WE HEAR a lot about advances in HIV treatment, the use of Truvada or PrEP to prevent HIV infection for the sexually active, and the latest programs designed to promote safer sex. Largely unreported, however, has been a huge shift toward addressing “upstream” mental health issues—such as depression, substance abuse, or partner violence—because it has finally become clear that gay men who don’t feel good about themselves or their lives are less likely to protect themselves and more likely to take risks.
Programs like the MPowerment Project, created in San Francisco, or Seattle’s Gay City Health Project are examples of a new generation of what are called “strength-based” or “resilience-based” interventions. They don’t begin from an assumption that gay men are irresponsible and must be reined in by shaming or scare tactics. Instead they build on gay men’s strengths and resilience. It turns out that addressing mental health issues is key to helping HIV-negative men act responsibly to stay negative and to helping HIV-positive people adhere to their treatment regimens.
The evidence has been mounting for the importance of addressing mental health in a holistic way. In a 2011 Pediatrics article, Columbia University assistant professor Mark L. Hatzenbuehler reported that in “unsupportive” Oregon school districts—he looked where there were no school-based Gay-Straight Alliances—gay, lesbian, and bisexual youth were five times more likely than their heterosexual peers to have attempted suicide in the previous twelve months.
That much is all too familiar. What’s surprising is something Hatzenbuehler found in another study: the positive effect of supportive policies on gay men’s health after same-sex marriage was legalized in Massachusetts in 2004. He found that after the state became the first to legalize same-sex marriage, the men had fewer medical and mental health care visits and lower medical costs. While researchers have said for years that marriage is conducive to better health, simply having the right to be married seems to have had a salubrious effect on gay men in the Bay State.
In my interviews with other researchers, Hatzenbuehler’s work regularly comes up because it offers empirical evidence to support what others have suspected but couldn’t yet prove. As he told me in an interview: “There has been a lot of speculation from theoretical writers who have talked about the importance of ‘minority stressors’ and how they might affect the health of LGBT populations broadly, and gay men specifically. But we haven’t had the data structures to look at these.”
Fortunately, that’s changing. Hatzenbuehler’s work has only become possible in the last ten to fifteen years, as individual states have adopted LGBT-supportive laws. This allows him to make state-to-state comparisons and to rely on objective markers instead of self-reporting, to gauge the effects of homophobic laws compared with laws protecting equality. Research such as Hatzenbuehler’s is laying a solid scientific basis for public policy regarding LGBT people that has been largely missing. The ability to offer scientific proof that homophobic policy causes measurable harm gives legal and policy advocates the ammunition they need to push for health-promoting, money-saving change.
But there is still an essential next step: translating academic research into real-world interventions and programs to counter the effects of bullying, unsupportive public policy, and the “syndemics” that University of Pittsburgh behavioral scientist Ron Stall describes. Stall, director of the university’s LGBT Research Institute, has identified four interconnected “epidemics” of psychosocial health conditions that disproportionately afflict gay and bisexual men, each one making the others worse: childhood sexual abuse, partner violence, depression, and drug use. Men who are most strongly affected by any one of these tend to be at high risk for HIV and substance abuse. Those of us from lower-income backgrounds or culturally marginalized ethnic groups are especially vulnerable to syndemic effects.
In one study, Stall (2003) found that eleven percent of 812 men who reported one problem—depression, for instance—had engaged in high-risk sex. Of 129 men who reported three or four problems, 23 percent said they had high-risk sex. The usual reaction to these numbers is shock and accusations: “Eleven percent! Twenty-three percent! Look how irresponsible gay men are!” Granted, these numbers are high relative to the general population. On the other hand, they tell us something quite astonishing when we look at them from a different angle: that 89 percent of the men reporting one mental health challenge did not engage in high-risk sex. Likewise, more than three-quarters of the men with three or four mental health challenges did not engage in high-risk sex.
