Thanks Terry and Rick for having me speak on this panel this afternoon. I am both excited and a little nervous to have the opportunity to talk about my most recent work. My presentation today is part of my Master of Public Health degree and is most definitely in progress. It is based on work I am doing with my current supervisor, Lorraine HalinkaMalcoe, who is also a co-author in this presentation. Although I am tempted to spend my full allotted time thanking the many incredible people I have had the opportunity to learn from and work with over the past two years of working in gay men’s health here in Vancouver, I am going to keep it brief, but acknowledge that my thinking in regards to this project, and gay men’s health more broadly, is undoubtedly shaped by these experiences. I am grateful to the various people who have mentored and supported me, and who have offered numerous insights from the work they do. So, to get started, I would like to thank the staff, volunteers and where pertinent, participants at the following organizations and projects: the Health Initiative for Men, the CIHR Team in the Study of Acute HIV Infection, Community Based Research Centre and the Gay Poz Sex project at Positive Living BC. The work I am presenting today is separate from the roles I hold in each of these projects and does not necessarily reflect their opinions. The last thing I’ll say before getting to the substance of my presentation is that I am committed to being an ally to the most inclusive notion of a gay men’s health movement. For me, part of being an ally is seeking the opinions of those within the communities I am speaking about and being open to being challenged in my thinking. I look forward to your comments and questions at the end of this presentation.
I’d like to acknowledge that the space in which I live and study is unceded First Nations land, and these diverse peoples continue to fight for sovereignty, equity and social justice. This is both a historical legacy and a significant social justice issue facing us as individuals, people working in gay men’s health, our municipal, provincial and national governments and First Nations people.
Arguments that have been advanced at this Summit so far have emphasized the importance of social determinants of health for addressing gay men’s health holistically. As many people here and elsewhere have acknowledged, the term ‘MSM’ focuses on behaviours and minimizes the attention paid to social determinants such as sexuality and gender, as well as simultaneous determinants of racialization and racism, colonization income inequity, social exclusion, ageism, and ableism. Our usage of the term ‘gay men’ is intended to be inclusive of diverse communities of gay men and other men who have sex with men, including cis and trans men who are primarily sexually attracted to men. In this presentation, ‘gay men’ includes men who self-identify as gay, queer, two-spirit, or homosexual. I will use masculine pronouns throughout. I recognize that both of these decisions are homogenizing, as such, where possible, I use terms chosen by participants; however, as this is a review of published research, opportunities to do so are limited. I exclude research primarily or exclusively addressing men who identify as bisexual or heterosexual as the privilege and penalty these men experience as a result of their gender and sexuality often differs from men who identify as gay. For example, bisexual men may experience biphobia within communities of gay men as well as heterosexual communities. Men who identify as heterosexual will not have had experiences such as coming out that are integral to many concepts of resilience in the published research. Lastly, a large part of the reason these men are included in some gay men’s or MSM research is because the organizing factor in that research is HIV risk stemming from anal sex. However, this is not the case in the current study. This decision is not intended to diminish the importance of work addressing bisexual and heterosexual men’s health needs.
Although there has been much discussion of the concept of resilience in gay men’s health literature, particularly over the past decade or so, we are not aware of a systematic review or assessment of the ways in which resilience has been taken up in gay men's health research. I had a clear sense from my work with gay men, the literature, and my training in social and health inequities that while there is a lot of opportunities arising from resilience-focused research, there are also some very real challenges to using this concept in a way that meaningfully advances gay men’s health. My work began with a review of the origin of the concept of resilience, and then looked at the roots of this concept in gay men’s health. We then undertook a systematic search of the gay men’s health literature to understand how the concept of resilience is being taken up. Today’s presentation will offer a brief review of existing resilience literature, focusing on explicit definitions of resilience and the ways resilience is measured. Finally, we will echo the argument that while resilience presents important opportunities for shifting from pathology-based approaches, it must be operationalized, measured and used in a way that promotes equity within and beyond gay communities.
