Journal of Homosexuality, 62:571–587, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0091-8369 print/1540-3602 online DOI: 10.1080/00918369.2014.987567
Moving Toward a Holistic Conceptual Framework for Understanding Healthy Aging Among Gay Men PERRY N. HALKITIS, PhD, MS, MPH and FARZANA KAPADIA, PhD, MPH Center for Health, Identity, Behavior and Prevention Studies, Global Institute of Public Health, and Department of Population Health, Langone School of Medicine, New York University, New York, New York, USA
DANIELLE C. OMPAD, PhD Center for Health, Identity, Behavior, and Prevention Studies, Center for Drug Use and HIV Research, and Global Institute of Public Health, New York University, New York, New York, USA
RAFAEL PEREZ-FIGUEROA, MD, MPH Center for Health, Identity, Behavior and Prevention Studies, New York University, New York, New York, USA
In the last four decades, we have witnessed vast and important transitions in the social, economic, political, and health contexts of the lived experiences of gay men in the United States. This dynamic period, as evidenced most prominently by the transition of the gay rights movement to a civil rights movement, has shifted the exploration of gay men’s health from one focusing primarily on HIV/AIDS into a mainstream consideration of the overall health and wellbeing of gay men. Against this backdrop, aging gay men in the United States constitute a growing population, for whom further investigations of health states and health-related disparities are warranted. In order to advance our understanding of the health and wellbeing of aging gay men, we outline here a multilevel, ecosocial conceptual framework that integrates salient environmental, social, psychosocial, and sociodeomgraphic factors into sets of macro-, meso-, and micro-level constructs that can be applied to
Address correspondence to Perry N. Halkitis, New York University, 41 East 11th Street, #716, New York, NY 10003, USA. E-mail: [email protected] 571
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comprehensively study health states and health care utilization in older gay men. KEYWORDS gay men, aging, health, HIV/AIDS, ecosocial
By 2015, approximately one third of the U.S. population will be 50 years and older (Population Division, United States Census Bureau, 2008). Within this group, 1.2–1.4 million Americans will be older gay men (Chandra, Mosher, Copen, & Sionean, 2011), a figure more pronounced in urban areas such as Los Angeles, New York City, and San Francisco (Black, Gates, Sanders, & Taylor, 2000; New York City Department of Health and Mental Hygiene, 2011). Adult and older gay men are more likely to have experienced a range of negative mental (Cochran, Sullivan, & Mays, 2003) and physical health conditions throughout their lifetimes—most notable of these being the HIV/AIDS epidemic (Halkitis, 2010; Halkitis, Wolitski, & Millett, 2013). Moreover, this generation of gay men came of age in an era where homosexuality was characterized as a psychiatric diagnosis (Bayer, 1987). As such, the psychosocial stressors, such as stigma and discrimination, ensuing from this labeling may be related to disparities in overall health, wellbeing, and health care utilization in older gay men. Both the Institute of Medicine (2011) and the U.S. Department of Health and Human Services (2013) have acknowledged these health and health care disparities, the former recommending a program of research to describe and understand the health needs of the U.S. sexual minority population. Similarly, the extant literature indicates the growing awareness for the unique health care needs of sexual minority populations, that extends beyond the HIV epidemic (Adams, Braun, & McCreanor, 2007; Halkitis, Wolitski, & Millet, 2013, Mayer et al., 2008; Meyer, 2001). Thus, a research agenda that is theoretically grounded and able to employ a scientifically sound and appropriate methodology is warranted to generate the essential and timely knowledge required to advance the health, wellbeing, and health care utilization of older gay men. Here, we advance a comprehensive framework developed around two sets of health-related outcomes (1) the health states (physical, mental/ neurocognitive, and sexual health) and (2) health care utilization (defined as need, access, usage, and satisfaction) of older gay men. We outline and describe a range of key micro-, meso-, and macro-level characteristics as well as their dynamic interactions, which merit consideration in future research endeavors aimed at health outcomes and health care utilization among older gay men.
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THE NEED TO UNDERSTAND THE HEALTH OF AGING GAY MEN Gay men of the baby boomer generation are characterized by unique developmental milestones (e.g., coming out, sexual onset, marriage and domestic partnerships), attributed to the significant sociocultural shifts including the burgeoning and mainstreaming of the gay liberation movement, the development of a health advocacy movement stemming from the HIV/AIDS epidemic, and the end of institutional segregation. Moreover, while the baby boomer generation, writ large, has benefited from public health, social, and medical advances, these benefits have not been evenly distributed, resulting in significant health and health care utilization disparities among gay men. There is a paucity of data addressing the overall health care needs of aging gay men and, in particular, the health care needs of racially/ethnically diverse gay men. Each of these groups represent a marginalized population, where the stigma and discrimination associated with a sexual minority identity, same-sex sexual partnering, a racial/ethnic minority identity, and HIV seropositivity can be cumulative and overlapping, exacerbating health disparities. A conceptual framework that allows investigators to capture this intersectionality is warranted and will aid in the development of programs targeted to reducing health care utilization–related disparities in this population (U.S. Department of Health & Human Services, 2013).
