative in their identity development and social processes. Annie mentioned that while growing up she felt concerned her family might judge her. When she went to college she felt more able to become herself and live more authentically. Even though she had gay and bisexual fieds goig up, she ast sue aout idetifig that a o ho she ould e teated.

This is a notable developmental process for a female who grew up to be in a same-sex life partnership.

I feel like I as poal iflueed hat as aoud e…. I feel like it as the fist

tie eig e eig out of sall south state to, ee though its a state town;

but, I feel like it was a new environment, and being exposed to new things and new

possibilities and new people, during that time is when I like realize, not realize but

aepted that Oh, ou ko I' poal ot straight” (i.e. not heterosexual)… So that

was like the first time that occurred to me that (that) could even be so, it was so taboo

…It as teated as a taoo. I had, you know, gay and bisexual friends, growing up, but I

just felt that it was not an option for me; Oh that's weird, my family will judge me, my

friends will judge me. But I feel like I became open to… eig myself, whoever myself is,

eause, it's just like" It's life…" Ad he ou'e ot suouded ou fail,…

ou feel ou a e oe… ope aout ho ou ae, I feel like. I just feel like though the

people I'd been around, and the places I've been, have kind of made me who I am.

(Annie, US)

Bobbi described an important friendship that supported her identity development process.

Ie alas kid of ko I as ga, i, uee… Ee sie I as little I as alas

pusuig gils, ad the I et a gil i shool. Wee still fieds to this da. “he as e,

ad she et up to e. “he said, Hi, ae is, ad I i, ad I as like, What does

that ea? We ee i the sith gade, ad she as like, I like os ad gils, ad I

as like, Me too. That akes sese. No I hae a od fo it. Ad shes kid of the

most pivotal moment that stands out to me. (Bobbi, US)

Nikki shared about an identity development process that began with her awareness at age five. She describes stigma in the African American community as a barrier to identity development. She shared with the researcher that having a friend whose mother was same- gender-loving facilitated her own process of self-acceptance. Nikki said that although she was able to work through her identity development process mostly on her own, other people would probably need more support.

I think the hardest thing was, was coming to terms with things myself, especially when

eig hooseual, iseual… i the Blak ouit is kid of looked down on. Ie

ko sie I as fie eas old…. Ad the I oked out feeligs fo myself. But a

lot of people at do that fo themselves, they need other people to help them through

it…. But eall I just spet tie ith self goig Oka, this is e. Ie felt this a fo a

long time. Yeah, I ignored it fo a lotta eas, ut its ot goig ahee appaetl.

“o… its tie to face (facts). I think it was a process over a few years. And then I finally

just got comfortable with me, and stopped caring hethe people aed… a lot. (Nikki,

US)

Theme 2: Social Support

Desied i this setio ae the oes epeiees ad esoues of soial suppot such as with friends, relatives, roommates, neighbors, coworkers, and colleagues. The women were asked to share about who knows them for who they are, and upon whom they can depend without fear of rejection if they are known.

The women were asked to describe a situation in which they disclosed bisexual orientation, or tried to avoid disclosing bisexual orientation, and what they considered in making their decision about whether or not to disclose. The women shared about good experiences they have with disclosing and being accepted as they are. They also shared about experiences they had in which they felt hesitant, worried or afraid to disclose sexual orientation, or in which they did disclose and felt they were not accepted or supported.

Probes asked about responses/results following disclosure, and/or what the participant thinks may happen if/when she does disclose to others, and/or what factors lead to her deciding not

to disclose. (For example, how did or might her family member respond?) Probes also aimed at obtaining details about the decision-making process, and factors considered by the participant regarding whether or not to disclose, including whether/when/how to disclose sexual orientation in their social support networks. The information in this section on social support is organized under three subthemes that emerged from the data:

. Experiences and resources of social support vary.

. Social networks are needed that suppot oes idetities.

. Behaviors constitute barriers and facilitators of disclosure.

Experiences and Resources of Social Support Vary

Participants described mixed positive and negative experiences related to social support. Annie described good social support from her partner and family, and wished she had closer relationships with friends.

I have a partner of more than a year; we do live together, so that would probably be the

first line of support. I have family that lives within the Metro [city name] aea… o,

ad siste… thee a soial suppot. I feel like that's one of my issues. I wish I had a

bigger support system. Because I have, we have lots of friends and acquaintances, me

and my partner, but not necessarily people that you want to go and share your problems

with. I do feel comfortable sharing my problems with my sister and my mom to an

extent. So that's good. Othe tha pate, ad o ad siste,… that's aout

it for the most part for social support. I have friends who I talk to,… ad I guess the do

poide soial suppot eause ou ko e ae soial togethe…. thee's a lot of people

who identify as gay or biseual o uee… i [this it]. “o that's a good thig, ause ou

ko it's ot like I feel aloe…. As far as plaes e like to go… to fieds houses, to

house paties,… thee's a lesia a i this it… so e go to that lesia a a lot.

(Annie, US)

Whe asked Hae ee ale to dislose iseual idetit o oietatio to soe people in your social networks? Deaadoa shaed she has ee ale to dislose he idetit ith many relatives, friends, and coworkers. When asked whether she feels able to rely on them without fear that they would withdraw social support, and depend on them to be there for her without fea of ejetio, she said ‘ight. Yes, I e fotuate. I eall a. Deaadoa spoke of the benefits of strong social support:

Oeall, fo eethig that Ie shaed, ou a see Ie ee e fotuate. I thik I

have a good life and I have a very strong support system and I always have, so really, I

started out really well and was able to build on that, and so I feel like I was very lucky.

(Dreamadonna, US)

She shared more specifically about disclosure within social support networks:

I think,... All of my close family, like my mom, dad, close aunt, and then most of my

extended family have some awareness. Ee if the dot eessail ko all

partners, they are aware. And then, the friends I have, close friends, even just

acquaintances pett uh ae aae. [‘eseahe: Ad… soe of ou ookes ho

ae fieds?] Yes, all of the…. Deaadoa, U“

Dreamadonna shared further that it can take time to develop social support networks, and the prospect of relocating can be challenging.

….I feel like Ie lied i [to] o fo te eas. Nee epeted to e hee this log,

ad o Ie ee hee so log that I do feel like I eall hae stog suppot etok

here. It ould e diffiult; if I leae I’d hae to start all oer it feels like. Because the

LGBT community center is here, I know where it is; for many years that I have been here

Ie ee ioled ith the LGBT ouit ete, ad Ie ade fieds fo the LGBT

community center that are still good friends now, and so I feel very comfortable in this

ouit…. I feel like athig I eed, I ko hee to go o I hae people that ae

thee fo e. Its a good plae. I at de its ee good. Deaadoa, U“

Nikki expressed a degree of isolation as a multiple minority:

I just feel that sometimes in our community we (ethnic minorities) stay so hidden that we

dot help eah othe, that ee hidig fo ouseles ot just fo eeod else, ad

that makes it hard to move forward as a community. When you go out ad oue the

ol oe thee, oue like Okay, hees eeod else? Ad I dot mind it, but at

the sae tie its ie to see soeod ho looks kida like ou…

Several participants described that they cannot always rely on family or ethnic community for unconditional support. Jasmine shared, M o ad I dot hae a lose

elatioship as e used to. We dot talk as uh…. I ish othe ad I had a lose relationship...

Bois fail osides he to e a Godless lesia, ad she pefers a more distant relationship using phone rather than in-person communication.

I ouldt oside fail a eall suppotie soial etok. The thik I a

Godless lesbian; ut thee gettig oe that eause he the teat e adl, I just

kind of separate myself from them (family), and that upsets them, so they do very well

he I fa aa. We talk o the phoe, ad thee a suppot etok o a lot of

thigs, ut ot eethig…. M fail ould ee outight ejet e, ut it still

wouldt e a ofotale situatio fo e to el o the. Boi, U“

Annie described conflicting experiences related to acceptance and support:

My mom might not love it, ut she has to aept it… M o's olde… Latel shes ee

saying "I'm from the South; I as't aised that a… But the she tells e "Oh yeah,

like I used to ok ith ga people all the tie… “o, I do't ko. She's a (medical

pofessioal, so she's oked ith all kids of people. But,… she's accepting, she likes

pate… But, shes still… I do't thik she's goig to gie up o e eig ith a a

and having grandkids for her. I don't think she's going to give up on that. (Annie, US)

Soial Networks are Needed that Support Oe’s Idetities

Jasmine described her decision-making process in disclosing with friends and in general.

Friends and co-workers have been more accepting than immediate family.

I foused o eig e geuie…. I ould alas hae these fieds eause Id goe

to ollege ad, like aod hos goe to ollege, ou hae fieds just fo patig,

you have friends that you really tell your information to, and then you have friends you

only studied with. So you have all these different groups and people who know you in

etai leels…. But eal last ea I said Jasie, I goig to sa ho I a ad let

people figue it out late, eause I got tied of eig a diffeet peson in different

iles…. Eeod ho kos e i [uet it] kos seualit, the ko

job, they know my living situation, they know my career goals. I try to tell them my

dreams. Everyone who I meet. In [state], I would say the bulk of people in college who

talked to e, ho still talk to e, the ko hee I at i life. (Jasmine, US)

Participants described that having LGBTQ community spaces is important to them.

Dreamadonna shared how she felt about having adequate community resources.

Well, I guess I would still say like the LGBT community center, like I said before, is

definitely one. It just makes me feel good that there is a place in my community, so I feel

like I dot hae to go ahee else to hae at least a fist plae, kid of like a home

ase. That akes e feel good, ad eehee that Ie oed, thats like oe of the

first things that I would look for. You know, I knew I had to get a new doctor. I might look

fo a huh if thats hat I ated, ut I alas as lookig fo the local LGBT

ouit ete o soethig to ko, Oka, its oka. Thees soeod hee. “o

yeah, always the LGBT community center, and then just, again, my friends, my

okplae, its defiitel a esoue. Deaadoa, U“

Jasmine shared about community resources she wished she had:

Well, I thik the thig that affets e loall ad that oes e all the tie,… thee

aet a lot of plaes hee i [uet it] that ae LBGT-friendly [in addition to the LGBT

ete]…. I thik thats poal the most difficult thing. I dot ko of a othe plae

that is a restaurant or a bookstore or just a safe area where you just come in and relax

and you can be gay. Thats poal the issue that affets e all the tie hee. (Jasmine,

US)

Behaviors Constitute Barriers and Facilitators of Disclosure

The following section details barriers and facilitators of bisexual identity disclosure in social networks. The process of disclosure varied depending upon the relationships. The women described disclosing identity or orientation with some people in social networks, though not everyone. Patiipats poesses eflet effots to aitai the soial suppot that the hae, clear decisions based on what they feel is the best approach in each situation or relationship.

As participants describe below, verbal comments can comprise barriers and facilitators influencing disclosure in social networks. Nikki expressed feeling more likely to disclose to people who have expressed tolerance.

I tend not to tell the overly-churched people laughte. Yeah! Ill just leae that aloe,…

unless through casual conversation they have expressed a tolerance for it. (Nikki, US)

Dreamadonna explained factors she feels influences her decision process regarding whether or not to disclose bisexual identity.

Now, I know there have been times when I have decided against it. There definitely

hae ee…. geeall it has had to do ith the people that ee thee, ho I felt aout

the as people, ho the teated e, o oe so ho Id see them treat other people,

or things that they might have said, if there had been a joke that I felt ast e PC

(politically correct) or something like that, then I might have been a little more fearful or

just felt like, Oka, ae this ist the right tie. Deaadoa, U“

Nikki also shared about cues she has considered in making a decision to not disclose with her parents at this time.

Ad he Ie thought aout tellig the paets, thell ake a oent here and

thee thats like Uhh… ae not yet to dislose. “o its ee eal tenuous with

them. From time to time a special would be on TV that I would be watching, and my

Mo ould e like I dot get it, o I dot understand it. Not eessail negative, but

not extremely positive. I think my parents would be accepting, and would still love me;

that would never be an issue. But its like ot eall… sigifiat at this poit…. Lets just

not put pebbles in the water (stated somewhat slowly and carefully). Thee e uh

more traditional. Its like Oka, ae all aet ead fo this oe et. Nikki, U“

There can be so much explaining and educating that may have to be done, this serves as a barrier to disclosing. Aie efes to passig fo staight, o poteted soietal presumption and assumption that she is straight, based on her gender presentation. As she does ot peset as eig asulie, she eliees she is ot suspeted o outed as o- heterosexual on the bases of gender presentation. Annie describes her decision making process in deciding not to disclose in all settings:

In some settigs,… I feel like I o't e explicit about being bisexual or being with a

oa… I soe soial settigs, I just feel like it's est ot to… oe out ith it.

Because I don't want a bunch of questions. And I don't want people to look at me…

differently eause o oe, I do't thik aoe looks at e ad autoatiall sas Oh,

she's probably gay. I ea, the ight, ut, I peset feminine, so…. soeties it's just

easier not to ig it up,… util ou hae a reason to bring it up. (Annie, US)

While not explicitly a facilitator, Jasmine has found useful a strategy of proactively disclosing in most settings, leaving the responsibility of processing perception and response upon others, rather than using non-disclosure as a management strategy. This eases her from feeling burdened about how they might potentially respond were they to learn later in the future.

Eeod kos ho I a hee. I this poit i life, I just too old to pretend

athig else…. To e hoest, its ot ee a leel of ofot that ou feel—that I feel,

fo e. To e, its I dot at to hae to eplai late. I just gettig tied of that, ad

so if I bring my identity to the table from day one, you can whisper about it or whatever,

ut its just goig to e o ou. Its o loge poit hee I hae to jup though

hoops to be a different ego. (Jasmine, US)

While not explicitly a barrier, it was further explained that not having a committed relationship with a same-sex significant other influences the decision to not disclose bisexual oietatio to oes paets. Nikki shaed, With paets, I still haet deided to tell the

et. Beause I haet had aod i life that as sigificant enough to tell them.

Theme 3: Health Care

Addressed in this section are experiences and recommendations pertaining to physical and mental health care. In this section the women describe processes of communication within health care settings. The women were asked to share about their health care experiences and decision-making processes related to disclosure and non-disclosure of sexual orientation.

The information in the beginning of this section is related to the first research question:

What ae the experiences of these women related to identity and disclosure in social support

etoks ad health ae settigs? I this setio o health ae, the ifoatio is fousig o health ae settigs, i.e. What ae the epeiees of these oe elated to identity, dislosue ad health? The eseahe espeiall atteded to epeiees elated to HIV prevention, including health information shared between peers.

The information in the beginning of this section is related to the following interview questions. The women were asked: Please tell e aout ou epeiees ith health ae.

The information in this section on health care is organized under three subthemes that emerged from the data:

. Experiences and resources of health care vary.

. Environmental cues and behaviors constitute barriers and facilitators of

disclosure.

. Specific changes can improve services for African descent bisexual women.

Experiences and Resources of Health Care Vary

Lack of health insurance presented challenges to accessing physical and mental health care. For half of the six US participants, lack of health insurance was a major obstacle to accessing health care. For women without health insurance, quality of health care is related to lack of health care access (as a larger more primary issue) rather than disclosure of bisexual identity. Even the participants who were employed could lack health insurance. Several of the women had better access to health care while enrolled in college, whether through school health services ad/o thei paets health isuae.

The interviews were completed prior to the passing of the Affordable Care Act. The participants lived in states that did not choose to expand Medicaid to cover more low-income people, following passage of the Affordable Care Act.

Annie struggled with lacking knowledge about how to access health care without insurance; despite residing in a large metropolitan city, known for being very LGBTQ-friendly, as she stated above in terms of social and community spaces. She shared that the determining factor in the quality of her health care experiences is whether she has insurance and access at all. She stated that if she could financially access care, she did not feel sexual identity or race/ethnicity/gender were factors which would play a role in providers giving a lower quality of care.

Right now accessing healthcare is kind of hard for me, cause I'm not employed anywhere

and I don't have any health insurance. So that's hard. So just the fact that I'm not from

[this city], so I didn't really know where can I get low income care, or whatever I really

wish there was soethig…. I feel as a low income Black woa,… iseual,… it's not

been easy to navigate in [this city]. Before when I did have insurance, it was much easier!

…If the ee i etok, I ould go to a doto, ad it as just easie. Ee afte I

stated idetifig self as iseual,… I didn't feel like I was being treated a certain way

because I'm a Black bisexual woman,... For me having health insurance (and) not having

health insurance have been the biggest things of what has played a difference in what

services I can receive. (Annie, US)

Emerald expressed difficulty affording sliding scale fees at community clinics:

“lidig sale doest ea slidig sale. Sliding scale means that there's a minimum

paet, ad its usuall aout uks. Whih, if I had uks, I ouldt eed a

sliding scale. Thats e high. Eeald, U“

Education and training foster overall empowerment. Dreamadonna described processes of self-initiative in seeking information. Through her education and career in health care, she has been empowered to access information.

Oeall, I feel like Ie ee e fotuate, I guess eause of eduatioal

background and then also because of the field that I work in. Information is just right

thee fo e. If thee ae thigs that I didt ko, I hae to ko o ecause of my

jo ad Ie ee ith the [HIV health age] o fo… eas. So there are a lot of

thigs I as eposed to eal o that people dot eessail ko,… just eause of

the nature of my job, with regard to HIV or just health in general. (Dreamadonna, US)

Dreamadonna shared further about taking the initiative to research health information online.

Outside of ok, I guess Ie alas ee e poatie i eseahig, gettig o the

iteet, if thees soethig I dot ko o if I haig a issue ad I odeig

hat a it e. I thik eause of eig ofotale ith oputes eal o ad I

ale to fid ifoatio fo self, so I dot feel like I dot ko hee it is o I dot

know how to get it. I can quickly access it. (Dreamadonna, US)

Environmental Cues and Behaviors Constitute Barriers and Facilitators of Disclosure

The women were asked: Please desie the ifoatio that ou hae shaed ith

ou health ae poide, ad Hae ou dislosed iseual idetit/oietation to anyone in a health ae settig? If so, ith ho?

Probes asked about responses/results following disclosure, and/or what the participant thinks may happen if/when she does disclose to others, and/or what factors lead to her deciding not to disclose. (For example, how did or might the medical provider respond?) Probes also aimed at obtaining details about the decision making process, and factors considered by the participant regarding whether or not to disclose, including whether/when/how to disclose sexual orientation in their social support networks.

Some participants expressed disclosing with mental health providers, but not doctors or nurses in other health settings. Although Emerald has been assertive about sexual orientation identity disclosure with mental health providers, she stated, “With medical doctors, it almost

ee oes up.

Dreamadonna had beneficial experiences of her provider acknowledging bisexual identity. She described an uncommon experience among the women of having good

communication with a long term provider, as described below. She has good social support from her family and friends. She credits her educational background and working in a health field as contributing factors in her assertiveness as a client. Her doctor was receptive to hearing what was going on generally, both physical and mental health concerns. He made the time to listen and go over everything with her, and provide culturally appropriate health information for a woman with male and female partners in her lifetime. Dreamadonna shared the following:

I hae a good elatioship ith uet doto, ho Ie had sie Ie ee hee, so

maybe about eight or nine years. Beause I e poactive about my health, I just

started out fresh right from the beginning with him. From the very first visit, you know,

I hae a feale pate, ut Ie dated e ad oe. It as just all out thee I

think largely because of my job and my educational background, I already knew that the

goup o goups that I a pat of ae histoiall ad taditioall like, I dot ko if

udeseed is a good od, ut ou health ae is kid of agialized to soe

degree, and so because of those health dispaities, eause I ko aout that, I like

ight thee i the foefot, Oka, this is hat Ie doe, o This is the epeiee Ie

had, so that the at least ko upfot, Well, ae I eed to ask ou this, o ae

You eed to hae this kid of testig doe. Whe I ig up these issues, Oh eah,

thats ight. You a potetiall e datig a ale o a feale, so ae e eed to talk

oe. Deaadoa, U“

Dreamadonna further described how her long time doctor responded to her disclosure of sexual orientation during the initial visit years ago. It may be encouraging to other women to note that at least this provider was receptive to having pertinent information, and was able to

provide culturally appropriate health care information as detailed in a later section titled Tpes of ifoatio gie to the oe poides.

…. He didt espod like he as shoked,… ut I thik he as glad, i a a, eause it

was our very first visit, so everything just kind of got put out there on the tale…. “o Id

say yeah, maybe a little surprised, but he seemed happy and very receptive and very—

like the he ould ask oe uestios. Well, hat do ou ea eatl? o Whe

ou sa oue iseual, hat does that ea? Well, ou ko sietifiall… ad

the hell just go ito all these diffeet thigs, so e eall hae a ate ak ad

foth hee, ee if at ties he ould hallege it kid of, ause he ade little

stateets ad I alas hae to oet hi ause hed sa thigs aout how I looked,

Well, ou ko, ae ou sue? Youe loel, ad lah lah lah, ad I had to just

oet hi... “o e just hae that kid of ak ad foth…. “o I thik I just hae a eall

good— health ae oeall has ee good eause Ie ee e proactive and I

ke eough thigs to e ale to thik, Oh, fid oe ad ask the ight uestios.

(Dreamadonna, US)

I otast to Deaadoas affiig epeiees i health ae, he asked if she had opportunities to disclose bisexual identity in health care settings, Nikki shared about her decision making process reflecting hesitancy to disclose sexual orientation and lifestyle.

No, ause I eall dot go that ofte…. As of et I hae ot dislosed to health ae,

eause I dot hae a speific doctor that I go to. Ie ee, sie Ie ee a adult,

Ie ee eall had like oe doto that I go to,… so I hae't dislosed to the…. I

dot hae a doctor that Ie deeloped a relationship ith, so… You ko, if I felt eall

comfortable with a doto the I poal ould dislose; its ot eall a issue fo

me. But I just dot go He! …ad the dislose pesoal ifoatio slight laugh….

I have health insurance through work; I have [an HMO] which I guess is fairly affordable.

But at the same time, I don't really feel that it's my choice of doctor. I go to their set of

dotos, ad thei liis ad eethig, so I dot… I haet gotte… its ot a bad

epeiee, it's just ot a supe supe I get to choose what I want experiee. Its

decent healthcare for what I need, I just need to be able to go get cough medicine or

whatever, annuals (exams) and all that good stuff. But ou ko I just dot get that

I goig to hae a lifelog oetio ith ou kid of thig ounicated by a

provider). (Nikki, US)

Nikki believes providers assume she is heterosexual:

Ie pett uh alas had a a i life, so thee ee asked a hole lot of

uestios light laugh. “o…The ae just like Oka, so I ee tell e aout sexual

oietatio o lifestle, etetea…. I thought aout doig it eetl, ae the et

tie I go to the dotos, ut the I dot go that ofte, so… Nikki, U“

Annie felt that she provided information about sexual orientation on intake questionnaires, but she was not given information specifically for same-sex dating and relationships.

I feel like as far as the gynecologist, there was always a questionnaire you filled out

before, that ould ask… I do't ko ho uh the looked at the information before

they came into the room and saw me. But I felt like there was always somewhere to

write hethe ou pates ae ale o feale, I pett sue… eause I ko the

always asked how many partners have you had. I think there was always a space to put

ale o feale oth… Ad ot util I as like i a elatioship ith a oa, did I ee

hae listed feale pate. I thik e ad geologist talked aout that. (Annie,

US)

Jasmine has also disclosed having partners of different genders; but as described later in the section on Health Information, she only learned about risk reduction with female partners through a Pride event and her peers. Pamphlets available at the medical office were for the general population, not specifically for sexual minority women.

I remember at my last female visit I disclosed the information that—Oh, yes, I was very

honest—I dated oe ad that I as also datig gus, ut ot that a. “o ee

had that conversation. (Jasmine, US)

Bobbi shared about her experiences in health care settings. Regarding the main provider, a nurse practitioner, Bobbi described factors that influenced her decision to not disclose sexual orientation. Bobbi felt the provider was not receptive to providing culturally appropriate care for sexual minority women, due in part to what she heard from peers.

I didt eall shae uh ith he. There was like a cultural rumor around the school

that shes alas offeig people odos, ad its a eall lage populatio of lesias,

and you know, e all just thik that its fu. “he ee offeed e odos, ut

thats just like the idset aoud he, that shes ot e sesitie to the fat that shes

speaking to women who cannot and will not make use of male condoms. So I never

really talked to he aout athig… Boi, U“

Bobbi further explained that issues around time and availability affected the ability to establish a relationship with the provider.

Also, even though she did have more time, it did take her a long time to get into an

appointment room with you, and it was walk-i ol, o appoitets…. O selet

Fidas, thee ould e a doto thee that ou ould see, ad that as all;…. I ee

saw her (doctor). (Bobbi, US)

At least one woman expressed concern about having personal information recorded in their medical record. She considered this in making decisions whether or not to disclose.

Types of information given to the women by providers.

The women were asked: Please desie the tpes of ifoatio that hae ee poided to ou. The fous hee is to detail the oes epeiees of poesses ioled i providing information to the women regarding HIV and STD testing and healthy relationships, when the women have and have not disclosed sexual orientation and/or relationship history.

Several of the women have not been offered HIV testing routinely, if ever, despite HIV risk for African descent women especially in the southeastern US. Several of the women described receiving very little information on HIV and STDs during their medical appointments.

Many of the participants have described being provided only information pertaining to opposite-sex intimacy, whether due to providers making assumptions about the women and/or due to limited knowledge on the part of providers. At least one uninsured participant lacked access to birth control beyond condoms.

The women were more likely to obtain information on healthy relationships with a same-sex partner from sources outside their regular health care settings, such as from peers.

Only one woman had a provider who shared information with her about risk reduction with same-sex partners.

A participant described that even when she had only male partners, she was not always offered or advised to have an HIV test during annual exams. She had to request the HIV test specifically.

When I started having a relationship with a woman, prior to that, my partners had been

male. So, I feel like when I went to the gynecologist - even though my partners were

male - ot all the tie,… the did't always, I remember having to ask to get tested. I

feel like I'm with anybody, whoever your sexual partner is, they should ask to test. Even

he I as't idetifig as iseual, soeties the ouldt ee ask e if I ated

HIV testing, which was strange. You know just go in for my annual, they wouldn't ask,

like That does't ake sense…" But, afte idetifig as iseual,… I' just e Ill ask,

ou ko,… “o, ae I dot gie people o poides a hae to offer, ause I just

like, Its just soethig that I at done. Annie, US)

Dreamadonna was the only US participant in the study who had a close relationship with a regular medical health care provider. Referring to her medical doctor she explains that, after she disclosed bisexual identity, he provided information specific to women who have same-sex and transgender partners.

He always has a lot to say and maybe even more to ask, trying to clarify what I mean

and what I really mean, but he was familiar with dental dams. He did mention dental

das if I hae a feale pate. He did talk aout testig, although I at tell ou o if

he eessail as the fist oe to sa, Would ou like to hae a HIV test? I thik I

poal as just like, I at a full “TD pael. I thik I poal just put eethig out

thee, ut usuall he I do isit hi, he kids of epets that I goig to at that, o

hell ask e, Hos eethig goig? Whats e? Who ae ou datig? as it

changes. So he has provided some inforatio… ostly just the dental dams. I think just

on some basic knowledge he had as far as lesbians are concerned, but I could tell it

ast eessail a seies of topics he maybe always discusses or very often, so he

seems very interested. (Dreamadonna, US)

When asked whether she recalled any providers talking to her about safer sex with male o feale pates, Aies epeiee efleted that of ost of the oen in terms of being provided only information about condoms.

Defiitel, like odos ad that kid of stuff… Yeah, defiitel. I feel like any time I

went to a gynecologist, that was brought up, I think... (i.e. safer sex). Cause I feel like I

was on bith otol fo a log tie, ut I feel like the did sa “till use odos,… As

fa as ith, sleepig ith oa, like I ko that… detal das ae… supposed to e a

good barrier, but I've ee used that efoe… And I don't think any doctors ever

suggested it for me either. (Annie, US)

Bobbi described infrequent medical visits. She had a list of health questions she would like to ask a provider. The researcher found this noteworthy, although Bobbi did not specify the questions on the list.

I as thikig aout it a lot efoe the iteie eause I haet eall ee to a doto

i a log tie, ad I dot eall ko h. I dot patiulal dislike goig to the doto;

I just keep a list of uestios that Ill ask if I ee do go to a doto. I guess, eah, its

poal ee like to o thee eas sie Ie ee to oe fo peetie ae. I do

hae isuae… Boi, U“

Bobbi continued to share about her experience of the kinds of information she has received in medical settings, in the passage below. She feels the information that has been provided to her has been minimal, and she has not been offered an HIV test. Time constraints in medical settings appear to affect her experience in those settings, and perhaps also influence her willingness to return. Boi efeeed the ole of soial ok i he health eduatio, which has implications for the role of non-medical professionals in health education, as discussed in Chapter 6.

Bobbi: Id sa iial ifoatio as poided. The only information about health

that oue gie, esides hat is speifiall ailig ou, is like the paphlets ou see

laig aoud ad the postes that ae up…. Thees usuall postes aout thigs like

insomnia or depression, every now and then about STDs, but usually the curable ones.

Interviewer: Did you feel that they gave you any opportunity to ask any questions? Did

they ask you whether you had any questions?

Bobbi: The nurse practitioner I felt more so she gave you that kind of opportunity

because her schedule was more relaxed, but in general, most doctors do rush through. I

hae defiitel felt ushed at dotos offies, ad Ie defiitel had like oe last

uestio, ut the ee too us leaig to get it the last uestio, ad thats really

frustrating.

Interviewer: Did any providers provide any information, verbally, about STDs or

HIV/AIDS?

Bobbi: No, the ol ifoatio Ie ee gotte as eithe i a lass o… at

university we had convocations that were about all sorts of thigs.... “o, I pett ell-

eduated, ut just fo soial ok, asiall….

Interviewer: Goig ak to the health lii, ith the uses ad the dotos,… did

anyone ever offer any kind of testing, any kind of testing at all?

Bobbi: No, The only testig that ee ee doe is e just gie lood eause thee

euied to otif ou if thees athig that the fid aoal, ad I ead the list of

thigs the see fo, ad I as like, Thatll e fie, ause I ot supe oied

about my exposure, or else I would go get something where the notification would be a

shote peiod of tie, ad the Id just ait, ad the I get othig, ad I like, I

guess thats fie. Boi, U“

Jasmine had described the process of annual testing and vaccinations required by her college, related to HIV, hepatitis, and tuberculosis. She also described her experience of feeling more comfortable and trusting when her regular provider made the time and effort to begin with a conversation. She shared that she feels more comfortable with a female gynecologist, and has always chosen a female provider.

If you were just to talk in general about the providers now and say what could they say

o do he ou oe ito the oo to ake ou feel ofotale, I dot ko if a

man could make me feel comfortable walking into an OB/GYN office, but a female

doctor, what could she say to provide me more information about being a healthy

iseual? You ko, hoestl, I hoestl dot ko. I thik its just ae the

conversation. I remember this woman (provider) that I had each summer, we had a

conversation before we got started. She asked me about sex, she asked me about

dating, she asked me about college, and so before we went into the actual examination,

I felt like she did know a little bit about me. (Jasmine, US)

During an appointment, Jasmine disclosed dating both women and men, but was not told specific information about STDs nor offered testing, as described in the following passage.

I remember at my last female visit I disclosed the information that—Oh, yes, I was very

honest—I dated women and that I was also datig gus, ut ot that a…. I as

like,… Ie ee datig gils fo the past ouple of oths, ad I haet had se ith a

gu. “o I dislosed ifoatio… “o ee had that oesatio.

When asked whether a provider offered any information regarding STD testing, Jasmine responded:

No, no. No; of course there were pamphlets there. There were pamphlets there for

everything fo teeage pega to “TDs… all that good stuff. (Jasmine, US)

The researcher asked her whether anyone had ever mentioned to her about syphilis, gonorrhea, or chlamydia tests. Jasmine replied:

Yes. Of ouse e studied it i shool also…. safe se paties. I eee that i

seeth gade, ut i high shool it aies oe. You hae these health lasses hee…

you talk aout sphilis, goohea,… ad all that stuff. Ie ee eposed to that,

definitely. (Jasmine, US)

When asked whether a provider mentioned these STDs or offered these tests, Jasmine

eplied, No, ad it as poal just eause I said I ast datig at the tie, hih I ast at the tie.

