Building Better Health for Gay Men: Challenges and Opportunities in British Columbia
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The document summarizes a presentation about building better health for gay men in British Columbia. It discusses the current health status of gay men, including issues like HIV, STIs, mental health challenges, and chronic diseases. It also examines social factors that influence gay men's health, such as stigma, shifts in community and connectivity, and political environments. Finally, it considers where gay men's health needs to go and opportunities to improve health, such as expanding prevention efforts and treatment, addressing mental health and substance use, and forming partnerships between public health and community groups.
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Building Better Health for Gay Men: Challenges and Opportunities in British Columbia
- 1. Building Better Health for Gay Men: Challenges and Opportunities in British Columbia Presentation to the Gay Men’s Health Summit October 31, 2008 Dr. Perry Kendall Provincial Health Officer
- 2. Part 1 – The Current Health Status of Gay Men Part 2 – Social Factors that Influence the Health of Gay Men Part 3 – Where does Gay Men’s Health need to go? Part 4 – Opportunities to Consider
- 5. STI/HIV Prevention and Control, BCCDC, 2008
- 6. STI/HIV Prevention and Control, BCCDC, 2008
- 7. STI/HIV Prevention and Control, BCCDC, 2008
- 8. Hall et al, JAMA 2008; 300(5):520-529
- 9. STI/HIV Prevention and Control, BCCDC, 2008
- 11. Mental Health & HIV Adapted from: Stall et al, AJPH, 2003; 93(6):939-944.
- 13. Substance Use – Crystal Meth Community Based Research Centre, Sex Now Surveys: 2002-2007 Self-reported Crystal Meth Use – Gay men in BC
- 17. Heterosexism Stigma Homophobia Prejudice events Discrimination Violence Adapted from: Dodds et al. It makes me sick . Sigma Research, 2005.
- 20. Internet Partners Self-reported use of Internet to find partners – Gay men in BC Community Based Research Centre, Sex Now Surveys: 2002-2007
- 21. Internet Partners - Opportunities Victoria Times Colonist, 2008
- 22. Community Attachment Self-reported affiliation with the gay community – Gay men in BC Community Based Research Centre, Sex Now Surveys: 2002-2007
- 23. Unintended Consequences of Greater Visibility
- 24. Gay Male Development and Violence/Victimization Friedman et al. AIDS and Behaviour 2008; 12:891-902. Gay-related development Parental physical abuse (2+ times, < 17 yo) % Harassed for being gay (2+ times, < 17 yo) * % Forced sex (1+ time, < 18 yo) % Early (n=603) 26.2 76.8 21.6 Middle (n=1462) 19.2 67.1 14.4 Late (n=308) 17.6 46.4 14.6
- 25. Developmental Profiles and Health of Gay Men Friedman et al. AIDS and Behaviour 2008; 12:891-902.
- 28. Ryan et al. Valuing gay men’s lives. Gay & Lesbian Health Services Saskatoon, 2001.
- 31. There is no magic bullet
Notas do Editor
- This presentation is divided into four parts: The first part considers the current health status of gay men in BC as defined and/or influenced by a number of indicators that are tied into some of the more prominent diseases or conditions that gay men as a face as a population (i.e. HIV; Syphilis; Substance use). In this context I aim to touch on: the prominent health issues that in large part drive the gay men’s health agenda; the current state of these issues in BC; and, the emerging health issues or challenges to consider. The second section will look at some of the environmental elements or forces that may influence specific vulnerabilities of gay men i.e. stigma, homophobia, patterns of social connections, etc. The third part of the presentation will focus on working towards defining the goals of the gay men’s health movement And the last part of the presentation will examine some of the opportunities that may provide leverage or support for efforts to reach the goals as they may be defined.
