Addressing the Social ISSUE REPORT Determinants of Health Inequities Among Gay Men and Other Men Who Have Sex With Men in the United States DECEMBER 2014 Acknowledgements Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority. This report was supported by a grant from the M·A·C AIDS Fund. The opinions expressed are those of the authors and do not necessarily reflect the views of the foundation. TFAH would like to thank M·A·C AIDS Fund for their generous support of this report. TFAH BOARD OF DIRECTORS REPORT AUTHORS Gail Christopher, DN Robert T. Harris, MD Arthur Garson, Jr., MD, MPH Derek Hodel President of the Board, TFAH Treasurer of the Board, TFAH Director, Health Policy Institute Independent Consultant Vice President for Policy and Former Chief Medical Officer Texas Medical Center Jeffrey Levi, PhD. Senior Advisor and Senior Vice President John Gates, JD Executive Director WK Kellogg Foundation for Healthcare Founder, Operator and Manager Trust for America’s Health Cynthia M. Harris, PhD, DABT BlueCross BlueShield of Nashoba Brook Bakery and Professor of Health Policy Vice President of the Board, TFAH North Carolina Milken Institute School of Tom Mason Director and Professor Barbara Ferrer, PhD, MPH, ED President Public Health at the George Institute of Public Health, Chief Strategy Officer Alliance for a Healthier Washington University Florida A&M University WK Kellogg Foundation Minnesota Anne De Biasi, MHA Theodore Spencer David Fleming, MD Eduardo Sanchez, MD, MPH Director, Policy Development Secretary of the Board, TFAH Director of Public Health Deputy Chief Medical Officer Trust for America’s Health Senior Advocate, Climate Center Seattle King County, American Heart Association Natural Resources Defense Washington Council CONVENING ON SOCIAL DETERMINANTS AFFECTING YOUNG GAY MEN PARTICIPANTS TFAH thanks the following Antigone Dempsey Kali Lindsay David Munar individuals for attending the Division Director for Policy and Deputy Director, Public Policy President and CEO convening. The opinions Data Office Howard Brown Health Center expressed in the report do not Health Resources and Services amfAR, The Foundation of AIDS Kyriell Noon necessarily represent the views Administration, HHS Research Director of Prevention and Client of these individuals or their George Fistonich Michael McFadden Services organizations. Federal officials Policy Assistant Callen-Lorde Community Health San Francisco AIDS Foundation were invited to participate in the Office of National AIDS Policy Center Carl Sciortino meeting as a resource and not Director of Funded Programs Noel Gordon Executive Director in their official capacities. Foundation Coordinator Jonathan Mermin AIDS Action Committee Brian Altman Human Rights Campaign Director Director of Legislative and Regu- Ron Stall Derek Hodel National Center for HIV/AIDS, latory Affairs / LGBT Policy Lead Professor Independent Consultant Viral Hepatitis, STD, and TB Substance Abuse & Mental Health University of Pittsburgh Prevention, CDC, HHS Services Administration, HHS Kevin Jones Adam Tenner Director, Evaluation and Training Greg Millet Douglas M. Brooks Executive Director Metro TeenAIDS Director of Public Policy Director Metro TeenAIDS amfAR, The Foundation of AIDS Office of National AIDS Policy Michael Kaplan Richard Wolitski Research President & CEO Senior Advisor Jeff Crowley Daniel Montoya AIDS United Division of HIV/AIDS Distinguished Scholar Deputy Executive Director The O’Neill Institute for Jennifer Kates Prevention, CDC, HHS National Minority AIDS Council National and Global Health Law Vice President and Director of Stephanie Zaza Global Health & HIV Policy Terrance Moore at Georgetown University Director Kaiser Family Foundation Director, Policy and Health Lindsey Dawson Division of Adolescent and Equity Senior Policy Analyst, HIV Policy Jeff Krehely School Health, CDC, HHS National Alliance of State and Kaiser Family Foundation Chief Foundation Officer Territorial AIDS Directors Human Rights Campaign 2 TFAH • HealthyAmericans.org FO REWO RD Addressing FOREWORD Foreword With support from the M·A·C AIDS Fund, Trust for America’s Health Health (TFAH) undertook a literature review and convened a Inequities: one-day consultation to consider strategies to mitigate the social determinants of health inequities among gay men and other men Gay Men & who have sex with men (MSM).† Invited participants included research scientists, lesbian, gay, bisexual and transgender MSM in the U.S. (LGBT) health service providers, public policy advocates, and issue report federal officials.* After reviewing current research pertaining to health inequities among MSM (including HIV epidemiology) and theoretical constructs to explain disparities, the remainder of the meeting focused on identifying opportunities for the federal government to intervene. Two caveats underpinned the discussion: 1) the need for additional research was stipulated, and 2) it was acknowledged that, while the evidence base to support interventions to address social determinants of health (SDH) among MSM is slim, health disparities (particularly HIV) are sufficiently grave to warrant taking immediate action. As such, meeting participants were charged with articulating ways in which the federal government could respond now to continuing health inequities among MSM based upon existing data. While this report reflects those conversations, the views expressed are solely those of Trust for America’s Health. DECEMBER 2014 EXECUTIVE SUMMARY: Addressing EXECUTIVE SUMMARY Executive Summary Health In the United States, gay men and other MSM continue to Inequities: be more profoundly impacted by HIV than any other group. Though representing approximately 2 percent of the population, Gay Men & MSM comprise a majority of new HIV infections (66 percent in MSM in the U.S. 2010) and represent more than half (56 percent) of all persons living with an HIV diagnosis. HIV incidence is disproportionately issue report higher among Black MSM than any other risk group. MSM also face a variety of other mental, Strategies to address health inequities physical and sexual health disparities, among MSM — including, but not limited including substance abuse and to, HIV — include interventions to 1) depression, both of which correlate with increase individual resiliency, 2) foster a high-risk behaviors for HIV infection, as supportive community, 3) improve access well as suicide. MSM also have elevated to quality healthcare, and 4) transform the rates of syphilis, gonorrhea, and other environmental context in which people sexually transmitted diseases (STDs), live. While new biomedical interventions which are associated with an increased such as pre-exposure prophylaxis or risk for HIV infection as well. Young MSM treatment-as-prevention show promise, are more likely than their heterosexual their uptake will also be affected by counterparts to report emotional distress, social determinants. Addressing social depression, or self-harm, and are at higher determinants at every stage of life will risk of suicidal ideation or attempts and require an array of linked individual, becoming homeless. biomedical and structural interventions throughout the life course. To account The many health inequities experienced for environmental factors, community- by MSM constitute a syndemic — i.e. level and structural interventions must multiple social determinants that include health policy and legislation, each independently influence health economic and social interventions, and outcomes, and which mutually reinforce cross-sector collaborations. Federal and amplify each other. Among MSM, coordination will be essential — the the syndemic comprising HIV, STDs, National Prevention, Health Promotion mental health, substance abuse, and and Public Health Council (NPC) is well violence has profound implications positioned to provide leadership. for HIV prevention — as numerous health challenges may overwhelm In the long term, however, reducing so- the capacity of some MSM to reduce cietal oppression and marginalization of their sexual risks. Moreover, for MSM LGBT people will diminish the need for DECEMBER 2014 who are also racial minorities, social individual and community-level interven- determinants of health may intersect in tions. The increasing recognition that for various, overlapping domains, including MSM, HIV constitutes but one of many not only sexual orientation, but race, health challenges provides an opportunity poverty, educational attainment and to refocus efforts to fight HIV by incorpo- immigration status. rating interventions within the context of MSM health and wellness promotion. I N TRO DUCT IO N Addressing INTRODUCTION Introduction In the United States, gay men and other men who have sex with Health men continue to be more profoundly impacted by HIV than any Inequities: other group. Though representing approximately 2 percent of the population aged 13 years or older, MSM (including MSM Gay Men & who inject drugs) comprise a majority of new HIV infections (66 percent in 2010)1 and represent more than half (56 percent) of MSM in the U.S. all persons living with an HIV diagnosis.2 Since the epidemic issue report began, more than 350,000 MSM with AIDS have died, 55 percent of the overall total.3 Studies have shown that MSM face a level, socio-demographic position, and variety of health disparities, including religion) and environmental (poverty, increased rates of substance abuse, violence, stigma, discrimination and depression and suicide, all of which homophobia, and acculturation to the significantly correlate with high-risk gay community) contexts, many of which behaviors for HIV infection. Recent may be of greater consequence for MSM. studies have also shown that social Continuing progress against HIV among determinants of such risk behaviors MSM will require strategies to address include multiple and intersecting factors, other psychosocial health disparities, including individual (peer pressure, including how these outcomes interrelate social and sexual networks, social with one another and with multilevel support, and access to care), as well as factors to mediate HIV transmission and sociocultural (race/ethnicity, educational acquisition risks.4 DECEMBER 2014 S EC T I ON 1 : Addressing SECTION 1: HEALTH DISPARITIES AMONG MSM Health Disparities Among MSM Health An increasing body of research over the past 25 years has shown Inequities: that LGBT individuals experience significant health disparities, compared to heterosexuals.‡ Gay Men & In 2000, for the first time, the U.S. Lesbian, Gay, Bisexual and Transgender Peo- MSM in the U.S. Department of Health and Human Services (HHS) included gay men and ple: Building a Foundation for Better Under- standing.6 That same year, as mandated health lesbians as a population group in the by the Affordable Care Act (ACA), LGBT federal government’s decennial effort to populations were added to the National disparities articulate science-based, 10-year national Healthcare Disparities Report.7 Overall, objectives for improving American’s LGBT individuals experience a higher health, Healthy People 2010: Understanding prevalence of many Healthy People indi- and Improving Health, for which a key goal cators, including substance abuse, obe- was reducing health disparities.5 sity, depression and anxiety, tobacco use, injuries and violence, responsible sexual In 2011, the Institute of Medicine (IOM) behaviors, and access to care. published a landmark study: The Health of MENTAL HEALTH A number of probability studies have than their heterosexual peers, even shown that lesbian, gay or bisexual after controlling for substance abuse (LGB) individuals are more frequently and depression.12, 13, 14 In an analysis diagnosed with mental health disorders, of data from the Youth Risk Behavior primarily depression and anxiety. 8, 9 Surveillance System (YRBS), prevalence MSM experience higher rates of suicidal among LGB youth was higher than among ideation or attempts over their lifetimes heterosexual youth for seven of 10 risk than do heterosexuals.10 LGB youth categories (behaviors that contribute to are more likely than their heterosexual violence, behaviors related to attempted counterparts to report emotional distress, suicide, tobacco use, alcohol use, other depression or self-harm 11 and are at drug use, sexual behaviors, and weight higher risk of suicidal ideation or attempts management).15 PHYSICAL HEALTH With a few exceptions, rates of chronic They were, however, more likely to receive physical diseases appear similar in a diagnosis for asthma.16 Though studies heterosexuals and sexual minority have failed to show differences in most DECEMBER 2014 populations, which may be counter- cancer rates (an analysis made more intuitive, in light of increased prevalence challenging by a lack of sexual orientation of substance abuse, heavy alcohol use, data in most cancer registries), multiple smoking and (among lesbians) obesity. For studies have shown that MSM are at example, though LGB individuals were more increased risk for anal neoplasia, largely likely to report risk behaviors, over their as a result of a high prevalence of human lifetimes, they are not more likely to receive papilloma virus among men who engage in a diagnosis of diabetes or heart disease. receptive anal intercourse.17 SEXUAL HEALTH NUMBER OF NEW HIV INFECTIONS Sexually transmitted diseases. With 12,000 11,200 respect to sexual health, disparities 10,600 among MSM are pronounced. Compared 10,000 to heterosexual men, MSM have elevated rates of syphilis, gonorrhea, 8,000 lymphogranuloma venereum (LGV), human 6,700 herpesvirus (HHV-8), and hepatitis B (HBV). MSM who are living with HIV are 6,000 5,300 particularly susceptible. 18 In 2012, MSM accounted for 75 percent of all primary- and 4,000 secondary-syphilis diagnoses in the United 2,700 States.19 In an analysis conducted by 2,000 the U.S. Centers for Disease Control and 1,300 1,200 1,100 850 Prevention (CDC) using data from states with confidential names reporting, in 2007, 0 White Black Hispanic/ Black Black White Hispanic/ Black Black MSM were 61 times more likely than MSM MSM Latino Hetero- Hetero- Hetero- Latino Male Female MSM sexual sexual sexual Hetero- IDUs IDUs heterosexual men and 93 times more likely Women Men Women sexual than women to be diagnosed with syphilis.20 Women Subpopulations representing 2% or less of the overall U.S. epidemic are not reflected in this chart. HIV. Nowhere are health disparities among MSM greater than with respect to SOURCE: CDC. Estimated HIV incidence among adults and adolescents in the United States, 2007– 2010. HIV Surveillance Supplemental Report, 2012;17(4). HIV. Among MSM overall, HIV prevalence is extraordinarily high. In 2011, 18 percent of MSM who received an HIV test in 20 cities participating in the National NUMBER OF NEW HIV INFECTIONS AMONG MSM HIV Behavioral Surveillance System 5,000 (NHBS) were HIV-positive, with prevalence White Black increasing with age.21 Hispanic/Latino 4,000 In an analysis conducted by CDC using 2007 data from states with confidential names reporting, MSM were 60 times 3,000 more likely than heterosexual men and 54 times more likely than women to be diagnosed with HIV.22 In 2010, 66 percent 2,000 of all new HIV infections (83 percent of new infections among men) were among MSM or men who have sex with men and 1,000 inject drugs (MSM/IDU). 