Operating Without a Safety Net: Gay Male Adolescents and Emerging Adults’ Experiences of Marginalization and Migration, and Implications for Theory of Syndemic Production of Health Disparities

Abstract

Health disparities among gay men (HIV, substance use, depression) have been described as a mutually occurring “syndemic” that is socially produced through two overarching dynamics: marginalization and migration. Although the syndemic theory proposes a developmental trajectory, it has been largely based on epidemiological studies of adult gay men and has not been examined using qualitative data from gay male adolescents and emerging adults describing their developmental experience. We conducted interviews with 54 HIV-positive gay and bisexual male adolescents and emerging adults at four sites in the United States. This study provides examples of developmental trajectories that help explain the early onset of socially produced health disparities among some gay male adolescents and emerging adults, but also the development of risk factors that may follow some gay men into adulthood.

Background

In the United States, men who have sex with men (MSM) are affected by marked health disparities, including elevated prevalence rates of drug use (Stall et al., 2001), HIV infection (Centers for Disease Control and Prevention [CDC], 2008), and depression (Mills et al., 2004). A theory of “syndemic production” of health disparities among gay men in the urban United States has been proposed, linking high rates of depression, substance use, and HIV/AIDS as intertwined epidemics among groups of gay men that arise from negative childhood or adolescent experiences associated with their emergent gay identities (Stall, Friedman, & Catania, 2008). It is posited that each of these epidemics mutually reinforce one another through intersections of high-risk behavior and function together to lower the health profile of gay men. There is ample evidence of the interconnection of these issues among samples of adult gay and bisexual men during the HIV/AIDS epidemic (Colfax et al., 2004; Ostrow et al., 1993; Stall et al., 2001; Stall & Purcell, 2000; Valdiserri et al., 1988), and recent research among young MSM has revealed preliminary evidence as well (Mustanski, Garofalo, Herrick, & Donenberg, 2007; Rusch, Lampinen, Schilder, & Hogg, 2004).

Theorizing that cultural marginalization alone may cause epidemics, Singer (1994) first used the term syndemic to explain low health profiles of substance-using Puerto Ricans in the urban Northeastern United States. Stall et al. (2008) proposed that syndemic health disparities among gay men are socially produced through two overarching dynamics: marginalization associated with early male adolescent socialization in heterosexist environments and the stressors associated with migration to large cities with sizeable gay communities. This theoretical model is also informed by prior conceptualizations of gay men’s health, including minority stress (Meyer, 2003; Meyer & Dean, 1995) and masculinity failure (Diaz, 1998), that explain health behavior as a result of socially produced stigma and stress.

Syndemic theory as applied to gay men is largely developmental in nature, beginning with adolescence and sexual awakening and continuing through formation of an adult gay male social identity. Most research and theoretical literature regarding gay sexual orientation identity development has proposed a process of progression through steps or stages (Cass, 1979; Coleman, 1982; Troiden, 1989). These stages may be summarized as (a) experience of same-sex sexual attractions followed by confusion and feelings of being different; (b) awareness of heterosexism and homophobia in the larger society and subsequent withdrawal into various states of isolation; (c) exploration of the gay community through personal contacts, dating, and sexual relationships with other gay individuals; and (d) acceptance and integration of one’s sexual orientation as an element of one’s identity. More recently, researchers have suggested that such stages may be viewed as more “fluid” steps in sexual orientation identity development and may not necessarily progress in a singularly linear manner (D’Augelli & Hershberger, 1993). Emerging research suggests that gay sexual orientation identity development may proceed in a more recursive manner in which young gay men cognitively evaluate and reevaluate their explorative experiences with perceived roles and responsibilities, family and community influences, and experiences of oppression in order to ascertain whether their sexual identity “fits” commonly used labels such as “gay,” “homosexual,” “bisexual,” “queer, “trade,” or “down-low” (Harper, Fernandez, Jamil, Hidalgo, Torres, Bruce, & the ATN, 2010). Stage-based gay sexual orientation identity development models have also come under challenge because of assumptions of a monolithic sexual orientation identity without consideration of the intersection of other social identities such as race/ethnicity, gender, or class (Gilbert & Sullivan, 1998). For gay male youth of color, sexual orientation identity development may occur simultaneously with ethnic identity development and be influenced by cultural norms within one’s ethnic group as well as experiences of oppression as an ethnic minority (Dube, Savin-Williams, & Diamond, 1995; Jamil, Harper, Fernandez, & the Adolescent Trials Network for HIV/AIDS Intervention [ATN], 2009; Savin-Williams & Rodriguez, 1993).

Informed by conceptual frameworks proposed by Meyer and Dean (1995) and Diaz (1998) and theories of sexual orientation identity development during adolescence, Stall et al. (2008) used epidemiological data to propose a theory of syndemic production to explain health disparities present in communities of urban gay men in the United States. Most of these epidemiological data were drawn from samples of adult, predominately white, gay men. To date, most research investigating links between stigma and the health behaviors of gay men have also utilized samples of adult men (Bruce, Ramriez-Valles, & Campbell, 2008; Diaz, Ayala, Bein, Henne, & Marin, 2001; Mays & Cochran, 2001), although recent research has documented significant associations between parental rejection and negative health outcomes among gay and lesbian adolescents (Ryan, Huebner, Diaz, & Sanchez, 2009). What is not well known is how the processes involved in developing one’s sexual identity within a heterosexist environment may lead to future syndemic behavioral health issues.

