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Day 1 0930 - nathaniel lewis


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Day 1 0930 - nathaniel lewis

  1. 1. ‚Placing‛ Gay Men’s Health across the Life Course: Assessing the Roles of Place and Mobility Nathaniel M. Lewis, PhD 1, 2 1 School of Geography, University of Nottingham Nottingham, United Kingdom (formerly School of Health and Human Performance, Dalhousie University Halifax, Nova Scotia, Canada) 2 Population Health Intervention Research Network (PHIRNET) National Research Intern, Department of Geography, University of Toronto Mississauga Mississauga, Ontario, Canada Faculty of Health Professions
  2. 2. The Life Course A model for explaining life events and outcomes, and their ordering   Alternative to human development paradigms (Levinson 1978) Instead, examines the confluence of:    Individual maturation Social and institutional contexts Historical time Critical issues for the gay life course Delays and interruptions of transitions Coming out    HIV/AIDS Differentials of support and acceptance compared with heterosexual men in multiple contexts Faculty of Health Professions
  3. 3. Place and Life Course/Health among Gay Men  Life course and health among gay men often presented as aspatial  Gay life course is presented as having different timing (e.g., interruptions and delays) but not different spatialities  But migration often emerges as central in gay men’s lives  Health outcomes (e.g., anxiety, depression, STIs) often explained through individual-based, psycho-behavioural factors and models (e.g., history of abuse, self-esteem)  But minority stress is rooted in place  Therefore, health outcomes among gay men are linked with the geographies of their lives Faculty of Health Professions
  4. 4. The Uneven Landscape of Minority Stress Distal Factors Proximal Factors Coping Structures Structural Prejudice Financial Status Prejudice Events Concealment or Suppression Informal Prejudice Internalized Homophobia SelfDevaluation Stigma Health Outcomes Treatment/Care Availability and Sensitivity Anxiety/Panic Disorder Substance Abuse Depression Suicide Suicide Ideation Risky Sexual Behaviors HIV and other STDs = place factor Reproduced from: Lewis, Nathaniel M. 2009. Mental Health in Sexual Minorities: Indicators, Trends, and their Relationships to Place in North America and Europe. Health & Place 15: 1029–1045. Faculty of Health Professions
  5. 5. Seeing Health Disparities as Place-Based Prevalence of suicide attempt, LGB youth, US and Canadian jurisdictions, 1987–2005 50 45 40 35 30 males only* 25 Gay LGB Hetero 20 males only ** 15 10 5 0 MN 1987 MN 2004 Seattle MA 1995 MA 2005 VT 1995 VT 2005 Boulder BC 2003 1995 Co. * 52/25 split in ** 38/8 split 2003 females in females Faculty of Health Professions
  6. 6. Place and Mobility in the Gay Life Course place b place a place c Institutions encountered across the life course Migration a, etc. … Life course from birth Individual maturation individual maturation Historical time place a place b Faculty of Health Professions place c
  7. 7. Presentation Outline 3 case studies linking health and gay life course: Moving ‚Out,‛ Moving On study (2009–2010)  Examines mental/emotional health and migration decision making among gay men in the United States and Canada (migration as self-care) Placing HIV Risk & Prevention among Gay Men in NS (2012)  Links rurality with men’s life courses, and the implications for HIV/AIDS risk and prevention outside MTV Promoting Sexual Heath for GBQ Newcomer men in ON (2013)  Uses service providers’ perspectives to view immigrant men’s sexual health through the lens of the migration experience Faculty of Health Professions
  8. 8. Moving ‚Out,‛ Moving On Study (2009–2010) Places moved from, 48 gay-identified men living in Ottawa and Washington, DC, as of 2009– 2010 Faculty of Health Professions
  9. 9. Migration up and down the urban hierarchy Origin of most recent migration, by age at time of migration and city type Number of respondents Large metropolis Mid-sized but larger Ottawa or Washington Mid-sized but smaller 1 3 2 5 4 7 6 Under 25 25–30 Over 30 Under 50,000 50000–500000 Mid-sized Very small city Very small city Small city Small city 500000–1000000 (Ottawa and Washington ≈ 650000) Large metropolis Over 1000000 Faculty of Health Professions
  10. 10. Migration as Self-Care  ‚In *Ontario town+, I had panic attacks on occasion. I’ve had like one or two since I’ve moved here, so … anxiety’s gone down … In high school, because there was a lot—it was a very kind of narrow-minded, homophobic high school—I … I developed ulcers … like I got really, really bad migraines, and just a lot of kind of stress-related health issues that were kind of having a really, really big impact on me … so, uh, once I kind of left the area, I felt a lot better.‛ ⁻ Luke, 24, white, French-Canadian, moved to Ottawa in his teens Faculty of Health Professions
