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Resilience pathways, childhood escape routes, and mentors reported by gay and bisexual men affected by syndemic conditions



Investigation of the social and psychological antecedents of the HIV epidemic has identified a syndemic of conditions associated with risk behavior and seroconversion. This study inquires into the resilient practices and developmental processes of gay and bisexual men at the nexus of syndemic conditions to understand the pathways that lead to health problems or well-being. Interviews with 40 men identified branching pathways from home environments into schools that either offer refuge or a regime of gender discipline and bullying. Some found escape routes from hostile environments in worlds of books, pop culture, or internet chat. In adolescence, one set of men identified the development of sexual relationships with older men as a lifeline that brought a measure of emotional growth. This study points to resilience pathways and social resources that could make a difference in the lives of those deemed to be “high risk.”.
Resilience pathways,
childhood escape routes,
and mentors reported
by gay and bisexual
men affected by
syndemic conditions
Barry D Adam
University of Windsor, Canada
Trevor A Hart
Ryerson University, Canada
Jack Mohr
Canadian Treatment Action Council, Canada
Todd Coleman
Wilfrid Laurier University, Canada
Julia Vernon
Ryerson University, Canada
Investigation of the social and psychological antecedents of the HIV epidemic has iden-
tified a syndemic of conditions associated with risk behavior and seroconversion. This
study inquires into the resilient practices and developmental processes of gay and
bisexual men at the nexus of syndemic conditions to understand the pathways that
lead to health problems or well-being. Interviews with 40 men identified branching
pathways from home environments into schools that either offer refuge or a regime
of gender discipline and bullying. Some found escape routes from hostile environments
in worlds of books, pop culture, or internet chat. In adolescence, one set of men
identified the development of sexual relationships with older men as a lifeline that
brought a measure of emotional growth. This study points to resilience pathways and
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!The Author(s) 2018
Reprints and permissions:
DOI: 10.1177/1363460718758663
Corresponding author:
Professor Barry D Adam, Department of Sociology, Anthropology and Criminology, University of Windsor,
401 Sunset Avenue, Windsor, Ontario, Canada N9B 3P4.
social resources that could make a difference in the lives of those deemed to be
‘‘high risk.’’
Gay men, HIV risk, resilience, school bullying, sexual mentor, syndemic
Over more than 30 years, intensive investigation into HIV risk among gay, bisex-
ual, and other men who have sex with men has identified a subset of men at
elevated risk for condomless sex and seroconversion. Out of a great many studies,
a small set of characteristics have emerged that have strong statistically significant
predictive power for risk. Applying the notion of syndemics to these characteristics,
Ron Stall and colleagues noted that depression, childhood sexual abuse, poly-drug
use, and partner violence tend often to occur together and to be associated with
risk behavior (Stall et al., 2003; Stall et al., 2007). In the ensuing decade, the
syndemics idea has been reconfirmed in a growing research literature that has
extended into a number of related conditions. The reliance of syndemics research
on categories of psychological deficiency and the production of general tendencies
described in statistical language has led to calls for investigation not only of the
predictors of risk but of resilient practices and developmental processes that show
how people navigate and overcome syndemic problems (Herrick et al., 2011;
Herrick et al., 2014).
It is with this objective in mind that this study conducted life-history interviews
with 40 gay men to identify pathways through the stresses and challenges under-
lying syndemic indicators. Interviews explored the ways in which gay and bisexual
men had dealt with the challenges they experienced and their capacity ‘‘to navigate
their way to health-sustaining resources, including opportunities to experience
feelings of well-being’’ and to examine the larger capacity of the ‘‘individual’s
family, community and culture to provide these health resources and experiences
in culturally meaningful ways’’ (Ungar, 2010: 405). Many of the men interviewed
here had inconsistent or blocked access to the social determinants of good health
widely identified in the research literature as family, peer, or school support or
‘‘community services, sports and artistic opportunities, cultural factors, spirituality
and religion, and lack of exposure to violence’’ (Herrman et al., 2011: 260). Among
the men participating in this study, many had unsatisfactory, conflictual, or unsup-
portive families of origin. Only a few traced syndemic indicators to other arenas
such as challenges experienced from international migration or major difficulties in
transitioning from home to college or work (Adam et al., 2017). Home and school
are the primary life spheres available to children and adolescents and going from
home to school offered a supportive alternative for some but additional pain for
others. In other words, some found school to be a refuge from a difficult home life
while others encountered bullying and rejection. Given these life histories,
we became particularly interested in the few remaining pathways to resilience
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that emerge from the narratives of youth and young men in coping with often
problematic home and school environments. What we dub childhood escape
routes and protectors and mentors were identified as lifelines that provided a
degree of safety or solace in the midst of troubling environments. The narratives
from these interviews also suggest a link between these resilience pathways and
likelihood of lower risk sexual practices in adulthood.
The multiple lines of research on resilience and adversity
There are a number of different, somewhat disconnected bodies of research that
take up aspects of the question of navigating syndemic conditions with a focus
on resilience, but very little that treats the nexus of all of these issues together.
These different strands of research focus on such organizing concepts as: resilience,
post-traumatic growth, adverse childhood experiences, minority stress, protective
factors, sexual minority resilience, as well as syndemics. These research strands
have kinship with sizeable research traditions on the coping strategies and collect-
ive mobilizations of a range of populations subordinated through repression and
discrimination by environing societies. Just a few studies try to explore questions of
syndemics, resilience, health, and HIV risk together.
The notion of resilience contains within it the idea of an adversity, challenge, or
trauma and the ability to cope with, manage, or overcome it. Though some have
sought to reduce resilience to an a priori psychological state, resilience studies have
increasingly focused on an interactive dynamic between the subject and ‘‘the qual-
ity of social relationships, processes, networks and communities and the mutuality
and circularity of such’’ (Aranda et al., 2012: 550). As Kay Aranda and colleagues
(2012: 552) contend, ‘‘Well-being and resilience are therefore argued to result from
the ongoing iterative and interactive navigations and negotiations between selves,
communities and environments.’’ The implications of this re-focus are to move
from psychological states per se to ‘‘practical knowledge or routinised dispositions,
or networks and assemblages of activities and things or in processes of embodied
performativity’’ (Aranda and Hart, 2014: 358) and thus from a therapy-facilitated
adjustment of individuals to their social environment to a critical assessment of
those environments as essential elements in the resilience of individuals and popu-
lations (Bottrell, 2009). Related to the idea of resilience is a small research literature
on post-traumatic growth, defined by Richard Tedeschi and Lawrence Calhoun
(2004: 1) as ‘‘positive psychological change experienced as a result of the struggle
with highly challenging life circumstances.’’ While sharing an interest with resili-
ence studies in the ways in which people successfully overcome adversity, the focus
of this literature has been more on singular or episodic trauma and its aftermath
rather than structural or chronic adversity.
