‘The big ole gay express’: sexual minority stigma, mobility and health in the small city

Abstract

Recent research has examined how gay and bisexual men experience and navigate the variations in sexual minority stigma that exist across geographic contexts, with implications for their health. We extend this literature on stigma, mobility, and health by considering the unique and understudied setting of the small city. Drawing on semi-structured interviews (n = 29) conducted in two small US cities (New Haven and Hartford), we find that these small cities serve as both destinations and points of departure for gay and bisexual men in the context of stigma. New Haven and Hartford attracted gay and bisexual men from surrounding suburbs where sexual minority stigma was more prevalent and where there were fewer spaces and opportunities for gay life. Conversely, participants noted that these small cities did not contain the same identity affirming communities as urban gay enclaves, thus motivating movement from small cities to larger ones. Our data suggest these forms of mobility may mitigate stigma, but may also produce sexual health risks, thus drawing attention to small cities as uniquely important sites for HIV prevention. Furthermore, our analysis contributes to an understanding of how place, stigma and mobility can intersect to generate spatially distinct experiences of stigmatised identities and related health consequences.

Introduction

Sexual minority stigma is a well-established source of health risk for gay and bisexual men (Hatzenbuehler 2009; Meyer 2003; Pachankis et al. 2015). Internalisation of stigma, expectations of rejection and experiences of discrimination are associated with increased risk of depression, anxiety, substance use and HIV vulnerability (Egan et al. 2011; Mustanski et al. 2007; Stall, Friedman, and Catania 2008). While much existing research on sexual minority stigma has focused on internal (e.g., negative views of self) and interpersonal (e.g., discrimination) forms of stigma, an emerging literature has begun to consider structural processes that link stigma to the health of sexual minorities (Hatzenbuehler and Link 2014). This emerging literature on structural stigma recognises the ways that local policies, cultural norms and institutional practices can intentionally or unintentionally shape the health of stigmatised populations such as sexual minorities (Hatzenbuehler and Link 2014). This research also introduces a spatial dimension to the existing stigma literature, drawing attention to variations in stigma and health across both time and place (Keene and Padilla 2014; Lewis 2014; Pearce 2012).

In particular, recent studies find that geographic variation in structural forms of sexual minority stigma predict a range of health outcomes for lesbian, gay and bisexual individuals. For example, studies have found that lesbian, gay and bisexual people have better mental health and lower mortality in states with more supportive sexual minority laws and policies and lower levels of anti-gay prejudice (Hatzenbuehler 2011; Hatzenbuehler et al. 2014). Research also demonstrates higher prevalence of sexual risk behaviours in high structural stigma locales (Oldenburg et al. 2015; Pachankis et al. 2015; Pachankis, Hatzenbuehler, and Starks 2014). Thus, geographic variations in stigma may be relevant to understanding HIV transmission among gay and bisexual men, the population at greatest risk for HIV infection and the only major risk group for whom new incident cases of HIV are increasing in the USA (Centers for Disease Control and Prevention 2015).

In addition to these epidemiological studies, some qualitative research has begun to explore how men experience these geographical variations in stigma (Bianchi et al. 2007; Bruce and Harper 2011; Egan et al. 2011; Frye et al. 2014; Kobrak, Ponce, and Zielony 2015; Lewis 2014; Valentine and Skelton 2003; Waitt and Gorman-Murray 2011; Weston 1995). In particular, research describes migration to well-established gay enclaves as a quest for identity affirming communities, visible gay spaces, opportunities for socialising and sexualising, and greater anonymity (Bruce and Harper 2011; Egan et al. 2011; Gorman-Murray 2007; Kobrak, Ponce, and Zielony 2015; Valentine and Skelton 2003). Additionally, research describes leisure travel to gay enclaves as a way for gay and bisexual men to escape stigma in their hometowns (Hughes 1997). This existing literature raises questions about other forms of mobility, which may also be relevant to the health of gay and bisexual men. In particular, with a few exceptions (Lewis 2014; Waitt and Gorman-Murray 2011), much less is known about movement to and from smaller cities.