Stall attributes the difference to resilience. The fact is, and it is statistically verified, the overwhelming majority of gay men are able not only to survive life’s traumas but to function at a normative level in their work and personal lives. How can this be? In the face of overwhelming pressures and struggles that can give gay men all the reasons they might need to harm or medicate themselves, how is it that most do not?
RESEARCH SUGGESTS that the journey toward being resilient for gay men begins with acceptance of their sexual orientation. Ron Stall told me in a January 2013 interview for The Atlantic: “Guys who do the best job of resolving internalized homophobia [or self-stigma]are the least likely to have current victimization, substance abuse, and compulsive [high-risk] sex.” Put a little differently, he said: “Getting a population of people to not hate themselves is good for their health. This is not rocket science.”
Besides confirming that most LGBT people cope remarkably well with difficult circumstances, two major reports provide ample evidence that the health of LGBT Americans has been a low priority in the country for a very long time—and that supporting our resilience is an important key to good health. A 2011 report from the Institute of Medicine found that a challenge in studying LGBT health is the sheer lack of even basic data: Who are we? Where do we live? What is our socioeconomic status? The IOM recommended including data on sexual and gender minorities in electronic health records as well as in the demographic information collected in federally funded surveys, just as race and ethnicity data are collected.
A follow-up report released in January 2013 by the National Institutes of Health (NIH) LGBT Research Coordinating Committee revealed exceptionally thin NIH resources committed to investigating the well-documented health disparities among LGBT Americans—including higher rates of alcoholism, cancer, depression, smoking, suicide, and violence. The NIH report found that in fiscal 2010 (the most recent year for which data were available) only 5.0 percent of the institutes’ LGBT health projects were focused on alcoholism, with 7.7 percent going to cancer, 2.7 percent to depression, 1.4 percent to smoking and health, 1.4 percent to suicide, and 6.3 percent to violence. The overwhelming majority of projects—81.5 percent—dealt with gay men and hiv/aids, particularly on ways to reduce HIV transmission.
It’s not entirely surprising that the research emphasizes gay men, because the hiv/aids epidemic trained a spotlight on the physical and mental health challenges that gay men face. “One important thing the epidemic did,” Gregory M. Herek, a professor of psychology at UC–Davis who served on the Institute of Medicine panel, told me, “was to force much of society, and the federal and state governments, to acknowledge the existence of people who are homosexual, especially gay men.”
By the time effective combination drug treatments for HIV became available in 1996, Boston’s Fenway Community Health Center had become one of the nation’s leading LGBT health organizations. Its services of necessity skewed heavily to caring for HIV-positive gay men. In the twenty-year interim, Fenway Health, as it’s known today, has been able to focus more resources on other matters, such as women’s health and the medical challenges of an aging population, according to Kenneth H. Mayer, a Harvard professor and medical research director of the Fenway Institute. Now they can also work to develop interventions aimed at countering the harmful psychosocial effects of anti-gay stigma, such as depression and substance abuse, which can undermine gay men’s sense of self-worth and lead to unsafe sexual behavior. Mayer told me in an interview that such interventions are particularly important for young people: “If we can identify programs that engage youth so they feel good about themselves, there will be fewer problems down the road.”
Even though HIV can largely be managed by medication, and even though gay men are at heightened risk for other health challenges—including the NIH’s list of under-investigated issues—newer research on gay men still mainly addresses HIV risk. However, as researchers look at “upstream” mental health issues that can lead to risky behavior, they are also proving empirically that, for example, young gay men of color—who have the highest risk for HIV transmission—take better care of themselves when they have healthy male role models to support and encourage them.
John A. Schneider, an assistant epidemiology professor at the University of Chicago, researches networks and how to use them to create change. “After thirty years,” he told me, “we are moving away from individualized behavioral interventions toward things that can integrate those components. We are looking at networks and structural things that can drive HIV.” His clinical work with mostly young African-American gay men on Chicago’s South Side is yielding intriguing findings about how best to support those at greatest risk. I would submit that what he is learning from young HIV-positive gay men of color offers lessons on the supportive role of men in the lives of all men, regardless of sexual orientation. Schneider has found, for example, that the more men, straight or gay, who are involved in a young man’s life, the more likely he is to protect himself against HIV if he’s negative and adhere to treatment if he’s positive.