23 But, while historically MSM in the United States have 0 always comprised the largest proportion 13–24 25–34 35–44 45–55 ≥55 of HIV cases, they are the only group for Age in years whom risk appears to be increasing. New infections among MSM increased by 12 SOURCE: CDC. Estimated HIV incidence among adults and adolescents in the United States, 2007– 2010. HIV Surveillance Supplemental Report, 2012;17(4). percent from 2008 to 2010, and, among young MSM (ages 13 to 24), new HIV infections increased 22 percent.24 TFAH • HealthyAmericans.org 7 Among Black MSM, the crisis is sobering. HIV incidence is disproportionately higher Estimated Numbers of Persons Living With HIV in 2009 and Percentage in the among Black MSM compared to White MSM. Continuum of Care by Selected Characteristics, United States In 2010, an estimated 10,600 new HIV 1,200,000 infections (36 percent of all new infections 1,148,200 among MSM) occurred among Black men 1,000,000 — nearly the same number that occurred 941,524 among White MSM (11,200, 38 percent), 800,000 even though Whites outnumber Blacks in the 757,812 population by more than a factor of five.25 600,000 Young Black MSM are especially affected. While, among Whites, the largest number 400,000 of new infections (3,300 or 29 percent) oc- 424,834 378,906 curred among men ages 25 to 34, among 287,050 Black MSM, the largest number of new 200,000 infections (4,800 or 45 percent) occurred among young men ages 13 to 24.26 And, 0 while HIV incidence is increasing among TOTAL Diagnosed Linked to Retained in Prescribed Achieved Care Care ART Suppressed young MSM overall, the rate of increase Viral Load is much higher among young Black MSM. Adapted from Hall HI, Frazier EL, Rhodes P et al. Differences in human immunodeficiency virus care and Between 2006 and 2009, while remaining treatment among subpopulations in the United States. JAMA Intern Med 2013; 173(14):1337-1344. stable or declining among all other racial and risk groups, HIV incidence increased by 21 percent among young people (ages remains far below ideal levels — among along the treatment continuum, however, 13 to 29), driven by a large increase (34 the 1,148,200 persons living with HIV in did not find statistically significant differ- percent) among young MSM, which, in turn, the United States in 2009, 82 percent had ences, with the exception of age: younger was driven almost exclusively by a 48 per- been diagnosed, 66 percent were linked to people ages 25 to 34 and 35 to 44 were cent increase among young Black MSM.27 care, 37 percent were retained in care, 33 less likely than persons ages 55 to 64 to Among people living with HIV, there are sig- percent received ART, and 25 percent had be retained in care, prescribed ART, or to nificant disparities in access to care and suppressed viral load (Figure 1). have a suppressed viral load (p<.001).28 treatment. Though antiretroviral therapy From a different perspective, as of 2009, Generally, HIV-positive MSM experience (ART) has rendered HIV a potentially man- approximately 18 percent of all people liv- better linkage and retention to care than ageable, chronic condition, successful ing with HIV remain unaware of their infec- do young people, females, those who inject treatment — as indicated by the sup- tion, while 50 percent of those who have drugs, and racial/ethnic minorities.29 But pression of viral load below a detectable been diagnosed remain without appropri- disparities related to race are observed level — requires a sequence of events ate care. More than 850,000 people among MSM. In two meta-analyses, HIV- that has become known as the “treatment living with HIV in the United States– 79 positive Black MSM were less likely to be cascade.”§ HIV-infected individuals must percent of Blacks, 74 percent of Latinos, diagnosed, to have a CD4>200, to attend be diagnosed, linked into care, initiated and 70 percent of Whites — do not have clinical visits, to access or adhere to ART, on ART, retained in care, re-engaged in a successfully suppressed viral load, or to be virally suppressed.30, 31 Moreover, care (if necessary), and then they must indicating no or substandard treatment Black MSM experience higher rates of dis- successfully adhere to their treatment regi- and a missed prevention opportunity. A ease progression and mortality than other men. Analyses employing the treatment review of disparities by race, gender, age MSM.32, 33 cascade model suggest that ART uptake and transmission category at each point 8 TFAH • HealthyAmericans.org SECTI O N 2: Addressing SECTION 2: DETERMINANTS OF MSM HEALTH (INCLUDING HIV) Determinants Of MSM Health (Including HIV) Health A variety of complementary conceptual frameworks have been Inequities: proposed to explain the disparities noted in MSM health indicators. Gay Men & Determinants of population health are generally considered to fall within five of health. As factors that may significantly affect an individual’s environment, MSM in the U.S. overlapping domains: 1) individual but that fall outside individual control, issue report behaviors (e.g. alcohol or drug use, the influence of SDH on health and smoking and unprotected sex); 2) biology health disparities has been increasingly and genetics; 3) social environment recognized.34 Moreover, the effects of (e.g. discrimination, poverty, education SDH may accumulate over a lifetime level, marital status and stigma); 4) and persist across generations.35 The physical environment (e.g. place of interplay of these five factors (i.e. residence, incarceration, crowding individual behavior + biological factors + conditions and built environment); and social determinants), each of which may 5) health services (e.g. access to care and affect and be experienced very differently insurance). The last three constitute the among LGBT populations compared to immediate and visible circumstances in heterosexuals, influences physical and which people live, or social determinants mental health — including HIV. Individual Behaviors Some behaviors that compromise mental among MSM, with 8 percent reporting and physical health are more common heavy drinking, 18 percent using three among LGBT youth and adults, while or more recreational drugs, and 19 the correlation of certain risk behaviors percent reporting recreational drug use with HIV transmission, morbidity and at least once per week.37 While there are mortality have been long established. occasional studies showing otherwise — one analysis of data from the National Substance abuse. Many studies have Epidemiological Survey on Alcohol and shown an association between LGBT Related Conditions showed the risk for orientation and an increased risk for substance abuse or dependence to be substance abuse, which in turn has been significantly higher among bisexual men linked to a variety of negative outcomes and women, but not among gay men, and has been well established to be a compared to other groups38 — many determinant of HIV risk. For example, studies suggest that MSM exhibit higher a meta-analysis of studies of mental rates of substance abuse than do their DECEMBER 2014 disorders among LGB people found that heterosexual counterparts, especially these populations have a 1.5 times greater if lifetime use rates are compared.39 risk for alcohol or substance dependence Population studies have also shown that over the previous 12 months.36 An marijuana use is more common among analysis of data from the Urban Men’s MSM compared to heterosexual men,40 Health Study found substantial rates and that lesbians and gay men have a of current recreational drug use (52 higher prevalence of tobacco use.41, 42, 43 percent) and alcohol use (85 percent) Among Black MSM, however, substance youth were more than three times as MSM may be at greater risk than their abuse rates were generally lower than likely to report use of any substance, with heterosexual counterparts, as LGB among White MSM — in a meta-analysis substantial differences for cigarettes, youth have higher rates of early sexual of studies conducted in Canada, the injection drugs and polydrug use.46 debut and report a higher number of United Kingdom, and the United lifetime or recent sexual partners.48 In Sexual Risk Behaviors. In a recent States, Black MSM were less likely to probability samples among youth in analysis of data from the Urban Men’s report any substance abuse, including British Columbia, young MSM were more Health Study, a much higher proportion methamphetamine, or to use drugs or likely than heterosexual males to have of MSM were found to recruit new alcohol during sex.44 ever had intercourse, to report two or sexual partners well into their thirties more sexual partners, and to have had Among youth, in national population (compared to heterosexuals, for whom first intercourse before age 14.49 Sexual studies, LGB adolescents in North America more than half reported no new partners risk-taking does not appear to differ had higher rates of smoking, alcohol use in the previous five years), to have a by race, however. In a meta-analysis of and other drug use (including injecting) much higher prevalence of concurrent studies conducted in the United States, compared with heterosexual teens, were partners, and to more frequently Black MSM had significantly fewer more likely to begin drinking earlier, partner with men of a different age partners than White MSM, though they and had higher levels of risky drinking.45 group — all of which could magnify the were less likely to identify as gay or to Compared to their heterosexual potential for HIV transmissions within disclose their homosexuality to others.50 counterparts, in a meta-analysis, LGB sexual networks.47 Similarly, adolescent Adolescent MSM may be at greater risk than their heterosexual counterparts, as LGB youth have higher rates of early sexual debut and report a higher number of lifetime or recent sexual partners. Biology and Genetics The disparities in HIV incidence among analysis of studies conducted in the United MSM are significantly affected by biological States, Canada and the United Kingdom, and epidemiologic factors, including compared to White MSM, Black MSM were background HIV prevalence, sexually more likely overall to have a current or transmitted disease prevalence, sexual lifetime STD diagnosis, three times as likely mixing patterns, and the relative risk to be HIV-positive, and six times as likely to for HIV transmission of various sexual have an undiagnosed HIV infection — in practices. Because MSM are more likely to spite of lower rates of sexual risk taking find sex partners locally, if HIV prevalence and substance abuse, and higher rates of in the surrounding community is high, preventive behaviors.52 the probability of encountering a sex Because the risk of HIV infection via anal partner who is HIV-positive is significantly sex is approximately 18 times higher than enhanced. Sexually transmitted diseases via vaginal sex, MSM are at proportionally increase the probability of HIV infection, higher risk than heterosexuals even with and as noted above, STD prevalence the same number of sex partners. And among MSM is far higher than among because MSM who engage in anal sex heterosexual men.51 Both factors are sometimes switch roles (between insertive magnified significantly among Black MSM, and receptive), the population risk is among whom HIV and STD prevalence is further elevated.53 higher than among White MSM. In a meta 10 TFAH • HealthyAmericans.org Social Environment LGBT ADULTS AND DISCRIMINATION Stigma and discrimination. The mi- l elf-stigma or internalized S nority stress model has been used as a homophobia that results from framework to understand the impact of individuals absorbing and believing select social determinants — i.e. those pervasive negative portrayals. stemming from stigma and discrimina- In the model, as a consequence of tion — on health disparities among LGB persistent social marginalization and individuals.54 The model proposes that discrimination, LGB individuals cope Two-Thirds of LGBT adults have LGB individuals suffer from excess and experienced discrimination because of in ways that are adaptive but ultimately disproportionate stress related to their their sexual orientation stressful, and therefore injurious to stigmatized social category, and that such health, including by concealing their stress leads to adverse health outcomes. It sexual orientation through passing is premised on the “heterosexual assump- (i.e. pretending to be heterosexual) or tion,” wherein everyone is assumed to be covering (i.e. suppressing characteristics heterosexual, where sexual minorities re- or information from which others might main generally invisible and unacknowl- infer their sexual orientation), or by being edged by society’s institutions, or, when out but only implicitly, by telling the truth they are made visible, are problematized. but using only ambiguous language. Such Stigma rooted in homophobia results in strategies require constant vigilance, and social marginalization and discrimination, also discourage forming relationships which are expressed in four ways: that might otherwise confer protective l nacted stigma refers to overt acts of E health benefits or accessing community personal ostracism or rejection; discrim- social support resources. Like social ination (in housing or employment, determinants in general, minority stress is for example); criminal victimization, additive (i.e. it requires adaptive responses violence or hate crimes — leading to a above and beyond those required by the reduced sense of order and security; everyday stresses encountered by others); chronic, in that it is based on relatively l elt stigma comprises a range of overt F fixed social ideas and cultural structures; manifestations of anti-gay sentiment and socially based (i.e. it comprises social (e.g. antigay violence, antigay “religious structures rather than biologic, genetic, or freedom” legislative campaigns and nonsocial characteristics of the individual hate crimes), which, even when not or group).55 personally experienced, contribute to a climate of stigmatization; The disproportionate experience among MSM of discrimination and l tructural stigma refers to laws, policies S other prejudice, and the adverse health or regulations that have a discriminatory consequences of such experiences, has or stigmatizing effect, such as the been repeatedly demonstrated. For denial of the right to marry or serve in example, LGB individuals were twice the military; disenfranchisement from as likely as heterosexuals to experience religious or spiritual resources (e.g. a major life event, such as being fired, rejection from institutional religion); related to prejudice.56 In population anti-discrimination provisions that fail studies, LGB individuals were all more to protect LGB people; or workplace likely than heterosexuals to experience practices that impede the hiring or sexual assault.57 In a recent poll, two- promotion of gay people, thus exerting thirds of LGBT adults had experienced negative economic stress; and discrimination based upon their sexual TFAH • HealthyAmericans.org 11 orientation; and nearly one-third (30 verbal, physical or legal contact