The Health Challenges of Emerging Adult Gay Men Effecting Change in Health Care

INTRODUCTION

In the United States, lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals experience a preponderance of health disparities.¹ These health challenges are predicated on the chronic marginalization and discrimination,^2,3 some of which are state sanctioned,^4,5 experienced by the population, coupled with a health care workforce that is inadequately prepared to effectively address the specific health needs of the population. These challenges continue even though policy makers have drawn attention to these matters in recent years.^6,7 In effect, it is imperative that health care providers are adequately prepared to meet the health needs of this population.⁸

Addressing the health needs of the LGBTQ population necessitates a thorough understanding of matters related to both sexual identity (also known as sexual orientation) and gender identity.⁹ Using and understanding the correct language and terminology as it relates to the identities of LGBTQ people is an essential initial step in providing competent and compassionate medical care. In this regard, it is critical that providers distinguish sexual orientation from gender identity, as these terms are often conflated with one another. Gender identity refers to “a person’s innate, deeply felt psychological identification as a man, woman, or something else, which may or may not correspond to the person’s external body or assigned sex at birth (ie, the sex listed on the birth certificate).”¹⁰ Terms that are commonly associated with minority gender identities include genderqueer, gender nonconforming, and gender bender, all of which can be used to refer to gender variations that are not typically associated with the dichotomous view of male and female. Sexual orientation refers to “a person’s enduring physical, romantic, emotional, and/or spiritual attraction to another person.”¹⁰ Examples of sexual identity include gay, lesbian, heterosexual, bisexual, pansexual (ie, a person’s attraction toward people regardless of their sex or gender identity), and asexual (ie, a lack of sexual attraction to others). Sexual identity encompasses both attraction and behavior, and is not limited solely to the sexual acts in which one engages. In this regard, ancient Athenian men engaged in same-sex behavior with young boys, but did not espouse a gay identity. As noted by classicist Eva Keuls¹¹ (pp. 1–2), “homosexuality as practiced by the Athenians was not about an identity, community, or movement; rather, it was part of a larger syndrome which included men’s ways of relating to boys, wives, courtesans, prostitutes, and other sexual partners, and, in a larger sense, to both the people of Athens and to the other city-states.” In a sense, Athenian homosexuality was about a patriarchy rooted in male dominance, misogyny, and power, and nothing akin to the gay rights movement of the twentieth century. In the end, homosexual behavior is only one sliver of gay identity, an identity that intersects with many other identities that gay men possess.^12,13

Over the past 30 years and directed by the acquired immunodeficiency syndrome (AIDS) epidemic, there has been an evolution of terminology associated with sexual orientation labels. The term men who have sex with men (MSM) was coined in 1994 by the Centers for Disease Control and Prevention and has often been used in the human immunodeficiency virus (HIV) literature.¹⁴ The argument for its initial use was driven by 2 perspectives: (1) epidemiologists sought to avoid complex social and cultural connotations that may hinder an epidemiologic investigation of disease by using identity-free terms, and (2) social construction suggests that sexualities are products of social processes and that a more textured understanding of sexuality does not assume alignments among identity, desire, and behavior.¹⁴ MSM and, more recently, WSW (women who have sex with women) have become dominant terms in health-related programming and research for sexual minorities.¹⁴ However, using these umbrella terms often implies a lack of gay or lesbian identity with an absence of community and networks in which same-gender relationships mean something more than just sexual behavior.¹⁴ Moreover, the use of these behavioral/epidemiologic terms fails to address the complex synergy that exists between identity and social conditions, effectively diminishing the significance that identity plays in affecting health, and ultimately framing sexual and gender minority individuals as vectors of disease.^14-16 Inherently, being gay is different from being bisexual or pansexual, although the sexual behavior may be the same, the feelings and salience can be quite distinct.

In addition, the umbrella term LGBTQ is limited in considerations of health and health care for this population recently estimated to constitute approximately 4.5% of the US population.¹⁷ The population is not monolithic, and there is great diversity in the life experiences of L, G, B, T, and Q people.¹⁸ Indeed, across these populations, there is even greater diversity when these identities are considered in relation to age, race, ethnicity, culture, gender identity, national origin, and social class, among other factors. In this regard, conceptualizations and frameworks that seek to target the entirety of the LGBTQ population often fail to address the specific and nuanced health challenges and health care needs of subpopulations within the LGBTQ population. For example, it would be inadequate and false to state that HIV is a health disparity that disproportionately affects the LGBTQ population; rather, it is a health disparity in the United States that overwhelmingly burdens gay and bisexual men and transgender women,¹⁹ who are part, but not the totality, of the LGBTQ population.