In a real sense, Schneider’s work, like that of others trying to find ways to fight stigma and bolster gay men’s health and well-being, is helping to put the LGBT health movement back on track after the AIDS epidemic hijacked it. It is also getting to the real issues behind sexual and drug-using risk behavior, including the depression, low self-esteem, shame, and loneliness that can easily drive people to do things that they know better than to engage in.
Meanwhile, public education campaigns have shifted from a reliance on scare tactics to motivate safer sexual behavior to an approach that treats gay men as responsible adults who have survived hardship and homophobia by drawing on their individual courage, creativity, and strength. In the first category, consider the HIV prevention campaign launched in 2010 by the New York City Department of Health. Using graphic images of anal cancer and dementia, the department wanted to make sure no one missed the point that being infected with a deadly virus isn’t the only thing they need to worry about. “When you get HIV,” warned the horror-movie style voiceover in the TV and YouTube spots, “it’s never just HIV.”
The New York campaign ignored what we know about risk behavior and the psychological wounds that so many of us carry. Those things can push people to do things they may later regret. How could they not realize that terrifying young gay men will only make them feel frightened and powerless? Instead of “It’s never just HIV,” a more honest and effective tagline might have been “It’s never just sex.” After all, the sex that we have is driven by all the factors that influence how and with whom we engage in it, and why. Doesn’t it make sense that motivating people to have safer sex requires getting to the heart of what sex means to them and how they make decisions about it?
FORTUNATELY, there are people thinking creatively and honestly about HIV prevention. They’re looking at what makes us tick—what quickens our pulse, what gives us heartache—as well as what gets our motor running. They are also looking at ways to build on our resilience in “strength-based,” rather than deficit-based, interventions. As Ron Stall told me: “We’re so focused on risk factors to the point that we forget about resilience.” A better approach would be to look at the guys who are thriving in spite of adversities, to understand how they accomplish that, what lessons they’ve learned, and then apply these to the interventions. This is exactly in line with the recommendations of the 2013 NIH report. The LGBT Coordinating Committee said that resilience should be studied to find out “how it develops, may protect health, and may buffer against the internalization of stigma and/or other negative experiences associated with sexual or gender minority status.”
One intervention that’s well underway is the CDC’s MPowerment Project, which is aimed at supporting young urban gay men to make healthy decisions. Technically, it’s an HIV-prevention program, and it isn’t officially billed as “resilience-building.” But co-principal investigator Greg Rebchook, an assistant professor at UC-San Francisco, told me, “We don’t start from a place where gay men are wounded, their wings are broken.” Instead, MPowerment uses outreach, drop-in centers, and community-building efforts to strengthen young gay men’s self-esteem and help them build positive relationships and social support. Using a “whole-man” approach, Rebchook said, “is not just about condoms but about all the factors that come together to affect their lives.” Although MPowerment is a subtly powerful way to build up young gay men’s resilience and health, its focus on the drivers of risk behavior is new territory for government prevention funders. Rebchook offered: “There is a lot of interest in my colleagues around resilience, but when you look at RFPs, they are all about the health disparities in the community.”
The often shocking disparities in the way gay males are treated compared with non-gay people are exactly why interventions must support gay resilience. Seattle’s Gay City Health Project has understood this since its founding in 1995. When it was introduced to a national audience during the 1996 National Lesbian and Gay Health Conference, held in Seattle, director John Leonard described Gay City’s vision in this way:
Imagine no more poignant memorial services. No more “twenty-something and HIV-positive” support groups. No more AIDS protests, no more AIDS fundraisers. And no more fucking red ribbons. Imagine a future of equality, diversity, community. Imagine a time when gay men count gray hairs and not T-cells. Imagine a world where we’re raised to love ourselves as healthy, whole, and beautiful. Imagine a place where holding hands is not an act of courage. And having sex is not against the law. Imagine no fear, no more grief. Imagine no more new HIV infections.