- Some people have questioned whether there is any mandate to treat gay men differently from other men As a population, the prevalence of health conditions and risk factors among gay men differ in many ways from heterosexual men, and as a result the gay male population can be considered to have a distinct health status This status allows for an equally distinct assessment based on indicators associated with the specific health conditions and risk factors at play such an assessment can reflect health status of the population at a specific point in time, or can be tracked longitudinally in order to determine trends Some of the health conditions and challenges that contribute to a unique health status for gay men in BC include: Communicable diseases such as HIV, Syphilis and hepatitis C; Issues of mental health and substance use connected to personal experience of violence, prejudice and poor self-esteem; Increased incidence of anal cancer associated with HPV infection; This is by no means intended to be a definitive or exhaustive list
- The 2003 and 2005 Canadian Community Health Surveys conducted by Statistics Canada included a question that asked participants to self-report on sexual orientation, as well as a number of health-related conditions. This allows for analysis that builds an understanding of the differences in health-related issues between the gay, bisexual and heterosexual populations. The results indicate that, for some health-related measures, there are significant differences between these populations. For example in terms of physical health: Although the self-perceived general health of gay men was similar or slightly higher to that of heterosexual men, bisexual men were more likely than heterosexuals to report fair or poor health; Gay men tended to report living with more chronic conditions than did the heterosexual or bisexual respondents; Gay men were also more likely to have had at least one disability/sick day due to physical illness in the previous two weeks. In terms of mental health: Bisexual men were more than twice as likely as heterosexual men to perceive their mental health as fair or poor When respondents were asked if they had been diagnosed with a mood or anxiety disorder, gay and bisexual men reported levels above those for the heterosexual population; The comparatively high prevalence of mood and anxiety disorders among gay and bisexual men was reflected in higher percentages reporting at least one disability/sick day in the previous two weeks for mental or emotional reasons. (Source: 2003 and 2005 Canadian Community Health Survey)
- Let’s look at the specifics of some of the health challenges faced by gay men in BC. Health issue: syphilis The outbreak of syphilis among MSM in BC (and indeed in many other jurisdictions) continues to grow By the end of September this year, the number of syphilis infections identified had already exceeded the total number of cases for all of 2007 Currently, syphilis infections in MSM represent the vast majority of all reported cases in the province (Source: STI/HIV Prevention and Control Division Annual Report 2007 (not yet released))
- Health issue: syphilis and the connection to HIV Here in BC the majority of new infectious syphilis cases in MSM are among HIV+ MSM HIV+ MSM comprise 64% of all MSM cases in 2007 (~ one third of all provincial cases) Information gathered during case and contact follow-up suggests that sero-sorting may be contributing to the observed trends (where men seek out other men of the same HIV status for unprotected sex, in this case HIV+ men seeking out other HIV+ men) Sexual network maps of MSM cases identify a concentration of HIV+ MSM within each of the network branches Other factors which may be contributing to this outbreak include the transmission of syphilis through oral sex The key message for HIV+ MSM is to get tested and treated for syphilis, and to be aware that even if one has been successfully treated for syphilis in the past, re-infections can occur Also important to note, syphilis infection promotes both the acquisition (i.e., due to primary lesion) and the transmission (i.e., due to increased viral loads) of HIV (Source: STI/HIV Prevention and Control, BCCDC)
- Health Issue: HIV Since 2002, the greatest number of new positive HIV tests has been among MSM Overall, the number of MSMs testing newly positive has been largely going up from year-to-year In contrast, trends in new positive HIV tests among other populations (IDU, Heterosexual) have been largely stable or decreasing Note: new positive HIV tests reflect when HIV is diagnosed, and not when HIV infection occurs – some of these newly reported cases may be long-standing as opposed to incident cases (Source: STI/HIV Prevention and Control Division Annual Report 2007 (not yet released))
- Health issue: HIV We do not yet have HIV incidence data for MSM in BC Data from the US (JAMA 2008): The CDC recently released estimates of new HIV infections in the US over the course of the epidemic, based on a combination of back-projection and detuned HIV testing (i.e., testing for recent HIV infections) By these projections, the number of new HIV infections has been increasing among MSM in the past decade, while stable or decreasing in other groups (Source: Hall HI, Song R, Rhodes P, et al. Estimation of HIV incidence in the United States. JAMA. 2008; 300(5):520-529)