It is with this idea in mind that the authors further contextualize the ideas presented in the pages to follow. Given the particularities of health challenges facing various segments of the LGBTQ population, efforts herein focus on one segment of the population: gay men. In particular, the authors consider the health challenges faced by gay men who are emerging adults, recognizing that it is during this period that a vast majority of gay men emerge into their sexual identities,^13,20 and that this developmental period is often fraught with risk behaviors²¹ that might impact the health profile of these men in the immediate and set the foundation for health issues across the life course.²²

ADOLESCENCE AND EMERGING ADULTHOOD IN GAY MEN

The psychologist Jeffrey Arnett (2000) conceptualized the developmental state of emerging adulthood to differentiate the period between adolescence and adulthood, which, in Western industrialized nations, encompasses approximately ages 18 to 25. More recently, the period has been expanded to age 29 so as to capture demographic and educational shifts and also due to the financial realities of Millennials, including Millennial gay men, brought about by the economic crash of 2008 to 2009.^23,24 The group that has come to be known as the Queer Generation¹³ is challenged to achieve the financial stability and economic security of generations that preceded them. The demarcation of these years as a developmentally significant period emerged from such demographic trends as an increase in the median age at marriage, lengthier periods of formal schooling, and later ages for having a first child. Some 30% of those graduating high school do not attend college,²⁵ compounded by those who do not complete high school, makes this a challenging period of exploration and selfdiscovery. Black and Latino emerging adults are especially challenged during this developmental period because of sociocultural stereotypes about the competencies of minority youth.²⁶ There has also been a sharp decline in employment opportunities for those with only a high school education, and recent data note that 65.8% of those ages 20 to 24 do not have a college degree.²⁷ Although there is no longer a lock-step pattern to this period of development, those who successfully negotiate more of the tasks as they transition from the adolescence period, including their education, will experience greater well-being than those who falter and stall.²⁸

For gay men, the period of emerging adulthood is a highly vulnerable period in which the confluence of sexual risk taking, drug use, mental health burden, incarceration, and other risk conditions,^29-31 precipitated by experiences of homophobia and discrimination^32,33 from society at large, as well as racism and hegemonic notions of masculinity within the gay population,¹³ compromise health and well-being that may last throughout adulthood.^34,35 All in all, these conditions necessitate that health care providers be adequately prepared to address the health needs of this population; to date, there is evidence that such preparation is lacking,³⁶ first documented in the seminal work of the National Academies.³⁷ The lack of health care workforce preparation often leads to conditions in which these young gay men forgo care.³⁸ Although the provision of care for emerging adult gay men has improved relative to past generations of gay men, who were pathologized due to their sexual identity being categorized as a mental illness, invisible to health care providers because of fear of discrimination, or neglected because they were afflicted with AIDS, the conditions are still far from ideal.³⁹

HEALTH CHALLENGES FACED BY YOUNG AND EMERGING ADULT GAY MEN

The emergence of the AIDS epidemic in the later twentieth century engendered an unprecedented public health focus on the health and health care needs of gay men.⁴⁰ Accordingly, a wave of biomedical and social science emerged that clearly demonstrated the extent to which gay men, including emerging adult gay men, are disproportionally affected by a host of health-related challenges relative to their heterosexual peers.^37,41

Health disparities among young and emerging adult gay men are well-documented^37,41; however, the mechanisms and pathways (eg, biological, psychological, and/or sociologic mediators) linking sexual orientation to differential health outcomes remain poorly understood. These health challenges can be conceptualized within a minority stress framework,^42-44 which postulates that sexual minority men evidence higher rates of suboptimal health outcomes, relative to heterosexuals, largely because of stress processes stemming from their minority status (eg, sexual identity) membership and the chronic stigmatization of that identity. That is, in addition to general life stressors, emerging adult gay men experience qualitatively unique social stressors because of their sexuality, which accumulate to negatively impact the health profile of this population. For instance, relative to young heterosexual men, young gay or sexual minority men are significantly more likely to experience childhood victimization (eg, parental psychological and physical abuse),^45,46 school-based/peer victimization,⁴⁷ low levels of parental support,⁴⁸ and forced homelessness because of their sexuality.⁴⁹ As such, the health challenges and inequalities addressed in this article are not causally related to homosexuality or gayness, but, instead, are the reflection of noxious social conditions (eg, social marginalization, exclusion, and structural stigmatization) that work in concert to corrode the health profile of young and emerging adult gay men.^41,50-52