To further investigate the processes involved in syndemic production among gay men, more data are needed on how the sexual identity development of gay male adolescents and emerging adults may interact with risk for syndemic health disparities. Qualitative data that describe the experience of this population at the intersection of sexual orientation identity development and health behavior will aid in the specification of processes involved in syndemic production and lay the groundwork for empirical testing of syndemic theory from a developmental perspective. In this article, we present analyses from interviews with a racially diverse sample of HIV-positive gay and bisexual male adolescents and emerging adults in order to delineate processes involved in (a) responding to marginalization in adolescence due to their sexuality, (b) subsequent search for other gay men and migration to gay communities, and (c) risks and resiliencies associated with their marginalization, exploration, and migration.

Method

Study Design

The data discussed in this article were derived from Phase 1 of a two-phase study investigating associations among HIV-positive MSM’s racial identities, sexual orientation identities, and identities as HIV-positive young men with their stressors, coping mechanisms, and health behaviors (ATN070). Qualitative data collection was conducted at four geographically and demographically diverse sites that were part of the ATN. Attempts were made to recruit a purposive sample that consisted of equal numbers of young men ages 16 to 19 and 20 to 24 years and was evenly divided among three ethnic categories: African American, Latino, and Other (e.g., White, Asian American, mixed, biracial).

Recruitment

Young HIV-positive men ages 16 to 24 years who were receiving care within clinic settings at one of the four sites were approached by study coordinators to assess study eligibility. To allay any concern by potential participants that they had been “identified” by the study coordinators, they were informed that all men in the clinic setting who appeared to be between the ages of 16 to 24 years were approached and screened for the study. Inclusion criteria for the study included the following: (a) biologically male at birth and identifies as male at time of study participation, (b) HIV-infected as documented by medical record review or verbal verification with referring professional, (c) HIV infection occurred through sexual or substance use behavior of the participant, (d) between the ages of 16 and 24 years at the time of informed consent/assent, (e) ability to understand both written and spoken English, and (f) history of at least one sexual encounter involving either anal or oral penetration (either receptive or insertive) with a male partner during the 12 months prior to study enrollment. Study coordinators conducted a brief screening interview in a private room to determine eligibility; on verification of eligibility, study coordinators then obtained signed consent/assent from participants.

Study Procedures

Because the population of interest for this study was young MSM, the institutional review boards of each study site were requested to grant a waiver of parental permission to participate in the study for participants under the age of 18. This was done to avoid the selection biases present in recruiting only youth whose parents are both aware of and comfortable with their sexual orientation. The research protocol was approved by the institutional review boards at all participating sites, as well as the home institutions of all primary investigators.

Once consent/assent was received, participants were enrolled in the study and assigned a confidential study ID that contained no identifying personal information. Interviews were scheduled by study coordinators at each site and conducted by interviewers trained by the study’s principal investigator and project director. All interviews were digitally recorded and transcribed. During the course of data collection, the interviewers met on a weekly basis to discuss their experiences in conducting the interviews and to ensure consistency across data collection. Original recordings and transcribed interviews were stored on a secure server with access restricted to key research staff at the principal investigator’s institution.

Interview Guide

A semistructured qualitative interview guide was created specifically for ATN070 by a team of researchers who had extensive experience working with both HIV+ and gay/bisexual youth. Questions were designed to elicit data in connection with three identities: their racial/ethnic identities, their sexual identities, and their identities as young men living with HIV. The Disability-Stress-Coping Model (Wallander & Varni, 1992) was used as a framework to develop questions that would investigate stressors (or risks) and coping mechanisms (or resiliencies) related to their healthy identity development, as well as substance use, sexual behavior, and adherence to health-care. This model had been previously adapted within the ATN to studies (ATN055, ATN068) of newly diagnosed HIV-positive youth in order to identify the psychosocial and medical needs of these youth. A semistructured interview format was developed that explored risk factors (psychological stress, functional independence, disease parameters), resiliency factors (intra-personal competence, socioecological support, coping strategies), and health behaviors (substance use, sexual behavior, adherence to healthcare) using parallel lines of questioning within each identity domain. The findings presented below emerged from questions regarding the development of gay/bisexual identities during adolescence.

Questions were designed to be open ended (“In general, what do you think are some of the positive things about being a young gay man?” “People use drugs and/or alcohol for a lot of different reasons. How do you think being a young bisexual man influences your use of drugs and/or alcohol?” or “How has being a young gay man affected your interactions with other people?”) to elicit specific and contextual data regarding individual participants’ experiences, beliefs, and behaviors. The semistructured format gave interviewers a guide with which to investigate the domains of interest while allowing for participants to determine the context of the interview’s questions through their own narratives.