HEALTH STATES OF AGING GAY MEN Over the last 30 years, the heath of gay men has been driven primarily by attention to sexual health and HIV/AIDS-related risk factors, but if we are to effectively address the wellbeing of this population, we must move beyond such myopic understanding of wellbeing, especially given the advances in HIV treatments (Halkitis, 2010). As such, the health of aging gay men must be considered in relation to several dimensions—physical, mental/emotional, and neurocognitive, in addition to sexual health—in order to effectively and comprehensively provide health care services that attend to all aspects of the health and wellbeing of aging gay men. The physical health of aging gay men may be compromised for several reasons. In terms of chronic conditions and poor health states, aging gay men exhibit higher rates of diabetes, hypertension, physical disability, and fair to poor self-rated health compared to demographically similar aging heterosexual adults (LGBT Movement Advancement Project (MAP) and Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders (SAGE), 2010). A significant body of research has demonstrated that gay men experience a higher burden of mental health disorders, such as mood disorder,
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anxiety disorder, and so forth, compared to their heterosexual counterparts (Cochran et al., 2003). Furthermore, it is likely that gay men may experience higher rates of substance use–related morbidities as they age (Green & Feinstein, 2012). The extant research also provides evidence indicating that older age and HIV independently increase the risk of neurocognitive impairment, particularly in the areas of attention, processing speed, and executive functioning, as well as memory (Hardy & Vance, 2009; Kohli et al., 2006). Finally, despite three decades of extant research on sexual behaviors associated with the acquisition of HIV and other sexually transmitted infections (STIs) among gay men (Halkitis, 2010), there is limited knowledge regarding the general sexual health of older gay men in the United States (e.g., Jacobs, Fernandez, Ownby, Bowen, Hardigan, & Kane, 2010), and what is known is often related to the sexual health of those who are seropositive (Halkitis et al., 2012; Pappas & Halkitis, 2011). While the bulk of this research has focused on understanding risk behaviors associated with HIV/STI acquisition and transmission, sexual health encompasses partnership, activity, behavior, attitudes, and function that may be more relevant to the lives of aging gay men. To better understand the sexual health of this population, future studies will need to be able to consider factors such as physiologic changes, other related health conditions, use of medications that can affect sexual drive, and communication and negotiation skills that may influence sexual behaviors and sexual health among older adults.
HEALTH CARE UTILIZATION Factors associated with timely access and entry into HIV-related health care have been extensively studied, with recent studies also focusing on the need for, access to, and utilization of general sexual health screenings among both HIV-positive gay men and the general population of gay men (Zou, Fairley, Guy, & Chen, 2012). Although this is an important expansion of health-related care seeking among older gay men, these studies again limit the health concerns of gay men and aging gay men to risk behaviors associated with HIV rather than the broad spectrum of health-related concerns that face an aging community. Moreover, empirical evidence suggests that gay men may not link their sexuality with overall health care (Adams, Braun, & McCreanor, 2007). As such, more attention must be paid to primary health care access and utilization among gay men, and especially among aging gay men given the increased need for physical and mental health care services among older adult populations. Such efforts to enhance health care utilization must target both providers and clients and must extend beyond individual behavior to encompass structural and policy approaches.
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The limited research to date suggests that older gay men delay or avoid seeking health and social services due to fear of discrimination and physician insensitivity to their health concerns compared to similarly aged older heterosexuals (Gee, 2006). Furthermore, fear of discrimination coupled with an inability to meet the specific needs of older gay men has resulted in reduced satisfaction with care received (MetLife, 2010). Even in New York City, health care services are predominantly heterocentric and not always gay-friendly (Office of the New York City Public Advocate, 2008).
A FRAMEWORK FOR STUDYING THE HEALTH OF AGING GAY MEN A conceptual framework guiding investigations of health and health care utilization among aging gay men must attend to multiple sets of factors that predispose health and wellbeing. Thus, the proposed model integrates the role of multilevel factors, with an understanding that individuals do not operate in isolation but must navigate diverse contexts and environments. Our conceptual model (Figure 1) draws on three theoretical frameworks: the social–ecological model of health (Bronfennbrenner, 1986), the theory of syndemic production (Singer, 2009), and the behavioral model of health service utilization (Andersen, 1968). Leveraging these theories will facilitate an examination of the impact of multilevel factors on both health states and health care utilization among older gay men. First, utilization of a social–ecological framework enables researchers to build on the extant literature that provides insights on the role of traditional, individual-, and relationship-level factors associated with health outcomes and health-related behaviors among gay men. The addition of macroand meso-level factors to these traditional, individual-level (micro-level)
Macro-level factors
Characteristics of the residential neighborhood
Meso-level factors
Micro-level factors
Civic engagement
Sociodemographic characteristics
Characteristics of primary socialization neighborhoods
Social engagement
Psychosocial burdens
Religious engagement
Social integration
Healthcare provider availability
Housing instability
Social support Social networks
Health outcomes
Health states: Physical Health Mental/Neurocognitive Health Sexual Health Healthcare utilization Need for care Access to care Utilization of care Satisfaction with care
FIGURE 1 Multilevel conceptual model for studying the health of aging gay men.
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characteristics, coupled with a focus on the relationship between individuallevel characteristics and a broader range of health outcomes, provides an opportunity to capture multi-level information on the overall health status of older gay men. Next, key elements of the theory of syndemic production, which posits that mutually reinforcing epidemics of risk factors exacerbate each other and lower the overall health profile of a population to a greater degree than an individual epidemic alone, are incorporated into this framework. The application of this theoretical perspective is based on prior work showing that co-occurring epidemics of salient risk behaviors persist into older adulthood and can affect the health and wellbeing of both HIV-positive and HIVnegative gay men (Halkitis et al., 2012; Pappas & Halkitis, 2011; Vosburgh, Mansergh, Sullivan, & Purcell, 2012). Building on this prior research around syndemic production among sexual minority men, the framework proposed here posits that the mechanisms of syndemic production will be influenced by risk and protective factors across the multiple levels. Finally, Andersen and Newman’s behavioral model for health care utilization (Andersen, 1968; Andersen & Newman, 1973) depicts health services utilization as a function of factors that predispose individuals to use health care services, those that enable or impede the use of services and individual need for care. Incorporating key components of the Andersen and Newman framework into this framework will enable an understanding of how factors related to health outcomes among older gay men may also be associated with health care utilization.
Micro-Level Determinants of the Health of Aging Gay Men Examination of individual-level determinants of health has dominated the health behavior literature for several decades. Studies delineating the role of sociodemographic characteristics such as race/ethnicity, socioeconomic status, educational attainment, and psychosocial/social cognitive states (e.g., self-efficacy, motivation) have saturated the literature. However, the role of individual-level factors, in particular the role of social cognition, may be limited in that they implicate individuals as sole and rational operators (Halkitis, 2010). Still, if sociodemographic factors, such as education, race/ethnicity, or sexual orientation, are viewed through the lens of fundamental causes (Link & Phelan, 1996), and psychosocial factors are nested within a larger framework as we propose in our model, then these characteristics provide a means for understanding their effect nested within broader structures and systems. An innovative aspect of our model is that is that it applies a multi-level conceptual framework integrating these individual micro-level variables, in relation to macro- and macro-level factors to understand health states and health care utilization. Below we consider the role of individual level
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factors, in particular, sociodemographics, psychosocial burdens, and social integration and social support in relation to the health of aging gay men.