  11. 11. Migration as Self-Care  ‚I had walked to the crest of the MacDonald Bridge and I stood there for—or was it the MacKay? I don’t remember which, it doesn’t really matter, they’re both high and they’re both over the harbor—and I stood there—it was rush hour—and I stood there until it got dark— waiting for myself to throw myself over. And I knew if I stayed in Halifax, one day I would throw myself over. So I had to get out, I had to leave.‛ ⁻ Randall, 45, black/Aboriginal, moved to Ottawa from Halifax in his late 20s Faculty of Health Professions
  12. 12. ‚Operating without a safety net‛: migration/risk  ‚I think there is some, um, disappointment—true disappointment— when you figure out that maybe you don’t fit the mold and you’re not welcomed over here and you’re not welcomed over there ... that’s a hard lesson to learn, you know?‛  ‚When I first came out [in D.C.], I dropped 60 pounds, I was running 21 miles a week, uh, you know, got myself into shape ... just coming screaming out of the closet, and just being like ... if I’m gonna do this, then I’m gonna be ... the best that I can be.‛  ‚I kind of do *know when I contracted HIV+ ... I think there’s probably some self-esteem issues there ... I think that trying to fit in thing that we talked about ... I think that always plays into things ... just trying to fit in ... you may not *use protection during sex+ because you don’t want to be rejected ... so you would just conform or just not say anything ...‛ ⁻ Joseph, 38, white, moved from the Florida panhandle to DC in his late 20s Faculty of Health Professions
  13. 13. AGGREGATE, N = 48, NEXT MIGRATION Migration & well-being later in the life course Destination of next planned migration, by age at time of interview and city type Number of respondents Large metropolis Mid-sized but larger Ottawa or Washington Mid-sized but smaller 1 3 2 6 4 9 Under 30 30–40 Over 40 Very small city Not planning to move: 12 (Under 30: 3, 30–40: 3, Over 40:6) Faculty of Health Professions Very small city Under 50,000 Small city Small city 50000–500000 Mid-sized 500000–1000000 (Ottawa and Washington ≈ 700000) Large metropolis Over 1000000
  14. 14. Migration & well-being later in the life course  In the 1980s: ‚What I sought [in moving to Ottawa], of course, was, you know, acceptance and a community ... but at that time when I moved here ... it was starting to grow. So I grew with it, and the things that I probably expected or sought were the things that I was creating or helping create‛ ⁻ Adrian, 56, moved from Nova Scotia to Ottawa in his 20s  Later in life and later in historical time: ‚the social and existential meaning of homosexual identity becomes less clear‛ (Kertzner 2001, 88).  In the 2000s: ‚It’s very comfortable to have [gay men] working without any issues in just about every federal agency [in Washington, DC] ... I didn’t get a sense of that in Ohio.‛ ⁻ Adam, 34, moved from northern Ohio to DC in his 30s Faculty of Health Professions
  15. 15. ‚Placing‛ HIV in NS Study (2012)  Looks purposefully at a the place-health link in terms of HIV  Interviews with individual gay-identified men and service providers  One of the first studies to examine risk and prevention in a rural region (as opposed to PLWHAs) Faculty of Health Professions
  16. 16. Masculinities Messages: Growing up Gay in NS  ‚Just trying to fit into … that rural culture and all the masculinity sort of driving the truck, going mud bogging and you know those types of things and you know I think [younger gay men] fear—I think it’s an irrational fear—but I think they fear, you know, people not liking them because they’re gay‛ ⁻ Justin, 30s, Colchester County Also a strong historic & institutional components:      Eric Smith (1991) & Lindsay Willow (2006) cases Banning of the sex book (2006) Truro pride flag refusal (2007) Intermittent banning of GSAs (up to 2012) Lack of investment in prevention structures Faculty of Health Professions The ‚sex book‛ banned in some NS schools
