This talk was presented at the AIDS Impact conference in Brighton, England, in July 2001. A poster presentation of these data was also displayed at the conference.

"Coming Out" is associated with HIV seroconversions among young gay men

Arn J. Schilder, Patricia M. Spittal, Mary Lou Miller, Steve Martindale, Jill Parsons, Kevin JP Craib, Michael V. O'Shaughnessy, Robert S. Hogg.

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Good morning everybody. Thank you for attending this session. I am presenting our study entitled: 'Coming Out' is a Factor Associated with HIV Seroconversions Among Young Gay Men.

BACKGROUND:

  • This prospective study of over 900 Gay youth mirrors the rising HIV infections in other cities throughout North America.

The Vanguard Project is a prospective study of over 900 sexual minority men in the Greater Vancouver region, in which HIV seroincidence has increased 7 fold in the last year. As the HIV pandemic matures, Gay men remain profoundly affected.

 

METHODS:

  • Case study methodology
  • All 26 study participants have been recruited
  • Participants are interviewed up to 4 times over 10 months
  • Textual data are coded, managed and explored using NUDIST qualitative research software
  • We explore the experiences with abuse, sex, family, community, substance use, beliefs about condom use and cum, and therapeutic optimism

This is a anthropological sub-study utilizing case study methodology. 26 participants will be interviewed up to 4 times each over 10 months. Textual data are coded, managed, and explored using NUDIST qualitative research software. We investigate the determinants and risk experiences including histories with abuse, sex, family, and community. We probed for intention and self-efficacy regarding condomless sex, substance use, and finally beliefs associated with condoms, 'cum' and HIV antiretroviral therapy.

 

WHY SEROCONVERT TO H.I.V. IN THESE TIMES?

  • Is antiretroviral therapy responsible for the slippage?
    Heard more in the hallways of public health then on the street.
  • Are there new trends in substance use?
    "You know how big drugs are now-a-days?"
  • Are beliefs about intimacy linked to barebacking?
    "Fucking is more intimate without condoms. Sex without condoms is the real thing"
  • Are Gay men just tired of being afraid?
    "Before I was just so worried about becoming HIV-positive... and now I am!"

In our study we asked these questions:

  • Why do young Gay men continue to seroconvert to HIV?
  • Are the new HIV therapies linked to a resurgence of HIV risk behaviour?
  • Are new trends in substance use a factor fueling HIV seroconversions?
  • Are beliefs about bareback sex linked to intimacy?
  • Are Gay men just tired of being afraid and wanting to get it over with?

 

SEXUAL VIOLENCE: Non Consensual Sex

"He was about seventeen and I was eight years old. I guess I was just giving off this energy. He started molesting me and forced me to blow him. That was my introduction to sex and that went on for years."

HIV Positive Young Gay Man

Our early findings indicate that a number of factors in early life landscape the risk for HIV infection as adults. In April, Jay Paul of San Francisco reported in the Journal of Child Abuse and Neglect that 20.6 percent of Gay men experienced childhood sexual abuse -- a rate much higher then for the general population of males. Here one participant reveals how he was introduced to sex at age eight by being forced to perform oral sex on someone who was much older. This sexual violence continued over six years. Paul found that the greater severity of childhood abuse was associated with higher rates of risky sex. Paul also found that men who were sexual abuse survivors had higher rates of sex under the influence of alcohol and/or drugs, more "one-night stands" and more intimate partner violence.

 

STIGMA: A Devalued and Spoiled Social Identity

"I think I was probably going through a really rough time. I was 'coming out [and] dealing with being 'Gay' and finally admitting it to myself? I was not really feeling very positive about my future. I was wondering are people going to accept me? Like... really accept me?"

HIV Positive Young Gay Man

As you must know, stigma is associated with a Gay identity as well as reduced safety, social inclusion and economic expectations. This young man who was adopted as a child, sexually assaulted throughout childhood and adolescence by older males, resonates the concern about adopting a Gay identity which was associated with shame, potential rejection, or loss of social status. This quote reflects how devalued he felt.

FAMILIAL DISCORD: Incomplete Interpersonal Skills

"In the past years I have had a lot of time to think about our family. Since seeing my behaviours and how I react in situations I get myself into; I am just really starting to appreciate how dysfunctional my family was."