Small cities are an important and understudied site for population health research among gay and bisexual men. Though the majority of research on gay and bisexual men's health has focused on large urban areas, and to a lesser extent rural areas, the majority of US residents live in small cities with populations of less than 250,000 (only 18% live in large cities of more than 250,000 and only 19% live in rural areas) (US Census Bureau 2015). Additionally, small cities have recently drawn particular attention from HIV prevention researchers in the USA, given that the majority of domestic HIV cases occur outside of the country's 12 major cities (White House Office of National AIDS Policy 2015).

Small cities also provide a unique vantage point from which to examine stigma processes and mobility because they contain features of both rural areas and large cities. For example, small cities contain gay spaces and communities that may attract gay and bisexual men from smaller towns. However, small cities also lack the large visible gay communities that exist in more established gay enclaves. This may have implications for how men navigate space and stigma, with implications for health. Men may move both to and from small cities as they seek to minimise stigma or find identity-affirming communities.

These types of movement may produce both health risks and benefits. On the one hand, movement to areas with lower levels of structural stigma may reduce stress associated with concealment, expectations of discrimination and homophobic victimisation (Egan et al. 2011). On the other hand, travel and migration among gay men has been associated with substance use, sexually transmitted infections and HIV risk behaviour (Egan et al. 2011), and some research finds evidence of sexual risk associated with travel between small and large cities in particular (Niccolai et al. 2007). This increase in risk has been attributed to cultural norms in urban gay enclaves that encourage substance use and unsafe sex, the challenge of navigating context-dependent health norms and social identities in new settings, and the loss of social support that can lead migrants to seek connections through fleeting, high-risk sexual encounters (Kobrak, Ponce, and Zielony 2015; Hammack 2009; Pachankis, Eldahan, and Golub 2016).

The present study examines how stigma contributes to patterns of mobility within and beyond small city spaces, and the potential health implications associated with these forms of mobility. This work builds on a large literature that has examined the geographic and contextual nature of gay identities (e.g., Brown-Saracino 2015) to consider the particular intersections of stigma, mobility and health in the relatively understudied setting of the small city. Our analysis draws on semi-structured interviews collected among 29 gay and bisexual men living in two small New England cities: New Haven and Hartford, Connecticut.

Methods

Setting

New Haven and Hartford have populations of approximately 150,000 people. These cities are located in Connecticut, a progressive state that was among the first in the USA to legalise gay marriage. Both cities also contain an ongoing history of active lesbian, gay, bisexual and transgender services and community organising. The New Haven Pride Center has been active since the early 1990s and hosts a variety of community programmes. The Hartford Gay and Lesbian Health Collective, founded in 1983, provides health services, education and advocacy for the local lesbian, gay, bisexual and transgender community. Both cities contain prominent HIV prevention organisations serving the lesbian, gay, bisexual and transgender communities, including AIDS Project New Haven, AIDS Connecticut and the AIDS Interfaith Network. Additionally, both cities contain universities that have active lesbian, gay, bisexual and transgender organisations. Furthermore, both cities are located in proximity to New york City, one of the most established gay enclaves in the USA. Finally, both cities contain racially diverse populations and large social class inequalities, thus providing an opportunity to examine the experiences of men across race and socioeconomic status.

Sampling and recruitment

We used a multi-pronged recruitment strategy that included online advertisements, flyers, direct recruitment and snowball sampling. We posted flyers on the bulletin boards of organisations serving the lesbian, gay, bisexual and transgender community. We also conducted direct recruitment at gay venues (bars and clubs) by handing out recruitment cards to patrons of these locales. In order to reach men who may not frequent lesbian, gay, bisexual and transgender-specific venues, we posted our recruitment materials on Craigslist, in the ‘personals: men seeking men’ section. The recruitment materials invited men to contact our study team if they were interested in participating in a study about the lives of men in Connecticut. This wording was intentionally broad in order to be inclusive of a wide range of sexual identifications, although the flyers specified the sampling frame was limited to ‘a man who has had sex with other men’.

