Sage Journals: Discover world-class research

Abstract

This article focuses on how health practitioners can better understand and intervene with gay men. Gay men’s health is situated within 3 prominent theoretical models (ie, minority stress, gender socialization, and identity development) and associated with 3 constructs (ie, internalized homonegativity, internalized homophobia, and internalized heterosexism) to contextualize gay men’s health concerns. Throughout the article, the authors draw particular attention to research that emphasizes the strengths of gay men, as this is a notable gap in the extant literature. Furthermore, HIV/AIDS is a central concern of gay men, and this article focuses on how cultural identities and factors may intersect with HIV/AIDS status among gay men and have implications for health decision making. Affirmative clinical interventions based on theory and research are presented throughout the article, which can be applied by health professionals in various settings. Given the confusion around terminology, lack of knowledge of available resources, and prevailing negative societal myths about gay men, the article provides a glossary of definitions for unclear terms, actively disputes myths that are not empirically supported, and provides a list of available resources.

Keywords

gay men men who have sex with men HIV/AIDS sexual orientation

Health practitioners are encouraged to help their gay clients discern and select what strategy may be most useful to them in the context of their environment, identity development, and available supports.

The extant literature on gay men’s health is large, covering many topics (eg, depression, HIV/AIDs) by several health disciplines (eg, nursing, medicine, counseling psychology). As we reviewed the known findings, a body of scholarship emerged that detailed the limitations of research involving gay men. The noted limitations have the potential to bias how practitioners interpret and apply research with their gay clients. As a result, we felt compelled to incorporate a critique of the extant literature as part of our review. We understand that the targeted audience of this journal is not researchers per se, but practitioners. Therefore, we do not intend to make statistical or research methodological critiques the basis of our review. Health practitioners are likely to benefit from this brief critique by becoming more aware of the research limitations and basing their practice with gay men on a fuller understanding of the literature.

Research Critique

Much of the current health research is based on a deficit model or a focus on diseases of gay men.¹ Indeed, we found that a collated body of research indicated that gay men are at an increased risk for self-harm, suicide ideation, eating disorders, legal and illegal substance abuse, tobacco use, panic attacks, depressive symptoms, and underutilization of health care services.^2-11 A lack of research on the strengths of gay men and positive health outcomes compounds the focus on deficits.

Another potential bias is that research has often benchmarked gay men’s health outcomes comparatively to heterosexual men, which interprets the experience of a sexual minority population within the sexual majority’s worldview.¹² Such an approach emphasizes the idea that being heterosexual is normal and being gay is abnormal. Stigma associated with being gay may prevent disclosure on a research questionnaire. Therefore, benchmarks of gay men’s population do not exist, which limits generalizability based on a representative sample.¹³

Phillips¹⁴ adds that multiple identities are often overlooked, resulting in a simple presentation of sexual orientation and minimizing the complex cultural variations of gay men. Sexual orientation is almost impossible to operationalize because self-labeling techniques do not capture the complexity of identity intersection, there is a lack of a widespread/accepted measure of sexual orientation, and some LGB (lesbian, gay, bisexual) individuals have difficulty defining themselves within preexisting categories.^13,15

As a result, defining the study’s sexual minority population of focus is critical as is clarity of terms used. For this study, we used literature based on the searchable terms “gay men” and “men who have sex with men” (MWSM). Although some studies consolidate different LGBT (lesbian, gay, bisexual, transgender) groups into their sample because of overlapping issues, we excluded studies that focused on bisexual men and transgendered individuals because we considered those populations distinct from gay men and MWSM since same-sex behavior does not necessarily equate with homosexual sexual orientation identification.¹³ Gay men refer to individuals with the physical and biological makeup of a male who are attracted to other men and identify as a sexual minority (Table 1). MWSM is a behaviorally based definition of men who engage in sexual acts with other men but do not necessarily identify as a sexual minority (Table 1). As noted, Table 1 is a glossary of commonly confused terms in the gay men’s literature. Knowing and understanding cultural terminology and language is important for practitioners to be culturally sensitive with gay clients.

Table 1.

Glossary of Terms

Term	Definition
Homosexual	Sexually attracted to members of the same sex
Men who have sex with men^a	Men who engage in sex with other males but do not necessarily identify as being gay
Same-gender loving	Typically used among African American and Latino men who engage in same-gender sexual behavior but do not have a meaningful connection to being labeled as gay¹
Gay men^a	Sexual identity used by men who exclusively have sex with men
Bisexual	Sexually attracted to both sexes
Queer masculinity	Ways of being masculine outside of traditional heterosexual constructions of masculinity¹⁶
LGBTQQA	Lesbian, gay, bisexual, transgender, queer, questioning, and ally; a commonly used acronym that sometimes places letters in different orders and that may omit or add various identities
Homophobia	Irrational fear of, aversion to, or discrimination against homosexuality or homosexuals
Internalized homophobia	Internalization of negative social attitudes toward self, leading to self-hatred, poor self-regard, internal conflict, and discomfort with one’s sexual orientation¹⁷
Internalized homonegativity	One’s internalized negative perceptions of his or her sexual identity as a reaction to internalizing societal heterosexism¹⁸
Internalized heterosexism	Internalization of the heterosexist ideology that nonheterosexual behavior, relationships, and communities are denied and inferior¹⁹
Homonegativism	Heterosexist ideology that heterosexuality is the normal and dominant sexual orientation, which forms the value and belief system of sexual minorities²⁰
Sexual prejudice	Negative attitude derived from judgment on sexual orientation²¹
Homosociobility	Describes same-sex displays of affection that are seen as acceptable within a heterosexist society²²
Sexual identity	Recognition, acceptance, and self-labeling of sexual behaviors, values, and preferences¹⁵
Sexual orientation^a	Attraction to men, women, both gender, neither gender, or another gender, expressed through sexual, affectional, and relational dispositions¹⁵
Sexual behavior	Specific expression of sexuality
Sex	Anatomical or biological characteristics of male or female¹⁵
Gender expression	Individual behaviors and characteristics that are outwardly visible to others (ie, clothing and mannerisms)¹⁵
Gender identity	Purposeful claiming and expression of a gender
Down low	Typically used among Latino and African American culture, in which men identify as heterosexual, engage in sex with both males and females, and do not share their sexual behavior with females¹
Homo thugz	Typically used among African American culture to describe young men who engage in gangster behavior and have sex with men¹
Barebacking	Intentional unprotected anal intercourse²³
HIV	Human immune deficiency virus: a virus that attacks the immune system
AIDS	Acquired immune deficiency syndrome: a syndrome that weakens the immune system, leaving a person at risk for different types of infections
Coming out	Disclosure of one’s same sex preference and orientation²⁴
Out of the closet	A more open and public expression of one’s sexual orientation
In the closet/closeted	Not disclosing one’s sexual orientation
Fag/faggot	Derogatory term to describe gay men and men who have sex with men
Conversion therapy (ie, reparative therapy)	Attempts to change one’s sexual orientation from homosexual or bisexual to heterosexual

Indicates the most commonly used language in our article.

In response to these limitations, a primary aim of this literature review is to contextualize gay men’s health concerns and issues within prevailing theories and constructs familiar to sexual minority groups and culture. Understanding the sociocultural factors involved in gay men’s health and debunking negative stereotypes (Table 2) may help clinicians be more affirmative toward gay men, make more accurate diagnoses, and treat gay men with more clinical compassion.^25,26 Another aim of this literature review is to detail the health benefits and strengths of gay men to facilitate the construction of a fuller picture of gay men’s health. We also seek to better understand the interaction between multiple identities (eg, ethnicity, age, spirituality) and HIV status for gay men. Since the health of gay men is situated within a hostile, systemic context, we demystify various societal myths about gay men (Table 2) and discuss ways for health practitioners to engage in systemic interventions.²⁷

Table 2.