The concept of resilience first emerged in the field of psychology in studying the impacts of maltreatment on children. At the time, it was acknowledged that the first responsibility is to prevent the maltreatment of children, and then secondly to support people who experience maltreatment and other “serious forms of adversity” throughout the lifespan. Since the 1980s, resilience research has become a key focus in many human services disciplines, and now extends to diverse groups across the lifecourse, including gay men (Dyer, 2004). The roots of resilience-focused scholarship in gay men’s health are in the desire and the need to move away from the religious, criminal and medical pathologization of gay men and other sexual minorities throughout history, and gay men’s activism and organizing prior to and throughout the HIV epidemic and beyond. The graph on the slide here shows the citation report from a keyword search of resilience and gay men, showing the first reference in 1993, and a dramatic increase in the last decade. The earliest reference to resilience in gay men’s health in the databases I searched was 1987; however, there were earlier usages of resilience within gay men’s health literature. Douglas Kimmel’s work used the concept of resilience as early as 1978.
Eric Rofes, a prolific gay scholar, addressed resilience in the opening comments of a gay men’s summit held in 1999: “And finally, fifth, we want to transform the ways in which we think about and evaluate gay men, shifting away from a perspective which exoticizes, demonizes, and pathologizes our bodies and our lives and into a model which recognizes the tenacity, survival-skills, and overall resilience of our cultures and communities. What would it mean to understand openly gay men as the resilient portion of our community, that portion which has suffered physical assault, religious abuse, and political violence yet emerged emotionally intact and spiritually strong? What would it mean to understand our gender play, kinship networks, and sexual cultures not as pathetic products borne of a homophobic society, but as adaptive survival strategies which have served us well?”Citing Eric Rofes’ work, Canadian gay men’s health policy documents produced in 2001 acknowledged that, “gay men are pointing out that work on gay men’s health should begin with recognizing, acknowledging and affirming the resilience, the reserves of strength, and the courage of gay men (Aggleton, 2000; Rofes, 1998)” (Ryan & Chervin, 2001, p. 32). This document made two key points about its conceptualization of resilience, noting that:Resilience is located in gay men and in their communities, and Resilience is informed by the experiences of heterosexism andby experiences of “community and personal resistance to other interconnected forms of oppression”.The shift towards resilience has also been seen in the wider literature on the health of sexual minorities, particularly amongst adolescents. RitchSavin-Williams is one the scholars who has consistently drawn attention to the importance of including stories of resilience in research amongst LGBT youth, and has argued that media sensationalism in regards to sexual minority and trans* youth has led to an incomplete, and often very negative, picture of LGBT individuals.
There is no consensus definition of resilience within or outside of gay men’s health. However, a 2011 review of the concept defined resilience as the study of individuals’ mental health in the face of adversity, and why some individuals are able to experience adversity without negative ongoing physical and mental health outcomes and others aren’t (Herman et al, 2011).
We conducted systematic searches in CINAHL, Medline, PsycINFO and Social Work Abstracts to identify gay men’s health literature addressing resilience. Our searches used three main concepts gay (queer, two-spirit, ‘men who have sex with men’ (MSM), down low, ibbi, yoos, radical faeries), man (trans, male, man, boy) and resilience (resilien*, protective factors, strengths-based approaches).No date limits were placed on the searches. A total of 245 articles were retrieved AFTER ELIMINATING DUPLICATES. We excluded articles that did not mention a resilience concept (as per our search terms) in relation to gay men, articles that used a genetic resilience, articles that were not written in the English language. Dissertations and theses were also excluded. Original research articles were included if the sample was a majority of gay men OR a separate analysis on gay men as a subset of a larger sample was conducted. Review articles in which gay men were considered as a distinct population from a wider LGBT and/or general population sample were included. Were were left with ~160 articles that met this criteria.Today’s presentation draws from a smaller subset of my data and only includes the 131 articles that specifically addressed resilience. The majority of the articles that we reviewed did not provide a specific definition of resilience or reference a specific theoretical perspective on resilience. Of 131 articles, ONLY 16% provided explicit definitions of resilience. Five articles only referenced resilience in the abstract or summary text.
While most definitions were unique, there were a few psychology definitions (Masten, Luttar et al.) that were included in more than one of the articles in our systematic search. With the exception of one case, definitions that were provided were not specific to gay men and commonly drew from general concepts. This FINDING is similar to the earliest work on resilience in gay men’s health which drew on definitions of resilience based on general population studies. Nearly all the literature used a non-specific concept of resilience. Six more specific types of resilience were also referenced: couple, ego, family, educational, emotional and psychological.The concepts of couple, ego and family resilience differentiates the social unit at which resilience is being understood: in these cases, a single individual, a couple or a family. Neighbourhood or community resilience could also be studied in this category. The latter three types of resilience – educational, emotional and psychological – refer to a content area within which resilience was assessed. Rather than assessing functioning in all aspects of a person’s life, each of these types of resilience limits its scope to one specific domain. Overall, the 21 explicit definitions generally share three characteristics: 1) resilience is the outcome of a dynamic process, 2) it is about an individual’s adaptation or response to adversity and 3) it results in something researchers define as a positive outcome.
