Reports

Addressing the Social Determinants of Health Inequities Among Gay Men & Men Who Have Sex With Men

December 2014

With support from the M·A·C AIDS Fund, TFAH undertook a literature review and convened a one-day consultation to consider strategies to mitigate the social determinants of health inequities among gay men and other men who have sex with men (MSM).† Invited participants included research scientists, lesbian, gay, bisexual and transgender (LGBT)‡ health service providers, public policy advocates, and federal officials.*

After reviewing current research pertaining to health inequities among MSM (including HIV epidemiology) and theoretical constructs to explain disparities, the remainder of the meeting focused on identifying opportunities for the federal government to intervene. Two caveats underpinned the discussion: 1) the need for additional research was stipulated, and 2) it was acknowledged that, while the evidence base to support interventions to address social determinants of health (SDH) among MSM is slim, health disparities (particularly HIV) are sufficiently grave to warrant taking immediate action. As such, meeting participants were charged with articulating ways in which the federal government could respond now to continuing health inequities among MSM based upon existing data. While Addressing the Social Determinants of Health Inequities Among Gay Men and Other Men Who Have Sex With Men in the United States reflects those conversations, the views expressed are solely those of Trust for America’s Health.

In the United States, gay men and other MSM continue to be more profoundly impacted by HIV than any other group. Though representing approximately 2 percent of the population, MSM comprise a majority of new HIV infections (66 percent in 2010) and represent more than half (56 percent) of all persons living with an HIV diagnosis. HIV incidence is disproportionately higher among Black MSM than any other risk group.

MSM also face a variety of other mental, physical and sexual health disparities, including substance abuse and depression, both of which correlate with high-risk behaviors for HIV infection, as well as suicide. MSM also have elevated rates of syphilis, gonorrhea, and other sexually transmitted diseases (STDs), which are associated with an increased risk for HIV infection as well. Young MSM are more likely than their heterosexual counterparts to report emotional distress, depression, or self-harm, and are at higher risk of suicidal ideation or attempts and becoming homeless.

The many health inequities experienced by MSM constitute a syndemic — i.e. multiple social determinants that each independently influence health outcomes, and which mutually reinforce and amplify each other. Among MSM, the syndemic comprising HIV, STD’s, mental health, substance abuse, and violence has profound implications for HIV prevention — as numerous health challenges may overwhelm the capacity of some MSM to reduce their sexual risks. Moreover, for MSM who are also racial minorities, social determinants of health may intersect in various, overlapping domains, including not only sexual orientation, but race, poverty, educational attainment and immigration status.

Strategies to address health inequities among MSM — including, but not limited to, HIV — include interventions to 1) increase individual resiliency, 2) foster a supportive community, 3) improve access to quality healthcare, and 4) transform the environmental context in which people live. While new biomedical interventions such as pre-exposure prophylaxis or treatment-as-prevention show promise, their uptake will also be affected by social determinants.

Addressing social determinants at every stage of life will require an array of linked individual, biomedical and structural interventions throughout the life course. To account for environmental factors, community-level and structural interventions must include health policy and legislation, economic and social interventions, and cross-sector collaborations. Federal coordination will be essential — the National Prevention, Health Promotion and Public Health Council (NPC) is well positioned to provide leadership. In the long term, however, reducing societal oppression and marginalization of LGBT people will diminish the need for individual and community-level interventions. The increasing recognition that for MSM, HIV constitutes but one of many health challenges provides an opportunity to refocus efforts to fight HIV by incorporating interventions within the context of MSM health and wellness promotion.

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Addressing the Social Determinants of Health Inequities Among Gay Men and Other Men Who Have Sex With Men in the United States was supported by a grant from the M·A·C AIDS Fund. The opinions expressed are those of the authors and do not necessarily reflect the views of the foundation. TFAH would like to thank M·A·C AIDS Fund for their generous support of this report.

† In Addressing the Social Determinants of Health Inequities Among Gay Men and Other Men Who Have Sex With Men in the United States, the term MSM is used to designate gay men and other men who have sex with men, a group that includes both men who do and those who do not self-identify as gay, and which includes men who also have sex with women. For purposes of the paper, this group does not include transgender men or women, who may be heterosexual, homosexual or bisexual in their orientation. Though data pertaining to transgender health are extremely limited, studies show that transgender people experience significant health inequities, and there are differences in health outcomes between transgender men and women, who are at far greater risk for HIV (a meta-analysis of 29 studies found an estimated HIV prevalence rate of 27.7 percent among transgender women — see Herbst JH, Jacobs ED, Finlayson TJ et al. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: a systematic review. AIDS Behav, 2008;12:1-7). Additional research to better understand transgender-specific health issues, as well as policy approaches to address transgender health inequities, are warranted in their own right and are urgently needed.

‡ In Addressing the Social Determinants of Health Inequities Among Gay Men and Other Men Who Have Sex With Men in the United States, the term LGBT (lesbian, gay, bisexual and transgender) is used, as it often is both colloquially and in the published literature, to refer to the community of people who share the fact that, and who are frequently stigmatized because, their sexual orientation is not exclusively heterosexual — but who are otherwise diverse in terms of gender, race, socioeconomic status, age, and other characteristics. LGBT health research is in a formative phase and has been limited by a lack of systematic population data collection, as questions pertaining to sexual orientation have appeared only recently in most national surveys. LGBT health research also poses numerous methodological challenges (see “Conducting research on the health status of LGBT populations” [chapter 3], in: Institute of Medicine. The Health of Lesbian, Gay, Bisexual and Transgender People: Building a Foundation for Better Understanding. Washington, D.C.: The National Academy Press, 2011), not the least of which is that for research purposes, these four populations are imperfectly and variously defined, separately and collectively, by attraction, behavior, and identity, designations that themselves sometimes overlap and in many cases cannot be considered fixed. For example, due to challenges in obtaining sufficient statistical power, research designs sometimes treat the four populations as a single “LGBT” group, though in studies that are able to distinguish among them, significant differences in health outcomes have sometimes been shown among these populations. Given these limitations, whenever possible, this paper references research conducted specifically among MSM. Research that examines the LGB or LGBT populations as a whole is also cited here to the extent that it refers to MSM specifically or draws conclusions that can be understood to apply to MSM — these references should not be interpreted to imply that the conclusions cited necessarily apply equally, or at all, to lesbian, bisexual (except to the extent that they fall within the definition of MSM, above) or transgender people.

* Federal officials were invited to participate in the meeting as a resource and not in their official capacities.