We purposively constructed our sample to ensure diversity with respect to race, age and HIV status. We began our study with the goal of recruiting equal numbers of HIV-positive and HIV-negative participants and equal numbers of White and non-White participants. As our research progressed we noticed that age was an important determinant of participants' experiences and thus, according to theoretical sampling principles (Corbin and Strauss 2014), adjusted our sampling strategy to obtain an age diverse sample. Of participants, 10 self-identified as Black, 4 Latino, 13 White and 2 Other/mixed. Our final sample contained 10 HIV-positive individuals and 19 HIV-negative individuals; 16 participants were over the age of 30 and 13 participants were 30 or younger; 23 participants resided in the New Haven area, where our research team is based, and six resided in or near Hartford. Six participants indicated that they were not ‘out’ or were out to only close friends and family members. Though yale University is a prominent institution in New Haven, only four participants were affiliated with the University (as alumni, students or employees). Recruitment lasted nine months and all interviews were conducted between May 2014 and February 2015. Participant pseudonyms, ages, race/ethnicity and residential city are shown in Table 1. We have made small adjustments to participants' ages in order to better protect their anonymity.

Table 1.

Participant characteristics.

Pseudonym	Agea	Race/ethnicity	Residential city
Aaron	27	Black	Hartford
Carlos	46	Latino	New Haven
Charles	25	White	New Haven
Daniel	41	Black	New Haven
Darren	29	White	New Haven
Derek	39	Black	New Haven
Desmond	49	Other	New Haven
Doug	43	White	New Haven
Elijah	51	Black	New Haven
Frederick	22	White	New Haven
George	59	White	Hartford
Hank	58	White	New Haven
Herbert	20	Latino	New Haven
Jamie	21	Latino	New Haven
Jason	20	Black	New Haven
Jay	48	Black	New Haven
Jordan	31	White	New Haven
Kevin	27	Black	Hartford
Kyle	22	Mixed	New Haven
Marcus	19	Black	New Haven
Marvin	67	Black	New Haven
Michael	58	White	Hartford
Patrick	41	White	New Haven
Paul	54	Black	New Haven
Rafael	29	Latino	New Haven
Ronald	63	White	New Haven
Sam	31	White	Hartford
Sean	25	White	Hartford
Steven	29	White	New Haven

^aTo protect anonymity ages have been altered ± 1–2 years.

Data collection and analysis

We conducted semi-structured interviews organised around broad themes related to gay and bisexual life in New Haven/Hartford, sexual and social networking, travel, HIV risk and protective behaviours and overall health. Interviews were conducted by three of the paper's authors (AE, DK and JP), lasted approximately 60–90 minutes and took place in private rooms at community-based organisations or university offices. Participants received US$50 cash for their participation. All interviews were recorded and transcribed. All men provided written informed consent and the study was approved by the Institutional Review Board of yale University.

We followed a grounded theory approach (Corbin and Strauss 2014), whereby our analysis was an ongoing process that co-occurred with data collection. Throughout the data collection and analysis process, our research team met weekly to discuss emerging themes and concepts. We wrote thematic summaries after each interview as well as frequent memos about developing concepts.

Upon completion of data collection, we worked collaboratively, in a series of team meetings, to organise previously identified codes into a codebook. Next, two coders (JWH and AE) coded five transcripts using the qualitative coding software Atlas.ti and iteratively refined the codebook through discussions with the full study team. Once the codebook was finalised, the same two coders coded the remaining interviews in Atlas.ti. Throughout the coding process, the research team met frequently to discuss the application of codes. Finally, the primary analyst (DK) compiled and analysed portions of coded text, reviewed the full transcripts to contextualise quotes within participants' larger narratives and drafted a preliminary analysis. This analysis was then refined through team discussions and subsequent reviews of the coded data.