A well-developed research literature on adverse childhood events has identified a
range of household problems that affect the health of children growing into adult-
hood. The presence of: mental illness, incarceration, or substance abuse among
household members, parental divorce, domestic violence, physical or emotional
Adam et al. 3
abuse or neglect, and sexual abuse all prove to be associated with later physical and
mental health problems (Dong et al., 2004; Felitti et al., 1998). These kinds of
adverse childhood events appear to lead to elevated rates of depression, anxiety,
eating disorders, suicide attempts, cigarette smoking, alcoholism, and multiple
sexual partners (Dube et al., 2003: 274; Norman et al., 2012) and to a range of
physical conditions such as obesity, diabetes, asthma, arthritis, cardiovascular dis-
ease, lung disease, and sexually transmitted diseases (McCrory et al., 2015; Monnat
and Chandler, 2015).
Several of the health outcomes identified in the adverse childhood events research
literature, such as depression, anxiety, suicidality, and substance abuse, appear to
have somewhat elevated levels among lesbian, gay, bisexual, and transgender
(LGBT) people compared to the general population (Hsieh, 2014). A growing
body of research traces these conditions to various forms of discrimination and
social exclusion such as sexual-minority-specific victimization and a heightened
sense of insecurity experienced in unsupportive or hostile social environments.
Ilan Meyer (2003: 676) argues that LGBT people face minority stress, that is an
additional level of chronic and socially based stress beyond that experienced by the
general population. Those who directly experience these forms of exclusion more
often manifest these psychological conditions and LGBT people experience higher
rates of exclusion compared to the general population (Brewster et al., 2013; Burton
et al., 2013; Feinstein et al., 2013; Goldbach et al., 2014; Meyer, 2013, 2012; Lea
et al., 2014; Wight et al., 2012). Damien Riggs and Gareth Treharne (2017: 600) call
this the problem of decompensation when people ‘‘have been inadequately resourced
and supported and ...have experienced considerable and repeated marginalization,
so much so that one’s protective resources no longer work.’’
It is perhaps not surprising then that a similar nexus of preconditions and health
outcomes has emerged from the study of HIV risk behavior and vulnerability to
sero-conversion among gay and bisexual men in particular. Ron Stall and col-
leagues (2003) applied the idea of co-occurring syndemics to a burgeoning HIV
research literature that repeatedly confirmed the role of depression, childhood
sexual abuse, and polydrug use in heightened HIV risk behavior, a set of factors
that has extended to such indicators as social isolation, social anxiety, sexual
compulsivity, and internalized homophobia among others (Bruce et al., 2011;
Dyer et al., 2012; Hart et al., 2008; Mimiaga et al., 2015; Parsons et al., 2012;
Tulloch et al., 2015; Vanden Berghe et al., 2014). These findings have further
stimulated investigation into larger socio-historical contexts (Adam, 2016;
Siconolfi et al., 2014), circuits and social networks (Adam et al., 2008; Egan
et al., 2011), and local cultures (Aggarwal and Gerrets, 2014; Kurtz, 2005;
Moeller et al., 2011; Stall et al., 2007) that generate and reproduce the social con-
ditions that heighten these psychological indicators.
The evidence cumulated on the adversity side of the ledger has also revealed
some of the protective factors that diminish these kinds of health outcomes both
for large population-based samples and for LGBT people. Protective factors
tend to fall into a few broad categories: psychological traits, social support,
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and socio-economic status (Woodward et al., 2017). Psychological traits like self-
esteem, internal locus of control, and positive affect may themselves be embedded in
personal histories of social support (Fergus and Zimmerman, 2005; Lawson, 2009;
Thoits, 2011). Social support in the form of family and personal relationships, strong
social networks, school connectedness, satisfactory neighborhoods and commu-
nities all appear to mitigate negative health outcomes predicted by adverse child-
hood events (Fergus and Zimmerman, 2005; Hart et al., 2017; Luthar and Brown,
2007; Nurius et al., 2015). Also, higher income, education, and employment status of
a person reduce the effects that adverse childhood events once had on that person
(Monnat and Chandler, 2015). Research on gay and bisexual men, while finding
many of these same conditions to be operative, find having close friends, feeling
connected to the gay community, feeling the larger community to be supportive of
LGBT people, having no recent experiences of discrimination, and low internalized
homophobia all help contribute to greater well-being (Colpitts and Gahagan, 2016;
Lyons et al., 2013; Lyons et al., 2016; Reed and Miller, 2016; Shilo et al., 2015). Work
on sexual minority resilience has extended this inquiry beyond looking for counter-
vailing protective factors to see how LGBT people may grow and thrive over time in
the face of adversity. Like the post-traumatic growth literature, it documents benefits
from learning to cope with and overcome adverse conditions (Wang et al., 2016).
Finally, all of these bodies of research stand alongside other major arenas of inves-
tigation into the subjectivity of subordination and oppression (Adam, 1978, 2005;
Foucault, 1988; Kardiner and Ovesey, 1972; Memmi, 1969; Sartre, 1973), and socio-
historical studies of the ways in which subordinated peoples have over time found
ways through adverse circumstances to develop sufficient personal and collective
resilience to transform the adverse conditions around them.
The challenge, then, is to study how ‘‘men with multiple syndemic conditions
remain sexually safe and HIV negative over time or how community mobilization
can strengthen community interactions and supports [that] will likely improve
health promotion efforts among gay men’’ (Herrick et al., 2011: S28). Much of
the research on adverse childhood events, syndemics, and protective factors relies
heavily on large databases with measures made meaningful through finding statis-
tical significance. The developmental and social interactive processes that underlie
these indicators remain opaque. To identify resilience pathways requires examin-
ation of social practices (Reckwitz, 2002), that is the ways in which individuals deal
with adverse events and chronically difficult environments, often as children or
adolescents. These processes may indeed be narratives of abuse and neglect, depres-
sion, and sometimes life-threatening substance use, but they are also stories of
lifelines found, refuge, turnarounds, and growth. Matt Mutchler and colleagues
(2005), for example, have documented how young gay men navigate divergent
social scripts to piece together safer practices by combining discourses from part-
ners, mentors, and other sources. To that end, this study seeks not to distinguish
those who have experienced adverse childhood events from those who have not, or
those caught in syndemic conditions from those who are not, but rather to look
inside the life histories of those experiencing syndemic conditions to see how some
Adam et al. 5
find their way to ‘‘the activities, places and relationships in which they find well-
being, belonging, and power’’ (Bottrell, 2009: 325).
Interviewees for this study were drawn from the larger Gay Strengths study, which
recruited 470 gay, bisexual, and other men who have sex with men in Toronto.
Participants in that study had to report being HIV-negative and to have engaged in
sexual activity with another man in the past six months. They were recruited
through posters at community organizations and local businesses, distribution of
flyers at community events such as the Toronto Pride festival, and advertisements
on social media sites and a website oriented to gay men. Particular attention was
given to enhancing the diversity of the sample through outreach to black, south
Asian, and east/southeast Asian communities. The study was reviewed by the
research ethics boards of Ryerson University and the University of Windsor.
