Exploring What’s Positive in Gay Men's Health - Executive Summary

Via San Francisco AIDS Foundation - thanks! Images from the wonderful Magnet site. Mag net is an inspiration to us all doing gay men's health work.

An HIVision Public Forum

“We planned the forum today believing it was time to develop a broader focus on gay men’s health. A broader focus is not only the strategy to reduce new HIV infections, or to improve the health of people with HIV; rather, we want to focus on improving the health of gay men with the hypothesis that refocusing on health may change the environment in which gay men reconsider risk behaviors for HIV.”
—Mark Cloutier, Executive Director, San Francisco AIDS Foundation

On July 10, 2007, the San Francisco AIDS Foundation—one of the oldest and largest community-based AIDS organizations in the United States—convened a group of community leaders for a public forum titled “Exploring What’s Positive in Gay Men’s Health.” This was the inaugural event in the Foundation’s HIVision series, public fora designed to bring research and evidence to bear on timely policy and program issues in a safe venue to engage community discussion on potentially controversial topics.

The panelists invited to discuss the topic gay men’s health were: Rafael M. Diaz, Professor of Ethnic Studies and Director of the César E. Chávez Institute, San Francisco State University; Steve Gibson, Director, Magnet, San Francisco AIDS Foundation; Ron Stall, Professor and Chair of Behavioral and Health Sciences, Graduate School of Public Health, University of Pittsburgh; John K. Williams, Assistant Professor, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles.

Steven Tierney, SFAF’s Deputy Director for Programs and Services, provided summary remarks and joined the panel for audience questions and discussion. Judy Auerbach, the San Francisco AIDS Foundation’s Deputy Executive Director for Science and Public Policy, served as moderator.

The purpose of this forum was to stimulate a meaningful conversation about how to approach the issue of improving gay men’s health, moving from a disease- and prevention-based paradigm to one that fosters, encourages, and supports a positive, organic approach to the well-being of gay men, both as individuals and as a community.

Since the beginning of the AIDS crisis, most discussion around gay men’s health has focused on specific health challenges facing gay men: the risk around sexual behaviors and practices, the role of drug and alcohol use and abuse, and even histories of sexual violence.

This focus has been driven by the need to address the specific health risks and vulnerabilities facing gay men; gay men suffer greater rates of addiction, depression, anxiety disorders, suicide, and HIV infection than do other populations. These health challenges, taken as a whole, can be overwhelming. And much of the discussion among those who are concerned about gay men’s health has, by necessity, centered on addressing deficits and pathologies.

But in the course of addressing these challenges, the San Francisco AIDS Foundation and other HIV/AIDS community organizations have learned one very important lesson: by focusing on the deficits alone, we can make inroads against specific health risks, but we have not eliminated them altogether. For example, while we have dramatically reduced HIV incidence among gay men in San Francisco over time, we are far from bringing the rate of new infections to zero.

This reality provides an interesting opportunity. If the prevention methods we have employed until now are insufficient, what must change? Do we continue to operate within the deficit-pathology model, or is it time for a broader approach to gay men’s health? Can we channel the inherent strengths of the gay community—strengths that have emerged so clearly as people have worked together to address the AIDS crisis—into a more positive model of gay men’s health?

This is a discussion whose time has come. We at the San Francisco AIDS Foundation believe that by focusing on gay men’s health broadly—encompassing both the health of individuals and that of the community—we will see the emergence of new opportunities that can be translated into new policies, programs, and community-based efforts to promote and support the well-being of gay men.

Following is a summary of key topics that emerged during the HIVision forum. We hope this event will serve to inaugurate a new health model that draws on gay men’s shared creativity, knowledge, and well-honed instinct for survival, and helps foster a vibrant, healthy future for the community.

Is it possible to reframe our health model from deficit-pathology to something more positive?

“From the numbers, I can say gay men are more depressed, gay men suffer more violence, gay men have more substance abuse, gay men have more HIV— but it’s hard to get to know what to do about any of these problems if you just focus on the problems themselves. If you’re going to do something about any of it, you’ve got to focus on the strengths, right? That’s the point. If we’re going to face up and work on the health problems that are facing the gay community, we’ve got to start by taking an inventory of our strengths first.”
—Ron Stall

The panelists began by evaluating where we are now, and how we got here. In John K. Williams’s opinion, “one of the biggest problems we have with medicine in general is that we begin by looking at the health problem, what brings people in.” This focus is the foundation of the deficit-pathology model of health care, and adherence to this model has been driven by a number of factors.