Findings

In the sections below, we describe how gay and bisexual men residing in two small cities experience and navigate geographic variations in stigma. We describe the pull of small cities for men in surrounding areas, the careful navigation of stigma within small cities and movement from small cities to urban gay enclaves. Finally, we discuss the health implications of such movement.

‘Everyone goes to New Haven and Hartford’: small cities as a place of refuge

Several participants described New Haven and Hartford as destinations for gay and bisexual men from surrounding suburbs and small towns. Some participants had themselves relocated from other areas. Others described witnessing a movement of men to these small cities. Stigma contributed to both push and pull factors associated with this movement.

For some participants, moving to New Haven provided a refuge from the gaze of family and thus, in the context of stigma, more freedom to express sexual identities. For example, Marvin (see Table 1 for the age, ethnicity and residential city of each participant) explained that in a suburban context where everyone knows everyone, being openly gay can cause ‘you or your family problems’.

In addition to anonymity, small cities were described as providing a more accepting environment relative to the smaller towns or rural areas from which several participants haled. For example, Carlos described New Haven as a ‘more accepting place’ than his small northeastern hometown. He said:

I mean there is a big – there is a [gay] community here and there's a lot of – it's you feel safe, you don't feel out of place, you don't feel, you know, less than anybody else being gay here in New Haven.

Similarly, Sam highlighted the contrast between his hometown and Hartford, where he now lives. He noted:

… because in [hometown], I don't think I know of anybody that's bisexual or anything, unless they're just holding it in for that same reason, you know what I mean? It could be because – yeah, it's weird, it's like when I come to Hartford it's almost like I'm welcome and then when I go back to my town it's like …

Fredrick, who grew up in a small town, also said that he felt more accepted as a gay man in New Haven than back home:

I feel much more comfortable being out here. And there is – there's a couple of places where you can go to actually meet gay people. There's a couple of gay bars and one or two clubs that are – have a gay night or a gay club or whatever. And I didn't have that at all where I lived before. So, for me, it was definitely a step up.

As Frederick noted, one appeal of New Haven was the presence of gay-specific spaces that provided safe and accepting environments. Other participants echoed this sentiment. For example, Carlos explained, ‘you know, they'll have their little gay flag up front, their little emblem where you know, okay, this is a safe zone.’

Marvin noted that these ‘safe zones’ are part of what draws gay and bisexual men from the suburbs. He explained:

there's nothing for them to be gay at, so they know there are bars here in New Haven. So, naturally, they're undercover in their own town. They come down to New Haven, and once in a while, I'm quite sure, a lot of these kids meet people they have fun with and become friends with and they eventually somehow move into New Haven.

Other participants reiterated the observation that New Haven and Hartford bars can serve as a hub for men from surrounding communities. As Jason noted, ‘everyone goes to New Haven or Hartford.’

In summary, participants described New Haven and Hartford as places that contained more accepting norms and anonymity relative to surrounding areas, as well as access to gay-specific spaces. These small city features created a hub of gay life that, as discussed below, was quite distinct from that which existed in large urban areas.

‘I don't wear a big flag out’: navigating the geography of stigma in a small city

Several participants described New Haven and Hartford as places where gay acceptance had its limits. For example, Patrick said, ‘even though it's a liberal state, it's not like being in New york City or San Francisco or something like that’. They also described careful management of stigmatised identities in small city landscapes that contained numerous ‘safe zones’, yet also contained spaces where gay and bisexual identities could be met with risk. In particular, participants described caution about publicly displaying their sexual identities. For instance, participants indicated that they would not hold hands with another man in public. As Desmond said, ‘I don't parade myself. I don't wear a big flag out’. Ronald reiterated these sentiments, characterising the gay community in New Haven as relatively undercover. He said, ‘it's a quiet group, it's not, we're not really that open so to speak. I guess we're all over the place, but I guess we're not that open. We don't flaunt it all around the place, most of us’.

