By: SPENCER COX AND BRUCE KELLERHOUSE, PH.D.
New data released by the New York City Department of Health shows that the highest rates of new HIV infections are among gay men 35 to 49 years old. These findings are alarming and, to some, perplexing.
Why are so many mid-life gay men who were able to avoid HIV infection for so long now taking risks that are exposing them to the disease?
We believe that one common thread runs through most of these men’s life histories – they came out and/or lived during the death-saturated culture of the 1980s and early to mid-1990s.
Mid-life gay men have lived most of their adult lives during the worst of the HIV/AIDS epidemic, experiencing the loss of partners, friends, and people in their community. As witnesses to so much illness, death, and loss, their voices have seldom been heard and their needs largely overlooked. Having once been the activists, caregivers, and volunteers for our community, many mid-life gay men now feel invisible and isolated. Not only lives were lost, during this period, but entire social networks and ways of living disappeared too.
The traumatic effects of AIDS-related losses were closely studied between 1988 and 1996. By 1988, gay men had already on average lost six lovers, friends, and/or family members. Researchers have shown that people who had more experiences of AIDS-related loss also had higher levels of traumatic stress response symptoms and recreational drug and sedative use.
However, almost no effort has been made to study the long-term impact of the AIDS epidemic on mid-life gay men, or to determine whether current elevated levels of risk-taking behaviors in gay men are related to the trauma of surviving one of the worst epidemics in our history. That lack of attention may now have come home to roost – in rising rates of risky behavior that are secondary to the effects of unprocessed traumatic responses to decades-old losses that haunt our daily conscious and unconscious lives as mid-life gay men.
Friendships have been shown to play an important role in health maintenance and in provision of care during poor health. The relationship between friendships and health is particularly important for gay men, for whom social networks often take the place of missing biological families. Conversely, many health problems that are now common among gay men are made worse by loneliness and lack of social opportunities.
Having survived the HIV pandemic, urban gay men in mid-life may be particularly vulnerable to the negative effects of decimated social networks. Difficulty in making and sustaining relationships is a characteristic effect of traumatized people. The normal stresses associated with mid-life, together with the lingering effects of loss associated with survival through the epidemic, may make it difficult for these men to create and maintain new groups of close friends.
Furthermore, gay men have high levels of depression and anxiety disorders, another characteristic of people who have survived trauma. Studies estimate that gay men have about twice the levels of depression than are found in Americans generally. Depression is strongly linked to high-risk behavior, including drug use, alcoholism, and risky sex.
The methamphetamine epidemic that has swept through urban gay communities also contributes to high levels of new HIV infections. A recent study from the Los Angeles Gay & Lesbian Center, which offers HIV testing, found that one in three new HIV-positive tests was associated with meth use. About one in 10 gay men in New York City report recent meth use.
In some ways, gay men in mid-life are at the center of a “perfect storm,” in which multiple problems converge to create a very high-risk environment.
Dr. Ron Stall, one of the leaders in studying gay men’s health, has shown that different kinds of psychosocial problems, such as depression, drug use, and partner violence, interact to create higher levels of risk for HIV – in other words, the more psychosocial problems that a person experiences, the higher their risk of getting infected.
We can’t just address these problems independently, but need to understand the dangerous ways they work together.
If we are to lower HIV infection rates for this population, we need a renewed focus on HIV prevention for gay men. Many of our AIDS organizations are missing in action when it comes to gay men. They’ve assumed that, because we know how to have safer sex, their job is done. But these data show that the problem isn’t lack of information.
Handing a 45-year-old man another safer sex brochure just isn’t going to do the job. We urgently need to create programs that directly address the real reasons that gay men engage in high-risk behavior.
Our AIDS organizations need to be experimenting with new programs and new models to prevent HIV infection, but most of them are nowhere to be found.
The development of effective treatments for HIV disease has given many of us a new lease on life. But if we are to make the most of this opportunity, we will have to understand the legacy of this plague – what it has done to us. We owe that much to those who fought and died, and to those of us who are fighting and have survived.
Spencer Cox is the founder and executive director of the Medius Institute for Gay Men’s Health. Bruce Kellerhouse, Ph.D. is the co-founder of HIV Forum and a psychologist in independent practice.