Study participants were screened in a one-hour initial assessment session and
provided written informed consent. They then completed a computer-assisted self-
interview questionnaire which included the following syndemic indicators:
1. Depression:. Symptoms of depression were measured using the 20-item Centre for
Epidemiologic Studies – Depression scale (CES-D) (Radloff, 1977). Participants
report on their feelings and behavior over the past week on a 4-point Likert-type
scale ranging from rarely or none of the time (less than 1 day) to most or all of the
time (5–7) days. Sample items include ‘‘I thought my life had been a failure’’
and ‘‘I felt sad.’’ Participants with a CES-D score of 16 or more screened
positive for this syndemic indicator.
2. History of childhood sexual abuse:. Childhood sexual abuse was measured using the
sexual abuse subscale of the Childhood Trauma Questionnaire – Short Form
(CTQ-SF) (Bernstein et al., 2003). Participants with a score of 6 or more on the
sum of items 20, 21, 23, 24, 27 on the CTQ-SF screened positive for this syn-
demic indicator. A score of 5 indicates that the participant indicated that none
of the following occurred during childhood:
1. Someone tried to touch me in a sexual way, or tried to make me touch them.
2. Someone threatened to hurt me or tell lies about me unless I did something sexual
with them.
3. Someone tried to make me do sexual things or watch sexual things.
4. Someone molested me.
5. I believe that I was sexually abused.
3. Multiple substance use:. Use of two or more substances within the last three
months, not including tobacco or cannabis: Alcohol use to the point of
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drunkenness; heroin; methadone; cocaine (including crack); speedball; crystal
methamphetamines or ‘‘Tina’’; ecstasy or ‘‘X’’; GHB or ‘‘G’’; other ampheta-
mines, uppers, or speed; ketamine or K; other barbiturates, downers, or sleeping
pills; erectile enhancing drugs (e.g., Viagra, Levitra, Cialis)
4. Homophobic harassment:. Indicating more than once on the question: ‘‘Before age
18, how many times were you made fun of, picked on, pushed, shoved, hit, or
threatened with harm because you were gay/bisexual?’’
Those scoring above the cut-off of two or more syndemic indicators became
eligible to be invited for a follow-up life history interview. Interviewees were sub-
sequently provided $30 to compensate for time and travel to the interview.
Once half of the study participants had been recruited to the larger study,
recruitment for the qualitative interviews began by inviting those whose scores
indicated three or four syndemic categories, followed by those who scored on at
least two syndemic categories, until 40 interviews were achieved. Semi-structured
interviews explored the life histories of study participants by inquiring into the
family, school, work, and neighborhood relationships in childhood, adolescence,
and adulthood (Halkitis et al., 2008; Se
´guin et al., 2007). Interviewers were parti-
cularly interested in exploring coping strategies to life challenges, sources of stress
and social support, and participants’ own assessments of adversity and resilience
(Friedman et al., 2008; Friedman et al., 2011). Interviews were transcribed and
coded to capture a wide range of themes concerning moving into and out of child-
hood sexual abuse and homophobic harassment, depression, and substance use,
along with personal reflections and strategies on pathways through these chal-
lenges. Narratives were examined to identify the range of views associated with
each topic using constant comparative analysis with the assistance of NVivo10
software, then discussed intensively by the co-authors to identify salient themes
and excerpts indicative of the range of views (Smith et al., 2009).
The types of syndemic indicators represented in the interview sample were as
.28 (70%) indicated having experienced childhood abuse of which 13 indicated
sexual abuse, 9 emotional abuse, and 6 more than one form of abuse
.39 (97.5%) indicated childhood homophobic harassment
.30 (75%) scored greater than 16 for depression (CES-D)
.18 (45%) indicated use of two or more substances in the past 3 months.
Sexual risk behavior was assessed in terms of receptive condomless anal sex with
a positive or serostatus-unknown male partner in the past three months (Adam
et al., 2017). At the time of the study, Truvada had not yet been approved as a pre-
exposure prophylaxis in Canada and its use was still rare (Wilton et al., 2016).
Adam et al. 7
The average age of the 40 interviewees was 38. They indicated their sexual
identity as: 34 gay, 2 bisexual, 2 two-spirit, 1 queer, and 1 pansexual.
Educational levels were relatively high with 3 having just high school education,
19 two years of post-secondary education, 10 four years, and 8 post-graduate
training. They reported their ethnic origins as: 17 British, 12 other European, 5
African and/or Caribbean, 2 Asian, and 1 each of Latin American, Middle Eastern,
Aboriginal, or mixed black and white backgrounds.
Pathways to resilience
These life history interviews point toward branching pathways, some that lead in
more supportive directions and others in less supportive ways. Examining current
sexual risk practices in adulthood suggests that those who found their way along
more supportive pathways were less likely to report higher risk sexual behavior
compared to those who did not. Though a qualitative study of this kind does not
have the numbers to compute statistical significance, these pathways raise hypoth-
eses worthy of further exploration.
From home to school
Rates of childhood abuse are high among men experiencing syndemic conditions.
When they go to grade school as children, their experiences tend to fall into two
contrasting modes. First, for 8 of the men interviewed, school was experienced as a
refuge and lifeline from an often problematic family environment: 6 of these 8
report current low risk sexual behavior. Second, 14 report experiencing consider-
able bullying in school. Just 6 of these 14 report current low risk sexual behavior.
For these boys, the school experience often compounded their sense of living in a
cold or hostile world both at home and at school.
Childhood escape routes and protectors
Eight men talked about childhood escape routes, that is finding personal refuges
where they were able to feel safer. Of these eight, four also reported school bully-
ing. Seven of these eight reported current low-risk sexual behavior. Nine of the
interviewees identified having had childhood protectors, often a relative or friend
who could provide them some sense of support outside of family and school. Just
four of these nine reported current low-risk sexual behavior.
Sexual mentorships
Finally, six reported having had older male lovers in adolescence. Only one of these
six falls into the current high-risk sexual category, suggesting that having these
male partners may have had some protective effect in the personal development of
the men interviewed here.
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In sum then, this examination of childhood and adolescent pathways to resi-
lience suggests hypotheses worth exploring further with large samples:
.School bullying appears to increase likelihood of later risk.
.Childhood escape routes and school experienced as a place of refuge and valida-
tion appear to offer some protective value.
.Older male partners in adolescence appear to enhance resilience and self-care
while childhood protectors such as friends, siblings and grandparents do not
appear to offer much protective value in later life, at least as measured in terms
of sexual risk behavior.
School as lifeline
For a sizeable set of the men interviewed here, school was described as a
‘‘sanctuary,’’ an ‘‘escape,’’ or a ‘‘reprieve’’ often in stark contrast to their experi-
ences at home. Indicative of these experiences are the following excerpts from
School was really positive because again I had a very dysfunctional home life and I
was smart so I ... integrated into the school situation. It was a reprieve – right? – from
home. (50s, European ethnicity)
My school friends were my adopted family while struggling to find safety in my
parents’ home and my teachers were my guidance counselors ... School was my
sanctuary. (40s, Pacific Islander)
Especially in high school, I had some teachers that were role models because I never
really confided in anybody about what was going on at home but ... still I really
appreciated the emotional stimulation and being able to escape ... School was an
escape for me. (20s, European)
For these men, school proved to be an alternative place where they could find
encouragement, support, and the opportunity to flourish.