Data Analysis

Although the Disability-Stress-Coping model provided parameters for the structure of the interview and for areas of inquiry, bounded by risk and resilience in association with the three identities, a phenomenological approach to content analysis (Creswell, 2007; Hycner, 1985) allowed for the emergence of clusters of findings not necessarily determined by the Disability-Stress-Coping model. Initial analysis of risk and resilience data regarding gay/bisexual identity development revealed clusters of participant experiences that corresponded to components of Stall et al.’s syndemic framework. Although data were not elicited through a data collection process bounded by a syndemic framework, the phenomenological approach to data analysis allowed for syndemic themes and subthemes to emerge.

A diverse team of analysts (in terms of gender, ethnicity, and sexual orientation) met weekly to discuss findings. After interviews were transcribed and validated, participant responses to question areas were summarized across interviews by three analysts. Content analysis was then performed by the lead analyst to identify all concepts related to the individual research questions. Next, thematic analysis was conducted in which codes were assigned to delineate precise descriptions of themes that emerged from the content analysis. Inductive coding procedures allowed for indigenous concepts and typologies to emerge from the participants’ descriptions of their own experiences. As data related directly to syndemic health issues began to emerge, codes were assigned in accordance with theoretical relationships within the model of syndemic production proposed by Stall et al. (2008), that is, stigma/marginalization, marginalization/migration, migration/risk behavior. A team of six analysts met weekly to review coding and subcoding and agree on final codes. Finally, we performed cross-case analyses by constructing matrices to compare the aggregate themes and sub-themes across cases. Throughout the Results section below, pseudonyms are used with self-reported race/ethnicity and age to identify respondents.

Results

Participants were African American (n = 31), Latino (n = 12), White (n = 7), and mixed race/ethnicity (n = 4) male adolescents/young adults living with HIV who identified as gay or homosexual (n = 45) or bisexual (n = 9). Ages of participants ranged from 17 to 24 years (M = 21.0 years, SD = 2.2). The results are organized into sections related to the two “overarching dynamics” that Stall et al. (2008) cite in their syndemic model: marginalization within heterosexist communities and subsequent migration to gay-identified communities. In addition, we present a summary of risks and resiliencies that participants described as outcomes of marginalization and migration trajectories. Within each section, we summarize themes that emerged from the interviews. Included are particularly salient quotes from the participants themselves that link together in their own voices the themes and subthemes revealed within these dynamic processes.

Stigma and Marginalization

Themes that emerged regarding marginalization during adolescence included (a) experience of stigma and discrimination, (b) feelings of isolation, (c) lack of social support and lack of role models, (d) loss of childhood friends, and (e) discomfort within one’s “own skin.” These themes correspond to the initial feelings of being different, awareness of heterosexism and homophobia, and withdrawal into various states of isolation that have been described in existing models of gay sexual identity development. In addition, they delineate specific effects of and responses to marginalization that characterized emergent gay/bisexual sexual identity development among many of our participants.

Experiences of gay-related stigma and discrimination were noted by participants within multiple social settings, including families, schools, and local communities. Across the interviews, participants described stereotypes and stigma as challenges that were constants underlying their existence as gay male adolescents. Within many of the environments in which they were raised, they reported gay men were perceived as lacking masculinity, being weak, or carrying disease. From the time they began to “act different” or notice that others “acted differently,” participants cited multiple incidents of discrimination, ranging from name-calling to instances of outright violence.

Several participants described deeply entrenched stigma within their schools and communities that often forced them to hide feelings and withdraw, face ridicule, and resultant loss of friendships. Antigay stigma and homophobia were often institutionalized within schools, the most egregious example being that expressed by a school official in an account related by Thomas, a 21-year-old African American young man:

When I was in 9th or 10th grade, me and a boy got into an altercation because they pick on when you gay because they feel as though “Oh, he gay, he a punk, he a faggot,” and they think he won’t fight back. … So me and a boy got into it and I maced him. So when I went back to school the next day, I got pulled into a conference. We had a long conference but this was a crazy thing where an administrator said, “Well, if you’re gay, you should expect to get beat up.” (Thomas, African American, 21 years old)

In some cases, incidents of stigma and discrimination hit very close to home. “In my apartment complex, I’ve actually gone home from a night being in the club,” reported one young man from Memphis. “I wake up about 10:30. I come outside, I got all type of stuff spray painted on my car. ‘Gay bitch, move out.’ That’s what it said.”