with the Youth are even more likely percent) had been physically threatened police, and more than twice as likely to than adults to be the victims or attacked.58 Moreover, harassment, experience negative sexual contact in victimization, and a history of childhood the preceding six months.69 of antigay prejudice or sexual abuse have been shown to In addition to the deleterious effects victimization, and may suffer negatively affect physical and mental of enacted or felt stigma, there is health and have been associated with greater consequences. emerging evidence that structural HIV infection.59 stigma may also be an important Multiple population studies have determinant of health. For example, LGBT ADULTS AND PHYSICAL THREATS demonstrated that LGB youth are more LGB individuals who live in states with likely than their heterosexual peers to be constitutional amendments banning targeted for violence, to report physical same-sex marriage have higher rates of violence or sexual abuse, to experience psychiatric disorders and are more likely forced sex or dating violence, or to to attempt suicide than those who live in endure harassment, bullying or physical states without such pernicious policies.70 assault at school.60, 61, 62 A number Recently, a population-based analysis 30% of LGBT adults have been of studies have demonstrated a link of mortality data found that sexual physically threatened or attacked between enacted stigma experienced by minority residents of communities LGBT youth and higher rates of mental with high levels of antigay prejudice health problems, including depression died an average of 12 years sooner and suicidal ideation, substance abuse than those who lived in communities and risky sexual behaviors.63, 64, 65 with low levels of antigay prejudice, even after controlling for multiple risk Family rejection may be a particularly factors at the individual and community important determinant of health among level. The findings showed that sexual LGB youth. Youth who were rejected minorities were more likely to die by by their families after coming out have suicide in high stigma communities, significantly higher rates of depression, and that completed suicides among this suicide attempts, substance abuse and group occurred at a significantly lower risky sex behaviors.66 Family rejection age (average 18 years earlier).71 may also contribute to higher rates of homelessness or street-involvement MSM living with HIV may experience among LGB youth, which may in turn additive stigma related to their contribute to higher rates of survival sex infection. Among people living or prostitution.67 with HIV, stigma has been shown to increase depression, psychological Both LGBT adults and youth may be stress, and shame, to increase a sense subject to disproportionate sanctions of hopelessness, and is associated with from school disciplinary or criminal poorer mental and physical health justice systems. For example, in outcomes and diminished social longitudinal studies conducted among support.72 People with HIV report adolescents, sexual-minority adolescents much higher levels of childhood sexual were 1.25 to 3.0 times more likely to abuse than does the general population, receive punishments from their schools, which in turn has been shown to predict police or courts.68 In a study conducted other problems (e.g. alcoholism, in New York City, LGB youth were substance abuse and recurring STDs) more likely to experience negative that might adversely affect HIV 12 TFAH • HealthyAmericans.org progression.73 Trauma severity predicts mortality, as those with more resources HIV mortality, and individuals who have increasingly positive health It has been well established experience more traumatic events are outcomes — while those at the bottom of that among heterosexuals three times more likely to die compared the socioeconomic scale do not.80 to those who report few such incidents.74 in the United States, HIV is Racial differences in HIV rates among those in the same socioeconomic predominantly a disease of Poverty, educational level. classes suggest that the nexus between the poor. While the links between socioeconomic race and poverty may amplify the class (e.g., poverty and educational effects of SDH, which influence not level) and LGB health have received only the underlying HIV prevalence of less attention, analyses of data from the communities (increasing the risk for American Community Survey showed HIV acquisition among residents), but that individuals in same-sex couples have also individual risk taking within those higher unemployment rates, even though communities. For example, those for they also have higher rates of college whom stable relationships are imperiled completion, compared to heterosexual by the stress of stigma, discrimination, couples.75 As poverty rates increased violence, incarceration and other factors during the recession, LGB Americans may be more likely to engage in sexual were more likely to be poor than mixing patterns (i.e. more partners, heterosexual people — among Black more frequent episodes, unprotected same-sex couples, poverty rates were sex) that can foster HIV transmission. more than twice that of heterosexual Because many sexual networks are married Blacks.76 In a new analysis of tight and racially homogenous (i.e. population surveys, 29 percent of LGBT sexual encounters are more likely adults experienced a time in the last year among individuals of the same race when they did not have enough money to and socioeconomic class), the HIV risk feed themselves or their family.77  within minority communities is even CDC reports that HIV prevalence is higher than might be attributable to highest among those at or below the socioeconomic factors alone.81 Racial poverty line, those with less than a high disparities in HIV determinants generally school education and those who are are consistent among MSM — in a meta- unemployed.78 The effects of poverty on analysis conducted in Canada, the United HIV health outcomes are profound. As Kingdom and the United States, Black many as half of people living with HIV MSM were more likely to be low income, in U.S. inner cities experience food have less than high school education, have insecurity, which is in turn related to ever been incarcerated or to be currently reduced medication adherence and poor unemployed than their White peers.82 health outcomes. Studies have shown As noted above, sexual minority youth that for impoverished people with HIV, are disproportionately represented food insecurity and housing instability among homeless youth populations and, have a greater impact on overall health compared to heterosexual youth, homeless than medication adherence.79 While LGBT youth are at significantly higher risk the introduction of highly potent ART for behavioral health conditions or to have more than a decade ago unquestionably been physically or sexually abused while improved survival and quality of life homeless,83 to engage in survival sex and to among people with HIV, it may have acquire HIV infection.84 increased inequalities in AIDS-related TFAH • HealthyAmericans.org 13 Physical Environment. Little research has been undertaken social stressors related to economic proportion of Whites who lived in to examine the relationship between survival, the threat of violence, poorer the county — with racial segregation geography and LGBT health, though health, and social discrimination may likely leading to disparities in health small studies have suggested that be even more acute in cities with high resources.85 Neighborhoods blighted isolation associated with rural residency income disparities, such as New York, with abandoned buildings and elevated may negatively affect health. The U.S. Washington, D.C. and San Francisco, crime rates also have higher rates of HIV HIV epidemic is highly concentrated where very affluent neighborhoods infection, often associated with injection among urban centers on the East abut areas with HIV infection rates drug use.86 Low social capital — i.e. and West coasts, and in cities and comparable to those in sub-Saharan the value of a group’s social network, as towns across the South, where in each Africa. In an examination of county- indicated by community organizational instance, poor neighborhoods are level data in 40 states, HIV diagnosis life, involvement in public affairs, affected far more than rich ones. While rates were significantly correlated with volunteerism, informal sociability and many chronic health conditions (e.g. income inequality. Underscoring social trust — is associated with higher diabetes, heart disease and cervical the intersection between race and HIV rates, above and beyond the effects cancer) are more prevalent among socioeconomic class, HIV diagnoses of poverty and disease.87 those lower on the socioeconomic scale, were inversely correlated with the With the exception of LGBT-focused HIV and STD prevention measures, public health interventions targeting LGBT communities for cancer prevention, alcohol, tobacco cessation, asthma or cardiovascular disease have been largely non-existent.88 Health Services LGBT populations may experience and mental health). In spite of these of studies conducted in Canada, the disproportionate barriers to accessing barriers, some population-based studies United Kingdom and the United States, quality healthcare services, as a result have failed to detect differences in access HIV-positive Black MSM were less likely of: 1) reluctance to disclose sexual to healthcare among MSM.89 Measures than their White counterparts to have orientation or gender identify for fear of may be too crude to detect quality been diagnosed, to have initiated ART, prejudiced reactions, being stigmatized, of care, however, and some studies or to have health insurance.92 or confidentiality breaches, or based on conducted among providers show wide While implementation of the negative past experiences; 2) a paucity of variability in attitudes about working with Affordable Care Act has increased providers competent to manage LGBT sexual minority patients,90 while studies access to care among young adults, health issues; 3) structural barriers among patients showed that many LGB who may now be covered by their that impede access to health insurance individuals fail to disclose their sexual parents’ health insurance until a later (which is often denied to unmarried orientation to their provider, which may age, LGBT youth who are not cared domestic partners, even in jurisdictions compromise their care.91 for by their families may not benefit.93 that do not recognize same-sex marriage) With respect to access to HIV care, Moreover, family physicians, who or limit visiting and medical decision- sharp disparities among racial/ethnic provide care to the majority of youth making; and 4) a lack of culturally groups have been noted, and these ages 15 to 24, are insufficiently trained appropriate prevention programs (e.g. persist among MSM. In a meta-analysis to provide care for LGBT youth.94 violence victimization, substance abuse 14 TFAH • HealthyAmericans.org SECTI O N 3: Addressing AND STRUCTURAL DETERMINANTS OF HEALTH SECTION 3: SYNDEMICS IN THE CONTEXT OF BIOLOGICAL Syndemics in the Context of Biological And Structural Health Determinants Of Health Inequities: While multiple social determinants of MSM health may each Gay Men & independently influence physical and mental health outcomes, it has been increasingly apparent that they may also mutually MSM in the U.S. reinforce and amplify each other. issue report In an analysis of data from the Urban socialization — during which many Men’s Health Study, determinants young MSM experience rejection, including childhood abuse, depression, ostracism, harassment, or even physical intimate partner violence and polydrug violence — combined with additional use were highly inter-correlated and stresses associated with initiation positively associated with high-risk into a gay culture marked by high sexual behaviors and HIV infection. prevalence of STDs, HIV and substance This syndemic, fueled by cultural abuse — contribute to later syndemic marginalization, comprises an additive production among urban MSM.96 interplay of health epidemics of HIV, A recent study explored the concept STDs, mental health, substance abuse of syndemic development over the and violence, each reinforcing each life-course — i.e. as the consequence other. With respect to HIV prevention of lifelong adversity — among the among MSM, this concept has profound Multicenter AIDS Cohort Study (MACS), implications — as men who are a long-term progressive cohort of MSM challenged by the combined effects living with HIV. Among participants, of depression, substance abuse and early childhood satisfaction, victimization violence may not have the capacity to (e.g. bullying or ostracism), perceptions reduce their sexual risks, underscoring of inadequate attainment of masculinity the need for community-level or norms and low social connectedness structural interventions.95 were associated with the development of The production of syndemic conditions syndemic conditions later in life.97 An among MSM may occur over the life analysis of Black MSM among the same course, suggesting the possibility of cohort showed similar results. Black early intervention. For MSM, many of MSM who experienced gay-specific the individual health problems (e.g. childhood or adolescent stressors depression and anxiety, substance (particularly parental abuse, victimization, abuse and HIV) that together comprise perceptions of failed attainment of DECEMBER 2014 an adult syndemic condition are masculinity norms or internalized characterized by their early onset, homophobia) were significantly more often during adolescence. Researchers likely to develop syndemic conditions have theorized that masculine later in life.98 Childhood or adolescent adversity has been long associated with and immigration status. While there adverse health outcomes later in life, is significant research examining the raising the possibility that addressing impact of each domain on LGBT the victimization experienced by young health (including HIV progression MSM might interrupt the development and survival), there are few studies of syndemic conditions later in life, with sufficient power to examine the thus contributing to better adult health intersectionality of domains.99 Moving outcomes. forward, additional research to examine the interplay of domains will be critical, Compounding syndemic production, as will the development of individual, many MSM, particularly racial minorities, biomedical, structural and policy experience determinants of health interventions that address the reality that related to multiple, overlapping domains, MSM health is mediated by biological, including not only sexual orientation, behavioral and structural drivers.100, 101 but race, poverty, educational attainment Biopsychosocial Drivers of the Syndemic in Gay, Bisexual and Other Men Who Have Sex With Men Biological Influences Behavioral Influences Psychosocial and Prevalence of Infectious Disease Partner Selection Structural Influences Infectiousness Number of Partners Knowledge, Attitudes and Beliefs Suceptibility Sexual Behavior Minority Stress, Homophobia and Racism Efficacy of Treatment Retention in Medical Care Social Capital and Social Support Efficacy of Risk Reduction Strategies Treatment Initiation and Adherence Safe Schools and Legal Protections Choice of Risk Reduction Strategy Allocation of Public Resources Adherence to Risk Reduction Strategy Access to Information and Tools Syndemic Health Problems Mental Health Substance Violence Abuse and Sexual Abuse NOTE: TIs = Sexually Transmitted Infections S SOURCE: Halkitis PN, Wolitski RJ, Millett HIV STIs GA. A holistic approach to addressing HIV infection disparities in gay, bisexual, and other men who have sex with men. American Psychologist, 2013;68/4:261-73. 