  17. 17. Individual Effects: Risk Behaviour & Perception  ‚… and then I just got to 30 and realized I had no sexual confidence, I had no sexual, like I don’t even really know what I like or what’s kind of weird, or what I want and so it was just a beautiful revolving door for like three years, hundreds [of sexual partners] I feel like, I just went totally crazy … it was fun and I’m just so thankful I came out of that and then now I’m in a place of comfort and pick and choose, and date, and do what I want.‛ ⁻  Mark, 30s, HIV-negative, Halifax County ‚They’re doing things that may be riskier because perhaps they don’t even want to really talk about it … if they’re not talking, they’re not comfortable talking to partners or going and getting condoms … I suppose you’re doing things a little bit more spur of the moment that you hadn’t planned on …‛  HIV nurse, Halifax County Faculty of Health Professions
  18. 18. Individual Effects: Mobilities and Risk  To Halifax: ‚There is no place close to them … they may not be out or they may have you know pent up energy or whatever—and they come [to Halifax] and all hell breaks loose sometimes. So [STIs] may not be the first thing on people’s minds and then they’re going home … they’re going back and they’re living their lives whether that’s gay relationships or … married to the opposite gender and potentially the spread.‛ ⁻  youth outreach worker, Halifax County To other cities: I’ve had many conversations with … gay men that might be around the 30, 32 in age, who have spent a number of years … in the Toronto, Vancouver area, who talk about the minute they got there … it was like fantasy land, right? And they took every advantage they could of course and nothing wrong with that, but we’re not at all prepared for the emotions, the responsibilities or any of that associated with it.‛ ⁻ ASO director, Halifax County Faculty of Health Professions
  19. 19. Community Effects: Sexual Speakability  This sort of unwillingness to be comfortable with their own sexuality, and just hating the gays that are *comfortable+… it’s more prevalent here I feel … ‘cause maybe there’s this undercurrent or this tone in our community where we’re still striving to be—either for their families or their dads—you know, somewhat masculine and not want to change.‛ ⁻  Mark, 30s, HIV-negative, Halifax County ‚… There’s sort of this badge of honor for normal gays like … I want a monogamous relationship and I want to get married. [My HIV-positive friend] was an example of what they could be and by sort of casting him aside … it allowed them to sort of look back to their sort of cocoon of … we’re all in open relationships, we all fuck around with everybody, we do engage in unprotected sex … like if we dismiss it and push it away … then we can keep on going and living our lives. ⁻ Jason, 30s, HIV-negative, Halifax County Faculty of Health Professions
  20. 20. Ontario Newcomer Sexual Health Study (2013)  Focuses on post- (international) migration shifts in sexual health  Shifts focus to the when of the life course  Systematic review, plus interviews with service providers serving newcomer men in London, Ottawa, Mississauga, and Toronto  One of the first studies to look specifically at GBQ immigrants rather than GBQ ‚ethnic minority‛ groups Faculty of Health Professions
  21. 21. Risk in GBQ immigrants and non-immigrants 12-month prevalence (%) of unprotected anal intercourse (UAI), nonimmigrants, Latin American immigrants, and other immigrants, Catalonia, Spain, 2008 (Folch, 2009) Group UAI Prevalence Adjusted Odds Ratio Spain (non-immigrant) 26.4 1.00 Latin Amer. immigrants 45.1 2.10 (significant at .01) Other immigrants 40.9 1.86 (significant at .05) 3-month prevalence (%) of unprotected anal intercourse (UAI), recreational drug use, and lifetime prevalence of getting an HIV test, full study sample, white non-immigrants, Latin American immigrants, and Eastern European immigrants, United Kingdom, 2007-2008 (Elford et al. 2012) Group UAI Prevalence Drug Use prevalence HIV Test Prevalence Full study sample 41 50 66 White British men 42 50 65 Latin Amer. Immigrants (~6 yrs. since arrival) 44 60 90 E. European Immigrants (~3 yrs. since arrival) 45 49 75 Faculty of Health Professions
  22. 22. 6-month prevalence (%) of (1) cocaine, (2) marijuana, and (3) ecstasy use, select Asian/PI and Latino studies, San Francisco (SF) Chicago/SF, and Miami, 2000–2005 Mean/median years since arrival Marijuana 13 13 ≤6 (60%) Ecstasy (E) 8.3 Cocaine ≤6 (60%) ≤6 (60%) 8.3 13 8.3 % of immigrants in the sample 20–39% 40–59% Faculty of Health Professions 60–79% 80–99% 100%
  23. 23. 3-month prevalence of any unprotected anal intercourse (UAI)*, select studies, New York City (NYC)/Los Angeles (LA), UK, San Diego (SD)/Seattle, United Kingdom, Northeastern US, Miami, and rural North Carolina, 2002–2008 Mean/median years since arrival 9 15 6 3 9 * Where reported, rates for UAI w/ “casual partners” were 17–34% % of immigrants in the sample 20–39% 40–59% Faculty of Health Professions 60–79% 80–99% 100%