Negative Myths and Suggested Health Responses

Negative Societal Myth	Effect on Gay Men	What Research Says	Suggested Response by Health Professional
Gay men molest children	Gay men may be excluded from work and family settings that involve children Political and legislative decisions (eg, bans on gay men adopting) may be made that are unfavorable to gay men based on the myth	Research has not found a connection between homosexuality and child molestation²⁸	Educate concerned individuals on the realities of child sexual abuse Understand the negative political climate Advocate for fair policies, such as equal employment legislation
Gay men are sexually promiscuous Gay culture is overly focused on sex	Young gay men may feel pressured to conform to these expectations Gay men may learn to base their self-worth and identity on sexual relationships Gay men may be considered unfit parents and unable to provide a stable home	Gay men place no greater importance on sex than other cultures and groups of people²⁹ Most gay men engage in safe sex practices³⁰	Provide information to gay men about nonsexualized events and places Be aware of the multiple identities and interests
All gay men are HIV positive or have AIDS All gay men will contract HIV	Gay men may be complacent and accept the risk of contracting HIV, thus placing themselves in risky situations Discriminatory policies, such as bans on donating blood	All individuals may be at risk for HIV, depending on their lifestyle and behaviorsGay men are not the only at-risk group for HIV and AIDS	Refrain from giving information on HIV prevention solely to gay men based on bias Counsel gay men about HIV prevention and assure them that contracting HIV is not inevitable Advocate for fair policies, such as a repeal of the ban on donating blood
Same-sex couples cannot appropriately parent children and only raise children to recruit them to a gay lifestyle	Gay men may not receive familial support in raising children Gay men may be banned from being adoptive parents Gay men may feel increased stigmatization as a parent	Children of same-sex parents have equal levels of functioning compared with children of opposite-sex parents³¹ Gay fathers raise less aggressive sons who express greater levels of caring Gay and lesbian children of gay men receive higher levels of parental support than gay and lesbian children of straight parents²⁹	Develop and offer a referral list of supportive services focused on parenting issues Refrain from expressing the belief that gay fathers are inappropriate parents Advocate for gay men who are prospective fathers or seeking custody rights
All gay men are feminine	Gay men may feel gender role conflict and restriction, which may cause psychological distress and difficulty expressing emotion³² Gay men may desire to conform to masculine ideals in order to avoid being perceived as feminine³²	Gay men have varying gender role identities, ranging from feminine to hypermasculine	Gay men should be counseled on gender identity and become aware of nontraditional gender roles and identities Professionals should be nonjudgmental about gender presentation Do not assume sexual orientation based on gender presentation Be aware of gender-assumptive language
Changing one’s sexual identity through reparative and conversion therapy is possible Gay men can choose not to be gay	Sexual orientation is seen as a choice Gay men may feel increased shame and guilt regarding their sexual orientation Gay men adhering to certain conservative religions may be especially pressured to attempt to change their orientation	Reparative/conversion therapy is not based on the current understanding of sexual orientation Attempts at reparative/conversion therapy may cause gay men increased psychological distress, including suicidality³³ There is no convincing evidence that reparative/conversion therapy produces enduring change in sexual orientation³³	Consider a homosexual orientation as inherently human as a heterosexual orientation Do not attempt to change gay men’s sexual orientation Provide information on the realities of reparative/ conversion therapies Create a gay-affirmative environment in your practice Normalize being gay and provide support for coming to terms with one’s identity
Gay men are gay because they were abused as children	This myth may add to shame and stigma experienced by gay men Gay men who were abused may refrain from receiving help in dealing with their abuse or may feel that their identity as gay is not valid	Gay men report having experienced child sexual abuse at a very similar rate (14%) to that of the national average for men (16%)³⁴ Research has not found a causal link between child abuse and homosexuality among gay men	Refrain from making this assumption about gay men Do not suggest services for coping with abuse if there is no evidence that they are needed Refrain from assuming that abuse is a causal factor in a gay man’s sexual identity

Contextualizing Gay Men’s Health

We discuss minority stress, gender socialization, and identity development theories as well as the overlapping constructs of internalized homonegativity, internalized homophobia, and internalized heterosexism to contextualize gay men’s health.

Minority Stress Model

Unfortunately, stigmatization, discrimination, and oppression of gay men is still prevalent in the United States; examples include negative societal myths (Table 2) about gay men as child molesters, verbal abuse, threats, hate crimes, and public policies that closet the mere identification as a sexual minority. The minority stress model posits that gay men are members of a minority group in the United States and experience chronic stress as a result of the discrimination, which leads to adverse health outcomes.^11,35-37 The minority stress model has been correlated with suicidality, depression, workplace problems, alcohol and substance abuse, body image dissatisfaction, eating disorders, and risky sexual behavior in samples of gay men.^37-42

Although considerably less studied than stress, the impact of one’s resilience and use of coping strategies to buffer against stress and maintain health is an emergent counter-process within the minority stress model.^11,36 David and Knight⁴³ argue that coping is a potential mediator between stress and negative health outcomes. Stigma competence, defined as the ability to cope with stigma, is a coping skill for gay men that helps approach and overcome the unique challenges associated with being a sexual minority.⁴³ Chenard⁴⁴ describes 3 stigma management strategies: (a) selective disclosure, which refers to a gay man’s incremental disclosure of sexual identity over time to a select group of trusted allies; (b) preemptive or open disclosure, which refers to a gay man’s proactive disclosure of sexual identity; and (c) reactive disclosure, which entails a gay man hiding or concealing his sexual identity to protect himself against stigma. In addition to stigma competence, crisis compe-tence is a strength that is derived from responding to difficulties, which gay men can use in various stressful situations. Research has yet to conclude which strategy is most effective or correlated with positive health outcomes. Health practitioners are encouraged to help their gay clients discern and select what strategy may be most useful to them in the context of their environment, identity development, and available supports.

In addition to stress from societal discrimination, gay men with HIV/AIDS may experience additional stress from the illness. Increased stress has been found to decrease the effectiveness of HIV medication, decrease T-cell counts, increase the speed at which the virus replicates, and trigger the onset of HIV symptoms.^45,46 Therefore, interventions that reduce stress can actually slow the progression and decrease the severity of HIV symptoms.⁴⁵ For example, Weiss et al⁴⁷ found that simply providing educational materials to HIV-positive gay men is an efficient way to improve gay men’s psychosocial well-being and coping.

An unfortunate stressor for some HIV-positive gay men is the experience of loss and bereavement as individuals in their social networks die from an AIDS-related death.^45,48,49 HIV-positive gay men encounter unique stressors to their grieving, such as coping with the real possibility that they will also die from the same illness and feelings of anger or guilt if the deceased individual infected the bereaved individual or was infected by the bereaved individual.^49,50 Gay men have reported that many health services do not address grief and loss issues.⁴⁹ Therefore, health providers should make sure to discuss the possibility of AIDS-related bereavement with their gay, HIV-positive clients and incorporate relevant services into their treatment plan. For example, gay men may benefit from a group intervention that focuses on emotional expression, group cohesion, and accessing social support to deal with bereavement.⁵¹ Health practitioners can work with HIV-positive gay men to access and use their strengths of independence and positive coping strategies that may have been used to deal with similar experiences of loss when faced with HIV-related bereavement.

In a related line of research, gay men are at an increased risk to have lost social and family support through the coming-out process and therefore are likely to develop necessary networking strategies and skills to enhance social supports.²² In addition to personal coping skills, social support may also represent a mediator between stress and negative health outcomes for gay men.⁴⁵ For gay men who report a lack of support from family or peers, health practitioners can offer referrals to community organizations and groups such as gay-friendly therapy groups, support groups, and religious organizations (Table 3). HIV-positive gay men, often strained from family support and stigmatized by society, have noted that social support from other HIV-positive gay men was integral to their self-care and helped to buffer them from stress and to feel safer.^44,48,50 Ideally, practitioners would be involved in local, regional, or national gay communities and therefore, know of resources for gay men. If a practitioner lacks such experience, Table 3 provides a list of available supports for gay clients. Health practitioners can help gay men identify both the positive and negative supports in their lives, suggest the appropriate source of support to access, and provide necessary referrals.

Table 3.