Loss of childhood friendships was reported by several participants to be a product of their sexual identity development during adolescence, further marginalizing them in the communities in which they were raised. The loss of such friendships was often attributed to others’ not wanting to be associated with a young gay man, as described by this participant:

I’ve lost some friends, developed a lot of enemies because of my sexuality. … Like real friends, childhood buddies like from us drinking baby bottles to a beer bottle, we’re friends and now all the sudden, “You did it with dudes, yo? No man you can’t—I can’t—I can’t hang around with you no more. How do you think that’s gonna make me look?” This shouldn’t make you look like anything because I’m still the same person I was. (Aaron, African American, 22 years old)

Many of the young men we interviewed described an environment of isolation and depressive symptoms as they realized they were sexually attracted to other men. Few had support from family or peers nor role models for navigating this stage of their development. Participants noted that during this time in their life, they felt they did not have other persons to talk to about their thoughts and feelings. A 21-year-old African American young man named Jon summarized the effects of stigma and isolation within his own adolescence as follows:

Just like walking down the street sometimes, you know, like they’ll say things to you. … So it’s just like you don’t really have nobody to talk to there. … My family was religious and stuff like that … what am I doing? Is it bad? Is it like really like a sin. I think that’s why a lot of gay men go through depression. … I know when I was coming up I had a lot of depression, thoughts of suicide … when they say negative things to you when you’re young it really—it really hurts. It’s like you’re not as strong … back then I wasn’t as strong as I am now. (Antonio, African American, 21 years old)

In addition to discriminatory messages they received regarding their sexual orientation from their community as well as the larger society and media (“you just always feel second class”), many participants described feelings of not being comfortable within their own bodies, and not being comfortable in the presence of others:

Like I say, I just wasn’t very comfortable in my own skin at that point, so I didn’t have very much peace with that. (Jamal, African American, 24 years old)

The most challenging issue as a gay man? Learning to be comfortable in myself and my identity has been a really difficult thing. (David, Hispanic, 24 years old)

Although the two participants quoted above described their struggles in learning to be comfortable with themselves, others related examples of attempting to hide their “true self” around others, and going so far as to accept their own discomfort in order to not make others feel uncomfortable.

The perceived lack of other “people like them” and multiple experiences of stigma and discrimination in many cases led the young men to drop out of school, leave home, and find their own way at an early age. Michael described his own response to bigotry at home, perceived difference to those around him, and his resultant decision to leave home:

My dad he when he first found out, he was kinda like real like fucked up about the whole situation. He was like, “You a minority, you just suck … I don’t want no fucking fags calling the house, being in this house.” It got lonely and so tired of being all alone like me. … I sat down watched all my peers, you know, grow up, all of them being, like straight and just—everything’s just right and I mean, like here I am. Like the only one like that. And it made me feel like alone. It made me wanna go out with people like me. (Michael, African American, 19 years old)

Search for “Others Like Them” and Migration to Gay Communities

Experiences of marginalization were viewed by many participants as precipitating a subsequent search for other gay men through multiple pathways. The lack of support and availability of role models coupled with multiple experiences of discrimination within their home communities that characterized the early phases of their sexual orientation identity development in turn led to looking to other gay men for companionship, romantic relationships, and environments in which they more freely explore their sexual identity without the threats experienced within their own communities.

The search for other gay men during their adolescence was a constant theme reported by participants when asked to discuss risks and resiliencies associated with their gay identity. This search resulted in a number of what may be considered exploratory patterns such as (a) moving back and forth from the community in which they grew up to the gay-identified neighborhood within their own city and (b) exploring online communities and networks on the Internet, as well as migratory patterns such as (c) moving from a smaller town to a larger metropolitan area that contained visible communities of gay men. These pathways provided participants opportunities to explore their sexual identities within new social networks. Much of this exploration was conducted discreetly, as participants often characterized initial forays to meet other gay men by “sneaking out,” “covering up tracks,” “making up stories,” and lying in order to hide these explorations from family and/or friends.

Several participants acknowledged the role of the Internet in exploring their emergent identities as gay men and in finding other gay men for a range of social or sexual interaction. Going online for images of gay men, information on gay life, and interaction with other gay men and possible sexual partners was viewed by participants as reducing young gay men’s isolation. At the same time, seeking out sexual partners online was also seen as potentially placing inexperienced adolescents at increased risk. One young man maintained that the existence of the Internet probably accelerated the development of his adolescent gay identity, and the opportunities presented online had the potential for both positive and negative consequences:

At a younger—an age where I probably would’ve never known the things I did know because of the Internet I did know them regarding the fact that there is a giant world out there of gay things. … Having the Internet, that resource and knowing that there are social outlets of all kinds of good and bad things. Porn like crazy … gay porn. (Neal, White, 20 years old)

Despite the opportunities provided by the Internet for exploring gay identities and meeting other gay men, many participants identified gay bars and nightclubs as prominent venues for men looking to meet other gay men. Participation in nightlife was seen by many of the young men we interviewed as a means of entry to the larger gay community in their cities. The emphasis on clubs and bars among young gay men was described across our sample and was present in each of the cities in which we conducted interviews. One young man noted:

I think gay people in general, especially young gay people, they look at life as a party … I think so many young gay people, that going out and drinking and drugging, like that is their life; that’s the extent of everything that they do, you know? … I think it comes from coming from a place where so many of us haven’t had the freedom to be who we are and … moving to a bigger city that has a gay scene and bars and all this—like as many possible things that anybody can think of for themselves to get into. I think it’s just like from so many gay people come from like small towns and from small communities where they don’t have an outlet, and going into a place where they do have an outlet, they just go crazy simply because they’re making up for lost time, you know? (Carl, African American, 18 years old)