  24. 24. Challenging the Acculturation Thesis  ‚From arrival until 3 or 4 years *after arrival+, they have so many other issues, that, you know, spending spare time, enjoying the life, it’s hard to say if they’re getting included at the gay bar or whatever.‛ ⁻  ‚The priority is for them to integrate, and then as soon as they settle, maybe then they would come out to me if they are closeted.‛ ⁻  newcomer centre director, Mississauga settlement counselor, London ‚ … back home I couldn’t be out and I’m glad to be here or we didn’t have a bath house back home … It’s sort of this place where you are guaranteed going to be meeting gay … you’re really being stressed and that’s the kind of release you’re looking for, a bath house can be one of those things … I don’t know anybody but at least I can go get laid.‛ ⁻ sexual health counselor, London Faculty of Health Professions
  25. 25. Post-Migration Vulnerabilities: Negotiating Sex  ‚Some people are coming having experienced extreme violence and extreme trauma … and for gay men … you’ve experienced some form of shame-based trauma that goes undealt with; how trauma can manifest, we can have voicelessness … we can have difficulty negotiating safer sex or negotiating relationships.‛ -  gay men’s sexual health advocate, Toronto ‚*An immigrant colleague+ said that … because he visually looked so different, he never felt empowered to insist on the kinds of sex that he wanted to have because the message … was you should feel lucky that the beautiful white boy wants to have sex with you … it caused him to bend the rules where he otherwise wouldn’t or to avoid sex altogether. Like I don’t want to rock the boat by insisting on condom use.‛ ⁻ sexual health educator, London Faculty of Health Professions
  26. 26. Conclusions  Gay men’s health continues to be affected by geographies of rights, social inclusion, and service provision, that are uneven both across space and over time:    Migration emerges as a personal self-care strategy:    Individuals carry forward personal trauma experienced earlier in life, sometimes in other places Communities—and gay communities within them—often perpetuate historical traumas through ongoing behaviours and modes of being That corrects interruptions and delays in the life course That can create additional stress and upheaval during transitions Clear points of entry into gay communities and gay-specific care are central to promoting resilience among diverse GBQ groups, including the recently arrived Faculty of Health Professions
  27. 27. The Disavowal of Gay Space?  ‚In Toronto, we’ve abandoned the Church Wellesley Village … we vacation with our boyfriends in fabulously rustic country homes that belong to our parents, who don’t mind us coming to stay as a couple. Hell, we even marry our boyfriends, if we choose to, on rooftops overlooking Queen West. Our sexual orientation is merely secondary to our place in society. We don’t need to categorize or define ourselves as gay, and who we sleep with—mostly men and, hey, sometimes women—isn’t even much of a topic of conversation anymore … say hello to the post-modern homo. The post-mo, if you will.‛  Paul Aguirre-Livingston, ‚The Dawn of a New Gay,‛ The Grid Toronto, 6/9/2011 Faculty of Health Professions
  28. 28. Problematizing Mobilities as Self-Correction ‚The IGB video is a mandate to fold into urban, neoliberal gay enclaves, a form of … upward-mobility that echoes the now discredited ‘pull yourself up from the bootstraps’ immigrant motto. [Dan] Savage embodies the spirit of a coming-of-age success story. His message translates to: Come out, move to the city, travel to Paris, adopt a kid, pay your taxes, demand representation.‛ ⁻ Jasbir Puar, ‚The Problem with It Gets Better,‛ The Guardian, 11/10/2010 Faculty of Health Professions
  29. 29. Community Investment as Alternative: Ottawa  ‚. . . There’s a lot of gays who arrive here from the [Ottawa] valley and from smaller communities … their experiences are quite different … whereas in Montreal … you arrive on the bus terminal . . . you’re practically in the Village already.‛ ⁻  Sam, 44, Moving ‘Out’, Moving On Study ‚… the opportunity for people who live in our area and the surrounding areas to … understand where to access services . . . that’s something that’s really … exciting and unique about *the+ Ottawa *village+ … we have organizations like the Centretown Citizens’ Association+ … the *Citizens’ corporation+‛ ⁻ Glenn Crawford, 2009 Faculty of Health Professions
  30. 30. Acknowledgements     Social Sciences and Humanities Research Council Vanier Scholarships Association of American Geographers Canadian Institutes of Health Research (CIHR) CIHR Population Health Intervention Research Network (PHIRNET) Faculty of Health Professions