AMA Journal of Ethics^®

Since the first cases of a strange, new illness among gay men were reported to the U.S. Centers for Disease Control and Prevention (CDC) in 1981, the parameters and measures of gay men’s health have unfortunately been defined by a disease-centered, myopic concentration on the area between the navel and the knee.

As a public health strategy for the control of sexually transmitted diseases such as HIV and syphilis, such a narrow focus has proven ineffective. We have failed to address the mental, physical, and spiritual lives of gay men and their connection to sexual health and wellness. And this failure has had consequences.

With regard to HIV/AIDS, gay men and other men who have sex with men (MSM) have always been the most affected population in the United States and throughout most of the global North. We are just beginning to understand fully the severe disparities in health status between gay men and MSM in the global South and that of other men in their demographic. Internationally, gay men and other MSM are 19 times more likely to be HIV-positive than members of the population at large.

While it is estimated that gay men represent 4 percent of the overall U.S. male population, they account for more than half of all new HIV infections in the country. More than 300,000 gay men and other MSM in the U.S. have died from AIDS since the beginning of the epidemic [1].

These appalling disparities can be explained in a number of ways. First, unprotected anal intercourse is simply a much more efficient means of transmitting and acquiring HIV. It is 10 to 20 times more likely to result in HIV infection than unprotected vaginal intercourse and accounts for the vast majority of HIV infections among gay men.

Next, the funding has not followed the epidemic, according to the CDC’s own data [2]. CDC spends approximately $650 million per year on HIV prevention activities, approximately $300 million of which goes to state and city health departments that have consistently underfunded services for gay and bisexual men. Between 2005 and 2007, only 29 percent of federal risk-reduction funding managed by state and local health departments supported services for gay men and other MSM. Similarly, state and local health departments directed only 11 percent of the total federal funds earmarked for counseling, testing, and referral (CTR) during the same period to gay and other MSM. Most of the CTR allocation went to the general population, and the majority of that money was directed to low-risk heterosexuals, according to the CDC. Globally, only 20 percent of gay and other MSM had access to HIV prevention services in 2009 [3].

The lack of resources has been exacerbated by pervasive stigma, structural and societal homophobia and racism, lack of access to health care, homelessness, untreated mental illness and substance abuse, civil rights inequality, and childhood sexual abuse—among other factors—all of which contribute to the HIV burden gay men confront. In the face of all this, gay men have often been characterized as reckless, careless, mentally ill, diseased, and infantile—narcissistic children who can’t be trusted and need to be told what to do. While inaccurate, this mindset forms the foundation  upon which public health has addressed the lives of gay men—if it addresses them at all. Enter the Gay Men’s Health Movement (GMHM).

Working on a New Script

Since the early 1970s, with the formation of volunteer-based STD and community health clinics, gay, bisexual, and transgender (GBT) men and allies have been engaged in creating culturally appropriate health care services for our communities. These early efforts, influenced to a large degree by the women’s Our Bodies, Ourselves health movement, have expanded to a nation-wide system of LGBT health care centers in many of our major urban areas. These centers have been at the frontlines of the community’s response to the HIV epidemic, providing care and prevention services when no one else would or could. Many of these centers continue to serve valiantly, but also suffer from inadequate financial support. Numerous smaller cities and rural areas are in need of such services.

From the mid-1990s to the present, leaders in the GMHM have organized a number of national and regional conferences and meetings in the U.S. to share information and resources, caucus, brainstorm, visualize, and strategize—all with an eye to developing plans for improving the health of gay male communities. Often these forums have been held in partnership with lesbians, transgender women, public health providers, medical and other clinical providers, scientific and policy communities, community leaders from other sectors, and other activists. Significant outcomes of these efforts include the founding of the National Coalition for LGBT Health, the formation of a working group on LGBT health at the U.S. Department of Health and Human Services (HHS), and the National Gay Men’s Health Summits.

Unofficially founded by Eric Rofes (longtime educator and activist), the GMHM has centered on nonhierarchical, grassroots organizing at the biennial National Gay Men’s Health Summits, promoting an inclusive, affirming, and asset-based approach to the lives and health of GBT men. The GMHM is informative, empowering, celebratory, multicultural, and relationally focused. Within this paradigm, sexual health is not simply defined as an absence of disease, but encompasses wellness and pleasure, and is inextricably tied to an individual’s physical, mental, and spiritual health.

Six foundational principles distinguish the GMHM.

