The Sexual Health of Bisexual Men: Examining the Roles of Bisexual Minority Stress and Substance Use Charles Joseph (CJ) Polihronakis Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy under the Executive Committee of the Graduate School of Arts and Sciences COLUMBIA UNIVERSITY 2019 ã 2019 CHARLES JOSEPH (CJ) POLIHRONAKIS ALL RIGHTS RESERVED ABSTRACT THE SEXUAL HEALTH OF BISEXUAL MEN: EXAMINING THE ROLES OF BISEXUAL MINORITY STRESS AND SUBSTANCE USE Charles Joseph (CJ) Polihronakis According to public health research, bisexual men are at elevated risk for contracting STIs and HIV relative to other sexual minority groups (e.g., gay men, lesbian women) as well as heterosexual people; yet, no studies to date have examined contextual factors that may contribute to this sexual health trend. Using a minority stress theory framework, the present study tested the direct and indirect associations of anti-bisexual discrimination with risky sexual behaviors in a sample of 508 self-identified bisexual men (age range = 18 - 76), with internalized biphobia, bisexual identity concealment, and substance use mediating this relation. Bisexual identity centrality’s direct relations with internalized biphobia, bisexual identity concealment, and risky sexual behavior were also tested. A path analysis was used to analyze the data. Results indicated that anti-bisexual discrimination yielded significant direct positive associations with internalized biphobia, bisexual identity concealment, and risky sexual behavior. Internalized biphobia, but not bisexual identity concealment, yielded a significant direct association with substance use, which yielded a significant direct positive link with risky sexual behavior. Bisexual identity centrality yielded significant direct negative associations with both internalized biphobia and bisexual identity concealment, but it yielded a nonsignificant association with risky sexual behavior. Internalized biphobia also yielded a total indirect link with risky sexual behavior through the mediating role of substance use. Implications of these findings for clinical practice and future research with bisexual men are discussed. TABLE OF CONTENTS ACKNOWLEDGEMENTS…………………………………………...…………………………. v CHAPTER I: INTRODUCTION………………………………………………………………… 1 Minority Stress and Risky Sexual Behaviors Among Sexual Minority Men……………. 3 Bisexual Minority Stress…………………………………………………………………. 7 Purpose of the Present Study………………………………………………………….…. 9 CHAPTER II: LITERATURE REVIEW………………………………………………………. 11 Sexual Minority Men and Risky Sexual Behavior……………………………………... 17 Drug Use………………………………………………………………………... 21 Alcohol Consumption…………………………………………………………... 24 Minority Stress Theory…………………………………………………………………. 26 Perceived Experiences of Heterosexist Discrimination……………………….... 32 Internalized Heterosexism……………………………………………………… 34 Sexual Identity Concealment………………………………………………….... 35 Sexual Identity Centrality………………………………………………………. 36 Limitations of Current Research………………………………………………... 38 Bisexuality……………………………………………………………………………… 38 Bisexual Minority Stress …………………………………………………………….…. 41 Anti-bisexual Discrimination………………………………………………….... 41 Bisexual Individuals as Sexually Irresponsible…...…………………..... 43 Interpersonal Hostility Towards Bisexual People……………………… 45 Instability and Illegitimacy of Bisexual Identity...................................... 47 Internalized Biphobia…………………………………………………………… 48 i Bisexual Identity Concealment…………………………………………………. 50 Bisexual Identity Centrality………………………………………………….…. 52 General Limitation in Current Bisexuality Research…………………………… 54 CHAPTER III: METHOD………………………………………………………………............ 56 Restatement of Research Question and Hypotheses……………………………………. 56 Participants………………………………………………………………........................ 57 Procedures………………………………………………………………......................... 59 Measures………………………………………………………………........................... 62 Perceived Anti-bisexual Discrimination………………………………...……… 62 Internalized Biphobia…………………………………………………………… 62 Bisexual Identity Concealment………………………………………...…...…... 63 Bisexual Identity Centrality ………………………...……………………….…. 63 Alcohol Consumption…………………………………………………………... 64 Drug Use………………………………………………………………............... 65 Risky Sexual Behavior………………………………………………………...... 66 Demographic Questionnaire……………………………………………………. 67 CHAPTER IV: RESULTS………………………………………………………………............ 68 Preliminary Analyses………………………………………………………………........ 68 Bivariate Correlations…………………………………………………………... 68 Exploratory Analyses………………………………………………………….... 69 Primary Analyses……………………………………………………………….............. 72 Test of Direct Relations………………………………………………………… 74 Test of Indirect Relations……………………………………………………….. 