Gay Men’s Health and the Theory of Cultural Resilience
Gay Men’s Health and the Theory of Cultural Resilience
Abstract and Keywords
This chapter explores health disparities among men who identify as gay, bisexual, queer, same gender loving, or some other sexual minority term, as well as men who engage in same-sex sexual behavior. It discusses why health disparities exist and offers a framework to address them. It suggests that current prevention and health promotion efforts could be greatly improved by expanding the current public health paradigm to include a focus on resilience.
According to the United States Department of Health and Human Services, health disparities are population-specific differences in the presence of disease, health outcomes, or access to healthcare (Health Resources and Services Administration, 2000). One population that experiences immense health disparities is men who have sex with men. This chapter explores health disparities among men who identify as gay, bisexual, queer, same gender loving, or some other sexual minority term, as well as men who engage in same-sex sexual behavior. Sexual orientation is a complex multidimensional construct and we do not intend to minimize the diversity inherent in this group, yet for the sake of simplicity, we will collectively refer to these individuals as men who have sex with men. In this chapter we will discuss why health disparities exist and offer a framework to address them. We suggest that current prevention and health promotion efforts could be greatly improved by expanding the current public health paradigm to include a focus on resilience.
HEALTH DISPARITIES AMONG MEN WHO HAVE SEX WITH MEN
The information we have about health disparities among gay men or men who have sex with men (MSM) is limited. Most information available about health inequalities experienced by MSM concerns sexual health (Wolitski, Stall, & Valdiserri, 2008). This is not necessarily because this is the area of greatest disparity, but, as a result of the HIV/AIDS epidemic, because this is where the greatest amount of research has been done. As more research is conducted that examines the association between same-sex sexual orientation and/or behavior and other health outcomes, evidence of health disparities in other areas of health is likely to emerge. For instance, many studies have shown that MSM smoke cigarettes at greater rates than heterosexual men (Greenwood et al., 2005; Ryan, Wortley, Easton, Pederson, & Greenwood, 2001; Tang et al., 2004. However, to our knowledge there is no evidence of disparities in rates of lung cancer. This is not necessarily because disparities do not exist; it may be because the research has not yet been done.
Another limiting factor in our understanding of health disparities among gay men is the homogeneity in the samples in most research studies. Historically, most sexual minority health research has been conducted with samples that are disproportionately white. A survey of MSM health research may give the impression that MSM are mainly white, middle class, and highly educated, obviously an inaccurate portrayal of the great diversity of MSM individuals and communities. Non-MSM health research has demonstrated immense disparities based on race/ethnicity, with African-Americans and Latinos faring much worse than whites on many health indicators (Arias, 2007; Hummer, 1996; Orsi, Margellos-Anast, & Whitman, 2010). The limited research that has been conducted with MSM of color suggests that these race/ethnicity-based health disparities also exist among MSM (Diaz, Peterson, & Choi, 2007; Harawa et al., 2004). However, more research is needed to understand the context and the extent of health disparities among MSM of color.
Another issue that limits a full understanding of health disparities among gay men is inconsistencies in the assessment of sexual orientation. Studies typically use identity, behavior, attraction, or a combination of these constructs to categorize an individual as gay. These methods all have limitations. (p.192) For instance, terms used for self-identification as gay are not necessarily consistent across different gay men’s communities. Whereas “queer” or “yag” (gay spelled backward) are terms often used by young gay men, these terms are less frequently used, or may even be perceived as offensive, by older gay men. Similarly inconsistent patterns of identification appear across racial/ethnic groups with some African-American gay men more likely to prefer the term “same gender loving” to the more commonly used “gay” or “homosexual.” Different methods for collecting sexual orientation data are often unavoidable as each research question and health topic requires a tailored approach. For a study of sexually transmitted diseases, it is best to classify individuals based on same-sex sexual behaviors, whereas a study of adolescent suicide risk might more effectively use measures of sexual attraction or sexual identity. Inconsistencies in what is defined as sexual minority limit the generalizations that can be made about health disparities in the gay male population.