Mental Health

To date, substantial disparities in mental health have been documented in populations of emerging adult gay men.^43,44,53,54 Indeed, past research suggests that gay men evidence higher rates of psychiatric diagnoses and greater lifetime risk for mood-anxiety-substance use disorders relative to heterosexual men.⁵⁵ That is, some studies have shown differential rates or levels of suicidal ideation,⁵⁶ suicide attempts,^57-60 social anxiety,⁶¹ self-esteem,⁶¹ body image dissatisfaction,^62-64 alcohol use,⁶⁵ eating disorders,⁶⁶ cigarette smoking,⁶⁷ and illicit substance use⁶⁸ as a function of sexual orientation. For instance, in a systematic review of mental health disorders and sexual orientation, King and colleagues⁶⁸ documented that, across studies, gay men evidenced greater risk for lifetime prevalence of suicide attempts, lifetime prevalence of depression, and lifetime prevalence of anxiety relative to heterosexuals.

Although many emerging adult gay men may struggle with adverse mental health outcomes and reduced psychological well-being, it is critical to note that certain subpopulations (ie, those who are multiply disadvantaged because of intersecting marginalized identities) may be more at risk than others. For instance, the intersection of racial and sexual identity may predict adverse mental health risk insofar as Choi and colleagues⁶⁹ documented an association between discrimination and mental health outcomes such that experiences of racism in the past year were positively associated with adverse mental health outcomes (eg, depression and anxiety) in a population of 1196 African American, Latino, and Asian Pacific Islander MSM. These data highlight the degree to which one marginalized identity (eg, nonheterosexual sexual identity) coupled with a second marginalized identity (eg, nonwhite racial identity) may increase the risk for adverse mental health outcomes.

In addition, Gallo and Matthews’ Reserve Capacity Model postulates that socioeconomic status (SES) is a worthwhile predictor of health disparities due to the well-documented associations among SES, stress, and health.^70-72 As such, emerging adult gay men from lower SES backgrounds may evidence significantly fewer social and psychological resources with which to manage general and minority stressors, thereby amplifying the risk of adverse mental health outcomes. In support of Gallo and Matthews’ model,⁷² Storholm and colleagues⁷³ documented the buffering effect of SES on mental health outcomes in emerging adult sexual minority men, such that sexual minority men of higher SES reported lower scores on depression and posttraumatic stress disorder scales relative to lower SES respondents.

Holistically, these data highlight the degree to which young and emerging adult gay men are susceptible to adverse mental health outcomes; however, clinicians must realize that the susceptibility is not uniform across subpopulations of gay men. Instead, the relation between sexual orientation and adverse mental health susceptibility is significantly moderated by identity intersectionality and the degree of disadvantage stemming from the intersections (for more comprehensive reviews on the application of intersectionality to clinical practice, see van Mens-Verhulst J, Radtke HL, Intersectionality and health care: support for the diversity turn in research and practice, unpublished paper, 2006).⁷⁴

Sexual Health

The most documented and researched health disparity among gay men is HIV. Indeed, gay men make up fewer than 5% of the overall US population,¹⁷ yet account for more than half of those currently living with HIV,⁷⁵ and approximately 70% of new HIV infections annually.⁷⁶ In addition, sexual minority men are the only population within the United States where rates of new HIV infection remain stable, in lieu of decreasing, each year.¹⁹ For example, in a meta-analysis of US population-based surveys, disease rates of HIV (38–75 times as high) and primary and secondary syphilis (63–109 times as high) were significantly higher for gay men, relative to other men.⁷⁴ In addition to HIV and syphilis, gay men are disproportionally burdened by other sexually transmitted infections (STIs),⁷⁷ such as bacterial STIs (eg, chlamydia and gonorrhea),⁷⁸ human papillomavirus,^79,80 Hepatitis B and C,^81,82 and herpes simplex virus (HSV)-2.⁸³ STI comorbidity remains a common problem among gay men, with syphilis and HIV coinfection being the most documented comorbidity among this population.⁵² Within the population, the preponderance of new infections manifests in black and Latino adolescent and emerging adult gay men (13–24 and 25–34) with a decrease in infection among men in their mid-30s.⁸⁴