SOCIODEMOGRAPHIC CHARACTERISTICS Sociodemographic characteristics such as race/ethnicity, age, and marital/domestic partnership status may moderate the influence of other micro-, meso-, and macro-level factors on the health of aging gay. The few studies that examined age and racial/ethnic disparities among gay men have focused primarily on Black-White differences. A growing body of research suggests that same-sex marriage is and will continue to be an important social determinant of health (Halkitis, 2012). Studies suggest that legalization of same-sex marriage will positively affect a range of outcomes including syphilis rates (Francis, Mialon, & Peng, 2012) and mental health outcomes (Hatzenbuehler et al., 2012; Wight, LeBlanc, de Vries, & Detels, 2012). Additionally, disentangling the impact of HIV as a health condition and as a social determinant of health can be challenging, as the effects may be overlapping. As a social determinant, HIV-related stigma has been negatively associated with quality of life (Slater et al., 2012), and HIV-related bereavement has been shown to influence mental health (Wight et al., 2012).
PSYCHOSOCIAL BURDENS Aging gay men experience greater psychosocial burdens as measured by stigma, loneliness, discrimination, physical assault, intimate partner violence, and caregiving burden compared to their heterosexual counterparts. These psychosocial burdens are associated with sexual risk taking and illicit drug use among aging gay men (Halkitis et al., 2012). Compared to their younger and non-gay counterparts, older gay men report higher levels of substance use (Green & Feinstein, 2012; Halkitis et al., 2011). Among aging individuals, and especially aging gay HIV-positive men, the burden of caring for a loved one is related to unprotected sexual behaviors (Mayne, Acree, Chesney, & Folkman, 1998), higher rates of depression (Wight, 2000), increased levels of loneliness, and post-traumatic stress disorder (Theuninck, Lake, & Gibson, 2010). This same cohort of men also reports a higher incidence of intimate partner violence (Houston & McKirnan, 2007) and childhood victimization, the latter a factor found to be associated with increased sexual risk-taking (Paul, Catania, Pollack, & Stall, 2001). Finally, hypermasculinity, which is also conceptualized as masculinity threat, is highly detrimental to the health of gay men (Stall, Friedman, & Catania, 2008) and has been implicated in sexual risk-taking as well as body image (Halkitis, Green, & Wilton, 2004), both of which have a direct impact on health. Rigid conceptions of masculinity
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may be additionally burdensome to gay men as they age (Pope, Wierzalis, Barret, & Rankins, 2007) due to wear and tear on the body and on sexual performance. SOCIAL INTEGRATION, SOCIAL SUPPORT,
AND
SOCIAL NETWORKS
A growing body of research suggests that social integration—defined as participation in a social community or social activities, one’s social relationships, and perceptions of being an integrated community member—is associated with a range of positive outcomes among older adults (Seeman, 2000). Several prior studies have shown that greater levels of social integration are associated with lower rates of mortality (Obisesan & Gillum, 2009), fewer depressive symptoms (Glass, De Leon, Massuk, & Berkman, 2006), and a greater likelihood of survival following a heart attack (Glymour, Weuve, Fay, Glass, & Berkman, 2008). Grounded in social network theory, social support and network factors focus on the relationships or ties between individuals within a social system (Wasserman & Faust, 1994). The social network approach assumes that the behaviors and attitudes of individuals are influenced by perceived behaviors, attitudes, and norms of network members (Hall & Wellman, 1985; House & Kahn, 1985). Therefore, exploring differences in social network structure (e.g., size, shape, and characteristics of network members) and content (e.g., information, resources) transmitted within social networks of older gay men will likely help to identify the social structures or interactions that facilitate or impede involvement in a range of health-related behaviors that may influence their collective health and wellbeing (Lin, 2001; Hall & Wellman, 1985). Additionally, network-level normative influences that can be tapped into or modified to encourage and support involvement in safer overall health-related behaviors (Borsari & Carey, 2003). Furthermore, the transfer of information or resources (social support) may be influenced by environmental factors as well as the opportunities or impediments it provides for social interaction between network members.
Meso-Level Determinants of the Health of Aging Gay Men Our model includes meso-level factors that capture the engagement of aging gay men with social structures. The extant literature has demonstrated that involvement with civic, social, and religious institutions may positively affect the health of aging gay men, while housing instability may undermine the health of these men. CIVIC ENGAGEMENT Civic engagement, defined here as volunteering and political participation through activism, has been associated with improved health among older
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adults. Volunteering has been associated with improved self-rated health, physical functioning, and quality of life as well as a decreased likelihood of functional dependency/disability and depression (Barron et al., 2009). For older gay men, the onset of the AIDS pandemic necessitated the need to take on greater roles in organizing and community activism (Institute of Medicine, 2011). Despite this role, information on the relationship between activism and health outcomes are limited. One study indicated that activists used more problem-focused and less emotion-focused coping strategies, had greater HIV-related knowledge, and better integrated social networks as compared to non-activists (Brashers, Haas, Neidig, & Rintamaki, 2002). SOCIAL ENGAGEMENT Gay social contexts, in particular community organizations, venues, and events, have played a significant role as the access points for HIV behavioral surveillance, education, and prevention. There is also a demonstrated significant protective outcome associated with social engagement among gay men with respect to lower risk for dementia, depression, and psychosocial risks (Glass et al., 2006). Conversely, social engagement has also been associated with HIV-positive serostatus, unprotected anal intercourse with regular partners, and drug use (Zablotska, Holt, & Prestage, 2012).
RELIGIOUS ENGAGEMENT Among older adults, religiosity and spirituality are related to better physical and mental health, including improved physical health and psychological wellbeing, decreased depressive symptoms, prolonged survival, and faster remission of depressive symptoms (Bosworth, Park, McQuoid, Hays, & Steffens, 2003; Cohen & Koenig, 2003). For gay men, exploring the conflicts that arise in relation to integrating a non-heterosexual identity with religious traditions has been explored among adults (Halkitis et al., 2009) and more recently among younger gay men (Cutts & Parks, 2009). However, there is an absence of research focusing on the relations that might exist between religiosity and healthy aging among older gay men.