Participants described gay bars and clubs as safe zones that were distinct from the spaces that surrounded them. For example, Herbert, an area college student explained, ‘I can go out into the gay bars and be that whole – be myself and open. But when I leave the bars, it's just I'm still gay, but let's say I be cautious about how to act’.

In addition to frequenting designated gay-specific spaces, participants also described claiming public spaces for gay use, thus creating additional unmarked ‘safe zones’. For example, Desmond described finding an escape from stigma at a beach that serves as a gay hangout. He noted, ‘I don't go down there to have sex. I just go down there just ‘cause I feel comfortable because that's my group of people, you know?’ Other participants described cruising zones in public parks. These undercover spaces provide a particular refuge for closeted men whose concealment made publically marked gay spaces off limits. As Jordan explained, before he came out, ‘those [gay bars] were like taboo places that you would go and wear hats so that no one saw you’.

Some participants described the navigation of ‘safe spaces’ in New Haven and Hartford as a racialised and class-based process. Jay, for example, felt that as a Black man, his ability to be publically open about his sexual orientation was more constrained than for White gay men. He said:

New Haven right now, umph. I seen girls holding hands in New Haven though. I do see, I mean a few girls holding hands. Two guys, once in a while I see that. But you know what I mean you don't see that often. But they usually be like Caucasian guys. you don't see two Black guys in this city holding hands, like in New york.

Jay also described marginalisation from predominantly White gay spaces that other participants considered to be safe zones. He explained that he often felt stereotyped by the predominantly White bar patrons as being a ‘thug’ or ‘gay for pay’, given prominent racialised stereotypes of male sex workers (Teunis 2007).

Other participants echoed Jay's sentiments about the exclusionary nature and Whiteness of some small city gay spaces. For example, Daniel said that he does not feel at home in New Haven's gay bars, attributing his discomfort to ‘an ethnic thing’. Similarly, Jamie, an African American undergraduate student, described New Haven's gay bars as white spaces, stating:

I'm going to expect to find gay men who are predominantly White. yeah, I mean, it's not unusual for me to go to [local gay bar] and be like maybe one of three or four people of colour there.

Jamie described the gay community at his university as similarly racialised, stating:

… yeah, I mean, it's a pretty odd community. I don't always feel a huge part of it. It's pretty predominantly white is one of the sort of issues that I have with it, and I sometimes have trouble relating.

In New Haven, yale was a prominent feature of the local social geography and participants' relationships to yale spaces seemed to vary greatly by race, class and age. yale's well-established gay community was cited as a draw for several New Haven participants, including those who did not attend the university. While some non-yale affiliated participants, all younger and White, described accessing and socialising within yale's gay community, others described university gay spaces as unwelcoming to town residents. The social distance between university and town was also reinforced by yale students who stayed within university boundaries. As one recent yale graduate in the sample explained:

… so being gay in New Haven for me, I guess I still am very closely connected with yale, so a lot it has to do with yale. New Haven generally, I'm not quite as experienced. I've been to a couple of gay events just in the community and those have been – I'm going to use the word ‘lackluster’.

The segregation of city and university spaces is not unique to the gay community, but may have particular implications for gay life in a small city where the size of the gay community and the number of gay spaces are already limited. As Marvin posited, this divide may impede the development of a broader gay community in the city. He explained:

The university, probably all the schools now, because they have so much – they integrated the lesbian and gay community into school, the kids don't have to go outside the university …. So, even though students do come to the bars, they don't have to come to the bars, so that's why there's not a whole lot of activity in town for gay people because the students don't have to be involved. The students are on campus and the students, whatever they're involved in, it's involved on campus, so the town is not involved.