The same young man continued by acknowledging that much of what might be described as adolescent experimentation with substance use and sex was not limited to only young gay men; however, the risks associated with such experimentation were magnified in settings in which the young persons were operating without many of the social structures that help shepherd other adolescents through stages of their identity development into adulthood:

Most young kids, they can operate in the world and learn about themselves and who they are and the world around them, and have some sort of safety net underneath them so when they do fuck up they have that safety net there. I think young gay men, the majority of them that are out, you know they don’t have [that]—they aren’t close with their families, they don’t have a community at their school. … So I think that the majority of the times, young gay people are operating in the world and really trying to find out who they are and not having a safety net in order to protect themselves from anything, and not really having anybody to stand over them and kinda be their parent. (Carl, African American, 18 years old)

Migration within gay men’s syndemic framework has previously been described as a movement to identified gay communities in large metropolitan areas, such as New York, Los Angeles, Chicago, and San Francisco. Our participants’ experience suggests that gay men’s migratory patterns may also exist in more regional contexts, such as moving from small towns to regional midsized cities:

Now I live in Memphis, I think bein’ in Mississippi was kinda like a little rut for me to be—you know, I was in a small town. … Movin’ to Memphis and meeting such a wonderful group of people have really influenced me to be positive and change my outlook on dressing, and also the workplace and want to succeed to do better. (Marcus, African American, 21 years old)

Another participant who had moved to Memphis, contrary to some other participants’ views of risks associated with gay communities described above, described a “safety net” that consisted of other gay men who had developed their own supportive networks:

I can say this from the gay community that I have experienced, so far being in Memphis, and that is that as far as me, I have nowhere to go. I have friends who took me in. … I would say the straight community would have not something like that, but in the gay community, it’s just us. We don’t know what the world think of us, so we have no choice but to help support one another. (Bryant, African American, 22 years old)

Risks and Resiliencies

As the participants’ observations in the previous section suggest, exploration of one’s gay sexual orientation identity and migration to gay communities may carry potential risks and provide sources of resilience. Without a “safety net,” young gay men who explore or migrate to gay communities may expose themselves to heightened behavioral health risks, as well as increased opportunities for social support and meeting potential friends and partners. In different cases, risk and resiliency were both perceived to be present in gay-identified venues, institutions, and social networks. Risks and resiliencies that emerged may be thematically organized as (a) responses to previous repression of feelings, (b) responses to previous isolation, (c) social influences in identity development related to health behaviors, and (d) community assets within gay communities, including alternative families.

As stated earlier, many of the young men we interviewed spoke of a history of not feeling comfortable within their own bodies or with their emergent gay identities as adolescents. The fluid sense of identity that some participants described was sometimes seen as making young gay men susceptible to influences that may promote risk behavior. One young man remarked that “if you’re not sure of who you are as an individual, you’ll let others to dictate how you should be or the image that you should—the image that another person figured that you should be.” The role of peer norms, and their potential for influencing young gay men’s behavior, was noted by another participant:

If you are a young gay male, especially if you’re coming to the city, it’s my experience, if you didn’t grow up here, or you’re just becoming exposed to the gay community, or you just start going out and meeting people, there are a lot, a lot of people who use drugs recklessly who have a lot of unsafe sexual practices, and if that is what you experience when you first come into the scene, then that is what you’re going to think of as normal. (Zack, White, 22 years old)

Several participants spoke to the potential risks for young gay men migrating to new communities due to the combination of the perceived glamour of gay nightlife, new-found freedoms, and attention paid to them in ways that may not have occurred in their previous communities.

I started doing drugs and I lost all this weight and like it suddenly—like instantly it became instant popularity like—and I started hanging out with the wrong people … like who wouldn’t want to go from being made fun of for 16 years of their life to being like instantly popular and hit it head-on, have fabulous sex and like—and just like all this stuff. (Peter, White, 22 years old)

Also problematic for some participants was the perceived promiscuity and hypersexuality present in some of the communities with which they came in contact. Some felt this was “just men being men,” but others cited the need to connect physically with other men as a replacement for deeper emotional needs. A 24-year-old African American man described his search as an adolescent for others like him as so entangled with his sexuality that he found it difficult to interact with other gay men outside sexual activity:

The only way I felt like I could relate to other gay men was sexually. Does that make any sense? I mean it was like I felt really empty and really isolated and then the only time that I didn’t feel really lonely or really isolated was when I was having sex. … It’s presented difficulties because it’s very hard for me to be friends with other gay men without wanting to have sex with them, not that I want to have sex with all my gay male friends but it’s made a lot of issues, like boundaries you know. (James, African American, 24 years old)

Beyond the need to connect physically with other men, whether separated from or intertwined with emotional connections, it was also suggested that some gay men may engage in high rates of sexual behavior with multiple sexual partners as a means for eradicating the very stigma associated with that same behavior:

I kinda think that most young gay men have a very unhealthy view of sex, solely because of the fact that they’re living a life that they grew up seeing as unnatural or wrong, you know? And I think once you—once a young gay person does start to become sexually active … somewhere still in the back of their mind they still have like what you’re doing is wrong and unnatural—like all that stuff is still there. And I think—sometimes I think they try to have as much sex as they possibly can, maybe subconsciously trying to convince themselves that what they’re doing is natural or right or okay—you know, like they’re trying to find some justification for what they’re doing. (Tony, Latino, 23 years old)