HOUSING INSTABILITY Being homeless or unstably housed is a source of chronic stress and is associated with a wide range of health problems (Shaw, 2004; Krieger & Higgins, 2002), including HIV/AIDS (Wolitski, Kidder, & Fenton, 2007). Factors such as a lack of housing, transient living conditions, and the communal sleeping arrangements in most homeless shelters are associated with multiple sexual partners, casual liaisons, sex exchanges, low rates of stable partner relationships, and substance use (Halkitis et al., 2011; Aidala, Cross, Stall,
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Harre, & Sumartojo, 2005; Reilly & Woo, 2002). Furthermore, unstably housed individuals concentrate in the most devastated neighborhoods (Saegert & Evans, 2003). Those who lack stable housing face multiple barriers to service utilization, including limited access to risk reduction services (Nwakeze, Magura, Rosenblum, & Joseph, 2003). However, information on the effects of homelessness and housing instability among older gay men is lacking.
Macro-Level Determinants of the Health of Aging Gay Men A robust body of work supports the impact of neighborhoods on older adults’ health. Neighborhood sociodemographic characteristics have been associated with cognition (Lang et al., 2008), psychosocial functioning (EversonRose et al., 2011), and self-rated health (Omariba, 2010). Furthermore, health care utilization is influenced by structural/place-related factors demonstrating that health care utilization is, in fact, lower when travel time to services is longer (Hiscock, Pearce, Blakely, & Witten, 2008; McCarthy, & Blow, 2004). Finally, greater availability of physicians is associated with lower levels of disability among older adults (Pruchno, Wilson-Genderson, & Cartwright, 2012) but not self-rated health (Subramanian, Kubzansky, Berkman, Fay, & Kawachi, 2006). Research on neighborhood-level factors affecting the health of gay men is limited. What exists has focused on residential neighborhoods with large gay populations. These studies demonstrated that residence in “gay neighborhoods” was associated with protective factors such as HIV testing (Mills et al., 2001) and consistent condom use (Frye et al., 2010) compared to those residing in “non-gay neighborhoods.” However, living in a gay neighborhood is also associated with risk behaviors such as methamphetamine and ecstasy use (Carpiano, Kelly, Easterbrook, & Parsons, 2011). Neighborhood studies typically focus on neighborhoods of residence, which likely differ from neighborhood of socialization (Egan et al., 2011).
CONCLUSIONS AND RECOMMENDATIONS Our integrated approach to the health of aging gay men is particularly timely and relevant, as it addresses four critical perspectives that framed the 2011 Institute of Medicine report on lesbian, gay, bisexual, and transgender (LGBT) health: minority stress, a life course perspective, intersectionality, and a social–ecological perspective. Furthermore, the model reflects three of the report’s suggested priority research areas in LGBT health: demographic research, social influences, and health care inequities. These identified priorities are intended to guide the National Institutes of Health LGBT research agenda.
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Because our paradigm is rooted in a social–ecological perspective, with attention toward minority stress, a life course perspective, and intersectionality, this model may also be applicable to other aging marginalized populations, including substance users, racial/ethnic minorities, sexual minorities, and other underserved populations. These populations experience myriad disparities with regard to health care access and health outcomes, and addressing these inequities requires a foundation of evidence that accounts for factors at the individual (micro), social (meso), and structural (macro) levels as captured in our integrated model. Further, eliminating disparities related to sexual health across populations will require evidence and programs that address these inequities at all levels of the socioecological framework. Moreover, aspects of this paradigm have applicability to gay men across the developmental and age spectra. Given the lack of strong conceptual frameworks for studying and serving gay men’s health, we have proposed a framework to inform the development of programs of research for the study of aging gay men that may inform best practices. It has been speculated that “social policies shaping HIV prevention largely have ignored the findings of social science” (Halkitis & Cahill, 2011). The same can be said for health and social policies affecting gay men generally, and aging gay men specifically. Thus, our framework attends to the social science literature as an equal partner to the biomedical literature. This framework will provide an opportunity to engage in research that stems from a perspective that understands that health must be viewed in relation to the total person (physical, emotional, social, as well as sexual) and that all aspects of health influence each other. Moreover, the multi-level nature of this framework will allow investigators to capture the significance of a variety of factors in determining heath, ranging from the individual to the context, and extends beyond an overly simplistic understanding of health behaviors that is nested solely within the individual as rational operator. Specifically, such an ecosocial and holistic framing allows us to attend to the role that social conditions and policies may play in shaping health outcomes of aging gay men, including but not limited to discrimination experiences in school and workplaces and denial of marriage equality (Halkitis, 2012, 2013a). While effective interventions that address individual risk factors and behaviors exist, ensuring good health in all communities requires a broader portfolio that looks at social and environmental factors as well (Centers for Disease Control and Prevention, 2010). Thus, we must consider how individual factors are nested in and influenced by contextual and environmental conditions. Finally, as supported by a theory of syndemics, health epidemics are often overlapping and mutually reinforcing (Halkitis, 2010), suggesting the need to consider multiple health states in relation to each other. Said differently, we cannot consider the physical health of aging gay men separate from other health states (i.e., mental, neurocognitive, sexual), and in relation to health care utilization. In effect, we must approach heath as total health.
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It is time for health studies of gay men to move beyond sexual health, which has dominated our approach to care for the last three decades. Finally, the proposed framework enables researchers to move beyond the deficit-oriented approaches that have dominated behavioral research and, in effect, gay men’s health research for close to three decades. Within the context of our proposed conceptual framing, an examination of health outcomes can be considered both in terms of negative outcomes and the deficits that facilitate these outcomes (Van Wagenen, Driskell, & Bradford, 2013) or, more importantly, in terms of positive health outcomes and the assets that facilitate these outcomes. In effect, the ethos of this framework is informed by a model of wellbeing and resilience, a condition manifested by gay men even at the height of the AIDS epidemic prior to effective antiviral treatment (Halkitis, 2013b). To this end, enacting scientific inquiry that identifies the healthy outcomes and beneficial antecedents will allow us to develop programs for care that are not based on what gay men lack but rather on the many positive attributes they possess.