This slide presents an image of how resilience is represented in the literature that provided definition. In the literature, resilience is the result of a process in which an individual negotiates with his social environment to acquire the needed resources to cope with a given circumstance (Ungar, 2004). These resources include individual characteristics and personality traits, behavioral patterns, functional competence, cultural capacities, developmental and situational variables, including various forms of social support. Whatever these resources may be, they support an individual in coping with changes he is facing or making changes to cope with new stressors or circumstances. Further, these resources may even protect an individual from certain types of adversity or prevent him from engaging in what researchers define as behaviours. Some research uses the terms protective factors or resiliency factors. Quantitative research often tests a number of measures (for example, number of friends one can count on for support) to see if it is significantly correlated WITH better outcomes. It is crucial to note that in these definitions, resilience must happen in the context of adversity. While this was clear in the majority of the definitions, some scholars continue to use definitions of resilience that do not include exposure to adversity.
Adaptation and responses to adversity entail a wide range of possibilities, and include changes in psychological, social and/or behavioral characteristics, interpersonal relationships and/or social context. These responses and adaptations are as varied as the individuals experiencing adverse circumstances. [For example, workplace convo from this morning]While the earliest resilience research focused on ongoing adversity in the form of childhood maltreatment, the study of resilience today includes both acute and chronic “negative life events across the lifespan statistically associated with adjustment difficulties or subsequent mental disorders” (p. 259 in Herman et al., 2011). Acute events included the death of a partner, HIV diagnosis or suicidal thoughts or attempts. Minority stress, societal stigma, cissexism, heterosexism, caregiving responsibilities, the possibility of HIV infection, and particularly in the earlier literature, living with HIV are all examples of chronic forms of adversity taken up by resilience research.
Many authors point out that resilience cannot be observed, only inferred. As such, researchers define specific outcomes that, if achieved, represent resilience. However, defining and measuring ‘positive outcomes’ has been the subject of a lot of discussion and some critique, both in communities (as discussed earlier) and, to a lesser extent, in the academic literature. In the 21 definitions we identified, there were four general categories of ‘positive outcomes’: 1) Thriving in spite of adversity: Achieving developmental milestones and/or levels of functioning deemed normal despite chronic adverse circumstances 2) Getting through: dealing with acute situations as they unfold while maintaining consistent physical & psychological functioning3) Bouncing back: returning to a state of “normalcy” in a specified domain following an acute event (e.g. HIV diagnosis, suicidality, loss of parther). This allows for a period of distress of some kind, and then focuses on return to ‘normalcy’ over time. Bouncing back usually uses some comparative 4) Growing from exposure to adversity (or, to quote Kelly Clarkson, what doesn’t kill you makes you stronger): not only bouncing back from adversity, but in fact, doing better than you were before as a result of the experienceRecent literature is mostly focused on ‘thriving in spite of adversity’, such as the general health and well-being of gay men and GLBT populations as a whole in a heterosexist society.While most definitions did not explicitly set markers at which point resilience was achieved, the studies that used these definitions set very clear standards. In some cases, scales were used to assess mental health-related outcomes such as depression, social support and current behaviours. Other studies used a developmental milestone approach, and assessed whether or not participants had completed certain tasks (high school, steady job, steady housing) and avoided others (the criminal justice system).There were two exceptions to these researcher-articulated markers of resilience. In one definition, resilience was considered to be achieved in the case where participants self-reported positive health (Ungar, 2004 definition). The second instance used a comparison between functioning before an adverse event (in this case, HIV diagnosis) to functioning after the diagnosis.
**Results from 21 articles***Successfully negotiating coming out tends to be reported as a source of resilience. In the aging literature, LGBT elders are said to cope better with the transition to aging than their hetero/cisgender peers because of their experience negotiating coming out. resilience is an experience that results not from avoiding risk, but being exposed to risk and navigating it successfully; caring environments, humour, faith, reframing neg experiences, feeling hopeful AND constitutional factors (self-efficacy, faith lives, redefining obstaclces – WHAT DOES IT MEAN TO LABEL THESE AS CONSTITUTIONAL FACTORS?) - being a category of emotional and cognitive factors - also need support networks and relational/cognitive factors; requires someone who provides a sense of wellbeing (Munro)Social support tends to be a major source: having a caring adult (esp. in educational resilience), chosen family, supportive friends, etc.