Although some participants we interviewed still felt significant degrees of stigma, shame, and fear associated with their sexual identity, most participants we interviewed maintained that they felt much better about themselves once they had come to terms with their sexual identity. Positive aspects of their gay identities included a sense of heightened self-reliance and resiliency due to past struggles and lack of support, as well as a belief that gay men were more “open” to possibilities that life presented to them, and open minded regarding other persons’ backgrounds and experiences. Despite experiencing stigma and internalizing it in varying degrees during adolescence and young adulthood, most participants described feelings of relief in coming to terms with their sexual identity, including the following young man:

In my whole life I’ve battled them, my feelings and emotions. And for fear of being seen as only gay or only emotional because I’m gay, I have not necessarily been the most open and comfortable with them. … I was so afraid of the possible negatives being okay with my emotions and feelings that I wasn’t allowing the positive expects of them … that you’re a much healthier, less tired, stressed out, inside out, anxious person when you’re just free to say or accept the feelings that you have. (Chet, White, 19 years old)

In many instances, this acceptance was facilitated by boyfriends and other gay persons with whom these young men came in contact. Community resources, such as gay organizations and youth-oriented organizations, were cited by participants in Chicago and San Francisco as sources of support, although these assets appeared to exist to a lesser extent in Baltimore and Memphis.

In the absence of support from family or childhood friends, many young men described alternative family structures in which they participated. Most commonly reported among the African American participants we interviewed, these families consisted of older gay men who selected younger men to mentor; sometimes, these families were structured around the various ball scenes that existed in each city, others were focused on professional development and serving as adult role models for younger gay men. Such families were described by Keith:

Well, I don’t know if you heard this or not, but homosexuals have organized different types of groups known as families. … And you have some families who, the families that stand for nothing are mostly of the gay [performance] scene, and the families who stand for something are not only gay scene, they’re about life. They’re about making something out of life. They’re about being successful. … I’m in two families. I have a family that’s on the scene. That’s what’s the family that I was indicted [sic] in when I was young, when I was being promiscuous. … And the other family that I’ve been invited in recently is more of a career-oriented family where they value education. They’re all successful. They’re all having careers. Most of them are in hotel and resort, hospitality management. … And it becomes one big family because we’ve all been isolated from our real families to where we all rely on each other. (Keith, African American, 19 years old)

Discussion

In this article, we present findings emerging from a study of young gay men’s identity development that begin to illustrate the processes and mechanisms through which some gay men may develop syndemic health issues as responses to experiences adolescence and young adulthood. In gay male adolescents and emerging adults’ own words we found links between childhood and adolescence marginalization, subsequent search for other men like them, and a range of resilience and risk factors associated with exploration of and migration to gay communities, as well as behaviors described as responses to past feelings of isolation, lack of support, and newfound freedoms as “out” gay men. This study contributes to the literature on syndemic health disparities among gay men by using qualitative data provided by HIV-positive gay male adolescents who have, given their age, more recently experienced the marginalization and migration theorized in the syndemic model. In addition, we used a multiethnic HIV-positive sample that racially approximates the current HIV epidemiology among adolescent MSM: 57% African American, 23% White, and 18% Latino/Hispanic (CDC, 2008).

The model of syndemic production was developed from population-based epidemiological data among adult (and mostly White) urban gay men from the previous decade. Descriptions of lived experiences from our racially diverse sample of adolescent gay men illuminate many of the theoretical assumptions that are present in the syndemic model. Participants’ narratives document links in their experiences of stigma, marginalization, isolation, exploration, migration, and subsequent responses to these experiences that lead to both risk factors and resiliencies in their health profiles. As such they provide examples of developmental trajectories among gay male adolescent and emerging adults that help explain the early onset of health disparities among some adolescents, including depressive symptoms, substance abuse, and HIV infection. Our sample was selected from a population that has already experienced at least one negative health disparity: seroconversion for HIV at a young age. It may be expected that risk factors for syndemic health issues would be more pronounced within this group than among an HIV-negative sample.

Much of the research that informed the development of the syndemic model presupposed a pattern of migration of gay men from smaller towns and cities to well-established gay “ghettos” in large metropolitan areas in order to pursue social and sexual relationships with other gay men (Stall et al., 2008). Our findings, drawn from data collected in two large metropolitan areas (Chicago and San Francisco) and two regional midsized cities (Baltimore and Memphis), revealed migratory patterns characterized by moving home neighborhood to gay neighborhood within large cities, as well as from small towns to larger cities. Gay communities within Chicago and San Francisco were identified with gay institutions and organizations, as well as nightlife venues. By contrast, in addition to bars and nightclubs, the gay communities in Baltimore and Memphis were characterized more by informal structures such as alternative families: The presence of gay-identified institutions and organizations in these cities was not mentioned by participants. Differentiation among each city’s sources of risk exceeded the scope of our inquiry and analysis in this study, but distinct variation among sources of resilience in large cities’ communities as opposed to those of midsized cities did emerge from our data. Variant capacities of gay communities within different cities to absorb the influx of exploratory and migratory gay youth within their communities merit further research.