Jasmine did date during college, as disclosed in her appointment, and as described in the section about communication with partners. She felt confident her and her partner had been screened, but indicates here that STD tests besides HIV may not have been automatically provided.

Specific Changes Can Improve Services for African Descent Bisexual Women

This setio is elated to the seod eseah uestio: What eoedatios do they have regarding their needs in order to feel safer to disclose and ways service provision can

e ipoed fo oe like the? Fo the puposes of this stud, seie poisio iludes physical health, HIV prevention, mental health, and social services. The women were asked the following interview questions:

Ho ight ou adise poides o othes to teat ou i ode to poote tust ad/o dislosue of seual oietatio, HIV status, o othe health ae oes o eeds?

Ca ou tell e aout health ae esoues, ad a hanges that you feel are ipotat to e ade?

The oes esposes to these uestios ee gouped as desied elo. Because similar responses could be provided related to either question, similar responses are categorized together rather than listed as duplicates under each question.

The women shared recommendations for important changes that would help them feel more comfortable about seeking health care services. The following recommendations pertain to increasing cultural competency in health care for bisexual women of African descent. The women made specific recommendations for increasing inclusion in professional training, outreach, and service provision.

Recommendations: Environments that welcome diversity.

The women described their sense of processes that would facilitate environments more welcoming of African descent bisexual women. Non-judgment and avoiding assumptions are valued.

Bobbi described processes through which she would discern a more welcoming health care provider or facility. She expressed that it is important to her to have pleasant feelings related to the health care setting and services, and that a queer-inclusive and competent provider would facilitate a positive experience for her.

If I had to pick, if I had to go through a list of doctors and choose one, I would either go

on word-of-mouth, or I would definitely go with a doctor that advertises themselves as

being gay-friendly, or If it was a gay-only doctor, like if I went into the waiting room and

I just saw a bunch of queer people, I would immediately feel at home and excited about

it. Boi, U“

Nikki shared:

If dotos ould post that the ae… alteate lifestle friendly, or supportive... Because

it makes it easier to talk to people ho ou ko aet goig to look at ou az as

soo as ou ope ou outh… You a fid that he ou hae oe taditioal

health insurance because you can pick and choose (your provider). But he oue

dealing with somebody like (an HMO) they have this select group of doctors, you know,

you have to go to their doctors. If it (alternate lifestyle friendly) was listed, you could

make better more informed decisions about the providers you are choosing. (Nikki, US)

Nikki also advised:

Just treat people like people. Its lifestle o seual oietatio ot athig ot

contagious) (laugh). Just because people (clients) operate on a different standard from

hat the poides thik is the o, doest ake it lifestle ight o og. It just

is hat it is lifestle. Ad… ou ko, the poides ae thee to poide a service.

They (providers) are not there to be judge, jury and executioner. (Nikki, US)

Dreamadonna shared:

But just for others and ultimately myself, I guess I wish to see greater strides in the

health care community actually trying to focus in. I know we have to focus on everyone

gloall, ut I feel like thee ae so a diffeet sugoups that as ou go i, thees

sugoup ude sugoup, ad eeoes health is ipotat, so ou eall at

oelook a oe goup just eause its oehelig ad oue tig to eet

eeoes eeds. I do ish thee as a geate fous o LGBT health oeall, ad the,

for me personally, I guess I wish it was easier to—for everyone to feel that they could

come forward and that they could state who they are and have the right questions be

asked, pertaining to what their sexual life or their health involves. So I guess I just hope

for improvement, whatever the improvement is, howee uh it is, if its oe

brochures that feature people that look like me. (Dreamadonna, US)

Recommendations: Inclusive intake screening and forms.

The women request conscious processes of culturally competent intake and assessment, and appropriate inclusive terminology. Providers being intentional and conscious about not

assuming sexual orientation/identity would facilitate client disclosure and a sense of well-being in the health care setting and professional relationship.

Bobbi expressed:

Not assuming that you are a straight person would help a lot. If they asked questions

ad let ou ko that the ko that oue ot eessail staight ad that the ko

that eeoes ot eessail staight. That ould e geat! Boi, U“

Dreamadonna suggested:

I think what I would say, and then too just what I wish all providers would do with all

their patients, is to never assume anything, just to be very open-minded in general. You

always want a person to be respectful, and use a tone that sounds pleasant or at least

non-judgetal; so I ould eouage that, ause o oe eall ats to offe up thei

pesoal ifoatio if the feel like thee alead eig judged fo a easo.

(Dreamadonna, US)

Dreamadonna made further recommendations:

The othe thig that I eall ish all liiias ould fous o is the ods thee usig,

like he thee askig uestios, agai, dot assue ad just ee at the isk of

eaassig soeoe if ou sa, Do ou hae a ale pate o do ou hae a female

pate? No atte if thee a ale o feale, just puttig all the uestios out thee

ad ot just estitig it eause oue lookig at the peso ad thikig, Oh, thee

olde. Thee Blak. Thee a oa. Thee poal aied. Cause you just really

never know. I wish that, in that way, they would keep their questions very open. Yeah,

and just be kind, like they would want you to be. So, I guess that would be the big thing.

(Dreamadonna, US)

After the recorded interview concluded, when Bobbi was leaving, she emphasized that she wants professionals to be attuned to grey areas and fluidity of gender and sexual orientation identity (and avoid expecting to be able to use check boxes). She found her life experience to reflect a spectrum, rather than discrete categories such as male and female.

Yeah, to e uee is a seual idetit as ell as, like, a gede idetit. Its kid of

had eause thee ae so a people ho ae so outside the o ad hats

considered to be normal, people who are transsexual and transgender. Once you realize

that there is a spectrum ad thees ot just to optios, its had to fid hee ou fit

ito the spetu, ad to e, uee is just like a udefied, ga aea, ad its ie

to be queer—nobod a pi ou do if ou defie ouself as uee. Boi, U“

Whe asked, If ou ould ake up a tes that ould e ilusie of ou epeiee o the epeiees of people like ouself is thee athig i patiula?

Dreamadonna replied:

Thats a iteestig thought … ause Ie alas thought, Ah these tes aet

geat, ut I dot ko that Ie ee eall thought of soethig that eall fit. I hae

used uee efoe, oe so he I as i ollege ause it as just, to e, a oe all-

eopassig te ad I ast % hee I as…. It ould e eat though if thee

was a word! I have a feeling it would be maybe not just one word but a phrase or a

seies of phases, ad I guess hat I ea is e ko hat the te iseual eas,

so it ight e I iseual ith a tede toads ales, o I iseual ith

whatever. It would be more like a category… Deaadoa, U“

Recommendations: Health screening and tests.

Comprehensive testing and health information are needed. Two of the six US patiipats stated that the had ot et take the HIV seeig test, oe oa i he s ad oe oa i he late s.

Dreamadonna explained that she feels universal screening is important:

If I see a new health care provider and they autoatiall ask e, Would ou like a

HIV test toda? That ould e e. A lot of people dot get that uless the ae i the

eege oo o uless the ehiit a etai tpe of isk fato… I ish it as just

everyone, ot just if oue pegat, or not just for any reason. I wish it was just a part

of geeal ae. Yeah, just like a atual… eeod gets asked that uestio;

everybody gets asked kind of the same things. That would be very helpful.

(Dreamadonna, US)

Recommendations: Time and communication with providers.

Bobbi stated that she would prefer adequate time, and a considerate conversational communication style.

I want to be able to go to a doctor and be treated like an old client and feel like they are

takig tie fo e. Cause, ou know, the technician checks you in, and then she leaves,

ad ou ait foee, ad the the doto oes i, ad its a shot aout of tie, ad

then they leave, and then the technician comes back. If it was either the doctor first or if

the doctor stayed loge… ad if the ade a effot to e oe oesatioal. (Bobbi,

US)

Nikki stated that there is an HMO office nearby, and shared her thought processes regarding what improvements would help her feel more comfortable to go in for health care. A nonjudgmental and respectful practitioner would be helpful, who would provide comprehensive testing on demand without invasive questions or recording personal history in the medical file. When asked if there is an alternative for her such as LGBT community clinics,

Nikki said she had checked and found that their fees were considerably higher than at her

HMO.

Interviewer: Do you feel that in terms of health care resources that your needs are met,

or that if something was different you would feel that your health needs overall were

better met? If something was different, would you want to go in more often, or do you

feel that things are relatively well met now?

Nikki: They (Nikkis health care needs) are relatively well met. I thik,… the comfort

level could be higher. It takes tie i uildig a elatioship ith ou doto, I thik…

Not so much as for questions, but if something did come up, just being comfortable

disussig the hole situatio.… O if ou ee oig ito a e situatio suh as a

new intimate relationship) feeling comfortable getting done what you need to get done,

for whatever reason. Mae its a e elatioship,… ad ou at to take ae of

yourself. Ad if oue ot ofotale ith the doto, its had to get the to do

things for you and sometimes understand hat ou eed; ad thell e elutat to

give you all the tests, o gie ou the ifoatio that ou eed, ee though oue

asking for certain things. (Nikki, US)

Recommendations: Choice of provider gender.

Jasmine prefers a choice of having a female provider, particularly for reproductive health services.

Well, I eee I as o os isuae ad I as goig to the doto, to the

female doctor, and I had these options, I can get a man gynecologist or a woman, and my

mom she has a woman gyno (i.e. gynecologist) and I felt like, okay, well, I want a woman

to e hekig feale aea as ell…. If ou ee just to talk i geeal aout the

providers now and say what could they say or do when you come into the room to make

ou feel ofotale, I dot ko if a a ould ake e feel ofotale alkig into

a OB/GYN offie… Jasie, U“

Recommendations: LGBTQ practitioners who are openly queer.

Several of the women wanted health care providers who are themselves sexual minority women and/or LGBTQ-identified. Considering how some of the women have expressed being treated by people of various backgrounds, the researcher believes it is important to consider how bisexual women would be treated in health and social care settings intended for gay and lesbian people.

I think that it would be really cool if there were, providers who were Black or women of

color who were sexual minorities, providing those sexual health services. I thik… that

would make people comfortable, because they can identify with that person. (Annie, US)

I dot ko a lesia dotors out there, or bisexual doctors, female doctors, but I

think that would be a great title or in your business model, perhaps put down that this is

an OB/GYN who is a bisexual woman. I think that a lot of women would flock towards

her because she would be able to automatically identify with being sexually active and

the feale od…. I ould loe to see that, LBGT OB/GYN. (Jasmine, US)

Recommendations: Prevention information for bisexual women of African descent.

As most of the women received little information from health care providers regarding health sexuality for a bisexual woman of African descent, the researcher asked about other sources of health information. While these statements were not directly recommendations, they refer to information that should be available.

Health information provided by agencies and events.

As stated above, Bobbi explained that the health information she has received regarding

HIV and STDs has been delivered through community settings, not by her medical providers.

She describes the information received through outreach, in the passage below. While information was provided on HIV and STDs, she did not recall information being provided about

HIV testing options such as the rapid tests.

Bobbi: The ol ifoatio Ie ee gotte as eithe i a lass o… at my university

we had convocations that were about all sorts of things, and there was one where, the

city I went to had a big HIV and AIDS advocacy clinic, and they came and did a talk

about, These ae all the diffeet “TIs, ad this is hat the look like, ad if oue ee

see athig like this, ee oe, ou should get it heked out. “o, I pett ell-

educated, but just from social work, basically.

Interviewer: Was any information provided specifically about HIV?

Bobbi: Yeah, they talked about HIV and AIDS, and what really made it stick was they

gave a lot of real-old epeiees, like We get people i the offie ho sa this, ad

it puts into perspective, to show you how a people dot ko aout it, ad ho

a people just hae o idea hats happeig ad didt ee suspet that the

should get tested regularly or go to the doctor before their symptoms become much

worse.

Interviewer: Did they provide any information about how, if you wanted to get an HIV

test, what would you have to do?

Bobbi: Atuall, the didt, I ea, eod oig do to the lii. I assue that

the did testig thee, ut the didt eall talk aout it.

Interviewer: Did they say anything about what the test is like?

Bobbi: No. I guess now that I think about it, I assume that you have to give blood, but

o, the didt talk aout the poess at all.

Health information shared between peers.

In this section the women described processes of sharing health information within peer networks. Peer education has been an important source of information on healthy relationships for women with same-sex and transgender partners. As a former peer educator and trainer in a college setting, Annie shared the following:

We would go through a whole segment hee oa sleepig ith oa… And,

basically, what we always suggested for woman sleeping with woman is, dental dams; if

ou use tos, use a odo,… ake sue oue ashig ad oue leaig your toys.

That's asiall the eduatio I'e ee eposed to, ad passed o to othe people…. It

was really fun, I enjoyed it. (Annie, US)

Bobbi shared earlier that there were many sexual minority women at her college. The researcher asked whether any information was provided about safer sex between women partners. She replied:

It ast eall shaed the lii o ouit age -- safer sex and risk reduction

for women with female partners, i.e. WSW), but, being amongst lesbians, it kind of

becomes—like things about dental dams—just kind of becomes common knowledge,

just ause eeod shaes that kid of thig.…The estated the Ga/“taight

Alliance on campus, and then they did a lot of advocacy, and they had a little thing

where they gave away condom lollipops and dental dams as well. They were educating

people that a, so its hagig, ad hopefull its gettig ette ad stas that a.

(Bobbi, US)

Communicating with partners.

In this section the information is related to healthy relationships, especially on communicating assertively about sexual health with a female partner. It's not uncommon for women with female partners to feel that there's less to be concerned about, especially since a lot of the focus is more with gay men. At least one US participant had difficulty in attempts to encourage her female partner to obtain comprehensive screening. Several of the women lacked resources and opportunities to connect with women for relationships, and found themselves in casual dating situations. One participant said it had been such a long time for her between pates, that she as oied she ould do soethig out of despeatio.

Jasmine shared in the passage below about her processes in managing communication about health with intimate partners. She is not alone in her difficulty broaching the subject of screening and safer sex.

Interviewer: Hae a fieds ee ale to talk to ou aout he oue datig ho to

talk to partners either about testing or safer sex? What is it like nowadays for people of

your generation, women of your generation, minority women, and dating same and

opposite se pates? Whats it like datig people ad tig to talk to the aout

testig o safe se o thigs ou ight eed? Whats it like?

Jasmine: You know, honestly, I wish I could give you a better explanation because I

haet had a gilfied hee… e hae that oesatio aout, Wee goig to stat

haig se this a, ad ee goig to go to a lii ad e tested togethe, o

something. Ie ee had that. Ie ol had these akeshift elatioships…. I used to

sleep around with my best friend; and she and I both were at the college which required

HIV testing and tuberculosis testing and everything you can imagine every single year,

because you were living in a dorm environment. So I was pretty sure that she had a

clean bill of health because I had a clean bill of health and we were both at that school

together, which required us to be tested for all these things every single year by a

feale doto. “o I didt talk aout that ith he, ad she as poal the logest

elatioship Ie had. Jasie, U“

Recommendations: Culturally relevant health literature.

Dreamadonna recommends health care and brochures developed with a focus on

African descent women who have same sex partners.

I hae to sa,… I thik still that thee ae a lot of thigs that ae liited, as fa as

esoues ad as fa as koledge that the liiias hae… to soe degee, ut the

also willingness to focus in more on a particular group, especially a female who has

female partners and, even more so, a Black female who has female partners. It just—I

dot hae the ipessio, as of this oet, that a geat it has haged. I still feel

like thee eeds to e oe… puliatios o like ohues that ae tageted. You dot

eall ee see athig that soeoe ould look at ad thik, Ah, that epesets

e. Thee still e kid of geei, oe speifi goup of people, so that eeds to e

broadened. It is up to the clinician to make sure that within their office there is kind of a

aiet of that kid of ateial thee. I ish that I sa oe of that, ut I dot feel like I

really have. Some, I would say some agencies, particularly if they are HIV agencies or

AID“ seie ogaizatios, ae good aout it, o thee ette tha ost ageies i

general. I guess because of the subject matter they would have a tendency to have

soe ateial thats tageted toads the LGBT ouit, ut ee i those ageies,

again the focus tends to be men, so all across the board, clinicians and their doctors

office, the local HMO, the AIDS service organization, I feel like there just needs to be

oe, ad I dot ko that I hae the ipessio that its eall ee oadeed a

whole lot. (Dreamadonna, US)

Recommendations: Outreach from agencies.

The women request conscious processes of outreach specifically for sexual minority women from health care and non-profit community based agencies.

Whe asked Ca ou tell e aout health care resources, and any changes that you feel ae ipotat to e ade? Boi oeed that it as diffiult to isualize esoues fo sexual minority women that are not already present. It was not easy for her to visualize what health care sensitive to minority women would look like. She recommends outreach.

Its had to thik of soethig. I guess ageies just eall hae to put theseles out

there and advertise or advocate, where you would go to set up booths and talk to

people. Like, if you ee go to oe of those east ae oes, its just full of

ifoatioal tets, ad ee tet is slightl diffeet, ad thees plaes hee ou a

t to see if ou a feel a lup i this east ad stuff like that. Boi, U“

When asked “What has it been like for you as an African descent bisexual identified

oa… aessig healthae? Aie epessed diffiult i loatig seies fo uisued sexual minority women.

I'm sure in [this city] there are resources that cater to Black lesbians or Black or

iseuals,… ut I did't feel that… hatee the are [resources], I feel, I wish their

presence was larger. Cause e okig at a HIV/AID“ plae, I feel like I ould'e

known if thee as soethig… Like there you can get free HIV testing [at the HIV/AIDS

place], you can get care, if you're living with HIV. But I do't ko, I just, I feel like… I

would like to see more attention paid to that to lesias i geeal ause like a lot - of -

the – time, a lot of the times gay men kinda get the focus of healthcare, LGBTQ

healthae, …. I think I have heard of like a, maybe like a lesbian woman health project,

or something like that. But like I said it doesn't have a big presence. You know, I know

there are thigs like,… ut thees othig that e ad fieds know, Oh, that's the

plae hee ou go, if oue iseual o lesia… Aie, U“

When asked Ho ight ou adise poides to teat… seual ad ethi ioit

oe, to ake soeoe… oe comfortable to oe i? Aie added ith a sese of urgency that outreach is needed.

I wish that there was more outreach… to queer women, …ause thee's a lot of

outreach to gay men here! I know; I volunteer and I worked at a place where (an

outreach program for gay men), and you know, it was called (an outreach program for

gay men) at (an HIV/AIDS organization in the city) They have different initiatives. They

did have one (initiative) that was for Black women, but it wasn't for, specifically for

queer Black women. “o, I do't ko, I just ished that… thee as oe outreach,

more education about it, and more resources…. There are resources now that people,

the general public, doesn't know about, for women of color, who are bisexual or lesbian.

They (resources) need to let themselves be known. They need to market bigger and

ide; eause I Id e iteested i it, ad… leaig oe aout it, ad… tellig people

aout it, ad… iolig self ith it,…. And they do, at ga e’s lus, they set up

HIV testing a lot, will have brochures there. But it's just ot, its ot like that,… ith

lesbian and lesbian woman. It's a major difference. This is making me think about it.

There's so much outreach to gay men. But ot,…. But, eah, ae itll hage,… ith

time. (Annie, US)

Experiences Related to Mental Health Care

The women shared about identity and disclosure in mental health settings, including individual and group counseling. The recommendations pertain to increasing cultural competency in mental health care for bisexual women of African descent. Several recommendations specified under physical health care, such as nondiscrimination policies, could apply to mental health care as well.

Need for mental health care.

Most of the participants wrote on their demographic forms or expressed during their interviews that they experience manifestations of suffering such as depression. As indicated in the section above on social support, few of the women were able to rely on families of origin for social, emotional, or economic support. Several of the women did not have close friends or partners in their local area upon whom they could rely for social support. Several of the women knew of no other African descent bisexual women in their social networks.

Several of the women found professional counseling crucial for their well-being, especially during times of crisis. Woes aess to ouselig ad suppot goups as liited by whether or not they had health insurance. In light of the limited socioemotional resources, availability of affirming and validating professional counseling is important.

One of the women who had health insurance did not mention having sought counseling;

Nikki felt she could process her identity development on her own with the support of a friend, but stated that other people would probably need additional support and guidance. Emerald spoke about her lack of access to health care and counseling since graduating from college, and how beneficial couselig as duig ollege, saig That saed life oe!

Several of the women spoke of leaving home for college as a major life transition and critical period for sexual orientation identity development. Annie describes her crisis in the passage below, and her process in obtaining professional support through inpatient and outpatient care. She was in her first same-sex relationship, was far from home, and had difficulty connecting with mental health resources.

I moved to [a state farther north] for this one-year position. And during that time, is like

the first time I ever dated a woman, … fist tie ee eig aa fo like hat I

considered home, ad… thee as a ig distae. I ea I feel like I as ot e lose

to my family; I did not really communicate with them that much…

Ad thee ee a lot of like az thigs goig o i life… like I got eall depressed,

like my relationship was really confusing me. I felt, I felt very isolated. It as like, I feel

like I at share my life with fail,…. I felt like I didn't really have a - lot - of –

support… Cause he I stated feelig eall depressed, and all these things were going

on, you know I was in a new town, new people, so I didn't really have anyone to reach

out to there… And I was in a long-distance relationship at that time with somebody who

lived in [neighboring state]…

eventually, like, I got to a really bad place, ad I as like Oka, I' just goig to hek

self i to a hospital I'd ee tig to connect myself like with a counselor, therapist,

pshiatist,… ad soeho as not successful, and it just got to a really bad breaking

poit,…. “o I did go to the hospital, and I like spent a few days in the psych ward and

eethig. Ad I didt tell fail aout that until about a month later; like it was

like that I do't ko ho to bring that up…

And then after that, I started regularly like going to a therapist, and a psychiatrist, and

yeah, so that's what happened at that time; it just got really bad it got to like a breaking

poit…. I as like, I at e ashaed, I hae to get help.Annie, US)

Disclosure in mental health care settings

Desied elo ae patiipats epeiees elated to dislosue i etal health care. Some participants, who had not disclosed bisexual identity with a physical health provider, had disclosed with a mental health provider.

Disclosure in mental health care settings: Individual counseling.

Annie shared about disclosure in the following passage:

Researcher: What it was like in terms of the series… were you able to talk about your

long-distance relationship? What was, or did you feel there were parts of yourself that

ou ouldt share when you went for the therapy? What were things like with the

counselor, and with the psychiatrist, if you're comfortable to say how you felt the quality

of the services were?

Annie: Yeah, I felt… it as't a optio to ot tell idetit o whatever, because it's

like if I do't sa hats going on, then how are they really going to really be able to

help e, ou ko? “o I feel like I as e open, about my life in general, because I

as like ou ko… I at get the help I eed ithout eig hoest I do't thik, so…

Researcher: So how did they respond to you in the sessions?

Annie: I do't thik I as teated… any differently tha aoe else… so

Researcher: Did you feel that the professionals were able to be helpful to you in terms of

guiding you?

Annie: Um, yeah! For the most part [upbeat tone of voice]. Yeah.

Researcher: And did you feel that they were knowledgeable enough to be able to help

someone with your life experiences and the challenges that you were struggling with?

Annie: Uhum. I did, I ea like… seual oietatio is just like one part of me. It is

ho I a, ut thees so uh more to me, you know. Eeoes just a person. (Annie,

US)

Bois paets sought ouselig fo he duig high shool, euiig that the counselors were either African American and/or Christian; she did not feel comfortable to disclose.

The ouselos I had see hile I as i high shool… I ee eealed a sae-sex

attatio to the, ause the ee all piked out paets, ad the ee eithe

Christian-based or African-American, and that was like a main point to them, which kind

of upset me. I felt like that was completely unnecessary. It was unnecessary for them to

feel like the eeded to fid a theapist fo e. If it ast a Chistia peso, it had to

be a Black person, and most Black people are Christian in America anyway. It was never

a comfortable situation. (Bobbi, US)

Emerald had beneficial experiences with African American female counselors, including a heterosexual-identified counselor. When Emerald disclosed about sexual orientation, the couselo affied Eealds idetit ad suppoted he deelopet.

In counseling seies, I eee it ae up he I as i idiidual ouselig…

and I was just coming out of the church, the idea of pursuing women, I was so used to

not doing that, and my counselor was actually not convincing me to do it, but,… straight

woman, as kida like, You should. I as tig to talk, to tell self that its kid of

like Ie ee idde a hose, so if I ee ide a hose Ill e oka. “he idiidual

couselo as like, Ae ou sue? Eeald, U“

Disclosure in mental health care settings: Group counseling.

Emerald participated with a support group at college, for Black women, facilitated by

Black female counselors. She participated for a year and a half. For much of that time, Emerald felt she as usuall the ol uee oe thee. A ouselo dislosed o ae out to the group as a bisexual woman with a female partner, and Emerald feels she would have benefitted if the ouselo had oe out earlier as a LGBTQ provider. Emerald wishes the counselor would have disclosed her identity early on, so that Emerald did not feel she was the only queer woman in the room. While conventional thought may caution sexual minority professionals regarding disclosure, this perspective is not applied to heterosexual-identified professionals. If the counselor had come out sooner, Emerald indicates she would have felt less alone and this would have potentially provided a role model for her. As stated in the earlier section on identity, Emerald lacked bisexual role models.

When I was in a counseling group of Black women, I felt that I needed to be open about it

seual oietatio idetit, ause,… a sea of staight oe, I as usuall the ol

queer one there. I was kind of ticked off, well not ticked, but one of the counselors, (a)

Black bisexual woman, I had been in counseling for over a year with her, and she never

mentioned it ouselos oietatio! Ad so he that finally came out, I was like

Dude! I sitting her all alone,… e oulde ee like, ou ko… But she was

hesitant, eause she felt she ast sue ho that ould affet the goup, o ho I

ould feel. I as like, Dude! I needed that! Cause Blak iseual oe, I dot eall

get that, haig spet a good pat of out tie efoe goig ito the huh,

with mostly gay White men. I mean, I need that othe out Blak iseual oe…. It

ast that she as gay, it was that she was bisexual.… ith a feale pate! ….That

was pretty awesome! (Emerald, US)

Recommendations for improving mental health care and well-being.

When the women were asked for recommendations for improved health care, they also provided information pertaining to mental health. The related interview questions were as follows.

Ho ight ou adise poides o othes to teat ou i ode to poote tust ad/o dislosue of seual oietatio, o othe health ae oes o eeds?

Ca ou tell e aout health ae esoues, ad a hages that ou feel are ipotat to e ade?

In the section above on identity, the women described their challenges related to identity development and experiences of discrimination. They described identity development processes related to race or ethnicity, gender, and sexual orientation. They spoke of experiencing racism, sexism, homophobia, and biphobia, which contributed to feelings of depression. The women also lacked role models. While the women did not specifically state recommendations that mental health providers be aware of these processes and needs for support, the researcher considered that these may be latent concerns.

The women faced challenges coming out and communicating with their families, friends, and communities. The women could potentially benefit from skillful support to manage processes of stigma and stigmatization, and to navigate complex sociopolitical environments.

As described below, the women expressed the need for access to quality mental health care, including resources specifically for African descent bisexual women. The women believe they will benefit from services such as counseling and support groups designed to meet the needs of African descent bisexual women and their children. The women continue to emphasize the importance of having openly LGBTQ providers and role models.

Improving mental health care: Cultural competence.

During college Bobbi had weekly visits for about six weeks with an on-campus counselor, and one long appointment with an off-campus counselor whom Bobbi felt was most affirming. Bobbi disclosed sexual orientation identity with the counselors during college, though she had always known she was a sexual minority. Bobbi said she volunteered the information; she did ot eliee she had ee asked the ouselos. Bois experiences are described below.

The counselor in college, she was definitely gay and queer friendly. Because of the

school that she taught at, she kind of had to be. But as I was with her more often, I got

the feelig that she ast eessail fiedl, she as just eutal, hih ast e

enjoyable. She had a little gay pride flag in her office, which started to feel kind of like a

prop to make people feel comfortable. (Bobbi, US)

Bobbi met only once with the only health care provider who has ever been affirming of her, a mental health counselor. It is important to Bobbi that her interactions with providers,

and the way services are delivered, are a comfortable and pleasant experience. As described below, this affirming off-campus counselor based her intervention and counseling upon her experiences with her gay son, and Bobbi felt that all of those experiences did not apply in her case, and she would have preferred that the focus was on her. The researcher infers that Bobbi would have felt benefitted had the provider been trained in evidence based interventions specifically for LGBTQ populations, rather than the provider having to rely on her own personal family experiences.

Then the woman (counselor) that I went to outside of school was the summer after my

freshman year. I was having a lot of problems, and my parents knew that I was just not

in a good place. Or it might have been the winter my freshman year that I went to see

her. But she was very gay-friendly, and she had a gay son that had just come out to her,

and she was very passionate about working with young gay people. That was really good

ause she had see ho ot eig ale to ope up had affeted he so as he ge up,

and she never knew what was wrong, and she wishes that he had felt comfortable

enough to tell her. But at the same time, she was really kind of focused on him

ouselos ga so i the oesatio. Ad I ol sa he oe aa, ut she as

ie, ad I ejoed he…. “he off apus ouselo as tig to elate, ad I guess I

noticed it because she was drawing a lot of conclusions about my situation from his, and

it was different. It just kind of put me off, but I really liked her, and if I had been able to

see her more often, I think we would have had a really good relatioship….. “he as

uh ette tha a of the ouselos I had see hile I as i high shool… (Bobbi,

US)

Improving mental health care: Groups for individuals and families.

The women request support groups for minorities. Nikki speaks of developmental processes and life challenges that would be better weathered with support rather than being faced in isolation.

The ould hae oe goups, o ifoatio sessios fo paets that dot lie the

taditioal lifestle, eithe iseual, ga,… suppot goups for like-lifestyle people

people of siila lifestle, so that oue ot alas aloe, ad ou hae othe people

who are going through the same things as you at the same time. (Nikki, US)

Nikki also described processes non-traditional families and children undergo, and the need for support groups for alternative families. She spoke of children being affected by stigma related to parental identity and/or disclosure.

I think some resources like hildre’s support groups would be good; because they have

to deal with a lot of the stigmas from their parents. Its ot just the paets dealig

with stuff. Ad thats oe thig that akes it had, eause ou at to potet the as

uh as possile, ad at soe poit ou at potet the fo everything. And to be

living a lifestyle that is out of the norm, puts them on that firing block for people to give

them grief. (Nikki, US)

Theme 4: Resilience

Petaiig to the thid eseah uestio, What esoues ae the oe aessig and utilizing in their day-to-day lives to support their well-being ad esilie? the oe were asked the following questions during their interviews.

I ou da-to-da life, hat sustais ou ad helps gie ou a sese of stegth?

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What ae soe of ou ai da-to-da oes?

What ae soe of the esoues that sustai ad suppot ou?

What helps ou feel that ou hae pupose ad ou life is eaigful ad

othhile?

What esoues o atiities ig a sese of ejoet o hope?

What esoues help ou to feel utued ad estoed?

The women shared the following about resources they are accessing and utilizing in their day-to-day lives to support their well-being ad esilie. The oes esposes to these general questions were grouped as described below. Because similar responses (i.e.

soial suppot o eeise ee poided to seeal uestios, siila esposes ae categorized together rather than listed as duplicates under each interview question.

The information in this section on resilience is organized under two subthemes that emerged from the data:

. Social support is a primary source for well-being and resilience.

. Activism and self-nurturing activities also facilitate resilience.

Social Support is a Primary Source for Well-being and Resilience

Participants often stated that their relationships and social support were very important primary resources for resilience. Since described in detail in sections above, the researcher will

ot go ito detail hee, ut ishes to ote that soial suppot as the ost feuet response to the questions about resources for resilience.