Perhaps the greatest limiting factor in our understanding of health disparities among MSM is the exclusion of sexual orientation information in population-based studies and in clinical trials. Few large-scale studies currently include questions about same-sex sexual behavior, sexual identity, or sexual attraction, making it impossible to draw conclusions about how the prevalence of conditions such as cancer, diabetes, or heart disease may vary between MSM and non-MSM populations. The large-scale studies that do include sexual orientation questions, such as the National Longitudinal Study of Adolescent Health (in its latest wave of data collection), the National Health and Nutrition Examination Survey, and the Youth Risk Behavior Survey (in this survey, questions about sexual orientation are voluntary and are added by individual states), have contributed greatly to our understanding of gay men’s health (Galliher, Rostosky, & Hughes, 2004; Garofalo, Wolf, Kessel, Palfrey, & DuRant, 1998; Marshal, Friedman, Stall, & Thompson, 2009; Saewyc et al., 2006). Many sexual minority health researchers have urged the routine inclusion of questions about sexual orientation in population-based questionnaires. Until a sexual orientation assessment, preferably including items concerning attraction, behavior, and self-identification, is added to such data collection tools, our depth and breadth of understanding about MSM health disparities will be limited.
Despite these limitations, there is still quite a bit of information about health disparities among MSM. A complete synthesis all of the literature documenting disparate negative health outcomes among gay men is beyond the scope of this chapter. For a comprehensive recent review, the reader is referred to Wolitski et al. (2008). Instead, the chapter focuses on HIV for two main reasons. First, HIV represents perhaps the greatest health disparity faced by gay men and has been the most critical health concern for gay and sexual men since the first cases of AIDS were reported in 1981. Second, the HIV epidemic can provide a framework for examining the etiology of health disparities. We will also focus broadly on the mechanisms by which gay men and MSM have developed other health disparities as a result of social marginalization and homophobia.
HIV AMONG MEN WHO HAVE SEX WITH MEN
According to a 2010 surveillance report released by the Centers for Disease Control and Prevention (CDC) regarding HIV prevalence rates in the United States, males who reported having sex with other men accounted for 73% of all new HIV infections and 75% of all people living with HIV. Even though gay men make up only a small minority of the U.S. population, the majority (53%) of all new infections are attributed to male-to-male sexual contact (Centers for Disease Control and Prevention, July 2010). Subpopulation estimates from the same year suggested that 72% of new HIV infections among males were in MSM (Centers for Disease Control and Prevention, 2008b). Epidemiological data indicate that not only are the rates of HIV infection high among MSM, but the trends in infection are alarming. From 2004 to 2007, there was an estimated 26% annual increase in HIV/AIDS diagnoses among MSM (Centers for Disease Control and Prevention, 2009b).
Nearly 30 years into the epidemic, the human immunodeficiency virus (HIV) has become a disease of adolescents and young adults. It is estimated that 50% of all new HIV infections in the United States occur among individuals under the age of 25 (Centers for Disease Control and Prevention, 2005b). Similar to subpopulation disparities among adults, the burden of HIV disease among youth is also being shouldered by MSM. Surveillance data indicate that 76% of new youth HIV infections (p.193) occur among MSM (Wolitski, Valdiserri, Denning, & Levine, 2001). The magnitude of this disparity in infection rates is further demonstrated by the fact that only 5–7% of the U.S. male population reports having had sex with other men, yet MSM make up over two-thirds of all persons currently infected with HIV (Centers for Disease Control and Prevention, 2007). A study of high-risk young persons who visited sexually transmitted disease (STD) clinics found seroprevalence rates among young heterosexual men to be less than 3% compared to 21% for young MSM (Centers for Disease Control and Prevention, 2001b).
Within the MSM population the burden of HIV infection is also unequally distributed. In particular, racial and ethnic minorities are more likely to be infected with HIV than white MSM, with African-Americans experiencing the highest rates of infection (Centers for Disease Control and Prevention, 2000, 2001a; Easterbrook et al., 1993; Lemp et al., 1994; Valleroy et al., 2000). Half (49%) of all new HIV infections in 2005 occurred in African-Americans, despite the fact that African-Americans make up an estimated 13% of the U.S. population (Centers for Disease Control and Prevention, 2006). Among these individuals, male-to-male sexual contact accounted for 63% of the new infections (Centers for Disease Control and Prevention, 2008a). In a study of MSM in five major U.S. cities, 46% of African-American MSM were HIV positive (Centers for Disease Control and Prevention, 2005a). The racial disparity in rates of HIV is even more pronounced among young MSM (YMSM). CDC surveillance data have shown that adult African-American MSM are five times more likely to be infected with HIV than white MSM. In comparison, African-American YMSM ages 13 to 19 have a rate of infection 19 times higher than of white YMSM (Hall, Byers, Ling, & Espinoza, 2007). The majority (76%) of HIV-seropositive youth (Rangel, Gavin, Reed, Fowler, & Lee, 2006), regardless of race/ethnicity or sexual minority identity, were infected through unprotected anal intercourse (Kingsley et al., 1987; Vittinghoff et al., 1999). Latino men also experience higher rates of HIV compared to white men. In 2006, the rate of new HIV infections among Latino men was 2.5 times that of white men. In the same year, HIV/AIDS was the fourth leading cause of death among Latino men aged 35–44 (Centers for Disease Control and Prevention, August 2009). As with white and African-American men, the leading pathway to HIV infection among Latino men is sexual contact with other men (Centers for Disease Control and Prevention, 2009a).