Resources for Health Professionals and Gay Male Clients

Resources	Description
Professional organizations
Gay and Lesbian Medical Association	www.glma.orgThe Gay and Lesbian Medical Association (GLMA) is the world’s largest and oldest association of lesbian, gay, bisexual, and transgender (LGBT) health care professionals. GLMA’s mission is to ensure equality in health care for LGBT individuals and health care providers.The Web site also has a “Find a Provider” search function to help gay clients find a health care professional in their area.
Association for Lesbian Gay and Bisexual Issues in Counseling	www.algbtic.orgALGBTIC recognizes both the individual and social contexts of mental health among sexual minorities and strives to promote greater awareness and understanding of gay, lesbian, bisexual, and transgender (GLBT) issues among members of the counseling profession to increase the quality and effectiveness of services to GLBT individuals and communities.
Community and Internet referrals and resources
Gay Health Blog	www.gayhealthblog.comThe purpose and goal for GayHealthBlog.com is to provide a safe haven for any LGBT people who are interested in access to essential, up to date, uplifting and informative health and wellness information in a safe, anonymous forum, from health care providers, writers and other professionals who care about promoting LGBT health.
Gay Men’s Health Crisis	www.gmhc.orgGMHC is the world’s first and leading provider of HIV/AIDS prevention, care, and advocacy.
Gay Scape	www.gayscape.comAn Internet search tool specifically targeted to the gay and lesbian community. The tool is categorized by location and topic. Examples of searches include Counseling and Psychotherapy, Gay Rights, HIV/AIDS, Professional Organizations, and Pride Events.
Gay City News	www.gaycitynews.comGay City News is distributed in print in New York City. However, all issues and other information regarding gay topics are posted online.
Advocate	www.advocate.comThe Advocate is a national lesbian and gay magazine that can be accessed online or ordered in print form.
Queer Arts Resource	www.queer-arts.orgQueer Arts Resource is an Internet resource devoted to expanding the range and depth of knowledge about contemporary and historical queer art, and making this information freely available on the Web site.
PRIDE Institute	www.pride-institute.comPRIDE Institute, based in Minnesota, offers mental health and chemical dependency care to the LGBT community. PRIDE Institute is committed to providing lesbian, gay, bisexual, and transgender people a road to recovery through evidence-based substance abuse, sexual health, and mental health treatment.
SAGE	www.sageusa.orgSAGE is the world’s oldest and largest nonprofit agency dedicated to serving and advocating for LGBT seniors. Since its inception, SAGE has pioneered programs and services for seniors in the LGBT community, provided technical assistance and training to expand opportunities for LGBT older people across the country and provided a national voice on LGBT aging issues.
Gay and Lesbian National Help Center	www.glnh.orgGLBT National Help Center provides free and confidential telephone and Internet peer-counseling, information and local resources for gay, lesbian, bisexual, transgender, and questioning callers throughout the United States. The Help Center also works to strengthen local GLBT hotlines and organizations in their mission of service to the community.
Gay, Lesbian, and Straight Education Network	www.glsen.orgGLSEN works to foster equality and respect in schools.
Parents, Families and Friends of Lesbians and Gays	www.pflag.orgParents, Families and Friends of Lesbians and Gays (PFLAG) is a national nonprofit organization with more than 200 000 members and supporters and more than 500 affiliates in the United States. PFLAG promotes the health and well-being of lesbian, gay, bisexual, and transgender persons, their families and friends through support, to cope with an adverse society; education, to enlighten an ill-informed public; and advocacy, to end discrimination, and to secure equal civil rights.
gaychurch.org	http://www.gaychurch.org/Find_a_Church/Denominations/denominations.htmA Web site offering a list of gay-affirmative religions, organizations, and churches.
Resources and referrals for adolescent/young gay men
Avert	www.avert.orgAVERT is an international HIV and AIDS charity based in the United Kingdom working to avert HIV and AIDS worldwide through education, treatment, and care. Avert.org has a section dedicated to personal stories from young gay and bisexual men and also has information about resources, youth groups, help lines for those who are lesbian, gay, bisexual, or unsure.
YouthResource	www.amplifyyourvoice.org/youthresourceYouthResource is a Web site created by and for gay, lesbian, bisexual, transgender, and questioning (GLBTQ) young people. YouthResource takes a holistic approach to sexual health and exploring issues of concern to GLBTQ youth by providing information and offering support on sexual and reproductive health issues through education and advocacy. Through monthly features, message boards, and online peer education, GLBTQ youth receive information on activism, culture, sexual health, and other issues that are important to them.
Sex, etc.	www.sexetc.orgSex, etc. offers sexual health information, teen to teen. GLBTQ topics are included. Teens are able to chat with each other, learn about sex terms, and gain information on getting tested for sexually transmitted diseases.
Academic and professional journals for health practitioners
Journal of Gay & Lesbian Mental Health	An interdisciplinary scientific forum on LGBT mental health issues that targets researchers and professionals, the Journal of Gay & Lesbian Mental Health provides a professional forum that provides clinicians with access to crucial information that will help them to effectively treat LGBT patients and their family members. This peer-reviewed scientific journal emphasizes original research articles, case reports, critical reviews of the literature, and reports on innovative services for LGBT people.
Journal of Homosexuality	Journal of Homosexuality is a peer-reviewed journal devoted to publishing a wide variety of disciplinary and interdisciplinary scholarship to foster a thorough understanding of the complexities, nuances, and the multifaceted aspects of sexuality and gender. The chief aim of the journal is to publish thought-provoking scholarship by researchers, community activists, and scholars who employ a range of research methodologies and who offer a variety of perspectives to continue shaping knowledge production in the arenas of lesbian, gay, bisexual, transgender (LGBT) studies and queer studies.
International Journal of Sexual Health	As the official journal of the World Association for Sexual Health, the International Journal of Sexual Health promotes sexual health as a state of physical, emotional, mental, and social well-being through a positive approach to sexuality and sexual rights. The journal publishes peer-reviewed scientific articles, editorials, and reviews, using quantitative and qualitative methods, descriptive and critical analysis, instrument development, surveys, and case studies to examine the essential elements of this broad concept. Leading experts from around the world present original work that covers a variety of disciplines, including sexology, biology, medicine, psychology, sociology, anthropology, history, and religion.
Archives of Sexual Behavior	The Archives of Sexual Behavior is a peer-reviewed academic journal in sexology. It is the official publication of the International Academy of Sex Research. The types of articles published in the journal include empirical research (both quantitative and qualitative), theoretical reviews and essays, clinical case reports, letters to the editor, and book reviews.
Sex Roles	Sex Roles is a peer-reviewed scientific journal. Articles appearing in Sex Roles are written from a feminist perspective, and topics span gender role socialization, gendered perceptions and behaviors, gender stereotypes, body image, violence against women, gender issues in employment and work environments, sexual orientation and identity, and methodological issues in gender research.
AIDS Education and Prevention	AIDS Education and Prevention integrates public health, psychosocial, sociocultural, and public policy perspectives on issues of key concern nationally and globally. Included are reports on innovative epidemiological studies, analyses of the full range of risk behaviors and processes, close examinations of the challenges facing particular communities, descriptions of leading-edge education and prevention initiatives, empirically based reviews of the efficacy of existing programs, reviews of new books and other resources for researchers, practitioners, and educators, and special supplements providing in-depth coverage of essential topics.
AIDS and Behavior	AIDS and Behavior provides an international venue for the scientific exchange of research and scholarly work on the contributing factors, prevention, consequences, social impact, andresponse to HIV/AIDS. The journal publishes original peer-reviewed articles addressing all areas of AIDS behavioral research including: individual, contextual, social, economic and geographic factors that facilitate HIV transmission; interventions aimed to reduce HIV transmission risks at all levels and in all contexts; mental health aspects of HIV/AIDS; medical and behavioral consequences of HIV infection, including health-related quality of life, coping, treatment and treatment adherence; and the impact of HIV infection on adults, children, families, communities, and societies.
Journal of Gay & Lesbian Social Services	The Journal of Gay & Lesbian Social Services provides empirical knowledge and conceptual information related to sexual minorities and their social environment. Dedicated to the development of knowledge that meets the practical needs of lesbian, gay, bisexual, and transgendered people in their social context, the Journal of Gay & Lesbian Social Services is a forum for studying, for example, the connection between the public issues of homophobia and heterosexism and the personal, day-to-day experiences of people affected by these attitudes.

Internalized Homonegativity, Homophobia, and Heterosexism

Internalized homonegativity, internalized homophobia, and internalized heterosexism are 3 overlapping, yet distinct, constructs in the literature (see Table 1 for clarification). The basic premise of each construct is that an individual of sexual minority status applies negative messages from society about sexual orientation to the self.¹⁵ To convey the literature appropriately, we will use the terminology used in each particular study within our review.

Internalized homonegativity is described as the internalizing negative “reaction to stigma associated with being homosexual” by individuals who identify as a sexual minority.⁵² Frost and Meyer²⁷ described stress as processing along a continuum of proximity to the self, with distal stressors based in the environment (eg, antigay stereotypes) and the most proximal stress of internalizing heterosexist social attitudes (ie, internalized homonegativity). Internalized homonegativity with samples of gay men has been found to be associated with depression, relationship difficulties, and unprotected anal intercourse.^18,27,37 Internalized homonegativity has also been found to lead to an increase in mood disorders and substance abuse, which ultimately may increase the risk of HIV infection and lead to poorer response to HIV treatment.⁵³

Internalized homophobia is the internalizing of an irrational fear of homosexuality.¹⁸ Internalized homophobia has been found to induce emotions of shame, guilt, and fear of one’s sexual orientation as well as risky behaviors (eg, suicide and self-harm).⁵⁴ Sexual minorities have been found to cope with internalized homophobia using 3 strategies: (a) Routinization and minimizing of homophobia, in which acts of discrimination are expected and viewed as normal. This strategy reduces the intense victimization that can accompany homophobia, and minimizes the severity of the impact of the dominant heterosexist view. (b) Maintaining individual “adult” responsibility, which is described as developing the skills necessary to emotionally and physically cope with homophobia, and developing the capacity to manage stigma. (c) Constructing “proud” identities, which can be explored in many different realms such as mature conversations, sexual exploration, and taking responsibility for actions and decisions. Positive and open conversations with adults about sexuality can reinforce a positive identity and self-acceptance for gay men, thus negating the influences of homophobia.⁵⁴

Internalized heterosexism is the internalization of the overt and covert societal stance that sexual minorities are inferior to heterosexuals.¹⁹ Internalized heterosexism has been linked to risky sexual practices and low compliance with HIV medications.⁵³ Although results are mixed, a moderate positive correlation is prevalent between internalized heterosexism and alcohol and substance abuse with gay men.^55-57 Mediating variables, such as disclosure of sexual identity, anxiety, depression, and self-acceptance can influence internalized heterosexism’s effect on substance use.⁵⁵

The associations between internalized homonegativity, homophobia, and heterosexism and adverse health outcomes and risks present a difficult challenge to health practitioners to understand internal processes that may not be explicitly manifested. We suggest that health practitioners respect the individual differences among gay men and be open to hearing personal experiences and learning their unique stories as well as investigating emergent literature about current gay culture. Furthermore, understanding the client’s experience of heterosexist beliefs and its impact on social relationships can help identify areas that need support.⁵⁵ Encouraging the gay client to inform his social network of the impact of heterosexism may help reduce these harmful perceptions and ultimately enhance support networks. When encouragement is insufficient, assertiveness training may help gay clients develop the necessary skills to initiate difficult conversations with people in their social network.

