Biphobia Limits Health Research and Hurts Patients

Someone with long hair in a white lab coat faces a laboratory bench full of equipment. The picture is colorized with the bisexual flag colors.

Structural biphobia has negative health effects on bisexual people, and health care providers must understand the relationships between biphobia, the low level of bisexual health research funding, and the existence of bisexual health disparities to avoid replicating these negative effects in their practice. Both scientific research findings and the experiences of bisexual communities speak to the urgent need to combat biphobia and scale up bisexual health research funding.

Over half of LGBT people identify as bisexual.1Gates GJ. How many people are lesbian, gay, bisexual and transgender? The Williams Institute: University of California at Los Angeles School of Law, 2011 April 2011.,2Copen CE, Chandra A, Febo-Vazquez I. Sexual Behavior, Sexual Attraction, and Sexual Orientation Among Adults Aged 18-44 in the United States: Data From the 2011-2013 National Survey of Family Growth. Natl Health Stat Report. 2016(88):1-14. PubMed PMID: 26766410.,3Beach LB, Turner B, Felt D, Marro R, Phillips GL, 2nd. Risk Factors for Diabetes are Higher among Non-Heterosexual US High School Students. Pediatr Diabetes. 2018. Epub 2018/07/15. doi: 10.1111/pedi.12720. PubMed PMID: 30006958. Similar bisexual majorities can be found when defining sexual orientation by attraction or behavior.4Copen CE, Chandra A, Febo-Vazquez I. Sexual Behavior, Sexual Attraction, and Sexual Orientation Among Adults Aged 18-44 in the United States: Data From the 2011-2013 National Survey of Family Growth. Natl Health Stat Report. 2016(88):1-14. PubMed PMID: 26766410. These demographic trends hold true across multiple intersections of identity and experience: people of color are more likely to identify as bisexual than white people,5Phillips II G, Beach LB, Turner B, Feinstein BA, Marro R, Philbin MM, Salamanca P, Felt D, Birkett M. Sexual Identity and Behavior among US High School Students 2005-2015. Archives of Sexual Behavior. and transgender and nonbinary people are more likely to identify as bisexual than cisgender people.6Meyer IH, Brown TN, Herman JL, Reisner SL, Bockting WO. Demographic Characteristics and Health Status of Transgender Adults in Select US Regions: Behavioral Risk Factor Surveillance System, 2014. Am J Public Health. 2017;107(4):582-9. Epub 2017/02/17. doi: 10.2105/AJPH.2016.303648. PubMed PMID: 28207334; PubMed Central PMCID: PMCPMC5343705. Large percentages of bisexual people are also transgender and people of color. Surveys among high-school-aged youth additionally show that the future is increasingly bisexual: a recent study showed that 2.1 percent of high school students identified as gay or lesbian, while 5.7 percent identified as bisexual.7Beach LB, Turner B, Felt D, Marro R, Phillips GL, 2nd. Risk Factors for Diabetes are Higher among Non-Heterosexual US High School Students. Pediatr Diabetes. 2018. Epub 2018/07/15. doi: 10.1111/pedi.12720. PubMed PMID: 30006958.