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Moving Toward a Holistic Conceptual Framework for Understanding Healthy Aging Among Gay Men PERRY N. HALKITIS, PhD, MS, MPH and FARZANA KAPADIA, PhD, MPH Center for Health, Identity, Behavior and Prevention Studies, Global Institute of Public Health, and Department of Population Health, Langone School of Medicine, New York University, New York, New York, USA
DANIELLE C. OMPAD, PhD Center for Health, Identity, Behavior, and Prevention Studies, Center for Drug Use and HIV Research, and Global Institute of Public Health, New York University, New York, New York, USA
RAFAEL PEREZ-FIGUEROA, MD, MPH Center for Health, Identity, Behavior and Prevention Studies, New York University, New York, New York, USA
In the last four decades, we have witnessed vast and important transitions in the social, economic, political, and health contexts of the lived experiences of gay men in the United States. This dynamic period, as evidenced most prominently by the transition of the gay rights movement to a civil rights movement, has shifted the exploration of gay men’s health from one focusing primarily on HIV/AIDS into a mainstream consideration of the overall health and wellbeing of gay men. Against this backdrop, aging gay men in the United States constitute a growing population, for whom further investigations of health states and health-related disparities are warranted. In order to advance our understanding of the health and wellbeing of aging gay men, we outline here a multilevel, ecosocial conceptual framework that integrates salient environmental, social, psychosocial, and sociodeomgraphic factors into sets of macro-, meso-, and micro-level constructs that can be applied to
Address correspondence to Perry N. Halkitis, New York University, 41 East 11th Street, #716, New York, NY 10003, USA. E-mail: [email protected] 571
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comprehensively study health states and health care utilization in older gay men. KEYWORDS gay men, aging, health, HIV/AIDS, ecosocial
By 2015, approximately one third of the U.S. population will be 50 years and older (Population Division, United States Census Bureau, 2008). Within this group, 1.2–1.4 million Americans will be older gay men (Chandra, Mosher, Copen, & Sionean, 2011), a figure more pronounced in urban areas such as Los Angeles, New York City, and San Francisco (Black, Gates, Sanders, & Taylor, 2000; New York City Department of Health and Mental Hygiene, 2011). Adult and older gay men are more likely to have experienced a range of negative mental (Cochran, Sullivan, & Mays, 2003) and physical health conditions throughout their lifetimes—most notable of these being the HIV/AIDS epidemic (Halkitis, 2010; Halkitis, Wolitski, & Millett, 2013). Moreover, this generation of gay men came of age in an era where homosexuality was characterized as a psychiatric diagnosis (Bayer, 1987). As such, the psychosocial stressors, such as stigma and discrimination, ensuing from this labeling may be related to disparities in overall health, wellbeing, and health care utilization in older gay men. Both the Institute of Medicine (2011) and the U.S. Department of Health and Human Services (2013) have acknowledged these health and health care disparities, the former recommending a program of research to describe and understand the health needs of the U.S. sexual minority population. Similarly, the extant literature indicates the growing awareness for the unique health care needs of sexual minority populations, that extends beyond the HIV epidemic (Adams, Braun, & McCreanor, 2007; Halkitis, Wolitski, & Millet, 2013, Mayer et al., 2008; Meyer, 2001). Thus, a research agenda that is theoretically grounded and able to employ a scientifically sound and appropriate methodology is warranted to generate the essential and timely knowledge required to advance the health, wellbeing, and health care utilization of older gay men. Here, we advance a comprehensive framework developed around two sets of health-related outcomes (1) the health states (physical, mental/ neurocognitive, and sexual health) and (2) health care utilization (defined as need, access, usage, and satisfaction) of older gay men. We outline and describe a range of key micro-, meso-, and macro-level characteristics as well as their dynamic interactions, which merit consideration in future research endeavors aimed at health outcomes and health care utilization among older gay men.
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THE NEED TO UNDERSTAND THE HEALTH OF AGING GAY MEN Gay men of the baby boomer generation are characterized by unique developmental milestones (e.g., coming out, sexual onset, marriage and domestic partnerships), attributed to the significant sociocultural shifts including the burgeoning and mainstreaming of the gay liberation movement, the development of a health advocacy movement stemming from the HIV/AIDS epidemic, and the end of institutional segregation. Moreover, while the baby boomer generation, writ large, has benefited from public health, social, and medical advances, these benefits have not been evenly distributed, resulting in significant health and health care utilization disparities among gay men. There is a paucity of data addressing the overall health care needs of aging gay men and, in particular, the health care needs of racially/ethnically diverse gay men. Each of these groups represent a marginalized population, where the stigma and discrimination associated with a sexual minority identity, same-sex sexual partnering, a racial/ethnic minority identity, and HIV seropositivity can be cumulative and overlapping, exacerbating health disparities. A conceptual framework that allows investigators to capture this intersectionality is warranted and will aid in the development of programs targeted to reducing health care utilization–related disparities in this population (U.S. Department of Health & Human Services, 2013).
HEALTH STATES OF AGING GAY MEN Over the last 30 years, the heath of gay men has been driven primarily by attention to sexual health and HIV/AIDS-related risk factors, but if we are to effectively address the wellbeing of this population, we must move beyond such myopic understanding of wellbeing, especially given the advances in HIV treatments (Halkitis, 2010). As such, the health of aging gay men must be considered in relation to several dimensions—physical, mental/emotional, and neurocognitive, in addition to sexual health—in order to effectively and comprehensively provide health care services that attend to all aspects of the health and wellbeing of aging gay men. The physical health of aging gay men may be compromised for several reasons. In terms of chronic conditions and poor health states, aging gay men exhibit higher rates of diabetes, hypertension, physical disability, and fair to poor self-rated health compared to demographically similar aging heterosexual adults (LGBT Movement Advancement Project (MAP) and Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders (SAGE), 2010). A significant body of research has demonstrated that gay men experience a higher burden of mental health disorders, such as mood disorder,
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anxiety disorder, and so forth, compared to their heterosexual counterparts (Cochran et al., 2003). Furthermore, it is likely that gay men may experience higher rates of substance use–related morbidities as they age (Green & Feinstein, 2012). The extant research also provides evidence indicating that older age and HIV independently increase the risk of neurocognitive impairment, particularly in the areas of attention, processing speed, and executive functioning, as well as memory (Hardy & Vance, 2009; Kohli et al., 2006). Finally, despite three decades of extant research on sexual behaviors associated with the acquisition of HIV and other sexually transmitted infections (STIs) among gay men (Halkitis, 2010), there is limited knowledge regarding the general sexual health of older gay men in the United States (e.g., Jacobs, Fernandez, Ownby, Bowen, Hardigan, & Kane, 2010), and what is known is often related to the sexual health of those who are seropositive (Halkitis et al., 2012; Pappas & Halkitis, 2011). While the bulk of this research has focused on understanding risk behaviors associated with HIV/STI acquisition and transmission, sexual health encompasses partnership, activity, behavior, attitudes, and function that may be more relevant to the lives of aging gay men. To better understand the sexual health of this population, future studies will need to be able to consider factors such as physiologic changes, other related health conditions, use of medications that can affect sexual drive, and communication and negotiation skills that may influence sexual behaviors and sexual health among older adults.