16 TFAH • HealthyAmericans.org SECTI O N 4: Addressing SECTION 4: PROTECTIVE FACTORS AND RESILIENCY Protective Factors and Resiliency These studies and others exploring syndemic conditions Health and their production have also foregrounded the concept Inequities: of resilience, often described as healthy development in the face of adversity — i.e., the capacity to avoid or overcome the Gay Men & negative outcomes associated with repeated exposures to risk. For example, another analysis from the MACS cohort showed MSM in the U.S. that the majority of adult MSM who had resolved previously issue report internalized homophobia had significantly higher odds of positive health outcomes.102 Importantly, most theories of resilience describe it is a process, rather than an inherent trait — i.e. individuals develop resilience over time. There has been relatively little research conditions, or the majority of MSM who to examine factors that may increase endure syndemic conditions who do resiliency to protect or promote health not acquire HIV.103, 104 For example, in among LGBT individuals, though the seminal Urban Men’s Health Study protective factors may be inferred from syndemics analysis described above, while deficit-based studies. For example, it the relatively high proportions of MSM has been increasingly noted that most experiencing multiple health problems MSM exhibit substantial resilience, were HIV positive (22 percent) or had and researchers have begun to explore recently engaged in high-risk behaviors the resiliency factors that characterize (23 percent) — 78 percent had not the majority of MSM who experience engaged in risk behaviors and 77 percent adversity associated with minority had remained HIV-negative, in spite of stress who do not develop syndemic the adversity they experienced.105 DECEMBER 2014 S EC T I ON 5 : Addressing SECTION 5: MOVING FORWARD MOVING FORWARD: Health Intervening to Address Inequities: Determinants of MSM Health Gay Men & To date, most individual-level HIV prevention interventions MSM in the U.S. targeting MSM have been based upon a deficit-based approach that attempts to reduce risk factors. While such approaches moving forward are effective and have reduced HIV transmission, their impact may be limited and ultimately insufficient to manage the HIV epidemic. Moreover, while framing behavioral risks for HIV infection as failures that must be avoided or corrected, this “broken person” approach neglects the potential value of MSM’s inherent resiliencies. Moving beyond a deficit-based approach will require interventions not only to reduce the negative consequences of determinants of MSM health, but also to enhance men’s natural resiliencies and support healthy living. Over the past decade, mitigating the that includes individual (behavioral) social determinants of health inequities and biomedical interventions, but has become a national and international also community-level and structural priority, and it is increasingly interventions, including health acknowledged that social determinants policy and legislation, economic are not merely coincidental, but rather and social interventions, and cross- are mediated by public and social sector collaborations. Moreover, policy: “This unequal distribution of it seems possible that if a culture health-damaging experiences is not of stigmatization produces health in any sense a ‘natural’ phenomenon inequities, then a culture of acceptance but is the result of a toxic combination and integration might promote positive of poor social policies and programs, health outcomes. Achieving such unfair economic arrangements, and an affirming environment for MSM bad politics.”106 As such, addressing will require changes at many levels, social determinants of health inequities including society, community, family among MSM (including HIV) will and social network. require a combination approach DECEMBER 2014 MARRIAGE EQUALITY The recognition of same-sex marriage ity and mortality, LGB individuals resid- privileges.109, 110 Preliminary results sug- provides one example of how public ing in jurisdictions without such laws gest that similar benefits are conferred policy mediates systemic stigma, posi- or policies had no increased adverse by same-sex marriage. In an analysis tively and negatively, which in turn can health outcomes.107,108 Considerable of data from the California Health Inter- affect health outcomes. While structural research has documented the posi- view study, being in a legally recognized stigma (such as constitutional amend- tive health outcomes associated with same-sex relationship reduced the men- ments banning same-sex marriage) has heterosexual marriage derived from the tal health disparities between LGB and been associated with increased morbid- economic impact of benefits, rights and heterosexual couples.111 It has been widely noted that improving Federal leadership With respect to health disparities, health outcomes and reducing The federal government will however, while there have been disparities will require efforts that have a strong role to play, though significant strides in cross-agency transcend the health sector.112 Non- intergovernmental coordination is collaboration, data-sharing, and health policies and programs -- including never easy, and will require high-level evaluation focusing on other education, job training and income leadership. The Obama administration populations (including women and support, transportation, land use, has undertaken important beginning racial minorities), such efforts have criminal justice and housing, to name efforts in this regard. Addressing SDH been rarer with respect to sexual only a few — clearly have an impact on constitutes an important part of the orientation. At the request of the health outcomes and health inequities. HHS Healthy People 2020 framework115 President, HHS established an LGBT In one analysis, as little as 10 percent of and is included as an objective in CDC’s Issues Coordinating Committee, the variability in premature deaths was National Center for HIV/AIDS, Viral which, in 2013, prioritized federal associated with differences in healthcare, Hepatitis, STD and TB Prevention’s recognition of same-sex spouses, LGBT while 60 percent was attributed to Strategic Plan 2010 to 2015.116 In 2013, enrollment outreach in the health social, environmental or behavioral the President issued an executive order insurance marketplace, LGBT-specific factors.113 A “health-in-all-policies” establishing the HIV Care Continuum research and data collection and the approach, which prospectively assesses Initiative, designed to mobilize and development of resources for families of and takes into account potential health coordinate federal efforts to take and providers serving LGBT youth. outcomes associated with non-health advantage of recent HIV prevention Across the federal government, related policies and programs, has been and treatment advances, via further the National Prevention, Health employed in some sectors and may integration of HIV prevention and Promotion, and Public Health Council be useful in efforts to improve MSM care efforts; expand successful HIV is perhaps best positioned to address health.114 Such an approach attempts testing and service delivery models; social determinants of MSM health to balance health concerns with other encourage innovative approaches to inequities. The NPC, the creation of imperatives and offers an opportunity to address barriers to accessing testing which was mandated by the Affordable collaborate across sectors, particularly and treatment; and ensure that federal Care Act, is charged with coordinating among non-traditional partners. resources are focused on evidence- efforts of 20 federal departments and The recommendations that follow are based interventions. A working group agencies** to “ensure the health, well- the synthesis of a literature review, comprising the Departments of Justice, being and resilience of the American interviews with key informants, and the Labor, HHS, Housing and Urban people.” In 2011, the NPC released the expert consultation convened by Trust Development (HUD), Veterans Affairs National Prevention Strategy (NPS), for America’s Health in July 2014. and the Office of Management and which “envisions a prevention-oriented Budget was established.117 society where all sectors recognize the TFAH • HealthyAmericans.org 19 value of health for individuals, families, and society and work together to FEDERAL LEADERSHIP IN ADDRESSING HEALTH INEQUITIES AMONG MSM. achieve better health for Americans.” Notwithstanding, while noting the The recommendations that follow fit easily with the NPS framework, and offer the disproportionate incidence of health opportunity to integrate efforts to mitigate MSM health inequities across government inequities and their correlation with programs. The Office of National AIDS Policy (ONAP) should immediately initiate the social determinants, the NPS includes collaborations described below: sexual orientation only among various l F EDERAL LEADERSHIP AND social determinants only in passing, sub-populations that suffer disparities.118 COORDINATION. Emphasizing the calling for a “more holistic approach Overall, the NPS employs four strategic connection between other social to health.”119 Insofar as MSM are directions to guide actions that will determinants of MSM health inequities disproportionately impacted by HIV, demonstrably improve health, all and HIV, ONAP and the Presidential ONAP should provide leadership in leading to the goal of “increasing the Advisory Council on HIV/AIDS promoting MSM health across federal number of Americans who are healthy (PACHA) should partner with the HIV programs, facilitating cross-agency at every stage of life”: 1) Healthy and NPC to delineate an agenda that collaborations, disseminating best Safe Community Environments; 2) incorporates MSM health priorities practices, and sharing information and Clinical and Community Preventive across federal agencies, including data among agencies. As the National Services; 3) Empowered People; and but not limited to HIV programs. As HIV/AIDS Strategy is updated, it should 4) Elimination of Health Disparities. the National Prevention Strategy is embrace an agenda to address social In addition to the strategic directions, updated, it should emphasize the determinants of health inequities the NPS provides evidence-based need to address health disparities among various subpopulations recommendations most likely to reduce related to sexual orientation or gender disproportionately affected by HIV, the leading causes of preventable identity, including those among MSM. but certainly among MSM. It should death and major illness, in seven ONAP and the National Prevention emphasize a life course approach priority areas (most of which dovetail Council should also promote public/ to MSM health, which will require a with health inequities experienced by private partnerships focusing on MSM greater focus on youth. MSM): tobacco free living, preventing health, or incorporate MSM health l F EDERAL DISCRETION (and the Bully drug abuse and excessive alcohol issues into existing partnerships. For Pulpit). Though many equality issues use, healthy eating, active living, example, ONAP recently convened may appear intractable, including mental and emotional well-being, LGBT funders to ensure that young some structural social determinants reproductive and sexual health, and MSM were specifically included in such as the recognition of same-sex injury and violence-free living. The President Obama’s My Brother’s marriage, the overall status of LGBT NPC is chaired by the acting Surgeon Keeper initiative, which strives to people has improved measurably General, who leads the U.S. Public connect young people to mentoring over the past few years. And while Health Service, and meets regularly to and support networks. President Obama certainly has his oversee agency initiatives associated l N ATIONAL HIV/AIDS STRATEGY. critics (among those who favor and with NPS implementation. The NPC While ONAP is charged with those who oppose LGBT equality), reports progress on meeting NPS goals coordinating the HIV response across the current administration deserves on a yearly basis to the President and the federal government, no such substantial credit — for declining to Congress. The Advisory Group on mechanism exists for MSM health. defend the Defense of Marriage Act, Prevention, Health Promotion, and As such, while the National HIV/AIDS and upon its demise, for aggressively Integrative and Public Health, which Strategy strongly emphasizes the implementing regulations through- comprises non-federal members, advises need to address prevention and out the government that recognized the NPC in developing public, private, treatment among MSM, it mentions same-sex unions; for executive orders and nonprofit partnerships. 