Gender Socialization Theory

Gender socialization theory contends that masculinity is a construct that is constantly negotiated within physical, psychological, and social interactions that include modeling, reinforcement, and punishment.^58,59 In the United States, men typically experience pressure to conform to norms of being independent, fearless, tough, invulnerable, self-reliant, stoic, and nonfeminine.^60,61 Research has indicated that men may be more likely to engage in negative health behaviors because of the gender socialization process, which discourages self-care and help-seeking while encouraging risky behavior.⁶²

Indeed, masculinity construction is difficult to negotiate for some gay men. A prevailing antigay stereotype is that all gay men are overly feminine (Table 2). However, expression of masculinity is quite variable among gay men and is often in direct reaction to the feminine stereotype.³² Research with gay men has found that those who placed more value on traditional norms of masculinity expressed negative feelings about being gay.⁶³ Nonconformity to traditional masculine norms has led to paternal, maternal, and peer rejection during the childhood of gay men.⁶⁴ For gay men, masculinity construction and conflict has been linked to substance use, steroid use, risky sexual behavior, dissatisfaction if their body does not meet the physically powerful masculine ideal, anger, anxiety, and depression.^65-68

Health practitioners can intervene by asking their gay clients what effect masculine ideals and gender role socialization have on their presenting concerns and stress during the initial assessment process.³² For example, traditional gender socialization has been linked to gay men having difficulty being in relationships with other men; a cost–benefit analysis of traditional masculinity’s effect on relationships has been identified as an appropriate intervention in these instances.⁶⁹ Health practitioners could begin the conversation by asking, “Do masculine ideals contribute to stress for you or in your relationships?” Many of the basic concerns (eg, emotional restriction, family conflict, relationship difficulties) related to gender role conflict and masculine socialization are found in both gay and nongay men; health practitioners are urged to acknowledge those similarities with gay men.⁶⁸

Identity Development Theories

Several stage models exist in the literature that detail the identity development process of gay individuals.^70-73 As summarized by Hill,⁷⁴ important themes are seen in each model: (a) awareness of difference prior to exploring sexuality, (b) initial exploration of sexuality and tentative self-identification, (c) feelings of separation from heterosexual others, (d) feelings of connection with homosexual others, (e) deepening connection with homosexual others, (f) awareness of and response to oppression, and (g) sense of sexuality as one part of a complex identity and increased skill interacting with both heterosexual and homosexual others.⁷⁴

The stage, timing, and pattern of identity development have implications for gay men’s health. Friedman et al⁷⁵ created 3 categories based on the pattern and timing of identity development for gay men: early developing (experiencing same sex attraction by 3rd grade, coming out by 12th grade), middle developing (experiencing same-sex attraction by sixth grade and coming out by 21 years old), and late developing (experiencing same-sex attraction by eighth grade and coming out by 28 years old). HIV status, gay-related victimization, and depression were associated with the early developing category. Victimization during the coming-out process may be of importance beyond the individual trauma for those who come out at a young age, as gay-related harassment experienced prior to age 17 years predicted 189% greater odds of experiencing gay-related victimization in adulthood.⁷⁵

“Coming out,” which refers to individuals disclosing their sexual orientation to others and establishing a public identity as a gay individual, is a significant process in the identity development of gay men (Table 1).⁷⁶ Coming out may best be understood as a continuous social process rather than as a single disclosure.⁷⁷ Many scholars consider coming out to be a long, complex, difficult, stressful, anxiety-provoking, and complicated process for gay men. Challenges and risks associated with the coming-out process among gay men might include more sexual risk behaviors, internalized homophobia, stigmatization, and disturbances to social relationships.^56,78 Other scholars contend that a current climate of openness and available supports may make coming out less daunting.⁷⁸ For example, gay adolescents are coming out an average of 10 years earlier than their counterparts from 30 years ago.²⁴

Riley²⁴ defined coming out as a 5-dimensional process, which entails involvement in gay activities, development of attitudes toward a gay identity, becoming comfortable with being gay, disclosing that one is gay to others, and identifying a specific sexual identity. Within the Riley²⁴ model, the dimension involving being comfortable with being gay correlated positively with self-esteem and negatively with anxiety and depression. The dimension involving participation in gay activities was positively correlated with the number of sexual encounters but negatively correlated with unsafe sex, indicating that participation in gay activities might lead to meeting more sexual partners but that individuals would be less likely to take sexual risks, perhaps because of social support from people at these events.

An exemplary study conducted by Riggle et al⁷⁹ explored the positive aspects of identity development in relation to disclosure of sexual identity and took a strength-based approach to understanding the characteristics of sexual minorities that develop due to their minority status. Coming out was seen as a critical step in the development of a positive identity, as it provided the opportunity to foster close relationships with other sexual minorities and generate a greater sense of self-awareness. Because of the very nature of disclosure, self-exploration forces gay men to be honest with who they are (and who they are not), which is integral to the emergence of an authentic self. With the continual presence of societal discrimination, participants described an ability to look within for self-acceptance rather than externally for reinforcement. This process of reflection and disclosure further promotes an authentic understanding of self, a strengthened identity, and an opportunity for gay men to become an affirmative role model for younger sexual minorities in the coming-out process.

Gay men have been theorized to have the capacity to successfully navigate and understand multiple cultures and identities, which contributes to an adaptable worldview. Such adaptability has roots in the coming out process, which fosters self-acceptance as well as acceptance of others, empathy, openness, tolerance, diversity, and compassion for others, specifically other minority populations.^79,80

With the potential for families to react negatively to their child coming out, gay men often find a creative way to develop their own family. Additionally, some gay men have felt liberated from pressure to conform to restrictive gender roles and norms while considering the opportunity to form their own gendered identity to be a powerful experience. Gay men have expressed their sexual minority status as positive because it cultivated freedom both in terms of gender roles and expression, and the choice of one’s own family.⁸⁰

It is important for clinicians to know that developmental sequences vary greatly among individual gay men and that identity development is not a simple linear progression through stages.⁸¹ Clinicians are cautioned to meet the client where he is in terms of identity development and disclosure to ensure that the client is not being pushed beyond his comfort.⁵⁵ Health care providers are at the front line to encourage the development of positive social supports in addition to providing a compassionate and safe health care environment.⁸² Through medical education and multicultural training in gay issues, practitioners can become well-equipped to provide appropriate and supportive services to gay males from adolescence into adulthood.⁸³

Impact of Age

Age is an important factor in considering how coming out and identity development impact a gay male. Young adult and adolescent gay men tend to have different experiences, but research samples often combine the 2 populations, which makes it difficult to detail differences between the 2 groups. This section includes the use of the terms adolescents and young gay men, depending on the language used by each study.

As much of the literature indicates, gay adolescents are at a critical developmental stage, which can either promote well-being and self-acceptance or induce feelings of shame and guilt.¹¹ Higher levels of internalized heterosexism are found to be present in young gay men, which may help to further contextualize their increased risk in health concerns.⁵⁵ One of the challenges that adolescent gay males are likely to encounter when coming out is being raised by heterocentric families that do not know how to prepare them for or support them through the identity development process.^24,84,85 Additionally, gay adolescent males who came out before age 18 years reported fewer peer contacts than heterosexual adolescent males their age.⁸⁶ Social support is a critical component to buffer gay adolescent males from anxiety and stress, so this lack of support from family and peers is detrimental to the well-being of gay adolescents.^87,88 Young MWSM are more likely to have depressive symptoms, less likely to use mental health services, more likely to use illegal substances such as Ecstasy, and more likely to have unprotected anal sex than older MWSM, and closeted young gay men have a higher risk of contracting HIV and other STDs than young gay men who come out.^86,89,90 Abusing substances was correlated with an increase in risk factors for having a positive HIV status in young MWSM, including greater odds of having multiple sexual partners and of having unprotected sex.⁹¹

These factors may indicate a need to design and implement more comprehensive interventions for adolescent and young MWSM by focusing on mental health, stigma reduction, substance abuse, and safe sex practices, with the school being a natural setting for service delivery.^90,91 Gay adolescents may benefit from parental involvement in HIV prevention programs in order to address communication skills and family dynamics.⁹²

Intersecting Identities With HIV/AIDS Status

For many gay men, sexual orientation composes only one part of their identity of many intersecting identities. HIV/AIDS status, age, ethnicity, and spiritual beliefs represent some examples of a complex web of interrelated identities that affect gay men’s health and well-being. Describing the intersections between all factors is beyond the scope of this article. We focused this section on the intersections listed above.

HIV/AIDS may be the most central and complex health issue facing some gay men, although the prevalence is not as high as stereotypes might suggest (Table 2). The centrality of HIV/AIDS to gay men’s health is highlighted in one study that found that HIV status mediated health differences between gay and heterosexual men and increased the likelihood of physical health complaints and mental health disorders.⁴ In the United States, MWSM account for 48.1% of the estimated 1.1 million individuals who are HIV-positive and gay men are considered the only population in which the rate of new HIV infections is increasing.^86,93

HIV/AIDS is not curable at this time but is managed with medications such as highly active antiretroviral therapy (HAART), which slow virus replication within the body.⁹⁴ Rerks-Ngarm et al⁹⁵ discovered the first vaccine demonstrating some effectiveness in preventing HIV infection, but the supporting data are not definitive. Patients are often reluctant to take antiretroviral treatment and/or are inconsistent with adhering to the regimen despite the survival benefits.⁹⁶ Many strategies have been employed and researched to address those treatment issues; we briefly highlight the intriguing role of spirituality. Research focused on spirituality and gay men with HIV/AIDS is scarce and inconsistent, but initial findings indicate that contracting HIV/AIDS is a life-changing event, moving individuals to feel more religious and spiritual.^97,98 Health practitioners can tap into specific religious and spiritual beliefs that motivate HIV-positive gay men to take antiretroviral medications and adhere to the treatment.⁹⁹ Yet health practitioners are urged to carefully approach conversations about religion and spirituality with gay men as sexual minorities often have had hostile, conflictual, and discriminatory experiences with their religious community.¹⁰⁰

Although medications and vaccines may offer some benefit and may improve in efficacy in the future, we contend that current HIV management must focus on preventative efforts that consider the intersecting identities while targeting risky behavior and improving sexual health decision making among gay men.