Current research among gay male adolescents suggests that gay youth are using the Internet as a pathway to connect with other gay men on multiple levels and to serve a range of functions related to their sexual identity development (Harper, Bruce, Serrano, & Jamil, 2009). Sexual identity development among gay male adolescents has been described as a largely private and solitary process, as opposed to racial identity development, which tends to be pursued in a public sphere (Jamil, Harper, Fernandez, & the ATN, 2009). The Internet would appear to facilitate gay identity development by providing gay youth with opportunities to make connections with others like them in venues that did not exist in past decades. Exploration of one’s sexual orientation identity through the Internet, particularly through social networking sites, is an avenue of identity development that needs to be integrated within future models of gay sexual orientation identity development.

For some, the exploration of and migration to the “gay-borhood” or a recognizable gay community may be associated with risks taken by many adolescents and emerging adults regardless of sexual orientation, including experimentation with substance use and sex; however, the risk associated with such experimentation may be heightened by the notable lack of support described by many of our participants during their identity development. Jessor (1991, 1993) conceptualized adolescent risk or problem behaviors as a constellation of behaviors, whereby involvement in one risk behavior increases the likelihood of involvement in other risk behaviors because of social linkages and opportunities to practice them with other adolescents. His problem behavior theory was grounded in an ecological framework in which the behavior constellation is in turn determined by risk factors and protective factors occurring in multiple domains (e.g., genetic, individual, family, society). Progressing along a developmental pathway without a “safety net” would seem to place adolescent and young gay men at increased risk for negative behavioral health outcomes. Resilience theory applied to adolescents also suggests that the absence of protective or compensatory resilience resources may predict trajectories that link risk exposure to negative health outcomes in adolescents (Fergus & Zimmerman, 2005).

The behaviors that adolescent gay men adopt during the process of migration to gay-identified communities and the search for other gay men should be viewed within cultural contexts. From an anthropological view, sexual cultures are generally accepted models of sexual behavior within societies, including gender norms, beliefs, rules, and emotions (Herdt, 1997). Thus, while young persons explore sexuality, they learn about sexual cultures and develop individualized identities within larger cultural social systems. Beyond sexual cultures, it has been proposed that there exists a larger “gay” culture that involves language, symbols, practices, organizations, and geographic living areas (Herdt, 1997; Leap, 2007; Pope, 1995), so that young gay people learn not only sexual behaviors within cultural contexts but also gay cultural norms and expectations regarding ways of acting, knowing, and being (Gee, 1990). Future research into examining sexual identity developmental trajectories among gay male adolescents, as well as potential health behavior interventions, should consider the ways in which gay male adolescents’ development is influenced by gay culture and sexual cultures within communities (Harper, 2007).

Risk factors that are present within some gay communities may indeed be a result of cycles of men migrating to such centers after experiences of stigma and marginalization, with the resulting syndemic health issues becoming concentrated within groups of gay men who may share such experiences and risk profiles. Community-based interventions targeting health disparities among urban gay men need to consider both the risks and resiliencies present within communities, with opportunities for community support and health promotion that are offered in addition to bars and nightclubs. Of particular concern was the lack of community-based organizations targeting gay male adolescents within the smaller cities in our sample. There is evidence that acceptance of a gay identity and involvement in a larger gay community can serve to buffer some of the negative effects of this stigmatization and lead to decreased participation in HIV sexual risk behaviors for gay youth (Ramirez-Valles, 2002; Ridge, Plummer, & Minichiello, 1994; Rosario, Hunter, Maguen, Gwadz, & Smith, 2001; Waldo, McFarland, Katz, MacKellar, & Valleroy, 2000).

Limitations

The data discussed are qualitative and exploratory, drawn from a purposive sample of HIV-positive gay and bisexual male adolescents and emerging adults who currently receive HIV primary medical care; therefore, the breadth of the data is limited in its representativeness of the larger young gay male population. Nonetheless, the young men in the sample have already experienced early in life at least one health issue associated with syndemic production (HIV diagnosis), and with their descriptions of depressive symptoms and substance use patterns may actually provide a high degree of commonality with gay men who experience syndemic health disparities. Furthermore, the effects of HIV seroconversion among the young men we interviewed cannot be overestimated in terms of the examples they drew from their pasts. Many participants described living with HIV as a “wake-up call” for examining how to live their life and undoubtedly brought into sharp relief some of the histories they related and the paths that their lives had taken from childhood through adolescence to young adulthood.

