Sunday, February 7, 2010

Seeing Healthy Gay Men

I've been invited to take part in a panel discussion on Wednesday. Here's a preview of my talk. I'd love feedback on the flow, grammar, anything to make it roll off the tongue easier. I don't have a lot of time to deliver the talk, and I want to get some key ideas out there clearly.

Introduce yourself to the person next to you, just your name. Hold their hand, and look right into their eyes, take a good deep look. Think about how healthy this person is. Through all of life's adversities, here is this healthy person in front of you.

What I've just asked you to do is very different from how I, as a public health researcher, look at gay men. To put it bluntly, in public health, we don't see healthy gay men.

First of all, we are not accustomed to look at health in anyone, queer or bland. We almost always look at sickness and death, and very rarely at health. Sickness is easier to measure than health. Sickness is seen as objective, while 'health' and 'well-being' are subjective states. Death is the most objective health outcome, and thus the most trustworthy object of study. So it's nothing special about gay men. We're not used to seeing anyone as healthy.

But there other reasons that public health, broadly written, is not used to seeing healthy gay men.

One of these is that a little over a hundred years ago, the fields of medicine (and later psychology) tried to exercise authority over homosexuality, to claim it as their turf, a claim widely supported by homosexuals at the time. It was a humane alternative to being regarded as the embodiment of sin, or being treated like a criminal.
Old habits die hard, and it has been hard to let go of these 'humane' impulses, despite the official depathologization of homosexuality in 1975.

Another reason that public health has a hard time seeing healthy gay men is that we actually have a lot invested in gay men being ill. That may sound strange at first, but think about it - citing health disparities is how we raise awareness about the health challenges facing us. Playing up health disparities is how we get money for programs. It's often how we make claims that legal protections are needed, how we describe ourselves in media stories to gather support.
So seeing healthy gay men risks upsetting the apple cart, derailing the gravy train, if you will.
And then there's the right wing. Not only are we a threat when we're sick, but if we're not sick, then we don't need "special" protections. We just can't win with those guys.

The last reason that public health has a hard time seeing healthy gay men that I want to raise is the perceived 'failure' of HIV prevention. While it would make sense to look at the relatively small number of new infections these days compared to the early 1980's and claim a great deal of success in HIV prevention, there is a tendency in public health circles to treat each and every new infection as a failure.
After all, we know a lot more about the biology and psychology of how HIV is transmitted. Hundreds of millions, probably billions of dollars have been spent on research and prevention efforts in the US, so even a single new infection represents some sort of failure in our prevention efforts.
Often implicit in our conversations about the 'failure' that each new infection implies is some blame directed at the man who got infected, and perhaps towards the man who infected him. Were these guys high? Careless? Selfish? Immature? Maybe they were just looking for love in a harsh world. Maybe they were possessed by the worst affliction a gay man can have in the eyes of public health: being a bug-chaser. All of these explanations imply that the infection was enabled by an individual weakness. So we are used to seeing gay men as sick, or at least as perpetually 'at risk'. And any attempt to break free from a life constantly 'at risk' must be a little crazy.

There may be other reasons that we public health types have trouble seeing gay men, but these are some of the big ones: 1) public health has a hard time seeing anyone as healthy, 2) the historical disciplinary claim of medicine and psychology implies that there is something inherently pathological about homosexuality, even though an explicit claim of pathology would be rejected in most circles. 3) seeing healthy gay men undercuts our ability to raise awareness within the community, and funds for services from public and private granting agencies, and 4) how else does one explain 'failures' in HIV prevention?

And so, a little over a year ago, when I came across evidence that gay men might well be healthier that straight men, I was dubious.
I was looking at data from the 2003/2005 California Health Interview Survey, the idea I had was to systematically go through the CHIS, documenting the disparity of each health outcome for gay and bisexual men relative to straight men, and for lesbians and bisexual women relative to straight women.
The first one on the list was pretty boring, at least from an epidemiologic standpoint: "in general, would you say your health is excellent, very good, good, fair, or poor?" Although this is by far the most common question on health surveys, analytically, we usually treat it like a throw-away question, basically a way to build rapport with the person on the other end of the phone before getting in to the more personal and revealing questions.
I expected to see what others before me had seen, that gay and bisexual men were more likely to report "poor" overall health. And they were in this dataset, too. But more striking was that gay men were also more likely to report being in excellent health. And that difference was larger.

But like I said, I was skeptical. Maybe it was a statistical fluke. I did what any sensible epidemiologist would do. I ignored it and moved on.

But, it stuck in the back of my mind.
When the 2007 data came on-line a short while later, I took another look, and the same pattern held. So now, I began to wonder if there might be something to it, these healthy gay men, not less healthy than straight men as everything had led me to expect, not equally healthy as straight men, but actually more likely to be healthy.
So then I began to look at other datasets. In most datasets, but not all, gay men were more likely to report excellent health.
I was still dubious.
Perhaps gay men were more likely to be in excellent health because they were younger, more educated, affluent. In most studies, men who say they are gay tend to be younger, more educated, affluent, and these things also tend to produce better health. So now I needed to find a dataset that was large enough to break people down by age and socioeconomic position.
I found two very large datasets, the Current Population Survey, and the Behavioral Risk Factor Surveillance System.
In both of these datasets, gay men were more likely to be in excellent health than straight men in all age groups, and within all levels of educational attainment. The BRFSS dataset was so large that I could stratify by both age and educational attainment simultaneously. Same result.
So now I knew it wasn't a fluke, it wasn't just because men who say they are gay to a stranger on the phone are just demographically healthier. Gay men were actually more likely to report being in excellent health.

Once I'd convinced myself that gay men are more likely to be in excellent health, that it was a 'real' finding, the next question is "Why?".
With all the HIV, STD's, alcohol abuse, drugs, depression and anxiety, even suicide documented in the literature, it still baffles the public health mind.
I'm going to leave the question "Why?" open, and move on instead to a related question: "So What?".
If gay men are more likely to be in excellent health, what are the implications of that?
One implication is that in the face of the long, oft-repeated litany of health-related faults, some gay men have found a way to thrive, arguably with no assistance from us in public health.
Perhaps we can learn from these healthy gay men. But that requires being able to see healthy gay men, and then to talk with them, and ask the right questions.

The salutogenic (health-creating) processes that these men have undertaken could be a blueprint for the rest of us, a novel approach to addressing the troublesome health disparities that gay men face.

Another implication is that gay men may well be doing some things 'right' that heterosexuals could do well to emulate. Perhaps the ways that we gay men have learned to structure our lives, with strong friendship networks, provides space for us to excel. Perhaps our more nuanced approach to monogamy and relationship structures gives us permission to be truer to ourselves and the ones we love. Pure speculation on my part, but if more of us are in excellent health despite all the social forces arrayed against us, we've got to be doing something right, and maybe if we knew what that something was, it would help society at large.

{I haven't quite figured out how to wrap it up yet}