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Activism and Self-Nurturing Activities also Facilitate Resilience

Detailed below are self-nurturing and creative resources that support their resilience.

The women described activities that support a sense of wellness in body, mind and spirit.

Physical and outdoor activities.

Physical exercise is an activity that can be beneficial. Bobbi shared, Yoga is good. I had a yoga class once where the teache… as agifiet.

Jasmine also described physical activities that contribute to her well-being:

It used to be running. I used to get up in the morning and run, and I would check in with

another girl about running. I would run a couple miles and then I would feel so much

ette. “o it ade e feel eall good at that tie…. I do jog, ut I dot u as ofte as I

used to, …I do skate ad I leaig ho to skate, and so that brings me a sense of

ejoet that I leaig soethig e. Jasie, U“

Creativity and self-expression.

Annie describes writing as a very important activity:

Expressing self ,…usuall though itig. I ejo itig… stated itig in

eleeta shool; I ould just like fill up jouals ad oteooks full of itig…, ad I

just continued,… , ou ko as alas like o the litea agazie staff, like I was a

editor,… oked o the newspaper i ollege,…. ajoed i a related field). I've just

have always loved writing (Annie, US)

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Self-affirmation.

Bobbi uses self-affirmation to support her sense of well-being. Her self-affirmation may be related to the lack of affirmation from her family and the stigma expressed in her workplace as described earlier.

Id sa ai thig is self-estee ad if I a ake up i the da ad sa, You ae

pretty awesome, by the way. No atte hat aod sas. You ko oue

awesome. Who cares what they say? Or who cares what they think? Ad, ou ko,

like if I read a quote that, you know, someone especially strong or self-assured has said,

I like, Yeah, pefet, aesoe. It keeps e fo gettig do o self o seod-

guessing the things that I do. (Bobbi, US)

Media and online bi resources.

The women described media they find helpful in their daily lives. Dreamadonna shared:

I like to ead. I ot a pat of a ook goups, although oe of fieds keeps tig to get me to join, but I do like to read.

Bobbi described activities she finds beneficial:

I liste to puli adio a lot, ad I alas keepig otes o aothe ook that I eed to

ead o a oie that I eed to ath. Moies ad usi, defiitel, hih,… I dot

ko h it didt ou to e he I as talkig aout the quotes that definitely

songs are really powerful in keeping me afloat and feeling collected and happy. (Bobbi,

US)

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The eseahe ifeed that Eealds sese of idetit as a Blak iseual oa sustains her, as well as her socially conscious beliefs and perspectives. Emerald shared, I like bi stuff; I follow a couple of bi blogs, bi vlogs – ideo logs,…

Community involvement.

Community organizing and activism contribute to a sense of purpose. Annie shared:

Beig ioled i the community. I consider myself an activist. I like eig ioled… Ad koig thee's alas soethig to ok o… it akes e eited… I thik that sustais e.

Jasmine shared about her community service work with women living with HIV/AIDS:

I was involved with the… hoeless oalitio i hoeto. Though the, I as ale

to stat a oes AID“ goup hee… this oa… she had this goup of oe ho

all, she wanted to get this group of women who had AIDS, but they all had children, and

there was no one to keep their children while they talk about adult stuff during the

meetings, and so I would, every (week) we would have the meetings, and I would

sepaatel take the hilde off to aothe oo ad e ould pla…. I eded up

actually having a good time. (Jasmine, US)

Travel.

The oe spoke of the ipotae of tael epeiees. Boi shaed, I loe to tael,… Just eig out ad aout.

Jasmine described cultural and LGBT events she has enjoyed traveling to attend:

I value experience, probably more than anythig. I loe to tael. I got to go to… a fee

concert festival, two day event. Everybody is just in this park, just having a good time,

ad thees a hole uh of food edos eause ou dot at to leae the pak

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eause the usi is thee…. Last summer, when I went to San Francisco Pride,

California had just, the day before Pride, they had just made it legal once again that you

can get married, same-sex couples, and so there was plenty of celebration in the Castro

aea…. I thik it stated at ie i the oig ad didt ed util fie i the afteoo.

It as a huge paade. I as atuall at… a Dke Mah goig o ight he it eded….

Ie had a to of taels. Jasie, U“

Safe spaces.

Several participants spoke of the experience of living with religious parents. Several expressed having more freedom for self-development, identity development, and personal growth, upon leaving home for the first time and living in an area further from their families of origin. Affordable housing and safe spaces are important resources for the women.

The thig that affets e loall ad that oes e all the tie,… I do go to the LGBT

ouit ete,… ut there are’t a lot of plaes here… that are LBGT-friendly. They

may have LBGT nights of the week where its oka fo gas to oe o “atudas, ut

thee aet a lot of—my college was very close to [major city], where I could go into a

coffee shop that had flags up and just relax or you watch a movie and this whole

ouit, thees a ouit of ookstores and yoga places, or even in New York,

Chelsea aea i Mahatta, its a hole ga ouit. Its a hole ga aea, heeas

i [uet it] thee aet a that Ie see ith flags up ad ou oe tet-four

hours of the day and this is a spot for gay people or bisexual or lesbian people. There are

o plaes like that, ad I thik thats poal the ost diffiult thig…. Othe tha the

Fida ight at… o the “atuda ight at… I dot ko of a othe plae that is a

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restaurant or a bookstore or just a safe area where you just come in and relax and you

a e ga. Thats poal the issue that affets e all the tie hee. Jasie, U“

Recreation.

The women also described social recreation that supports a sense of resilience. Annie shared, …just spedig tie ith good people,… kaaoke, gae ight, just… akig sure to hae fu.

A mother described activities she enjoys:

I like going to some of the meet-ups aoud to… Ad just hagig out ith adults

(laugh), having adult conversations (laugh). At this poit, that does it light laugh… A

movie here and there, something like that. But, just hanging out with people that are

over the age of eighteen (light laugh). (Nikki, US)

Chapter Summary

Participants with better experiences of social support over their lifetime, particularly in terms of being accepted by their parent and family of origin, also expressed experiencing supportive health care providers with whom they felt safe to disclose bisexual identity. Those who were able to disclose and be accepted by family members and friends expressed more confidence in communicating with health care providers and were more likely to be willing to disclose bisexual identity in health care settings and with health care providers. Women with low social support and limited disclosure in general, were generally less likely to disclose bisexual identity in health care settings. Participants with low family social support but with a practice of disclosing generally, were more likely to disclose in health care settings also.

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Some participants, who had not been affirmed by their families of origin, express not seeking health care even if covered by insurance. Beig oeed oes paets isuae may play a role in reluctance to seek health care related to sexual health or mental health, and only seeking care for conditions such as the common cold.

Although they would ideally prefer more preventive care or regular testing, not having developed a solid relationship with a regular provider like one participant was able to establish, has influenced some of the women to seek care only for acute or severe illness. Women like

Annie would go in for care more regularly, potentially, if treated less impersonally and provided comprehensive testing without invasive questions and judgment.

The oes deisio-making processes related to disclosure and non-disclosure of bisexual identity have at times been influenced by their environment and those around them.

Several women had described hearing biased comments by family members who work in health care, or co-workers in health care settings, that may influence their decisions about whether to disclose their identity with their own health care providers. Hearing biased comments by other health care workers may contribute to a sense of distrust by the women. Disclosure is sometimes avoided because it may result in a need for too much explaining.

Some of the women expected to be treated respectfully, while others expected they would be responded to differently than a heterosexual married woman client would experience. One woman had concerns about having information recorded in her medical record that could potentially contribute to stigma.

Some participants were more likely to disclose sexual orientation with mental health care providers than with physical care providers. Participants were more likely to have disclosed

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sexual orientation with physical care providers if the provider was more conversational and focused the visit on the discussion of health related topics. Women were less likely to disclose if they felt sexual orientation and lifestyle would be recorded in a medical record and have far reaching consequences, especially for single mothers who have child custody and receive government assistance.

Most of the participants wrote on their demographic forms or expressed during their interviews that they experience manifestations of suffering such as depression. At least one participant spoke of frequent alcohol consumption. Considering their experiences of low social support and lack of validation in society in which they are devalued as African descent and bisexual women, their expression of mental health challenges seems understandable.

Professionals can encourage women to continue to pursue self-nurturing activities of resilience, such as those the women mentioned in the section on resilience.

In Chapter 5, the data and results from the UK will be presented. In Chapter 6 the US and UK results will be discussed. Themes which emerged during analysis will be described in relation to the research questions. The findings of this study will also be discussed in relation to earlier studies, and the extent to which the findings of the current study confirm or extend earlier findings on the well-being of sexual and ethnic minority women. The findings from the

US will be compared with the findings from the UK.

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CHAPTER 5

PRESENTATION OF UK DATA AND RESULTS OF THE ANALYSIS

In this chapter, the data from the UK interviews is presented, with results of the analysis related to the main research questions and the interview questions. The format in which these findings are detailed with examples, describes the data in categories of themes and subthemes that emerged from the content, including barriers and facilitators of disclosure, and recommendations for improved health and social care. Subthemes which emerged from the data are listed in Table 1. The subthemes are described below in the sections of the main themes and corresponding research questions. Barriers and facilitators to disclosure, and recommendations, are also detailed. This format is essentially the same as for the presentation of the US data and results in Chapter 4, except for additional subheadings related to health care.

To explain further, each topic in the interview usually began with a broader question, followed

Chapter 6.

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Participants

The pseudonyms selected by the participants in the UK, not in the order of the interviews completed, are: Angela, Clarissa, Tolu, Clara, Kareema, Lola, Katrina, and Annie. As mentioned in Chapter 4, two of the women (one in the US and one in the UK) both selected

Aie fo a pseudo.

Sample size: Eight women in the UK participated in this study (N=8).

Age: The eight patiipats ages aged fo to eas M=, “D=.

Sex: All eight patiipats speified feale.

Gender: Six of eight patiipats speified feale fo gede. One participant wrote in

gede fluid, ad aothe patiipat epessed gede fluidit duig the iteie.

Sexual orientation/identity: “ee of the eight patiipats seleted iseual ol, fo seual orientation/identity. Oe patiipat seleted iseual ad also ote i uee fo seual orientation/identity.

Ethnicity: To of the eight patiipats pefeed to idetif as Bitish ol, although oe

ote i Blak Bitish. To patiipats seleted Blak Afia. Oe patiipat seleted

Blak Afia Bitish. Oe patiipat speified Blak Afia, Asia, ad White paetage.

One participant specified Black, African Caribbean and White parentage. Seven of the eight participants were born in the UK; one participant had immigrated to the UK.

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Faith: Two of the eight participants reported Christian faith; one participant reported Buddhist faith; one participant reported Islamic faith; two participants reported no religious affiliation; and two participants declined to state.

Health: Three of the eight participants reported no disabilities (with two reporting situational depression during the interview); three participants reported mental illness; two participants reported chronic illness, (and one of these participants also reported depression during the interview).

HIV status: All eight participants in the UK stated they had received an HIV-negative test result.

Relationship status: Regarding relationship status at the time of the study, four of the eight patiipats seleted a status of sigle; thee patiipats stated the ae datig; oe participant stated that she has two partners in different locations; and one participant stated that she has a partner and is dating.

Housing: Four of the eight participants lived alone; two lived with their minor children; one lived with her partner and a roommate; and one did not specify.

Education: Three of the eight women reported holding one college degree; three participants reported holding a graduate degree; one participant reported some college education; and one participant did not specify.

Employment status: Two of the eight participants were employed full time; two were employed part-time; one stated she is self-employed; two participants did not have paid employment at the time of the study, but one is attending college part-time; one participant is enrolled at university full-time with funding. One participant who works full-time stated she is glad she is able to work though living with disabilities. One participant who did not have paid employment

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stated in the interview that her disability prevents her from working in a regular full-time capacity. Participants who did not have paid employment specified last working approximately two years prior to the interview.

Profession: The patiipats pofessios ad aoatios iluded teahig, aadeia, health and HIV work, peer education, community organizing, and writing. Three participants are mothers.

Income: Five of the eight participants reported incomes ranging from 9,000 to 27,000 GBP, with most reporting incomes below 25,000 GBP. [With monetary conversion at an exchange rate of

.67 British Pounds Sterling (GBP) to 1 US Dollar (USD), this is approximately equivalent to a range of $13,000 to $40,000 USD. 25,000 GBP was approximately equivalent to $37,000 USD].

Two participants declined to state income.

Theme 1: Identity

The experiences of the women related to identity are described in this section. The

oes poesses elated to identity development and disclosure are detailed. The data

elates to the fist eseah uestio, What ae the epeiees of these oe elated to identity and disclosure in social support networks?

The researcher began each interview by telling partiipats, Thee ae a theoies and thoughts about self-identity. The purpose of this interview is to understand life experiences fo ou pespetie. The ifoatio as sought though askig the oe seeal questions:

Ho did ou oe to ou sese of self, that is how did you determine who you are as a peso?

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“What does it ea to ou to idetif as iseual?

What ae soe of the thigs that atte the ost to ou i ou life?

The information in this section on identity is organized under three subthemes that emerged from the data:

. Bisexual identity is experienced as non-binary.

. Identities of race, gender, and sexual orientation are intersectional.

. Identity development is impacted by stigma and influenced by support.

Bisexual Identity is Experienced as Non-Binary

The women were asked to share what it means to them to identify as bisexual. Several indicated a capacity for attraction regardless of gender (male, female, or transgender). The women commonly described experiences and meanings of identity as follows.

Annie shared:

Biseual to e eas that I ope to possiilities, eall, that I ould e oatiall

or emotionally involved with anyone, regardless of gender or more than one gender and

some people who may not identify with any gender at all, that my heart is open and

thees possiilit. (Annie, UK)

Tolu shared:

I idetif as a iseual… It eas to e that I attated to oth sees ad all gedes

eause I also of the elief that its ot just aout the ia gede. Its not just about

the male/female or man/woman biological sex. As a bisexual I believe that sexual

attraction can come in all shapes and sizes, in all genders, be you male or female or any

other gender you identify as. I look at this way as pansexual, but I stick with the bisexual

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eause I eliee it oes eethig. Its ot just ia. Biseual, its ot just aout the

ale ad the feale. Its aout all gedes, so I idetif as a iseual eause I ko I

have the capability or the capacity to be attracted to all genders, basically most attracted

towards the personality and sometimes towards the physique, whatever. So for me,

thats idetifiatio, ad I self-identify as such, so. (Tolu, UK)

Identities of Race, Gender, and Sexual Orientation are Intersectional

Clarissa describes a continuing complex process of identity development:

I thik its still ogoig, tig to figue out ho I a as a peso. I thik eig ied ae

ad iseual soeties feels like thees ot a defiite kid of plae fo ou so oue

kid of tig to figue it out… But I alas ke fo a e oug age that I as

iseual, ad it just as soethig that as, ad I didt thik aout it too uh util it

eae oe a issue he I as olde. “o eah,… its ogoig I think. (Clarissa, UK)

Identity Development is Impacted by Stigma and Influenced by Support

Prejudiced attitudes and stigma were barriers. Having supportive people around them facilitated identity development.

Angela shared about how haig suppotie people i oes soial etok facilitates identity development.

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My identity is really important to me; and making community, finding people who are

queer and people of color, are really important to me to kind of make a sense of who I

a… Close fiedships ad a sese of a shaed udestadig aoud issues of politis,

and sexuality and gender and race are really important to me, so like Black feminist

activism and queer, trans people of color in activism too. (Angela, UK)

Being expected to educate and explain is a barrier to disclosure, she further shared.

I dot shae it ith eeod ad aod eause its just too opliated to t ad

explai h, ou ko…. I fed up ith haig to eplai self. Agela, UK

Lack of role models, prejudiced attitudes and stigma were barriers. Bullying is a barrier to identity development and disclosure. Lola explained in detail in the following passage.

Yeah, thees a lot, ou ko, I thik eause I didt hae aoe to kid of look

up to, look to as I as goig up, I kid of feel as if Ie just ee sept o these huge

aes of, ou ko, oalit ad ofoit…. I feel as if Ie ee tossed around in a

sto of oetio, so to speak…Whe I as little thee …. ast athig that I as

aae of that ould help e sta ith ho I as the. Thee ast athig at all. I

et though shool. I et to a gils shool … the te lesia as used in terms of

bullying in a girls school. No one actually was confidently lesbian. If you were lesbian you

ee just ast ad ad. “o I shook off that loak, so to speak. I just deied it….

I have to be careful not to sort of compare myself to other people, as well,

because I have a lot of friends who are gay and they even, a lot of them are the same age

as e ad the didt hae the epeiee that I had. The foud ole odels. The

found things that enabled them to hold themselves as they are and to maintain their

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identity of being gay from a young age, and sometimes I think, you know, why did you

take the path that ou took? Wh didt ou just eae ho ou ee at that tie?

Ad thats had to oe to tes ith as ell eause thees kid of like a sense of loss

as ell….

The journey has, it has worn me in a way to kind of hone me into being more

self oe tha athig else eause I supised soeties he I thik that

actually, you know, decades have gone by where I spent like at least twenty or thirty

eas, ou ko, liig this kid of, I dot ko, sot of heteooal kid of Waltos

Mountain lifestyle of you know, going through relationships, you know, with men and

raising children and being the perfect mother and the perfect wife and everything like

that, and I come out the other end of it and I still feel, I can still connect with those

feeligs of eig attated to oe as uh as I did as he I as ouge. Its like,

that I just, you know, I find, I find that amazing, that ou at eall de ho ou ae,

o atte ho legth of tie it takes ou to fid ouself agai. You just at de it,

(Lola, UK)

Concerns about raising young children can be a barrier. Lola further described a greater sense of freedom developing later on after her children reached adulthood.

My children were quite young at the time and my social life was very much separate to

fail life. Eethig as oflited, ad I didt ko ho to deal ith, so I a

aa fo it…. I still okig though. I still pullig out e fo all of this, ad

thats also pat of e like leaig the jo that I as i. All hilde ae eightee o

oe o…. So I kind of feel this is my time now where I can kind of come out of my shell

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oe, ad I, eah…. and not apologizing about it and not keeping myself

compartmentalized. I realized that causes me a lot of anxiety and a lot of difficulty, and

its ee a issue up util o eause Ie also ee keepig oe kid of pesoa

pesetale…. I ealized I eed to be true to myself more importantly than anything else.

so hat Ie foud, the oe I uhige self fo that, atuall the ette I feel ithi

myself because I realized I need to be true to myself more importantly than anything

else. …. I dot ant to dance that dance anymore. (Lola, UK)

Theme 2: Social Support

Probes asked about responses/results following disclosure, and/or what the participant thinks may happen if/when she does disclose to others, and/or what factors lead to her deciding not to disclose. (For example, how did or might her family member respond?) Probes also aimed at obtaining details about the decision making process, and factors considered by

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the participant regarding whether or not to disclose, including whether/when/how to disclose sexual orientation in their social support networks.

The information in this section on social support is organized under three subthemes that emerged from the data:

. Experiences and resources of social support vary.

. “oial etoks ae eeded that suppot oes idetities.

. Behaviors constitute barriers and facilitators of disclosure.

Experiences and Resources of Social Support Vary

Social support from family and friends was very important to the participants.

Participants usually first mentioned social support, from family and/or friends as their most important source of strength, as described below by several of the women.

Lola felt supported by her partner:

M pate full udestads e ad ejos the joue ith e…. Lola, UK

Annie expressed gratitude for her social support network:

The people ho ae aout e ad ho loe e, thee iedil ipotat fo e, to

hae people out thee… Its like, thees oe tha oe peso o, its fatasti, ad

thats a e thig,… a good thig. Aie, UK

Angela spoke of her friendship network:

Fiedship defiitel sustais e… I lie uite etall that I a pop i ad see fieds

in town almost every day if I want to have a coffee or hang out with someone, so that is

really helpful. (Angela, UK)

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Kareema shared about the importance of her close family relationships:

M fail… ae eall ipotat to e,… fail, u, dad…. M paets ad

my family, they mean the wold to e. I feel soeties if it ast fo the, I dot

ko hee Id e. “o that is e ipotat to e…. I asolutel loe the to piees….

Yeah, its uite diffiult ith fail eause ou hae the ajoit of fail uite

supportive, but then ou hae the oes that ae eall suppotie ad the dot id

what you do, and then you have the supportive to your face but then you hear what they

say. (Kareema, UK)

Communication facilitated disclosure and acceptance for Tolu. She spoke of difficult processes communicating with relatives who are affected by stigma related to her disclosure.

When I came out strong fighting for bisexual rights, for LGBT rights, they were like,

What is it to ou? Ad so it kid of de a ift etee us… The felt uomfortable

aoud e, ad it ast as though the ee hoophoi, ut the just didt at

that ko. The felt, Wh dot ou just keep it silet? Wh dot ou just keep it

seet? You dot hae to ake oise aout all this. You dot hae to atagonize

people ith it. You dot hae to e i the fae of people ith this. Just ake it a fail

seet. ….Fo o, it took tie fo he to oe aoud, ut I just ealized that o

atte hat, a o ill alas e a o. “hes, aoud seual oietatio, shes

supportive in the sense that she, when I want to go for my protests or anything, she

doest id. “he a help i hatee a she a help. “o Ie oe to disuss ith

he aout ights ad she aepts that people shouldt e hoophoi. People

shouldt—it took tie gettig aoud to that, ut she eliees she is, she ouldt

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at he hild to e hut eause of he seual oietatio….“he as ale to

understand how this affects us. How the homophobia talks and religious talks and all

that affets us ad h I a speakig up agaist this…. You ko, i a a, shes

aeptig, ut ot totall eaig, ad as I ould hae loed to get, ut shes ade a

big step forward, and, but to me she has been very supportive in my times of need, and

thats eall, thats ee helpful fo e to ko that she is thee…The all ko, ad

fail like I said, its still a ok i pogess ith fail. Tolu, UK)

A participant lacking supportive relationships expressed profound loneliness. Katrina shared:

I suffe teil fo loeliess…. Ve, e diffiult. Iesel…. I pett depessed.

I sped a lot of tie i ed. I dot hadl get up…. I dot do athig. I dot hae the

valued life I had. Relationships are really important to me and are part of my identity,

ad I dot hae that a elatioships at the oet. “o thees a sese of gieig

ad loss. Its a e, e diffiult tie fo e. Katrina, UK)

The women commonly said they knew no other bisexual African descent women. I dot thik I ko a othe, eah, Afia deset oe ho ae iseual…. I thik it ould e

ie to ko othe Afia deset iseual oe. Agela, UK

One cannot always rely on family or ethnic community for support, and low social support from family can be a challenge. Clara shared:

Yeah, I thik i tes of soial suppot, if I eig hoest, fail is like zeo,

ufotuatel. Its ot hat I at at all. Id loe to hae a fail, ut I dot. “o I hae

nobody in my family I can rely on for anything. Friends is a really interesting one because

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very few friends know me and, sorry, very few friends know the most important things

about me. (Clara, UK)

Katrina shared:

M othe ad I ee lose, ad the I ae out ad e eet so lose. I pushed her

away, and I think a lot of people do that with their families and you end up having a

lifestle that doest hae a oo fo the ulea fail. You ed up haig ou

lesbian friends and your gay friends. You end up in sort of a village that is around that

istead of ou fail, ad at the ed of the da ou fail is eall ipotat…. One

thig that I ode is if the distae has to do ith seualit…. “o I thik soeties

you get to this stage where there can be rifts within the family that are not really spoken

aout that hae to do ith seualit…. I thik that ae its easie to e lose to ou

fail if ou ae ot, ad thats h a lot of people hide it…. so I aae that it a e

really, really difficult. (Katrina, UK)

Social Networks are Needed that Support Oe’s Idetities

Several participants described those closest to them in their social networks as being

LGBTQ people of color and/or supportive. QTIPOC as aothe ao used i the UK, inclusive of queer, transgender, and intersex people of color.

Annie shared about her social support:

Ie got a couple of work mates here ho ae also LGBT, ad also get it, ad e sot of

at to eah othe, ad I thik just eig ale to let off stea is geat…. Without eig

brushed off. (Annie, UK)

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Clarissa described her social network:

Yeah, so pretty much all my friends—a lot of my friends—are QTIPOCs. I have a few

staight fieds ho I out to, as ell. I dot thik I ko aod soiall that I ot

out to…. So many of the thigs I go to soiall ae kid of like speifiall fo QTIPOCs….

(Clarissa, UK)

Behaviors Constitute Barriers and Facilitators of Disclosure

Detailed below are barriers and facilitators of bisexual identity disclosure in social networks. The process of disclosure varied depending upon the relationships. The women described disclosing identity or orientation with some people in social networks, though not everyone. Patiipats poesses eflet effots to aitai the soial suppot that the hae, clear decisions based on what they feel is the best approach in each situation or relationship.

Tolu chose a strategy of proactively disclosing in most settings, and explained that this empowers her to know where people stand and to be better positioned to interact with people.

I ould sa Ie ee e ope aout seualit… so I ould sa eeod ho

kos e atuall kos e fo ho I a eause… I a e oal adoate. M

family knows my sexuality, my feminism, my sexual orientation, and even my ideology.

Ad ok olleagues…. I dot thik thee ould e a situatio hee I dot o

would feel uncomfortable disclosing my identity at this stage because if anything, even if

its a uofotale situatio, I alas at to dislose so that I kow how to handle it

ad hee to hadle it eause I dot ee thik I should e i the loset aout ho I

am. (Tolu, UK)

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Katrina uses discretion in making decisions about disclosure:

People that I am having relationships with at the moment—sexual relationships—they

all ko that I iseual, ad I hae a fe fieds ho do. I thik ost of fieds

do. Its pat of e. I dot hide it, ut soeties I aae of the appopiateess.

(Katrina, UK)

Lola described how fear of job loss, especially as a mother, is a barrier to disclosure.

All it ould take is fo oe peso to go ad etio to… ok…. ad thats just it. You

ko,… its ee doe offiiall these thigs. Its alas, thee ae as that ou

suddenly lose your job or ways where your job suddel eoes so diffiult ou at

do it anymore and you have to resign, and I never wanted to put myself in that position.

“o, thats h Ie alas kept e uiet aout it, ut I ealize o I a gie self

permission to be a lot more open, and I thik also eause hilde ae olde… Lola,

UK)

Kareema discusses facilitators and barriers around disclosure. As she describes, unconditional compassion facilitates disclosure and acceptance.

M u is like ok…. I loe he to piees… M u. “he just doest ae. M u

just loes ee it of e so I ko, o atte hat,… u is ok. “he loes e,

ad I loe he. “hes alas suppotie, o atte hat. “he a disappoe of

soethig, ut shell alas stad ehid e. M u is the peson that I depend on

the ost, othe tha God…. M u, she is e suppotie. M us just, shes just so

elaed. “hes like, As log as oue happ, Kaeea, thats fie. …. With u, I

just eee us haig a oesatio like, Mu, I thik I like gils, ou ko, ad

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shes like, Oh, is it? I as like, Yeah, ad the the et iute I as like, Mu, I kid

of seeig he. “hes like, Oka. “o that as it. I didt feel like I had to uild up to tell

her. (Kareema, UK)

Kareema shared about how religious beliefs can be a barrier to disclosure:

Me ad dad had a e diffeet elatioship fo othe, ut o ee eall

lose, ad I loe hi to piees…. M dad,… He ast haig it. He liteall ut e off fo

a couple of years afte tellig hi ause hes like, Kaeea, o. Its disgustig. You at

do that. Its og. Its agaist the Bile, ad all of that, ut o, I thik the ol easo

h hes talkig to e is eause I atuall oke up ith e-gilfied. “o thats

eall the ol easo h hes talkig to e…. ut o, I thik its ot aout e tig

to pesuade hi to aept ho I a i that sese. Its just e ad hi haig that

relationship and not speaking about it, which is—its a shae that I at sho him that

its othig,… ut thats his elief, ad Ie got to espet that, just like I at hi to

espet eliefs. Its just a sujet that e o just dot talk aout ad oetate

o ou elatioship, so its kid of fogotte. But I ko that if I was to get in a

elatioship ith a oa, it ould e staied agai, hih is uite sad ause I eall

love my dad. (Kareema, UK)

Tolu explained why she feels many African descent people can not disclose in all social settings.

So because you find the Black person comfortable or trying to be comfortable in the

LGBT ouit doest ea the dot hae fail pessues o ultual pessues

that the ae tig to fae ad still tig to suout. “o dot judge the less if ou

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realize that they are not openly, proudly out to their family. Because some may feel that

Oh, if I sa I ot out to the fail, I a ot e so aepted i the ai LGBT

ouit. I ot e aepted. I ill e see as soeod ho is ashaed of

sexual orientation ad thigs like that. “o the oe out fist ith us if the ae out, ut

the ae ot, ost of the Blaks Ie see hee, the ae ot eall out ith thei fail

members. (Tolu, UK)

Tolu further described severe potential consequences that comprise barriers to disclosure, and the lack of a supportive community for those who are both ethnic and sexual minorities.

Util the ae ead to e out, ou dot foe aod out eause I ko e ell

what the repercussions could be. They have real repercussions. You could lose your job,

ou ould lose ou fail ees, ou ould lose ou fieds… The eed to e

empowered to come out. They need to be empowered. They need to have a community

where they can discuss those things amongst themselves, ad e dot hae that stog

Black community, LGBT. (Tolu, UK)

Religious and spiritual communities.

Acceptance facilitates disclosure. Lola shared:

I am also beginning to talk more openly about that in my Buddhist community. I gave, we

have like courses for women every year and some course that I went to last year I did

shae a epeiee aout eig iseual…. I etioed eig pol as ell, ad that as

really, really well-received. I was surpised… An African Caribbean woman came up to me

afterwards, and she really thanked me for the experience that I shared; because she said

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that she also felt the same, and that after hearing me talk she was more confident about

coming out herself. (Lola, UK)

Kareema shared her experiences:

The (Islamic) sister circles—he ou go to a siste ile, ou dot go i thee ad sa

Oka, ell, I iseual. It depeds o the kid of elatioship that ou hae ith

the. The lad that ought e, she ke ause she had et gilfied ause I had

a girlfriend at the time when she brought me to the sister circles, so she had met her,

ad that as fie, ut it ast athig that as dislosed to aoe else at the siste

circles. (Kareema, UK)

Judgment can comprise a barrier to disclosure. Katrina shared:

There are people i the huh that I talk to aout thigs that upset e, ad I haig a

teedousl diffiult tie at the oet…. Nobody in church knows me for who I am.

“o eall, just God, eall. Its a diffiult oe eause soeties I feel like I liig

copateted lies…. I ko that iiste, ia hes alled, is agaist gas i the

huh. He doest at ga people i the huh…. I ko that stae, ias

stance, but I also know other people are very okay about it. (Katrina, UK)

Theme 3: Health Care

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The information in the beginning of this section is related to the first research question:

What ae the epeiees of these oe elated to identity and disclosure in social support

etoks ad health ae settigs? I this setio o health ae, the ifoatio is fousig o health ae settigs, i.e. What ae the epeiees of these oe elated to idetit, disclosure and health? The eseahe espeiall atteded to epeiees elated to HIV prevention, including health information shared between peers.

The information in this section on health care is organized under three subthemes that emerged from the data:

. Experiences and resources of health care vary.

. Environmental cues and behaviors constitute barriers and facilitators of

disclosure.

. Specific changes can improve services for African descent bisexual women.

Experiences and Resources of Health Care Vary

The information in the beginning of this section is related to the following interview questions. The women were asked: Please tell e aout ou epeiees ith health ae.

Clarissa shared that the health care system is affected by privatization and budget reductions.