HEALTH CARE UTILIZATION Factors associated with timely access and entry into HIV-related health care have been extensively studied, with recent studies also focusing on the need for, access to, and utilization of general sexual health screenings among both HIV-positive gay men and the general population of gay men (Zou, Fairley, Guy, & Chen, 2012). Although this is an important expansion of health-related care seeking among older gay men, these studies again limit the health concerns of gay men and aging gay men to risk behaviors associated with HIV rather than the broad spectrum of health-related concerns that face an aging community. Moreover, empirical evidence suggests that gay men may not link their sexuality with overall health care (Adams, Braun, & McCreanor, 2007). As such, more attention must be paid to primary health care access and utilization among gay men, and especially among aging gay men given the increased need for physical and mental health care services among older adult populations. Such efforts to enhance health care utilization must target both providers and clients and must extend beyond individual behavior to encompass structural and policy approaches.
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The limited research to date suggests that older gay men delay or avoid seeking health and social services due to fear of discrimination and physician insensitivity to their health concerns compared to similarly aged older heterosexuals (Gee, 2006). Furthermore, fear of discrimination coupled with an inability to meet the specific needs of older gay men has resulted in reduced satisfaction with care received (MetLife, 2010). Even in New York City, health care services are predominantly heterocentric and not always gay-friendly (Office of the New York City Public Advocate, 2008).
A FRAMEWORK FOR STUDYING THE HEALTH OF AGING GAY MEN A conceptual framework guiding investigations of health and health care utilization among aging gay men must attend to multiple sets of factors that predispose health and wellbeing. Thus, the proposed model integrates the role of multilevel factors, with an understanding that individuals do not operate in isolation but must navigate diverse contexts and environments. Our conceptual model (Figure 1) draws on three theoretical frameworks: the social–ecological model of health (Bronfennbrenner, 1986), the theory of syndemic production (Singer, 2009), and the behavioral model of health service utilization (Andersen, 1968). Leveraging these theories will facilitate an examination of the impact of multilevel factors on both health states and health care utilization among older gay men. First, utilization of a social–ecological framework enables researchers to build on the extant literature that provides insights on the role of traditional, individual-, and relationship-level factors associated with health outcomes and health-related behaviors among gay men. The addition of macroand meso-level factors to these traditional, individual-level (micro-level)
Macro-level factors
Characteristics of the residential neighborhood
Meso-level factors
Micro-level factors
Civic engagement
Sociodemographic characteristics
Characteristics of primary socialization neighborhoods
Social engagement
Psychosocial burdens
Religious engagement
Social integration
Healthcare provider availability
Housing instability
Social support Social networks
Health outcomes
Health states: Physical Health Mental/Neurocognitive Health Sexual Health Healthcare utilization Need for care Access to care Utilization of care Satisfaction with care
FIGURE 1 Multilevel conceptual model for studying the health of aging gay men.
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characteristics, coupled with a focus on the relationship between individuallevel characteristics and a broader range of health outcomes, provides an opportunity to capture multi-level information on the overall health status of older gay men. Next, key elements of the theory of syndemic production, which posits that mutually reinforcing epidemics of risk factors exacerbate each other and lower the overall health profile of a population to a greater degree than an individual epidemic alone, are incorporated into this framework. The application of this theoretical perspective is based on prior work showing that co-occurring epidemics of salient risk behaviors persist into older adulthood and can affect the health and wellbeing of both HIV-positive and HIVnegative gay men (Halkitis et al., 2012; Pappas & Halkitis, 2011; Vosburgh, Mansergh, Sullivan, & Purcell, 2012). Building on this prior research around syndemic production among sexual minority men, the framework proposed here posits that the mechanisms of syndemic production will be influenced by risk and protective factors across the multiple levels. Finally, Andersen and Newman’s behavioral model for health care utilization (Andersen, 1968; Andersen & Newman, 1973) depicts health services utilization as a function of factors that predispose individuals to use health care services, those that enable or impede the use of services and individual need for care. Incorporating key components of the Andersen and Newman framework into this framework will enable an understanding of how factors related to health outcomes among older gay men may also be associated with health care utilization.
Micro-Level Determinants of the Health of Aging Gay Men Examination of individual-level determinants of health has dominated the health behavior literature for several decades. Studies delineating the role of sociodemographic characteristics such as race/ethnicity, socioeconomic status, educational attainment, and psychosocial/social cognitive states (e.g., self-efficacy, motivation) have saturated the literature. However, the role of individual-level factors, in particular the role of social cognition, may be limited in that they implicate individuals as sole and rational operators (Halkitis, 2010). Still, if sociodemographic factors, such as education, race/ethnicity, or sexual orientation, are viewed through the lens of fundamental causes (Link & Phelan, 1996), and psychosocial factors are nested within a larger framework as we propose in our model, then these characteristics provide a means for understanding their effect nested within broader structures and systems. An innovative aspect of our model is that is that it applies a multi-level conceptual framework integrating these individual micro-level variables, in relation to macro- and macro-level factors to understand health states and health care utilization. Below we consider the role of individual level
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factors, in particular, sociodemographics, psychosocial burdens, and social integration and social support in relation to the health of aging gay men.