School for me was always a constant. It was always like the only place where I felt
successful. (40s, French)
I can name specific teachers who were very, very helpful. You know you go to
poor, relatively low-income schools and then, you know, if you’re someone
with a lot of potential, there’s teachers that sort of glom on to you and
encourage you in different ways ... I was doing all advanced work, won national
science fairs, Canadian Idol finalist, performing ensembles, musicals, travel.
(20s, British)
Adam et al. 9
Public school was wonderful. I mean, I had a few fights the same as any other kid
does, arguments and stuff like that, but ... I had friends and public school was great
and I got along with the teachers. (40s, British)
For these boys, many of whom did not experience supportive home lives, school
provided an alternative route to new horizons and opportunities that contributed
to self-esteem and emotional well-being.
School bullying
A larger set of boys had a fundamentally different school experience. In their
narratives, operative descriptors like ‘‘terrible,’’ ‘‘hate,’’ and ‘‘nightmare’’ apply
to their recollections of going to school. For them, an often hostile home environ-
ment was reinforced by school mates and even teachers, many of whom engaged in
campaigns of vilification against them, often labeling them as ‘‘gay’’ well before
having any sense of their own sexuality.
At school, I was constantly informed by others that I didn’t belong. I was very slight,
like I was a tiny kid, so I was constantly picked on, and I was beat up more than once
and when you lisp, you know in those days they caught on to it very quickly and also
my choice of extra-curriculars, like gymnastics, and other things. I was a big target.
(40s, French)
Especially now that everybody thinks you’re gay, I got beat up at least once a week for
the next few years ... I hated to be at home and I hated to be at school. (40s, British)
Terrible, I hated it so much ... I was I guess a loser you would call it, like grade 1 to
grade 8, for sure. Yeah, I wasn’t, I wasn’t treated very nicely by other kids. (20s,
I was bullied by a female ... I remember her throwing in sexuality as a jeer as one of
the things, pretty much having the entire class to join in on it ... She kind of made
remarks about my sexuality based on my appearance and my presentation of self and
what made matters worse was she made that situation even far different than every-
thing else, she went out to physically attack me. (20s, Caribbean)
In a couple of particularly egregious instances, teachers and school administrators
joined in the torment:
It was a nightmare. I had people laughing and throwing things ... I went to a Catholic
school – I was brought to the office because there was a disorder in the school. They
decided to send me home for the week and then they allowed me to come back and I
was forced to use the teachers’ washrooms. I was forced to, not allowed to stand up
for prayer. I was told that if I stand up for Oh Canada that I would have to leave the
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classroom for prayer ... Going up to grade 9, 10, 11, I got teased everyday and made
fun of everyday and I had the odd teacher that would stand up for me and some of the
teachers that would always blame it on me and I would get suspended. I was sus-
pended several times in school for standing up for myself but because the way I did it
was so angry and reactive to the person, they said it was my fault. (20s, British-
Primary school, a terrible experience I had, I think it was my first, I felt immense
mistrust in the world. I felt very, very scared ... She [teacher] said, ‘‘Look, look at this
little nancy-boy, look at this sissy. Look at him he’s brought a doll.’’ ... I remember a
few days later, he [childhood friend] came to school and he said to me, ‘‘I cannot be
your friend anymore because you’re what we call ... a nancy-boy or gay boy.’’ (40s,
In some instances, school bullying was further compounded by racist harassment.
Me and my brother were kind of stuck in the middle, being native, and the entire city
was very racist towards natives ... Everyone knew I was gay except for me, I guess.
They were calling me names; I didn’t even know what they meant ... Absolutely
horrible ... If anyone picked on anyone, it was me. I was bullied. I was beat up. It
was just relentless. (30s, Aboriginal)
I went to a Catholic school. My bottom still hurts from all the whips and my hands
still hurt. Every time my hand hurt, I remember it well. I think I wore the dunce cap a
lot and that was rough. I hated school, I hated school. I would skip school ... Grade 5
... then the bullying started, the very first day. They called us Paki (laughs) ... High
school, I would be called gay, because I would be hanging around with the nerdy sort
of, the nerd group would be called gay. (40s, Caribbean)
Unlike the boys who found school to be a lifeline and respite from home, this
other sizeable group of boys use words like ‘‘horrible’’ and ‘‘relentless’’ to
describe a regime of homophobic and racist bullying that further added to their
Childhood escape routes and sources of support
Perhaps most interesting in tracing the life pathways sketched out in interviews
were the ways in which a set of men experiencing adverse conditions carved out
safer spaces for themselves and made connections often in the absence of suppor-
tive home or school environments. One theme that recurred in the narratives was
the world of books as one of those spaces:
I just focused on things I could control, like I was an avid reader, I read a lot. I would
do, I painted. I would watch TV, just things that I knew. (40s, French)
Adam et al. 11
School was very hard for me. I remember being picked on. I guess I was a bit of a fem
and I expressed myself the way I felt comfortable doing ... (I: Right, right. So were
books a bit of a refuge for you?) Yes, totally. Totally, yeah. (40s, British)
Another found inspiration in the world of pop divas, identifying with the lives and
lyrics of tragic or resilient women who themselves battled adversity.
I was bullied a lot before everyone knew I was gay because I was very quiet and very
dorky and you know, I kept mostly to myself and then I came out and it just got worse
because this kid that was always so invisible was like the center of relevance for 1200
students in school and it was just a lot of unnecessary attention and everyone was
discussing my own personal life ... I identified a lot, and I know this is going to sound
ridiculous: through this time Britney Spears and Amy Winehouse were going through
a lot of like stuff in their lives, like they were doing drugs and stuff, and I saw how
people were attacking them and how they were just dealing with their own thing
personally and just taking their own time to heal, and I thought that I should do
the same. Just take all these negative things that people are throwing at me, analyze
why they’re doing it, and just take the best from that. Like, it wasn’t my fault that
I grew up in this patriarchal, horrible, colonial society, and they didn’t really know
how to deal with homosexuality. I always knew there wasn’t anything wrong with me,
there was something wrong with them, so there was nothing for me to change. (20s,
Caribbean-Latin American)
For younger men whose formative experiences came about in the internet age,
virtual worlds provided access to alternatives to home and school that were restrict-
ing their everyday lives:
I isolated myself and I talked to people on the computer as opposed to going out and
my friends were older but the people I talked to were generally on the computer
around the world. Ninety-five percent of those friends I’ve met, we’re still in touch
with today and it’s amazing that we’ve been able to do that. (20s, British-French)
Ten years ago so I would go on the internet and I would go on these Latin websites
and I would meet young guys, older guys or guys around my age and we would talk
about our experiences or sensual experience or what not ... It was interesting to hear
about their experiences but that’s the only way I could get information about the gay
communities. (20s, Latin American)
Another found a childhood escape route in the virtual world of gamers.