Well, i tes of health, the NH“ is kid of ulig ad gettig piatized. Its ee

e affeted the uts so thees a lot of seies hae just ee ut fo the NH“, a

lot of thigs that ee peiousl aailale…. In the NHS a lot of the services are being

piatized…. hih sees to e soethig that ood ats, ood i the puli

ats, ut its eig pushed though the goeet aa. (Clarissa, UK)

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Participants described that services can vary by location or area. Katrina shared:

Ie had eall fatasti teatet at NH“. Ie ee had a issues at all. Ie ol had

the est dotos, hih ust hae soethig to do ith eig i [to]. Thats hee I

lie. Yeah, I fie ith hat Ie had, eall…. I get to see the same poide…. I am an

aious peso, ut I alas feel I a listeed to…. I ude the doto fo thigs that

I supised I ude the doto fo (i.e. being treated for), ad I thik thats eall

good that Ie ee listeed to. “o eah, its eall good. (Katrina, UK)

Clarissa shared that she feels her area has more resources than other areas:

I thik Ie got it a lot ette tha a lot of people. The oough that I lie i the hospital

seies ae uite good, uite uik. The aitig lists aet that log, hih is useful…. I

guess the ai thig I feel aout the health sste is its log ad its udefuded.

Eethig takes a eall log tie…. I thik a lot of it sees to e aout… post ode luk,

as ell. Yeah, like hih oough oue i I think has a big impact. (Clarissa, UK)

Whe asked, Is it ou ipessio that ouself o ou fail, pate, o fieds that if the ated a feale poide…? Claissa espoded:

I thik it depeds hih oough oue i ad ho kid of lued up aout stuff they are.

“o i oough, its uite aeage fo oe to euest oes ol seies, ad

thats kid of aoss the oough,…. so I thik i a oough hee thats ateed to oud

autoatiall hae thed t ad hie staff to ake that easier, but in other boroughs I

thik the dot thik aout it, so its hade o ou ould hae it ut oud hae to ait.

(Clarissa, UK)

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Clarissa also stated that the ualit of health ae a e elated to oes eooi lass and cisgender identity. She shared, I think my experience has been a lot better than a lot of othe peoples, hih I thik has a lot to do ith lass piileges ad eig isgedeed as ell.

Annie described ideal health care experiences, contrasted with earlier experiences that were unhelpful. The clinic she referred to was formerly the Audre Lorde Clinic; now services are mainstreamed, but the location is the same. She mentioned wanting to seek health care, knowing the services of this clinic would be culturally competent.

The [nae of hospital] hih is just do the oad, thee got the lii… fo oe,…

The ae just so good. “o pofessioal…. Yeah, thee asolutel illiat…. The ask all

the ight uestios… The, gie ou seual health stuff thats appopiate. Thee heard

of iseuals. laughs Thell go ad fid ou detal das if its the last thig the do.

Whe Ie goe to othe plaes efoehad, the just look at ou… But eah, this lii

is just absolutely brilliant. Really professional, they speak a dozen different languages

thee,… ad the dot judge ou, ad ou at to go thee eause ou ko oue

goig to e take ae of…. you know, do tests for some other things, and just sort me

out, and without looking down their nose, without judging, without making snide

eaks, ause Ie had all of that i the past, ad I ould ee go ahee else

except there, really. (Annie, UK)

Environmental Cues and Behaviors Constitute Barriers and Facilitators of Disclosure

Related to the information presented in this section, participants were asked: Please desie the ifoatio that ou hae shaed ith ou health ae poide, ad Hae ou disclosed bisexual identity/orientation to anyone in a health ae settig? If so, ith ho?

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Referring to health care settings in general, Tolu described family ties as a barrier to disclosure.

Defiitel assue that fo the Blak peso oig fo,… ee if oue hee, oue

oed to a oe deeloped, oe aeptig soiet,… thee ae still ties that affect

people or prevent them from coming out as who they are with their sexual orientation.

Youe got fail ties to thik of. Youe got people ak hoe that ould e affeted

ith ou dislosue….. It ould affet the. I iue to it o, ut they are not, and

the vitriol of comments coming from people with such bitter, vengeful, vicious comments

soeties ould affet ou fail ees, ad people dot at to oe out opel

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to advocate for that. It could be because they want to protect their family members from

going through that kind of trauma. (Tolu, UK)

The pospet of haig pesoal ifoatio eoded i oes edial eod is a aie that reduces willingness to disclose. Lola described that even if the provider at the time is nonjudgmental, she will limit disclosure to prevent having personal information placed in her medical record.

I think encouraging people to be open-minded is very important, but to record, I think

thats a diffeet issue.… Ee he I et to the lesia ad iseual oes lii….

I fid that the ae usuall e fiedl, ad I dot ko ho uh of that the ould

ite that do i eods ad I dot ko ho uh… I ould at the to

eause its like, Oka, I ko ou at to ko edial status, but do you need to

ko athig oe of life?....I ea its like the uestioaie thig that I had to

fill out, which is similar when you have your STI test, especially for the HIV one, they ask

you all these questions about the sort of history of the people that you have had sex

ith, ad I ouldt at the to keep all of that o edial eods. Lola, UK)

Clarissa had concerns about having information recorded in her medical record that could contribute to being treated with stigma. She shared, I thik I ould e oe oied about getting homophobia from my GP surgery (i.e. general practitioner) than I would at the seual health suge.

Having to educate a provider is a barrier. Angela expressed mixed feelings about the types of questions asked during her appointment.

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Yeah, okay. I think that I still find it quite nerve-akig if I go to a e doto ad Id

have to tell them my sexuality. I think like— Yeah, nerve-wracking, definitely. Yeah, I

thik, eah, its just oe of those times when you have to come out in health care, and I

feel like I sort of grit my teeth and I kind of just go in there and say it and just see what

happes, ad Ie had, I dot thik Ie had a egatie eatio. Like, oe doto, he as

like a GU doctor and he was asking me how it was with my family in terms of coming out

and stuff, just kind of out of interest, which was fine to talk about, but I also felt a bit kind

of, I dot ko, like kid of teahig hi ad like I as thee fo a appoitet, so I

dot ko, it as a it, I ast sue aout ho I felt aout it. But I thik Ie had uite

positive experiences. (Angela, UK)

Friendly communication by a provider facilitates disclosure. When the researcher asked

Hae ou ee felt ofotale to disclose that you might at some point in your life have same-se pates o tasgede pates? Claissa shaed:

I hae oe o tie. Moe ofte tha ot, I dot. But, eah, I hae doe oe o tie. I

dot ko hat its do to. I thik like a certain kind of like friendliness or something

aout the a thee askig uestios akes e feel like the ot take that kid of

thing badly. (Clarissa, UK)

Registration and intake processes and disclosure.

Detailed in this section are descriptions from several participants regarding how they experience the registration or intake process. The manner in which registration or intake is conducted can comprise a barrier to effective disclosure. The oes deisio-making processes around disclosure and non-disclosure of bisexual identity were at times influenced by

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provider communication, in terms of whether their tone is clinical or friendly, and the types of questions asked (heteronormative versus LGBTQ-inclusive questions).

Clarissa described that it made a difference in terms of the manner used by a provider in asking questions.

Oe ause I had a gu ho I assued as uee ad he asked the sae uestios ut

in just a much more LGBT-friendly way, and he was just very friendly and chatty when he

was doig sas ad stuff like that ad just felt eall ofotale ith hi. Thats

the ol tie that I thik, I thik I geeall ted to assue that people, ad I dot ko

why, but health care coworkers, even though I have friends who work in health who are

queer, but I kind of assume that most people are straight that I come across in health.

(Clarissa, UK)

Annie stated that the information she specifically provided about her bisexual orientation and identity, for her medical record, was not acknowledged.

I said, he I as fillig the, joiig the, appliatio fo to joi, that I a iseual. I

really want to make that clear. I am bisexual, you know. I pointed to the little bit so

thee ot just like tikig oes ithout ee askig ou, ut the dot ted to ead

the ifoatio the hae,....Annie, UK)

Angela described discomfort with provider assumptions:

Thees still pesuptios aout ou seualit… I ish ou didt hae to oe out. I

ish that ou didt hae to oet… Coetig people is the difficult thing; when

soeoe assues that oue heteoseual its e had… “o I thik ost of the tie its

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oka he people ae askig aout the gedes of ou pates, ut its diffiult I thik.

(Angela, UK)

Katrina described not disclosing due to her perception that the information is used for statistical purposes rather than individual client intervention.

The ask Hae ou ee slept ith soeods hos iseual ad I sa No. I just lie

because I talk about where I am now. Thats e. Thees o poit. It doest hae

athig to do ith the tests that I haig at the oet. It has to do ith thei

eseah, if ou get hat I ea. What I goig fo… doest hae athig to do ith

me sleeping with a bisexual person. I can eee oe… I just told the You ko I

ot goig to ase a of those uestios, ight? [“he eplaied that he esposes ae

geaed] …to get hat I eed. What I eed, ot hat the eed. Katrina, UK)

Kareema described receiving no reaction to disclosure of bisexual identity, which gave her the impression that the clinical process was impersonal and not individualized for the client.

Befoehad the didt eall ask a uestios othe tha, ou ko, just egula

heterosexual sex. Now, they hae a list of uestios,… Hae ou ee ith a a?....

Hae ou ee ith a oa? Ae ou iseual? Thell ask ou a list of thigs, ad

the oull just sa Yes o No to it, o state hatee ou ae. “o I fid that the ae

going into depth a little bit more about your private life. It seems to have been like

ae the past thee eas that the stated askig e that. Thee o fou eas Id sa.

Just like, Would ou oside ouself iseual? Oka, et uestio. “o thees ee

been any reatio fo it. I thik its liial. Its just tik the oes, do hat ou hae to

do if ou eed ediatio, if ou dot, the fie, et. Kareema, UK)

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Tolu described a negative initial experience related to questions about birth control being asked without first having been asked questions about sexual orientation and identity.

She emphasized that she was sad and depressed at this time, following the end of a same-sex

elatioship, hih ade the poides heteoseist assuptios a ee oe paiful experience.

I ated to aess ette health ae…. I iediatel egisteed ith the NH“ at the

university health care, and my first experience was really bad because there was only one

osultat fo the shool, ad he I et to eet hi…. the fist thing was when I was

i the egistatio, ad he as askig aout… ith otol ad thigs like that, ad I said,

Well… Ie just oke up ith sae-se pate… I haet had a seual

elatioship ith a a fo a log tie…. Whe the doto as asking me about birth

otol ad I said, I dot use ith otol, ad he as like, “o hat do ou use? You

just do it? It as like, “oe of us dot eed ith otol. Hae ou thought that

ae I iseual? Ad he ast e eeptie to that because you just assume I

ust e o ith otol, I ot usig odos, o I just a Blak peso, doest ko

aout ith otol. I felt it as kid of aist ad iphoi ad all that, so I ast eall

pleased with his services then, but he was the only consultant, the only one assigned to

the shool,…. But as fo GP (i.e. general practitioner), pesoal GPs, I alas supised

he the ask ou aout ith otol ad ou tell the ell, ou dot alas eed it

because you are bisexual, and sometimes I feel they just expect that every woman is

heteoseual, ad he ou tell the that ou ae iseual o that ou haet ee

ith a a, oue ee oe ith oe ad all that, ad eause the alas thik

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he ou sa ou dot use ith otol, its like, Ae ou daft o soethig? efoe

you start explaining to them. (Tolu, UK)

Clarissa had oes aout ho iseual peso is defied as ol efeig to a ale person. She also mentions she is aware that the intake process for men who have intimacy with men addresses issues specific to them.

Thee got a itake fo hee I thik… oe of the uestios as Hae ou ee had

se ith a iseual peso? What the ea is Hae ou ee had se ith a isgede

iseual a? Ad if you indicate that you might have had sex with a bisexual cisgender

oa the sa, Oh, thats ot hat this uestios eas, ad Ie had aout fie o

six people report that same experience where they (clinic staff) sa, Oh, o, this

questions means this thig, this e speifi thig. I thik thats the ol uestio aout

seualit o it, ut if oue a isgede gu ad ou eeal that ou hae se ith othe

cisgender men, then they ask you, they have like a different form that they go on to. So

thell stat askig ou thigs aout like the stle of haig se, hih I kid of gateful

is soethig that the ee go ito ith e, ut I defiitel thik thees a lot lakig.

(Clarissa, UK)

Types of information given to the women by providers.

The women were asked: Please desie the tpes of ifoatio that hae ee poided to ou. The fous hee is to detail the oes epeiees of poesses ioled i information provided to the women regarding HIV and STD testing and healthy relationships, when the women have and have not disclosed sexual orientation and/or relationship history.

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Types of information: Sexual and reproductive health testing.

Clarissa described processes of universal testing in her borough.

I guess i oough its quite—HIV is quite prevalent, so they test everybody. Well,

they offer to test everybody… Do the very quick, the prick finger test. Yeah, when you

first go in, like when you first register at a surgery, which I think is quite useful, so they

make sure eveoes oeed asiall. Clarissa, UK)

Kareema described being proactive with testing, citing no cost as an incentive. She shared, I like to go ee si oths….Cause its fee, so I ight as ell utilize it!.... I like to just be that one step ahead…. Yeah, Ill take a da off ad I ill go. I hae to.

Some of the women have not been offered HIV testing routinely, despite HIV risk for

African descent women in the UK. As Tolu described below, education and training facilitated empowerment to request testing.

Beause Ie doe a lot of ok o HIV,… ad I also atteded thigs like AID“

conferences, international AIDS conferences. I tend to ask for it without them asking. I

ask fo test. Wheee I ith a e doto o egiste ith a e doto, I ask, Ca I

hae a “TD test? ad all that, so I euest fo it…. I oall ask fo it eause I just

at to e lea. I ask fo it, just if I a get it fee, h ot? “o I oall ask fo it…

The oall dot. (Tolu, UK)

Types of information: Prevention.

The eseahe asked: What do oe do aoud tig to e health ith thei feale partners? And have any providers been more sensitive to provide information whether you hae ale pates o feale pates?

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Annie was the only participant who stated she had received information from providers that was designed for a woman who may have partners of different genders in her lifetime. She had named a specific community-based HIV/AIDS agency serving people of color and sexual minorities.

I think in this out its e good seual health fo L, G, ad B people. With T people

(i.e. transgender people), its, the dot get suh good adie, ut thees a lot of

information. Whether people take notice of it is another thing, and nowadays within the

last o so eas, thees ee a lot oe thigs aied at oe ho hae se ith

other women. (Annie, UK)

Most of the participants described being provided only information pertaining to opposite-sex intimacy, whether due to providers making assumptions about the women and/or due to limited knowledge on the part of providers. Inadequate communication, lacking appropriate follow up questions and discussion, can be barriers to disclosure. Kareema described:

Yeah, ut oall thats at the ed. Like, the might ask you if want condoms or

athig like that, ut the ot eall hae uh of a disussio aout it. It is e

liial the a that the deal ith ou soeties. The dot eall sit do ad

converse with you much. (Kareema, UK)

Annie was the only participant, quoted above in the section on health care experiences, who mentioned having a provider who shared information about risk reduction with same-sex partners. Several of the women described receiving very little information on prevention during their medical appointments, as detailed below. Generally, the women are provided no

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prevention information specifically designed for bisexual women who may have male or female partners in her lifetime, even when they have disclosed.

Katrina shared about eig gie liited esoues: They give you pamphlets and they gie ou odos, ad ou hae a hoie of ho oue told test esults, hethe eail, tet message.

Clarissa contrasted her clinical experiences with health education at school:

Ie ee ee gie athig else. The fist tie I sa a detal da as iteestigl at

shool… I got the ipessio that the ee pat of oal otaeptie paaphealia.

Ie ee ee offeed oe, ee. The ol kid of pe-contraception that Ie ee ee

offeed is odos, othig else. No ifoatio aout athig else… that a doule

as contraception, like gloves or cling film... Literally no information whatsoever. (Clarissa,

UK)

Angela described encountering providers who lacked knowledge of how to intervene with ABW:

Whe I fist ae out I foud it diffiult aoud seual health stuff ause… people

eet sue hat to adise e, eall. If ou go to a lii, like seual health, its ostl

odos thell gie ou; ad he ou ask aout safe se fo oe thees ot eall

a lot aoud…. I ko fo peious ok aout detal das ad stuff, ut thee

ot eall take seiousl ad o oe uses the…. thees othig eall thee. Agela,

UK)

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Lola was not provided safer sex information during an appointment in a special time slot for sexual minorities.

I had regular screening, STI screening; only once did I go to the lesbian and bisexual

oes tie slot. But when I did go, I did say that I had female, I think I was seeing two

oe at the tie, ad I also had a ale pate that I as seeig…. Ad, o she didt

atuall talk to e aout safe se.… Lola, UK

Tolu was not provided any information on healthy same-sex relationships, despite disclosure of bisexual identity.

I dot eall thik thees uh ifoatio i that egad eause ee he I

mentioned to my GP (i.e. general practitioner) that I iseual, the dot oe ad

gie e a oe taiig o, Oka, ou should do this o You should do that. The

dot… ot uh ifoatio. Its just hat oue leaed o ou o aout tig to

potet ouself, ad eig iseual, udestad that if I ith a oa,… ee

women that identify as lesbians have to put up a kind of social façade where they have

to date e just to potet theseles… so I ko that its ot alas safe… Whe

oue ith oe, ou hae to e e aeful, ut the dot hae uh ifoatio

as to how you can do it, from service providers. Those things you just have to learn on

your ow. Ee hee i the UK,… Ie told GPs that I iseual he the ask aout

the ith otol thig, ut the dot ee oe up ith Oka, what do you use with

ou pate? o athig, o follo-up questions regarding that. (Tolu, UK)

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Heteronormative questions are a barrier discouraging disclosure. Clarissa stated she was more likely to obtain information on healthy relationships with a same-sex partner from sources outside their regular health care settings, such as from peers.

If I have a question about sexual health, I really go to my friends. I find them much

better-informed than any of the sexual health services, I go in kind of knowing what I

at ad hat I at to get, ad the oe out. I dot ko ho ell-informed they

are, but from the questions that they ask, which are very like hetero-normative, I kind of

guess that the dot hae that uh ifoatio. Cause I iagie that if the had

more information about LGBTQ stuff they would ask their questions in a different way.

So I kid of assue that thee ot patiulal ell-ifoed o that thee ae a

little it hoophoi o thigs like that. “o I defiitel, thee ot kid of the plae I

would go for information. (Clarissa, UK)

Specific Changes Can Improve Services for African Descent Bisexual Women

This setio is elated to the seod eseah uestio: What eoedatios do they have regarding their needs in order to feel safer to disclose and ways service provision can

e ipoed fo oe like the? Fo the purposes of this study, service provision includes physical health, HIV prevention, mental health, and social services. The women were asked the following interview questions:

Ho ight ou adise poides o othes to teat ou i ode to poote tust and/or dislosue of seual oietatio, HIV status, o othe health ae oes o eeds?

Ca ou tell e aout health ae esoues, ad a hages that ou feel ae ipotat to e ade?

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The oes esposes to these uestios ee gouped as described below. Because similar responses could be provided related to either question, similar responses are categorized together rather than listed as duplicates under each question. The women shared recommendations for important changes that would help them feel more comfortable about seeking health care services. The following recommendations pertain to increasing cultural competency in health care for bisexual women of African descent. The women made specific recommendations for increasing inclusion in professional training, outreach, and service provision.

Recommendations: Medical record confidentiality.

There is the option when you go to the sexual health clinic to not have those records sent automatically to the GP (i.e. general practitioner) for the main record but not everybody is informed that they have that option for confidentiality. The eseahe ifeed fo Claissas stateets that it ould e helpful to e ifoed of oes optios.

I always request to not have anything disclosed, just ause... I dot ko ho o hih

GP (i.e. general practitioner) in the practice the information will go back to, and I just

dot ko hat that ould ea fo ou health ae…. With all the othe seual

health services, there is that option, but they dot ake that optio lea to ou, so

you only request if you know about it. (Clarissa, UK)

Recommendations: Environments that welcome diversity.

The women described their sense of processes that would facilitate environments more welcoming of African descent bisexual women. Non-judgment and avoiding assumptions are valued.

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Providers should avoid making assumptions.

Lola recommended avoiding assumptions:

I think for people to be open to difference in diversity with someone who walks through

their door and not make the assumption that because someone comes into a clinic at a

etai tie the hae a etai lifestle, ou ko… I thik ou assuptios do lead us

to treat people in a certain way and have conversations in a certain way, but because

more and more people are coming out now in terms of how they live their lives and they

hae the ofidee ith thei lies i oe diese as o, its ipotat to ot

make those assumptions. (Lola, UK)

Providers should make LGBT inclusion visible.

Angela described how she found it helpful to see a plaque in the NHS health center, that

was given by an LGBT agency.

My GP (i.e. general practitioner)… had i the eeptio aea a… Pide i Patie plaue,

which meant that they had been part of some kind of training around LGBT issues, and

when I saw that out on the reception that was really, really helpful. It made me feel

oe ale to sa aout seualit, ad Ie foud that efoe i othe health ae

settigs, that if thee as soethig that is isile that akes it see like its oka to

talk about being queer, then I feel much more comfortable. (Angela, UK)

Recommendations: Inclusive intake screening and forms.

The women request an LGBTQ-sensitive intake process. The women request conscious processes of culturally competent intake and assessment, and appropriate inclusive terminology. Providers being intentional and conscious about not assuming sexual

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orientation/identity would facilitate client disclosure and a sense of well-being in the health care setting and professional relationship.

Clarissa recommends gender neutral language:

I definitely think if the form was more LGBTQ-fiedl… if the fo as oe like, What

kind of people do you have se ith? It ight e like oe ope uestios… I thik that

would definitely help people to feel more comfortable. (Clarissa, UK)

Lola recommends awareness of diversity:

I think for people to be open to difference in diversity with someone who walks through

their door and not make the assumption that because someone comes into a clinic at a

certain time they have a certain lifestyle, you know?... I guess our assumptions do lead us

to treat people in a certain way and have certain conversations in a certain way, but I

thik its eause oe ad oe people ae oig oe out o i tes of ho the

live their lives and they have the confidence with their lives in more diverse ways now, I

thik its ipotat to ot ake those assuptios. Lola, UK)

Acknowledge and affirm bisexual identity.

Acknowledging disclosure of bisexual identity is important. Tolu emphasized:

I think the first thing is actually to acknowledge that there are bisexuals. There are

oe ho sleep ith e ad oe. Beause the dot see to akoledge it at

all. The ust akoledge that ad ot assue that eeods heteoseual, ad

they also ust look at poidig seies fo those kid of oe. I ea, if I sa I

iseual, I dot epet ou to just sa, oka, et uestio o the list, hih has

nothing to with my bisexuality. I want you to provide me with some information and

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what I can do. Tell me. No one has, no doctor has ever told me, whom I told I was

iseual, oe of the hae ee told e that, Do ou ko ou still stad at isk ith

oe? Noe of the hae ee told e that. The just take o to the et uestio.

Okay, ou dot eed ith otol, et uestio. “o I ould at the to ask that, ot just ask birth control, but first ask about sexual orientation or partners. Do you have male or female partners, or do you have both? (Tolu, UK)

Include sexual orientation and identity in general intake.

Tolu made recommendations for improving the intake process:

Not just jup to ith otol, ad aoud that issue, it shouldt all e tied to ith

otol. It should e tied to health ae itself…. It should e aout health care, around sexual health care, and there should be a comprehensive list around that area for women who sleep with women and men or men. It should be around that, not just tied to hethe I goig to hae a hild o I eed ith otol o aotio o things like that. (Tolu, UK)

Tolu further stated:

So I think they need to do more in that area to provide information for women, and that should be from the GPs (i.e. general practitioners). It shouldt e fo speialists. It shouldt e a speialist issue. If you have a GP, your GP should be able to give you that information as you register or just ask you as a routine question when you come for your routine assessment. So I think they should make it sort of routine thing to ask about sexual health care, not just tied to birth control, but just general sexual health care. (Tolu, UK)

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Avoid making assumptions on the basis of marital status.

Tolu made further recommendations, explaining that disclosure is inhibited by potential consequences to the client, their family, and others.

First and foremost, people should not just assume that because a woman is married or

that a Blak a is aied the the ae heteoseual…. Dotos shouldt assue,

people shouldt just assue that people ae heteoseual…. Dot let just (marital

status ake ou assue the seualit of the peso. Youe got fail ties to thik of.

Youe got people ak hoe that ould e affeted ith ou dislosue….. It ould

affect them. (Tolu, UK)

Recommendations: Health screening and tests.

Providers should discuss prevention. Health information is needed, Tolu emphasized.

I would just say just to add that they should give information as to the type of risk you

face in a same-sex relationship and if you are bisexual they add that risk of being with a

man, being with a woman, and the possibility of passing it across or if you are also with

a bisexual woman, the risks that you could face from them even if you are solely a

lesbian but dating a bisexual woman or just woman to woman dating generally I think.

There should be that list of the likely sexual diseases or sexual health implications it

could have. They should mention that. They should let people know. (Tolu, UK)

Clarissa recommends partners testing together:

I think being able to go for testing together might encourage more people to get tested

sipl eause, sa if oe pate has a oilit disailit ad its diffiult fo the to

get to the clinic by themselves, it might be a greater incentive if their partner can get

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tested at the same time when they go together so transport is easier and they can get it

all done at the same time. Just for convenience. (Clarissa, UK)

Partners should also have the option of requesting the same general practitioner (GP).

Tolu recommended:

They should also help on how to broach the issue with your girlfriends. They could have

you to, was your, your girlfriend has a GP? When was she there? Has she ever been

tested? Just ask and if you want to have the same GP with your girlfriend, maybe the

same GP, use the same GP and together go for the testing or something like that could

ake it easie if oue doig it togethe athe tha oe peso doig it. Could suggest

that. What if ou ould do it togethe? Wh dot e get ou “TD, our sexual health

report? We could do it together. (Tolu, UK)

Clarissa suggested independent self-testing as a means of empowerment:

I want to organize some kind of system where you can just do it yourself, maybe get,

have a group of people trained up who can train other people to do it yourself or do it

ith soe assistae so oull e eithe i a fiedl eioet o oull e i ou

o hoe ith ae a fied helpig ou o a pate o soethig like that…. I do

think people should be doing it themselves. I think training and the resources to do it

ourselves is the best option. (Clarissa, UK)

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Recommendations: Time and communication with providers.

Kareema made recommendations about improving communication, especially during intake:

Also, when thee askig the uestios if oue lesia o iseual, thats he the

ould also ae ask ou diffeet uestios eause thee just goig to ask ou all

the sae uestios, so I thik the ould e a little it oe sesitie to peoples

specific needs. Other than that, although it is quite clinical, personally I think that they

do a good jo ause I dot at to go thee ad hae to eplai life to ou o

athig like that. I just at ou to ake sue eethigs oka ad the I a go, but

thats just e pesoall, ut soe people ight go thee a little it oe oied tha

I am and they may need that extra time. How would they manage that? Because they

literally treat you within—ou a see that thee got a ouple of iutes to teat you.

I dot ko. I thik thats aout it, eall, ause othe tha that I thik that thee

doing a good job. (Kareema, UK)

Recommendations: Prevention information for bisexual women of African descent.

As most of the women received little information from health care providers regarding health sexuality for a bisexual woman of African descent, the researcher asked about other sources of health information. Tolu recommends that sexual minority women acknowledge risks.

Basically women act as if we are not at risk at all. They assume that a lot. In the [African

atioalit] ouit Ie see that. Ee hee i the UK ouit Ie see that.

We just assue e ae ot at isk. Oh, I ot ith a a, so I ot goig to hae

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“TDs. Thats oe of the plus of ot datig a a. I dot thik that is the ase. I thik

e eed oe ifoatio. We eed to e oe hoest ith ouseles, ad e dot

eall talk uh aout seual potetio, dot talk uh aout “TDs he ou ae

within the lesbian communit ad the iseual ouities too. Whe oue ith ou

LGBT ouit, its alas assued ou ae lesia aa laughs ad ou hae to

keep o assetig, I iseual. I iseual, ut its alas assued that oue all

lesbians or same-sex lovig ad ou dot hae a isk of the othe pate eig

heterosexual or being opposite-se ifetig ou ith athig. “o, its ot eall fo

disussio. I haet eall had that disussio i the LGBT ouit, to tell ou the

truth. The reason I know about it has been from my own personal research. (Tolu, UK)

Prevention information is more readily available for men with same-sex partners. Tolu recommends workshops for women, in the following passage.

They talk more of MSM, men having sex with men. There has been a lot of focus

o that, okshops o that. Ie helped ogaize okshops o that…. e talked aout

MSM, men having sex with men, how they could use the condom, and things like that.

We have so many condoms to give out. But it was just all about the men.

What about women? What about women sex? What about women who are

lesias? What health pole do the fae ad thigs like that? We dot eall get to

hear much.

I would say maybe little workshops outside conferences where you have, it

wouldt e foused, ost of the okshops ae ot just foused o se, ut ou ould

have the sub-committee workshops. Sub-committees. Maybe you have a big

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conference, but you have this sub-committee that could be LGBT related and you enter that and you could get… ifoatio o health ae, so….

I got that from international conferences, from workshops that I was opportuned to attend. Not everybody is opportuned to have access to such workshops and seminars and things like that, so I think it should be more easily accessible. Such information should be easily accessible to people. (Tolu, UK)

Recommendations: Culturally relevant health literature.

Kareema recommends literature developed for sexual minority women.

One thing I would say is the leaflets that they give out. I think that they need to have something more, not just for gay men, but for bisexual women and lesbian women,

eause I ko its alas see that thed ee ath athig, the dot ath a

STDs, but it would be nice to have a leaflet saig oka, ell, these ae the thigs thats most common with lesbians or bisexuals, so it has a bit of an awareness and so when they are giving out leaflets about things that this can be included. (Kareema, UK)

Recommendations: Sexual health product information.

Clarissa described information she received:

From what I understand, the sex education I received at that age is a lot better tha the se eduatio a lot of pees of the sae age eeied…. They seemed to be quite good at sexual health lessons. We had uite a lot of the, like oe tha Ie head of othe people haig, so e had kid of a oth hee ed hae se education once a week. Yeah, but I think also, it very much depends on which teacher it had. So I think we had a teacher who was uite ell ifoed ad as like, This is a

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detal da, this is a feido, this is a odo. This is ho ou use the. The she

went into all the kinds of oral contraception and the implant I think was just coming out

then.

It was still under the time when there was—I at eee hat la its alled

o, ut its suseuetl ee aolished, hee ou eet alloed to e see to

promote homosexuality at school, so there was very little information about LGBTQI

sex, but I think the teacher at the time was quite keen to inform us, so it was kind of

eupheisti. “he as like, This is useful fo all kids of se ith a detal da ad like

implied that you can well she made it clear that condoms can go on your finger, which I

think a lot of people in the class at the time found confusing but probably meant a little

bit more to them in later life. (Clarissa, UK)

Recommendations: Communicating with partners.

I thik, eah, fo epeiee that as a iseual I thik its easie actually to

deal with that with a man than it is with a woman. With a man, you can always insist on

the odo. You dot hae to sa, Its eause I thik ou hae “TD. You a sa, I

dot at to get pegat. laughs “o ou alas isist o haig condom when you

want to have sexual intercourse, but with a woman, you are just starting a relationship

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ad oue like, Ca I see ou “TD epot sheet? laughs Its kid of akad, ad ou ko, oue ot goig to use odo aa.

So how do you oah the issue of the “TD thig? I thik its akad….I hae

hole test esults o phoe. I ould easil just sa, Oh, hello. B the a, I just got

, this is “TD. Just plafull, ut, ho do I euest fo ous? “o it ould e uite awkward ad like ou dot tust the o—ith e, I e oal aout haig a a,

Whats ou status? But I fid it diffiult askig a oa that, so ad I thik othes hae that pole too….

Its oal disussio, ut ith a oa thee ist uh ifomation out there of ho to appoah it… “oe just thik its safe eause oue oa to oa, ut thee ae still isks out thee, ad just dot hae the koledge of ho to eall ope with that or how to broach it with women. (Tolu, UK)

Recommendations: Reduce sexual health stigma.