Bisexual people also experience striking health disparities. Compared to straight, gay, and lesbian people, bisexual people are more likely to experience poor mental health, substance use disorders, and interpersonal violence, among other disparities.8Ward BJ, Dahlhamer, James, M., Galinsky Adena M., Joestl, Sarah S. Sexual Orientation and Health Among U.S. Adults: National Health Interview Survey, 2013. 2014 July 15, 2014.,9Gonzales G, Przedworski J, Henning-Smith C. Comparison of Health and Health Risk Factors Between Lesbian, Gay, and Bisexual Adults and Heterosexual Adults in the United States: Results From the National Health Interview Survey. JAMA Intern Med. 2016;176(9):1344-51. doi: 10.1001/jamainternmed.2016.3432. PubMed PMID: 27367843.,10Bostwick WB, Dodge B. Introduction to the Special Section on Bisexual Health: Can You See Us Now? Arch Sex Behav. 2019;48(1):79-87. Epub 2018/12/12. doi: 10.1007/s10508-018-1370-9. PubMed PMID: 30535566.,11Walters ML, Chen J., & Breiding, M.J. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Findings on Victimization by Sexual Orientation. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2013. An analysis of the 2015 U.S. Transgender Survey data set showed that bisexual transgender people have worse health than monosexual transgender people.12Movement Advancement Project. A closer look: Bisexual transgender people [Internet]. Movement Advancement Project; 2017. Available from: https://www.lgbtmap.org/file/A%20Closer%20Look%20Bisexual%20Transgender.pdf For selected outcomes, a growing number of studies have found bisexual people of color–in particular, black bisexual people–have worse health than white bisexual people.13Friedman MR, Stall R, Silvestre AJ, Mustanski B, Shoptaw S, Surkan PJ, et al. Stuck in the Middle: Longitudinal HIV-Related Health Disparities Among Men Who Have Sex With Men and Women. Jaids-J Acq Imm Def. 2014;66(2):213-20. doi: 10.1097/Qai.0000000000000143. PubMed PMID: WOS:000337685800025. Bisexual people also experience higher rates of poverty and are more likely to lack access to health care than their gay, lesbian, or straight peers.14Mirza SA. Disaggregating the Data for Bisexual People [Internet]. Center for American Progress; 2018. Available from: https://cdn.americanprogress.org/content/uploads/2018/09/04103516/BiCommunityStats-factsheet2.pdf,15Ward BJ, Dahlhamer, James, M., Galinsky Adena M., Joestl, Sarah S. Sexual Orientation and Health Among U.S. Adults: National Health Interview Survey, 2013. 2014 July 15, 2014.,16Beach LB, Elasy TA, Gonzales G. Prevalence of Self-Reported Diabetes by Sexual Orientation: Results from the 2014 Behavioral Risk Factor Surveillance System. 2018. PubMed PMID: 29377760.

Moreover, bisexual people report high levels of biphobia from straight people as well as LGBT communities, which leads to poorer health outcomes.17Roberts TS, Horne SG, Hoyt WT. Between a Gay and a Straight Place: Bisexual Individuals’ Experiences with Monosexism. J Bisexuality. 2015;15(4):554-69. doi: 10.1080/15299716.2015.1111183.,18Beach L, Bartelt E, Dodge B, Bostwick W, Schick V, Fu TJ, et al. Meta-Perceptions of Others’ Attitudes Toward Bisexual Men and Women Among a Nationally Representative Probability Sample. Arch Sex Behav. 2018. Epub 2018/11/18. doi: 10.1007/s10508-018-1347-8. PubMed PMID: 30446861.,19Friedman MR, Dodge B, Schick V, Herbenick D, Hubach R, Bowling J, et al. From Bias to Bisexual Health Disparities: Attitudes toward Bisexual Men and Women in the United States. LGBT Health. 2014;1(4):309-18. doi: 10.1089/lgbt.2014.0005. PubMed PMID: 25568885; PubMed Central PMCID: PMCPMC4283842.,20Dodge B, Herbenick D, Friedman MR, Schick V, Fu TJ, Bostwick W, et al. Attitudes toward Bisexual Men and Women among a Nationally Representative Probability Sample of Adults in the United States. PLoS One. 2016;11(10):e0164430. doi: 10.1371/journal.pone.0164430. PubMed PMID: 27783644; PubMed Central PMCID: PMCPMC5082634. This “double discrimination” leads to an increase in social isolation and loneliness experienced by bisexual people.21Mereish EH, Katz-Wise SL, Woulfe J. Bisexual-Specific Minority Stressors, Psychological Distress, and Suicidality in Bisexual Individuals: the Mediating Role of Loneliness. Prev Sci. 2017;18(6):716-25. Epub 2017/06/09. doi: 10.1007/s11121-017-0804-2. PubMed PMID: 28593529. A growing number of studies link biphobia at the structural, interpersonal, and internalized levels to broad-ranging, population-level bisexual health disparities.22Friedman MR, Dodge B, Schick V, Herbenick D, Hubach R, Bowling J, et al. From Bias to Bisexual Health Disparities: Attitudes toward Bisexual Men and Women in the United States. LGBT Health. 2014;1(4):309-18. doi: 10.1089/lgbt.2014.0005. PubMed PMID: 25568885; PubMed Central PMCID: PMCPMC4283842.,23Mereish EH, Katz-Wise SL, Woulfe J. Bisexual-Specific Minority Stressors, Psychological Distress, and Suicidality in Bisexual Individuals: the Mediating Role of Loneliness. Prev Sci. 2017;18(6):716-25. Epub 2017/06/09. doi: 10.1007/s11121-017-0804-2. PubMed PMID: 28593529.,24Ross LE, Dobinson C, Eady A. Perceived determinants of mental health for bisexual people: a qualitative examination. Am J Public Health. 2010;100(3):496-502. doi: 10.2105/AJPH.2008.156307. PubMed PMID: 20075326; PubMed Central PMCID: PMC2820049.,25Bostwick W. Assessing Bisexual Stigma and Mental Health Status: A Brief Report. J Bisex. 2012;12(2):214-22. Epub 2012/01/01. doi: 10.1080/15299716.2012.674860. PubMed PMID: 24683314; PubMed Central PMCID: PMCPMC3966467.