- Emerging Health Issue: HCV There are an increasing number of reports from Europe which have identified outbreaks of Hepatitis C through sexual transmission among MSM, primarily HIV+ MSM In BC, we are beginning to look at enhanced surveillance initiatives for HCV in MSM, including analysis of HCV and HIV testing data (for negative and positive test results), and through M-Track (a second-generation HIV surveillance system which combines a fingerstick dried blood spot tested for HIV and HCV, and a behavioural risk questionnaire) M-Track was performed in Victoria in 2007, and is currently underway in Vancouver (known as the ManCount survey) The data we do have is based on linkage of the HIV and HCV surveillance databases to identify individuals co-infected with both HIV and HCV. These results are difficult to interpret as data reflects diagnoses (not incident infections) Data is also highly influenced by testing behaviours (I.e., dependent on testing patterns among MSM for HIV and HCV, most MSM without a history of injection drug use are probably are less likely to be tested for HCV) The overall trend in co-infections is for an increasing number of co-infections identified per year among MSM in BC, particularly MSM not known to have a history of injection drug use (orange bars) which could indicate increasing sexual transmission of HCV (subject to the limitations described above) Note: Classification of MSM as IDU or non-IDU is based on risk information collected at the time of HIV diagnosis (which may be far removed from the time of identification of HCV). (Source: HIV and HCV Co-infection cube (not published), STI/HIV Prevention and Control, BCCDC, 2008)
- Health Issue: Mental Health Vulnerabilities The Urban Men’s Health Study is a population-based sample of MSM – data was collected through telephone interviews based on random-digit dialing. A total of 2,881 MSM in San Francisco, Los Angeles, Chicago and New York City were interviewed between 1996/97 Participants were asked about four mental health related issues: polydrug use, depression, childhood sexual abuse, and partner violence. Results demonstrate high correlation between these four mental health issues in the survey participants, suggesting the idea of “inter-twining epidemics” of mental health issues Interpretation: isolated, disease-specific approaches may be of less use than integrated approaches. Results also suggest that looking for common determinants of these conditions is an appropriate approach to improving the overall health of gay men (Source: Stall et al)
- (Urban Men’s Health Study continued) When survey participants were stratified by number of mental health (psychosocial health) problems reported, you can see a clear gradient between an increasing number of health problems and both self-reported high-risk sex and HIV prevalence This finding supports emphasis on a more holistic approach to HIV prevention among gay men
- Health Issue: Substance Use Much of the discussion related to use of drugs and alcohol among gay men has tended to focus on how it may inform risk behaviours related to diseases like HIV Research conducted by the BC Centre for Excellence in HIV/AIDS (BCCfE) looked at a cohort of gay men in Vancouver from 1997-2002 and observed significant increases in substance use and unprotected anal intercourse (UAI) with casual partners: the latter was a strong risk factor for HIV seroconversion However, although the results demonstrated an association between ‘club’ drug use and unprotected anal intercourse, they concluded that dis-inhibiting effects of drugs alone were unlikely to explain this association, as it depended on partner serostatus, disclosure, or another closely related factor In 2001, the AIDS Committee of Toronto (ACT) conducted a literature review examined drug use among gay men who frequent clubs or parties as part of a larger resource for community-based organizations Themes that emerged from this review suggested: that within the dance party scene, poly-drug use, prominently including party drugs, is normative and expected, but that such drug use is rarely excessive a number of studies have demonstrated a link between sexual risk behaviour and the use of illicit drugs or the heavy use of alcohol, but that it is unclear whether such links are causal or merely co-relational drug use among gay men at clubs or parties is seen as a collective rather than individual practice, and that social networks are the number one source of knowledge about drug use and how to combine and use different substances
- Health Issue: Substance Use In recent years reported increases in the use of crystal meth, in both the gay community as well as the broader community, have generated a great deal of concern It was widely suggested that wide-spread use of crystal meth within the gay community would trigger a significant upswing in high-risk sexual behavior Again, it is unclear whether there is a causal link between crystal meth use and high-risk behavior However, on a positive note, between 2002 and 2007 the Sex Now surveys, conducted by the Community Based Research Centre, have registered a steady decrease in the reported use of crystal meth among respondents (Source: Community Based Research Centre, Sex Now Surveys: 2003-2007)