Physical Health

A focus on physical health disparities among populations of gay men has lagged behind research in other domains, namely mental and sexual health. Despite this notable lacuna in the literature, recent findings have found sexual orientation to be a robust predictor of adverse physical health outcomes, such as migraine headaches,⁸⁵ asthma,⁸⁶ cancer-related risk behaviors,⁸⁷ and cardiovascular health.⁸⁸ Indeed, adolescent gay men are significantly more likely to engage in behaviors that amplify lifetime cancer risk and have long-term physical health consequences relative to heterosexual men, such as smoking, consuming alcohol, using illicit drugs, engaging in risky sexual behaviors, reporting little physical activity, and consuming a diet low in fruits and vegetables.⁸⁷ As Rosario and colleagues⁸⁷ highlight, many of these health and cancer-related risk behaviors emerge early in the life course of sexual minority men (ie, adolescence), effectively increasing lifetime cancer risk among certain subpopulations of gay men due to earlier engagement in cancer-related risk behaviors.

In addition to behavioral risk factors, gay men have been documented to report lower levels of perceived physical health and higher rates of adverse physical health outcomes. In fact, a Netherlands-based study found that, relative to heterosexual men, gay men reported significantly lower perceptions of general health.⁸⁹ Similar findings have been replicated in the United States, with Conron and colleagues⁸⁶ documenting that, relative to heterosexuals, sexual minorities were more likely to report asthma, smoking, tension and worry, and activity limitation. More recent work has documented associations between sexual orientation and cardiovascular health such that MSM exhibited elevated cardiovascular risk factors and biomarkers.⁸⁸ For instance, MSM exhibited elevations in diastolic blood pressure, C-reactive protein, and pulse rate when compared with heterosexual men. Notably, differences in cardiovascular risk as a function of sexual orientation and gender emerged early, with the mean age of the participants being 28.9 years.⁸⁸

It is important to note that research examining the influence of sexual orientation on physical health is still in its infancy, highlighting that the true magnitude of physical health disparities as a function of sexual orientation remains unknown. However, the preceding data offer preliminary support for the extent to which sexual orientation may be a robust predictor of physical health outcomes and, thus, a clinical focus on gay men’s physical health is warranted.

HEALTH CARE CHALLENGES

The myriad health challenges faced by emerging adult gay men are magnified due to hardships in accessing adequate and competent health care that serves the unique needs of this population.³⁷ Contributing factors to inadequate care include overall lack of provider knowledge on health care needs,^90,91 history of stigmatizing experiences in the health care setting, and discomfort around discussing sexual orientation and/or sexual behaviors.^92-94 Because of these conditions, 18% of LGBTQ Americans avoid receiving health care in fear of being discriminated against or treated poorly by health care providers.⁹⁵

As a result of the discomfort and distrust of health care providers, fragmentation of care is common; research indicates that sexual minority men separate their sexual health care from other forms of health care,^96,97 which can lead to inconsistent and inadequate preventive and/or tertiary care. Integrative models using counseling psychologists have been proposed as a means of ameliorating the effects of this schism in health care access.^98-100 It is for this reason that one goal of the Healthy People 2020 campaign is to “improve the health, safety, and well-being of lesbian, gay, bisexual, and transgender (LGBT) individuals.”¹⁰¹ However, the threatened reversal of protective policies (eg, threats to repeal the Affordable Care Act [ACA] and reinterpret the ACA’s antidiscrimination mandate)^102-104 and the removal of sexual and gender identity questions from national health-related surveys by the federal government of the United States since 2016 are clear barriers that undermine the efforts that are sought in the goal of Healthy People 2020.