Biphobia’s negative impacts on health research

Notwithstanding these disparities, public and private funding for bisexual health research remains low. The 2016 Funders for LGBTQ Issues report shows that in 2016, funders gave around $202 million to support LGBT projects.26Kan LM, Maulbeck BF, Wallace A. 2016 Tracking Report: LGBTQ Grantmaking by U.S. Foundations [Internet]. New York: Funders for LGBTQ Issues; 2018. Available from: https://lgbtfunders.org/wp-content/uploads/2018/04/2016_Tracking_Report.pdf Of this funding, $37 million was allocated to support LGBT community sub-populations but only $300 were dedicated to serving bisexual people or communities. These numbers are not an anomaly. Every tracking report ever published by Funders for LGBTQ Issues has shown that bisexual communities have received less than 1 percent of all LGBT philanthropic dollars.

The NIH Sexual and Gender Minority (SGM) Research Office’s 2012 SGM research portfolio analysis–the most recent to break down funding by SGM sub-population–at first appears more promising: 13.6 percent of NIH funded SGM research projects included bisexual health.27NIH SGM Research Coordinating Committee. National Institutes of Health FY 2012 Sexual and Gender Minority Health Research Portfolio Analysis Report [Internet]. National Institutes of Health; 2015. Available from: https://www.edi.nih.gov/sites/default/files/public/EDI_Public_files/downloads/people/lgbti/sgm-research/sgm-nih-fy2012-portfolio-analysis-report.pdf The comparatively higher percentage of NIH dollars (13.6 percent) compared to private foundation dollars (less than 1 percent) dedicated to bisexual health is driven largely by one condition: HIV. In 2012, 75 percent of funded SGM health research studies focused on HIV/AIDS. The majority of these studies assessed HIV prevention, care, and treatment outcomes among cisgender men who have sex with men (MSM).

The use of “MSM” as a HIV research funding category, however, limits the ability to count bisexual men in these research studies. In this way, bisexual erasure limits the transparent assessment of the total financial investment in HIV research that includes bisexual people. Compared to the general population, bisexual men and men who have sex with men and women (MSMW) are greatly underrepresented within HIV “MSM” research.28Bostwick WB, Dodge B. Introduction to the Special Section on Bisexual Health: Can You See Us Now? Arch Sex Behav. 2019;48(1):79-87. Epub 2018/12/12. doi: 10.1007/s10508-018-1370-9. PubMed PMID: 30535566.,29Friedman MR, Stall R, Silvestre AJ, Mustanski B, Shoptaw S, Surkan PJ, et al. Stuck in the Middle: Longitudinal HIV-Related Health Disparities Among Men Who Have Sex With Men and Women. Jaids-J Acq Imm Def. 2014;66(2):213-20. doi: 10.1097/Qai.0000000000000143. PubMed PMID: WOS:000337685800025.,30Friedman MR, Wei CY, Klem ML, Silvestre AJ, Markovic N, Stall R. HIV Infection and Sexual Risk among Men Who Have Sex with Men and Women (MSMW): A Systematic Review and Meta-Analysis. Plos One. 2014;9(1). doi: ARTN e87139 Unsurprisingly, a more granular breakdown of SGM population-specific funding in the same 2012 NIH report revealed that only 0.5 percent and 3 percent of resources were specifically dedicated to research the health of bisexual men and bisexual women, respectively.

Structural biphobia drives the systematic under-investment in bisexual health research.