I was a pretty flamboyant little kid; I was very girly so I never had too many
friends. I was bullied a lot in New York. I did well in school, I excelled in school,
I was gifted, but yeah I was bullied a lot ... I gamed a lot; I played PS2 I think it
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was a lot. I watched a lot of TV. I didn’t really have anyone I could go to.
(20s, African)
The notion of childhood escape routes is an unexplored topic in social and health
science studies of young gay men, but it is a topic that has had resonance in some
work in the humanities. The place of the Broadway musical, divas, and movies in
gay culture has been the subject of some reflection in cultural studies (Dyer, 2002;
Miller, 1998) and perhaps exemplified in the novel, and subsequent play, of Manuel
Puig’s (1979) Kiss of the Spider Woman. David Halperin (2012) ruminates in How
to be Gay about ‘‘the queer appeal of the Broadway musical – which takes the gay
subject back to its presexual but ecstatic enjoyment of ‘kid stuff’ and to all the
shameful, embarrassing emotional vicissitudes of its solitary childhood.’’
Interestingly enough, the Broadway musical per se does not appear in the life
histories of these men dealing with syndemic conditions, but other childhood
escape routes do, ones that fulfill many of the same impulses identified in cultural
studies as roots of gay cultures. These refuges and escape routes help build a culture
of resilient practices with emotional resonance and practical utility in facing hostile
social environments.
Some study participants also identified other childhood protectors, usually in
the form of siblings, grandparents, or friends who provided some alternative
sources of support:
I was kind of safe because my older brother was usually ahead of me [in school], so
nobody beat me up. I found out later he did beat up people and throw them out of
windows for calling me a sissy. I was very effeminate and I think I, my voice is, was
probably very effeminate, but I kind of didn’t realize it because I think I had this little
bubble of safety around me from my older brother. (50s, French)
We [siblings] did everything together. We protected each other and there was my
cousin for example, and we would do bad things that would get us in trouble when
we were kids (laughter) but we were really close. (20s, British-French)
My grandparents helped a lot without realizing it. They lived right around the corner
and we saw them sometimes several times a day and I know I hid out there a lot
without it ever really being acknowledged, so there was, that was kind of the safest
place for me, and probably my siblings too, growing up. (40s, White)
Adolescent sexuality and older male mentors
Finally, six interviewees identified an older male partner as the source of safety and
personal growth in high school and beyond. Because the topic of adult men and
adolescent men together is largely silenced in contemporary culture, or subject to a
Adam et al. 13
totalizing discourse of sexual abuse (Lancaster, 2011), it is worthwhile quoting each
of these narratives in their own words:
I don’t really want to meet people my age ... I’ve always, since the age of my coming
out, related to older men and was able to sit down and have these conversations and
tell them how I was feeling. (20s, British-French)
He eventually got a job in [city] just so that I could come back to [city] and he paid for
a course I took and was really – he was an older person than I was. I was like twenty
or twenty-one at this time and he was really, really good to me, and I miss him. (40s,
I, luckily at the age of fourteen, I met an older man whose, well he’s twelve years older
than me. He’s still alive and he was a bit of a nut, but he, his name is B and he didn’t
abuse me or anything. There was never any abuse. It was always consensual because I
wanted it. I was looking for it, I was looking for affection and I found it. I discovered
sex and I realized it felt good, you know, for many reasons ... He had a house and he
had a stable bunch of friends and he sort of showed me you can be gay and lead a
regular life. (40s, British)
I realized that I was searching for that physical and emotional and intellectual con-
nection with men and that was a boy who was only four years older than me at the
time, but that was quite clear to me when I was going into my late teens just before I
was twenty, I desperately needed this love from an older figure or an equal, but it had
to be male. (70s, European)
I went to [gay bar]. I didn’t know why I was going, I was just going and then I met this
guy named H ... He was French, he was from Paris and he took me home and I lived
with him for three years ... He was lovely ... He was fifty-five years old. (40s,
I was eighteen. It was someone I had met cruising. He was a flight attendant. He was
thirteen years older than me. It was pretty, it was pretty drama laden because I was
drinking a lot and he was actually being the responsible person. He had been in social
work previously ... I’m still in touch with him so we’ve stayed, I wouldn’t say friends,
but we’ve stayed contacts. He was pretty formative in helping me kind of identify as
being gay. (50s, British)
Each of these narratives is quite strong in asserting the speaker’s own agency in
these relationships, in some instances anticipating and resisting the implication of
abuse. Each of these narratives comes up in response to interviewers’ questions
about sources of support over the course of their lives and older male mentors are a
recurring theme. Being taken in and supported by an older man was experienced by
these youths as a healing and validating experience. These relationships provided
14 Sexualities 0(0)
immediate emotional and sometimes material support, as well as entry into social
networks and spaces that gave them safety and new opportunity.
This study was particularly interested in examining sources of support and resi-
lience among gay, bisexual, and other men who have sex with men who experience
syndemic conditions. Set against research literatures that trace health problems to
adverse childhood events and which identify protective factors leading to healthy
outcomes, these life histories inquire into the resilience strategies developed in
childhood and adolescence among those facing considerable adversity and limited
protection. Some of these men found safety, encouragement, and reward in school
but more encountered school environments that compounded their distress
through a regime of gender discipline and bullying. Nevertheless, some succeeded
in finding escape routes or refuges from cold or hostile home and school environ-
ments through immersion in worlds of books, pop culture, or internet chat. In
adolescence, one set of men identified the development of sexual relationships
with older men as a lifeline that brought a measure of emotional grounding, sta-
bility, and personal growth.