SOCIODEMOGRAPHIC CHARACTERISTICS Sociodemographic characteristics such as race/ethnicity, age, and marital/domestic partnership status may moderate the influence of other micro-, meso-, and macro-level factors on the health of aging gay. The few studies that examined age and racial/ethnic disparities among gay men have focused primarily on Black-White differences. A growing body of research suggests that same-sex marriage is and will continue to be an important social determinant of health (Halkitis, 2012). Studies suggest that legalization of same-sex marriage will positively affect a range of outcomes including syphilis rates (Francis, Mialon, & Peng, 2012) and mental health outcomes (Hatzenbuehler et al., 2012; Wight, LeBlanc, de Vries, & Detels, 2012). Additionally, disentangling the impact of HIV as a health condition and as a social determinant of health can be challenging, as the effects may be overlapping. As a social determinant, HIV-related stigma has been negatively associated with quality of life (Slater et al., 2012), and HIV-related bereavement has been shown to influence mental health (Wight et al., 2012).
PSYCHOSOCIAL BURDENS Aging gay men experience greater psychosocial burdens as measured by stigma, loneliness, discrimination, physical assault, intimate partner violence, and caregiving burden compared to their heterosexual counterparts. These psychosocial burdens are associated with sexual risk taking and illicit drug use among aging gay men (Halkitis et al., 2012). Compared to their younger and non-gay counterparts, older gay men report higher levels of substance use (Green & Feinstein, 2012; Halkitis et al., 2011). Among aging individuals, and especially aging gay HIV-positive men, the burden of caring for a loved one is related to unprotected sexual behaviors (Mayne, Acree, Chesney, & Folkman, 1998), higher rates of depression (Wight, 2000), increased levels of loneliness, and post-traumatic stress disorder (Theuninck, Lake, & Gibson, 2010). This same cohort of men also reports a higher incidence of intimate partner violence (Houston & McKirnan, 2007) and childhood victimization, the latter a factor found to be associated with increased sexual risk-taking (Paul, Catania, Pollack, & Stall, 2001). Finally, hypermasculinity, which is also conceptualized as masculinity threat, is highly detrimental to the health of gay men (Stall, Friedman, & Catania, 2008) and has been implicated in sexual risk-taking as well as body image (Halkitis, Green, & Wilton, 2004), both of which have a direct impact on health. Rigid conceptions of masculinity
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may be additionally burdensome to gay men as they age (Pope, Wierzalis, Barret, & Rankins, 2007) due to wear and tear on the body and on sexual performance. SOCIAL INTEGRATION, SOCIAL SUPPORT,
AND
SOCIAL NETWORKS
A growing body of research suggests that social integration—defined as participation in a social community or social activities, one’s social relationships, and perceptions of being an integrated community member—is associated with a range of positive outcomes among older adults (Seeman, 2000). Several prior studies have shown that greater levels of social integration are associated with lower rates of mortality (Obisesan & Gillum, 2009), fewer depressive symptoms (Glass, De Leon, Massuk, & Berkman, 2006), and a greater likelihood of survival following a heart attack (Glymour, Weuve, Fay, Glass, & Berkman, 2008). Grounded in social network theory, social support and network factors focus on the relationships or ties between individuals within a social system (Wasserman & Faust, 1994). The social network approach assumes that the behaviors and attitudes of individuals are influenced by perceived behaviors, attitudes, and norms of network members (Hall & Wellman, 1985; House & Kahn, 1985). Therefore, exploring differences in social network structure (e.g., size, shape, and characteristics of network members) and content (e.g., information, resources) transmitted within social networks of older gay men will likely help to identify the social structures or interactions that facilitate or impede involvement in a range of health-related behaviors that may influence their collective health and wellbeing (Lin, 2001; Hall & Wellman, 1985). Additionally, network-level normative influences that can be tapped into or modified to encourage and support involvement in safer overall health-related behaviors (Borsari & Carey, 2003). Furthermore, the transfer of information or resources (social support) may be influenced by environmental factors as well as the opportunities or impediments it provides for social interaction between network members.
Meso-Level Determinants of the Health of Aging Gay Men Our model includes meso-level factors that capture the engagement of aging gay men with social structures. The extant literature has demonstrated that involvement with civic, social, and religious institutions may positively affect the health of aging gay men, while housing instability may undermine the health of these men. CIVIC ENGAGEMENT Civic engagement, defined here as volunteering and political participation through activism, has been associated with improved health among older
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adults. Volunteering has been associated with improved self-rated health, physical functioning, and quality of life as well as a decreased likelihood of functional dependency/disability and depression (Barron et al., 2009). For older gay men, the onset of the AIDS pandemic necessitated the need to take on greater roles in organizing and community activism (Institute of Medicine, 2011). Despite this role, information on the relationship between activism and health outcomes are limited. One study indicated that activists used more problem-focused and less emotion-focused coping strategies, had greater HIV-related knowledge, and better integrated social networks as compared to non-activists (Brashers, Haas, Neidig, & Rintamaki, 2002). SOCIAL ENGAGEMENT Gay social contexts, in particular community organizations, venues, and events, have played a significant role as the access points for HIV behavioral surveillance, education, and prevention. There is also a demonstrated significant protective outcome associated with social engagement among gay men with respect to lower risk for dementia, depression, and psychosocial risks (Glass et al., 2006). Conversely, social engagement has also been associated with HIV-positive serostatus, unprotected anal intercourse with regular partners, and drug use (Zablotska, Holt, & Prestage, 2012).
RELIGIOUS ENGAGEMENT Among older adults, religiosity and spirituality are related to better physical and mental health, including improved physical health and psychological wellbeing, decreased depressive symptoms, prolonged survival, and faster remission of depressive symptoms (Bosworth, Park, McQuoid, Hays, & Steffens, 2003; Cohen & Koenig, 2003). For gay men, exploring the conflicts that arise in relation to integrating a non-heterosexual identity with religious traditions has been explored among adults (Halkitis et al., 2009) and more recently among younger gay men (Cutts & Parks, 2009). However, there is an absence of research focusing on the relations that might exist between religiosity and healthy aging among older gay men.