Bisexual community organizations and leaders have long advocated for the urgent scaling up of resources dedicated to bisexual health research. Bisexual people, community organizations, and researchers have fought for decades to advance bisexual visibility and equality within both mainstream society and LGBT organizations. As scientifically rigorous bisexual health research studies have emerged, bisexual leaders have also tirelessly fought to raise awareness that biphobia disproportionately contributes to the poor health of bisexual populations.31Movement Advancement Project. Invisible majority: The disparities facing bisexual people and how to remedy them [Internet]. Movement Advancement Project; 2016. Available from: https://www.lgbtmap.org/file/invisible-majority.pdf The calls of bisexual community leaders and health policy advocates to scale up bisexual health research funding, however, have almost entirely gone unanswered.

Taken together, these findings indicate that structural biphobia drives the systematic under-investment in bisexual health research. This under-investment limits the ability to develop and implement evidence-informed care to improve the health and well-being of bisexual people. Nationally representative studies show that at least five million American adults identify as bisexual–a number that is increasing over time. The breadth, magnitude, and pervasiveness of bisexual health disparities negatively affecting the lives of bisexual people is shocking and well-documented. What’s more, empirical evidence increasingly supports the view that biphobia is the overarching mechanism responsible for these disparities. The content of publicly available portfolio analyses from both private LGBT and governmental funders shows that grant-making institutions are aware these funders do not dedicate resources to bisexual health.

In addition to working as an SGM health researcher, I have also served as a bisexual community organizer and health policy advocate for over half of my life. In my experiences as a bisexual person, a bisexual community stakeholder, and an SGM health researcher, I can personally attest that the lack of investment in the health and well-being of bisexual people–whether in government, health care, or LGBT community organizations–is the norm, not the exception. Given this context and history, the lack of bisexual health research funding must be named for what it is: structural biphobia.

How providers can combat biphobia and improve bisexual health

Health care providers committed to providing high quality care to their bisexual patients cannot bring this commitment to life without understanding and taking steps to limit structural biphobia. To avoid exacerbating the impact of structural biphobia within health research and health care contexts, providers should consider implementing the following recommendations.

  • Due to biphobia, bisexual people are less likely to be out to their health care providers. Providers should seek out tailored training to ensure they are learning to provide quality, culturally responsive care to their bisexual patients. Due to the structural biphobia present within LGBT community organizations, providers should hire bisexual community organizations or bisexual professionals specialized in providing culturally responsive care to bisexual patients to lead these trainings.
  • Providers should consider displaying resources designed to empower bisexual patients to come out to their providers within patient waiting rooms. In March 2019, the Human Rights Campaign’s (HRC) Bisexual Pan Fluid and Queer Employee Resource Group developed an outstanding resource for this purpose. The resource guide to coming out as bisexual published by The Bisexual Resource Center, BiNet USA, and the Bisexual Organizing Project, in partnership with HRC, is another strong option.
  • Providers should familiarize themselves with recommendations for health care screenings tailored to the needs of bisexual populations. GLMA: Health Professionals Advancing LGBTQ Equality has a top ten list of health issues that bisexual people should discuss with their health care providers that can serve as a starting point for clinicians’ self-directed learning.
  • Clinician scientists should collaborate with bisexual community organizations and stakeholders to apply for funding for bisexual health research studies. In this way, bisexual organizations can work toward obtaining the resources necessary to advance bisexual health, and clinician scientists can help lead the way to flesh out the evidence needed to improve health and health care for bisexual populations.

In summary, health care providers should collaborate with bisexual patients, stakeholders and community organizations to sound the alarm for the need to scale up bisexual research funding. Health care providers everywhere should take at least one action to support efforts to expand the resources dedicated to bisexual health research. Every conversation led by providers to expand support for bisexual health research decreases structural biphobia and contributes to the expedited formation of evidence-informed best practice recommendations to improve the quality of care for bisexual patients. By collaborating with bisexual community stakeholders to increase bisexual health research funding, engaged providers can help improve the health and well-being of bisexual people within the health care system and society at large.

Sources   [ + ]

Lauren B. Beach, Ph.D., J.D.

Lauren B. Beach is Associate Director of the EDIT Program in the Institute for Sexual and Gender Minority Health and Wellbeing at Northwestern University Feinberg School of Medicine. A longtime bisexual community organizer and health policy advocate, Lauren loves to engage and empower bisexual communities in real life and on Twitter (@laurenbbeach).

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1 Response

  1. Jan Steckel says:

    Well done, Lauren Beach!

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