20 TFAH • HealthyAmericans.org prohibiting discrimination in federal Assistance Program (ADAP) — fail topic areas to include two national programming; for interpreting dis- to collect sexual orientation data, objectives aimed at increasing the crimination based on sexual orienta- foreclosing the possibility of additional number of population studies that tion or gender identity to apply under analyses to assess sexual orientation include LGBT populations.122 Other federal anti-discrimination statutes, and gender identity-specific health important surveys only include such such as the Civil Rights Act or the Fair disparities. As the government questions on an optional basis, or in Housing Act, none of which explicitly refines meaningful use standards for a limited way. For example, only a prohibit such practices; for program- electronic health records (EHR), it is handful of states (13 and the District ming designed explicitly for sexual imperative that sexual orientation and of Columbia in 2009) asked sexual and gender minorities; for ensuring gender identify fields be included (see orientation questions in their annual the Affordable Care Act’s positive ap- also healthcare section, below). Behavioral Risk Factor Surveillance proach to LGBT health; for developing System (BRFSS) survey.123 Virtually l E PIDEMIOLOGICAL RESEARCH. As the first National HIV/AIDS Strategy; no longitudinal studies have followed detailed by the Institute of Medicine, and importantly, for the President young MSM as they grow older MSM health programming has been and his cabinet publicly and unapolo- or adult MSM as they transition significantly hobbled by a lack of getically defending LGBT equality in a to middle- and old-age. Few HIV research. It is critical that sexual wide range of settings, including the interventions have been specifically minorities be included in population State of the Union address. Advanc- evaluated among young MSM, while studies. In 1995, the YRBS was ing LGBT equality — and by extension virtually no interventions addressing the first CDC survey to include reducing MSM health inequities — will other social determinants of health sexual minority questions — while require continued, sustained federal among this population have been initially optional, these questions leadership. tested. were recently added to the national l F INANCING DATA. The extent to questionnaire and to the standard Population data are essential to which federal HIV programs target core questionnaire used by states understanding MSM health. As such, key populations, specifically including and cities. The National Healthcare where they have yet to do so, CDC, MSM, should be tracked and updated Disparities Report included LGBT SAMHSA and other federal agencies with every budget cycle. While populations for the first time in should add questions pertaining certain programs are not population 2011.120 In 2013, CDC included a to sexual orientation, identity and specific and others target only the sexual-orientation specific question behaviors to core instruments general population, it is essential in the National Health Interview for national health surveys. The to disaggregate population-specific Survey for the first time, 121 while the National HIV Behavioral Surveillance programs in order to demonstrate Substance Abuse and Mental Health system should be expanded both how well federal funding aligns with Services Administration (SAMHSA) geographically (it is currently epidemiologic data. added two questions, one on sexual conducted in 20 cities) and to include attraction and one on sexual identity, participants ages 13 to 18. To better l S ERVICE UTILIZATION DATA. to the National Survey on Drug understand the life course of MSM Health service utilization data should Use and Health dress rehearsal, health inequities, the NIH should capture information related to sexual in contemplation of including them immediately support longitudinal orientation and gender identity. Many in the 2015 survey. The Office of research examining HIV and other programs — even those with obviously the Assistant Secretary for Health health issues among a broad cohort of high numbers of MSM, including HIV expanded Healthy People 2020 LGBT young MSM. programs such as the AIDS Drug TFAH • HealthyAmericans.org 21 A LIFE COURSE APPROACH Nationally, there is increased attention account for gay-specific bullying), and on the long-term health and social con- in some cases, anti-gay bias combined TO INTERVENTIONS TO sequences of early childhood trauma. with very strict anti-bullying policies INCREASE RESILIENCY In the Adverse Childhood Experiences may actually punish victims who fight (ACE) Study, childhood abuse, neglect, back or defend themselves in the face of or exposure to other traumatic stressors homophobic abuse. Beyond bullying, (e.g. familial substance abuse, mental LGBT students are more likely to health disorders, sexually transmitted encounter school discipline, and to be infections and violence) were linked to suspended, often as a result of dress codes a number of short- and long-term health that enforce gender conformity or policies and social problems.124 That MSM suf- that suppress behaviors that would be fer disproportionate rates of many early considered normal among different sex childhood traumas, and that such trau- couples, such as holding hands or kissing. mas have been linked with later develop- Students must not only feel safe from ment of syndemic conditions, argues for violence, harassment, or other abuse interventions to address social determi- in schools, but also valued, respected nants of MSM health inequities early in and accepted by school professionals life and throughout the life course.125 and peers. A population study in Massachusetts showed that LGB youth Young MSM in schools. in schools with supportive staff, anti- Sadly, schools are among the most hostile bullying policies and Gay/Straight environments encountered by LGBT Alliance (GSA) clubs reported lower youth, and even supportive families are rates of victimization, skipping school insufficient to counter bullying and and suicide attempts.127 In a recent victimization that many LGBT adoles- analysis of data from the Youth Risk cents experience in and out of schools. Behavioral Surveillance System, LGB Though bullying per se does not violate students living in states and cities with federal laws, students are protected from more protective school climates reported discriminatory harassment when it is fewer past-year suicidal thoughts.128 based on race, national origin, color, sex, age, disability or religion. While sexual In a truly safe school climate, students, orientation is not a protected class, the teachers, administrators, parents and U.S. Department of Justice and U.S. De- board members alike would be unafraid to partment of Education (DOE) have made disclose their sexual orientation. Schools it clear that harassment based on sex with supportive environments for LGBT and sexual orientation are not mutually youth are characterized by safety and con- exclusive, and that when LGBT students sistently enforced anti-bullying policies. are harassed based on their actual or per- To establish positive norms, employment ceived sexual orientation, they may also be policies protect teachers and administra- subjected to forms of sex discrimination tors against LGBT-related discrimination, recognized under Title IX (1972 Educa- and school policies welcome alternative tion Amendments to the 1964 Civil Rights family configurations. Professional train- Act). Recent DOE guidance made clear ing instills in teachers and other profes- that Title IX extends to claims of discrimi- sionals the importance of LGBT issues and nation based on gender identity.126 prepares them for conversations about LGBT topics, and to develop supportive Though anti-bullying policies are relationships with all students, regardless becoming more commonplace, many of their sexual orientation.129 such policies are generic (i.e. they fail to 22 TFAH • HealthyAmericans.org SUPPORTING ADOLESCENT MSM IN SCHOOL Federal education policies and pro- why it is critical that teen pregnancy as Safe Schools/Healthy Students, a grams should consistently support and sexually transmitted infection/ SAMHSA led initiative that supports school environments that are welcoming HIV prevention messages and projects community-level partnerships that are and supportive of all students, includ- are inclusive of all youth, and strate- designed to address youth violence ing sexual minorities and gender non- gies for creating a safe and inclusive and promote the wellness of children, conforming youth. For example: classroom setting. Through the Divi- youth and families,135 incorporate sion of Adolescent and School Health policies that consider the needs of l evelop and promulgate BEST PRAC- D (DASH), CDC provides funding for state LGBT youth. Because the effective- TICES for SCHOOLS and SCHOOL and local education agencies to help ness of bullying prevention programs DISTRICTS to support LGBT children. districts and schools deliver exemplary has not been well demonstrated, the A number of resources are available sexual health education emphasizing Suicide Prevention Resource Center that outline approaches for schools HIV and other STD prevention; increase recommends that school programs to achieve an environment that is adolescent access to key sexual health include strategies to identify LGBT safe and supportive for LGBT stu- services; and establish safe and sup- youth at risk for suicide and referrals dents.130,131 SAMHSA publishes Top portive environments for students and to mental health services.136 Health Issues for LGBT Populations, an staff. Such initiatives should include information and resource kit targeting l S EXUAL HEALTH. Birth control, STD LGBT specific programming and be ex- prevention professionals, healthcare screening and treatment are critical for panded nationally. providers and educators.132 Training adolescents who are learning about for teachers and administrators, includ- l S CHOOL SAFETY. Implement poli- their sexuality, and youth may have ing continuing education requirements, cies to ensure that all students are fewer resources for sexual health ser- are essential components. safe from violence. Resources are vices, given the erosion of the public available from many organizations, STD clinic system. Where possible, l rovide comprehensive SEXUALITY P including the S.A.F.E Classrooms co-location of health clinics within EDUCATION in schools. To ensure project, a collaboration of Teach schools may facilitate access — for that LGBT students feel included, it is For America, The Trevor Project and example, in Washington, D.C., Unity essential that sexuality education be GLSEN, which provides resources and Health Care operates a student health gender neutral and non-shaming. It toolkits to help teachers create learn- center in Eastern High School, offering is also critical to employ a life-course ing environments that are safe and a full range of healthcare and sup- approach — i.e. one that recognizes affirming for everyone. 133 Similarly, portive services throughout the year, that the needs of 13- to 15-year-olds the American Federation of Teachers including summer and vacations. are very different from those of 15- to has partnered with GLAAD on the See 18-year-olds. One resource, the Family l W ELCOMING LGBT PARENTS. Parent a bully, Stop a bully campaign, which and Youth Service’s Bureau’s National involvement in education can have includes events and activities to edu- Clearinghouse on Families and Youth’s a positive impact on schools and cate teachers, parents and students online training module, “Creating a student achievement. To expose ado- on bullying and provides them with Safe Space for LGBTQ Teens,” was de- lescents to a diverse range of positive resources to effectively handle and signed to help those who deliver teen adult role models — and to dem- prevent harassment at school.134 pregnancy prevention programming onstrate to LGBT youth that sexual While many schools have anti-bullying to understand sexual orientation and minorities are respected and valued policies, it is important that such gender identity, the challenges lesbian, — policies and protocols to involve policies specifically reference sexual gay, bisexual, transgender and queer parents in schools must be welcoming orientation, gender identity, and gen- and/or questioning (LGBTQ) youth and inclusive of both parents of LGBT der non-conforming youth. It is im- face, the importance of prevention youth, as well as LGBT parents. perative that federal initiatives, such messages being inclusive of all youth, TFAH • HealthyAmericans.org 23 l OSITIVE LGBT ROLE MODELS. Ado- P harassment and violence. Strong, well- be supported in their gender identity lescents learn from positive role models supported GSAs can have a major im- and never required to conform to gen- in schools, but also from how adults are pact on the education environment and der stereotypes in order to receive ap- treated. Schools that provide a safe possess the power to transform individu- propriate education. As young people’s and inclusive environment for LGBT als, school cultures and educational in- sexual orientation and gender identify teachers and administrators demon- stitutions. While most such groups are is often more fluid than adults, profes- strate to youth that sexual minorities started by students and are youth-led, sionals should be educated about are valued and protected. It is essen- school sanction and support is critical. transgender issues and should under- tial that anti-discrimination and other stand that gender identity may or may l G ENDER NON-CONFORMING YOUTH. employment policies include sexual ori- not correlate with sexual orientation. For some LGBT youth, the outward entation and gender non-conformity. communication of gender through their l S CHOOL DISCIPLINE. School behavior l P EER SUPPORT. Gay/Straight Alliance behavior or appearance may differ from policies should eliminate provisions that clubs provide a safety net for students expectations associated with their sex. punish the expression of sexual orienta- during the coming out process, educate Like all young people, gender non-con- tion or non-gender conforming dress. teachers and student peers to reduce forming students are entitled to bias- Disciplinary officials should receive train- slurs, and work with school administra- free attention to their unique needs and ing to support LGBT students and to dis- tions to implement policies that prevent to be safe in their school. They should cern homophobic harassment or abuse. Young MSM outside of schools. from their homes for status offenses (such While school-based policies and services as “willful defiance,” “incorrigibility,” or are essential for LGBT youth, it is impor- “ungovernability”) or divert them into al- tant to acknowledge that many young ternative schools or day-placement settings MSM encounter substantial challenges may derail their education, setting off a outside of school. As discussed above, lifelong cascade of economic insecurity.137 LGBT youth are more likely to become And, LGBT youth are much more likely to homeless than their heterosexual peers, be placed in foster care, though the system often after being rejected by their families is poorly equipped to meet their needs — tellingly, they are sometimes referred and many suffer homophobic abuse. In a to as “throwaway” youth. As such, they are recently completed study in Los Angeles more susceptible to substance abuse and County, approximately one in five foster sexual and physical victimization. LGBT youth identified as LGBTQ, and LGBTQ and non-gender conforming youth are foster youth were twice as likely to report more likely to encounter problems with poor treatment and more likely to live school discipline or the criminal justice in group homes and to have more foster system, as they turn to sex work, drug care placements. More than 18 percent trade, or petty crime to survive and are reported experiencing discrimination more likely to be harassed by police. They related to their perceived sexual are more frequently criminalized, sanc- orientation or gender identity/expression, tioned by schools, labeled as sex offenders, including some who didn’t identify as detained for minor offenses, and denied LGBTQ. The percentage of LGBTQ due process, and are consequently over- youth who were hospitalized for emotional represented in the juvenile justice system, reasons (13.5 percent) was nearly triple accounting for 13 to 15 percent of youth the percentage of similar hospitalizations who come in contact with the system. Poli- for non-LGBTQ youth (4.2 percent).138 cies that detain or remove LGBT youth 24 TFAH • HealthyAmericans.org SUPPORTING MSM YOUTH OUTSIDE OF SCHOOLS l O RGANIZED ACTIVITIES. Among all Health Center operates a GED program sions of sexual orientation. Sensitivity youth, idleness provides an environ- at their Broadway Youth