Despite over two decades of prevention efforts aimed at MSM, rates of HIV infection remain high. A 2008 report released by the CDC showed that MSM accounted for 46% of all new HIV/AIDS infections and HIV infection rates among young MSM increased at a rate of approximately 12% each year between 2001 and 2006 (Centers for Disease Control and Prevention, 2008c). During the same 6-year time period, the number of HIV/AIDS cases among African-Americans increased regardless of age, but the number of new HIV/AIDS cases among African-American MSM aged 13 to 24 increased by an astounding 93% (Centers for Disease Control and Prevention, 2008c). This report further noted that MSM were the only risk group that experienced an increase in infection rates during this time.
It must be noted that CDC incidence and prevalence estimates—including the estimates presented here—are typically made available 2–3 years after the data are collected. It is therefore possible that the HIV risk that MSM are currently facing is worse than the data suggest. In fact, according to analysis conducted by Stall and colleagues, even if the incidence of HIV among MSM remains at the current level, by the time a cohort of young MSM who are currently 18 years olds reaches the age of 40, 41% of them will be HIV positive (Stall et al., 2009). Thus, the trends that have been seen in rates of HIV among MSM are alarming.
UNDERSTANDING HEALTH DISPARITIES AMONG MSM
MSM also experience disparities in rates of other psychosocial health outcomes, such as illicit drug use, alcohol misuse/abuse, and depression. Marshal et al. (2008) conducted a meta-analysis study focusing on the relationship between sexual orientation and substance use. Using 18 studies and 125 independent effect size estimates, the researchers found that the odds of substance use among sexual minority youth was significantly higher than among heterosexual youth. This pattern of increased rates of substance use has long been shown to exist among adult MSM as well (Chesney, Barrett, & Stall, 1998; McCabe, Hughes, Bostwick, West, & Boyd, 2009; (p.194) Woody et al., 2001). In a recent study of over 1000 high school youth in Massachusetts, sexual minority male youth were found to have significantly higher depressive symptomotology scores than heterosexual youth (Almeida, Johnson, Corliss, Molnar, & Azrael, 2009). The results of a meta-analysis on the relationship between mental health outcomes and sexual orientation conducted by King et al. (2008) found that MSM were more than twice as likely as heterosexual men to experience both lifetime depression and depression in the past year. These studies demonstrate that disparities in psychosocial health outcomes are present in MSM at a young age and suggest that they continue into adulthood.
These negative psychosocial health outcomes are thought to interact to form a syndemic, a set of cooccurring health conditions that together can lower overall health and increase susceptibility to disease. According to the CDC, a syndemic two or more afflictions, interacting synergistically, contributing to excess burden of disease in a population” (Centers for Disease Control and Prevention, 2011). For example, psychosocial health problems such as substance use, depression, and intimate partner violence have been found to interact so that their impact on the overall health of the individual is greater than would be expected from an additive effect (Stall et al., 2003). Although many studies involving MSM have shown interconnections among health problems, such as substance use and high-risk sex (Hirshfield, Remien, Humberstone, Walavalkar, & Chiasson, 2004; Stall et al., 2001), two studies have focused on the syndemic condition in samples of adult gay men (Stall et al., 2003) and young gay men (Mustanski, Garofalo, Herrick, & Donenberg, 2007). Using a probability sample of MSM in four major U.S. cities, Stall and colleagues (2003) found that the more psychosocial health problems an individual reported, the greater their risk for both participation in sexual risk behaviors and HIV infection. Mustanski and colleagues (2007) found similar results in a sample of young MSM; the experience of each additional psychosocial health problem significantly increased the odds of unprotected anal intercourse, having multiple sex partners, and HIV seroprevalence. These two studies demonstrated that as the number of psychosocial conditions experienced by an individual increased, the individual’s likelihood of engaging in HIV sexual risk behaviors increased, as did their likelihood of HIV infection. It has been suggested that this set of cooccurring health problems may be driving the HIV epidemic among MSM and may reinforce other health disparities among MSM as well (Stall et al., 2003).