In summary, participants described New Haven and Hartford as cities that contained pockets of acceptance that were not uniformly welcoming to all gay and bisexual men. While the contrast between ‘safe zones’ and other spaces is not unique to small cities, the nature of these spaces seems to differ from those in gay enclaves. In particular, participants described these gay spaces as hidden and small in number. Perceived access to and comfort within these spaces shaped participants' day-to-day movements within and also beyond these small cities.

‘The big ole gay express’: movement between small cities and gay enclaves

Given the challenges of navigating stigma in a small city, particularly for minorities and non-students, many participants described seeking refuge in cities with larger and more well-established gay communities. Some participants, including those who had recently relocated to New Haven or Hartford, described plans to leave these cities in order to find more identity affirming environments. For example, one participant hoped to move to Atlanta, where he felt it would be easier to be gay, Black and HIV-positive.

Additionally, several participants described frequent travel to other cities, and New york in particular. For example, Herbert said that he goes once a week to ‘get away from New Haven’. Aaron travels frequently to New york City from Hartford. Darren travels to New york in order to find ‘a totally different experience than going to your local dive bar’. While participants travelled to New york for reasons not specific to stigma or gay identities (e.g., to shop and see shows), several articulated a connection between stigma and this type of movement. This sense of escape was particularly evident among older and non-White participants who described more anticipation of sexual minority stigma relative to younger and White men. For example, Desmond described New york as a place where he can be more open about his sexual identity than in New Haven. He said:

… to me, people was more friendlier there, more open minded than up here. Like, you know – like, I had to live in a shell. Like, you know, it's like, I had a piggyback on my shell like I'm a turtle. I came out my shell.

Similarly, Jay explained:

[When] I'm in Connecticut I got to put my hair up in a bun. In New york, I let my hair down because New york – I love New york … I mean you know you just be yourself.

Carlos noted that his ‘at least once a month’ trips to New york City were motivated by a search for accepting gay spaces. He said:

I'll do it [go to New york] when I feel like having what I call my gay day, when I feel like just interacting with gay people, when I'm sick of heterosexuals or just sick of going to [straight bars in New Haven] and having the wine and the conversation, where I just get sick of talking to straight people. you know, we'll get a group and we'll all say, ‘To hell with it, why don't we just go on to Manhattan and just walk in the Village and go to the gay bars in the Village and just a little pub and have a beer and just be campy. And we'll go to a good drag show and stuff like that’. But here they don't even have that.

Carlos described the train between New Haven and New york as an important site to connect these two distinct geographies, one where gay life was undercover and another where it was open. He explained:

Like Gay Pride in New york this year. That train was – that was a big ole gay express. I mean there were so many people on that damn train that I'm like, ‘Where the hell are all you guys out on a regular night? Why are there 10,000 gay men at Union Station? Where the hell are you during the rest of the week?’ It's like today and you could tell, you know, ‘cause they had the colours, the rainbow flags, the feathers. They were just big ole, you know, that was our holiday. you know, we could be as flamboyant and as gay, because we're going to walk around New york, be on the train and not worry about it.

In summary, participants described movement from small cities to well-established gay enclaves that was in part motivated by stigma. In particular, they described regular back and forth travel facilitated by a direct train connection. They also described travel as a group activity, perhaps facilitated by the existence of local, albeit small, gay communities in these two small cities.

Stigma, mobility and health in the small city

In the sections above, participants described the intersections of stigma and mobility in the unique context of small cities. These forms of movement have several implications for health. First, participants described migration to small cities, travel to enclaves and navigation of ‘safe zones’ as opportunities to escape sexual minority stress, a known source of health risk for gay and bisexual minority men (Hatzenbuehler 2009; Meyer 2003). As noted above, participants described being able to ‘let their hair down’ or be themselves in some contexts, but not others. Additionally, participants described how movement can help to avoid unhealthy coping behaviours employed to manage stigma. For example, Jay explained how the stress of coming out to his family contributed to his drug use, but that leaving his hometown, and the associated stress of being gay in this space, helped him to get clean.