Negative attitudes toward the LGBTQ population and limited expertise on the particularities of gay men’s health create these substandard conditions as emerging adult gay men navigate the health care system. For some, there may be a period of failing to access health care as they emerge into adulthood and migrate from their pediatricians and/or family physicians to providers of their own. Indeed, one study identified that 18.7% of California-based physicians indicated discomfort providing care to gay men,¹⁰⁵ harkening back to the early days of the AIDS epidemic when many gay men were abandoned by their health care providers.¹⁰⁶ These realities emerge in medical school; one study indicated that 15% of medical school students reported mistreatment of LGBT students at their schools, whereas 17% of LGBT medical students reported a hostile learning environment.¹⁰⁷ Implicit preferences for heterosexual people versus lesbian and gay people are pervasive among heterosexual health care providers. Sabin and colleagues¹⁰⁸ report that implicit preferences for heterosexual people versus lesbian and gay people are pervasive among heterosexual health care providers; that implicit preferences for heterosexual women were weaker than implicit preferences for heterosexual men; and that heterosexual nurses held the strongest implicit preference for heterosexual men over gay men. Such implicit bias is also noted in public health and other health professions, as has recently been reported by Halkitis.¹⁰⁹

Moreover, a number of studies indicate that medical schools are inadequately preparing students to enact effective LGBTQ health care provisions.¹¹⁰ LGBTQ health care training in undergraduate medical education is limited to approximately 5 hours,¹¹¹ ranging from a minimum of 3 to a maximum of 8 hours. Compounding the conditions nested within the health professions are the attitudes of the general public: 30.4% of those polled in one study indicated that they would change providers if they discovered that their provider was gay or lesbian, demonstrating the pervasiveness of LGBTQ stigma in American society.¹¹²

The aforementioned health care challenges experienced by emerging adult gay men are echoed by the results from a recent mixed-methods study conducted by some of the authors.⁹⁰ The study participants, all of whom were emerging adult gay men, sought providers who possessed knowledge of the specific health care needs of gay men, especially with regard to same-sex sexual health, which are deficient in most medical school curricula¹¹³: “I definitely could’ve used a doctor to talk to like a – yeah, a doctor to talk to just about what’s healthy, and what’s not with gay sex.” These findings also underscore the extant literature regarding negative provider attitudes: “The doctor wasn’t knowledgeable with the LGBT community… She’s never really had gay patients so for her it’s kinda new and her reaction was kinda like oh, you’re young, right now you shouldn’t be having anal sex…It wasn’t the reaction I was expecting.” The social conditions experienced by some of the gay men were indicative of the homophobia of health care providers: “He’s [the doctor] a Muslim… So his thing is he doesn’t wanna hear too much about sex with guys on guys. So it really makes it really uncomfortable to talk about it because all I’m gonna get is ‘Marry a girl’- …It just comes up all the time because he knows I am gay.” As a result of such situations, many young gay men turn to sources outside the medical profession for knowledge about their health: “I’ve always gotten knowledge of gay men health and about risk and HIV and stuff through outside sources…I feel uncomfortable speaking to my doctor.”

LGBTQ health care centers such as Callen-Lorde in New York City and Fenway Health in Boston provide an important service to emerging adult gay men: “When I visited the gay center, then they taught me a whole new vocabulary and certain different aspects of myself that I should pay attention to more, which helped me out.” This perspective underscores the need for not only more robust, thorough, and tailored education and training on gay men’s health care for medical providers, but it also underscores the need for health care spaces and settings that are affirming of sexual minority individuals.

In addition, economic circumstances might compound the aforementioned matters that undermine the health of gay men. Indeed, LGBT individuals experience higher levels of poverty compared with their heterosexual counterparts.^114,115 Thus, LGBTQ health care access is an economic justice issue.¹¹⁶ For young emerging adult gay men of the Millennial generation, financial worries reside alongside their concerns about their health and their experiences of loneliness and isolation that function to undermine their health.¹¹⁷

ADDRESSING THE HEALTH CHALLENGES OF EMERGING ADULT GAY MEN

Emerging adult gay men are disproportionally burdened by and at an increased risk for health challenges and inequalities spanning multiple health domains (eg, mental, physical, and sexual).^37,41 These health burdens do not occur in isolation; instead, the health profile of emerging adult gay men is defined by a set of co-occurring, comorbid, and mutually enforcing health problems.¹¹⁸ As conceptualized by Singer and colleagues^119,120 and adapted for gay men by Stall and colleagues,¹¹⁸ the syndemic paradigm postulates that multiple co-occurring epidemics interact synergistically to modify disease risk, transmission, and progression, and that these syndemic conditions are directed by psychosocial burdens, often emanating from experiences of homophobia and discrimination, experienced by this population. These health disparities are largely directed by social and sexual stigma⁶; when laws and policies, such as marriage equality, are enacted, health conditions, including HIV, are projected to improve for the population of emerging adult gay men.¹²¹