Theoretical Explanations of Syndemic Processes
To fully understand syndemic processes we must determine the causes of the disparities in psychosocial health outcomes that make up the syndemic condition. Several theories have been posited to explain these disparities by focusing on the associations between adversity and health outcomes. One such theory is the Minority Stress Theory (see Meyer and Frost, Chapter 18, this volume). This theory suggests that experiences of social discrimination based on sexual orientation lower the overall health of sexual minority individuals (Diaz, 1998; Meyer, 1995, 2003). This process happens over time as minority individuals are exposed to both explicit and implicit discrimination and social marginalization. These experiences cause stress, have a negative impact on an individual’s self-esteem, increase emotional distress, and render the individual more vulnerable to health problems, such as depression and substance use. Meyer (1995) originally conceived of minority stress as stemming from three sources: internalized homophobia, perceived stigma, and prejudice (violence and/or discrimination). Using a sample of 741 gay men recruited from New York City, Meyer (1995) found that these three forms of minority stress, when taken together, significantly predicted five psychological distress outcomes—demoralization, guilt, suicide, AIDS-related traumatic stress response, and sexual problems. These findings support Meyer’s hypothesis that experiences of minority stress contribute to poor health among gay men.
In their study on the effects of minority stress in the lives of Latino MSM, Diaz, Ayala, Bein, Henne, and Marin (2001) found that the most men had been exposed to negative views about homosexuality while growing up. Of the sample, 91% reported hearing that gay people were not normal, 71% heard that gay people grow up to be alone, and 70% were told that their homosexuality would damage their family relationships. These experiences of social discrimination were (p.195) associated with low self-esteem and social isolation, which in turn were correlated with more psychological distress. This study, along with others (Meyer, 1995; Stall, Friedman, & Catania, 2007), suggests that social marginalization experienced during development has effects on health outcomes in adulthood.
Another theory that recognizes the importance of life circumstances on the health status of minority populations is the Theory of Syndemic Production (Stall et al., 2007). Similar to Minority Stress Theory, the Theory of Syndemic Production posits that cultural and social marginalization experienced by MSM puts them at risk for long-term negative health outcomes. Syndemic Production differs from Minority Stress in that it focuses on the impact of early life events and the collective effect of marginalization throughout the life course. In other words, the adversity that a young gay man experiences during boyhood and adolescence contributes to the development of the negative psychosocial health conditions across the life course and into adulthood.
Both Minority Stress Theory and the Theory of Syndemic Production focus on the long-term negative health effects of living in a world that not supportive or is outwardly hostile toward sexual minority group members. The social response to an individual’s minority sexual identity (or nontraditional gender presentation) negatively impacts long-term health outcomes, rather than the identity or presentation itself. Studies have found that YMSM who reported serious childhood adversity were significantly less likely to exhibit positive outcomes when compared to their peers (Gwadz et al., 2006 Koblin et al., 2006; Safren & Heimberg, 1999; Savin-Williams, 1994). The correlation between experiences of adversity and negative health outcomes is particularly problematic given the prevalence of adversity within this highly stigmatized population. It is estimated that sexual minority youth hear homophobic slurs such as “faggot” or “sissy” approximately 26 times during a typical school day (Bart, 1998) and that 31% of sexual minority youth report having been threatened or injured at school in the past year (Chase, 2001). In summarizing the results of studies using national probability samples of lesbian, gay, and bisexual individuals, Herek and Sims (2008) found that as many as 32% reported having experienced a hate crime based on their sexual orientation at some point in their lives. Perhaps even more detrimental are the pervasive forms of adversity such as institutionalized homophobia and heterosexism. For example, looking at data from a national probability sample, Hatzenbuehler, McLaughlin, Keyes, and Hasin (2010) found that among lesbian and gay individuals living in states that instituted same-sex marriage bans during the 2004/2005 elections, psychiatric disorders increased significantly from before to after the ban. No such increases in psychiatric disorders were observed among heterosexual men and women in these states, or among lesbian and gay individuals in states that did not enact such bans. MSM of color, compared to white MSM, may experience even more adversity based on sexual orientation due to cultural norms that consider heterosexuality the only acceptable sexual identity (Ernst, Francis, Nevels, & Lemeh, 1991; Harper, 2007; Stokes & Peterson, 1998).