Clarissa recommended ways to reduce stigma:

Thees a lot of stiga still aoud agaist people ho hae a kid of seual health

issue…. I thik the pole… is soial… Thees a fea of eig see as soeod ho

has a “TI…. Mae talkig aout it i a a to e idful of health, like oe

information about how different things will affect different people. So if somebody has

opoised iuit, I feel like thees ot a ifoatio aout ho diffeet “TIs

affect diffeet people, fo states. I thik thats ig…. ad fo it to e kid of oe

about like community care, so more of an air of like this is—ause I thik at the

oet, a lot of ifoatio aout “TIs is e still uh like this sa peso ight

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hae a disease ad ou ight get it fo sleepig ith the, ad I thik that stiga—I

a see h the do it. Thee oiousl tig to ake people—its kid of like a fea-

mongering, but I think that makes the stigma worse, and then it makes people less likely

to atuall use a otaeptio eause the dot at to ipl that thei pate

ight e oe of these disgustig, stigatized people, ad I thik thees a lot of ot

wanting to cause offense, and also not wanting to be seen as diseased for the person

themself. (Clarissa, UK)

Experiences Related to Mental Health Care

The women shared about identity and disclosure in mental health settings, including individual and group counseling. Although the community social groups that some of the women participate with are very important to them, no women in the UK mentioned having participated with a mental health support group specifically for minority women. The recommendations pertain to increasing cultural competency in mental health care for bisexual women of African descent. Several recommendations specified under physical health care, such as nondiscrimination policies, could apply to mental health care as well.

Mental health challenges.

Annie described experiences of suffering:

I stopped drinking, and I suddenly could stop being numb for the first time after a very

log tie… I kid of sot of suashed do ad igoed o epessed a lot of past,

hih is a e diffiult past that I oe fo…. Its depessio ad etal health ad

emotioal thigs thats a ig oe, its a ig theat…. It takes a lot of stegth to get

, ut if I stop, ou ko,…Ie had depessio ost of life,… suiidal thoughts, the

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self-harming thoughts are there. I know if I stop being positive for any length of time,

those can get a lot stronger, and, you know, I would like to stay here as long as possible

ut e ale to lie i peae as ell… Annie, US)

Tolu described experiencing distress as a result of homophobic prejudice that affected her same-sex relationship.

I as kid of sad eause e oke up eause of the soietal pessue. “he ouldt

handle the pressure from her family anymore, and she left. She just packed her things

ad left, ad I as heatoke… I ealized that, efoe she et e she ast out of

the loset, ut eause I as so uh out of the loset, I didt thik aout the effet it

as goig to hae o he ad if she as ead fo it ad all that… That as eall sad. I

was also depressed about my relationship breaking down. (Tolu, UK)

Tolu shared about the stigma she has experienced, and the barriers she faces in social environments. She describes depression as an outcome of loss of social support.

I think I understand why my friends, some of them have stayed away.... Some, they give

ou suppot, ut the dot at to e pulil see ith ou, ad so it ould e e

depressing if you are not a staunch believer in what you are, and you will find yourself

depessed…. Tolu, UK)

“he futhe desies ho oes soial etoks a be impacted:

M o has eoe used to it… “he as just tellig e that people ask he, Wh is

ou daughte so oal aout this? Is she ga? Its ot soethig the ould ask i

good faith. Its soethig the ask to taut he… ad soeties she fids herself

saig, “hes just a hua ights atiist. Leae he aloe. Thigs like that. Tig to

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sta ad keep the peae ith he fieds, so its ot just aout ou as a peso. It flos

to people around. I can imagine my son will be affected too, by his friends, his young

fieds. Oh, ou o is a ko LGBT atiist. You o is ga. You o is this... It

ould eall ause depessio fo ou fail ees ad fieds….Tolu, UK)

Accessing mental health care.

The women described challenges in accessing mental health care. Clara expressed, I think for me personally I have nowhere where I feel comfortable and where it would, people would think it was like a point to be able to speak about how I feel as an LGB—how I feel as an

LGBT person, as a Black peso. Claa, UK

A referral from a general practitioner is required, and therefore presents a barrier to accessing mental health care, as Annie explained:

With the last peso I sa, it as fo sessios I thik;… thats like the allotted tie

oue given and then you sort of have a break and she said like if things get really bad

again I can be referred, but I have to ask my doctor first and start the process over, which

I ouldt hae ided, ut I haet, ou ko, I haet eall goe ak…. I know that

she said that she could extend it for a bit longer, but it would be a case of going back to

the dotos agai to get it…. Annie, UK)

Kareema also shared concerns about a requirement of a GP referral presenting a delay and a barrier to accessing mental health care. She did not know how to access mental health care services.

I thik fist ipessio is ho ould I talk to? I ouldt hae a lue. The ol tie I

see anything for counseling anyone is for those that have HIV, but for anybody that has

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a othe issues, I haet seen anything to say okay, well, you can go to this person and speak to the, ut that ould e eause I ot lookig out fo it. “o I ouldt ee know where to start with that or even how to answer that question fully, to be honest

ith ou. I ouldt ko uh aout eig ouseled o athig like that.… Ad seeing the GP (i.e. general practitioner) is quite time-osuig eause Ie ooked a appoitet to see doto fo soethig so siple, ut Ie had to ait thee

eeks, so i etee that tie if ou eall eed ouselig, oud ost probably just

at to tho ouself out the ido o soethig like that. “o I kid of dot see the point. It should be—a counseling session should be something that you can go to and the the a ae speak to ou doto aout it, ut ou shouldt have to wait for an appointment for the doctor and then to see a counselor. The process is too long.

(Kareema, UK)

Disclosure in mental health care settings.

Participants described experiences related to disclosure in mental health care settings.

Angela shared:

I recently had some counseling which actually really helped to make myself feel more assetie ad ofidet aout e. I thik… of hat othe people thik aout e ad thats diffiult soeties…. Around being bisexual and being of African descent, something that I struggled with and talked through with my counselor, although she was

White so she as supised hat I said ut she listeed,… the idea of ot elogig to your ethnic community, and feeling very much like if I meet other specifically Black people, eig eous to oe out…. Angela, UK)

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Katrina has not found a counselor who she felt was knowledgeable about someone of her identities and lifestyle, and for whom she did not have to provide a lot of education.

I have had counseling in the past. I have a myriad of issues. Very dysfunctional family.

Ie had ouselig, ut the people Ie see, the sped so uh tie like, Oh, o.

Youe eall diffeet. Youe eall eid. The dot eatl sa that. Disoe ho I

a. The dot eall sa that, ut its oe of a fat-fidig thig… athe tha atuall

helpig e. The hae to get oe the fat that I ot a feak fist, ou ko hat I

mean?.... Thats eatl ho I felt… its eteel uethial. The ould sa i thei

defese that the eed to udestad efoe the ould deal ith… Katrina, UK)

Lola preferred a counselor of a different background:

“he is White Eglish ad she as, she as atuall elutat at fist ause she aised the

uestio of that ith e e eal o. “hes aised it a ouple of ties eause shes

said that she doest hae the akgoud that I oe fo ad she ated to know

ho ofotale I felt ith that…. I feel e ofotale talkig ith he ad poal

feel more so comfortable because if I sat in the room with a counselor of, you know,

African Caribbean background, I would feel very uncomfortable because I would, Id feel

the alls lose i o e ad that the ould ake assuptios…. ad the thig is that

my experience of being amongst people of the same ethnicity as me has always been

e diffiult. Its a ouit that I as aised i. It as a ouit that I was forced

to ofo to, ad I just didt fit i ith a of it…. ad I feel that he I ith the

ouselo that I ith, thees a eutalit thee ad thees a spae thee. “hes ope

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to e…. Yeah, as a idiidual. Yeah, ad I just dot feel that I get that with a lot of

people of my cultural background. (Lola, UK)

Annie also described professionals not making assumptions as a facilitator. She gave her counselor a copy of a report on bisexuality.

The didt ake thei ids up aout e efoe I stated talkig. The didt just keep

goig ak to the sae thig. The let e sot of lead the disussio. The eet

akig assie assuptios. The last oe I sa,… I actually printed up a copy of The

Bisexual Report and gave it to her because she didt, she said, I dot, I just dot ko

athig aout iseualit. That as soethig good. I said, Keep it ad shae it ith

ou fieds. (laughs) (Annie, UK)

Recommendations for improving mental health care and well-being.

When the women were asked for recommendations for improved health care, they also provided information pertaining to mental health. The related interview questions were as follows.

Ho ight ou adise poides o othes to teat ou i ode to poote tust ad/o dislosue of seual oietatio, o othe health ae oes o eeds?

Ca ou tell e aout health ae esoues, ad a hages that ou feel ae ipotat to e ade?

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depression. The women also lacked role models. While the women did not specifically state recommendations that mental health providers be aware of these processes and needs for support, the researcher considered that these may be latent concerns.

The women face challenges coming out and communicating with their families, friends, and communities. The women could potentially benefit from skillful support to manage processes of stigma and stigmatization, and to navigate complex socio-political environments.

Improving mental health care: Cultural competence.

Clara recommends holistic services for African descent bisexual women.

In terms of my ethnicity and gede ad seualit, the I… at to e ale to go

to oe age ad fo the to e ale to delie ause otheise, ou ko, Id sped

fa too uh tie, ad also its haig to eplai ou sto…. If people ignored that,

especially with gender, ethnicity, and sexuality, if people were like dismissive or

negative about what it means to them, how would that make you feel?.... You get

onboard with your client. You get onboard the train with your client. (Clara, UK)

Improving mental health counseling: Support groups and family counseling.

Kareema recommended services such as counseling and support groups designed to meet the needs of African descent bisexual women and their children. Kareema described the processes non-traditional families and children undergo, and the need for support groups for alternative families in the passage below.

I think the only thing that I would like to see is more support for children with

parents that are not heterosexual because when I had my girlfriend and my children,

obviously they grew up and they became aware of these things. It was very difficult for

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the, ad I didt fid a help o athig like that. It as soethig that I liteall had to deal with on my own and with my family.

So it would have been nice if there was maybe something—or even a counseling session or something that I could go to with my children so they could talk about what issues they have, what help would have been available to them, and just for them to speak to somebody else other than me, do you know what I mean? So that would be

ie eause thees I ko a lot hilde out thee that thei paets ae ga, ut the

hilde ae dealig ith a ose aklash tha the paets, espeiall at shool ause kids are really cruel. I know that happened with my son and then someone was like,

Oh, ou os a lesia! You os ga! Thee eall, eall uel….

There was nobody to speak to, so I think there needs to be something where—I dot ko hethe a ogaizatio eeds to e uilt, hethe its to do ith

ouselig, I dot ko, ut just soethig fo the hilde that I thik thee completely—as much as we speak about the adults and the bisexuals and all the

ople issues ithi the ga ouit, thees hilde that oe out of that, and I thik that thee e uh fogotte.

I hae ee see oe, so I thik thees a gap thats ope. If I ke ho to stat soethig like that Id ost poal at to stat it self eause Ie kid of got maybe a small little bit of experience or even help out with something like that. I would love to be quite visible in that. (Kareema, UK)

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Theme 4: Resilience

I ou da to da life, hat sustais ou ad helps gie ou a sese of stegth?

What ae soe of ou ai da-to-da oes?

What ae soe of the esoues that sustai ad suppot ou?

What helps ou feel that ou hae pupose ad ou life is eaigful ad

othhile?

What esoues o atiities ig a sese of ejoet o hope?

What esoues help ou to feel utued ad estoed?

The women shared the following about resources they are accessing and utilizing in their day-to-day lives to support their well-being and resiliency. The oes esposes to these general questions were grouped as described below. Because similar responses (i.e.

soial suppot, o eeise) were provided to several questions, similar responses are categorized together rather than listed as duplicates under each question.

The information in this section on resilience is organized under two subthemes that emerged from the data:

. Social support is a primary source for well-being and resilience.

. Activism and self-nurturing activities also facilitate resilience.

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Social Support is a Primary Source for Well-being and Resilience

Participants often stated that their relationships and social support were very important primary resources for resilience. Since described in detail in sections above, the researcher will

ot go ito detail hee, ut ishes to ote that soial suppot as the ost feuet response to the questions about resources for resilience.

Activism and Self-Nurturing Activities also Facilitate Resilience

Detailed below are self-nurturing and creative resources that support their resilience.

The women described activities that support a sense of wellness in body, mind and spirit.

Activism.

Tolu described her social justice perspective as a motivating force: I thik its just aout my freedom, my love for freedom, my belief in equality has been my motivating factor in everything, in all the aspets of life. I thik its ee a fiee otiatio, ispiatio. Tolu,

UK)

Physical and outdoor activities.

Physical exercise is an activity that can be beneficial. Angela shared:

Yeah, I was thinking actually dancing for me is like a real a of like, I dot ko,

feelig eall i self, i od, ad feelig uite fee. Like thees a e lu ight

hee ad its like a just alteatie hip hop lu ight ad e ad fieds hae ee

goig eall egulal ad its just, I ould just, I could spend the whole night on the

dae floo ad I dot at to do athig else, like just epess self ad it feels like

a outlet. “o daig is eall ipotat to e ad eah, a geat a to just, I dot

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know, just be for a little while and not really think about anything else and enjoying

myself. (Angela, UK)

Community involvement, creativity and self-expression.

Several women enthusiastically described the role of the arts in their lives, including group activities. Claissa shaed: I eall ejo itig it. I feel like it feels puposeful. Claissa,

UK)

Several women spoke of the benefits of music. Katrina said: “I like usi a lot. I e into listening to jazz at the moment. Kind of sociable because everybody—the same—I like that.

I like going to different plaes to do that.

Kareema utilized uplifting music. She shared, I loe usi. “o thats soethig that I wake up just loig to do ad that gies e aothe soue of stegth he I feelig a little bit on the low side…. I thik I a liste to that ad get upliftet fo that…

Tolu finds music with social justice messages inspiring. She shared, I loe Bo Male, and he was one of my greatest, earliest inspiration, you know, talking about human rights for all. “tad up, get up, stad up, stad up fo ou ights… That kid of ispied e as a oug

hild… He ispied e ith his usi…

Lola benefits from an inclusive community choir:

I i a hoi. Thees a alteatie hoi, ad asiall it iludes eeybody from

diese ouities, so LGBTQ,… o athig like that o aoe ho suppots the. I

take pat i this hoi, ad…. thats aothe spae hee I a just e self ad

eeoe else thee is just eall ofotale ith just eig theseles…. But eah its

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been really good to just stand up and just be myself and sing as well. The new normal is

being yourself, not fitting into what other people want for you. (Lola, UK)

Cultural heritage and spirituality.

Angela described ways she incorporates culture, history, and literature to support a holistic sense of self.

Learning about my history at the moment is really important to me, so that and like

leaig aout spiitual kid of heitage, so fo Jaaia ad fo Afia. I tig

to learn a lot more about the different spiritual traditions and as a way of just trying to

fid like o oots…. Ad also leaig aout Blak feiis ad Blak histo ad

like fidig uees ithi that is eall soethig that I fid eall poeful ause

theres a lot of silees aoud Blak uee oe, patiulal i histo. Whe e

fid stuff out its so eitig, ad so eadig like Zami by Audre Lorde. That was really

poeful to kid of plae soe of ou epeiees i the past... Cause I thik i a lot of

Caribbean countries and African countries this idea that being queer is a White Western

kind of import, and that makes me feel disconnected from my kind of cultural heritage.

“o eah, I tig to ake those liks is eall ipotat to e. (Angela, UK)

Though several women choose not to have religious affiliation, some have found religion beneficial. Kaeea shaed aout he spiitual idetit deelopet: It gies e a sense of strength sometimes to know I have to actually get up, pray, and it makes me feel a lot

ette he I do that. Ie gie God the paises, so I ko thee ust e soe ead soehee. “o I get a lot of stegth fo pae. Kaeea, UK

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Travel.

Experiences of travel can contribute to resilience. Katrina shared, I like to travel a lot.

Places where nobody knows me. I like to go places where nobody knows me. Just enjoy

self.

Chapter Summary

As indicated in the section above on social support, few of the women were able to rely on families of origin for social, emotional, or economic support. Several of the women did not have close friends or partners in their local area upon whom they could rely for social support.

Several of the women knew of no other African descent bisexual women in their social networks.

The women were asked to share about their health care experiences and decision- making processes related to disclosure and non-disclosure of sexual orientation.

Nonjudgmental health care delivery facilitates health care seeking behaviors. Judgment and biased comments are barriers to developing an effective relationship between provider and client. Participants did not mention providers asking them whether they have questions.

The women tend to go in for care regularly, for which they have mentioned no charges is an incentive and facilitates access, even if treated impersonally. One participant felt more comfortable upon seeing a plaque in a clinic indicating LGBTQ awareness and training.

Some of the women had concerns about having information recorded in their medical record that could contribute to stigma. They want women to be informed about their options for records confidentiality.

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Participants were at times more likely to disclose sexual orientation with mental health care providers than with physical care providers. Participants were more likely to disclose sexual orientation with physical care providers if the provider was more conversational and made the time for a health discussion. One participant was hesitant to disclose if she felt sexual orientation and lifestyle would be recorded in a medical record.

Women who disclose bisexual identity publicly, with better experiences of social support over their lifetime, were more assertive in disclosing bisexual identity in health care settings. Those with a background in community organizing were also more likely to communicate assertively with health care providers. With the national health care system, women in the UK did not mention a need for outreach to the same degree as women in the US mentioned a need for outreach to connect women with health care resources, though one participant recommended workshops for sexual minority women.

Most of the participants wrote on their demographic forms or expressed during their interviews that they experience manifestations of suffering such as depression. At least one participant spoke of recovery from alcohol use. Considering their experiences of low social support and lack of validation in society in which they are devalued as African descent and bisexual women, their expression of mental health challenges seems understandable.

Several of the women found professional counseling crucial for their well-being, especially during times of crisis. In light of the limited socioemotional resources, availability of affirming and validating professional counseling is important. Professionals can encourage women to continue to pursue self-nurturing activities of resilience, such as those the women mentioned in the section on resilience (i.e. writing, exercise, etcetera).

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In Chapter 6 the US and UK results will be discussed. Themes which emerged during analysis will be described in relation to the research questions. The findings of this study will also be discussed in relation to earlier studies, and the extent to which the findings of the current study confirm or extend earlier findings on the well-being of sexual and ethnic minority women. The findings from the UK will be compared with the findings from the US.

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CHAPTER 6

CONCLUSIONS AND IMPLICATIONS

The research questions for this study sought more information in the following areas.

1) What are their experiences related to identity and disclosure in social support networks and health care settings? 2) What recommendations do they have regarding their needs in order to feel safer to disclose and ways service provision can be improved for women like them? 3)

What resources are the women accessing and utilizing in their day-to-day lives to support their well-being and resiliency?

In Chapters 4 and 5, data was presented supporting the main themes and subthemes which developed during analysis. In this final chapter, the main themes and subthemes are discussed in relationship to the literature and earlier research findings. Similarities and diffeees of the oes epeiees i the U“ ad the UK ae also discussed in this chapter.

Concern was expressed earlier about lack of attention to the HIV prevention health issues and needs of sexual minority women (Mays, 1996; Morrow, 1995). Recent studies on the health concerns and unmet needs for prevention for sexual minority women indicate more needs to be done to improve cultural competency particularly in health care (Champion et al.,

2005; Teti & Bowleg, 2011). The importance of focusing not just on sexual health but more broadly on health and well-being is emphasized (Teti & Bowleg, 2011). Therefore this study sought to examine, through the research and interview questions, well-being overall and more specifically social support and health care including prevention. Unfortunately, the perspectives of women living with HIV/AIDS were not able to be included in this study.

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Discussion Related to Research Question 1

In this section, the first research question is addressed. What are the experiences of these women related to identity and disclosure in social support networks and health care settings? Related themes are discussed.

Theme 1: Identity

For sexual minorities, identity development usually involves difficult processes of coming to terms with oneself and a struggle for self-acceptance (Bates, 2004; Bates, 2012;

Brewster & Moradi, 2010; Fingerhut, Peplau & Gable, 2010; Meyer, 2003). The women participating in this study described similar difficult and complex processes of identity development. The women exercised empowerment in seeking to develop social networks that support their identities as bisexual women of color. Participants believed that affirming social support was essential to their sense of integration, wholeness, and well-being.

Bisexual identity is experienced as non-binary.

This subtheme emerged from participants emphasizing their choice to use the term

iseual to desie a o-dualistic identity. The women commonly expressed a capacity for attraction regardless of gender (male, female, or transgender), in both the US and UK. Some participants had only female partners. Some of the women had male, female, and transgender partners during their lifetime.

Identities of race, gender, and sexual orientation are intersectional.

Most of the women in the US and UK described intersectional experiences of identity, as researched and written about earlier (Cole, 2009; Moore, 2010). At least half of the UK participants expressed identifying with LGBTQ people of color, and relying on these social

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etoks; oe of those patiipats also epessed haig oe to a sese of a universal hua ae. Half of the U“ patiipats epessed that epeieig disiiatio i soiet contributed to ethnic identity being considered primary, gender identity secondary, and sexual orientation identity being considered tertiary. Some of these US participants still found social support in friendships with White people.

Some though not all of the women in both the US and the UK indicated that heteooatie ias fo oes ethi ouit ould otiute to a edued sese of ethnic affiliation for some women. Heteronormative bias involves operating as though heterosexuality is the norm, reducing the likelihood of affirmation for ABW. At least one participant in the US and one participant in the UK who had experienced conservative views in their families and communities of origin, expressed self-acceptance while not prioritizing affiliation with an ethnic community.

Identity development is impacted by stigma and influenced by support.

Stigma, prejudice, and biased perspectives, especially ithi oes fail ad/o ethi community, were barriers to bisexual identity development. Bullying and lack of role models were cited as barriers. Leaving home as a young adult, and finding supportive people and communities, facilitated bisexual identity development. Having young children, and fear of job loss, were barriers reducing likelihood of disclosure.

Theme 2: Social Support

Experiences and resources of social support vary.

Consistent with the model of minority stress (Meyer, 2003), social support was a very important resource that the women considered essential to their well-being. As found in earlier

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studies, several participants in this study expressed caution about disclosing their identity as a sexual minority especially with members of their ethnic community (Bowleg, et al., 2008;

Moradi, et al., 2010). As found in these earlier studies, both US and UK participants experienced actual or potential loss of social support as very harmful; and considered it important to maintain existing levels of social support if possible. At least one UK participant had experienced significant and nearly total loss of socioemotional and instrumental social support following her disclosure as a sexual minority woman. Some US and UK participants decided not to disclose or discuss their identity with family members, if the participant believed acceptance would be unlikely due to biased attitudes.

Persons who are both ethnic and sexual minorities can face grave challenges obtaining unconditional acceptance and support within their African descent community (Moore, 2010;

Woody, 2011). Facing similar challenges, most participants in both the US and UK, had low or no social support from their family of origin, though several had a supportive parent and/or sibling. Some of the participants, in the US and UK, had at least one very supportive parent who often still struggled with acceptance. A few US and UK participants grew up in single mother headed households. Only one participant in the study, based in the US, described having the unconditional support of both of her parents. Some women had no contact with parents or family of origin, including two UK participants who were survivors of child abuse and violence.

Social networks are needed that support oe’s idetities.

The women sought affirming relationships and social networks that support their identities. Judgment and rejection, including from family members, contributed to stress and distress, as found in a review of earlier studies (Meyer, 2003). Most participants in the US and

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UK expressed experiences of suffering such as depression and even suicidal feelings. Some though not all of the participants in the US and UK who spoke of having good social support resources, spoke less of depression. Therefore, social support did seem to serve as a buffering effect in relation to stigma and discrimination for some of the participants, as found in an earlier study (Szymanski & Kashubeck-West, 2008).

Earlier research is limited about social support for bisexual African descent women

(Page, 2012; Woody, 2011), as much research focuses on sexual minority identity. Several women in this study emphasized the helpfulness of having friends, especially queer and transgender people of color, who understood and were willing to hear about and discuss experiences of oppression. In recent years, most participants in the UK had success in deelopig ilusie etoks, teed uee, tasgede ad itese people of olo

(QTIPOC) community. Only one participant in the UK expressed isolation and loneliness as a bisexual woman of African descent, at the time of the interview. At least half of the US participants expressed isolation, lacking close supportive local friendships, and/or having social networks without other LGBTQ people of color. At least half of participants in the US and in the

UK indicated having no other bisexual women of African descent in their social networks; some thought it would be helpful if they could share concerns with a woman who may have similar life experiences.

Behaviors constitute barriers and facilitators of disclosure.

Close socioemotional relationships characterized by unconditional compassion and acceptance, especially from family members, facilitated ease of disclosure. Having to explain bisexual identity and orientation was cited by participants as being a barrier to disclosure.

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Biased and judgmental views, including religious beliefs, discourage disclosure. Family dysfunction and poor communication were cited as barriers to disclosure.

Being in a significant same-sex relationship facilitates motivation to disclose and

ouiate, toad ieasig fail ees ad othes udestadig. The women were more likely to embark on a process of disclosure if in a significant relationship with a same-sex partner. Participants tended not to disclose to their parents unless they were in a significant relationship with a same-sex partner; otherwise they felt it was not worth the risk to disclose bisexual orientation.

Theme 3: Health Care

Experiences and resources of health care vary.

The experiences the participants described were similar to those reported in earlier studies conducted in both the US (Cochran, Sullivan & Mays, 2003; Miller et al., 2007; Teti &

Bowleg, 2011) and in the UK (Barker, et al., 2012; Colledge, Hickson, Reid & Weatherburn,

2015; Hunt & Fish, 2008). Health care experiences and resources are discussed below.

Disclosure.

Several US and UK participants in the current study felt uncomfortable to disclose bisexual identity with physical health providers, which is consistent with findings of earlier studies in both the US (Bowleg, et al., 2008; Cochran & Mays, 1988; Durso & Meyer, 2012) and in the UK (Hunt & Fish, 2008). In the current study, half of the six US participants had not felt comfortable to disclose sexual orientation or identity to physical health care providers, as was found to be the case in an earlier study with lesbian and bisexual women (Bowleg et al., 2008).

At least seven of the eight UK participants had disclosed sexual orientation or identity in

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physical health care settings, though at least two expressed discomfort about potential reactions by providers.

Some of the women felt more comfortable to disclose with mental health providers, which has not been reported in many earlier studies. Participants of the current study in the US and UK who had disclosed to providers, reported more experiences of being affirmed by mental health providers than by physical health providers. As detailed through UK patiipats uotes in Chapter 5, physical health providers were notably less likely to acknowledge the disclosure or respond with affirmation. As detailed in Chapter 4, two participants in the US, who had not disclosed with physical health providers, had mental health providers with whom they had felt safe to disclose bisexual identity. Two participants in the UK who declined to share (or limited information they shared) with physical health providers, were willing to share more information about their relationships with mental health providers.

At least one participant, in both the US and UK respectively, were more fearful of potential bias from mental health providers who are of African descent. The US participant mentioned here had negative experiences with the African American mental health provider(s) her parents selected while she was in high school. The UK participant mentioned here, who sought out and selected an affirming provider who is White, stated that she found the perspective of African Caribbean persons to generally be too conservative for her to feel comfortable with them. However, one of the US participants mentioned in the paragraph above, who had never disclosed sexual orientation or identity to a medical provider, had good experiences of services from mental health providers who were African American heterosexual and bisexual women.

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The few participants in the US and UK who had health care experiences with a nonjudgmental and affirming medical doctor who provided competent services, found these experiences beneficial. Only one participant in the US expressed a very good relationship with her long-term primary physician. Only one participant in the UK expressed very good experiences with services at a reproductive health clinic designed for sexual minority women, although she encountered less competency in physical and mental health services at other locations.

Most US and UK participants in this study encountered biased assumptions about sexual orientation and identity in health care environments, particularly during intake processes. Even when bisexual orientation was written on the intake form or recorded in their medical record, at least one US participant and several UK participants felt providers did not read or acknowledge the information. It was difficult that the UK questionnaire was anchored to birth control, and sexual orientation was not asked until later in the process.

Unlike in their social networks, few women had their bisexual identity affirmed by doctors and nurses. Reluctance to seek care may be related to non-affirmation on the part of medical providers. This is potentially a very critical finding, as failure to affirm the identity of bisexual women of African descent is likely to adversely affect the ability of the health profession to build effective working relationships with these women. A UK participant mentioned being excited about LGBTQ-inclusive settings that reflect diversity in staff and clientele, and half of the US participants stated they would be more interested to seek care if

LGBTQ-inclusive services were available.

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Mental health.

Several US and UK participants in this study expressed life experiences entailing severe suffering in the forms of mental illness and depression, as found in earlier studies with sexual minority women in both the UK (Barker, et al, 2012; Hunt & Fish, 2008) and in the US (Lehavot,

2012; Lehavot & Simoni, 2011; Mays et al., 2003; San Francisco Human Rights Commission,

2010). The UK participants spoke in greater detail regarding mental health. At least one UK participant stated she had prior suicide attempts; another described having had suicidal feelings. One US participant had sought in-patient care, and another stated counseling had

saed he life at oe poit; oth epoted these as good health ae epeiees.

Prevention.

There have been a few important studies regarding HIV/AIDS prevention and care for lesbian and bisexual women (Champion et al., 2005; Teti & Bowleg, 2011; Teti, et al., 2008). It is known that bisexual women are less likely to receive preventive health care than heterosexual women in the US (Mays, et al., 2002), and in the UK (Hunt & Fish, 2008). Women who have only female partners can still face risks and health issues (Bailey, Benato, Owen, & Kavanagh, 2008;

Hunt & Fish, 2008; Marrazzo, Koutsky, Kiviat, Kuypers & Stine, 2001), including HIV transmission

(Kwakwa & Ghobrial, 2003). It has been emphasized that bisexual women need information about safer sex and risk reduction practices (Barker, 2007; Champion et al., 2005; Fethers,

Marks, Mindel & Estcourt, 2000; Fish, 2007; Hunt & Fish, 2008; Marrazzo et al., 2005; Miller et al., 2007; Tao, 2008; Teti & Bowleg, 2011; Teti, et al., 2008).

There are significant disparities in HIV and STD screening in the US compared to the UK, related to the difference in health care access. In the UK, access to services could vary by

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location, however basic health care was available without charge. Even employed participants in the US often lacked health insurance and access to health care; three of the six US participants lacked insurance, including two who were working. This is especially true when considering primary care, the setting in which women are most likely to receive comprehensive and holistic services.

Prevention and testing.

This study obtained more information about testing for ABW. In both the US and the UK, women usually had to specifically request HIV and STD screening. All eight women participating in the UK stated they had tested for HIV, and had received a negative result. Four of the six women participating in the US stated they had tested for HIV and received a negative result; however two of the six women stated they had not yet tested. Of the women in the US who had ot et tested, oe patiipat as i he s ad oe patiipat as i he late s.

Participants in the UK described obtaining comprehensive STD screening as often as every six months, as well as on an as-needed basis if symptoms arose, yet most were not provided comprehensive safer sex and prevention information relevant for a bisexual woman.

One participant who is committed to screening every six months had never been provided health information for a woman who dates women or has a female partner. In the US, one participant said comprehensive STD screening could be unavailable outside of a major city, and that the fees at a clinic within a major city were expensive. Some participants in both the US and UK were uncomfortable about being asked to provide personal history information in order to obtain screening. Some participants in the US expressed discomfort to seek health care and screening, even if they had insurance, in some cases due to low trust of provider cultural

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competence. At least one UK participant mentioned stigma as a barrier to going to a sexual health clinic, even for the purpose of obtaining condoms. Women who were trained in health and HIV education, and women who were community organizers, tended to be able to be more proactive and assertive in seeking health care, and disclosing sexual identity, in both the US and

UK.