74 ii Test of Moderation……………………………………………………………… 75 Test of Rejection-Identification Model................................................................. 76 CHAPTER V: DISCUSSION………………………………………………………………....... 78 Overview of Findings………………………………………………………………....... 78 Bivariate Correlations.……………………………………………………….…. 78 Exploratory Analyses…………………………………………………………… 79 Direct Associations……………………………………………………………... 84 Indirect Associations……………………………………………………………. 88 Test of Moderation…………………………………………………………….... 90 Test of RIM........................................................................................................... 91 Implications for Practice and Research…………………………………………………. 91 Implications for Practice………………………………………………………... 91 Implications for Research………………………………………………………. 95 Strengths, Limitations, and Directions for Future Research……………………………. 99 Summary and Conclusions……………………………………………………………. 102 REFERENCES…………………............................…………………………………………... 104 APPENDICES…………………………………..........................………………………….…. 149 APPENDIX A: Demographic Table............................................................................... 149 APPENDIX B: Hypothesized Model.............................................................................. 151 APPENDIX C: Bivariate Correlation Table................................................................... 152 APPENDIX D: Risky Sexual Behavior by Substance Use Group................................. 153 APPENDIX E: Gender Identity ANOVA Table............................................................ 154 APPENDIX F: HIV Testing ANOVA Table.................................................................. 155 iii APPENDIX G: Social Class ANOVA Table.................................................................. 156 APPENDIX H: Hypothesized Model Results................................................................. 157 APPENDIX I: Total Indirect Relations (Hypothesized Model) .................................... 158 APPENDIX J: Moderation Model Results..................................................................... 159 APPENDIX K: Moderation Table.................................................................................. 160 APPENDIX L: Alternative Model Results..................................................................... 161 APPENDIX M: Total Indirect Relations (Alternative Model)....................................... 162 APPENDIX N: Informed Consent.................................................................................. 163 APPENDIX O: Participants’ Rights............................................................................... 164 APPENDIX P: Introduction Message............................................................................ 165 APPENDIX Q: Anti-Bisexual Experiences Scale.......................................................... 166 APPENDIX R: Lesbian, Gay, and Bisexual Identity Scale – Identity Centrality.......... 168 APPENDIX S: Sexual Orientation Concealment Scale................................................. 169 APPENDIX T: Bisexual Identity Inventory – Internalized Binegativity Subscale........ 170 APPENDIX U: Alcohol Use Disorder Identification Test............................................. 171 APPENDIX V: Drug Abuse Screening Test.................................................................. 172 APPENDIX W: Sexual Risk Survey.............................................................................. 173 APPENDIX X: Demographic Questionnaire................................................................. 178 APPENDIX Y: Debriefing Message.............................................................................. 181 iv ACKNOWLEDGEMENTS Thank you to my mother, Patricia Ann Polihronakis, who has encouraged me to strive towards my academic and professional goals from a young age. Mom, you have always believed that I had the skills, aptitude, and resilience to do and be anything I wanted to in my life, even when the odds may have been stacked against me. You molded me into the man I am today, and for that I am eternally grateful. To my grandmother, Helen Megaloudis, who taught me that my happiness – in all areas of life – matters. As an adolescent, Greek immigrant in America, you were fearless and captivated by what life had to offer to you and the next generations of your family. You lived your life with a determination to excel that was paired with a vivacious charisma – a striking balance that I always admired and strive to embrace for myself. You may not be here to witness the end of my academic journey, but I carry your spirit and memories with me. I hope that I continue to make you proud, and I miss you every day. To my family members, Brittni, Matthew, David, Andrew, Crystal, Ti-Ti Linda, Tio