Overcoming Adversity: Evidence for Strengths and Protective Factors
In the lives of gay men, adversity and marginalization are pervasive. Many gay men grew up being told that they were abnormal or immoral. As adults, gay men living in the United States are denied equal rights. However, negative health outcomes that result from living in hostile environments are not universal. Although many have experienced some form of adversity, the majority have not experienced the deleterious effects of those experiences in terms of cooccurring psychosocial health problems or HIV infection. Rather, most gay men cope with adversity and are somehow protected from the potential negative consequences of negative experiences. This capacity for an individual to cope successfully with adversity is called “resilience.” Resilience necessitates two components: (1) exposure to adversity and (2) achievement of positive situational adaptation in the face of this exposure (Luthar, Cicchetti, & Becker, 2000). The difference between those who survive or thrive and those who do not may be in part explained by the existence of protective factors. That is, some individuals may have strengths and resources (skills, social support, personality traits, etc.) that buffer the effects of adverse experiences, thereby preventing the development of health problems. These protective factors moderate the association (p.196) between adversity and risk by providing resources that facilitate coping (Rew & Horner, 2003). The Search Institute, a youth advocacy organization, developed an index of 40 protective factors that predict resilience among youth at risk (Roehlkepartain, Benson, & Sesma, 2003). They have found that there is an inverse relationship between the number of assets and the likelihood of youth participating in risky behaviors. Resilience is a characteristic of an individual, but it results from the interplay of individual and environmental factors (Garmezy, 1991; Olsson, Bond, Burns, Vella-Brodrick, & Sawyer, 2003). When individuals have access to sufficient protective resources, they can recover from adverse circumstances. This ability to recover does not render a person invincible; at increased levels of adversity, factors that were previously protective may no longer function in this way (Garmezy, 1991).
Protective factors are the building blocks of resilience. Not unlike risk factors, protective factors exist on multiple levels of influence with reciprocal associations among these levels (Luthar et al., 2000). In some cases, protective factors may be the obverse of risk factors (and vice versa). For instance, high levels of self-esteem might protect against engagement in health risk behaviors such as unprotected anal intercourse, whereas low levels of self-esteem might be associated with this behavior. However, in some cases risk factors and protective factors are not the obverse of each other. For example, gay men who report high levels of openness about their sexual orientation may be at risk for HIV-related conditions including victimization (Chesir-Teran & Hughes, 2009). Yet the obverse of being out (i.e., remaining in the closet) is also a risk factor rather than a protective factor (Hays et al., 1997; Waldo, McFarland, Katz, MacKellar, & Valleroy, 2000). In some cases, factors may only be protective and have little or nothing to do with risk. For example, participating in community events may be protective against health risks, but it is highly unlikely that not participating in these activities would constitute risk (yet to our knowledge neither of these relationships has been evaluated among gay men). Protective factors are not the same for all people, nor are they necessarily stable across the life course. Many variables, including developmental stage, age, and individual personality, may cause protective factors to be more or less effective across individuals or over time. Furthermore, protective factors may interact with other factors.
Few studies have investigated resilience in MSM communities. There has, however, been some investigation of specific protective factors that contribute to resilience. Studies focusing on sexual minority youth, for example, have found that condom self-efficacy, perceived susceptibility to HIV infection, positive attitudes toward practicing safe sex, and perceived self-control are associated with consistent safer sex (Rotheram-Borus, Rosario, Reid, & Koopman, 1995; Waldo et al., 2000). Self-acceptance, when combined with family support, has been found to buffer effects of victimization on mental health outcomes, but neither factor was protective when measured alone (Hershberger & D’Augelli, 1995). In fact, self-acceptance (defined as a positive view of your sexual orientation) was much more highly associated with mental health than was victimization. Being more educated and more gay identified (on the Kinsey Scale) predicted safer anal sex (Ross, Henry, Freeman, Caughy, & Dawson, 2004). High self-esteem has also been found to be correlated with low levels of emotional distress (Resnick et al., 1997).