In both the US and the UK, most participants did not receive information about healthy same-sex relationships from medical providers, even when they disclosed bisexual identity and orientation, consistent with earlier findings (Hunt & Fish, 2008). In the UK, most participants stated that they are asked during the standardized registration or intake process for demographic information, but then are treated the same as though they had not disclosed bisexual identity. Males disclosing same-sex partners in the UK are offered specialized information and culturally appropriate health information as well as testing, according to participants. Several US participants emphasized a lack of outreach to sexual minority women compared to outreach for sexual minority men. A UK participant recommended educational workshops for sexual minority women, as has been offered for sexual minority men.

The information provided in medical settings was usually heteronormative, except for one participant in the US and one participant in the UK who were told about or offered dental dams in addition to condoms. In general, participants in both the US and UK received more health information from peers than from professional providers. For several of the women, more health education was received in school rather than in medical settings, but they often were not able to integrate and apply this information in intimate relationships. Several

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participants in the US and UK expressed particular difficulty broaching issues of prevention and health relationships with same-sex partners.

Environmental cues and behaviors constitute barriers and facilitators of disclosure.

For both US and UK participants there seemed to be a pattern whereby family and friend social support may facilitate increased likelihood of confidence, assertiveness and disclosure in health care settings. Some of the few participants in the US and UK with better experiences of social support over their lifetime, particularly in terms of being accepted by their parent and family of origin, also expressed experiencing supportive health care providers with whom they felt safe to disclose bisexual identity. Some of those who were able to disclose and be accepted by family members and friends expressed more confidence in communicating with health care providers and were more likely to be willing to disclose bisexual identity in health care settings and with health care providers.

Judgment and rejection by parents and family, and family dysfunction compounded by socioeconomic disadvantage, may contribute to decreased confidence and assertiveness with medical providers and in health care settings. Participants in the US and UK with low social support and limited disclosure in general, were less likely to disclose bisexual identity in health care settings. Three participants in the US, who had not been affirmed by their parents, expressed seeking health care infrequently; two of these participants had health insurance, and neither had disclosed sexual orientation or identity to a physical health provider.

The registration or intake process can either facilitate disclosure or comprise a barrier.

Provider knowledge, and appropriate intake questions, facilitate disclosure. Participants in the

US and UK were less likely to disclose if provider communication conveyed heteronormative

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assumptions. In such situations, the women believed the provider was unlikely to have information specific to the health of bisexual women.

Having an established long-term relationship with an individual provider, rather than seeing a different practitioner at each appointment, facilitated disclosure. Providers making time for quality communication, with a respectful manner, facilitated disclosure. Participants in the US and UK expressed being more likely to disclose sexual orientation with physical care providers when the provider was more conversational, and focused the discussion on appropriate clinical topics pertinent to the client, without placing the burden upon the client to educate or inform the provider.

As mentioned above, it was notable that participants in both the US and UK were more likely to disclose sexual orientation and identity with mental health care providers rather than with physical health care providers, perhaps in part due to the length of time of the appointment and/or seeing the same provider more than once. Participants in the US and the

UK mentioned not always being seen by the same provider each time for physical care appointments, and were more likely to state having had the same provider for a series of mental health care sessions.

Posting LGBTQ training certification in the health care agency facilitated disclosure in the UK. One participant in a major UK city stated that she appreciated access to health care clinics with services designed specifically for sexual and gender minorities. Some participants in the US stated they could not afford to seek care at private clinics that advertised as LGBTQ- inclusive. A participant in the UK expressed uncertainty that settings developed for lesbian and gay clients would also welcome bisexual clients.

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A US participant expressed hesitancy to disclose if she felt sexual orientation and lifestyle would be recorded in a medical record and have potential consequences, especially for single mothers who have child custody and receive government assistance. A participant in the

UK was concerned a general practitioner could react with bias to information recorded by a sexual health provider; she expressed knowledge that sexual health records can be kept out of oes ai edial eod upo euest, ut stated she did ot ko hethe othes ee informed or aware of this option. Beig oeed oes paets isuance in the US may play a role in reluctance to seek health care related to sexual health or mental health, and only seeking care for conditions such as the common cold.

Discussion Related to Research Question 2

Theme 3: Health Care (Continued)

In this section, the second research question is addressed. What recommendations do they have regarding their needs in order to feel safer to disclose and ways service provision can be improved for women like them? For the purposes of this study, service provision includes physical health, HIV prevention, mental health, and social services. Related themes are discussed.

Specific changes can improve services for African descent bisexual women.

As described in detail above, the participants faced many challenges related to health and social care. Changes are needed in order for health and social care to be delivered appropriately for bisexual women of African descent in the US and UK.

The women who participated in this study made recommendations that focused on creating more inclusive and supportive environments for delivery of health and social care. The

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oes oeall well-being would be supported by medical providers who affirm their identity and provide appropriate health information and testing. Health care will not be able to support the well-being of these women until the institutions treat them as normal within the human spectrum of diversity, as marginalization and pathologizing contribute to distrust and health disparities.

Most importantly, the women cited a need for comprehensive health care access. The women in the US who lacked access to health care were very distressed, and are unable to address health needs including chronic physical and mental health issues. Some participants in the UK felt affected by budget reductions, with the general availability of some health care services varying by location.

Participants requested that providers use inclusive language, that reflects knowledge of and respect for diversity. Particularly in the UK, the women emphasized that the physical health registration or intake questionnaire should focus on general health, and not be anchored to birth control. Some women requested that the process facilitate disclosure, through being asked questions that convey provider knowledge about diverse sexual and gender identities.

When bisexual identity is disclosed, the provider should acknowledge and address this information without immediately proceeding with unrelated questions, perhaps similar to health care processes designed for men who disclose having male partner(s) in terms of being tailored specifically for the population.

Women in the US and UK emphasized a need for services and outreach tailored for ethnic and sexual minority women. The women recommend posting an LGBTQ-inclusive nondiscrimination policy, and advertising that the health and social care services are inclusive of

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diversity. Participants frequently mentioned resources targeting heterosexual women, and gay and bisexual men. The women expressed that resources need to be developed that are intended for and feature bisexual women of African descent. Bisexual women of African descent have special needs due to lack of information about options for risk reduction in same- sex relationships. Providers need education and training about the health and prevention needs of bisexual women of African descent.

Several participants in the US and UK stated they want comprehensive HIV and STD screening to be offered routinely and provided upon request without invasive questions. A participant in the UK expressed that services not be provided exclusively in sexual health clinics, but be made available and addressed by general practitioners. Two US participants expressed preferring to be able to choose a provider who is female and/or openly LGBTQ. The women in the UK want to be offered the option that their partners, especially female partners, have the same practitioner in order to facilitate screening and partner communication about sexual health. Earlier studies found treatment ineffective when only one partner is being treated

(Fethers, et al. 2000; Fish, 2007; Hunt & Fish, 2008). A woman in the UK recommended that stigma against those living with a sexually transmitted disease be addressed and eliminated, and that the focus be increased on prevention for immune compromised persons. Based upon concerns expressed by the women, the researcher believes providers need to consider how changes in record keeping policies and practices may facilitate and/or discourage client disclosure of sexual identity or sensitive information.

In both the US and the UK, several participants spoke of the importance of mental health services. Several participants, in the US and UK respectively, spoke of severe experiences

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of depression in their lifetimes, sometimes related to the ending of a significant relationship particularly a same-sex relationship. Participants felt it was important that physical health providers be willing to take information about their mental health concerns and address any needs such as referrals; at least one participant in the UK did not know that mental health services are available at no cost. Participants recommend that culturally competent counseling and inclusive support groups are available for bisexual women of African descent and their children, in the US and the UK. Participants felt benefitted by providers competent in providing professional support for identity development and establishing interpersonal relationships.

Several recommendations specified under physical health care, such as inclusive nondiscrimination policies, could apply for mental health care as well.

It is very important that health care providers, including doctors and nurses, normalize diversity of sexual identity and orientation, and affirm bisexual women of African descent. The affiatio is ipotat fo the oes well-being, and is fundamental to an effective professional and therapeutic relationship according to researchers in both the US (Bradford,

2006; Brooks, et al., 2010; Fox, 2006; Page, 2004) and in the UK (Barker, 2007). Participants in the US and UK reported numerous distressful experiences encountering non-inclusive health and social care. They need culturally competent and sensitive providers who can provide holistic comprehensive services for bisexual women of African descent.

Discussion Related to Research Question 3

In this section, the third research question is addressed. What resources are the women accessing and utilizing in their day-to-day lives to support their well-being and resiliency?

Related themes are discussed.

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Theme 4: Resilience

Social support is a primary source for well-being and resilience.

The women emphasized the primary role of social support for their well-being. Most ofte etioed ee soial suppot, elatioships ad etoks as suppotig the oes well-being, resilience and strength. Unconditional affirming social support was important, whether from family or friends; though it was particularly beneficial to have a fully supportive parent. This confirms the theory developed on the fundamental importance of a Sense of

Belonging for African descent bisexual and lesbian women (Page, 2012).

Activism and self-nurturing activities also facilitate resilience.

The oes esoues of esiliee ee siila to those etioed i a ealie stud with women who are both ethnic and sexual minorities (Bowleg, et al., 2008), particularly working actively to resist oppression. For at least half of the participants in the US and UK respectively, community organizing across a range of socioeconomic issues was a fundamental practice for the purpose of collective well-being. Spirituality was an important resource for some of the women, as mentioned in earlier literature (Canda and Furman, 2009; Tan, 2005;

Jeffries et al., 2008). Resources and activities that support their resilience include: Multicultural, feminist, and LGBTQ literature; inspiring music and lyrics; writing; the arts; exercise; and affirmations.

Barriers and facilitators of resilience practices.

Women who were mothers expressed the necessity of prioritizing meeting the needs of their children, especially single mothers of young children. At least one mother in the US working full-time found it difficult to find time to nurture herself, but stated that she enjoyed

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opportunities to join alternative lifestyle meet-up groups. A mother in the UK also had difficulty spending time focusing on herself individually, but was happy to share about creative and artistic activities and performances that she participates in together with her child. Therefore, having young children could both encourage a mother to engage in activities that support her resilience, while understandably influencing the availability of time to focus on her own individual needs.

Several participants in the US and UK were very motivated to work for socioeconomic justice. The women sometimes described their perspective not so much as how they keep going which can feel very difficult, but how they manage to not stop struggling for a better life and world.

Implications for Practice and Policy

The findings of the current study indicate that many of the concerns and recommendations of earlier studies regarding needs for improvements in health care for sexual minority women, still need to be implemented. Participants in the current study shared extensively about ways health care can be made more responsive and inclusive for bisexual women of African descent.

A finding of the current study that adds to the information currently available on the needs of bisexual women of African descent, is that the participants had more beneficial experiences following disclosure of sexual identity with mental health providers rather than physical health providers . However, consistent with earlier studies in the US and UK (Bowleg, et al., 2008; Cochran & Mays, 1988; Hunt & Fish, 2008), at least half of participants in the US

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and UK respectively reported actual and/or anticipated negative experiences with physical health providers related to disclosure of bisexual identity.

A primary motivation for this study was the disproportionate impact of HIV among

African descent women in the US and UK (AIDS.gov, 2012; Centers for Disease Control (CDC),

2011; CDC, 2012; Health Protection Agency, 2011), and the limited empirical information regarding the well-being and needs of bisexual women as a subgroup, especially for HIV prevention and care (Champion et al., 2005; Teti & Bowleg, 2011; Marrazzo, 2000; Morrow,

1995). In the current study, in-depth interviews were conducted with women in the US and the

UK, in order to increase attention to the life experiences and health needs of African descent bisexual women. Despite extensive efforts to reach women living with HIV, all participants in the study who had tested had received a negative result. Yet, the importance of health care and universal screening for African descent bisexual women is not premised on prevalence of HIV within the population; universal screening is a best practice, as implemented in the US state of

New York (The New York City Department of Health and Mental Hygiene, 2010).

Nondiscrimination policies in health and social care should be clear. Provider intake processes should be non-biased, and verbal and written language should indicate awareness of the normalcy of varying sexual and gender identities over the lifespan of the individual.

Providers should appropriately acknowledge information about sexual and gender identity specified by a client, and deliver care accordingly.

Provider Education

LGBTQ education and training should be required for all social workers, doctors, nurses, and other health and social care providers (US Department of Health and Human Services,

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2011). Whereas many syllabi contain a statement regarding diversity and inclusion, curriculum content and pedagogy are still substantially heteronormative. Professionals and students in training need to be familiar with all of the seminal and recent conceptual and empirical literature on LGBTQ issues (such as Fairtlough, Bernard, Fletcher & Ahmet, 2013; Fish, 2008;

Fish, 2009; Fish, 2012; Hunter & Hickerson, 2003; Israel & Hackett, 2004; Lim, Brown, & Jones,

2013; Martin et al., 2009; Mayer, Mimiaga, VanDerwarker, Goldhammer & Bradford, 2007). An online source for locating literature and educational programs is LGBT Health Resources:

Resources and Literature for Clinicians on LGBT Health Topics (American Medical Association,

2015).

Social workers can play a key role, supporting the interdisciplinary team in increasing awareness and understanding of the needs of ABW. As stated above, some participants were affirmed by mental health providers, experiences which they found beneficial. Overall, participants were considerably more comfortable to disclose sexual orientation and identity with some mental health care providers rather than with most of their physical health care providers. If this is the case more broadly, social workers could perform a useful role in raising awareness of diversity in health care settings; and mental health providers should be willing to support prevention for ABW, including encouraging HIV and STD testing.

Social workers can also aid bisexual women of African descent in accessing health and social care. Social workers can provide professional support in the absence of familial support, and offer LGBTQ community resource referrals. Social workers can provide professional and therapeutic support and guidance, as the women navigate disclosure processes. Social workers

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can encourage health care seeking behaviors, providing health and prevention information, and encouraging comprehensive testing.

In terms of policies and programs, the role of social support in increasing healthier behaviors should be incorporated in effective strategies with this population. The oes grassroots efforts to promote health information in their communities and amongst their peers should not be overlooked, including their locating LGBTQ-affirming health care providers via word-of-mouth recommendations. Some women in this study mentioned benefitting from community organizing that was specific to promoting health knowledge and healthy behaviors among women who have female partners. Other women in the study were interested to have more options for healthy intimate same-sex relationships, but had not accessed information on prevention for sexual minority women and did not know how to access such information.

Furthermore, information alone is not adequate, as the women frequently mentioned their diffiult i oahig issues of seual health ad well-being particularly in their same-sex relationships. It appears that were health professionals to provide the outreach requested by several participants in this study, with accurate and specific information on prevention for

ABW, the women would be empowered to continue a process of disseminating this information in their networks effectively. Therefore, professionals should incorporate the oes eistig social networks in public health strategies, even more broadly than sexual health to address mental health, smoking, and other issues that disproportionately impact sexual minority women as identified in LGBTQ health research and reports in the UK (Barker, et al. 2012; Fish,

2007; Hunt & Fish, 2008) and in the US (Mays, et al., 2002; Meyer, 2003; Meyer, 2010; Miller, et al., 2007; The Institute of Medicine of the National Academies, 2011; Ramsey, et al., 2010; Tao,

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2008; San Francisco Human Rights Commission, 2010). This collaborative public health strategy, incorporating social capital at the community level, has been very effective with other sexual minority populations such as African American men who have male partner(s) (Jones et al.,

2008).

Limitations

Diversity and Inclusion in Research

Women living with HIV.

In regard to sampling and recruitment, although extensive efforts were made to reach

HIV-positive bisexual women of African descent, no woman who knew her self to be living with

HIV was reached for participation in this study. The voices, perspectives, and recommendations of women living with HIV are absolutely essential for informed policies and evidence-based practice.

Socioeconomic background.

Also notable is that most participants of the current study had a college or university degree. Only one participant in the US and one participant in the UK had attended but not yet completed college. Therefore this study did not reach women who did not have at least some college education. Studies on the needs of multiple minority women need to include the voices of women of diverse backgrounds.

Delimitations

Especially in the UK, a preference was expressed for studies inclusive of both the Asian and African diaspora, as well as transgender women and persons. Qualitative studies tend to focus with a limited sampling frame and homogenous sample, while quantitative studies with a

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broader sampling frame and larger sample sizes seek a diverse heterogeneous sample. Hence this study focused with African descent cisgender women, to illuminate their life experiences.

It is notable that several participants in this study emphasized strong relationships with transgender persons, as well as with people of color and White people more broadly.

Particularly for this study, had the sampling frame been broader, the research in the UK would potentially have comprised a study of a diverse and vibrant social network.

Because of the increased disparities affecting transgender women, the researcher felt this study could not encompass their life experiences as effectively as recent studies focusing specifically with transgender needs (Baral, Poteat, Stromdahl, Wirtz, Guadamuz, & Beyrer,

2013; Poteat, German, & Kerrigan, 2013). At least one UK participant of the current study stated that particularly the experiences of transgender women and persons in health care settings can be substantially worse, with greater barriers, as detailed in recent studies (Poteat,

2012; Poteat, Reisner & Radix, 2014). Also, the increased risk of HIV infection of transgender women in the US has been recognized; while prevention needs of bisexual cisgender women have not been recognized at the federal level. Due to health care coverage in the UK, a scholar stated that transgender women may not have the same degree of HIV disparities or increased risk as in the US (C. Richards, personal communication, February 28, 2014).

The researcher would like to indicate that this study appears to be among the first to specify that sampling was limited to cisgender women. The researcher encourages other researchers to approach research with women consciously and to specify as well as justify if their study includes only cisgender women, which is the case for most studies categorized as

eseahig oes issues. Lage sale studies o oes issues should atiel euit

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transgender women participants, and report any disparities. More qualitative and quantitative research is needed that focuses with transgender women specifically, especially transgender women of color.

Methodology.

Regarding methodology, it can be valuable to proceed through the entire Grounded

Theory Method of data collection and analysis, as in an earlier study with African descent LGBQ women that made a significant contribution in developing the first theory on Sense of

Belonging for African American sexual minority women (Page, 2012). However, techniques of the Grounded Theory Method can also be used to identify and develop themes (Strauss &

Corbin, 1998), as in another earlier study with African descent lesbian and bisexual women which effectively identified useful themes increasing knowledge and understanding of the

oes life epeiees Bates, . While theoretical sampling, theoretical saturation, and selective coding were not used for the current dissertation study, grounded analysis techniques guided data analyses, and useful themes were identified. Although not generalizable, the findings may provide useful insights for future research.

Recommendations for Future Research

Research focusing on the experiences of bisexual people is important due to lack of information and inadequate cultural competence in health and social care in both the UK

(Barker, et. al., 2012; Fish, 2007; Hunt & Fish, 2008) and in the US (Fredriksen-Goldsen et al.,

2011; Greene et al., 2007; Marrazzo,2000; Mays et al., 2003; Mays, et al., 2002; Miller et al.,

2007; The San Francisco Human Rights Commission, 2010; Turner, Pastrana, Jr. & Battle, 2014).

This warrants further study, considering the ethical importance of culturally competent health

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care to avoid prescribing interventions without an accurate assessment of the client. Especially important to note is the need for improvement addressing provider competence and sexual

ioit oes peetio eeds.

A key potential theoretical implication of this study expressed by the women involves the fundamental necessity of holistic affirmation of their identities, as bisexual women of color and genderqueer persons, for their day-to-day sense of well-being and an integrated sense of whole self. The women actively seek social networks that affirm their identities, their human right to exist, and to live their lives authentically as their true selves. At this time, many professionals largely fail to provide this much needed respect and crucial fundamental affirmation of human dignity for bisexual women of African descent.

The Natioal Istitutes of Health, folloig the The Health of LGBT People epot completed for them by the Institute of Medicine (The Institute of Medicine of The National

Academies, 2011), specified several areas in need of empirical research. Guided by their recommendations, I suggest further research related to the well-being of bisexual women of

African descent, in the specified areas of 1) Provider competence, 2) Sexual health, 3)

Resilience.

Toward increasing provider competence, research is needed on how health and social service providers can become more effective in working with bisexual women of African descent. Researchers can invite providers to participate in interviews and focus groups toward identifying and addressing any barriers they face in working with sexual minority women.

Toward addressing community sexual health, research is needed on how bisexual women of African descent can become more empowered in communicating with partners

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regarding healthy relationships. Researchers can design and implement interview and focus group studies toward identifying more effective strategies for sexual minority women.

Toward increasing knowledge of resilience, research is needed on how bisexual women of African descent are accessing and utilizing resources in their day-to-day lives for resilience.

Researchers can design and implement PhotoVoice studies. PhotoVoice studies empower participants to use photo and text in sharing about their life experiences, and is particularly well suited for research on resources and activities of resilience.

Additional important concerns raised by the women that extended beyond the scope of the current study includes a need to focus on socioeconomic concerns and priorities of ABW including disability. Most participants were underemployed despite having college or university degrees.

Future research also needs to focus on the impact of violence and reducing violence in the oes lies. Although women living with HIV were not reached for this study, HIV/AIDS workers emphasized that violence against women contributes to HIV risk and infection.

Therefore, prevention needs to address violence and socioeconomic issues jointly (The

Woes Colletie & Geogeto Uiesit La Cete, .

Future research needs to focus on the relationship, familial, parenting, and social support needs of ABW particularly in regard to the oppression that impacts their intimate relationships, their children, and their needs for security across the lifespan and as they age.

The feedback received during the course of this study is that vulnerable groups such as women living with HIV, transgender women, and working class women, need to benefit from research in which they are involved. When conducting research with vulnerable groups, it is

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important that they are empowered to determine the research agenda, as they are the experts regarding the issues for which they seek social justice and change.

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Table 1

Subthemes Related to Identity, Social Support, Health Care, and Resilience

Themes Subthemes

1) Identity Bisexual identity is experienced as non-binary.

Identities of race, gender, and sexual orientation are intersectional.

Identity development is impacted by stigma and influenced by support.

2) Social Experiences and resources of social support vary. Support “oial etoks ae eeded that suppot oes idetities.

Behaviors constitute barriers and facilitators of disclosure.

3) Health Care Experiences and resources of health care vary.

Environmental cues and behaviors constitute barriers and facilitators of disclosure.

Specific changes can improve services for African descent bisexual women.

4) Resilience Social support is a primary source for well-being and resilience.

Activism and self-nurturing activities also facilitate resilience.

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APPENDIX A

ORIGINAL INTERVIEW GUIDE

The eseahe ill state There are many theories and thoughts about self-identity. The purpose of this interview is to understand life experiences from your perspective. You are the expert here, and any information you provide will be helpful. Please feel free to include good experiences as ell as diffiulties o halleges.

Main Interview Guide

1) How did you come to your sense of self, that is how did you determine who you are? a. What matters the most to you? b. What does it mean to you to identify as bisexual? c. Who knows you for who you are? d. Who can you depend on to be there for you, without fear of rejection if you were known? e. Please describe a situation in which you disclosed bisexual orientation, or tried to avoid disclosing bisexual orientation, and what you considered in making your decision about whether or not to disclose?

2) Please describe your sources of social support. a. Probes may ask about different relationships including partners, family, friends, neighbors, fellow workers, colleagues, etcetera. b. Have you disclosed bisexual identity/orientation to anyone in your social networks? If so, with whom? c. Have you disclosed your HIV status to anyone in your social networks? If so, with whom?

3) In your day to day life, what sustains you and helps give you a sense of strength? a. What are your main day-to-day concerns? b. What are the resources that sustain you and support you? c. What helps you feel that you have purpose and your life is meaningful and worthwhile? d. What resources help you to feel nurtured and restored? e. What resources or activities bring a sense of enjoyment or hope?

4) Please tell me about your experiences with health care. a. Please describe the types of information that have been provided to you. i. Probe for: HIV/AIDS, sexually transmitted diseases (STD), or other health issues?

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b. Please describe the information that you have shared with your health care provider. ii. Probe for bisexual identity. iii. Probe for HIV status.

c. How might you advise providers or others to treat you in order to promote trust and/or disclosure of sexual orientation, HIV status, or other health care concerns or needs?

5) Is there any more information about your life experiences and /or concerns you have that would like to share for this research study? a. What are you most concerned about? b. Can you tell me about socioeconomic conditions you feel affected by or that you would like to change? c. Can you tell me about human or civil rights laws or policies that you feel affected by or that you would like to change? d. Can you tell me about health care resources, and any changes that you feel are important to be made?

Continued below are additional probes that are relevant to both social network and health care settings.

. Please tell me about good experiences you have with being accepted as you are.

. Can you please describe a situation(s) you can recall in which you disclosed HIV status, or tried to avoid disclosing HIV status, and what you considered in making your decision about whether or not to disclose?

. Please tell me about any experiences you may have had in which you felt hesitant, worried or afraid to disclose (sexual orientation and/or HIV status), or in which you did disclose and felt you were not accepted or supported.

. Probes may also ask about responses/results following disclosure, and/or what the respondent thinks may happen if/when she does disclose to others, and/or what factors lead to respondent deciding not to disclose. (For example, how did or might the family member or health care provider respond?)

. Probes may also aim at obtaining details about the decision making process, and factors considered by the respondent regarding whether or not to disclose, including whether/when/how to disclose sexual orientation and HIV status in their social support networks and health care settings.

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APPENDIX B

REVISED INTERVIEW GUIDE

The eseahe states There are many theories and thoughts about self-identity. The purpose of this interview is to understand life experiences from your perspective. You are the expert here, and any information you provide will be helpful. Please feel free to include good experiences as ell as diffiulties o halleges. Main Interview Guide

1) How did you come to your sense of self, that is how did you determine who you are as a person? a. What does it mean to you to identify as bisexual? b. What are some of the things that matter the most to you in your life?

2) Please describe your resources of social support. a. Who knows you for who you are? b. Have you disclosed bisexual identity/orientation to anyone in your social networks? If so, with whom? c. Have you disclosed your HIV status to anyone in your social networks? If so, with whom? d. Who can you depend on to be there for you, without fear of rejection if you were known? e. Please describe a situation in which you disclosed bisexual orientation, or tried to avoid disclosing bisexual orientation, and what you considered in making your decision about whether or not to disclose? (Probes may ask about different relationships including partners, family, friends, neighbors, fellow workers, colleagues, etcetera).

3) In your day to day life, what sustains you and helps give you a sense of strength? f. What are some of your main day-to-day concerns? g. What are some of the resources that sustain and support you? h. What helps you feel that you have purpose and your life is meaningful and worthwhile? i. What resources or activities bring a sense of enjoyment or hope? j. What resources help you to feel nurtured and restored?

4) Please tell me about your experiences with health care. b. Please describe the types of information that have been provided to you. i. Probe for: HIV/AIDS, sexually transmitted diseases (STDs), or other health issues

c. Please describe the information that you have shared with your health care provider.

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i. Probe for bisexual identity. Have you disclosed bisexual identity/orientation to anyone in a health care setting? If so, with whom? ii. Probe for HIV status and disclosure. d. How might you advise providers or others to treat you in order to promote trust and/or disclosure of sexual orientation, HIV status, or other health care concerns or needs? e. Can you tell me about health care resources, and any changes that you feel are important to be made?

Continued below are additional probes that are relevant to both social network and health care settings

. Please tell me about good experiences you have with being accepted as you are.

5) What kinds of things in society are you most concerned about? a. Can you tell me about socioeconomic conditions you feel affected by or that you would like to change? b. Can you tell me about human or civil rights laws or policies that you feel affected by or that you would like to change?

Is there any more information about your life experiences and /or concerns you have that would like to share for this research study?

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APPENDIX C

PARTICIPANT COMMENT FORM

Other information you would like to share about your life experiences, or about the interview, can be written here:

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APPENDIX D

DEMOGRAPHIC QUESTIONNAIRE FOR US PARTICIPANTS

Participant Research Study Case Number: ______

Please select or provide as many answers as describe you and your life. You are not required to answer or respond to all of the questions, and you can refuse to respond to any questions. Completing as many questions as you are able will be helpful for this study. Please let me know if you have any questions or need me to explain any information on this form.

1) Please write your age: _____

2) How do you classify your biological sex?  Male  Female  Intersex  Other, please specify ______

3) How do you classify your gender? Please check all that apply.  Male  Female  Transgendered/sexual  Female to Male Transgendered  Male to Female Transgendered  Other, please specify ______

4) What is your sexual orientation or identity? Please check all that apply.  Heterosexual/Straight  Gay  Lesbian  Bisexual  Other, please give brief explanation: ______

5) How would you best classify your race/ethnicity?  African American  Black African  African Caribbean  Hispanic or Latino/a  Asian or Asian American  White/Caucasian  Native American  Multi-racial or mixed race, please specify: ______ Other, please specify ______

6) How would you best classify the race/ethnicity of your biological mother?  African American  Black African  African Caribbean

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 Hispanic or Latino/a  Asian or Asian American  White/Caucasian  Native American  Multi-racial or mixed race, please specify: ______ Other, please specify ______

7) How would you best classify your race/ethnicity of your biological father?  African American  Black African  African Caribbean  Hispanic or Latino/a  Asian or Asian American  White/Caucasian  Native American  Multi-racial or mixed race, please specify: ______ Other, please specify ______

8) Which religion do you belong to? (Select as many as apply)  Christian. Please write in the denomination:______ African traditional religion. Please say which:______ Islam  Buddhism  Other religion. Please say which:______ No religion  Prefer not to state religion

9) Do you have any disabilities?  Yes  No If yes, please check all that apply.

 Vision  Hearing  Mobility  Learning  Mental illness  Cognitive/developmental  Chronic illness  Other, please describe

10) Have you ever received a test result for HIV (human immunodeficiency virus)? ฀ No, I’ve never tested for HIV ฀ Yes, I’ve received a POSITIVE HIV test result (I do have HIV) ฀ Yes, I’ve received a NEGATIVE HIV test result (I did NOT have HIV at the time of the test)

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11) Which best describes your current relationship status?  Single  Dating  Married/partnered  Separated  Divorced  Widowed  Other (specify) ______

12) Number of minor children: ______Number of adult children: ______

13) What best describes your current living situation? Please check all that apply.

 Alone  With parent(s) or step-parent(s)  With grandparent(s)  With roommate(s) or house-mate(s)  With partner(s)  With minor children – please specify number ______ With adult children – please specify number ______ Other - please specify ______

14) Highest level of education completed:

 Less than high school  High school  Technical School  Some College / University  College graduate  Graduate (masters)  Postgraduate (doctorate)  Other: ______

15) Which of these best describes your current situation? (Select as many as apply)

฀ Full-time student ฀ Part-time student ฀ On a training scheme / Back-to-work activity ฀ Full-time employment ฀ Part-time employment ฀ Casual / cash-in-hand employment ฀ Homemaker and/or caregiver ฀ Not in employment and registered for benefits ฀ Not in employment and not registered for benefits ฀ Unable to work (long-term illness / disability / medically retired) ฀ Not allowed to work (immigration reasons) ฀ Retired ฀ Other :______

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16) Which best describes your usual occupation?

 Executive, Administrative, and Managerial Occupations (legislators, chief executive officers, managers of all kinds, buyers, inspectors, etc.)  Professional Specialty Occupations (computer/IT professionals, architects, artists, engineers, physicians, teachers, lawyers, clergy, veterinarians, etc.)  Technicians and Related Support Occupations (dental hygienists, air traffic controllers, legal assistants, etc.)  Sales Occupations  Administrative Support Occupations, Including Clerical  Service Occupations (restaurant and bar workers, domestic service, armed forces, police and firefighters, care-taker of children or others, etc.)  Farming, Forest, and Fishing Occupations  Precision Production, Craft, and Repair Occupations (construction workers, mechanics, locksmiths, machine repair, , etc.)  Operators, Fabricators, and Laborers (machine operators, engravers, photographic developers, etc.)  Handlers, Equipment Cleaners, and Helpers (garbage collectors, freight handlers, helpers of all kinds, etc.