Culture and Ethnicity: Latino, African, Asian, and Native American Gay Men

Understanding the culture of African Americans, Native Americans, Asian Americans, and Hispanics and Latinos has been highlighted as central to offering competent interventions to historically stigmatized groups in American society.¹⁰¹ Variations and differences exist within and across these subgroups of gay men; however, research indicates that those 4 groups may uniquely experience double and triple minority status as a gay man, an ethnic minority, and an individual positive for HIV/AIDS.^102,103 The result of the multiplied minority status could be additive stress, which reinforces the call for tailored interventions for ethnic minority gay men.¹⁰⁴

Many Native/Indian American cultures maintain a unique and more accepting set of beliefs related to homosexuality, which is manifested in individuals of “two-spirit,” that is, a male and a female spirit.¹⁰⁵ When working with two-spirited Native American men, health practitioners are encouraged to explore the role of alcohol as a coping mechanism, emphasize the spiritual nature of the man’s identity over the sexual nature, avoid stereotyping all characterizations of gay men as two-spirited, and carefully explore the family’s role relative to the client’s coming out.¹⁰⁶ Latino, African American, and many Asian cultures often maintain negative perceptions of homosexuality, perhaps as a result of outdated beliefs that homosexuality is a disease and traditional gender roles that do not accept homosexuality.^102,107-109 Additionally, spirituality and religious issues may be salient for African American gay men, either as a source of positive support and coping or alienation, oppression, and conflict.^110,111

A clear distinction in the Latino, Asian, and African American cultures exists between sexual behavior and sexual identity; for example, “down low” (Table 1) refers to Latino and African American men who do not identify as gay but have sex with men and do not tell their female partner. Furthermore, “homo thugz” (Table 1) refers to Latino and African American men who are considered tough and involved in gangster behavior but have sex with men; the hypermasculine external appearance has been interpreted as a coping mechanism against antigay prejudice.¹ Among Chinese men who have unprotected sex with men, a large proportion are married or maintain a romantic partnership with a woman.¹¹²

For gay men in ethnic minority groups, there are several factors that may increase the risk of HIV infection, and these factors are sometimes unique to different groups of men. African American and Latino gay men who maintain more allegiance to their cultural background had a more traditional ethnic identity, experienced lower levels of acceptance from their families and communities, have been found to participate in riskier sexual behaviors, and to be at an increased risk for contracting HIV.^113,114 Regarding African American men in particular, Myers et al¹¹⁵ identified psychological distress, older age, and lower socioeconomic status as factors that increase risky sexual behavior. In Mexico and some other Latin American countries, cultural heterosexism and judgmental attitudes toward MWSM are considered to be contributing factors to the risk of HIV infection.¹¹⁶ Increased risk of unprotected anal intercourse was found in younger, more “out” Asian American/Pacific Islander MWSM.¹¹⁷ Finally, experiences of victimization have led to increased HIV risk behaviors among two-spirited American Indian men.¹¹⁸

Cultural norms among ethnic minority groups may create stigma for men to openly disclose their gay sexual orientation making it difficult to develop and implement preventative interventions.¹¹⁶ Gay men of color have been considered “forgotten” in HIV/AIDS prevention research, and scholars have noted that there is a lack of empirically supported prevention interventions for gay men of color.^104,119 For example, research with men of color on the “down low” and condom use produced mixed findings.^120,121 Some recommendations may be considered based on the limited research in this area. When addressing HIV prevention with African American, Asian, and Latino MWSM, it may be necessary to target behavior rather than identity as a way to maintain their outward heterosexual identity but decrease risky sexual practices.^121,122 When approached by men for advice on safe sexual practices, health professionals should ask what genders the man is sexually active with rather than what the man’s sexual orientation is to provide appropriate information. Health practitioners are recommended to provide all men, regardless of sexual orientation, information on abstinence-only approaches to sexual practices, proper condom use, and the increased risk of HIV contraction when sexual behavior is mixed with illicit drug use.

Interventions focusing on improving the self-view of gay men as well as their positive roles and places in their communities may also be useful. Training Latino and African American gay men to be positive role models for safe sex behaviors may be an effective preventative strategy to decrease unsafe sexual practices among at-risk men in those communities.^123,124 Consistent with the minority stress model, supportive family and friend networks helped Asian/Pacific Islander gay men cope with discrimination, which decreased depressive symptoms and HIV risk.¹⁰⁴ Increasing the self-efficacy of Asian gay men to avoid risky sexual practices represents an additional preventative intervention that has been found to decrease HIV risk.¹²⁵

Applying Contextualization to Gay-Affirmative Practices

Throughout the literature review, we connected research findings to interventions for health practitioners to implement with gay men. This section elaborates on those connections and provides additional practical recommendations for health practitioners working with gay men in various settings.

In line with scholarship on multicultural competencies in the health disciplines, we also contend that health practitioners need to be active in examining their own feelings, biases, attitudes, and stereotypes related to sexual orientation, homophobia, heterocentrism, and homonegativity.¹²⁶ Reflective health practitioners understand their worldview and how it may be manifested in their practice with gay men, which can help avoid potential harm through implicit or explicit pathologizing or discrimination of gay clients.⁷⁴ In addition to self-awareness, health practitioners are urged to learn as much as possible about gay men, subgroups of gay men, and associated cultural norms and resources in order to understand their worldview more fully and to more effectively and ethically treat gay male clients.^22,126,127 Indeed, research has indicated that increased self-awareness and knowledge of culturally different clients enhances clinical care and contributes to positive treatment outcomes.¹²⁸

To avoid a pathological view of gay men, health practitioners should recognize that homosexuality per se is not indicative of health pathology and integrate these theoretical models (minority stress, gender socialization, and identity development) and constructs (internalized homonegativity, homophobia, and heterosexism) into their practice with gay men.^127,129,130 For example, health practitioners can ask gay men, “Sometimes sexual minorities internalize societal messages. How do you think societal messages have affected you?” or “Where do you think stress comes from in your life as a sexual minority?” In line with a nonpathological view of gay men, health practitioners are urged to adopt a strength-based approach that is accepting of sexual orientation diversity, focuses on health instead of deficits, and actively works to enhance the strengths of gay men.⁷⁴ Asking a gay client to “tell me about the strengths that you have developed as a sexual minority man” may go a long way toward building a supportive therapeutic relationship.

Health practitioners can incorporate additional principles of gay-affirmative therapy (GAT) into their clinical care of gay men such as (a) creating a safe place to discuss complex and difficult sexual orientation issues; (b) communicating empathy, care, and affirmation to facilitate a positive health practitioner–gay client relationship; (c) willingness to equalize power in the health practitioner–gay client relationship vis-à-vis presenting as more personable and self-disclosing; and (d) viewing the gay client through a holistic perspective by recognizing that the gay clients’ sexuality is only one part of a whole person and sexual health concerns are intertwined with the entire person.^131,132

The risk of a mental disorder is largely reduced among MWSM when discrimination and perceived threat are controlled.¹³³ Awareness of the social contexts that increase health risks for gay men may pose a unique challenge for some health practitioners to become involved in systemic interventions.¹³⁴ As some gay men consider general health materials and settings to be nonaffirmative, health practitioners may start by ensuring that the environment in which they work is comfortable and safe for gay men to feel at ease to openly disclose and discuss their health concerns.¹³⁵ For example, health practitioners can stock the office with relevant educational materials (eg, Gay and Lesbian National Help Center), develop inclusive patient intake and other forms, and pay attention to office décor and waiting room publications.^135,136 Health offices can offer Gay City News and the Advocate as publications to stock in waiting rooms and use Queer Arts Resource to generate ideas about gay-friendly art to display in the health setting (Table 3). Health professionals can play pivotal roles in challenging negative policies against gay men such as restrictions and bans against adopting children, donating blood, and even simply the freedom to disclose their sexual orientation.

Some health practitioners may be inclined to intervene on behalf of gay men at other systemic levels by focusing on professional organization initiatives, public health, advocacy, and awareness education in the community.^137-139 For example, health practitioners can become involved at a professional organization level such as sitting on the GLBT Advisory Committee of the American Medical Association or the American Psychological Association’s task force that developed treatment guidelines for lesbian, gay, and bisexual clients. If such groups and initiatives do not exist in a particular health discipline or organization, an obvious opportunity to make systemic changes on behalf of gay men’s health is to develop such committees, groups, and initiatives in your home professional organization. In addition, for adolescent gay males, health practitioners can collaborate with schools by providing information on gay male development and the impacts of heterosexism and homophobic victimization, which can improve the school environment for sexual minority youth.⁸³ Understanding the language surrounding sexual prejudice increases cultural competence and allows for clinicians to advocate for social change by knowing and debunking the negative societal stereotypes about gay men (Table 2).¹⁴⁰

Conclusions and Directions for Future Research and Practice

As noted, the extant literature lacks a full understanding of gay men’s strengths and positive developmental processes related to their health. An unfortunate consequence of this gap in the literature is that health practitioners may lack the appropriate knowledge and training to implement a strength-based treatment approach with gay men. We suggest that interdisciplinary efforts are made to address this gap in both research and practice. Along those lines, health professionals should always critically examine the research they draw on when working with gay clients to avoid being influenced by the noted research limitations and negative implications of the deficit models (see Table 4 for a summary of main points for health practitioners). The adoption of a gay-affirmative perspective can be more beneficial to the health of gay clients and to the professional development of health practitioners.