Center. training for law enforcement personnel ment that facilitates risky behaviors. who encounter homeless or truant LGBT l S EX WORKERS. MSM sex workers MSM youth, who are often excluded youth should be widely available and may be at significant risk for HIV, STDs, from extracurricular activities, may implemented. For example, the Office physical abuse or violence. Moreover, face additional risks. It is essential of Juvenile Justice and Delinquency males are often not well served at that LGBT youth have access to after- Prevention offers an online training, “Un- programs targeting commercial sex school activities that provide a safe derstanding and Overcoming the Chal- workers, though significant numbers of and welcoming environment. lenges Faced by Lesbian, Gay, Bisexual, young MSM, particularly those who are Transgender, Questioning and Intersex l OUTH CENTERS. While some youth Y homeless, may rely on survival sex. Youth in Schools and Communities,” may feel comfortable at or prefer l C ROSS-GENERATIONAL PARTNER- designed to instill in practitioners the im- LGBT-specific venues, for others it is ING. Young MSM may be more likely portance of becoming an ally to sexual important to have access to non-LGBT- than their heterosexual counterparts to minority youth, of teaching children to be identified venues that are welcoming. have older sexual partners, and young tolerant and accepting, and changing the In particular, homeless MSM youth may Black MSM are more likely to partner culture of schools and communities to be reluctant to attend LGBT-identified with older men that their White coun- be safer for sexual minority youth. services, but need drop-in sites where terparts. Outreach programs should they can receive services and referrals. l F OSTER CARE. Though the Adminis- instill in older men the importance of tration on Children, Youth and Families l G ED PROGRAMS. Completing second- HIV prevention for younger men, while issued guidance to child welfare agen- ary education is a powerful determi- teaching young MSM how to negotiate cies on the support of LGBT youth in nant of health consequences later in safer sex and condom use, even in the their care, additional training is sorely life, and helping young MSM to finish face of differential power dynamics as- needed for practitioners and foster par- high school, particularly those who may sociated with differences in age. ents alike. Exclusions against foster have interrupted their education after l L AW ENFORCEMENT PRACTICES. parents based on sexual orientation having been rejected by their families, Federal guidance to law enforcement, ju- should be prohibited as a condition of may yield substantial benefits. Co- venile justice and child welfare agencies federal support, and anti-discrimination locating GED programs within programs should encourage policies that protect and confidentiality provisions should providing other services to LGBT youth LGBT youth, and discourage forced gen- be implemented to protect foster care may enhance their accessibility — for der conformity or punishment for expres- facilities and placements. example, Chicago’s Howard Brown TFAH • HealthyAmericans.org 25 Young MSM and their families. Positive social support and validation Particularly for LGBT youth, who must of relationships is clearly important. confront a corrosive, stigmatizing Earlier convenience samples have environment just as they become aware suggested the protective mental and of their sexual orientation, individual physical health benefits from family and community initiatives that facilitate support for relationships140 and social sexual minority youth’s self-acceptance networks.141 In a community sample of their sexual orientation and among LGBT youth, those whose integration of their sexual identity into families were more accepting and a self-concept (i.e. coming out) without supportive had significantly lower rates fear of victimization or marginalization of depression, substance abuse, suicidal are central to promoting health.139 ideation and attempts.142 SUPPORT FOR FAMILIES OF MSM YOUTH Federal programs that address family schools, healthcare and justice needs should promote acceptance of systems. For example, SAMSHA LGBT children by their families, and recently published best practices for provide support to families with LGBT mental health and substance abuse children. For example: practitioners on how to support parents with LGBT children.143 l P ARENTING SKILLS-BUILDING — All parents should foster a safe envi- l I n programs that provide support ronment for their children and be for families, consider employing a prepared to offer support and guid- BROADER DEFINITION OF POSITIVE ance as their children develop sexual ROLE MODELS for LGBT youth. In identities. While many parents may particular, youth whose parents do not anticipate raising LGBT children, it not accept their sexuality may turn is important that those adults serving to other relatives or trusted acquain- as role models for youth (including but tances for familial support. not limited to parents) are aware of l E mploy social marketing to the possibility and prepared to be sup- PROMOTE POSITIVE ROLE MODELS portive. Parents of LGBT youth may of successful or prominent parents have particular needs for resources, of LGBT children; consider recruiting tools, support and skills-building in celebrities such as Magic Johnson, order to best support their children. Cher and others. l I n crisis situations, consider LGBT- l ork with FAITH COMMUNITIES to W friendly CASE MANAGEMENT support families with gay children, par- SERVICES designed to meet the ticularly among communities of color. needs of families with gay children. For example, the Human Rights Cam- l D evelop and promulgate paign’s Faith and Religion initiative’s A PROFESSIONAL BEST PRACTICES La Familia project provides trainings to for professionals to support parents promote the inclusion of LGBT people of gay or gender non-conforming within Latino congregations. children in a variety of contexts: 26 TFAH • HealthyAmericans.org Young Adult MSM. in an environment that stigmatizes substance abuse, depression and violence. While physical and sexual child abuse is homosexuality may have difficulty Among young MSM who are susceptible more prevalent among MSM than their forming relationships, may devalue to health problems, such challenges can heterosexual counterparts, many men do gay men or experience internalized snowball, producing syndemic conditions not confront memories of early traumas homophobia, all of which may predispose that may overwhelm whatever resilience until their twenties. Moreover, many them for relationship difficulties, and social capital they otherwise possess.144 of the health inequities experienced depression, or physical or sexual violence. LGBT-specialized agencies such as the by young or adolescent MSM, such as While initiation within gay culture may Howard Brown Health Center report depression, substance abuse and HIV, provide their first experience of social seeing high numbers of MSM ages 14 to may persist or even worsen during early acceptance of their sexual orientation, it 25 with severe needs. Ironically, young adulthood, particularly among MSM may also present challenges in forming and adolescent MSM may have more who migrate to urban “gay ghettos.” relationships in the context of high services available to them than do MSM in Young MSM who have been raised background prevalence rates of HIV, STD, their early- to mid-20’s. SUPPORTING YOUNG ADULT MSM l R ELATIONSHIP SKILLS. Young adult and establishing an identity for the l E CONOMIC, HOUSING SUPPORT. Partic- MSM may experience substantial dif- first time within an openly gay culture. ularly in settings with high unemployment, ficulties in finding romantic partners and For many MSM, the decade between young adults are at particular risks from establishing relationships, particularly at ages 25 and 35 represents one of the effects of economic disadvantage, an age where only a minority of men may substantial experimentation with and which for MSM correlates with elevated be open about their sexual orientation, uptake of drugs and alcohol use. As risks for HIV infection. To the extent that and encounters via commercial venues such, and particularly in light of el- many gay-identified communities in the (bars, clubs and bookstores) or the In- evated background prevalence rates of United States have witnessed unprec- ternet may pose health and safety risks. alcohol and substance abuse among edented gentrification over the past two Young adult MSM would benefit from MSM in general, direct and truthful in- decades, lower socio-economic MSM community settings that provide a safe formation concerning alcohol and drug may be at particular risk. Socio-economic means to meet, socialize and form devel- use is essential. To avoid excessive challenges may also exacerbate other opmentally appropriate relationships.145 risks, young adult MSM need plain, stressors, and LGBT-competent job train- non-judgmental information concerning ing, skills building and housing support l OSITIVE ROLE MODELS. While the P drug dosing, effects and interactions. may help reduce overall health inequities mental and physical health benefits of among MSM, including HIV. heterosexual marriage are well estab- l S PIRITUAL SUPPORT. For many young lished, for young adult MSM, the evolv- adult men, their twenties represent a l T RAUMA-INFORMED APPROACH. As ing landscape of same-sex marriage time where they are struggling to find previously discussed, many MSM ex- instills a degree of uncertainly related meaning in their lives and seeking perience trauma early in life related to to societal acceptance of their relation- spiritual support. Insofar as attitudes violence, abuse, neglect or other emo- ships. While the eventual uniform legal- toward homosexuality largely align with tionally harmful experiences, which, if un- ity of same-sex marriage in every state degree and type of religious affiliation, addressed, can lead to health disparities. will go far to change community norms, many young adult MSM may become In particular, MSM may be re-traumatized increased visibility of same-sex relation- disconnected with the institutional in public institutions and systems (such ships and marriages — in families, religion in which they were raised. as healthcare, foster care, juvenile communities and the media — help Strengthening the viability of gay- justice, the behavioral health system youths to identify positive role models. positive faith-based organizations might and others) that are intended to provide be especially beneficial, particularly for services and support. It is important l A LCOHOL AND SUBSTANCE ABUSE, young adult MSM, including those from that such systems incorporate a trauma- HARM REDUCTION. Young adult- Black, Latino and fundamentalist com- informed approach that is designed to hood is a time that for many MSM is munities, whose histories may have ease an individual’s capacity to cope with characterized by exploration, partying been profoundly shaped by religion.146 traumatic experiences.147 TFAH • HealthyAmericans.org 27 Older adult MSM. experiencing dual stigmatization — interventions.149 In a population study, Older MSM experienced a very different as a result of rejection among the LGB older adults were at greater risk for developmental trajectory than younger heterosexual world for being gay, and disability, poor mental health, smoking MSM. Many came of age, and some among the gay world for being old. and excessive drinking, while gay and spent a significant part of their adult The experience of growing older as a bisexual men had a higher risk of poor lives during a period when stigmatization minority or lower-socioeconomic status physical health and were more likely of homosexuality was more pronounced gay man may be less well understood to live alone than heterosexuals.150 than today, and when the majority of — even more so than among young Lifetime victimization, financial gay men hid their sexual orientation. populations, research on older MSM hardship, obesity and a sedentary Moreover, older MSM lived through the tends to skew towards White, well- lifestyle are significant predictors of poor beginning years of the AIDS epidemic, educated and middle- to higher- health outcomes, while internalized losing large numbers of friends and socioeconomic class populations.148 homophobia predicts depression and colleagues to an unknown disease that disability.151 In 2020, it is estimated Among older MSM, depression and emerged from nowhere, and for which that 50 percent of people living with suicidality are elevated, compared to at least initially, causality was unknown HIV will be 50+ years of age or older. their heterosexual counterparts, while and there were no effective treatments. The support of friends and community LGBT elders may be less likely to seek LGBT elders report discrimination, may be even more important for older health services, in some instances stigma and victimization throughout LGBT adults, who are more likely to be because of fear of discrimination. HIV their lives, though many report less disengaged from their biological family remains a significant concern among during their youth than current young and to rely on families of choice for older MSM, though it receives far less people do. Many older MSM report support in times of crisis. attention and there are fewer targeted SUPPORTING OLDER ADULT MSM l F ELLOWSHIP. Many older MSM are l M ENTORSHIP AND PARENTING. Partic- l H OUSING: As older MSM retire, interested in contributing to their com- ularly in light of the isolation experienced they may find challenges in finding munity, either as a means of finding by older and younger MSM alike, there a welcoming retirement community, fellowship or leaving a legacy. Organi- may be significant opportunities for older as housing discrimination against zations such as Gay For Good, which MSM to mentor or even care for younger LGBT people persists. (A recent has affiliates in many cities, San MSM. As previously discussed, dis- HUD study found that heterosexual Francisco’s Bridgemen, or Washington proportionate numbers of young MSM couples who inquired about D.C.’s Burgundy Crescent, provide are rejected by their families and risk advertised housing were favored by volunteer opportunities for social wel- becoming “throwaway” kids — it would 16 percent over LGB couples, with fare, environmental service, and other be tragic not to take advantage of older, all other factors being equal.152) community development projects. Or- more experienced MSM who might not In some parts of the country, ganizations like Let’s Kick Ass (AIDS only provide a loving home, but be better developers have constructed LGBT- Survivor Syndrome) seek to honor positioned than many heterosexual par- welcoming (but still inclusive) and contextualize the experience of ents to support young MSM in confront- senior housing, such as the those who survived — HIV positive ing the developmental issues they may John C. Anderson apartments in and negative — the worst days of the face. Adoption and foster care rules Philadelphia. Particularly for men AIDS epidemic. should encourage, rather than discour- who may have spent much of their age such arrangements. life in the closet. 