The role of school as an alternative source of support and esteem for gay men
growing up has been noted by John Pachankis and Mark Hatzenbuehler (2013:
186) who argue that ‘‘compared to others’ acceptance of a presumably devalued
stigmatized self, academics, appearance, and competition may be safer domains in
which young sexual minority men can invest their self-worth.’’ Reliance on alter-
native childhood escape routes from home and school has been taken up primarily
in a few works in cultural studies but has yet to be studied systematically by the
social and health sciences. Finally a few studies have inquired into the role of
mentorship in the lives of LGBT youth, but for the most part they have skirted
the issue of sexual mentorship in providing protection and nurturing resilience
(Johnson and Gastic, 2015; Sheran and Arnold, 2012). One of the few to raise
the role of sexual mentorship is the work of Sonya Arreola and colleagues (2013:
398) who also found through life history interviews with Latino gay men that
‘‘social structures in childhood limited agency through symbolic forms of struc-
tural hostility, such as the recurrent homophobic messages of unworthiness and
humiliation, and physical manifestations of structural violence, such as forced sex’’
but that voluntary youthful sexual exploration actually improved later resiliency
and well-being. Both supportive family members and same- or older-aged men
discovered through sexual exploration contributed to ‘‘a sense of self and a quality
of agency when describing both their childhood and adult sexual episodes, even
in the face of virulent homophobic environments.’’ While the health
research evidence is strong concerning the deleterious effects of child sexual
abuse, these findings point to the need for an analytic distinction to be made for
adolescent sexuality where older male mentors may play a part in pathways to
Adam et al. 15
This study, then, points to some of the social resources that can mitigate the
harm caused by family and school abuse and that could contribute to the longer-
term health and well-being of gay and bisexual men. School anti-bullying programs
and gay-straight alliances may constitute structural reforms with very practical
consequences for the immediate security of school children (demonstrated, for
example, by Taylor and Peter (2011)) but also for the long-term health of these
same children as they emerge into adulthood. Both schools and alternative spaces
to home and school can provide additional avenues to well-being by providing safe
spaces for self-expression, communication, and social connection by supporting
childhood escape routes from hostile social environments. For these 40 men,
such alternatives as sport and religion – whether Protestant, Catholic, or Islamic
– which often appear in the biographies of heterosexual men as places of support or
relief, figure in their narratives as additional enforcers of deprecation, harassment,
and rejection. Rather, intellectual, artistic, and internet pursuits offered a measure
of solace for these narrators. Finally, adolescent romantic and sexual connection,
almost entirely discouraged if not punished for gay youth, opened a path to direct
emotional support and access to the cumulative wisdom of gay cultures, experi-
enced by a sizeable set of these men as healing and beneficial. From a psychological
perspective, these resilience pathways may contribute to decreasing social isolation,
improving self-esteem, increasing internal locus of control, and increasing emo-
tional self-regulation. They also point to arrays of social interaction and social
capital that could make a difference for those often deemed as ‘‘high risk’’ by
health science and practice. This cumulating research on resilience among gay
men suggests, then, several avenues by which the social capital of young gay
men could be enhanced, avenues that very likely mitigate the effects of syndemics
on HIV and other health risks. Work on these kinds of social structures and
environments is a necessary complement to appeals for individual behavior
change that have been the primary strategy for doing HIV prevention.
We would like to thank the other members of the Gay Strengths research team, David J
Brennan, Syed Noor, Sandra Gardner, Winston Husbands, and Ted Myers for their assis-
tance. We would also like to thank the volunteer research assistants of the HIV Prevention
Lab for transcribing the interviews, including Aidan Ablona, who also contributed to the
coding of interviews.
The author(s) disclosed receipt of the following financial support for the research, author-
ship, and/or publication of this article: This research was funded by the Canadian Institutes
for Health Research.
Barry D Adam
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Barry D Adam is Distinguished University Professor Emeritus of Sociology at the
University of Windsor and Senior Scientist at the Ontario HIV Treatment
Network. He has an extensive research record on the dynamics of domination
and empowerment, LGBT studies, and HIV prevention. In recent years, he has
received the Simon-Gagnon award for a distinguished career in the study of sex-
ualities, the Sociologists’ AIDS Network Career Award for outstanding contribu-
tions to the sociology of HIV, the Community Partners Award of the Ontario
AIDS Network, the Anselm Strauss award for qualitative research on family rela-
tions, and the Queen’s Diamond Jubilee Medal.
20 Sexualities 0(0)
Trevor Hart is Professor of Psychology at Ryerson University. He holds a Chair in
Gay and Bisexual Men’s Health from the Ontario HIV Treatment Network.
Dr. Hart’s research examines factors associated with HIV transmission, and inter-
ventions to reduce HIV transmission risk and to promote sexual health among gay
and bisexual men.
Jack Mohr is a health researcher, currently based at St Michael’s Hospital in
Toronto. His interests include health promotion, HIV prevention, health policy
and implementation science. He holds an MA in Sexuality Studies from San
Francisco State University.
Todd Coleman is an Assistant Professor of Health Sciences at Wilfrid Laurier
University. He has worked on several Canadian community-based research pro-
jects with gay, bisexual, and other men who have sex with men, and other sexual
and gender minority populations. In addition to his research with sexual and
gender minority communities, his research interests include population health, epi-
demiology, research methods, HIV, and sexual health.
Julia Vernon studied Psychology and International Development Studies at McGill
University, where she earned a Bachelor of Arts degree in 2013. Julia has worked at
the HIV Prevention Lab in the Department of Psychology at Ryerson University
since 2013, and served as coordinator for the Gay Strengths Study.
Adam et al. 21
... Life-story interviews, for example, offer the opportunity to explore how early challenges shaped the narratives and lives of individuals. A qualitative study conducted by Adam et al. (2018) is a good example of this. They found one major pathway of syndemic production characterised by childhood adversity leading to depression, substance abuse and risk taking and two minor pathways characterised by migration stress, or transition stress from home to college/work. ...
... Similarly, Hart et al. found that psychosocial strengths were associated with lower likelihood of engaging in condomless anal sex, despite the presence of syndemic conditions . In qualitative studies, resilience was also found to exert a protective effect against syndemic conditions (Adam et al., 2018;Chakrapani et al., 2019a;Reed and Miller, 2016). Furthermore, the review by Woodwards et al. found a protective effect of most resilience resources identified against HIV (Woodward et al., 2017). ...
Men who have sex with Men (MSM) represent a population affected by numerous health conditions. Syndemic theory has been used as a framework to study the health of MSM for nearly 20 years. However, the literature is plagued by a lack of consensus regarding what constitutes a synergy in a syndemic and recent reviews have shown that most of the papers published thus far have failed to demonstrate a synergy nor describe the bio-social interaction needed to account for a true syndemic. Moreover, to our knowledge, none of the existing reviews have focused specifically on MSM. This scoping review aims to fill this gap by mapping in detail how syndemic research on MSM has been conducted. A systematic database search was conducted between 2020 and 2021 and 115 studies were included. Our findings showed a lack of diversity regarding the location, design, subpopulation, and outcomes studied. In addition, the syndemic conditions, as well as their measurement, were not focused enough to ensure the robustness and reproducibility of the findings. Furthermore, our results support previous reviews showing a lack of empirical data to support disease interaction in syndemic research applied to MSM. Our review offers some important recommendations to help move the field forward in future work and describes some promising methodological advances.
... This process is dynamic and changes over time, based on lived experiences [10]. Multiple qualitative and quantitative studies highlight resilience among sexual minority individuals as buffering the negative impact of prejudice and, in turn, promoting positive health outcomes [11][12][13][14][15]. While previous research has identified associations between resilience and good mental health, there is limited research that applies a strengths-based resilience approach to understanding the risks of HIV transmission among GBM. ...