- Health Issue: Anal Cancer HPV is a sexually transmitted infection (STI) which is known to be a cause of anal carcinoma. Data from American studies indicates that the incidence of anal cancer is low for men overall, but is much higher in gay men and in particular HIV-positive gay men. Currently, equivalent Canadian data is lacking, but screening done as part of Vancouver’s M-Track enhanced HIV surveillance study should give us a sense of what the local incidence of anal cancer among gay men looks like. This type of information will be tremendously useful – informing development of both effective detection programs as well as potential prevention programs involving delivery of a vaccine to prevent HPV infection. (Source: M-Track Survey - HPV Component, Study Protocol, Vancouver Site. 2008)
- Turning from health issues gay men face to what drives these issues it can be helpful to apply a population health lens. Within this construct many of the shared vulnerabilities or health deficits, as well as the resiliencies or health assets are determined by shared social or environmental factors Some of the determinants of health vulnerability among gay men may be seen to include: Stigmatization and marginalization Shifts in how gay men choose to define community and how they connect with each other Some unintended consequences of a broader presence/visibility in mainstream society The influence of political environments
- Social factors: Stigma, marginalization and homophobia Despite some significant advances in recent decades in building broader social acceptance of gay/lesbian/bisexual and transgendered populations, there are still clear and glaring examples of the on-going stigma, discrimination and prejudice that persists today These are examples of recent news stories related to stigma, discrimination and prejudice events in Canada directed towards gay men
- Social factors: Stigma, marginalization and homophobia Gay men live in an environment where many people are heterosexist (assume heterosexuality is normal, natural, right) and most everyone recognizes there is a stigma associated being gay (i.e., that there is a shared knowledge that people in society have negative attitudes towards homosexuality) In some instances, the high-level of heterosexism in individuals can be characterized as homophobia – in essence a fear and dislike of gay people Homophobia can result in negative attitudes based exclusively on sexual orientation, which in turn may lead to demonstration of prejudice, discrimination (e.g., workplace), and in extreme circumstances physical assault (gay-bashing) These factors can impede the development of a healthy and balanced sense of identity as a gay man, which in turn can have a strong influence on overall health of gay men and result in adverse outcomes related to mental health, substance use and sexual risk. (Source: Dodds C, Keogh P, Hickson F. It makes me sick: Heterosexism, homophobia and the health of Gay men and Bisexual men. Sigma research, May 2005)
- Social factors: Stigma, marginalization and homophobia A 2004 study published by the UK gay men’s health network found a significant correlation between the experience of stigma and homophobia among gay men, and: Low-self esteem Eating disorders Problematic alcohol and substance use Depression Heightened levels of anxiety Attempts at suicide and self-harm (Source: Scott SD, Pringle A, Lumsdaine C. Sexual exclusion - homophobia and health inequalities: a review. UK Gay Men's Health Network. 2004)
- Social factors: Stigma, marginalization and homophobia The BC Adolescent Health Survey, targeted youth in grades 7-12 in 1992, 1998, and 2003 The responses received across the three survey years demonstrate some of the characteristics and unique health status of lesbian, gay and bisexual (LGB) youth in BC compared to students identifying as heterosexual Respondents were asked to define their sexual identity based on feelings of attraction to other people best described as: 100% heterosexual (hetero), mostly heterosexual, bisexual (bi), mostly or 100% homosexual (gay/lesbian) In general, Lesbian/Gay/Bisexual youth were more likely to report the risk factors, health conditions and environmental influences that are listed on this slide (with some minor variation according to gender and reported sexual identity), and were less likely to report known resiliency factors (Source: Saewyc E, Poon C, Wang N, Homma Y, Smith A & the McCreary Centre Society. Not yet equal: the health of lesbian, gay, & bisexual youth in BC. Vancouver, BC: McCreary Centre Society. 2007)