First and foremost, many of San Francisco’s organizations have grown out of the gay community’s need to deal with the very real, very challenging health threats that gay men have faced and continue to face.

Second, as Rafael Diaz pointed out, funding for these organizations has been driven by a need-based paradigm that relies on the existence of a problem. To secure funding, we have been required to argue that there is a major risk factor, disease, or problem that needs attention, and to indicate a methodology for addressing the issue.

Third, funding sources require quantifiable, measurable outcomes, and as panelist Steve Gibson noted, it is “easier to measure disease than it is to measure health.” It is relatively simple to quantify how many people test positive or receive services at a given site, which reinforces use of the deficit model.

For these reasons, the panelists agreed, our community organizations have necessarily operated according to the deficit-pathology model. This can be seen as a major structural obstacle, but it has provided an interesting side benefit: it has helped lead gay men to an awareness of their strengths as a community, and to recognition of their resourcefulness and ability to address health issues.

As an example, panelist Ron Stall pointed to the incidence of smoking and tobacco addiction among gay men, mentioning recent studies showing that prevalence rates among gay men have been reduced by half; substantial numbers of gay men have quit smoking, and they have done it without accessing gay-specific smoking cessation programs. This success is an indicator of the substantial strengths that exist within the gay community, and of the resilience of many gay men to take active, positive steps to support their own health and well-being.

Similarly, Stall observed that there are “very high prevalence rates of use of drugs but very comparatively low rates of addiction” in the gay community, suggesting that some gay men are able to use drugs “without getting into trouble.” How? We don’t know, said Stall, but we have anecdotal evidence that many gay men are able to resolve addictions on their own and make positive choices toward more healthy behaviors. Further exploration of the strengths that allow some gay men to avoid or overcome addiction could help inform new substance abuse interventions; “if you build prevention programs and treatment programs based on strengths rather than the deficits,” Stall said, “you’d have a lot more to offer the community.”

How do we move toward a more realistic approach to the role of substances?

“When I began studying issues of substance use among Latino gay men, I was [shocked] by the fact that men talked about substances as their comforters, as their helpers.”
—Rafael M. Diaz

Rafael Diaz explained that, within the gay community (and among some funding agencies), there is a bias that if a gay man is using substances, there is something wrong with him. This bias has served to drive underground any opportunity for real, meaningful discussion about substance use in the gay community. The prevalence of substance use among gay men begs a deeper exploration of the perceived benefits of drug and alcohol use in this population.

In Diaz’s study of methamphetamine use among Latino gay men, the primary motivation cited for using meth was increased energy. Meth use was seen as a means to address the exhaustion that men experience from living in a stress-filled urban environment. The drug provided the energy needed to get out, socialize, and play. “Sex and drugs in our community are referred to as ‘party and play,’” said Diaz, “and I think that’s a very profound cultural construction.”

“Human beings need to play in order to restore their psycho-physiological homeostasis,” Diaz added. The men in his study were well aware of the negative consequences of drug use but had made conscious choices to use meth because the potential benefits—more energy for recreation— outweighed the repercussions.

Beyond the question of specific perceived benefits, what differentiates the gay man who uses drugs recreationally from the man who is more likely to become an addict? According to the panelists, the underlying markers for substance abuse are alienation and isolation.

As Stall put it, gay male substance abusers are typically “guys who are lonelier, the guys who have less social connection, the guys who are more depressed,” and who may have more of a history of violence. Internalized homophobia, Stall said, also has a probable role, and gay male substance abusers may see involvement in gay culture as “a double-edged sword.”

Williams observed that these are often men who fear that coming out or fully embracing the gay community will cost them some other core aspect of their identity. If they first identify is as a black man, for example, the threat of losing support from the black community may outweigh the potential benefits of coming out. This fear of loss, Williams noted, may encourage clandestine, higherrisk behaviors and foster social isolation. The panel agreed that therein lies the underlying challenge of treating substance abuse in the gay community: how to address the ambivalence of self-identity, the feelings of isolation and loneliness, the inability to develop deep, meaningful connections, and the conflict of competing cultural identifications.

What is the role of sex in gay men’s sense of well-being?