Second, participants described sexual risk associated with mobility. Men came to New Haven and Hartford for leisure and also for sexual opportunities that were lacking in surrounding towns. However, residents of these cities also described both social and sexual opportunities as limited due to their relatively small gay communities. One way that participants transgressed the sexual boundaries of small city life was through sex with men who passed through the city. For example, Darren explained:

… it's just everyone knows everyone, and I feel like everyone dates each other, or they're already hooking up with each other. But, like somebody new will come into town and everyone will jump on that one piece of guy, and they'll be like ‘oh, fresh meat’.

Participants also escaped small city boundaries through casual sex while travelling. These sexual connections were often facilitated by mobile networking applications (e.g., Grindr). For example, Jason relied on a location-based mobile application to meet other men while traveling, explaining: ‘I'll set my location to where I'm going to be and then I'll just start talking to guys in that area and try to figure out if I want to meet someone.’

Darren estimated that during his regular travel to New york City, he met someone for sex ‘3 or 4 out of 10 times’. He also considered these sexual encounters, which often occurred in the context of substance use, to be risky, leading him to consider taking HIV pre-exposure prophylaxis (PrEP). He said:

When I go on vacation, I tend to – ‘cause like, when I go on vacation, I'm like those guys that visit here; I'm visiting there, and these – I'm fresh meat wherever I go. So I tend to have some sexual partners when I go on vacation, and just to be safe, I'm thinking about getting on that [pre-exposure prophylaxis]. ‘Cause it's always – it's usually alcohol that makes me make the bad decisions.

Darren described travel to New york City as a time when he could abandon his otherwise more cautious sexual norms. As he said, ‘when I'm on vacation, I turn into a totally different person.’ In contrast, he explained that engaging in sexually risky behaviour in the context of New Haven's small community could earn him an unwanted reputation as promiscuous. He said:

If I were to have sex with people at the bar here in New Haven, I would definitely be safe about it, only because, working at the bar, I don't wanna be known as the that guy that's running around having unprotected sex with everybody.

Similarly, Jordan described travel as an opportunity to escape the scrutiny of the relatively small and interconnected gay community in New Haven. He explained:

… but if we partied like that here like we do there? By Monday morning: ‘Oh, my God – Jordan's life is in shambles. Did you see how drunk he was on Saturday night?’ Whereas, if we go out, we're on vacation. We're not from here. We're not going to see them ever – these people ever again. So go nuts.

Discussion

The narratives above describe some of the ways in which gay and bisexual men in two small cities navigate a geography of stigma. Participants described these cities as uniquely positioned between larger urban areas and smaller communities. The small cities of New Haven and Hartford attracted gay and bisexual men from surrounding smaller towns and suburbs where sexual minority stigma was more prevalent, there were limited opportunities for gay life, and lack of anonymity made it difficult to cover stigmatised identities. Conversely, however, these narratives suggest that small cities may not contain the same visible and identity-affirming communities as urban gay enclaves, thus motivating travel from small cities to larger ones. In this sense, New Haven and Hartford were described as both destinations and as places of departure for gay and bisexual men.

While an existing literature has emphasised the migration of gay and bisexual men to urban gay enclaves (Bruce and Harper 2011; Egan et al. 2011; Gorman-Murray 2007; Kobrak 2015; Valentine and Skelton 2003), our study finds that small cities may represent a unique and understudied destination for sexual minority men who are searching for identity affirming communities and safe spaces. Indeed, recent demographic research points to small cities as particularly attractive locales for sexual minority individuals and couples, perhaps representing a more affordable and accessible alterative to gentrifying gay enclaves (Cooke and Rapino 2007). On the one hand, migration to small cities may provide access to ‘safe zones’ without the ‘fast lane’ context of substance use and high-risk sex that has been associated with health risk among migrants to traditional gay enclaves (Bruce and Harper 2011; Carpiano 2006). On the other hand, the marginal nature of small city spaces may mean that men leave behind hometown support networks and arrive at a destination where their sexual identities are still marginalised. Our data suggest that this may be particularly true for men of colour. Research finds that gay and bisexual men of colour often feel alienated from broader gay communities or experience racism and discrimination within them (Haile et al. 2014; White et al. 2014; Haile, Padilla, and Parker 2011; Teunis 2007). The challenges posed by this intersection of multiple stigmas may be compounded in small cities given the limited and homogeneous nature of small city gay spaces.