- Social Factors: Community and connection Looking now at interaction among gay men, let’s consider relatively recent changes to social environments such as widespread use of the Internet. The way gay men meet each other for sex and relationships is changing and this presents some challenges and opportunities with respect to health status The Sex Now surveys in BC, conducted by the Community Based Research Centre, have reported a significant increase between 2002 and 2007 in the number of men using the Internet to find partners Studies in other jurisdictions have linked increases in use of Internet sites to locate sexual partners with increases in HIV and other sexually transmitted diseases The virtual nature of this form of connection defies some of the more traditional, face-to-face interventions commonly used for prevention purposes in settings such as bathhouses and bars, but it also presents some unique opportunities for health messages and support services (Source: Community Based Research Centre, Sex Now Surveys: 2003-2007)
- Social Factors: Community and connection By way of an example: Launched in San Francisco in 2004, InSPOT is an online STI notification system that allows individuals who receive a diagnosis for an STI to send an electronic greeting card to contacts to inform them that they may have been exposed to an STI and to consider being tested More than 30,000 people have used the service to date and a Canadian extension of the site was recently launched in Toronto and Ottawa This is a novel approach to partner notification efforts that takes advantage of a virtual platform for social interaction and sexual connection
- Social Factors: Community and connection BC’s Community Based Research Centre through Sex Now surveys has also looked at how well gay men feel they are connected with their community The surveys has asked respondents to indicate their level of interest and involvement in gay community social events and activities, as well as their volunteer involvement with community groups and organizations Between 2004 and 2006, such community involvement dropped considerably for survey respondents Lack of community involvement, combined with more frequent use of the Internet to establish social and sexual connections may indicate a growing detachment among gay men from community as it has been traditionally defined This is turn may have implications on a personal level related to identity and self-esteem (Source: Community Based Research Centre, Sex Now Surveys: 2003-2007)
- Social Factors – Unintended consequences As gay men may be experiencing a diminished connection with the gay community as it has been traditionally defined, it is important to note that at the same time their relationship with the broader community is also changing Hard won battles for comparable rights and social status have shifted aspects of the lives of gay men increasingly closer to the mainstream, and as a result many gay men now finding greater opportunities to lead their lives and create their families completely in the open alongside their heterosexual peers While this is largely very good news, and a clear victory for gay rights, there may be unintended consequences of a more significant presence and greater visibility, and these consequences can also affect the health status of gay men The picture on this slide is a good illustration of the pressures that mainstream society place on gay men to conform to traditional roles and family structures in order to secure a place at the table Greater visibility and greater integration within mainstream society carries the risk that the specific health needs of gay men and the culture context for the appropriate delivery of those services may be overlooked or lost Assumptions may be made that gay men’s health related issues and needs are being addressed through services within the health system with a broader focus Likewise, although efforts are being made to support gay youth who are ‘out’ within the school system, the specific sexual health education needs of these youth are likely not well addressed within the overall curriculum
- Social Factors – Unintended consequences To further explore these unintended consequences lets look again at data from Urban Men’s Health Survey cited earlier: The survey stratified participants according to their self-reported timing of achieving important gay developmental milestones (first attraction to another male, first sexual experience, deciding you are gay, first telling someone you are gay). Stratified into three groups with early, middle, and later achievement of milestones When looked at self-reported experiences of harassment and victimization, the researchers found that those participants who had earlier achievement of the developmental milestones (e.g., came out earlier) had greater reporting of experiences of harassment and victimization Interpretation: being “out” and increased visibility, can increase the likelihood of being subjected to harassment and discrimination Generally, the age of coming out and achieving developmental milestones is decreasing. This may not necessarily be a good thing for everyone. ( Source: Friedman MS, Marshal MP, Stall R, Cheong JW, Wright ER. Gay-related Development, Early Abuse and Adult Health Outcomes Among Gay Males. AIDS Behav 2008; 12:891-902)
- Social Factors – Unintended consequences The same analysis found that timing of gay-related development was also related to reporting of unprotected sex, being HIV positive, and poly-drug use This is cross-sectional data so it does not provide proof of causation, but it does suggest an association between visibility as a gay man, negative social/environmental factors, and health status