Some of the strongest factors protective against risk-taking behaviors among young MSM can be found on the interpersonal level. Close and warm parental relationships appear to be quite influential in protecting against HIV risk. Parental/family connectedness was protective against emotional distress, experienced violence, substance use, and risky sexual activity in populations of youth (Resnick et al., 1997). Studies have found similar patterns of protection among young MSM populations (Jaccard, Dittus, & Gordon, 1996; Voisin, 2002); however, sexual minority youth report less parental/family connectedness than their peers (Williams, Connolly, Pepler, & Craig, 2005). Qualitative studies of parental relationships have found that these relationships were perceived to be important protective factors even when coming out was not well received (Warwick, Douglas, Aggleton, & Boyce, 2003) and that most parents came to accept their children’s sexuality and were generally concerned about their health (LaSala, 2007). LaSala (2007) found that most youth reported that their relationship with parents influenced their decision to engage in safer sex, regardless of how accepting their parents were of their sexuality. Thus, parents may not need to (p.197) be accepting of their child’s sexual orientation to provide the general support that fosters resilience (Fenaughty & Harre, 2003).
Peer relationships also play an important role in protecting against HIV risk, although this association does not appear to be as straightforward for sexual minorities as it is for heterosexual people. For instance, peer support for condom use is associated with abstinence, safer sex behaviors, and health-promoting behaviors (e.g., smoking cessation) in heterosexual populations (Diclemente, 1991; DiIorio et al., 2001; Maxwell, 2002), but this same association has not been found among sexual minorities (Hays, Kegeles, & Coates, 1990; Rotheram-Borus et al., 1995). This may be due in part to the heteronormative pressures and victimization sexual minorities experience at the hands of their peers. Likewise, Williams and colleagues found that sexual minority youth reported less companionship with their best friends than did heterosexual youth (Williams et al., 2005). However, peer relationships with other sexual minority youth may provide some protection against risk (Ueno, 2005).
In general, the social support provided by the daily presence of close personal relationships appears to be very important. When these relationships have been evaluated, they have been shown to be strong moderators of risk for young MSM. Perceived social support is associated with a reduced likelihood of depression and suicidality, increased self-esteem, and less sexual risk behaviors (Anderson, 1998; Williams et al., 2005). Research on the interpersonal relationships of young MSM has barely begun and much more work is needed to understand how these relations function and how they can be promoted.
Though religious affiliation and high values placed on religiosity have shown some protective effects (Resnick et al., 1997; Rostosky, Danner, & Riggle, 2007), the organizational/community level factor that appears to be most important in the development of resilience among youth is the school community. School connectedness has been shown to be associated with emotional health of youth, as measured by emotional distress, violence, and suicidality (Resnick et al., 1997). However, very little is known about how school environments—and other organizational/community level environments—influence the healthy development of sexual minority youth.
THE THEORY OF CULTURAL RESILIENCE
Because gay men are stigmatized in our culture, many have experienced a significant amount of adversity in their lives. As previously noted, these experiences of adversity can contribute significantly to risk behaviors and contribute to the negative health outcomes among MSM. However, lesbian and gay communities and individuals resist cultural attack and turn marginalization into pride. Such an occurrence is an example of “cultural resilience.” MSM and other sexual minorities have developed a culture in which pride is a central tenet. This culture of pride may well increase the resilience of MSM and MSM communities, buffering individuals from negative messages that are abundant in the dominant culture. In addition, protective factors that may be present in the lives of young gay men can become stronger across the life course as they become more involved with their communities.
Cultural Resilience Theory (see Figure 14.1) is an attempt to explain the process of overcoming adversity specifically as it relates to gay men and other sexual minority communities and individuals. Strengths and protective factors can break down the syndemic process thereby preventing adversity from resulting in negative health outcomes. Until such a time that adversity experienced by MSM through homophobia and cultural marginalization is eliminated, ways to prevent the harmful effects of this adversity will be needed. Understanding and capitalizing on Cultural Resilience will likely increase the effectiveness of existing prevention programs, and in this way also improve the health of gay men and other MSM.