Table 4.

Summary of Main Points for Health Practitioners

• Research focused on gay men may be biased because of sampling errors, difficulty defining the population, and a lack of appropriate measurement tools. Health practitioners should critically read research focused on gay men and carefully draw practical implications.

• Being gay is not the cause of health concerns per se. Rather, gay men’s health concerns should be understood in context to account for stress, social support, internalized negative messages about sexual orientation, gender role socialization, and health effects of identity development.

• Health practitioners should identify the strengths of their gay male clients and integrate enhancement of their strengths into treatment planning.

• Gay men have multiple identities in addition to their sexual identity. Health practitioners should explore the whole person, including how culture, ethnicity, spirituality, and age affect the health of gay men.

• Establishing a gay-affirmative practice for gay men is important. Health practitioners should be active in exploring their own potential biases and assumptions about gay men, and to actively seek to learn about gay men’s culture and available supports in the community.

• Systemic change may be necessary to improve the health and well-being of gay men. Suggestions include displaying gay art and magazines in the health setting, advocating for changes to discriminatory laws and policies, and focusing on gay men’s health in professional organizations.

Health practitioners are encouraged to further develop their multicultural competences in relation to gay men. The development of multicultural competences is an ongoing, intentional process that entails increased self-awareness, knowledge of gay men, and appropriate choice of interventions for your gay client. For example, it is important to remember that minority stress is the basis for contextualizing gay men’s health, in that it is stress and discrimination that underlie negative health outcomes, rather than being gay in and of itself. Such an understanding of gay men’s health may lead health practitioners to choose more systemic interventions in order to address negative societal discrimination that contributes to negative health outcomes for gay men. We advocate for practitioners and researchers to continue to collaborate on empirical support for systemic interventions.

A reoccurring theme in the literature is the vast and differing roles of social support in the lives of gay men. Overall, social support is viewed as a positive factor for gay men’s health and a buffer against negative stress. Health practitioners should not assume who or what group is a support for gay men. Rather, we suggest that health practitioners work with gay men to maximize and encourage the use of their identified support networks.

Furthermore, gay men have many components to their identity beyond their sexuality and should be treated as multifaceted individuals. With this in mind, it is crucial to remember that gay men who are members of other minority groups may be especially vulnerable to the negative impact of stress and discrimination, and therefore may experience even more negative health consequences from a double or even triple minority status.

When interpreting literature, including this review, it is important to keep in mind that individual gay men have unique differences and cannot be treated uniformly. Results from studies with a particular group of gay men may not generalize to all gay men. Even within gay culture, there are subcultures and variations that call for health practitioners to interact with each gay client on an individual basis, much as practitioners would do for any client.

References

DeBlaere

Brewster

Sarkees

Moradi

. Conducting research with LGB people of color: methodological challenges and strategies. Couns Psychol. 2010;38:331-362.

Berg

Mimiaga

Safren

. Mental health concerns of HIV-infected gay and bisexual men seeking mental health services: an observational study. AIDS Patient Care STDs. 2004;18:635-643.

Burke

Jordan

Owen

. Cross-national comparison of gay and lesbian domestic violence. J Contemp Criminal Justice. 2002;18:231-257.

Cochran

Mays

. Physical health complaints among lesbians, gay men, and bisexual and homosexually experienced heterosexual individuals: results from the California Quality of Life Survey. J Public Health. 2007;97:2048-2055.

Cochran

Mays

. Lifetime prevalence of suicide symptoms and affective disorders among men reporting same-sex sexual partners: results from NHANES III. Am J Public Health. 2000;90:573-578.

Cochran

Mays

Sullivan

. Prevalence of mental disorders, psychological distress, and mental health services use among lesbian, gay, and bisexual adults in the United States. J Consult Clin Psychol. 2003;71:53-61.

Gabriel

Banse

. Helping behavior as a subtle measure of discrimination against lesbians and gay men: German data and a comparison across countries. J Appl Soc Psychol. 2006;36:690-707.

Greenwood

Paul

Pollack

. Tobacco use and cessation among a household-based sample of US urban men who have sex with men. Am J Public Health. 2005;95:145-151.

King

Nazareth

. The health of people classified as lesbian, gay and bisexual attending family practitioners in London: a controlled study. BMC Public Health. 2006;6:127.

10.

Longfield

Astatke

Smith

McPeak

Ayers

. Men who have sex with men in southeastern Europe: underground and at increased risk for HIV/STIs. Cult Health Sex. 2007;9:437-487.

11.

Meyer

. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129:674-697.

12.

Kitzinger

Wilkinson

. Social advocacy for equal marriage: the politics of “rights” and the psychology of “mental health”. Anal Soc Issues Public Policy. 2004;4:173-194.

13.

Meyer

Wilson

. Sampling lesbian, gay, and bisexual populations. J Couns Psychol. 2009;56:23-31.

14.

Phillips

. Eight articles, eight journals, 8 years: selected disappointments and celebrations from an outstanding major contribution. Couns Psychol. 2010;38:434-441.

15.

Moradi

Mohr

Worthington

Fassinger

. Counseling psychology research on sexual (orientation) minority issues: conceptual and methodological challenges and opportunities. J Couns Psychol. 2009;56:5-22.

16.

Heasley

. Queer masculinities of straight men. Men Masc. 2005;7:310-320.

17.

Kelley

Robertson

. Relational aggression and victimization in gay male relationships: the role of internalized homophobia. Aggress Behav. 2008;34:475-485.

18.

Rosser

BRS

Bockting

Ross

Miner

Coleman

. The relationship between homosexuality, internalized homo-negativity, and mental health in men who have sex with men. J Homosex. 2008;55:185-203.

19.

Szymanski

Kashubeck-West

Meyer

. Internalized heterosexism: a historical and theoretical overview. Couns Psychol. 2008;36:510-524.

20.

Hudson

Ricketts

. A strategy for the measurement of homophobia. J Homosex. 1980;5:357-372.

21.

Herek

. Beyond “homophobia”: thinking about sexual prejudice and stigma in the twenty-first century. J NSRC. 2004;1(2):6-24.

22.

Dermer

Smith

Barto

. Identifying and correctly labeling sexual prejudice, discrimination, and oppression. J Couns. 2010;88:325-331.

23.

Halkitis

Green

Wilton

. Masculinity, body image, and sexual behavior in HIV-seropositive gay men: a two-phase formative behavioral investigation using the Internet. J Men. 2004;3:27-42.

24.

Riley

. GLB adolescents’ “coming out”. J Child Adolesc Psychiatr Nurs. 2010;23:3-10.

25.

Eubanks-Carter

Goldfried

. The impact of client sexual orientation and gender on clinical judgments and diagnosis of borderline personality disorder. J Clin Psychol. 2006;62:751-770.

26.

Röndahl

. Lesbians’ and gay men’s narratives about attitudes in nursing. Scand J Caring Sci. 2009;23:146-152.

27.

Frost

Meyer

. Internalized homophobia and relationship quality among lesbians, gay men, and bisexuals. J Couns Psychol. 2009;56:97-109.

28.

Herek

. Myths about sexual orientation: a lawyer’s guide to social science research. Law Sex Rev Lesb Gay Legal Issues. 1991;1:133.

29.

Barret

Logan

. Counseling Gay Men and Lesbians: A Practice Primer. 1st ed. Pacific Grove, CA: Brooks Cole; 2001.

30.

Dean

Meyer

Robinson

. Lesbian, gay, bisexual, and transgender health: findings and concerns. J Gay Lesb Med Assoc. 2000;4:102-151.

31.

Perrin

. Committee on Psychosocial Aspects of Child and Family Health. Technical report: coparent or second-parent adoption by same-sex parents. Pediatrics. 2002;109:341-344.

32.

Sánchez

Greenberg

Liu

Vilain

. Reported effects of masculine ideals on gay men. Psychol Men Masc. 2009;10:73-87.

33.

Munsey

. Insufficient evidence to support sexual orientation change. Monit Psychol. 2009;40:29.

34.

Ratner

Johnson

Shoveller

. Non-consensual sex experienced by men who have sex with men: prevalence and association with mental health. Patient Educ Couns. 2003;49:67-74.

35.

Meyer

. Minority stress and mental health in gay men. J Health Soc Behav. 1995;36:38-56.

36.

Meyer

. Identity, stress, and resilience in lesbians, gay men, and bisexuals of color. Couns Psychol. 2010;38:442-454.

37.

Hatzenbuehler

Nolen-Hoeksema

Erickson

. Minority stress predictors of HIV risk behavior, substance use, and depressive symptoms: results from a prospective study of bereaved gay men. Health Psychol. 2008;27:455-462.

38.

Abelson

Lambevski

Crawford

Bartos

Kippax

. Factors associated with ‘feeling suicidal’: the role of sexual identity. J Homosex. 2006;51:59-80.

39.

Frisell

Lichtenstein

Rahman

Långström

. Psychiatric morbidity associated with same-sex sexual behaviour: influence of minority stress and familial factors. Psychol Med. 2010;40:315-324.