In addition to migration, participants described regular back and forth movement between small cities and New york City. This type of weekend travel is distinct from what is described in the literature on migration to gay enclaves (Bianchi et al. 2007; Egan et al. 2011) Whereas gay and bisexual men's migration to large urban areas is often conceptualised as a singular event (e.g., Kobrak, Ponce, and Zielony 2015; Pachankis, Eldahan, and Golub 2016), our results point to more fluid movement between urban gay enclaves and small city locales. Similarly, whereas existing literature on gay and bisexual men's leisure travel conceptualises vacations as discrete, relatively infrequent trips to relatively faraway destinations (Clift and Forrest 1999; Hughes 1997), our findings suggest that gay and bisexual men living near urban enclaves might engage in more frequent and brief trips that nonetheless invoke a vacation mentality free from the constraints of local scrutiny and judgment.

As discussed above, these forms of mobility have several potential implications for health. In particular, the unique position of small cities as both destinations and points of departure may make them particularly important sites for HIV prevention. Participants described engaging in anonymous sex with men ‘passing through’ small city spaces and also in sex during travel. To the extent that health behaviour is determined by local norms and social identities, this intersection of sex and mobility might circumvent one's otherwise health-promoting goals formed in a specific place, thus leading to decreases in protective behaviour and increases in sexual risk (Bouton 2002; Fisher 2008; Zimmerman and Connor 1989). Given that health norms and social identities can change from place to place, interventions impervious to context represent promising avenues of health promotion among mobile populations. For example, recent work has begun to examine the episodic use of pre-exposure prophylaxis as a way to reduce HIV transmission during gay and bisexual men's travel (Elsesser et al. 2015). Psychosocial interventions that help individuals anticipate and prepare for high-risk contexts, such as travel, might also offer promise for maintaining health across contexts (Brownell et al. 1986).

This study describes the experiences of a diverse sample of gay and bisexual men in two small New England cities. Our participants' experiences are likely influenced by the unique features of our study contexts, including proximity to New york City. Thus these experiences may not be transferable to men in other similar-sized cities that lack these unique features. Furthermore, though our data describe two cities containing different features (e.g., New Haven contains a direct train connection to New york), they do not allow us to compare these environments, given the small number of Hartford participants. Future research that examines the experiences of gay and bisexual men in other small cities represents an important addition to the literature. Furthermore, research that documents migration experiences of gay and bisexual men to non-traditional destinations (e.g., outside of gay enclaves) will help to clarify the ways that variation in receiving and sending contexts may affect the nature of migration related health risk and benefits. Finally, research that documents the role of social networking technology in patterns of mobility, health and risk among gay and bisexual men will be an important contribution to the literature.

While we cannot extend these findings to the experiences of gay and bisexual men in other small US cities, these data do speak to a phenomenon of stigma-induced movement that is unlikely unique to our study setting. In particular, our findings provide one example of how stigma operates to limit gay and bisexual men's access and claims to space. Participants described going somewhere else, such as a gay bar in their own city or a gay enclave in another city, in order to more fully express themselves. As a result, they often lived their lives across a number of spaces. While existing stigma research has focused primarily on internal processes related to stress and identity formation, our data suggest that limited access to place may be an understudied and significant consequence of stigma that contributes to health. Future research that examines the spatial dynamics of stigmatised identities may thus be important to understanding and ameliorating health disparities experienced by stigmatised groups.