 Other: ______

 If unemployed: What was your last job? ______

When did you last have work? ______(date)

17) What is your approximate current personal annual income (before taxes)? ______

18) What is your current approximate annual household income (before taxes)? ______

19) Your country of birth: ______

20) The country in which you grew up: ______

21) Years you have lived in the US: ______

22) The state in which you live : ______

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APPENDIX E

REVISED DEMOGRAPHIC QUESTIONNAIRE FOR UK PARTICIPANTS

Participant Research Study Case Number: ______

1) Please write your age: _____

2) How do you classify your biological sex?  Male  Female  Intersex  Other, please specify ______

4) What is your sexual orientation or identity? Please check all that apply.  Heterosexual/Straight  Gay  Lesbian  Bisexual  Other, please give brief explanation: ______

5) How would you best classify your race/ethnicity?  Black African  African Caribbean  Black African British  Hispanic or Latino/a  Asian  White/Caucasian  Multi-racial or mixed race, please specify: ______ Other, please specify ______

6) How would you best classify the race/ethnicity of your biological mother?  Black African  African Caribbean  Black African British  Hispanic or Latino/a

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 Asian  White/Caucasian  Multi-racial or mixed race, please specify: ______ Other, please specify ______

7) How would you best classify your race/ethnicity of your biological father?  Black African  African Caribbean  Black African British  Hispanic or Latino/a  Asian  White/Caucasian  Multi-racial or mixed race, please specify: ______ Other, please specify ______

9) Do you have any disabilities?  Yes  No

If yes, please check all that apply.

 Vision  Hearing  Mobility  Learning  Mental illness  Cognitive/developmental  Chronic illness  Other, please describe

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11) Which best describes your current relationship status?  Single  Dating  Married/partnered  Separated  Divorced  Widowed  Other (specify) ______

12) Number of minor children: ______Number of adult children: ______

13) What best describes your current living situation? Please check all that apply.  Alone  With parent(s) or step-parent(s)  With grandparent(s)  With roommate(s) or house-mate(s)  With partner(s)  With minor children – please specify number ______ With adult children – please specify number ______ Other - please specify ______

14) Highest level of education completed:  Less than high school  High school  Technical School  Some College / University  College graduate  Graduate (masters)  Postgraduate (doctorate)  Other: ______

15) Which of these best describes your current situation? (Select as many as apply)

 Full-time student  Part-time student  On a training scheme / Back-to-work activity  Full-time employment  Part-time employment  Casual / cash-in-hand employment  Homemaker and/or caregiver  Not in employment and registered for benefits  Not in employment and not registered for benefits  Unable to work (long-term illness / disability / medically retired)  Not allowed to work (immigration reasons)  Retired  Other :______

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16) Which best describes your usual occupation?

 Executive, Administrative, and Managerial Occupations (legislators, chief executive officers, managers of all kinds, buyers, inspectors, , etc.)  Professional Specialty Occupations (computer/IT professionals, architects, artists, engineers, physicians, teachers, lawyers, clergy, veterinarians, etc.)  Technicians and Related Support Occupations (dental hygienists, air traffic controllers, legal assistants, etc.)  Sales Occupations  Administrative Support Occupations, Including Clerical  Service Occupations (restaurant and bar workers, domestic service, armed forces, police and firefighters, care-taker of children or others, etc.)  Farming, Forest, and Fishing Occupations  Precision Production, Craft, and Repair Occupations (construction workers, mechanics, locksmiths, machine repair, etc.)  Operators, Fabricators, and Laborers (machine operators, engravers, photographic developers, etc.)  Handlers, Equipment Cleaners, and Helpers (garbage collectors, freight handlers, helpers of all kinds, etc.)

 Other: ______

 If unemployed:

What was your last job? ______

When did you last have work? ______(date)

17) What is your current approximate personal annual salary (before taxes)? ______

18) What is your current approximate annual household income (before taxes)? ______

19) Your country of birth: ______

20) The country in which you grew up: ______

21) Years you have lived in the UK: ______

22) The country in the UK you live in: ______

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APPENDIX F

INSTITUTIONAL REVIEW BOARD APPROVALS

Use of Human Subjects in Research - Approval Memorandum

The Florida State University Office of the Vice President For Research Human Subjects Committee Tallahassee, Florida 32306-2742 (850) 644-8673 · FAX (850) 644-4392

RE-APPROVAL MEMORANDUM

Date: 11/13/2014

To: Kristin Brown

Address: C2500 University Center, Florida State University, Tallahassee, FL 32306-2570 Dept.: SOCIAL WORK

From: Thomas L. Jacobson, Chair

Re: Re-approval of Use of Human subjects in Research The Voices of African Descent Bisexual Women: Experiences Related to Identity and Disclosure in Social Support Networks and Health Care Settings in the United States and United Kingdom

Your request to continue the research project listed above involving human subjects has been approved by the Human Subjects Committee. If your project has not been completed by 11/11/2015, you must request a renewal of approval for continuation of the project. As a courtesy, a renewal notice will be sent to you prior to your expiration date; however, it is your responsibility as the Principal Investigator to timely request renewal of your approval from the committee.

If you submitted a proposed consent form with your renewal request, the approved stamped consent form is attached to this re-approval notice. Only the stamped version of the consent form may be used in recruiting of research subjects. You are reminded that any change in protocol for this project must be reviewed and approved by the Committee prior to implementation of the proposed change in the protocol. A protocol change/amendment form is required to be submitted for approval by the Committee. In addition, federal regulations require that the Principal Investigator promptly report in writing, any unanticipated problems or adverse events involving risks to research subjects or others.

By copy of this memorandum, the Chair of your department and/or your major professor are reminded of their responsibility for being informed concerning research projects involving human subjects in their department. They are advised to review the protocols as often as necessary to insure that the project is being conducted in compliance with our institution and with DHHS regulations.

Cc: HSC No. 2014.13869

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The Florida State University Office of the Vice President For Research Human Subjects Committee Tallahassee, Florida 32306-2742 (850) 644-8673 * FAX (850) 644-4392

APPROVAL MEMORANDUM

Date: 4/9/2013

To: Kristin Brown

Address: C2500 University Center, Florida State University, Tallahassee, FL 32306-2570 Dept.: SOCIAL WORK

From: Thomas L. Jacobson, Chair

Re: Use of Human Subjects in Research The Voices of African Descent Bisexual Women: Experiences Related to Identity and Disclosure in Social Support Networks and Health Care Settings in the United States and United Kingdom

The application that you submitted to this office in regard to the use of human subjects in the research proposal referenced above has been reviewed by the Human Subjects Committee at its meeting on 03/13/2013. Your project was approved by the Committee.

The Human Subjects Committee has not evaluated your proposal for scientific merit, except to weigh the risk to the human participants and the aspects of the proposal related to potential risk and benefit. This approval does not replace any departmental or other approvals, which may be required.

If you submitted a proposed consent form with your application, the approved stamped consent form is attached to this approval notice. Only the stamped version of the consent form may be used in recruiting research subjects.

If the project has not been completed by 3/12/2014 you must request a renewal of approval for continuation of the project. As a courtesy, a renewal notice will be sent to you prior to your expiration date; however, it is your responsibility as the Principal Investigator to timely request renewal of your approval from the Committee.

You are advised that any change in protocol for this project must be reviewed and approved by the Committee prior to implementation of the proposed change in the protocol. A protocol change/amendment form is required to be submitted for approval by the Committee. In addition, federal regulations require that the Principal Investigator promptly report, in writing any unanticipated problems or adverse events involving risks to research subjects or others.

By copy of this memorandum, the Chair of your department and/or your major professor is reminded that he/she is responsible for being informed concerning research projects involving human subjects in the department, and should review protocols as often as needed to insure that the project is being conducted in compliance with our institution and with DHHS regulations.

This institution has an Assurance on file with the Office for Human Research Protection. The Assurance Number is FWA00000168/IRB number IRB00000446.

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Cc: Neil Abell, Advisor HSC No. 2013.9039

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The Florida State University Office of the Vice President For Research Human Subjects Committee Tallahassee, Florida 32306-2742 (850) 644-8673 · FAX (850) 644-4392

APPROVAL MEMORANDUM (for change in research protocol)

Date: 5/2/2013

To: Kristin Brown

Address: C2500 University Center, Florida State University, Tallahassee, FL 32306-2570 Dept.: SOCIAL WORK

From: Thomas L. Jacobson, Chair

Re: Use of Human Subjects in Research (Approval for Change in Protocol) Project entitled: The Voices of African Descent Bisexual Women: Experiences Related to Identity and Disclosure in Social Support Networks and Health Care Settings in the United States and United Kingdom

The form that you submitted to this office in regard to the requested change/amendment to your research protocol for the above-referenced project has been reviewed and approved.

If the project has not been completed by 3/12/2014, you must request a renewal of approval for continuation of the project. As a courtesy, a renewal notice will be sent to you prior to your expiration date; however, it is your responsibility as the Principal Investigator to timely request renewal of your approval from the Committee.

By copy of this memorandum, the chairman of your department and/or your major professor is reminded that he/she is responsible for being informed concerning research projects involving human subjects in the department, and should review protocols as often as needed to insure that the project is being conducted in compliance with our institution and with DHHS regulations.

This institution has an Assurance on file with the Office for Human Research Protection. The Assurance Number is FWA00000168/IRB number IRB00000446.

Cc: Neil Abell, Advisor HSC No. 2013.10408

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The Florida State University Office of the Vice President For Research Human Subjects Committee Tallahassee, Florida 32306-2742 (850) 644-8673 · FAX (850) 644-4392

APPROVAL MEMORANDUM (for change in research protocol)

Date: 7/26/2013

To: Kristin Brown

Address: C2500 University Center, Florida State University, Tallahassee, FL 32306-2570 Dept.: SOCIAL WORK

From: Thomas L. Jacobson, Chair

The form that you submitted to this office in regard to the requested change/amendment to your research protocol for the above-referenced project has been reviewed and approved.

This institution has an Assurance on file with the Office for Human Research Protection. The Assurance Number is FWA00000168/IRB number IRB00000446.

Cc: Neil Abell, Advisor HSC No. 2013.10408

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APPENDIX G

REVISED LETTER OR EMAIL MESSAGE TEMPLATE

FOR ORGANIZATION, PROFESSIONAL, OR ORGANIZER

[Date] To Whom It May Concern, I am a social work Ph.D. Candidate and would like to share information about my dissertation study. The purpose of this research study is to learn more about the life experiences of African descent cisgender women who self-identify as bisexual, within socioeconomic and political contexts.

Specifically,support networks, the study related seeks mainly to learn to moreidentity about and the disclosure women’s of experiences sexual orientation of health and care HIV and statu in ssoci. I wouldal also like to ask the women about what kind of health care information has been shared with them, especially related to HIV/AIDS. Last, I seek information regarding resources the women draw upon to sustain themselves in their day-to-day lives and support their resiliency. I ask that your organization share information about the study through your staff meetings and list serves. What would also be helpful, is for staff to share information about the study with cisgender female members or clients, 18 years and older, who have disclosed to you that they are of African descent and self-identify as bisexual. Women living with HIV, and older women, are encouraged to participate. Two flyers are attached that can be posted and distributed. One flyer briefly describes the study, and the other flyer provides more detailed information. I appreciate your interest and support for this study. I can be reached at (___) ___ - ____ or by email at ______should you have any questions. Sincerely, Kristin Brown Kristin M. Brown, MSW, MPA Doctoral Candidate College of Social Work Florida State University C2500 University Center Tallahassee, FL 32306-2570 [Website]

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APPENDIX H

REVISED US LETTER OR EMAIL MESSAGE TO ORGANIZATION, PROFESSIONAL, OR ORGANIZER

[Date] To Whom It May Concern, I am a Social Work Ph.D. Candidate and would like to share information about my dissertation study. The purpose of this research study is to learn more about the life experiences of African descent cisgender women who self-identify as bisexual, within socioeconomic and political contexts. Specifically, thenetworks, study seeks related to mainlylearn more to identity about theand women’s disclosure experiences of sexual orientation of health care and and HIV in status social. I supportwould also like to ask the women about what kind of health care information has been shared with them, especially related to HIV/AIDS. Last, I seek information regarding resources the women draw upon to sustain themselves in their day-to-day lives and support their resiliency. I ask that your organization share information about the study through your staff meetings and list serves. What would also be helpful, is for staff to share information about the study with cisgender female members or clients, 18 years and older, who have disclosed to you that they are of African descent and self-identify as bisexual. Women living with HIV, and older women, are encouraged to participate. Two flyers are attached that can be posted and distributed. One flyer briefly describes the study, and the other flyer provides more detailed information. I appreciate your interest and support for this study. I can be reached at ( ) ___-_____ or by email at ______should you have any questions. Sincerely,

Kristin Brown Kristin M. Brown, MSW, MPA Doctoral Candidate College of Social Work Florida State University C2500 University Center Tallahassee, FL 32306-2570 [Website]

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APPENDIX I

REVISED UK LETTER OR EMAIL MESSAGE TO ORGANIZATION, PROFESSIONAL, OR ORGANIZER

[Date] To Whom It May Concern, I am a Social Work Ph.D. Candidate, presently in the United Kingdom, and would like to share information about my dissertation study. The purpose of this research study is to learn more about the life experiences of African descent cisgender women who self-identify as bisexual, within socioeconomic and political contexts of the UK and US. Specifically, the study seeks to learn more aboutidentity the and women’s disclosure experiences of sexual of orientation health care and and HIV in socialstatus. support I would networks, also like to related ask the mainly women to about what kind of health care information has been shared with them, especially related to HIV/AIDS. Last, I seek information regarding resources the women draw upon to sustain themselves in their day-to-day lives and support their resiliency. I ask that your organization share information about the study through your staff meetings and list serves. What would also be helpful, is for staff to share information about the study with cisgender female members or clients, 18 years and older, who have disclosed to you that they are of African descent and self-identify as bisexual. Women living with HIV, and older women, are encouraged to participate. Two flyers are attached that can be posted and distributed. One flyer briefly describes the study, and the other flyer provides more detailed information. I appreciate your interest and support for this study. I can be reached at [phone] ______or by email at ______should you have any questions. Sincerely,

Kristin Brown Kristin M. Brown, MSW, MPA Doctoral Candidate College of Social Work Florida State University [Website]

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APPENDIX J

REVISED US BRIEF RECRUITMENT FLYER

Are you a woman of Black African or African-Caribbean ancestry who identifies as bisexual? I seek to speak with women, ages 18 and older, about life experiences related to social support, health care, and resources that sustain you. The purpose of this research study is to increase available information about the well-being and needs of African descent bisexual women. A small token of appreciation is provided!

For information about the study, please email ______or call ( ) ______. The university institutional review board approval number for this study is: 2013-9039.

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APPENDIX K

REVISED UK BRIEF RECRUITMENT FLYER

For information about the study, please email ______or call or text ______. The university institutional review board approval number for this study is: 2013-10408.

219

APPENDIX L

REVISED US DETAILED RECRUITMENT FLYER

Research Study Opportunity

The purpose of this research study is to learn more about the life experiences of Black African descent cisgender* women who identify as bisexual. More specifically, the study seeks to learn about the oes epeiees of health ae ad soial suppot. The study, as well, focuses o oes idetit and their choices about disclosing their sexual orientation and HIV status to others. The researcher would like to ask about the kinds of health care information that has been shared with you, especially related to HIV or AIDS. The researcher would also like to ask about what sustains you in your day-to-day life, and helps provide a sense of meaning, purpose, or hope. You are not required to have any particular knowledge to participate in this study.

Women ages 18 and older may participate in the study, who are cisgender female, and descended from Black African or African-Caribbean people. Older women and HIV positive women are encouraged to participate. Participation is not required. If you choose to participate, your time and efforts are appreciated. If you choose to participate in any way, you may stop at any time without penalty.

The interview will be audio recorded, and is confidential. The records of the study will be kept private and confidential to the extent permitted by law. The interview may take between 1 to 3 hours to complete, depending on the time you need. Your completion of the interview will represent your consent to participate in the study. An incentive is provided to reimburse you for your time. The information you provide may contribute toward a better understanding of the life experiences and needs of African descent bisexual cisgender women.

* While there is a need for research with minority women who are transgender as well as those who are cisgender, some current studies focus with women who have a transgender life experience, and this study is focusing with cisgender women. The purpose is to better focus on the specific life experiences of the minority women.

Kristin Brown, PhD Candidate, is the Principal Investigator. Dr. Neil Abell is the Faculty Advisor, and can be contacted at ______. If you would like to speak with a staff person who is independent from the study, please contact the Florida State University Office of Research at phone number ( ) ____-______, or by email at ______. Your contact to the Office of Research can be anonymous, and will be kept confidential.

The Florida State University Office of Research approval number for this study is: 2013-9039.

For more information about the study, please contact Kristin Brown at ( ) ___-______, or by email at ______.

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APPENDIX M

REVISED UK DETAILED RECRUITMENT FLYER

Research Study Opportunity

The purpose of this study is to learn more about the life experiences of Black African descent cisgender* women who identify as bisexual. More specifically, the study seeks to learn about the oes epeiees of health ae ad soial suppot. The study, as well, focuses on oes idetit ad their choices about disclosing their sexual orientation and HIV status to others. The researcher would like to ask about the kinds of health care information that has been shared with you, especially related to HIV or AIDS. The researcher would also like to ask about what sustains you in your day-to-day life, and helps provide a sense of meaning, purpose, or hope. You are not required to have any particular knowledge to participate in this study.

Kristin Brown, PhD Candidate, is the Principal Investigator. Dr. Neil Abell is the Faculty Advisor, and can be contacted at ______. If you would like to speak with a staff person who is independent from the study, please contact the Florida State University Office of Research at phone number 00-1 ( ) ____-______, or by email at ______. Your contact to the Office of Research can be anonymous, and will be kept confidential.

The Florida State University Office of Research approval number for this study is: 2013-10408.

For more information about the study, please contact Kristin Brown by email at ______, or call or text ______.

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APPENDIX N

SCREENING SCRIPT

Participant Research Study Case Number: ______

I appreciate your interest in this research study, and would like to answer questions or concerns you may have. I also need to ask a few questions to determine your eligibility to participate in the study. [If we become disconnected during this phone call, you are welcome to call back].

How did you learn or hear about the study? ______

฀ An individual ฀ An organization or agency: ______฀ Flyer ฀ Other: ______

Can you please tell me your age? ______

Can you please tell me how you identify your race or ethnicity? ______

Ca ou please tell e ho ou idetif ou se ad gede? [“tate Male, feale, tasgede, o othe please speif] ______

Can you please tell me what word(s) you use to describe your sexual orientation or identity?

______

I would now like to provide some inforatio aout the study…

The purpose of this research study is to learn more about the life experiences of African descent cisgender women who identify as bisexual. More specifically, the study seeks to learn aout the oes epeiees of health ae ad in social support networks related to identity and disclosure of sexual orientation and HIV status. The researcher would like to ask about what kind of health care information has been shared with you, especially related to HIV/AIDS. The researcher would also like to ask about what resources you use to sustain yourself in your day-to-day life. You are not required to have any particular knowledge to participate in this study.

Women ages 18 and older are eligible to participate in the study. Your ethnicity must be descended from Black African people, and you must be cisgender female. Older women and women living with HIV/AIDS are encouraged to participate.

222

You are not required to participate. If you choose to participate, your time and efforts are appreciated. If you choose to begin the interview, you may stop at any time without penalty. You are not required to answer or respond to all of the questions, and you can refuse to respond to any questions.

The audio recorded interview is confidential. The audio recorded interview will be transcribed word for word. The only people who will hear the audio recordings or read the transcribed interview are the researcher, trained transcribers, and members of the research team including coders analyzing the interview. Statements from the transcribed interview may be included in the written dissertation and future publications, though every effort will be made to make sure this information is presented in a way that should not reveal your identity.

The records of this study will be stored securely, and kept private and confidential to the extent permitted by law. Any personally identifiable contact information collected (such as phone, eail, addess ill e stoed sepaatel, liked ol the patiipats eseach study case number and destroyed soon after the scheduled interview.

If you share information that you intend to harm yourself or another, or that someone may be abusing or neglecting a minor, elder, or disabled person, I am required by law to report this information to authorities. Every attempt will be made to keep confidential any other information disclosed.

The recorded interview may take approximately 1 to 3 hours to complete. Your completion of the interview will represent your consent to participate in this study. An incentive is provided for the interview, a ____ gift card in the amount of $25 in the US (or 25 GBP for the UK). The information you share may contribute toward a better understanding of the life experiences and needs of African descent bisexual women.

Would you like to schedule an interview?

Date of interview: ______Day: ______Time: ______

Your case number for the study is: ______.

Please provide a pseudonym for use during the study. (A pseudonym is a first name that is different from your real or legal name, and is also different from any nick name that you usually use). ______

There is a chance that the maximum number of interviews needed for the study may be reached before the day of your interview. Please contact me before the day of the interview to confirm that the interviews are continuing.

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APPENDIX 0

PARTICIPANT CONTACT INFORMATION

[This form is used to record contact information of potential subjects who have first contacted the researcher through a voicemail or email message regarding the study, to be used for contacting back to provide information about the study and/or screen for eligibility].

Participant Research Study Case Number: ______

Contact phone number: ( ) ______-______

Record any specifications about a phone call here: ______

______

Email address: ______

Information to be collected at the time of telephone interviews only: Can you provide an email address or mailing address to which I can send the gift card? ______

Date of interview: ______Day: ______Time: ______

The interview will take place __ in person __ or by phone.

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APPENDIX P

CODE LIST WITH CASE NUMBER AND PARTICIPANT INITIALS

Code List

Case Number Initials (First and Last)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

225

APPENDIX Q

CODE LIST WITH CASE NUMBER AND PARTICIPANT PSEUDONYM

Code List

Case Number Pseudonym

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

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APPENDIX R

REVISED US RESEARCH STUDY CONSENT INFORMATION

Participant Research Study Case Number: ______

RESEARCH STUDY CONSENT INFORMATION

Please keep this document for your records.

WHAT THIS STUDY IS ABOUT:

The purpose of this research study is to learn more about the life experiences of African descent cisgender women who identify as bisexual. More specifically, the study seeks to learn aout the oes epeiees of health ae ad i soial suppot etoks, elated ail to identity and disclosure of sexual orientation and HIV status. The researcher would like to ask about what kind of health care information has been shared with you, especially related to HIV/AIDS. The researcher would also like to ask about what resources you use to sustain yourself in your day-to-day life. You are not required to have any particular knowledge to participate in this study. The information you provide may contribute toward a better understanding of the life experiences and needs of African descent bisexual cisgender women.

WHO IS ELIGIBLE TO PARTICIPATE:

HOW THE RESEARCH STUDY IS CONDUCTED:

You are not required to participate in this study. If you choose to participate, your time and efforts are appreciated. The audio recorded interview is confidential. The audio recorded interview may take approximately 1 to 3 hours to complete. If you choose to begin the interview, you may stop at any time without penalty. You are not required to answer or respond to all of the questions, and you can refuse to respond to any questions. Your completion of the interview will represent your consent to participate in this study. At any time during the appointment, you can state that you have changed your mind and that you do not want your information to be used for the research study.

HOW YOUR CONFIDENTIALITY IS PROTECTED:

The records of this study will be stored securely, and kept private and confidential to the extent permitted by law. Any personally identifiable contact information collected such as legal name and other contact information (phone, email, address) will be stored separately, linked only by

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your participant research study case number, and destroyed within 24 hours following the scheduled interview. I will not access your private medical or educational records.

The audio recorded interview will be transcribed word for word. The only people who will hear the audio recording or read the transcribed interview are the researcher, trained transcribers, and members of the research team including coders analyzing the interview. The audio recording and transcript will be identified by your participant research study case number and pseudonym, and will not contain your legal or real name or other personally identifiable information. Statements from the transcribed interview may be included in the written dissertation and future publications, though every effort will be made to make sure this information is presented in a way that should not reveal your identity.

If you share information that you intend harm to yourself or another, or that someone may be abusing or neglecting a minor, elder, or disabled person, I am required by law to report this information to authorities.

Every attempt will be made to keep confidential any other information disclosed, however if you have concerns about potential consequences for disclosure of HIV status, or illegal activity such as drug use, sex work, and unprotected sex with partners to whom one has not disclosed HIV positive status, please do not disclose this information during the audio recorded interview or on the demographic questionnaire.

BENEFITS AND RISKS IN PARTICIPATING:

There are no direct benefits for you from participating in the research study. The purpose of the study is to make available information regarding African descent bisexual cisgender women to increase cultural competency in research, education, health care, social services, and policy development. The information from the study may improve diversity sensitivity and awareness, and be useful for training and better service provision.

Because the interview is about life experiences, emotional distress is a potential risk of participating in the study. Sometimes thinking about experiences in our lives can bring up different memories and feelings. You would be able to stop the interview at any time you need to, with no obligation to continue. Do you have sources of support available to you? If you need support and feel comfortable doing so, please contact the organization through which you learned about this study, and/or your health care provider(s). I am also providing a resource list of organizations that can be contacted if you need information or referrals.

Disclosure of personal health information is a sensitive issue that may cause you concern. As described above, great care will be taken to maintain your confidentiality. At this time, very little information is available regarding African descent bisexual cisgender women and HIV/AID“, ad gatheig ifoatio aout the oes epeiees a otiute to ioit oes eeds eig ette addessed.

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With any research study, there is a very small chance that information could become exposed. You can protect yourself by not providing your legal or real name to the researcher, and by not sharing any information you prefer not to share.

THE INCENTIVE FOR PARTICIPATING:

An incentive is provided for your participation, a gift card in the amount of $25 in the US (or 25 GBP for the UK). In order to receive the incentive, you are not required to provide any information that you are not comfortable to provide. You are not required to answer all questions in order to receive the incentive. Even if you change your mind and do not want to participate in the study, you can keep the incentive.

INFORMATION ABOUT STATING CONSENT:

If you decide to participate in the study, at the beginning of the audio recording I will ask you to state aloud the folloig stateet: M esearch study case number is ______, the pseudonym I am using for the study is ______(if applicable). I have been provided with a copy of the Research Study Consent Information document, which has been explained to me. I am consenting to begin this audio recorded interview. I understand that I can refuse to answer any questions. I can state at any time that I would like to end the interview. I can also state at any time during this appointment that I have changed my mind and that I do not want ifoatio I hae poided to e used fo this stud. MAY I ANSWER ANY QUESTIONS YOU HAVE?

Please tell me in your own words your understanding regarding what the research study is about. Please ask me questions you have regarding the study.

YOUR PSEUDONYM FOR USE DURING THE STUDY:

Please provide a pseudonym for use during the study, if you decide to participate. (A pseudonym is a first name that is different from your real or legal name, and is also different from any nick name that you usually use). ______

RESEARCH STUDY CONTACT INFORMATION:

Kristin Brown is the Principal Investigator, and can be contacted at ______. Dr. Neil Abell is the Faculty Advisor, and can be contacted at ______. If you would like to speak with a staff person who is independent from the study, the Florida State University Office of Research can be contacted at phone number ( )____-______, or by email at ______. The address is ______, ______. Your contact to the Office of Research can be anonymous, and will be kept confidential.

IN ORDER TO PROTECT YOUR CONFIDENTIALITY, THIS RESEARCH STUDY DOES NOT REQUIRE DOCUMENTATION OF SIGNED CONSENT. THEREFORE, BY CONTINUING YOU ARE CONSENTING TO PARTICIPATE IN RESEARCH.

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APPENDIX S

REVISED UK RESEARCH STUDY CONSENT INFORMATION

Participant Research Study Case Number: ______

RESEARCH STUDY CONSENT INFORMATION

Please keep this document for your records.

WHAT THIS STUDY IS ABOUT:

The purpose of this research study is to learn more about the life experiences of African descent cisgender women who identify as bisexual. More specifically, the study seeks to learn aout the oes epeiees of health ae ad i soial support networks, related mainly to identity and disclosure of sexual orientation and HIV status. The researcher would like to ask about what kind of health care information has been shared with you, especially related to HIV/AIDS. The researcher would also like to ask about what resources you use to sustain yourself in your day-to-day life. You are not required to have any particular knowledge to participate in this study. The information you provide may contribute toward a better understanding of the life experiences and needs of African descent bisexual cisgender women.

WHO IS ELIGIBLE TO PARTICIPATE:

HOW THE RESEARCH STUDY IS CONDUCTED:

HOW YOUR CONFIDENTIALITY IS PROTECTED:

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your participant research study case number, and destroyed within 24 hours following the scheduled interview. I will not access your private medical or educational records.

BENEFITS AND RISKS IN PARTICIPATING:

231

THE INCENTIVE FOR PARTICIPATING:

INFORMATION ABOUT STATING CONSENT:

If you decide to participate in the study, at the beginning of the audio recording I will ask you to state aloud the folloig stateet: M eseah stud ase ue is ______, the pseudonym I am using for the study is ______(if applicable). I have been provided with a copy of the Research Study Consent Information document, which has been explained to me. I am consenting to begin this audio recorded interview. I understand that I can refuse to answer any questions. I can state at any time that I would like to end the interview. I can also state at any time during this appointment that I have changed my mind and that I do ot at ifoatio I hae poided to e used fo this stud. MAY I ANSWER ANY QUESTIONS YOU HAVE?

Please tell me in your own words your understanding regarding what the research study is about. Please ask me questions you have regarding the study.

YOUR PSEUDONYM FOR USE DURING THE STUDY:

RESEARCH STUDY CONTACT INFORMATION:

Kristin Brown is the Principal Investigator, and can be contacted at ______. Dr. Neil Abell is the Faculty Advisor, and can be contacted at ______. If you would like to speak with a staff person who is independent from the study, the Florida State University Office of Research can be contacted at phone number 00 -1 ( ) ___-______, or by email at ______. The address is ______, USA. Your contact to the Office of Research can be anonymous, and will be kept confidential.

IN ORDER TO PROTECT YOUR CONFIDENTIALITY, THIS RESEARCH STUDY DOES NOT REQUIRE DOCUMENTATION OF SIGNED CONSENT. THEREFORE, BY CONTINUING YOU ARE CONSENTING TO PARTICIPATE IN RESEARCH.

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REFERENCES

AIDS.gov (February 2012). U.S. Statistics. Retrieved from http://www.aids.gov/hiv-aids- basics/hiv-aids-101/overview/statistics

American Medical Association (2015). LGBT Health Resources: Resources and Literature for Clinicians on LGBT Health Topics. Retrieved from http://www.ama- assn.org/ama/pub/about-ama/our-people/member-groups-sections/glbt-advisory- committee/glbt-resources/lgbt-health-resources.page

Anderson, J. & Doyal, L. (2004). Women from Africa living with HIV in London: A descriptive study. AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 16(1), 95-105.

Austin, S. B., Roberts, A. L., Corliss, H. L., & Molnar, B. E. (2008). Sexual violence victimization history and sexual risk indicators in a community-ased ua ohot of ostl heteoseual ad heteoseual oug oe. American Journal of Public Health, 98, 1015-1020.

Bailey, J. V., Benato, R., Owen, C., & Kavanagh, J. (2008). Vulvovaginal candidiasis in women who have sex with women. Sexually Transmitted Diseases, 35, 533-536.

Bailey, J. V., Farquhar, C., Owen, C., Mangtani, P. (2004). Sexually transmitted infections in women who have sex with women. Sexually Transmitted Infections, 80, 244-246.

Baral, S. D., Poteat, T., Strömdahl, S., Wirtz, A. L., Guadamuz, T. E., & Beyrer, C. (2013). Worldwide burden of HIV in transgender women: A systematic review and meta- analysis. The Lancet Infectious Diseases, 13, 214-222.

Barker, M. (2007). Heteronormativity and the exclusion of bisexuality in psychology. In V. Clarke & E. Peel (Eds.), Out in psychology: Lesbian, gay, bisexual, trans, and queer perspectives (pp. 86-118). Chichester, UK: Wiley.

Barker, M., Richards, C., Jones, R., Bowes-Catton, H., Plowman, T. Yockney, J., Morgan, M. (February 2012). The bisexuality report: Bisexual Inclusion in LGBT equality and diversity. Milton Keynes, UK: The Open University, Centre for Citizenship, Identities and Governance and Faculty of Health and Social Care.