So, with that review of some of my findings, I wanted to move into a bit of a discussion about where this leaves us as ‘team gay men’s health’: how can we best use resilience to address some of the challenges we are facing in regards to both HIV prevention, but also broader notions of achieving equity for and amongst gay men?
As I mentioned, I undertook this project with an awareness of some existing critiques regarding resilience, both within and beyond the field of gay men’s health. Although people are quick to praise the importance of moving away from problem-oriented approaches, many have argued that the concept of resilience comes with its own shortcomings. In the past few years, participants at the Ontario Gay Men’s Sexual Health Summit and in a pan-Canadian deliberative dialogue have raised concerns about the ways resilience is being used. In the report on this national dialogue, New Directions in Gay Men’s Health and HIV Prevention, written by my co-panelist Len Tooley, participants said resilience can be a positive thing in some contexts, and heighten vulnerability in others, that gay men are expected to be more resilient than the rest of society, and that resilience leads to integration, which can depoliticize efforts of gay men.
My thinking about the limitations and opportunities re: resilience has been informed by intersectionality. This concept originated from the work of women of colour and has since been used by women and some men in disciplines including policy, health, law and social work. Given our focus on social and health equity, we chose to use intersectionality to inform our analysis. Intersectionality seeks to advance equity by drawing attention to:the multiplicity and simultaneity of individual identities, diversity within the ways these identities are experienced, and the need for an analysis of the “productive forces”, that is processes through which difference is ascribed on the basis of social locations such as (perceived) gender, sexual orientation, race/ethnicity and systems of domination (e.g. heterosexism, heteropatriarchy), that create and construct difference and inequities (Dhamoon, 2011, p. 236).
Some studies have focused on sub-groups of gay men or sexual minorities defined by their simultaneous social location defined by race/ethnicity, HIV status, geographic location (rural/urban), indigeneity, family status (i.e. partnered, raising children), or defined by behavioural habits, such as substance use and suicidality. While many of these studies report on within-group diversity in the demographic section of their research, very little primary research reports differences in resilience within its sample. In quantitative work, this is often the result of the logistics of running statistics which require minimum numbers of people classified as “the same” to have any conclusion. In one example, Gwadz et al. (2006) report Latino and trans men, within a sample of MSM in New York City, had lower rates of “adaptive functioning” and yet noted this may be the result of the way that particular study measured resilience. Ensuring adequate sample size for specific sub-group analyses has long been a challenge within gay men’s health are also true of the literature on resilience. Numerous authors have also pointed out the need to recognize within-group variation, and this While qualitative work does not have the same numerical requirements to conduct analyses, it is often challenging for researchers to give meaning to social categories, such as race or gender unless participants specifically address it in their narratives. FOCUS ON RESLIENCE COULD BE SEEN AS DIRECTING ATTN AWAY FROM SOCIAL JUSTICE AND SOCIAL CHANGE.
-Risk and resilience are not dichotomous ends of a spectrum, and may exist simultaneously. Further, -As per the original definitions of resilience, it is important to think about protecting the adverse outcome that leads to, or requires, resilience for people to survive, thrive or just get through it. In most definitions, resilience requires adversity, and in a lot of the contexts in the literature, that adversity is systems of oppression like heterosexism. The result is people are constantly exposed to stress, and regardless of how resilent they are to it, that stress exposure has health outcomes. -Diversity in terms of what we count as a “positive outcome”: measuring outness at work (and elsewhere), HIV status, home ownership, -Imagining what should these positive outcomes be? Who would be healthy gay men, if we could build some ideals against which to measure? In part, this is a much bigger question about the goals of gay men’s health.