IMPLICATIONS FOR PREVENTION
In a meta-analysis of the efficacy of HIV prevention interventions targeted at MSM, Herbst and colleagues (2005) found that these interventions resulted in a 23% reduction in the odds of engaging in unprotected anal intercourse and a 61% increase in the odds of condom use during anal sex. This suggests that current prevention paradigms are functioning effectively to some degree. Nonetheless, there is no evidence that overall health disparities between MSM and non-MSM are diminishing. To minimize or eliminate health disparities, prevention efforts will need to be increased. Cultural Resilience Theory can be useful in guiding such efforts. (p.198)
Cultural Resilience Theory suggests that experiences of sexuality related adversity lead to increased participation in risky behaviors and to the development of cooccurring psychosocial health conditions. These syndemic conditions in turn contribute to health disparities. Both steps in this process could be moderated by protective factors. The predominant public health approach is to attempt to eliminate health disparities by eliminating adversity, eliminating risk factors, or eliminating psychosocial health problems. As demonstrated by Herbst et al. (2005), this approach has had some success. However, interventions and health promotion efforts could be improved by addressing protective factors that moderate these processes.
The content and impact of positive youth development programs support our contention that health promotion may be as important as risk reduction in the elimination of health disparities. Positive youth development programs are driven by the philosophy that resilience and competency building are critical in supporting healthy development among youth (Roth & Brooks-Gunn, 2003). Positive youth development programs promote bonding, build competencies, enhance belief in the future, and enhance self-efficacy, positive identity, prosocial norms, spirituality, and self-determination (Catalano, Berglund, Ryan, Lonczak, & Hawkins, 2004). Such programs often attempt to strengthen familial, educational, and community systems (Gavin, Catalano, David-Ferdon, Gloppen, & Markham, 2010). A comprehensive review found that at least some positive youth development programs improve interpersonal skills, strengthen relationships with peers and adults, and increase self-control, self-efficacy, academic achievement, problem-solving, and other competencies. Some of these programs may also decrease drug and alcohol use, aggressive behavior, violence, and high-risk sexual behavior (Catalano et al., 2004). Other reviews have found that positive youth development programs are effective in promoting adolescent sexual and reproductive health and that their effects are sustained over time (Gavin et al., 2010; Kirby, 2001; Solomon & Card, 2004). Gavin et al. (2010) (p.199) suggest that positive youth development programs target a different and complementary set of factors compared to traditional health education programs, and that although traditional programs provide youth with knowledge and skills to reduce risk, positive youth development programs provide motivation to use the skills. Together, the findings suggest that health disparities among gay and bisexual men could be reduced by promoting healthy development through a focus on protective factors and resilience.
It has been 30 years since HIV began to decimate the MSM population in the United States and health disparities among MSM were forced into the forefront of consciousness for lesbian and gay communities. Since that time, much important prevention work has been done to address these disparities. Nonetheless, health disparities still exist among MSM.
Future studies are needed to expand our knowledge of the ecological context of health risk among MSM. To accomplish this, it will be important to expand the scope of prevention research to focus on protective factors as well as risk factors. There is as much to be learned from those who have faced adversity and thrived as there is from those who have experienced negative outcomes. There is also a need to examine protective factors beyond those at the individual level. Community and interpersonal protective factors may facilitate individual efforts to develop resilience. To the extent that this view is correct, a narrow focus on individual level risk and protective factors will not be likely to eliminate health disparities. There also needs to be a focus on identifying modifiable protective factors that will have direct applicability to prevention and health promotion programs. Many MSM health studies have demonstrated an association between health risk behaviors and individual personality characteristics such as sensation seeking (Adam, Teva, & de Wit, 2008; Newcomb, Clerkin, & Mustanski, 2010) or impulsivity (Patterson, Semple, Zians, & Strathdee, 2005; Semple, Zians, Grant, & Patterson, 2006). Although knowledge of these factors is necessary for our understanding of prevention, personality characteristics are difficult to change. It is more feasible to change interpersonal or community contexts by developing a mentor program or setting up community centers, or by making policy level changes such as the adoption of antibullying legislation.
It has long been acknowledged that sexual minorities face health disparities, not because of who they are, but because of the environments in which they live. Even so, prevention efforts have a tendency to focus on changing the individual with messages about more condom use, less substance use, and so forth. Although data show that MSM exhibit considerable strengths in reducing or avoiding health-related risks, these strengths have been underemphasized in public health prevention work. Cultural Resilience Theory and other strength-based approaches provide powerful frameworks that can serve to advance prevention and health promotion by identifying new variables and new mechanisms that will increase the effectiveness of current public health interventions and improve the health of men who have sex with men.
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