Full-text available
This study evaluated the association between resilience and PrEP use among a population-based sample of Canadian gay, bisexual, and other men who have sex with men (GBM). Sexually active GBM aged ≥ 16 years old were recruited via respondent-driven sampling (RDS) in Toronto, Montreal, and Vancouver from 02/2017 to 07/2019. We conducted a pooled cross-sectional analysis of HIV-negative/unknown GBM who met clinical eligibility for PrEP. We performed multivariable RDS-II-weighted logistic regression to assess the association between scores on the Connor-Davidson Resilience-2 Scale and PrEP. Mediation analyses with weighted logistic and linear regression were used to assess whether the relationship between minority stressors and PrEP use was mediated by resilience. Of 1167 PrEP-eligible GBM, 317 (27%) indicated they took PrEP in the past six months. Our multivariable model found higher resilience scores were associated with greater odds of PrEP use in the past six months (aOR = 1.13, 95%CI = 1.00, 1.28). We found that resilience reduced the effect of the association between heterosexist discrimination and PrEP use. Resilience also mediated the relationship between internalized homonegativity and PrEP use and mediated the effect of the association between LGBI acceptance concern and PrEP use. Overall, PrEP-eligible GBM with higher resilience scores had a greater odds of PrEP use in the past six months. We also found mixed results for the mediating role of resilience between minority stress and PrEP use. These findings underline the continued importance of strength-based factors in HIV prevention.
... This is consistent with other work exploring alternative pathways to resiliency in the face of social rejection in family and peer networks. For example, young queer men may benefit from community connections via alternative spaces that provide safe venues for self-expression and connection with other queer-identifying and sexual and/or gender minority individuals (Adam et al., 2019). Indeed, connection to one's community is closely associated with feeling positively about and taking pride in one's identity, which has been linked (via higher self-esteem) with better physical and psychological health and better social functioning (e.g., Perrin et al., 2020). ...
Among sexual minority men, gay, bisexual, and queer men (GBQM) may experience differences in terms of their sense of belonging to a sexual minority community (community connectedness), outness about their sexual identity, and their experiences of proximal and distal sexuality-based stressors. Although group membership can confer unique benefits to members of marginalized groups, including GBQM, these benefits are likely unequal across the range of identity groups included in this acronym. We analyzed data from 1,827 human immunodeficiency viruses (HIV)-negative cisgender men living in Canada to examine how three different sexual identities, gay, bisexual, and queer, are associated with minority stress, social variables, and outness. Compared with gay and bisexual men, queer men scored lower on measures of identity concealment and internalized homonegativity, were more open about their sexuality in their social networks and reported higher community connectedness. Compared with queer and gay men, bisexual men reported higher rates of identity concealment and internalized homonegativity, were less open about their sexuality and reported less perceived social support and lower community connectedness. Although bisexual men overall also reported less discrimination, bisexual identity moderated the association between distal stress and proximal stress, such that bisexual men who experienced more distal stress were particularly sensitive to its impact and experienced higher proximal stress. Future research with sexual minority men should attend to identity diversity within this group, as minority stressors, social variables, and outness differ between GBQM
... In another study assessing the social and risk behavior networks of young adult, ethnically diverse sexual minority males, about one-fourth who had a relationship with a non-parental adult engaged in risky behaviors with the adult, such as substance use and unprotected sex (Sterrett et al., 2015). These different perspectives suggest a need for further investigation of the mentoring opportunities and experiences of SGM minority youth, as these mentoring relationships cannot be assumed to be monolithic or uniform across different youth and settings (Adam et al., 2019;Arreola et al., 2013). While there is certainly some level of risk of harm in any mentoring setting (Rhodes et al., 2009), these previous studies do not present a complete picture of the potential influence of mentoring for SGM youth. ...
This study explored how mentoring begins and the benefits provided for African American sexual and/or gender minority (SGM) youth. Participants were mentors and mentees living in three Mid-Atlantic cities. Mentees (ages 15–21, n = 14) identified as African American; cisgender male, transgender female, or non-binary assigned male; and had sexual interest in men. Mentor participants (ages 18+, n = 13) mentored such youth. Qualitative in-depth interviews were conducted with mentoring relationship partners (both partners did not necessarily participate). All interviews were audio-recorded, transcribed, and imported into Atlas.ti. Using a basic interpretive qualitative analysis, a codebook was developed through inductive and deductive techniques. Analysis focused on mentees’ and mentors’ descriptions and interpretations about how they formed a mentoring relationship and any observed benefits that arose. Themes showed mentoring relationships were formed through introductions via social circles or social media. Mentoring was described as providing a trusted confidant and support with identity formation, relationships, transitioning to adulthood, and health. Results indicate a potential for natural mentoring relationships to provide trusted adult support to SGM adolescents in ways that are experienced as authentic and beneficial to the mental health of African American SGM male youth.
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Adverse childhood experiences (ACEs; e.g., neglect, sexual abuse) among gay, bisexual, and other men who have sex with men (GBM) may not occur in isolation, but may be connected and occur in clusters. Most studies have measured ACEs individually, hierarchically, additively, or in a binary fashion (presence or absence of ACEs), rather than treating them as connected and clustered. This study examined these competing approaches of scoring ACEs and their relative power at predicting health outcomes. We examined abuse (sexual, physical, and emotional) and neglect (physical and emotional) experiences among a non-random sample of 470 Toronto GBM using the Childhood Trauma Questionnaire Short Form subscales. We compared five scoring schemas: (1) five individual scores for each form of maltreatment; (2) a composite score summing all of the maltreatment scores; (3) a hierarchical regression model with sexual abuse entered first then followed by physical abuse, emotional abuse, physical neglect, and emotional neglect; (4) a severity-based categorization; and (5) a latent profile-based categorization. Experiences of abuse and neglect were not uncommon (22–33%) and some participants experienced multiple forms of abuse and neglect (r = .33–.65, df = 464–467; p < .001; shared variance, r2 = 11–43%). Results show the dose–response effects of ACEs and highlight the importance of examining ACEs in clusters rather than individually. Latent profile analysis identified GBM who experienced multiple and frequent ACEs, and also identified the types of ACEs they experienced: crucial information that was obscured in score-based or severity-based approaches.
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Syndemics research shows the additive effect of psychosocial problems on high-risk sexual behavior among gay and bisexual men (GBM). Psychosocial strengths may predict less engagement in high-risk sexual behavior. In a study of 470 ethnically diverse HIV-negative GBM, regression models were computed using number of syndemic psychosocial problems, number of psychosocial strengths, and serodiscordant condomless anal sex (CAS). The number of syndemic psychosocial problems correlated with serodiscordant CAS (RR = 1.51, 95% CI 1.18–1.92; p = 0.001). When adding the number of psychosocial strengths to the model, the effect of syndemic psychosocial problems became non-significant, but the number of strengths-based factors remained significant (RR = 0.67, 95% CI 0.53–0.86; p = 0.002). Psychosocial strengths may operate additively in the same way as syndemic psychosocial problems, but in the opposite direction. Consistent with theories of resilience, psychosocial strengths may be an important set of variables predicting sexual risk behavior that is largely missing from the current HIV behavioral literature.