In addition, these data were drawn from a larger study of racial/ethnic identity, sexual identity and HIV-positive identity; the effects of racial stigma and HIV-positive stigma on health behavior were in some cases noted by participants. An expansion of the syndemic model to include effects of and responses to these stigmas is warranted, in light of the elevated prevalence rates of HIV and STIs among gay men of color. We did not note significant differences in patterns of risk exposure among the racial groups in terms of their sexual orientation identities, although descriptions of alternative families as sources of resilience predominately came from our African American participants. The elicitation protocol for ATN070 treated racial identity, sexual orientation identity, and HIV-positive identity development as separate domains of inquiry for the purposes of this exploratory study. The intersection of sexual identity development and ethnic identity development, and HIV-positive identity development exceeds the scope of this study but will be important to consider as alternative models of gay sexual orientation identity development emerge. In addition, our data were drawn from elicitation protocol based on the Disability-Stress-Coping model and not the syndemic framework as applied to gay men. More qualitative data are needed from gay/bisexual male adolescents and emerging adults using the syndemic framework to more fully explore its components.

All interviews for this study were conducted in English. As such, we clearly did not access the experience of gay male youth for whom English may not be the primary language. Sexual orientation development and experiences of marginalization, exploration, and migration among immigrant young gay/bisexual men in this country merit research to document their experience and further develop theory to more broadly apply the syndemic framework to diverse groups of gay and bisexual men in the United States.

Another limitation of our findings is that we did not specifically ask when participants (a) believed they had been infected and (b) tested positive for HIV. Thus, we are not able to fully explore how HIV infection may be directly related to participants’ forms of risks and resiliencies developed both before and after they became involved in the gay communities. Future research into the development of syndemic health disparities among this population would benefit from detailed questioning and event-level data related to specific HIV risk behavior and seroconversion that may be attributed to experiences of adolescence and migration to gay communities.

Implications for Practice and Future Research

These findings advance the use of a syndemic framework for investigating social determinants for health disparities among gay men in the United States by confirming salient factors that affect the development of gay male adolescents and their attendant health issues. Future research into health disparities among gay men should expand on this exploratory study and empirically test the associations among the factors discussed. Measurement of gay-related stigma processes using a minority stress framework has been tested and empirically validated (Bruce et al., 2008). Improved measurement of gay sexual orientation identity development processes that allows for multiple developmental trajectories is needed in order to estimate the effects of marginalization and migration on health disparities within a developmental perspective (Frable, 1997). Using population-based samples of gay/bisexual male adolescents and emerging adults would help to estimate the impact of factors associated with marginalization and migration on the syndemic production of health disparities. Furthermore, longitudinal studies of the development of gay/bisexual male adolescents and emerging adults would further measure the impact of stigma, identity, marginalization, and migration on health outcomes by measuring change over time and disentangling specific causal effects. Although the focus of this article was the relation of gay sexual orientation identity development to marginalization, migration, and health behaviors, future studies of syndemic production of health disparities among gay men should consider racial identity and responses to racial stigma among young gay men of color.

The findings in this study present multiple opportunities for interventions to reduce risk and enhance resiliency among gay male adolescents and emerging adults. Family-based interventions are needed to help families adapt to adolescent emergent gay sexual identities, and help prevent negative health outcomes. Research has shown that family rejection is significantly associated with negative health outcomes for gay and lesbian adolescents, including depressive symptoms, drug use, sexual risk behavior and suicide attempts (Ryan, Huebner, Diaz, & Sanchez, 2009). Alternative families, such as some of the groups of gay men described by participants in our study, merit further consideration for how they may be used to develop support structures for young gay men. Mentoring relationships and availability of role models would appear to be two functions that alternative families might help bolster resilience within gay communities.

Discrimination and harassment at schools were described by many participants, from fellow students and in some cases administration. School-based intervention, including trainings to develop more supportive staff and teachers, as well as anti-bullying programs, are warranted given the high incidence of antigay discrimination described by our participants in schools during their adolescence.

Internet-based interventions been developed to deliver sexual health information, sexual risk reduction counseling, and skills training to MSM (Carpenter, Stoner, Mikko, Dhanak, & Parsons, 2010; Moskowitz, Melton, & Owczarzak, 2009) using a variety of formats, including instant messaging and web-based training modules. Development of social networking sites that promote the healthy identity development of gay and bisexual youth is an opportunity to reach this population while they may be experiencing isolation and marginalization within their home communities and exploring their emergent sexual orientation identities.

Another potential opportunity for intervention with young gay/bisexual men lay in the area of dating, romance, and relationships. Emergent research has shown that gay/bisexual male adolescents and emerging adults report challenges in initiating and maintaining nonsexual relationships with other gay/bisexual males, finding dating partners, doubts about ever finding a long-term partner, and a complex interplay of sex and romantic relationships, and detailed various roles sex can play in modulating their psychosocial status (Harper, Bruce, Rogers, & the ATN, 2010).

Community-based interventions targeting health disparities among young gay men need to consider both the risks and resiliencies present within gay communities, with opportunities for community support and health promotion that are offered in addition to bars and nightclubs. Outreach programs targeting recent arrivals in identified gay communities to assess risk and alternative spaces to bars and nightclubs may help address substance use and other risk behavior patterns that were described by some participants in our sample. As mentioned above, bars and nightclubs were viewed by many of our participants as ports of entry into the gay communities in their cities and as such—despite the expanding role of the Internet and associated forms of networking in their lives—continue to serve as potential venues for identifying and conducting outreach with gay male youth.