HOUSING INSTABILITY Being homeless or unstably housed is a source of chronic stress and is associated with a wide range of health problems (Shaw, 2004; Krieger & Higgins, 2002), including HIV/AIDS (Wolitski, Kidder, & Fenton, 2007). Factors such as a lack of housing, transient living conditions, and the communal sleeping arrangements in most homeless shelters are associated with multiple sexual partners, casual liaisons, sex exchanges, low rates of stable partner relationships, and substance use (Halkitis et al., 2011; Aidala, Cross, Stall,
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Harre, & Sumartojo, 2005; Reilly & Woo, 2002). Furthermore, unstably housed individuals concentrate in the most devastated neighborhoods (Saegert & Evans, 2003). Those who lack stable housing face multiple barriers to service utilization, including limited access to risk reduction services (Nwakeze, Magura, Rosenblum, & Joseph, 2003). However, information on the effects of homelessness and housing instability among older gay men is lacking.
Macro-Level Determinants of the Health of Aging Gay Men A robust body of work supports the impact of neighborhoods on older adults’ health. Neighborhood sociodemographic characteristics have been associated with cognition (Lang et al., 2008), psychosocial functioning (EversonRose et al., 2011), and self-rated health (Omariba, 2010). Furthermore, health care utilization is influenced by structural/place-related factors demonstrating that health care utilization is, in fact, lower when travel time to services is longer (Hiscock, Pearce, Blakely, & Witten, 2008; McCarthy, & Blow, 2004). Finally, greater availability of physicians is associated with lower levels of disability among older adults (Pruchno, Wilson-Genderson, & Cartwright, 2012) but not self-rated health (Subramanian, Kubzansky, Berkman, Fay, & Kawachi, 2006). Research on neighborhood-level factors affecting the health of gay men is limited. What exists has focused on residential neighborhoods with large gay populations. These studies demonstrated that residence in “gay neighborhoods” was associated with protective factors such as HIV testing (Mills et al., 2001) and consistent condom use (Frye et al., 2010) compared to those residing in “non-gay neighborhoods.” However, living in a gay neighborhood is also associated with risk behaviors such as methamphetamine and ecstasy use (Carpiano, Kelly, Easterbrook, & Parsons, 2011). Neighborhood studies typically focus on neighborhoods of residence, which likely differ from neighborhood of socialization (Egan et al., 2011).
CONCLUSIONS AND RECOMMENDATIONS Our integrated approach to the health of aging gay men is particularly timely and relevant, as it addresses four critical perspectives that framed the 2011 Institute of Medicine report on lesbian, gay, bisexual, and transgender (LGBT) health: minority stress, a life course perspective, intersectionality, and a social–ecological perspective. Furthermore, the model reflects three of the report’s suggested priority research areas in LGBT health: demographic research, social influences, and health care inequities. These identified priorities are intended to guide the National Institutes of Health LGBT research agenda.
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Because our paradigm is rooted in a social–ecological perspective, with attention toward minority stress, a life course perspective, and intersectionality, this model may also be applicable to other aging marginalized populations, including substance users, racial/ethnic minorities, sexual minorities, and other underserved populations. These populations experience myriad disparities with regard to health care access and health outcomes, and addressing these inequities requires a foundation of evidence that accounts for factors at the individual (micro), social (meso), and structural (macro) levels as captured in our integrated model. Further, eliminating disparities related to sexual health across populations will require evidence and programs that address these inequities at all levels of the socioecological framework. Moreover, aspects of this paradigm have applicability to gay men across the developmental and age spectra. Given the lack of strong conceptual frameworks for studying and serving gay men’s health, we have proposed a framework to inform the development of programs of research for the study of aging gay men that may inform best practices. It has been speculated that “social policies shaping HIV prevention largely have ignored the findings of social science” (Halkitis & Cahill, 2011). The same can be said for health and social policies affecting gay men generally, and aging gay men specifically. Thus, our framework attends to the social science literature as an equal partner to the biomedical literature. This framework will provide an opportunity to engage in research that stems from a perspective that understands that health must be viewed in relation to the total person (physical, emotional, social, as well as sexual) and that all aspects of health influence each other. Moreover, the multi-level nature of this framework will allow investigators to capture the significance of a variety of factors in determining heath, ranging from the individual to the context, and extends beyond an overly simplistic understanding of health behaviors that is nested solely within the individual as rational operator. Specifically, such an ecosocial and holistic framing allows us to attend to the role that social conditions and policies may play in shaping health outcomes of aging gay men, including but not limited to discrimination experiences in school and workplaces and denial of marriage equality (Halkitis, 2012, 2013a). While effective interventions that address individual risk factors and behaviors exist, ensuring good health in all communities requires a broader portfolio that looks at social and environmental factors as well (Centers for Disease Control and Prevention, 2010). Thus, we must consider how individual factors are nested in and influenced by contextual and environmental conditions. Finally, as supported by a theory of syndemics, health epidemics are often overlapping and mutually reinforcing (Halkitis, 2010), suggesting the need to consider multiple health states in relation to each other. Said differently, we cannot consider the physical health of aging gay men separate from other health states (i.e., mental, neurocognitive, sexual), and in relation to health care utilization. In effect, we must approach heath as total health.
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It is time for health studies of gay men to move beyond sexual health, which has dominated our approach to care for the last three decades. Finally, the proposed framework enables researchers to move beyond the deficit-oriented approaches that have dominated behavioral research and, in effect, gay men’s health research for close to three decades. Within the context of our proposed conceptual framing, an examination of health outcomes can be considered both in terms of negative outcomes and the deficits that facilitate these outcomes (Van Wagenen, Driskell, & Bradford, 2013) or, more importantly, in terms of positive health outcomes and the assets that facilitate these outcomes. In effect, the ethos of this framework is informed by a model of wellbeing and resilience, a condition manifested by gay men even at the height of the AIDS epidemic prior to effective antiviral treatment (Halkitis, 2013b). To this end, enacting scientific inquiry that identifies the healthy outcomes and beneficial antecedents will allow us to develop programs for care that are not based on what gay men lack but rather on the many positive attributes they possess.
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