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For Full text, go here: Most HIV prevention for sexual minority men and men who have sex with men targets risk behaviors (e.g., condom use) and helps <50% of participants. Bolstering resilience might increase HIV prevention’s effectiveness. This systematic review identified resilience resources (protective factors) in high-risk, HIV-negative, sexual minority men. We reviewed PsycINFO, PsycARTICLES, MEDLINE, references, and Listservs for studies including sexual minority men with 1+ HIV risk factor (syndemics): childhood sexual abuse, partner abuse, substance abuse, or mental health symptoms. From 1356 articles screened, 20 articles met inclusion criteria. Across the articles, we identified and codified 31 resilience resources: socioeconomic (e.g., employment), behavioral coping strategies (e.g., mental health treatment), cognitions/emotions (e.g., acceptance), and relationships. Resilience resources were generally associated with lower HIV risk; there were 18 low-risk associations, 4 high-risk associations, 8 non-significant associations). We generated a set of empirically based resilience variables and a hypothesis to be evaluated further to improve HIV prevention.
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Introduction Identifying appropriate pre-exposure prophylaxis (PrEP) candidates is a challenge in planning for the safe and effective roll-out of this strategy. We explored the use of a validated HIV risk screening tool, HIV Incidence Risk Index for Men who have Sex with Men (HIRI-MSM), to identify “optimal” candidates among MSM testing at a busy sexual health clinic's community testing sites in Toronto, Canada. Methods Between November 2014 and April 2015, we surveyed MSM undergoing anonymous HIV testing at community testing sites in Toronto, Canada, to quantify “optimal” candidates for scaling up PrEP roll-out, defined as being at high objective HIV risk (scoring ≥10 on the HIRI-MSM), perceiving oneself at moderate-to-high HIV risk and being willing to use PrEP. Cascades were constructed to identify barriers to broader PrEP uptake. The association between HIRI-MSM score and both willingness to use PrEP and perceived HIV risk were explored in separate multivariable logistic regression analyses. Results Of 420 respondents, 64.4% were objectively at high risk, 52.5% were willing to use PrEP and 27.2% perceived themselves at moderate-to-high HIV risk. Only 16.4% were “optimal” candidates. Higher HIRI-MSM scores were positively associated with both willingness to use PrEP (aOR=1.7 per 10 score increase, 95%CI=1.3–2.2) and moderate-to-high perceived HIV risk (aOR=1.7 per 10 score increase, 95%CI=1.2–2.3). The proportion of men who were “optimal” candidates increased to 42.9% when the objective HIV risk cut-off was changed to top quartile of HIRI-MSM scores (≥26). In our full cascade, a very low proportion (5.3%) of MSM surveyed could potentially benefit from PrEP under current conditions. The greatest barrier in the cascade was low perception of HIV risk among high-risk men, but considerable numbers were also lost in downstream cascade steps. Of men at high objective HIV risk, 68.3% did not perceive themselves to be at moderate-to-high HIV risk, 23.6% were unaware of PrEP, 40.1% were not willing to use PrEP, 47.6% lacked a family physician with whom they felt comfortable discussing sexual health, and 31.6% had no means to cover the cost of PrEP. Conclusions A higher HIRI-MSM cut-off may be helpful for identifying candidates for PrEP scale-up. Improving engagement in the PrEP cascade will require interventions to simultaneously address multiple barriers.
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To date, research that has drawn upon Meyer’s (2003) minority stress model has largely taken for granted the premises underpinning it. In this paper we provide a close reading of how ‘stress’ is conceptualised in the model, and suggest that aspects of the model do not attend to the institutionalised nature of stressors experienced by people with marginalised identities, particularly lesbian, gay, bisexual and transgender individuals. As a counter to this, we highlight the importance of a focus on the effects of ideology and social norms in terms of stress, and we argue why an intersectional approach is necessary in order to ensure recognition of multiple axes of marginalisation and privilege. The paper then outlines the concept of decompensation and suggests that it may offer one way to reconsider the effects of ideology and social norms. The decompensation approach centres on the need for social change, rather than solely relying upon individuals to be resilient.
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Health science research on HIV risk focuses strongly on psychological traits of individuals as determinants of health and vulnerability. This paper seeks to place these findings in a larger social context marked by neoliberalism to provide some insights into the arenas of vulnerability to risk. These arenas are shaped by shifts in the environing political economy which generate subjectivities concordant with the pressures of the neoliberal turn to increasing marketization, individualization, and responsibilization. These pressures create cultures of expectation that accentuate particular trends defining success, masculinity, and risk in contemporary societies. In other words, the “risk factors,” identified in the now voluminous research literature on HIV, cumulate in particular social locations that, at least in part, articulate with masculine gender performance in marketplaces. These intersections affect the expression of sex between men and vulnerabilities to risk, providing an alternative understanding to the deficit models currently in health science research.
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Background Historically, lesbian, gay, bisexual, transgender and queer (LGBTQ) health research has focused heavily on the risks for poor health outcomes, obscuring the ways in which LGBTQ populations maintain and improve their health across the life course. In this paper we argue that informing culturally competent health policy and systems requires shifting the LGBTQ health research evidence base away from deficit-focused approaches toward strengths-based approaches to understanding and measuring LGBTQ health. Methods We recently conducted a scoping review with the aim of exploring strengths-based approaches to LGBTQ health research. Our team found that the concept of resilience emerged as a key conceptual framework. This paper discusses a subset of our scoping review findings on the utility of resilience as a conceptual framework in understanding and measuring LGBTQ health. Results The findings of our scoping review suggest that the ways in which resilience is defined and measured in relation to LGBTQ populations remains contested. Given that LGBTQ populations have unique lived experiences of adversity and discrimination, and may also have unique factors that contribute to their resilience, the utility of heteronormative and cis-normative models of resilience is questionable. Our findings suggest that there is a need to consider further exploration and development of LGBTQ-specific models and measures of resilience that take into account structural, social, and individual determinants of health and incorporate an intersectional lens. Conclusions While we fully acknowledge that the resilience of LGBTQ populations is central to advancing LGBTQ health, there remains much work to be done before the concept of resilience can be truly useful in measuring LGBTQ health.
Life history interviews were conducted with 40 gay and bisexual men to identify modes of syndemic experience and risk practice. Out of the interview narratives emerged one major and two minor modes of developmental pathway whereby syndemic conditions are navigated and expressed: (1) a combination of adverse childhood events with later episodes of depression and/or substantial substance use; (2) personal disruption that led to periods of depression and anxiety associated with the stresses of migration; and (3) a disorientation and an unravelling of life trajectory in the transition from family of origin to college or work. Risk practices fell into three high-risk modes: active and frequent engagement in condomless sex; unassertive deferment to a partner's initiation of condomless sex; and episodic risk combined with a risk reduction strategy. Three low risk modes were also identified: no recent condomlessness but multiple risk history in interview; a trajectory over time from high to low risk; and consistent low risk practice. These different modes of syndemic experience and risk management may have implications for identification of the effective HIV prevention tools that work best for different sets of men.