40.

Hospers

Jansen

. Why homosexuality is a risk factor for eating disorders in males. J Soc Clin Psychol. 2005;24:1188-1201.

41.

Paul

Catania

Pollack

. Suicide attempts among gay and bisexual men: lifetime prevalence and antecedents. Am J Public Health. 2002;92:1338-1345.

42.

Reed

Prado

Matsumoto

Amaro

. Alcohol and drug use and related consequences among gay, lesbian and bisexual college students: role of experiencing violence, feeling safe on campus, and perceived stress. Addict Behav. 2010;35:168-171.

43.

David

Knight

. Stress and coping among gay men: age and ethnic differences. Psychol Aging. 2008;23:62-69.

44.

Chenard

. The impact of stigma on the self-care behaviors of HIV-positive gay men striving for normalcy. J Assoc Nurses AIDS Care. 2007;18(3):23-32.

45.

Antoni

. Stress management effects on psychological, endocrinological, and immune functioning in men with HIV infection: empirical support for a psychoneuroimmunological model. J Biol Stress. 2003;6:173-188.

46.

Hansen

Tarakeshwar

Ghebremichael

Zhang

Kochman

Sikkema

. Longitudinal effects of coping on outcome in a randomized controlled trial of a group intervention for HIV-positive adults with AIDS-related bereavement. Death Stud. 2006;30:609-636.

47.

Weiss

Mulder

Antoni

de Vroome

Garssen

Goodkin

. Effects of a supportive-expressive group intervention on long-term psychosocial adjustment in HIV-infected gay men. Psychother Psychosom. 2003;72:132-140.

48.

McDowell

Serovich

. The effect of perceived and actual social support on the mental health of HIV-positive persons. AIDS Care. 2007;19:1223-1229.

49.

Sikkema

Hansen

Meade

Kochman

Lee

. Improvements in health-related quality of life following a group intervention for coping with AIDS-bereavement among HIV-infected men and women. Qual Life Res. 2005;14:991-1005.

50.

Sikkema

Hansen

Ghebremichael

. A randomized controlled trial of a coping group intervention for adults with HIV who are AIDS bereaved: longitudinal effects on grief. Health Psychol. 2006;25:563-570.

51.

Sikkema

Kalichman

Kelly

Koob

. Group intervention to improve coping with AIDS-related bereavement: model development and an illustrative clinical example. AIDS Care. 1995;7:463-475.

52.

Ross

Simon Rosser

Neumaier

. The relationship of internalized homonegativity to unsafe sexual behavior in HIV seropositive men who have sex with men. AIDS Educ Prev. 2008;20:547-557.

53.

Johnson

Carrico

Chesney

Morin

. Internalized heterosexism among HIV-positive, gay-identified men: implications for HIV prevention and care. J Consult Clin Psychol. 2008;76:829-839.

54.

McDermott

Roen

Scourfield

. Avoiding shame: young LGBT people, homophobia and self-destructive behaviours. Cult Health Sex. 2008;10:815-829.

55.

Brubaker

Garrett

Dew

. Examining the relationship between internalized heterosexism and substance abuse among lesbian, gay, and bisexual individuals: a critical review. J LGBT Issues Couns. 2009;3:62-89.

56.

Rosario

Schrimshaw

Hunter

. A model of sexual risk behaviors among young gay and bisexual men: longitudinal associations of mental health, substance abuse, sexual abuse, and the coming-out process. AIDS Educ Prev. 2006;18:444-460.

57.

Weber

. Using to numb the pain: substance use and abuse among lesbian, gay and bisexual individuals. J Mental Health Couns. 2008;30:31-48.

58.

Levant

. The new psychology of men. Prof Psychol Res Pr. 1996;27:259-265.

59.

O’Neil

Helms

Gable

David

Wrightsman

. Gender-role conflict scale: college men’s fear of femininity. Sex Roles. 1986;14:335-350.

60.

Mahalik

Good

Englar-Carlson

. Masculinity scripts, presenting concerns, and help seeking: implications for practice and training. Prof Psychol Res Pr. 2003;34:123-131.

61.

O’Neil

. Summarizing 25 years of research on men’s gender role conflict using the Gender Role Conflict Scale: new research paradigms and clinical implications. Couns Psychol. 2008;36:358-445.

62.

Garfield

Isacco

Rogers

. A review of men’s health and masculinity. Am J Lifestyle Med. 2008;2:474-487.

63.

Sánchez

Westefeld

Liu

Vilain

. Masculine gender role conflict and negative feelings about being gay. Prof Psychol Res Pr. 2010;41:104-111.

64.

Landolt

Bartholomew

Saffrey

Oram

Perlman

. Gender nonconformity, childhood rejection, and adult attachment: a study of gay men. Arch Sex Behav. 2004;33:117-128.

65.

Halkitis

Moeller

DeRaleau

. Steroid use in gay, bisexual, and non-identified men-who-have-sex-with-men: Relations to masculinity, physical, and mental health. Psychol Men Masc. 2008;9:106-115.

66.

Hamilton

Mahalik

. Minority stress, masculinity, and social norms predicting gay men’s health risk behaviors. J Couns Psychol. 2009;56:132-141.

67.

Kimmel

Mahalik

Body image concerns of gay men: the roles of minority stress and conformity to masculine norms. J Consult Clin Psychol. 2005;73:1185-1190.

68.

Simonsen

Blazina

Watkins

. Gender role conflict and psychological well-being among gay men. J Couns Psychol. 2000;47:85-89.

69.

Wade

Donis

. Masculinity ideology, male identity, and romantic relationship quality among heterosexual and gay men. Sex Roles. 2007;57:775-786.

70.

Cass

. Homosexual identity formation: a theoretical model. J Homosex. 1979;4:219-235.

71.

Cass

. Homosexual identity formation: testing a theoretical model. J Sex Res. 1984;20:143-167.

72.

Coleman

. Developmental stages of the coming out process. In: A Guide to Psychotherapy With Gay and Lesbian Clients. New York, NY: Harrington Park Press; 1985:31-43.

73.

Troiden

. The formation of homosexual identities. J Homosex. 1989;17:43-73.

74.

Hill

. Affirmative practice and alternative sexual orientations: helping clients navigate the coming out process. Clin Soc Work J. 2009;37:346-356.

75.

Friedman

Marshal

Stall

Cheong

Wright

. Gay-related development, early abuse and adult health outcomes among gay males. AIDS Behav. 2008;12:891-902.

76.

Bogaert

Hafer

. Predicting the timing of coming out in gay and bisexual men from world beliefs, physical attractiveness, and childhood gender identity/role. J Appl Soc Psychol. 2009;39:1991-2019.

77.

Cant

. Exploring the implications for health professionals of men coming out as gay in healthcare settings. Health Soc Care Community. 2006;14:9-16.

78.

Floyd

Bakeman

. Coming-out across the life course: implications of age and historical context. Arch Sex Behav. 2006;35:287-296.

79.

Riggle

Whitman

Olson

Rostosky

Strong

. The positive aspects of being a lesbian or gay man. Prof Psychol Res Pr. 2008;39:210-217.

80.

Brown

. Lesbians, gay men, and their families: common clinical issues. J Gay Lesb Psychother. 1989;1:65-77.

81.

Schindhelm

Hospers

. Sex with men before coming-out: relation to sexual activity and sexual risk-taking behavior. Arch Sex Behav. 2004;33:585-591.

82.

Perrin

Cohen

Gold

Ryan

Savin-Williams

Schorzman

. Gay and lesbian issues in pediatric health care. Curr Probl Pediatr Adolesc Health Care. 2004;34:355-398.

83.

Hirsch

Carlson

Crowl

. Promoting positive developmental outcomes in sexual minority youth through best practices in clinic school consultation. J Child Adolesc Psychiatr Nurs. 2010;23:17-22.

84.

Cooper

. On the other side: supporting sexual minority students. Br J Guidance Couns. 2008;36:425-440.

85.

Heatherington

Lavner

. Coming to terms with coming out: review and recommendations for family systems-focused research. J Fam Psychol. 2008;22:329-343.

86.

Centers for Disease Control and Prevention NPIN. HIV/AIDS today. 2010. http://www.cdcnpin.org/scripts/hiv/hiv.asp . Accessed July 21, 2010.

87.

Galliher

Rostosky

Hughes

. School belonging, self-esteem, and depressive symptoms in adolescents: an examination of sex, sexual attraction status, and urbanicity. J Youth Adolesc. 2004;33:235-245.

88.

Hirsch

DuBois

. The relation of peer social support and psychological symptomatology during the transition to junior high school: a two-year longitudinal analysis. Am J Community Psychol. 1992;20:333-347.

89.

Klitzman

Greenberg

Pollack

Dolezal

. MDMA (“ecstasy’) use, and its association with high risk behaviors, mental health, and other factors among gay/bisexual men in New York City. Drug Alcohol Depend. 2002;66:115-125.

90.

Salomon

Mimiaga

Husnik

. Depressive symptoms, utilization of mental health care, substance use and sexual risk among young men who have sex with men in EXPLORE: implications for age-specific interventions. AIDS Behav. 2009;13:811-821.

91.

Mustanski

Garofalo

Herrick

Donenberg

. Psychosocial health problems increase risk for HIV among urban young men who have sex with men: preliminary evidence of a syndemic in need of attention. Ann Behav Med. 2007;34:37-45.