HIV Positive Young Gay Man

Some men made the connection between their own vulnerabilities in relationships with that of the discord between their own parents. Balanced family lives informed their capacity for balanced interpersonal relationships. This capacity informed their ability to balance power and negotiate sexual safety.

BEING OUT often means inevitable migration

"For me and a lot of people especially if you're from a small town, when you first come out, you are a new face in town. You are a kid in a candy store because all these men want you."

HIV Positive Young Gay Man

I chose this slide to demonstrate how histories of violence, stigma and familial discord all inform how vulnerable one becomes. This especially the case at the times of coming out and/or migration to an urban center. This statement is given by a man who was abandoned by his mother, often beaten by his father, and sexual abused by a family friend. He ended up in foster homes and became a prostitute at age 17 subsequently migrating to Vancouver where he worked as a transvestite prostitute because it paid better. He was drugged, raped and infected with HIV. Like so many, coming out was often linked to a migration to an urban Gay village, usually for reasons of education, career, emotional and/or social support. In this study, participants defined coming out as -- 'being out' to one's family, friends, and at work about one's 'Gay' identity.

 

Convergence of Vulnerability and Risk in 'Liminal Time'

  • Times of "coming out" are "liminal times"
  • Liminal time is a cross-cultural phenomenon
  • These are times of social transition
  • Transitions are usually marked by 'rites of passage'

In this sample, coming out was a time of transition and the convergence of individual vulnerabilities with nested social risks during an unmarked 'rite of passage'. Histories of violence and family dysfunction, and the adoption of a devalued identity and along with migration make these times chaotic and very risky . In Anthropology, these times of sexual and social transition are known as "liminal times" and correspond to the 'coming out' phenomenon. "Liminal" time is a cross-cultural phenomenon wherein youth transition into adult life which is an unmarked passage in current Gay culture. All cultures have rites of passage linked to these transitions of social identity.

 

COMING OUT IN LIMINAL TIME: Starting at Ground Zero

"Adolescents have all this knowledge that they have been given, but even then emotions can take-over completely. That is the same thing that is happening to Gay youth. We start from ground zero as far as dating and emotional involvement. Gay men just don't have the tools to negotiate safer sex , especially in those first few years when we first come out. Intellectually you know you should be using a condom and think: 'this is insane what I am doing'. But at the same time there is that little voice saying: 'He won't love me, won't want me, and will walk out the door. I will lose this partner and intimacy.' "

To make a point, I want read for you what one participant advised: "Adolescents have all this knowledge that they have been given, but even then emotions can take-over completely. That is the same thing that is happening to Gay youth. We start from ground zero as far as dating and emotional involvement. Gay men just don't have the tools, especially in those first few years when we first 'come out'. Tools to negotiate safer sex. Intellectually you know you should be using a condom and thinking 'this is insane what I am doing'. But at the same time there is that little voice saying... 'He won't love me, won't want me, and will walk out the door. I will lose this partner and intimacy.' "

 

ISOLATION: Sex and Loneliness

"I was just so lonely coming out. I went out and met someone. I think that because of loneliness and that need to connect emotionally, that probably does override a lot of common sense and teaching."

HIV Positive Young Gay Man

A number of other factors make coming out a hazardous period of time. Gay youth arrive into urban communities as if out of a vacuum ---unguided and without support. In this process, isolation, loneliness, depression, and substance use exacerbate the risk of HIV infection. When coming out, one's sexual identity is deconstructed and reconstructed and a new identity and sexuality is adopted.

 

TIMES OF PARTYING: Party Drugs and Alcohol

"When I came out, I would party for a good year. We would go out like every weekend. Sometimes I was going out 5 of 7 nights a week. I was not necessarily doing party drugs every one of those times."

HIV Positive Young Gay Man

This participant illustrates how coming out is not unlike the hazing experience of any first year university student away from home. In these data, substance use increased during these stressful times of coming out . In this social context, 'to party' means to socialise, consume drugs and/or alcohol, and to have a lot of sex. As we know, from the literature, substance use is a factor that potentiates the risk for HIV infection. In many studies on Gay men, unprotected receptive anal intercourse and drug use such as alcohol, cocaine, poppers and injection drug use have been shown to be independently associated with HIV infections.