Bartlett, J. G., & Finkbeiner, A. K. (2006). The guide to living with HIV infection (6th Ed.). Baltimore, MD, US: The Johns Hopkins University Press.

Bates, D. D. (2012). Beyond expectations: The experiences of two African American bisexual women. Journal of Bisexuality, 12, 404-416.

233

Battle, J., Cohen, C., Warren, D., Fergerson, G., & Audam, S. (2000). Sa it loud I’ Blak ad I’ proud: Black Pride Survey 2000. Washington, D.C., US: The Policy Institute of the National Gay and Lesbian Task Force. Retrieved from http://www.thetaskforce.org/downloads/reports/reports/SayItLoudBlackAndProud.pdf

Beaber, T. (2008). Well-being among bisexual females: The roles of internalized biphobia, stigma consciousness, social support, and self-disclosure (Doctoral dissertation). Retrieved from ProQuest Digital Dissertations. (UMI Number 3310083)

Beals, K. P., Peplau, L. A., & Gable, S. L. (2009). Stigma management and well-being: The role of perceived social support, emotional processing, and suppression. Personality and Social Psychology Bulletin, 35, 867-879.

Belgrave, F. Z., Corneille, M., Hood, K., Foster-Woodson, J., & Fitzgerald, A. (2010). The impact of perceived group support on the effectiveness of an HIV prevention intervention for African American women. The Journal of Black Psychology, 36(2), 127-143.

Bowes-Catto, H., Bake, M., ‘ihads, C. . I didt ko that I ould feel this elaed i od: Usig isual ethods to eseah iseual peoples eodied epeiees of identity and space. In P. Reavey (Ed.), Visual methods in psychology: Using and interpreting images in qualitative research (pp. 255-270). Hove, East Sussex, UK: Psychology Press.

Bowleg, L., Burkholder, G., Teti, M., & Craig, M. L. (2008). The complexities of outness: Psychosocial predictors of coming out to others among Black lesbian and bisexual women. Journal of LGBT Health Research, 4(4), 153-166.

Bowleg, L., Huang, J., Brooks, K., Black, A., & Burkholder, G. (2003). Triple jeopardy and beyond: Multiple minority stress and resilience among Black lesbians. Journal of Lesbian Studies, 7(4), 87-108.

Bradford, M. (2006). Affirmative psychotherapy with bisexual women. Journal of Bisexuality, 6 (1-2), 13-25.

Bradford, M. (2004). The bisexual experience: Living in a dichotomous culture. Journal of Bisexuality, 4(1-2), 7-23.

Braxton, N. D., Lang, D. L., Sales, J. M., Wingood, G. M., & DiClemente, R. J. (2007). The role of spirituality in sustaining the psychological well-being of HIV-positive Black women. Women & Health, 46(2-3), 113-129.

Brewster, M. E. & Moradi, B. (2010). Personal, relational, and community aspects of bisexual identity in emerging, early and middle adult cohorts. Journal of Bisexuality, 10, 404-428.

234

British Association of Social Workers (2012). The Code of Ethics for Social Work: Statement of Principles. Retrieved on December 17, 2012 from http://cdn.basw.co.uk/upload/basw_112315-7.pdf

Brooks, L. M., Inman, A.G., Klinger, R.S., Malouf, M.A., Kaduvettoor, A. (2010). In her own words: Ethnic-minority bisexual women's self-reported counseling needs. Journal of Bisexuality, 10, 253-267.

Brown, K., & Abell, N. (2009). Development of the Social Support Scale for Use with Diverse Populations (SSDP). Unpublished manuscript.

Canda, E. R., & Furman, L. D. (2009). Spiritual diversity in social work practice: The heart of helping (2nd ed.). New York, NY, US: Oxford University Press.

Centers for Disease Control (2012). HIV among African Americans. Retrieved June 22, 2012 from http://www.cdc.gov/hiv/topics/aa/index.htm

Centers for Disease Control and Prevention (February 2012). HIV incidence. Retrieved from http://www.cdc.gov/hiv/topics/surveillance/incidence.htm

Centers for Disease Control and Prevention (January, 2012). HIV in the United States. Retrieved from http://www.cdc.gov/hiv/resources/factsheets/us.htm

Centers for Disease Control and Prevention (August 2011). HIV among women. Retrieved from http://www.cdc.gov/hiv/topics/women/pdf/women.pdf

Cervantes, J. M. & Parham, T. A. (2005). Toward a meaningful spirituality for people of color: Lessons for the counseling practitioner. Cultural Diversity and Ethnic Minority Psychology, 11(1) 69-81.

Champion, J. D., Wilford, K., Shain, R. N., & Piper, J. M. (2005). Risk and protective behaviours of bisexual minority women: A qualitative analysis. International Council of Nurses, 52, 115-122.

Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative analysis. London, England, UK: Sage Publications, Ltd.

Clemens, S. C. (2004). Extent of outness, depressive distress, and mental health concerns among African American lesbians (Doctoral dissertation). Dissertation Abstracts International. (UMI No. 3133422)

Cochran, S. D. S., & Mays, V. M. V. (1988). Disclosure of sexual preference to physicians by Black lesbian and bisexual women. The Western Journal of Medicine, 149, 616-619.

235

Cochran, S. D. S., Sullivan, J. G., & Mays, V. M. (2003). Prevalence of mental disorders, psychological distress, and mental health services use among lesbian, gay, and bisexual adults in the United States. Journal of Consulting and Clinical Psychology, 71(1), 53-61.

Cohen, S. & Wills, T. A. (1985). Stress, social support, and the buffering hypothesis. Psychological Bulletin, 98, 310-357.

Cole, E. R. (2009). Intersectionality and research in psychology. American Psychologist, 64(3), 170-180.

Colledge, L., Hickson, F., Reid, D., & Weatherburn, P. (2015). Poorer mental health in UK bisexual women than lesbians: Evidence from the UK 2007 Stonewall Women's Health Survey. Journal of Public Health, fdu105, 1-11.

Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW), United Nations General Assembly, 1979. Retrieved December 17, 2012 from http://www.cedaw2011.org

Cooperman, N. A., Simoni, J. M., & Lockhart, D. W. (2003). Abuse, social support, and depression among HIV-positive heterosexual, bisexual, and lesbian women. Journal of Lesbian Studies, 7(4), 49-49.

Denton, T. C. (1990). Bonding and supportive relationships among Black professional women: Rituals of restoration. Journal of Organizational Behavior, 11, 447-457.

DiClemente, R. J., & Wingood, G. M. (1995). A randomized controlled trial of an HIV sexual risk- reduction intervention for young African-American women. Journal of the American Medical Association, 274, 1271-1276.

Durso, L. E., & Meyer, I. H. (2013). Patterns and predictors of disclosure of sexual orientation to healthcare providers among lesbians, gay men, and bisexuals. Sexuality Research and Social Policy, 10(1), 35-42.

Effective Interventions (2012). HIV Prevention that Works: Behavioral Interventions. Retrieved from https://www.effectiveinterventions.org/en/Home.aspx

El-Bassel, N., Caldeira, N. A., Ruglass, L. M., & Gilbert, L. (2009). Addressing the unique needs of African American women in HIV prevention. American Journal of Public Health, 99, 996- 1001.

Fairtlough, A., Bernard, C., Fletcher, J., & Ahmet, A. (2013). Experiences of lesbian, gay and bisexual students on social work programmes: Developing a framework for educational practice. British Journal of Social Work, 43, 467-485.

236

Fethers, K., Marks, C., Mindel, A., & Estcourt, C. S. (2000). Sexually transmitted infections and risk behaviours in women who have sex with women. Sexually Transmitted Infections, 76, 345-349.

Fingerhut, A. W., Peplau, L. A., & Gable, S. L. (2010). Identity, minority stress and psychological well-being among gay men and lesbians. Psychology & Sexuality, 1(2), 101-114.

Fish, J. (2012). Social work and lesbian, gay, bisexual and trans people: Making a difference. Bristol, UK: Policy Press.

Fish, J. (2009). Invisible no more? Including lesbian, gay and bisexual people in social work and social care. Practice: Social Work in Action, 21(1), 47-64.

Fish, J. (2008). Far from mundane: Theorising heterosexism for social work education. Social Work Education, 27(2), 182-193.

Fish, J. (2007). Reducing Health Inequalities for Lesbian, Gay, Bisexual and Trans People. Briefings for Health and Social Care Staff. National Health Service. Department of Health. United Kingdom.

Fox, R. C. (2006). Affirmative psychotherapy with bisexual women and bisexual men: An introduction. Journal of Bisexuality, 6(1-2), 1-11.

Fredriksen-Goldsen, K. I., Kim, H.-J., Emlet, C. A., Muraco, A., Erosheva, E. A., Hoy-Ellis, C. P., Goldsen, J., Petry, H. (2011). The aging and health report: Disparities and resilience among lesbian, gay, bisexual, and transgender older adults. Seattle: Institute for Multi- generational Health. Retrieved from http://caringandaging.org/

Fung, H. H., Carstensen, L. L. & Lang, F. R. (2001). Age-related patterns in social networks among European Americans and African Americans: Implications for socioemotional selectivity across the life span. The International Journal of Aging and Human Development, 52(3), 185-206.

Gates, G.J. 2014. LGB/T Demographics: Comparisons among population-based surveys. Williams Institute, UCLA School of Law.

Glaser, B. G., & Strauss, A. L. (1999). The discovery of grounded theory: Strategies for qualitative research. Piscataway, NJ, US: AldineTransaction.

Gómez, C. A. (2011). Preventing HIV in US women and girls: A call for social action. Women's Health Issues, 21(6), S287-S294.

Greene, B. (1996). African American lesbians: Triple jeopardy. The psychology of African- American women. New York, NY, US: Guilford.

237

Greene, B., Miville, M. L., & Ferguson, A. D. (2007). Lesbian & bisexual women of color, racism, heterosexism, homophobia & health: A recommended intervention and research agenda for reducing health care disparities. In B. Wallace (Ed.), From health inequity to equity in health: A new global approach to health disparities. New York, NY, US: Springer Publications.

Ham, C. (2009). Health Policy in Britain (6th ed.). Hampshire, UK: Palgrave MacMillan.

HealthCare.gov (December 2012). US Department of Health and Human Services. http://www.healthcare.gov/index.html

Health Protection Agency. HIV in the United Kingdom: 2011 Report. London, UK: Health Protection Svs., Colindale.

Henderson, L. (2009). Between the two: Bisexual identity among African Americans. Journal of African American Studies, 13(3), 263-282.

Herek, G. M. (2002). Heterosexuals' attitudes toward bisexual men and women in the United States. Journal of Sex Research, 39, 264-274.

Hughes, C., & Evans, A. (2003). Health needs of women who have sex with women: Healthcare workers need to be aware of their specific needs. British Medical Journal, 327(7421), 939-940.

Hughes, D., ad MGuie, A. . Legislatig fo health: The hagig atue of the NH“. I R. Dingwall, and P. Fenn (Eds.) Quality and regulation in health care. Oxford, UK: Routledge.

Human Rights Campaign (2011-2012). Issue: Coming out. Bisexual populations. Retrieved from http://www.hrc.org/issues/pages/bisexual

Hunt, R. & Fish, J. (2008). Prescription for change: Lesbian & bisexual women's health check 2008. London, UK: Stonewall Lesbian Gay and Bisexual Charity. Retrieved from http://www.stonewall.org.uk/what_we_do/research_and_policy/health_and_healthcar e/3101.asp

Hunter, S., & Hickerson, J. (2003). Affirmative practice: Understanding and working with lesbian, gay, bisexual, and transgender persons. Washington, D.C., US: NASW Press.

Israel, T., & Mohr, J. J. (2004). Attitudes toward bisexual women and men: Current research, future directions. Journal of Bisexuality, 4(1-2), 117-134.

238

Israel, T., & Hackett, G. (2004). Counselor education on lesbian, gay, and bisexual issues: Comparing information and attitude exploration. Counselor Education and Supervision, 43(3), 179-191.

Jeffries, W. L., Dodge, B., Sandfort, T. G. M. (2008). Religion and spirituality among bisexual Black men in the USA. Culture, Health and Sexuality, 10, 463-477.

Jonas, S. (2003). An Introduction to the US Healthcare System (4th Ed.). New York: Springer Publishing Company.

Jones, K. T., Gray, P., Whiteside, Y. O., Wang, T., Bost, D., Dunbar, E., Foust, E. & Johnson, W. D. (2008). Evaluation of an HIV prevention intervention adapted for Black men who have sex with men. American Journal of Public Health, 98, 1043-1050.

Josephs, L. L., & Abel, E. M. (2009). Investigating the relationship between intimate partner violence and HIV risk-propensity in Black/African-American women. Journal of Family Violence, 24(4), 221-229.

Junge, M. B. (1999). Mourning, memory and life itself: The AIDS Quilt and the Vietnam Veterans Memorial Wall. The Arts in Psychotherapy, 26, 195-203.

Keyes, C. L. M. & Waterman, M. B. (2003). Dimensions of well-being and mental health in adulthood. In M. H. Bornstein, L., Davidson, C. L. M. Keyes, and K. A. Moore, Well-being: positive development across the life course (pp. 477-497). Mahwah, NJ, US: Lawrence Erlbaum Associates, Inc.

Kwakwa, H. A., & Ghobrial, M. W. (2003). Female-to-female transmission of Human Immunodeficiency Virus. Clinical Infectious Diseases, 36(3), e40-e41.

Lehavot, K. (2012). Coping strategies and health in a national sample of sexual minority women. American Journal of Orthopsychiatry, 82, 494-504.

Lehavot, K., & Simoni, J. M. (2011). The impact of minority stress on mental health and substance use among sexual minority women. Journal of Consulting and Clinical Psychology, 79(2), 159-170.

Lichtenstein, B. (2005). Domestic violence, sexual ownership, and HIV risk in women in the American deep south. Social Science & Medicine, 60, 701-714.

Lim, F. A., Brown Jr., D. V., & Jones, H. (2013). Lesbian, gay, bisexual, and transgender health: fundamentals for nursing education. The Journal of Nursing Education, 52(4), 198-203.

Lincoln, Y. S., & Guba, E. G. (1985). Naturalist inquiry. Beverly Hills, CA, US: Sage.

239

Lincoln, K. D. (2000). Social support, negative social interactions, and psychological well-being. Social Service Review, 74, 231-252.

Logie, C., Bridge, T. J., & Bridge, P. D. (2007). Evaluating the phobias, attitudes, and cultural competence of Master of social work students toward the LGBT populations. Journal of Homosexuality, 53(4), 201-221.

Logie, C. H., James, L., Tharao, W., & Loutfy, M. R. (2011). HIV, gender, race, sexual orientation, and sex work: A qualitative study of intersectional stigma experienced by HIV-positive women in Ontario, Canada. PLOS Medicine, 8(11), e1001124.

Long, S. M., Ullman, S. E., Long, L. M., Mason, G. E., & Starzynski, L. L. (2007). Women's experiences of male-perpetrated sexual assault by sexual orientation. Violence and Victims, 22, 684-701.

Lorde, A. (1995). The black unicorn: Poems. New York: Norton.

Lorde, A. (1982). Zami: A new spelling of my name. New York: Crossing Press.

Lubben, J., & Gironda, M. (2004). Measuring social networks and assessing their benefits. In C. Phillipson, G. Allan and D. Morgan (Eds.) Social networks and social exclusion: sociological and policy perspectives. Burlington, VT, US: Ashgate Publishing.

Malchiodi, C. A. (2007). The art therapy sourcebook. New York, NY, US: McGraw-Hill.

Maman, S., Campbell, J., Sweat, M. D., & Gielen, A. C. (2000). The intersections of HIV and violence: Directions for future research and interventions. Social Science & Medicine, 50, 459-478.

Marrazzo, J. M. (2000). Sexually transmitted infections in women who have sex with women: who cares? Sexually Transmitted Infections, 76(5), 330-332.

Marrazzo, J. M., Coffey, P., & Bingham, A. (2005). Sexual practices, risk perception and knowledge of sexually transmitted disease risk among lesbian and bisexual women. Perspectives on Sexual and Reproductive Health, 37(1), 6-12.

Marrazzo, J. M., Koutsky, L. A., Kiviat, N. B., Kuypers, J. M., & Stine, K. (2001). Papanicolaou test screening and prevalence of genital human papillomavirus among women who have sex with women. American Journal of Public Health, 91, 947-952.

Martin, I., Messinger, L., Kull, R., Holmes, J., Bermudez, F., & Sommer, S. (2009). Council on Social Work Education-Lambda Legal study of LGBT issues in social work. Alexandria, VA, US: Council on Social Work Education. Retrieved from http://www.lambdalegal.org/publications/bkl_study-of-lgbt-issues-in-social-work

240

Mayer, K. H., Mimiaga, M. J., VanDerwarker, R., Goldhammer, H., & Bradford, J. B. (2007). Fea Couit Healths odel of itegated, ouit-based LGBT care, education, and research. In I. H. Meyer and M. E. Northridge (Eds.) The health of sexual minorities: Public Health Perspectives on Lesbian, Gay, Bisexual and Transgender Populations (pp. 693-715). New York, NY, US: Springer.

Mays, V. M. (1996). Are lesbians at risk for HIV infection? Women's Health: Research on Gender, Behavior, and Policy, 2(1-2), 1-9.

Mays, V. M., Cochran, S. D., & Roeder, M. R. (2003). Depressive distress and prevalence of common problems among homosexually active African American women in the United States. International Journal of Sexual Health, 15(2), 27-46.

Mays, V. M., Yancey, A. K., Cochran, S. D., Weber, M., & Fielding, J. E. (April 2002). Heterogeneity of health disparities among African American, Hispanic, and Asian American women: Unrecognized influences of sexual orientation. American Journal of Public Health, 92, 632-639.

Mazza, N. (2004). Poetry therapy: Theory and practice. New York, NY, US: Brunner-Routledge.

McGrady, M. L. & McDonnell, K. A. (2006). Helping lesbian and gay clients work toward positive spiritual health. In K. B. Helmeke & C. F. Sori (Eds.), The therapist’s oteook for integrating spirituality in counseling II: Homework, handouts and activities for use in psychotherapy (pp. 163-175). New York, NY, US: Haworth Press.

Melton, M. L. (2011). Sex, lies, and stereotypes: HIV positive Black women's perspectives on HIV stigma and the need for public policy as HIV/AIDS prevention intervention. Race, Gender & Class, 18(1-2), 295-313.

Meyer, I. H. (2003). Minority stress and mental health in gay men. In L. D. Garnets, & D. C. Kimmel (Eds.), Psychological perspectives on lesbian, gay, and bisexual experiences (2nd ed.) (pp. 699-731). New York, NY, US: Columbia University Press.

Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129, 674- 697.

Meyer, I. H. (2010). Identity, stress, and resilience in lesbians, gay men, and bisexuals of color. The Counseling Psychologist, 38, 442-454.

Meyer, I. H., & Ouellette, S. C. (2009). Unity and purpose at the intersections of racial/ethnic and sexual identities. In P. L. Hammack & B. J. Cohler (Eds.) The story of sexual identity: Narrative perspectives on the gay and lesbian life course (pp. 79-106). New York, NY, US: Oxford University Press.

241

Miller, M., André, A., Ebin, J., and Bessonova, L. (2007). Bisexual health: An introduction and model practices for HIV/STI prevention programming. New York, NY, US: National Gay and Lesbian Task Force Policy Institute; Boston, MA, US: The Fenway Institute at Fenway Community Health; and Arlington, VA, US: BiNet USA. Retrieved from http://www.thetaskforce.org/downloads/reports/reports/bi_health_5_07_b.pdf

Monro, S., & Richardson, D. (2012). Sexuality, equality and diversity. Hampshire, England, UK: Palgrave Macmillan.

Moon, C. H. (2010). A history of materials and media in art therapy. In C. H. Moon (Ed.) Materials and media in art therapy: Critical understandings of diverse artistic vocabularies (pp. 3-47). New York, NY, US: Routledge, Taylor & Francis Group.

Moore, M. R. (2010). Articulating a politics of (multiple) identities: Sexuality and inclusion in Black community life. DuBois Review: Social Science Research on Race, 7(2) 1‐20.

Morris, J .F., Waldo, C .R., & Rothblum, E. D. (2001). A model of predictors and outcomes of outness among lesbian and bisexual women. American Journal of Orthopsychiatry, 71(1), 61-71.

Morrow, K. M. (1995). Lesbian women and HIV/AIDS: An appeal for inclusion. In A. O'Leary, & L. S. Jemmott (Eds). Women at risk: Issues in the primary prevention of AIDS (pp. 237-256). New York, NY, US: Plenum.

Musgrave, C. F., Allen, C. E., & Allen, G. J. (2002). Spirituality and health for women of color. American Journal of Public Health, 92, 557-560.

National AIDS Trust (2012). Everyday Issues: Benefits. Retrieved from http://www.nat.org.uk/Our-thinking/Every-day-issues/Benefits.aspx

National Association of Social Workers (2012). NASW Code of Ethics, 1996, revised 2008. Washington, D.C., US: NASW Press. Retrieved on December 17, 2012 from http://www.socialworkers.org/pubs/code/code.asp

National Association of Social Workers (2001). NASW Standards for Cultural Competence in Social Work Practice. Washington, D.C., US: NASW Press.

Newman, V. (2010). Creating a safe place for lesbian, gay, bisexual, and transgender youth: Exhibiting installation art for social change. In C. H. Moon (Ed.) Materials and media in art therapy: Critical understandings of diverse artistic vocabularies (pp. 137-153). New York, NY, US: Routledge, Taylor & Francis Group.

Nobles, W. W., Goddard, L. L., & Gilbert, D. J. (2009). Culturecology, women, and African- centered HIV prevention. The Journal of Black Psychology, 35, 228-246.

242

Office for National Statistics (2012). "Resident population estimates by ethnic group peetages: Eglad. United Kingdom: The Office for National Statistics. Retrieved October 28, 2012 from http://www.ons.gov.uk/ons/index.html

Page, E. H. (2004). Mental health services experiences of bisexual women and bisexual men: An empirical study. Journal of Bisexuality, 4(1-2), 137-160.

Page, K. V. (2012). Reflected appraisals and racial and sexual identity development in the lives of Black lesbian and bisexual women. (Doctoral dissertation, The University of North Dakota).

Piccirillo, E. (1999). Beyond words: The art of living with AIDS. In C. Malchiodi (Ed.), Medical art therapy with adults (pp. 163-188). London, UK: Jessica Kingsley Publishers.

Poteat, T. (2012). The role of stigma and discrimination in health care utilization and HIV risk among transgender adults. (Doctoral dissertation, The Johns Hopkins University).

Poteat, T., German, D., & Kerrigan, D. (2013). Managing uncertainty: A grounded theory of stigma in transgender health care encounters. Social Science & Medicine, 84, 22-29.

Poteat, T., Reisner, S. L., & Radix, A. (2014). HIV epidemics among transgender women. Current Opinion in HIV and AIDS, 9(2), 168-173.

Potoczniak, D. J., Aldea, M. A., & DeBlaere, C. (2007). Ego identity, social anxiety, social support, and self-concealment in lesbian, gay, and bisexual individuals. Journal of Counseling Psychology, 54, 447-457.

Powers, D., Bowen, D. J., & White, J. (2001). The influence of sexual orientation on health behaviors in women. Journal of Prevention & Intervention in the Community, 22(2), 43- 60.

Ramsey, F., Hill, M. J., Kellam, C. (July 2010). Black lesbians matter: An examination of the unique experiences, perspectives, and priorities of the Black lesbian community. Sacramento, CA, US: Zuna Institute. Retrieved from http://zunainstitute.org/2010/research/blm/blacklesbiansmatter.pdf

Rutledge, S. E., & Abell, N. (2005). Awareness, acceptance, and action: An emerging framework for understanding AIDS stigmatizing attitudes among community leaders in Barbados. AIDS Patient Care & STDs, 19(3), 186-199.

Saleebey, D. (Ed.). (2002). The strengths perspective in social work practice. Boston, MA, US: Allyn and Bacon.

243

Scott, R. (2006.) Promoting well-being: An ecology of intervening with African American bisexual clients. Journal of Bisexuality, 6(1-2), 65-84.

Shaw, B. A., Krause, N., Liang, J., & Bennett, J. (2007). Tracking changes in social relations throughout late life. Journal of Gerontology: Social Sciences, 62B(2), S90–S99.

Shenton, A. K. (2004). Strategies for ensuring trustworthiness in qualitative research projects. Education for Information, 22(2), 63-75.

Steinhouse, K. (2001). Bisexual women: Considerations of race, social justice and community building. Journal of Progressive Human Services, 12(2), 5-25.

Strauss, A. & Corbin, J. (1998). Basics of qualitative research: Techniques and procedures for developing grounded theory (3rd ed.). Thousand Oaks, CA, US: Sage Publications, Inc.

Szymanski, D. M., & Kashubeck-West, S. (2008). Mediators of the relationship between internalized oppressions and lesbian and bisexual women's psychological distress. The Counseling Psychologist, 36, 575-594.

Tan, F. D. (2005). The importance of spirituality among gay and lesbian individuals. Journal of Homosexuality, 49(2), 135-144.

Tao, G. (2008). Sexual orientation and related viral sexually transmitted disease rates among US women aged 15 to 44 years. American Journal of Public Health, 98(6), 1007-1009.

Teti, M. & Bowleg, L. (2011). Shattering the myth of invulnerability: Exploring the prevention needs of sexual minority women living with HIV/AIDS. Journal of Gay & Lesbian Social Services, 23(1), 69-88.

Teti, M., Bowleg, L., Rubinstein, S., Lloyd, L., Berhane, Z., & Gold, M. (2008). Present but not accounted for: Exploring the sexual risk practices and intervention needs of nonheterosexually identified women in a prevention program for women with HIV/AIDS. Journal of LGBT Health Research, 3(4), 37-51.

The Institute of Medicine of the National Academies, Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, Board on the Health of Select Populations (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, D.C., US: The National Academies Press. Retrieved from https://www.iom.edu/Reports/2011/The- Health-of-Lesbian-Gay-Bisexual-and-Transgender-People.aspx

The Names Project Foundation (1987-2011). Call My Name Workshop Program. Retrieved from http://www.aidsquilt.org/callmyname.

244

The New York City Department of Health and Mental Hygiene (September 1, 2010). HIV Testing Is Now a Routine Part of Health Care in New York. http://www.nyc.gov/html/doh/html/pr2010/pr043-10.shtml

The San Francisco Human Rights Commission (2010). Bisexual Invisibility: Impacts and Recommendations. Retrieved from http://www.birequest.org/docstore/2011-SF_HRC- Bi_Iinvisibility_Report.pdf

The Woes Colletie & Geogeto Uiesit La Cete “eptee, . A capitol offense: The gender dimensions of Washigto D.C.s HIV/AID“ risis. Retrieved from http://www.womenscollective.org/research-reports

Thoits, P. (1982). Conceptual, methodological, and theoretical problems in studying social support as a buffer against life stress. Journal of Health and Social Behavior, 23, 145- 159.

Thomas, F. R. (2005). A comparison of the levels of perceived stress between African American women heterosexuals and lesbians in and out of the closet (Doctoral dissertation). Dissertation Abstracts International, 66(05). (UMI No. 3176524)

Townsend, T. G., & Belgrave, F. Z. (2009). Eliminating health disparities: Challenges for African American psychologists. Journal of Black Psychology, 35(2), 146-153.

Turner, C. B., Pastrana Jr, A. J., & Battle, J. (2014). From the perspectives of Black LGBTs in the US: Medical providers' comfort with patients' sexuality. Journal of Black Sexuality and Relationships, 1(1), 45-64.

UK AIDS and Human Rights Project (2005). http://www.aidsactioneurope.org/members/uk- aids-and-human-rights-project

US Census Bureau (2012). USA QuickFacts. Retrieved from http://quickfacts.census.gov/qfd/states/00000.html

US Department of Health and Human Services (2011). US Department of Health and Human Services recommended actions to improve the health and well-being of lesbian, gay, bisexual, and transgender communities. Retrieved from http://www.hhs.gov.proxy.lib.fsu.edu/secretary/about/lgbthealth.html

Warren, B. J. (1997). Depression, stressful life events, social support, and self-esteem in middle class African American women. Archives of Psychiatric Nursing, 11(3), 107-117.

Wayment, H. A., & Peplau, L. A. (1995). Social support and well-being among lesbian and heterosexual women: A structural modeling approach. Personality and Social Psychology Bulletin, 21(11), 1189-1199.

245

Webster, C. (2002). The National Health Service: A political history. Oxford, England, UK: Oxford University Press.

Wekker, G. (1993). Mati-ism and Black lesbianism: Two idealtypical expressions of female homosexuality in Black communities of the diaspora. Journal of Homosexuality, 24(3-4), 145-145.

Wenzel, S. L., Tucker, J. S., Elliott, M. N., & Hambarsoomians, K. (2007). Sexual risk among impoverished women: Understanding the role of housing status. AIDS and Behavior, 11(2), 9-20.

Werner, E. E., & Smith, R. S. (2001). Journeys from childhood to midlife: Risk, resilience, and recovery. Ithaca, NY, US: Cornell University Press.

Wheaton, B. (1985). Models for the stress-buffering functions of coping resources. Journal of Health and Social Behavior, 26, 352-364.

Whyte IV, J. (2006). Sexual assertiveness in low-income African American women: Unwanted sex, survival, and HIV risk. Journal of Community Health Nursing, 23(4), 235-244.

Willinger, B. (2003). The missing support: Group interventions with AIDS patients. In B. I. Willinger & A. Rice (Eds.) A history of AIDS social work in hospitals: A daring response to an epidemic (pp. 155-160). Binghamton, NY, US: The Haworth Press.

Wingood, G. M., Camp, C., Dunkle, K., Cooper, H., & DiClemente, R. J. (2009). The theory of gender and power: Constructs, variables, and implications for developing HIV interventions for women. In R. J. DiClemente, R. A. Crosby, & Kegler, M. C. (Eds.), Emerging theories in health promotion practice and research (2nd ed.) (pp. 393-414). San Francisco, CA, US: Jossey-Bass.

Wingood, G. M., & DiClemente, R. J. (2000). Application of the theory of gender and power to examine HIV-related exposures, risk factors, and effective interventions for women. Health Education and Behavior, 27, 539-565.

Wingood, G. M., & DiClemente, R. J. (2000). The WiLLOW Program: Mobilizing social networks of women living with HIV to enhance coping and reduce sexual risk behaviors. In W. Pequegnat & J. Szapocznik (Eds.) Working with families in the era of HIV/AIDS (pp. 281- 298). Thousand Oaks, CA, US: Sage Publications, Inc.

Wingood, G. M., DiClemente, R. J., Mikhail, I., Lang, D. L., McCree, D. H., Davies, S. L., Hardin, J. W., Hook, E. W., Saag, M. (2004). A randomized controlled trial to reduce HIV transmission risk behaviors and sexually transmitted diseases among women living with HIV: The WiLLOW program. Journal of Acquired Immune Deficiency Syndromes, 37(2), S58-S67.

246

Woitke, M. J. B. (2002). Assessing level of outness among gay, lesbian, and bisexual individuals and its relation to depression, anxiety, and self-esteem (Doctoral dissertation, Southern Illinois University Carbondale).

Woody, I. (2011). Lift every voice: A qualitative exploration of ageism and heterosexism as experienced by older African American lesbian women and gay men when addressing social services needs (Doctoral dissertation, Capella University).

Young, L. (2011). Identity, adult development, and narrative: An interview study of women with a bisexual life history. (Doctoral dissertation, City University of New York).

Young, R. M. & Friedman, S. R. (2005). Exploring an HIV paradox. Journal of Lesbian Studies, 9 (3), 103-116

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BIOGRAPHICAL SKETCH

Kristin Brown is a graduate of the Florida State University College of Social Work, and Reubin

OD. Askew School of Public Administration and Policy. Social work internships were completed in health care settings. Conference presentations have been delivered on the health and well- being of minority women. Brown has published on LGBT nondiscrimination policy and HIV care.

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