1. Replace the HIV-centric paradigm of health advocacy for gay men with holistic models that integrate (but do not default to) HIV.
2. Exit the crisis paradigm of HIV work, and embrace contemporary understandings, meanings, and implications of HIV for gay men of all colors and classes.
3. Replace deficit-based models for work with gay men with asset-based approaches.
4. Strategically confront political and structural forces that challenge the well-being of gay men.
5. Embrace a “big tent” vision of community, respecting diverse ways of organizing sex and relationships. Shame and guilt are the health hazards, rather than specific sex practices and sex cultures.
6. Launch only efforts that are neither overtly or covertly sanitizing, sanctimonious, fear-based or moralistic.

GMHM core priorities are the support of healing from trauma (e.g., AIDS, homophobia, addiction); grappling with the emotions, pleasures, and wounds from childhood; exploration of the needs for intimacy, connection, and belonging between men and the structures that both promote and prevent that; and tapping into the resilience, creativity, and determination of gay men to take care of each other. Developing an understanding of the psychological significance and values associated with anal intercourse is another key component that is almost universally overlooked elsewhere.

In 2008, movement leaders across the country undertook a year-long process to develop a National Gay Men’s Health Agenda, soliciting input both electronically via the gay men’s health blog LifeLube and through interaction on other web portals. In-person brainstorming occurred at the 2008 National Gay Men’s Health Summit. Dozens of ideas were pared down into eight  policy objectives:

1. Fund and expand social, behavioral, and biomedical research.
2. Develop and financially support data collection efforts on sexual orientation and gender identity in all federally funded research.
3. Fund campaigns to combat homophobia, biphobia, and transphobia.
4. Immediately repeal Section 2500 of the federal Public Health Service Act (42 U.S.C. Section 300ee(b), (c), and (d)) that prohibits the “promotion” of any type of sexual behavior–heterosexual or homosexual.
5. Create an office for LGBT health at HHS.
6. Develop and implement a strategy to reduce disparities in health status that affect gay, bisexual, and transgendered (GBT) men through direct programmatic funding.
7.  Create and fund sexual health and wellness campaigns directed toward GBT communities, utilizing an array of public and private resources.
8. Develop and implement a strategy to remove barriers to health care among transgender people.

After years of concerted organizing efforts nationally, we are beginning to see the adoption of many of the main tenets of the GMHM—including but not limited to the priorities outlined in the National Gay Men’s Health Agenda—into large, mainstream organizations and governmental institutions.

Released by the Gay Men’s Health Crisis (GMHC) on July 12, 2010, the report Gay Men and HIV: An Urgent Priority provides recommendations for addressing the epidemic that go well beyond condom-centered social marketing campaigns and regular HIV testing, care, and treatment. These include promoting comprehensive, accurate sex education for youth in all public schools, Gay-Straight Alliances, and other safe schools programs; fostering family acceptance and community connectedness; acknowledging gay men’s needs for love, relationships, and intimacy; dismantling societal and structural homophobia and racism; and providing readily accessible, culturally competent treatment of substance abuse and mental illness.

The CDC recently began sharing plans for a new sexual health framework to address sexually transmitted diseases, including HIV. A major departure from previous deficit-based, disease-centered models, their new approach positively connects sex and sexuality to physical and mental health, with the goal of increasing healthy, responsible, and respectful sexual behaviors and attitudes.

Institutions such as GMHC and the CDC have powerful influence and a reach that extends around the world. If they advocate and implement guiding principles and objectives that jettison outmoded, fragmented, disease-focused approaches—strategies which have only served to reinforce stigma, foster silence, and diminish access to critical health care services with resulting poor health outcomes—everyone wins. People of all genders and sexual identities will benefit from policies that promote understanding of the social determinants of health and an integration of the individual’s sexual, physical, mental, and spiritual health with that of the family—in all its iterations—and the community.

It would be a stretch for the GMHM to claim total credit for such transformation, but the movement should be recognized for the years of planting and tending the seeds of change that are being reaped in ways that gay men’s health activists only dreamed of a decade ago. While the script rewrites have been accepted, and adopted, the real work begins with implementation. Beyond just learning their lines, the actors will need to walk the talk. And the GMHM and allies will be paying attention, encouraging, cajoling, pushing, and holding feet to the fire to get it done until we have a society in which it is safe to be whoever you are wherever you are, where your health care needs are met with dignity, respect, and integrity, and where sex is not a four-letter word.