“What do you want sexually? There’s power and meaning in how we have sex and how we make love. It’s really important to figure that out before you talk about ‘Put on a condom! Disclose your HIV status!’”
—Steve Gibson

Agreeing with Steve Gibson, Diaz commented that many “see [it] as part of our calling as gay men to really be liberated about sexuality…and I think that’s one of our most beautiful strengths.” Stall noted that “sex is a valued thing; it’s how we feel healthy; it’s how we feel alive. Most men feel that way, and one of the sad things about the AIDS epidemic is that it’s made us medicalize our ways of finding connections and our ways of feeling alive. And it’s made us approach a basic piece of who we are as humans in such a cautious and fearful way.”

How do we deal with the conflicting and often intersecting beliefs about sexuality and sexual expression? How do we help gay men understand their own needs and define what is truly and deeply satisfying to them sexually? How do we help them have the courage to claim what they need and want while being responsible in the midst of an ongoing epidemic?

In Diaz’s words, “the natural, normal thing is to feel the warm, wet…sensation [of] flesh-to-flesh” sex. But, he went on, “the fact is that we’re in an epidemic that is a tragedy, and we have to take precautions for our health and the health of our brothers.” Most gay men in San Francisco, he said, are maintaining an enormously heroic effort to continue expressing and enjoying their sexuality in the midst of a 26-year-old epidemic. Their efforts should be applauded and supported, and as a community, Diaz commented, we must support them in determining safer ways to experience fulfilling, healthy sex.

How effective is serosorting as a tool for HIV prevention?

“The answer is really in the community, because agencies tend to follow the community. Gay guys are figuring it out for themselves and making it work. We have a responsibility to make sure and support them in those decisions.”
—Steve Gibson

The strategy and practice of serosorting, or choosing partners of the same HIV status for unprotected sex, has evolved out of “condom fatigue” after 26 years of AIDS; as Gibson put it, “positive guys got kind of tired of saying, ‘You know what? I don’t want to worry about infecting somebody else.’” While the discussion of serosorting was lively, the panelists concurred that its effectiveness as an HIV prevention strategy is unproven, and acknowledged the public health dilemma around supporting or promoting behaviors whose efficacy has not been established.

That said, serosorting is part of the current landscape of gay sexual behavior, and, as Stall pointed out, important questions must be considered: For whom does serosorting work? Under what conditions does it work? And how do individuals make it work for themselves, given their HIV status and other factors in their lives?

For men who know they are HIV-positive and disclose their status to sexual partners, serosorting offers the chance to have condomless sex without fear of transmitting HIV to a negative partner. Stall commented that, for them, aside from the risk posed by other sexually transmitted infections and the (albeit apparently limited) threat of superinfection, serosorting may work well.

For HIV-negative men who serosort for unprotected sex, the risks are far greater; as Stall pointed out, “there’s not a strong concordance between serostatus and self-identity among the negatives” in some studies. Negative men may make assumptions about their own or their partner’s status and run the risk of unwittingly transmitting or acquiring HIV. Indeed, both positive and negative men may make erroneous assumptions about a partner’s status based on non-verbal communication; for example, Williams said, a man having sex with an unknown-status partner might think “if he lets me do this, he must be positive.” It is clearly critical that individuals’ choices around serosorting be communicated clearly—and be based on up-to-date test results.

The panelists agreed that, as research continues, public health officials and organizations serving gay men can most effectively address the issue of serosorting by educating gay men about the potential benefits and risks, and by supporting them in making informed decisions about their sexual behavior.

Can prevention messages be affirming?

“Fear-based messages don’t work when you’re talking about an epidemic that we’ve been dealing with for a quarter of a century already. Period.”
—Ron Stall

Stall cited anti-smoking campaigns as a prime example of the fleeting effect of fear-based messaging: “You flash a photograph of a lung full of lung cancer…to somebody smoking, and they leave the room swearing they’ll never take another cigarette, and by the time they’re on the corner, they’re smoking another cigarette.”

Williams agreed, commenting that “that one of the things we have to do is change the language” of prevention messaging and mentioning a recent hepatitis C prevention campaign that featured a dead man lying on a morgue slab, talking about his experience with the disease. The connection between hepatitis and death, while real, made few waves in a community that had already experienced a constant barrage of messages that connect specific behaviors or diseases with death: “hepatitis equals death, meth equals death; HIV equals death— everything equals death.”

Rather, Williams said, the language of prevention messaging should be changed “to something that really encompasses personal health and a shared responsibility for each other’s health.”

Can legal, institutional policy changes that are not specific to health have an effect on health?

