A recently published study connects the dots between the disproportionate rate of mental health problems among gay and bisexual men and their equally disproportionate rate of HIV infection. It suggests that to be effective, HIV prevention efforts must first support our mental health, rather than simply try to discourage risky sexual behavior.
HIV prevention and gay men's health experts for years have said a holistic approach is needed to address the "upstream" drivers of risk behavior -- exactly the sorts of psychosocial problems the new study measured. The study, reported in the Journal of Acquired Immune Deficiency Syndromes, examined how five mental health conditions -- depression, alcohol abuse, stimulant use, multi-drug abuse and exposure to childhood sexual violence -- affect gay and bisexual men's risk for HIV infection. Researchers analyzed data from 4,295 HIV-negative men who reported having sex with men within the previous year. The men completed a behavioral survey and were tested for HIV every six months for 48 months.
Of the 680 men who completed the study, those who reported the largest number of psychosocial problems were the most likely to be HIV-positive by the end of the study. Men who reported four or five psychosocial problems were about nine times more likely to have become infected. They were also more likely to have unprotected anal sex with an HIV-positive man than men without any of the problems measured.
Based on their findings the behavioral scientists concluded "the HIV prevention agenda requires a shift toward improved assessment of psychosocial comorbidities and stronger integration with mental health and substance abuse treatment services." In other words, healthy and protected sexual behavior will follow if we first focus on healing the psychological wounds gay men routinely experience in a society where we can now legally marry a same-sex partner in 36 states while in 29 states we can be fired from a job simply for being gay.
My interviews with leading researchers on gay men's health and HIV prevention make clear that what is most needed is interventions and programs that build on the resilience and strength most gay men develop simply to survive into adulthood.
Ronald Stall, Ph.D., director of the University of Pittsburgh's Center for LGBT Health Research, was the first to identify four interconnected "epidemics" of psychosocial health conditions that disproportionately afflict gay and bisexual men. Each one -- childhood sexual abuse, partner violence, depression, and drug use -- makes the others worse. Their insidious effects are referred to as syndemics. Men from lower income or culturally marginalized ethnic groups are especially vulnerable to syndemic effects.
In one study, Stall and his colleagues found that 11 percent of 812 men who reported one problem--depression, for instance--had engaged in high-risk sex (condomless anal intercourse). Of 129 men who reported three or four problems, 23 percent said they had high-risk sex.
There is no disputing the fact that the numbers are high relative to the so-called general population. But we see something astonishing when we flip the numbers on their head: 89 percent of the men reporting one problem did not engage in high-risk sex. Likewise, more than three-quarters of the men with three or four problems did not engage in high-risk sex.
These numbers make it abundantly clear: Despite even our own internal psychological challenges, the overwhelming majority of gay men are incredibly resilient and actually do take care of, protect and value ourselves.
Ron Stall in an interview for my Atlantic article about gay men's resilience called resilience "an untapped resource" in protecting gay men's health, avoiding HIV and building a strong community.
In fact, a 2013 report from the National Institutes of Health LGBT Research Coordinating Committee pointed out that understanding resilience--how it develops, may protect health, and buffers against the stigma that sexual minorities risk turning upon themselves--should be a cornerstone of the institutes' future LGBT health research.
Research suggests our journey toward being healthy, resilient gay men begins by accepting our sexual orientation as a natural, normal part of ourselves. Ron Stall told me in our interview, "Guys who do the best job of resolving internalized homophobia [or self-stigma] are the least likely to have current victimization, substance abuse, and compulsive [high-risk] sex."
Put a little differently, he said, "Getting a population of people to not hate themselves is good for their health. This is not rocket science."
Interventions and programs aimed at building our resilience and bolstering our mental health can be the "rocket fuel" propelling us to greater heights of self-esteem, good health and even lower rates of new HIV infections.
One of the researchers of the new Journal of AIDS study, Harvard medical professor and Fenway Institute research director Kenneth D. Mayer, M.D., told me in our interview for the Atlantic resilience article, such interventions are particularly important for young people. "If we can identify programs that engage youth so they feel good about themselves," he told me, "there will be fewer problems down the road."
Healthy men make healthy choices. It's that simple -- and that complex.