13 1900 1530-chown-bc summit final slides - sarah chown
CHALLENGES AND OPPORTUNITIES: UNDERSTANDING RESILIENCE IN THE GAYMEN’S HEALTH LITERATURE Sarah Chown Lorraine Hailnka Malcoe
INDIGENOUS LANDS - VANCOUVER 10 First Nations lived on and from this land prior to the beginning of colonization in the mid 1800s
GAY, NOT MSMGay men includes cis and trans* men who are primarily attracted to men, and identify as gay, queer, two- spirit, homosexualThis presentation does not speak to experiences of bisexual and heterosexual men who have sex with other men
WHERE IT ALL BEGAN…Shift to resilience began in the 1980sAlternative to pathologizing gay men Web of Science Citation report, results from keyword searches for gay men and resilience in October 2012
CALL FOR RESILIENCE“…we want to transform the ways in which we thinkabout and evaluate gay men, shifting *…+ into a modelwhich recognizes the tenacity, survival-skills, andoverall resilience of our cultures and communities.What would it mean to understand openly gay men asthe resilient portion of our community, that portionwhich has suffered *…+ yet emerged emotionally intactand spiritually strong? What would it mean tounderstand our gender play, kinship networks, andsexual cultures *…+ as adaptive survival strategieswhich have served us well?” –Eric Rofes, 1999
RESILIENCE“Individuals’ mental health in the face of adversity,and why some individuals are able to experienceadversity without negative ongoing physical andmental health outcomes and others aren’t.” -Herman et al, 2011
METHODS Systematic searches in CINAHL, Medline, PsycINFO and Social Work Abstracts (n=245) Gay: queer, two-spirit, ‘men who have sex with men’ (MSM), down low, ibbi, yoos, radical faeries Man: trans, male, man, boy Resilience: resilien*, protective factors, strengths-based approaches 131 articles specifically used the concept of resilience in relation to gay men 21 (16%) of 131 articles provided explicit definitions of resilience
THE LITERATUREMost literature is quantitative or reviewsPeople living with HIV and youth were the most common populations Studies reported demographic breakdowns of their samples, but rarely included analysis of how or why the demographics they report matter
THE LITERATURE Most articles used a non-specific concept of resilience Subtypes: couple, ego, family, educational, emotional and psychological resilience Three characteristics were common across definitions of resilience: Outcome of a dynamic process About individuals adapting or responding to adversity Results in a researcher-defined positive outcome
RESILIENCE = DYNAMIC PROCESS adversity IndividualResilience Social Resources environment
ADAPTING/RESPONDING TO ADVERSITYAdaption or response Behavioural, social or psychologicalAcute adverse event Suicidality, HIV diagnosis, loss of partnerChronic adversity Systems of oppression, potential for HIV infection
“POSITIVE” OUTCOMESThriving despite adversityGetting throughBouncing backGrowing from exposure to adversity
HOW GAY MEN BUILD RESILIENCESuccessfully negotiating coming outIndividual, constitutional factorsSocial support across the lifecourseMultiple experiences of oppression
CONCERNS FROM COMMUNITYStrength in some contexts, heightens vulnerability in othersUnparalleled expectation of resilience amongst gay menDepoliticizes gay men’s needsNarrow definition
INTERSECTIONALITYMultiplicity and simultaneity of individual identitiesDiversity within the ways these identities are experiencedAnalyses of the processes through which difference is ascribed on the basis of social locations that create and construct difference and inequities (Dhamoon, 2011, p. 236)
LIMITATIONS OF DEFINITIONSMeasures of resilience are often Eurocentric and based on “mainstream” valuesSystems of oppression that people are resilient to often left unexaminedRarely, if ever, is resilience studied at the community level
MOVING BEYOND THE DEFINITIONSRecognizing the simultaneity of risk and resiliencePreventing adverse conditions that create resilienceCreating space for diversity within healthy gay communitiesImagining healthy gay men and healthy gay communities
SUMMARYVariety of definitions, measures and operationalizations of resilienceConcerns advanced in academic and non-academic forums regarding the social and health equity implications of resilience
NEXT STEPS FOR MY WORKIncorporating literature on resilience amongst indigenous people and other groups experiencing minority stressExpanding this analysis to articles with implicit definitionsDiscussing relationships between protective factors and resilience
NEW DIRECTIONSDespite these concerns, resilience has beenidentified as a priority for gay men’s healthresearch moving forward both in thisreport and elsewhere. The question thereport poses is, “What are the componentsof assets and resilience among gay and bimen and how do they influence behaviour?(What keeps gay men healthy, versus whatmakes them sick?)” (p. 20).
WITHIN-GROUP DIVERSITYPeople living with HIV and youth were the most common populations Studies reported demographic breakdowns of their samples, but rarely included analysis of how or why the demographics they report matterMany calls for greater attention to within- group variation