“We all want to feel validated. …We want acceptance, we want to be able to feel proud of who we are. …From a mental health perspective, it is important that people know they have access to everything—access, rights, privileges— that everyone else has.”
—John K. Williams

The panelists agreed that the issues of equality and equal rights can have a strong effect on health. The issue of marriage was used as an example. Stall pointed out that “we live in a country where the Federal government tells us that official policy is abstinence until marriage…. However, if any of us who are gay men or men who have sex with men decides to get married, it undermines the entire foundation of the country!” Williams agreed that the denial of equal rights, such as the right to marry, “has a strong impact on the way that you view yourself and the way that you think other people view you,” and has serious implications for self-esteem and mental health.

How can we organize and deliver meaningful, comprehensive health services for gay men?

“The fact is that we need to have a different focus. We need to build strong, resilient communities and strong, resilient programs and strong, resilient organizations that can support, as Ron said, not disease but health and wellness.”
—Steven Tierney

Gibson commented that an asset-based approach to delivering services must begin by assessing what the community actually needs and wants, and cited Magnet’s storefront clinic in San Francisco as a model of how this principle works. The clinic began its work by surveying its potential client population; Advisory board members canvassed the Castro, asking gay men “What do you like about the neighborhood? What do you not like about the neighborhood? What does the neighborhood need? What’s the last thing the neighborhood needs?”

The organization’s intent was to provide HIV and STD testing, but the founders knew that it would not be successful unless Magnet could combine testing with other services deemed necessary by the community. By listening and responding to that feedback—as Gibson puts it, “[we] didn’t pretend that we knew better”—the organization cemented its credibility within the community.

In his summary remarks, Steven Tierney noted that this broad, ecological approach clearly must address the larger context of health and wellness. He cited a Kellogg study of men’s health that determined that men are more inclined to take better care of themselves—and have better health outcomes—“if they belong to a family or community system that affirms who they are as a person.”

The community-based approach to dealing with addiction or HIV infection must start by building that community solidarity: in Tierney’s words, “we can manage meth, and we can handle addiction, and we can manage HIV and other things by working together—and, in fact, we can’t do that alone.” He acknowledged that gay men live in a larger society that continues to treat them with stigma, discrimination, and homophobia—and that it is therefore essential to build a sense in the community that gay men are working toward a greater good. “We want to have a community that works, and when men are the happiest and when men are feeling the most engaged is not when we’re asked to donate. It’s when we’re asked to do.”

This approach, Tierney contended, is not about creating a false, “feel-good” illusion; it’s about creating a sense of common identity that affirms individuals’ value in a collective sense. He reminded the audience that Harvey Milk used to say in the early days of the health crisis, “We have to give them hope.” While it may have seemed a “Pollyanna” response to the epidemic, there was real scientific value in that approach, said Tierney, citing studies by Dr. Jerome Groupman of Boston’s Deaconess Hospital, which found that HIV-positive patients who were given hope of survival had lower viral loads and longer life expectancy; their hope was expressed in tangible ways, including strategies to access health care and community support. Fostering an expectation of a positive outcome had a beneficial effect on the outcome itself.

In practical terms, this research tells us that community organizations must build hope and optimism into what we do; it means our focus should include assets as well as deficits. That sense of hope and optimism has been inherent in the response to the crises gay men have faced as a community; when the AIDS epidemic began, there were no systems of health care that were culturally appropriate for men who love men. So, as Tierney observed, members of the San Francisco gay community learned to take care of each other.

Gay men built systems and changed the way health care, social services, and housing services were delivered. And they wound up not just changing these institutions for themselves. “The health care system in this country and around the world is radically different based on what we did,” said Tierney.

Conclusion

“The goal cannot simply be disease prevention or disease management. If those were the primary organizing goals, it would require us to think of ourselves as diseased. The goal has to be health and wellness defined by us and for us.”
—Steven Tierney

This HIVision forum’s discussion topics reflect a serious attempt to develop a broader approach to gay men’s health. Building on our current methodologies around HIV and substance abuse prevention, treatment, and care, this discussion explored new, uncharted territory, engaging in frank and sometimes uncomfortable conversation about the issues gay men collectively face each day.

Within that conversation lies a new way forward. As Tierney stated, “the fact is, we need to change the dialogue from one of disease, as Ron pointed out in the earliest of his remarks, to one of health.” Our hope is that this frank discussion will help to shift the gay men’s health paradigm from disease prevention and management to a comprehensive approach to health and wellness.