28 TFAH • HealthyAmericans.org Insofar as MSM health inequities are the product of a hostile BUILDING A STRONG environment, creating a safe and supportive cultural context AND SUPPORTIVE may offset the impact of marginalization and promote COMMUNITY resilience among young, middle-aged and older MSM alike. Positive cultural messages may instill It is important to anticipate that for some individual or community pride, which MSM, paradoxically, integration into in turn may serve as a protective factor, the larger gay community may increase counteracting internalized homophobia their risks, at least initially. For men and promoting resilience. For sexual who have been systematically harassed minority youth, coming out may also for their entire lives, the discovery of an provide access to a shared history and environment with less approbation may subculture, instilling pride, which may be an incentive to increase the frequency constitute a protective factor.153 Strong of sexual contacts. The relatively higher communities may facilitate links with background HIV and STD prevalence individuals who can serve as mentors, rates, as well as higher rates of substance establish and model healthy behavioral abuse, smoking and sexual risk taking norms, provide emotional support, among MSM communities further and safe spaces to congregate, meet increases their risks. While in the long people and establish relationships. term, for individuals to escape the For example, in some urban centers, constant victimization of a stigmatizing young, Black MSM, some homeless, environment will benefit their health, have formed “ball communities” some men may need support to manage (underground LGBT subcultures the initial transition to a very different focused on competitions among environment. “houses” or “families,” most of which For MSM who are living with HIV, are led by a “house mother” or “house stigmatization is a problem within the father”) that provide them with familial gay community, as well. On gay social support, addressing their physical networking sites, which among many and emotional needs.154 Stronger MSM have become a common means community structures may provide of meeting partners, men routinely post individuals with greater social capital profiles with designations proclaiming — connections among social networks “disease free,” and some HIV-positive men that establish and reinforce norms of report a community climate so hostile trustworthiness and reciprocity, and that they characterize their experience of establish standards of behavior — it as “HIV apartheid.” As a consequence, which may in turn increase individual many HIV-positive men may be reluctant resiliency.155 Such standards have the to disclose their status, increasing the potential to reduce alcohol or substance possibility of unsafe encounters. abuse and sexually risky behaviors. TFAH • HealthyAmericans.org 29 SUPPORTING A STRONG COMMUNITY l C OMMUNITY SUPPORT. Particularly important factor in overcoming the for MSM who have migrated to an adversity posed by social stigma and urban gay ghetto from a smaller discrimination. Among marginalized community, support for healthy communities, group identity — i.e., social interactions that could affiliation with an oppressed group help establish support networks and its collective struggle — may could help forestall syndemic enhance individual resiliency.156 production, even among those l S UPPORT FOR HIV DISCLOSURE. For otherwise predisposed. Community MSM who are living with HIV, being organizations that encourage the able to disclose their serostatus development of friendships — such requires sufficient confidence that as sports teams, social groups, colleagues, family and community will faith-based groups, neighborhood be supportive and non-judgmental. coalitions and others — may help Programs that encourage acceptance vulnerable MSM cope with health of HIV-positive individuals may help related stressors. educate people and facilitate greater l H EALTH EQUITY. Among the LGBT acceptance. In 2012, the President’s community, there is less broad Advisory Council on HIV/AIDS and the awareness of health equity issues, CDC/Health Resources and Services compared to other equality concerns, Administration (HRSA) Advisory such as marriage. Promoting the Committee on HIV, Viral Hepatitis concept of health equity may serve and STD Prevention and Treatment to enhance community cohesion. (CHAC) jointly convened a Disclosure Some suggest that the decision to Workgroup, which developed policy “live healthy” may itself constitute a recommendations and principles to political action — i.e., the pursuit of address structural barriers to safe individual and community health as and voluntary HIV disclosure.157 an agent of change. CDC’s new “Start Talking — Stop HIV” campaign encourages open l P OLITICAL, COMMUNITY discussion about a range of HIV MOBILIZATION. Having access prevention strategies and related to LGBT social and political sexual health issues. organizations may also be an 30 TFAH • HealthyAmericans.org Though the extent to which access to quality healthcare is associated HEALTHCARE ACCESS with health inequities in MSM is not well understood, barriers to AND QUALITY quality care clearly correlate with poorer health outcomes in the general population. Moreover, MSM have unique healthcare needs as a result of increased susceptibility to adverse outcomes associated with stigma and discrimination, as discussed previously. MSM are more likely to contract HIV or workplace benefits. LGBT individuals or STDs, both because of the relatively with insurance are less likely to be covered Likelihood of Having Health higher prevalence in the communities by their employer and more likely to be Insurance – 2008 in which they live, but also related enrolled in Medicaid. For example, in the to increased risk associated with 2008 California Health Interview Study, common sexual practices, particularly LGB adults were less likely to have health 77% 82% receptive anal intercourse.158 If insurance than heterosexuals (77 percent MSM are reluctant to disclose their v. 82 percent).160 same-sex attraction to their provider Though many public health prevention LGB Adults Heterosexual Adults due to perceived stigma, they may interventions are designed to address a be less likely to receive appropriate range of interpersonal and community care, including screening for HIV or dynamics (e.g. triggers, social supports STDs.159 They may also be less likely and others), few substance abuse to report substance abuse, particularly treatment providers, tobacco cessation related to drugs commonly associated programs, or the like have programs with MSM, such as methamphetamine tailored to meet the specific needs of or anabolic steroids. MSM. The association of substance abuse MSM sometimes face a variety of structural with other health problems (e.g. HIV and barriers to care, as well, including depression) among MSM suggests that inequalities in access to health insurance integrated services could be of benefit. TFAH • HealthyAmericans.org 31 IMPROVING ACCESS TO QUALITY HEALTHCARE AMONG MSM. The federal government plays an important role in the delivery and regulation of healthcare. As such, it is essential that federal poli- cies support and encourage wider access to culturally competent services for MSM. Recently, there have been substantial improve- ments in federal policies. For example, in 2013, the HHS Office of Minority Health published LGBT-inclusive National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (National CLAS Standards) that provide a more inclusive definition of culture that includes sexual orientation and gender identity.161 While other government and non-government organiza- tions also have efforts underway, significant progress is still needed. For example: l B EST PRACTICES IN MSM CLINICAL ment meetings. Leadership programs in l M SM-SPECIFIC CASE MANAGEMENT. CARE. It is important to document best MSM healthcare may further incentivize Case management services have proven HIV clinical care practices in general professional development. In addition to effective in the management of HIV and and specifically among MSM popula- training materials promulgated by a range other patients with complex needs. It tions. For example, while significant ra- of Community-based organizations, may be that such practices can be ad- cial disparities in HIV diagnosis, linkage SAMHSA and HRSA have developed a opted to meet the spectrum of needs to care, treatment and adherence to list of LGBT curricula that train behavioral presented by social determinants of medications have been documented in health and primary care practitioners, for MSM health inequities. a variety of settings, some clinics have which continuing medical education and l I NSURANCE ENROLLMENT. Particularly developed practices where such dispari- continuing education unit credits are avail- with the rollout of the Affordable Care ties virtually disappear — such as the able.162 Through a cooperative agreement Act, there are increased needs for LGBT- Moore Clinic for HIV Care, an outpatient with Fenway Health, HRSA supports the specific outreach to facilitate insurance en- unit supervised by the Johns Hopkins National LGBT Health Education Center, rollment, particularly among younger MSM University AIDS Service. designed to help community health cen- ages 20 to 35, who are less likely to have ters improve the health of LGBT popula- l P ROVIDER INCENTIVES. Billing, employment-based insurance. For ex- tions. Following the overturn of DOMA, reimbursement and professional ac- ample, Trust for America’s Health recently HHS Divisions revised federal regulations creditation protocols should incentivize published an Action Plan designed to ex- and policies across its programs to recog- practices that are likely to improve MSM plain to providers and the young MSM they nize same-sex spousal relationships. health or reduce health inequities. For serve the importance of health coverage, example, sexual health screenings are l D ISCRIMINATION PROTECTION. In facilitate enrollment in coverage, address too often overlooked and could be of 2012, HHS developed a sexual ori- structural barriers to care, and support the significant benefit among this population. entation and gender identity-inclusive engagement of young MSM with the health With respect to HIV care, appropriate in- non-discrimination policy applicable to system once they obtain coverage.164 centives might serve to enhance patient all HHS-funded programs. Culturally Managed care organizations for which new retention in care. competent care can be delivered by any patients are auto-enrolled should be re- provider, and it is important that MSM quired to conduct specific outreach among l ROFESSIONAL TRAINING, CULTURAL P receive appropriate care in any setting, MSM and other patients — potentially via COMPETENCE. Providers who are able to rather than segregating specialty service subcontract with Congressional Budget establish trusting relationships with MSM providers. In fact, in a small cross-sec- Office (CBO) providers, who may be better patients are better equipped to promote tional survey among LGBT youth, provider equipped to reach target populations. healthy behaviors. Providers must be qualities and interpersonal skills were as sensitive to MSM-specific health needs, l E LECTRONIC HEALTH RECORDS. In- important as knowledge and experience as well as alternate expressions of creasingly, the use of electronic health and more important than gender and sexuality and family structures. Medical records comprises an important strategy to sexual orientation.163 Nonetheless, vis- training should incorporate LGBT health- improve healthcare safety and quality. Too ible positive role models among author- specific modules, while continuing medi- often, however, the standardization of elec- ity figures are important and hiring and cal education programs should reinforce tronic records is based on a “heterosexual promotion procedures at healthcare facili- skills. Medical practices should solicit assumption” that assumes that patients ties should protect LGBT personnel from participation from LGBT community repre- fall within a normative (i.e. heterosexual) discrimination. sentatives in planning and quality-improve- profile and fail to capture the lived experi- 32 TFAH • HealthyAmericans.org ence of sexual minorities. Without sexual flects the stages of patient activation l P OSITIVE HEALTHCARE NORMS. As orientation data, clinicians may fail to offer — to assess patient readiness for ART, a result of longstanding health inequi- appropriate screening or care to LGBT pa- and to tailor care and support accord- ties, many communities may have tients, while analyses of aggregated data ingly. Such measures could be further come to rely on sporadic, emergency- may fail to recognize disparities or unique adapted for MSM-specific care. driven healthcare. For young MSM in needs of LGBT populations. As the Office particular, it is important to normalize l C ONSUMER EDUCATION. Particularly in of the National Coordinator for Health IT routine preventive care, and to encour- light of changes to the healthcare system, (ONC) implements EHR meaningful use age healthy living. Venues where young it is increasingly important for MSM (par- standards, which govern the type and na- people socialize may provide one oppor- ticularly young men) to understand and ture of data collected, it is important that tunity — for example, Boys/Girls Clubs advocate for quality healthcare services. data fields capture information relevant or YMCAs could be supported to conduct Those who have not previously had insur- to sexual minorities, including preferred outreach and health education among ance, for example, may require assistance name, sexual orientation and gender iden- MSM. Another idea would be to support in understanding how to obtain coverage tity. ONC should collaborate with industry healthcare professionals, such as physi- and how health insurance can be used to to ensure the inclusion of sexual orienta- cians or nurses, to visit schools, similar support healthy living. Provider and non- tion and gender identity data, but also to to how law enforcement officers visit government organization outreach to the implement sufficient privacy protections to schools in an effort to establish posi- LGBT community may help consumers lo- guarantee that such data are protected. tive relationships with young people and cate LGBT-competent providers or medical discourage drug abuse. The LGBT com- l C ONFIDENTIALITY. Particularly among facilities. Systems that allow consumers munity itself must play a greater role in young MSM, the provision of confidential to rate providers based on cultural compe- normalizing risk-reduction and health pro- health services is essential. For exam- tency may be a useful strategy. motion — importantly, this must include ple, young MSM need access to HIV and l F EDERALLY QUALIFIED HEALTH CEN- a nuanced discussion that considers STD prevention and screening without TERS. Community-based and patient- the relative risk of various sexual and such services appearing on their parents’ directed Federally Qualified Health Centers drug behaviors in a non-judgmental way, explanation of insurance benefits. (FQHC) serve populations with limited rather than a one-size-fits-all approach. l M EDICAID EXPANSION ADVOCACY. access to healthcare and provide com- l H EALTH DEPARTMENT OUTREACH. While implementation of the Affordable prehensive primary and preventative care, For some MSM with HIV, retaining con- Care Act promises to increase access including oral health and mental sistent care and remaining adherent to to healthcare for many disadvantaged health/substance abuse services to ARTs pose significant challenges. In populations, realizing the Act’s potential persons regardless of their ability to pay the two-thirds of states that collect viral is dependent on the expansion of the or health insurance status.  