A holistic health care paradigm has applicability to addressing the health of gay men across the lifecourse.^122,123 In this view, health care services for the LGBTQ population broadly, and for emerging adult gay men specifically, must be (1) holistic in nature addressing the multiplicity of health burdens; (2) understood in relation to the social conditions that exacerbate these health disparities, including the transmission of pathogens (ie, a biopsychosocial perspective); and (3) attend fully to sexual and gender identities in the delivery of care. With regard to the latter, it is imperative that emerging adult gay men do not continue to be invisible to health care providers,¹²⁴ as they had been before and for years following the Stonewall Riots, which ignited the LBGTQ civil rights movement.³⁹ One critical step in ensuring this visibility and chipping away at the otherness young gay men feel is the inclusion of sexual and gender identity on all health care intake forms and electronic records.^125,126 Inclusion of these elements function (1) to communicate openly to the provider the identity of the patient, thus directing the provider to tailor services as needed; (2) to validate the life/lived experiences of the patient; and (3) to diminish the stigma and shame too often felt by LGBTQ people. For emerging adult gay men who are in the process of developing their own sexual identity and enacting strategies to disclose who they are, the addition of these 2 questions on any and all health care forms will function to alleviate the already undue burden of a lifetime of “coming out.”¹³

Numerous resources and guidelines^127,128 have emerged in recent time in response to the mounting evidence on the numerous health disparities burdening the lives of emerging adult gay men and the LGBTQ population more broadly, much informed by the approaches postulated by leading medical providers and advocates such as Harvey Makadon and colleagues¹²⁹ and organizationally through the National LGBT Health Education Center at the Fenway Institute.^10,129 These efforts advance a set of domains that might impact a positive change in the health care delivery to emerging adult gay men: (1) addressing and developing polices that attend to the well-being of LGBTQ people within health care facilities; (2) creating health care environments that are welcoming; and (3) training staff fully and thoroughly to become more adept at addressing the health of the population. These recommendations are enumerated more fully in the aforementioned guidelines. Briefly, policy strategies include the development or adoption of nondiscrimination polices to protect patients as well as recruiting and/or identifying health care providers and staff with expertise working with sexual minority gay men. Welcoming environments would include the creation of gender-neutral bathrooms and the clear display of relevant LGBTQ literature. Finally, ongoing staff training to address biases (eg, homophobia and heterosexism), intersectionality, and tailored education on gay men’s health are essential. All of these elements should be complemented by the development and implementation of intake forms that include the collection of sexual and gender identity information.

SUMMARY

Ultimately, effective health care for emerging adult gay men must be cognizant of the fact that these young gay men are grappling with their sexuality during this period of emerging adulthood, which compounds and exacerbates the multitude of developmental issues that emerge during this stage of life. Second, a holistic approach to the health of emerging gay men must use a biopsychosocial frame^15,130 in understanding health challenges with an eye to how social conditions may shape health and how social and emotional well-being are critically tied to physical well-being. Third, skilled and competent health care providers must further recognize that the population of emerging adult gay men is not monolithic, and that all possess intersectional identities,^3,122,131 necessitating tailored approaches to care that fully consider the role of race, ethnicity, culture, social class, and nation of birth, among other factors. Finally, and importantly, the health of emerging adult gay men is not solely defined by HIV; and although the disease continues to persist in the population, the health of young gay men must be envisioned with a broader and less stigmatizing frame if the nation and those that provide care to gay men are to advance the well-being of current and future populations of gay men.

KEY POINTS.

• Emerging adult gay men are disproportionally burdened by myriad health disparities, spanning multiple domains (eg, mental, physical, and sexual health).

• The health profile of emerging adult men is complicated further by barriers to accessing competent health care.

• Health care provider knowledge on the unique health and health care needs of emerging adult gay men is severely lacking.

• The utilization of a holistic health care paradigm, the addition of staff education and training sessions, and the creation of a welcoming clinical atmosphere and environment are necessary first steps in providing competent health care to populations of emerging adult gay men.