From its beginning as a county health department task force exploring prevention options for gay men, Leonard said, “Gay City wasn’t just about something bad that we wanted to prevent but about something really good that we wanted to create.” The group’s mission, he explained, is “building community, promoting communication, and nurturing a culture where gay men see their lives as worth living.” Drawing on essentially the same models as MPowerment, Gay City created its programs in response to what they heard from gay men. Commented Leonard: “We were told to build community, build connections among gay men, build a greater sense of responsibility among men for each other, and help men feel better about being gay.”
Three hundred people attended Gay City’s first community forum in January 1994, called “Why Are Fags Still Fucking Without Condoms?” I asked Leonard how people reacted when men spoke up about their unsafe sexual experiences, a taboo subject among gay men who looked at prevention educators as authority figures. His reply: “I remember a collective sigh of relief that finally somebody was saying it. I don’t think anybody was shocked, because I think on some level we knew that we weren’t being good little boys all the time, but it wasn’t okay to talk about, and people did and do feel a lot of stigma admitting that, especially if they’re HIV-positive.”
Hundreds more showed up at subsequent forums, each one dedicated to timely issues such as dating, oral sex, coming out, relationships between HIV-positive and -negative men, drug and alcohol use, and other topics that don’t, at first blush, look like HIV prevention. More than 700 participated in a May 1996 forum on “charting our futures,” featuring lesbian activist Urvashi Vaid. A forum on gay history the following month grew out of one young man’s standing up at an earlier forum and saying: “I don’t know who Judy Garland was. Talk to me about pre-Stonewall. It would help me feel better about the gay community and other gay men to know a little about where I came from.”
As Leonard explained: “We talk about how you need more than just condoms and practice putting them on a banana to practice [safer sex]over the long run. You need to address broader social issues, and those have to do with self-esteem, and feeling a part of a community that you feel connected to.” He said that gay men in Seattle responded very positively to Gay City’s vision: “In the surveys we do, people report that coming to forums, even if not directly about HIV prevention, has an impact on them that makes them leave the forums feeling more pride and connection to the gay community, and feeling greater motivation to practice safer sex and take care of their health.”
Feeling pride and connection to the gay community; nurturing a culture where gay men see their lives as worth living; supporting healthy men to make healthy choices—John Leonard in the late 1990s could have been talking about today. In fact, Gay City has always been ahead of its time. Today the agency serves as Seattle’s lgbtq Center with its own Seattle coffeehouse and a mission of “promoting wellness in lgbtq communities by providing health services, connecting people to resources, fostering arts, and building community.” Welcome to the future of HIV prevention and gay men’s health. It’s not rocket science, Ron Stall said, but it is what we need to thrive as healthy, resilient gay men at every age and whatever our HIV status.
References
Institute of Medicine. “The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding.” National Academy Press, 2011.
Kegeles, S. M., et al. “Dissemination of Behavioral Interventions: The MPowerment Project: a community-level HIV prevention intervention for young gay men.” American Journal of Public Health, Aug. 1996.
Leonard, John. “Welcome to Gay City,” a presentation at the National Lesbian and Gay Health Conference, 17 July 1996.
National Institutes of Health LGBT Research Coordinating Committee, “Consideration of the Institute of Medicine (IOM) Report on the Health of Lesbian, Gay, Bisexual, and Transgender (LGBT) Individuals.” January 2013.
NIH, LGBT Research Coordinating Committee, “Consideration of the Institute of Medicine (IOM) Report on the Health of Lesbian, Gay, Bisexual, and Transgender (LGBT) Individuals.”
Stall, Ron, et al. “Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men,” American Journal of Public Health 93(6), 2003.
Interviews with Ron Stall and Mark L. Hatzenbuehler, Gregory M. Herek, Kenneth H. Mayer, M.D., Gregory Rebchook.
John-Manuel Andriote is the author of Victory Deferred: How AIDS Changed Gay Life in America (University of Chicago Press) and Stonewall Strong, forthcoming from Rowman & Littlefield.