Of the more load data, it may be possible to identify Medicaid program, which a number of than 1,000 FQHCs, however, only about individuals who are failing on ART therapy states, disproportionately in the South, a dozen LGBT clinics have been desig- and follow up with community health have declined to endorse. MSM who live nated. While these clinics provide cultur- workers, who could proactively attempt to in states that do not expand Medicaid will ally appropriate and targeted services to dismantle barriers and facilitate health- have fewer options for health coverage, thousands of LGBT patients, their relative care. Such an approach would require and, in some instances, higher income scarcity means that many patients do not significant consent and confidentiality thresholds for subsidized coverage. Sus- have easy access. Moreover, other “main- protections, but similar models exist — tained advocacy efforts will be needed to stream” FQHCs may simply refer sexual for example, the San Francisco Homeless ensure that, ultimately, all states choose minority patients to other providers rather Outreach Team (SF HOT) consists of 20 to expand their Medicaid program. than develop competent services. As a experienced outreach professionals who primary healthcare provider for disadvan- l P ATIENT ACTIVATION MEASURE. The engage chronically homeless “super-uti- taged communities, it is important that Howard Brown Health Center in Chicago lizers” in services that would get them off FQHCs develop competence to meet the has employed the Patient Activation the streets and into stabilized situations. needs of all their patients, including MSM. Measure — a validated scale that re- TFAH • HealthyAmericans.org 33 BIOMEDICAL Treatment as Prevention. overall, addressing disparities in health The potential of “treatment as outcomes among MSM along the INTERVENTIONS prevention” has gained significant treatment cascade will require mitigating attention recently. Studies conducted the adverse effects of social determinants among sero-discordant heterosexual of MSM health — particularly couples demonstrate that the early among MSM who face intersecting initiation of ART reduces the risk of determinants, including socio-economic HIV transmission to the uninfected status and race/ethnicity. partner by 96 percent.165 Theoretically, were such early use of ART to be Pre-Exposure Prophylaxis (PrEP). widespread among HIV-infected The CDC recently recommended PrEP individuals, community viral load would — i.e. the use of anti-HIV medications decrease. In San Francisco, overall among uninfected individuals to reductions in community viral load were prevent infection — for those who are associated with fewer HIV infections.166 HIV-negative and at substantial risk for Mathematical models have suggested HIV infection.169 In the iPrEx study the possibility that widely deployed among MSM and transgender persons, early detection and treatment to lower a once-daily dose of tenofovir/FTC community viral load could substantially (Truvada®) delivered in the context eliminate new HIV transmissions.167 of comprehensive HIV prevention services was associated with a 44 percent Notwithstanding, as has been amply overall reduction in HIV incidence. demonstrated in the treatment cascade Adherence varied substantially among model, successful HIV treatment participants, however. Among those requires a continuous sequence of self-reporting more than 90 percent events, from diagnosis to adherence, adherence, risk was reduced by 73 and the interruption of any step may percent; among those for whom preclude viral suppression. As such, blood drug levels were confirmed by “treatment-as-prevention” strategies assay, the reduction was 92 percent. are susceptible to a range of behavioral Participants in both treatment and and structural factors that pose similar placebo arms reported significantly uptake challenges. In fact, in one lower risk behaviors during the course mathematical model, an improvement of the trial.170 As with treatment as in any single component of the cascade prevention strategies, the successful (diagnosis, linkage, retention, treatment, implementation of PrEP will also persistence or adherence) would yield depend on mitigating a range of adverse only a marginal decline in community effects of social determinants of health. viral load. 168 Similar to health inequities 34 TFAH • HealthyAmericans.org THE WIDESPREAD USE OF PrEP AS A PREVENTION INTERVENTION POSES SUBSTANTIAL CHALLENGES. l rEP GUIDANCE. There are substan- P to insurance coverage, provider knowl- tial knowledge gaps among both pro- edge, patient knowledge and motiva- viders and patients related to the use tion, community standards, and other and efficacy of PrEP, and broad-based factors. And, without paying careful outreach efforts will be needed to attention to communities with less ensure appropriate implementation. A healthcare access, implementation of number of community-based resources PrEP could exacerbate health inequi- have been developed by the San Fran- ties. While Medicaid covers PrEP in cisco AIDS Foundation (www.prepfacts. some states (e.g. New York and Flor- org), the AIDS Vaccine Advocacy Coali- ida), coverage policies are set at the tion (www.prepwatch.org), and others. state level, and sustained advocacy While the CDC has issued guidelines will be necessary to ensure uniform for the use of PrEP among individuals coverage. Even with coverage, some at risk for HIV, it will be important to re- providers remain unsure how such fine and expand official guidelines and services should be billed. The possi- to promote community norms to ad- bility that the ADAP could be expanded dress how at-risk populations should to subsidize the cost of PrEP has been incorporate biomedical with other pre- raised, but this would require a statu- vention interventions (i.e. condoms) in tory change as ADAP can now serve a more nuanced way. only those already infected with HIV. Out-of-pocket costs for PrEP can be as l U NDERSTANDING THE IMPACT OF high as $13,000 per year. PrEP ON SEXUAL NORMS. Anecdotal reports suggest that the use of PrEP l N ON-OCCUPATIONAL POST-EXPO- may be changing sexual behavior SURE PROPHYLAXIS (NPEP). CDC norms in ways that are not well under- issued guidelines some time ago for stood — for example, there is some non-occupational post-exposure HIV evidence of non-prescription PrEP use prophylaxis — the temporary provi- (i.e. with drugs obtained from friends sion of antiretroviral drugs following or acquaintances), and, among social an unexpected sexual, injection-drug networks that facilitate sexual partner- or other nonoccupational exposure ing, HIV positive and negative MSM to HIV.171 Anecdotal experience are advertising their use of PrEP, sug- suggests that the availability and gesting a misunderstanding between provision of NPEP in hospital and HIV prophylaxis and treatment. As emergency room settings is incon- the use of PrEP becomes more com- sistent, however. LGBT clinics who mon, it is essential to study how its offer NPEP report that its provision is uptake may affect the epidemiology of complex (as NPEP patients typically HIV transmission. present as an emergency), expensive and disruptive. In addition to greater l A CCESS DISPARITIES. While it is too provider and community education, early to know how PrEP is or will be over-the-counter availability of NPEP prescribed, early experience with ART regimens should be considered. suggests that access will be related TFAH • HealthyAmericans.org 35 S EC T I ON 6 : Addressing SECTION 6: CONCLUSION Conclusion Health Though stigma and discrimination against LGBT people are Inequities: diminishing at an unprecedented pace, the effects of historical and continuing marginalization persist. MSM continue to suffer Gay Men & health inequities, not the least of which are dramatic disparities MSM in the U.S. in HIV rates, many related to social determinants that include pervasive stigma and discrimination. As a result, a minority of conclusion MSM experience a syndemic of overlapping adverse health outcomes including depression, substance abuse, STDs, violence and HIV. Ultimately, addressing the social determinants of MSM health inequities will require a greater emphasis on community- level and structural interventions to improve the environment in which sexual minorities, including MSM, live. In the near term, helping MSM to avoid or overcome immediate challenges will require focused interventions to mitigate adverse determinants and increase resiliency. An approach that fosters MSM health and well-being — and which includes HIV interventions — is essential. But, while increasing individual resiliency among MSM will undoubtedly be important, as one researcher noted: “resilience in the face of adversity is not the same as health equality.”172 In the long term, reducing societal oppression and marginalization of LGBT people will reduce the need for individual and community-level interventions. DECEMBER 2014 Endnotes * ederal officials were invited to participate F Washington, D.C.: The National Academy of Veterans Affairs; Department of Hous- in the meeting as a resource and not in Press, 2011), not the least of which is that ing and Urban Development; Office of their official capacities. for research purposes, these four popula- Management and Budget; Department of tions are imperfectly and variously defined, the Interior; General Services Administra- † n this paper, the term “MSM” is used to I separately and collectively, by attraction, tion; Office of Personnel Management. designate gay men and other men who behavior, and identity, designations that have sex with men, a group that includes 1 DC. Estimated HIV incidence in the C themselves sometimes overlap and in many both men who do and those who do not United States, 2007–2010. HIV Surveillance cases cannot be considered fixed. For self-identify as gay, and which includes men Supplemental Report, 2012;17(No. 4). example, due to challenges in obtaining who also have sex with women. For pur- http://www.cdc.gov/hiv/topics/surveil- sufficient statistical power, research designs poses of the paper, this group does not in- lance/resources/reports/#supplemental sometimes treat the four populations as a clude transgender men or women, who may (accessed May 26, 2014). single “LGBT” group, though in studies be heterosexual, homosexual or bisexual that are able to distinguish among them, 2 DC. HIV Surveillance Report, 2011;23. C in their orientation. Though data pertain- significant differences in health outcomes http://www.cdc.gov/hiv/topics/surveil- ing to transgender health are extremely have sometimes been shown among these lance/resources/reports/ (accessed May limited, studies show that transgender populations. Given these limitations, 26, 2014). people experience significant health ineq- whenever possible, this paper references re- uities, and there are differences in health 3 bid. CDC. HIV Surveillance Report, I search conducted specifically among MSM. outcomes between transgender men and 2011;23. http://www.cdc.gov/hiv/topics/ Research that examines the LGB or LGBT women, who are at far greater risk for HIV surveillance/resources/reports/ (accessed populations as a whole is also cited here to (a meta-analysis of 29 studies found an esti- May 26, 2014). the extent that it refers to MSM specifically mated HIV prevalence rate of 27.7 percent or draws conclusions that can be under- 4 uadamuz TE, Friedman MS, Marshal G among transgender women — see Herbst stood to apply to MSM — these references MP, Herrick AL, Lim SH, Wei C, Stall JH, Jacobs ED, Finlayson TJ et al. Estimat- should not be interpreted to imply that the R. Health, sexual health, and syndemics: ing HIV prevalence and risk behaviors of conclusions cited necessarily apply equally, toward a better approach to STI and HIV transgender persons in the United States: a or at all, to lesbian, bisexual (except to the preventive interventions for men who have systematic review. AIDS Behav, 2008;12:1- extent that they fall within the definition of sex with men (MSM) in the United States 7). Additional research to better under- MSM, above) or transgender people. [chapter], in Aral SO, Fenton KA, Lipshutz stand transgender-specific health issues, as JA (eds). The New Public Health and STD well as policy approaches to address trans- § he “treatment cascade” was first extrapo- T Prevention. New York, NY: Springer, 2013. gender health inequities, are warranted in lated to a national level (see: Gardner EM, their own right and are urgently needed. McLees MP, Steiner JF, Del Rio C, Burman 5 ealthy People 2010: Understanding and H WJ. The spectrum of engagement in HIV Improving Health. Washington, DC: U.S. ‡ n this paper, the term LGBT (lesbian, I care and is relevance to test-and-treat strate- Department of Health and Human Ser- gay, bisexual and transgender) is used, as gies for prevention of HIV infection. Clin vices, 2000. it often is both colloquially and in the pub- Infect Dis 2011;52:793-800) based upon a lished literature, to refer to the community 6 nstitute of Medicine. The Health of I framework originally developed to illustrate of people who share the fact that, and who Lesbian, Gay, Bisexual and Transgender treatment uptake in Washington, D.C. (see: are frequently stigmatized because, their People: Building a Foundation for Better Greenberg AE, Hader SL, Masur H, Young sexual orientation is not exclusively het- Understanding. Washington, DC: The Na- AT, Skillicorn J, Dieffenbach CW. Fighting erosexual — but who are otherwise diverse tional Academy Press, 2011. HIV/AIDS in Washington, D.C. Health Af- in terms of gender, race, socioeconomic fairs (Millwood) 2009;28:1677-87). 7 .S. Department of Health and Human U status, age, and other characteristics. LGBT Services. National Healthcare Dispar- health research is in a formative phase and ** epartment of Health and Human D ties Report 2013. http://www.ahrq. has been limited by a lack of systematic Services; Department of Agriculture; gov/research/findings/nhqrdr/ population data collection, as questions per- Department of Education; Federal Trade nhdr13/2013nhdr.pdf (accessed June 4, taining to sexual orientation have appeared Commission; Department of Transporta- 2014). only recently in most national surveys. tion; Department of Labor; Department of LGBT health research also poses numerous Homeland Security; Environmental Pro- 8 ochran SD, Mays VM, Sullivan JC. 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