 

SUBSTANCE USE: Loneliness and Distress

"I was pretty messed up when I came out in the summer of 1995. I was going out with this guy and then we broke up. I started drinking a lot and going to the bathhouse. This one time, I just slipped up and was not careful."

HIV Positive Young Gay Man

Stressful experiences like the break-up of a relationship inform risk as articulated in this quotation. Alcohol and drugs are linked to a vortex of risk. Prevention messages that moralize about the avoidance of 'sex under the influence' may not be effective for those men who use of substances as a form of coping with the disturbing aftermath of untreated traumatization. Thus, prevention messages miss the mark for those most vulnerable who may be self-medicating.

 

INTIMACY:

"Sex with condoms is what you do until you get to the point where you can have sex without condoms. But you get to a point where you want that intimacy. Bareback sex is real. I feel you and you feel me. There is nothing in between us. It is the ultimate in intimacy."

Living to old age was collateral and not an important goal. This quote expresses that that danger of HIV infection was not always perceived as a fundamental concern. As this participant states "Sex was intimacy --- bareback sex was real Gay sex --- bareback sex was seen as the ultimate in intimacy." After an early life that was filled with difficulty and isolation, many of these men fundamentally wanted intimacy above anything else.

 

DISASSOCIATION: Separating Emotions From Sex

"When I'm depressed... I have incredibly low self-esteem and feel self-destructive. It is like anyone can do anything they want to me. And I don't care. It is almost like I'm not there. And I go for physical intimacy, and separate myself from emotions. That is my escape."

HIV Positive Young Gay Man

Some men said they could separate their emotions from the sexual experience. As he clearly articulates, this fellow separated himself from his emotions during sex. Here he describes it as an escape. He had also experienced sexual assault as a child and grew up in foster care, and depression was a key factor associated with his seroconversion. Sex often appeared to be someone else's experience. This is disassociative behavior, which is a predictable survival strategy used by victims of abuse. One becomes trance-like, leaves the body and disengages. Our early data are consistent with Van der kolk who reported child sexual abuse leads to dysregulation of boundaries. We also know the adult sequelae of child abuse are sexual impulsivity, mental distress & depression, patterns of revictimization, and substance abuse.

 

FACTORS ASSOCIATED WITH "COMING OUT" IN LIMINAL TIME

  • Histories of violence
  • Adopting a devalued social identity
  • Familial discord led to poor interpersonal skills
  • Migration to urban Gay villages
  • Transitions were unsupported and unguided
  • Loss of identity and social support
  • Substance use
  • Loneliness and depression
  • Need for intimacy
  • Disassociation during sex

The capacity or even consideration to object is highly overrated and poorly defined in prevention, especially when boundaries are obliterated, undeveloped or submerged by systemic social and criminal abuse. Within this sample, All the following factors that converge in a vortex of risk within liminal time are thus associated with seroconversion during coming out . These were: histories of sexual and physical violence; adopting a devalued social identity; familial discord which led to poor or incomplete interpersonal skills; migration to urban Gay villages; transitions that were unmarked, unsupported and unguided; the loss of identity and social support; substance use; loneliness, depression and distress; the need for intimacy and disassociative behavior during sex.


WHAT CAN BE DONE: Health care and prevention and Gay communities need

  • To be aware of 'liminal' time in the context of Gay men.
  • To address child abuse and its subsequent disregulatory adult sequelae and make referrals.
  • To help innovate customs and a mentoring process to assist in the safe passage of youth during the liminal time of coming out.
  • To become aware of the cultural issues of Gay men.

What needs to be done? Practitioners of health care and prevention as well as the Gay community need to be aware of 'liminal' time in the context Gay men's culture. This will require they address child abuse and its' subsequent disregulatory adult sequelae and make referrals. Culturally safe environments are required for youth to safely transition into adult life. Gay communities need to innovate customs and a mentoring process to assist in the safe passage of youth during the liminal times of coming out. Finally, these data illustrate that policy makers should incorporate culture to reduce the risk of HIV infection among youth. This means researching, understanding and accepting Gay cultural values and beliefs. It is unlikely HIV infections will subside if policy makers continue to deal with Gay men only in part, or as behavioral risk factors, and not as whole social beings.