92.

LaSala

. Parental influence, gay youths, and safer sex. Health Soc Work. 2007;32:49-55.

93.

Rangel

Gavin

Reed

Fowler

Lee

. Epidemiology of HIV and AIDS among adolescents and young adults in the United States. J Adolesc Health. 2006;39:156-163.

94.

AIDS.gov. Welcome to AIDS.gov. 2010. http://aids.gov/ . Accessed July 21, 2010.

95.

Rerks-Ngarm

Pitisuttithum

Nitayaphan

; MOPH-TAVEG Investigators. Vaccination with ALVAC and ADISVAX to prevent HIV-1 infection in Thailand. N Engl J Med. 2009;36:2209-2220.

96.

Bangsberg

Moss

Deeks

. Paradoxes of adherence and drug resistance to HIV antiretroviral therapy. J Antimicrob Chemother. 2004;53:696-699.

97.

Tsevat

Cotton

Puchalski

. Spirituality and religion in patients with HIV/AIDS. J Gen Intern Med. 2006;21(Suppl 5):S5-S13.

98.

Kremer

Ironson

Kaplan

. The fork in the road: HIV as a potential positive turning point and the role of spirituality. AIDS Care. 2009;21:368-377.

99.

Kremer

Ironson

Porr

. Spiritual and mind-body beliefs as barriers and motivators to HIV-treatment decision-making and medication adherence? A qualitative study. AIDS Patient Care STDs. 2009;23:127-134.

100.

Rostosky

Riggle

Brodnicki

Olson

. An exploration of lived religion in same-sex couples from Judeo-Christian traditions. Fam Process. 2008;47:389-403.

101.

Sue

Arredondo

McDavis

. Multicultural counseling competencies and standards: a call to the profession. J Couns Dev. 1992;70:477-486.

102.

Guarnero

Flaskerud

. Latino gay men and depression. Issues Ment Health Nurs. 2008;29:667-670.

103.

Valverde

Purcell

Waldrop-Valverde

. Correlates of depression among HIV-positive women and men who inject drugs. J Acquir Immune Defic Syndr. 2007;46(Suppl 2):S96-S100.

104.

Yoshikawa

Alan-David Wilson

Chae

Cheng

. Do family and friendship networks protect against the influence of discrimination on mental health and HIV risk among Asian and Pacific Islander gay men? AIDS Educ Prev. 2004;16:84-100.

105.

Simoni

Walters

Balsam

Meyers

. Victimization, substance use, and HIV risk behaviors among gay/bisexual/two-spirit and heterosexual American Indian men in New York City. Am J Public Health. 2006;96:2240-2245.

106.

Garrett

Barret

. Two spirit: counseling Native American gay, lesbian, and bisexual people. J Multicult Couns Dev. 2003;31:131-143.

107.

Graham

Braithwaite

Spikes

Stephens

Edu

. Exploring the mental health of black men who have sex with men. Community Ment Health J. 2009;45:272-284.

108.

Han

. A qualitative exploration of the relationship between racism and unsafe sex among Asian Pacific Islander gay men. Arch Sex Behav. 2008;37:827-837.

109.

Kim

Hahn

. Homosexuality in ancient and modern Korea. Cult Health Sex. 2006;8:59-65.

110.

Miller

. An appointment with God: AIDS, place, and spirituality. J Sex Res. 2005;42:35-45.

111.

Miller

. Legacy denied: African American gay men, AIDS, and the Black church. Soc Work. 2007;52:51-61.

112.

Wei

Guadamuz

Stall

Wong

. STD prevalence, risky sexual behaviors, and sex with women in a national sample of Chinese men who have sex with men. Am J Public Health. 2009;99:1978-1981.

113.

O’Donnell

Agronick

San Doval

Duran

Myint-U

Stueve

. Ethnic and gay community attachments and sexual risk behaviors among urban Latino young men who have sex with men. AIDS Educ Prev. 2002;14:457-471.

114.

Warren

Fernández

Harper

Hidalgo

Jamil

Torres

. Predictors of unprotected sex among young sexually active African American, Hispanic, and White MSM: the importance of ethnicity and culture. AIDS Behav. 2008;12:459-468.

115.

Myers

Javanbakht

Martinez

Obediah

. Psychosocial predictors of risky sexual behaviors in African American men: implications for prevention. AIDS Educ Prev. 2003;15(1 Suppl A):66-79.

116.

Kendall

Herrera

Caballero

Campero

. HIV prevention and men who have sex with women and men in Mexico: findings from a qualitative study with HIV-positive men. Cult Health Sex. 2007;9:459-472.

117.

Choi

Han

Hudes

Kegeles

. Unprotected sex and associated risk factors among young Asian and Pacific Islander men who have sex with men. AIDS Educ Prev. 2002;14:472-481.

118.

Simoni

Walters

Balsam

Meyers

. Victimization, substance use, and HIV risk behaviors among gay/bisexual/two-spirit and heterosexual American Indian men in New York City. Am J Public Health. 2006;96:2240-2245.

119.

Choi

McFarland

Kihara

. HIV prevention for Asian and Pacific Islander men who have sex with men: identifying needs for the Asia Pacific region. AIDS Educ Prev. 2004;16:v-vii.

120.

Bond

Wheeler

Millett

LaPollo

Carson

Liau

. Black men who have sex with men and the association of down-low identity with HIV risk behavior. Am J Public Health. 2009;99(Suppl 1):S92-S95.

121.

Martinez

Hosek

. An exploration of the down-low identity: nongay-identified young African-American men who have sex with men. J Natl Med Assoc. 2005;97:1103-1112.

122.

Icard

. Reaching African-American men on the “down low”: sampling hidden populations: implications for HIV prevention. J Homosex. 2008;55:437-449.

123.

Peterson

Rothenberg

Kraft

Beeker

Trotter

. Perceived condom norms and HIV risks among social and sexual networks of young African American men who have sex with men. Health Educ Res. 2009;24:119-127.

124.

Ramirez-Valles

. The quest for effective HIV-prevention interventions for Latino gay men. Am J Prev Med. 2007;32(4 Suppl):S34-S35.

125.

Mao

Van

Ven

McCormick

. Individualism-collectivism, self-efficacy, and other factors associated with risk taking among gay Asian and Caucasian men. AIDS Educ Prev. 2004;16:55-67.

126.

Sue

Arredondo

McDavis

. Multicultural counseling competencies and standards: a call to the profession. J Couns Dev. 1992;70:477-486.

127.

Pixton

. Experiencing gay affirmative therapy: an exploration of clients’ views of what is helpful. Couns Psychother Res. 2003;3:211-215.

128.

Worthington

Soth-McNett

Moreno

. Multicultural counseling competencies research: a 20-year content analysis. J Couns Psychol. 2007;54:351-361.

129.

American Psychiatric Association. Therapies focused on attempts to change sexual orientation. http://www.psych.org/Departments/EDU/Library/APAOfficialDocumentsandRelated/PositionStatements/200001.aspx . Accessed August 5, 2010.

130.

American Psychological Association. Resolution on sexual orientation and marriage: research summary. http://www.apa.org/about/governance/council/policy/gay-marriage.pdf . Accessed August 5, 2010.

131.

Pixton

. Experiencing gay affirmative therapy: an exploration of clients’ views of what is helpful. Couns Psychother Res. 2003;3:211-215.

132.

Langdridge

. Gay affirmative therapy. J Gay Lesb Psychother. 2007;11:27-43.

133.

Frisell

Lichtenstein

Rahman

Langstrom

. Psychiatric morbidity associated with same-sex sexual behaviour: influence of minority stress and familial factors. J Res Psychiatr Allied Sci. 2010;40:315-324.

134.

Aguinaldo

. The social construction of gay oppression as a determinant of gay men’s health: ‘homophobia is killing us’. Crit Public Health. 2008;18:87-96.

135.

Mayer

Bradford

Makadon

Stall

Goldhammer

Landers

. Sexual and gender minority health: what we know and what needs to be done. Am J Public Health. 2008;98:989-995.

136.

American Medical Association. Optimizing care for gay men and lesbians. Report 9 of the Council on Science and Public Health (A-08). http://www.ama-assn.org/ama1/pub/upload/mm/443/csaph9a08-summary.pdf. Accessed August 5, 2010.

137.

O’Hanlan

. Health policy considerations for our sexual minority patients. Obstet Gynecol. 2006;108:212.

138.

Davison

. Conceptual and ethical issues in therapy for the psychological problems of gay men, lesbians, and bisexuals. J Clin Psychol. 2001;57:695-704.

139.

O’Hare

Williams

Ezoviski

. Fear of AIDS and homophobia: implications for direct practice and advocacy. Soc Work. 1996;41:51-58.

140.

Constantine

Hage

Kindaichi

Bryant

. Social justice and multicultural issues: implications for the practice and training of counselors and counseling psychologists. J Couns. 2007;85:24-29.

A Review of Gay Men’s Health

Abstract

Keywords

Research Critique

Contextualizing Gay Men’s Health

Minority Stress Model

Internalized Homonegativity, Homophobia, and Heterosexism

Gender Socialization Theory

Identity Development Theories

Impact of Age

Intersecting Identities With HIV/AIDS Status

Culture and Ethnicity: Latino, African, Asian, and Native American Gay Men

Applying Contextualization to Gay-Affirmative Practices

Conclusions and Directions for Future Research and Practice

References