- Social Factors – Political Environments Finally, it is important to acknowledge the role that political environments can have in determining the health of various populations In recent years it has become increasingly common for political parties to focus on sensitive social issues as a way of defining party platforms and attracting voter support We have seen social and health related issues such gay marriage and harm reduction become in some instances rallying points for political debate The profile of ‘wedge issues’ can have a negative impact on the health and well-being of populations affected … it can also serve to refocus attention away from other more pressing issues
- As we have seen on previous slides there are some significant challenges to the health status of gay men in BC However, gay men clearly share some significant strengths and resiliencies that serve to mitigate some of these challenges By way of an example, the medical, policy and health system response to HIV here in BC and indeed in most developed countries, is directly attributable to early, intensive and passionate advocacy on the part of gay men, responding to a new and devastating illness appearing in their midst In moving the gay men’s health agenda forward it will be important to define a shared vision – inclusive of goals and desired outcomes – that builds on the strengths and resiliencies that already exist It will also be important to identify the most effective and strategic ways to communicate the specifics of this vision to relevant decision-makers I would suggest that in shaping this vision it may be helpful to consider: What is required to foster a more positive and healthier environment for gay men Where gaps exist in programs and services for gay men, and how those gaps may be most effectively addressed Who the leaders and champions are that can help to advance the vision What opportunities exist that may be helpful, or at least need to be accounted for?
- This framework came out of a review of the literature looking at the association of determinants of health to HIV infection and sexual risk in gay and bisexual men Review of the literature led to the identification of three cross-cutting and inter-related determinants of health that were deemed the most important determinants for gay men: 1. Social and physical environments 2. Social support networks 3. Conditions that affirm choices of coming out (Source: Ryan B. Gay & Lesbian Health Services of Saskatoon. Valuing gay men's lives: Reinvigorating HIV prevention in the context of our health and wellness. 2001)
- Again, looking at HIV as an example. Given the resurging numbers of new HIV infections among gay men, it may be time to shift the response among gay men from a disease-specific focus to one that has a broader gay men’s health focus Because of the HIV epidemic and its disproportionate impact on gay men, much of the focus of health services and research for gay men has been HIV and other STI, and has been focused on individual behaviour change and individual-level variables affecting HIV and STI transmission (e.g., crystal meth) Many have called for a need to have a broader approach to HIV prevention which is more holistic, and addresses structural factors which have an influence on the health of gay men such as stigma, homophobia, addressing cultural norms within the gay community In the spirit of fostering strong social support networks it is also important to consider and address stigma within the community related to HIV and other health vulnerabilities
- There are a number of opportunities to consider as this work unfolds: Plans to expand HIV care and treatment - HIV is back on the health planning agenda, and rising rates among gay men are of significant concern …there may be opportunities through this work to re-position the response to HIV among gay men into the context of broader gay men’s health Mental Health and Substance Use planning – an emphasis through this work on upstream, prevention of mental illness could support development of approaches to promote mental health among gay men, and address related mental health challenges earlier. There is a general shift in policy to support prevention and health promotion work (i.e. creation of Ministry of Healthy Living and Sport) in order to reduce the incidence of chronic disease and reliance on tertiary and acute care services – this environment lends itself to efforts that promote good health and prevent diseases and chronic conditions As the broader men’s health movement evolves, there may be opportunities for direct linkage and/or partnership on issues of mutual interest/concern (i.e. prostate health) In terms of partnerships, there is tremendous value in exploring who is missing from the planning table that could contribute a unique perspective or important resource
- Finally, as you all move forward will the important work ahead I would like to suggest that you continue to look at evidence and experience, and have discussions of the type that are fostered through this summit. There is no one single, or easy solution – or magic bullet as it were – and it is only through shared experience and wisdom that progress will be made in building gay men’s health within BC and other jurisdictions.