Speaking at the HIV Endgame conference in November, 2016, Ron Stall, of the University of Pittsburgh, argues for more research and interventions focused on the resilience of gay and bisexual men.
The HIV Endgame logo appears on screen. Titles read: Ron Stall, How can we build on our resiliencies? Ron Stall stands alone on the Endgame stage. On-screen graphics identify him as a Professor at the University of Pittsburgh. Unless otherwise noted, his slides present the same information as his speech in bulleted form.
Ron Stall: And, if you stood back, if you were from another planet, and stood back and looked at our community, you would probably be astonished that the overarching trope about gay men is about our vulnerabilities rather than our strengths. It takes a lot of nerve to come out. We’re really good at homophobia management. You don’t see me at a Trump rally. We — right? Think about the ways that we all manage homophobia. We have gone to the mat to create safe religious homes where we can be who we are in institutions that, historically, have been horribly homophobic, and we’ve turned that around and made a safe religious home for ourselves. We’re good at finding and creating families, even though we have major societal institutions, historically, that kept us — and were very exercised about keeping us from doing just that.
We’re great at community building. There has been a community of gay men in lower Manhattan since the days when Walt Whitman went off to go teach soldiers during the Civil War. And that community has reproduced itself for generation after generation, even though we — by and large — were not having kids, which the way that most cultures reproduce themselves. So, we’ve been able to reproduce our culture outside of procreation. That’s very unusual in human history.
We’ve done activism for citizenship rights that’s really impressive, even during the height of the AIDS epidemic, when there were lots of kind of nasty people doing their best to kick us when we were down, and we still won. This is about heroism. This is about resilience. This is about strength.
This is — and that we’re not talking about this stuff, in terms of gay men’s health, strikes me is really surprising. And even when you look at the medical literature, if you read between the lines, you can find resiliencies, once you start looking for them, everywhere you look. Like I said, there’s tons of substance use, but hardly any of us, at least at any one point in a time, compared to all the drugs we’re using, actually reporting substance abuse problems that suggests addiction. We may have, despite our still high rates of smoking, the highest rates of smoking cessation of any group I can find in the medical literature. We’ve really done a good job of smoking cessation, it’s an untold story.
Of course the vast majority of gay men remain HIV-negative throughout the lifespan, even though it’s very easy to get infected in our community. And positive men remain productive and thriving even while dealing with a dangerous infection, and there’s a big — there’s a big story about the resolution of substance abuse careers, and on and on and on. I could probably mention other things.
Stall presents a slide showing a line graph with four coloured lines. The title reads, “Trajectories of stimulant drug use from visit 40-48 (Oct 2003-March 2008) in MACS.” The total number of participants is 2457. 68.8% of men, represented by a red line on the graph, had no use. 7.2% had some use. 5.8%, represented by a blue line, had increasing use. 8.5%, represented by a green line, had decreasing use. 10.5%, represented by a purple line, had consistently high use.
So, even on the health side specifically, there’s a lot of resiliencies there that people are not talking about. This is a slide from the multi-city AIDS cohort study — the MACS, where I’ve done a lot of work — and I thought about this a lot. So, these are trajectories of stimulant drug use, mostly meth, during the height of the meth epidemic among gay men. These are about three years of data, and these are trajectories. So, there’s a group of guys right here, the purple line, who are the ones that you get on the front page of the New York Times. So, these are the guys who are using speed at every — it’s and amphetamine at every wave. There’s another group of guys who are starting to join them, so they’re doing what the DEA and our mothers tell us is going to happen if we use these very dangerous drugs, right? But there’s another group, here, who is quitting. And they’re quitting on their own. And the way I know that is there are no effective treatments for methamphetamine addiction.
So, somehow, they’re doing that and that whole — of all the thousands of papers that have been written about gay men and substance abuse, no ones that I know of has ever talked really carefully about resolution of substance abuse careers, and I’ll talk more about that in a minute. And then there’s a group of guys who’s, during the height of the epidemic, never touched this stuff. Notice that, of the increasing and the consistent use, that that accounted for about 16% of the sample. So, the entire focus on meth and gay men and chemsex and all that stuff is talking about 16% of the gay male world, and we’re throwing away the drug using or non-drug using experiences of 85% of the cohort. Think about that for a minute.
What’s going on with the guys who are declining use even during the height of an epidemic? And how are they pulling that off? What’s going on with the guys who never touch this stuff and are exhibiting resiliency against a substance use epidemic during the height of it, and how do they do that? We don’t know the answers to those things.
Stall presents a smaller image of the same graph alongside his bullet points.
So, a central question is, should the evidence be based on the guys in the purple line at the top of the graph or the green line — the guys who are doing what we want them to do? Why aren’t we learning from the guys in the green line? And how they’re reducing — and how would our intervention designs be different if we took the guys in the green lines, or the guys who never ever never, you know, did the risk to begin with — learn from those guys about how to support broader health in the gay community?
Saying it in other ways, which insights are most valuable? Is it about trajectories of increasing risk, the guys are getting into trouble? Or declining risk? And my real point here is that why aren’t we using both insights to do the intervention designs? A really important thing to think about is, thinking about the guys in the purple lines or the guys in the blue lines, that the trajectories of risk production are probably really, really different than the trajectories of risk reduction. And so, if we focused on the risk reduction piece of this, we would probably come up with novel intervention activities that we are not now doing, that might speak more to the broader reach of the gay community — remember the 85% that we’re throwing away?
And one of the things that happens, and you hear a lot with guys who go to our interventions, is that — the idea is that, you know, why you hammering on these things? This isn’t true for me. And so, by going after the things that are false assumptions with the deficit-based interventions, and the false assumptions about where gay men are at, it introduces credibility and men are voting with their feet. That’s why so many of our interventions are in rooms with lots of empty seats.
Another piece of this, also from the point of view of intervention efficacy, deficit-based approaches tell me what not to do, but they don’t tell me what to do, when I’m in a risky environment. They’re negative skill sets, they’re not positive skill sets. And that risk reduction involves exercising strengths and this focus on telling me not what to do as opposed to building up the strengths that I have to reduce risk, doesn’t help me over the long haul. This probably explains why so many of our interventions have very short time periods of efficacy. You know, most the studies go for six months to a year, because they’re focused on the deficits but if it’s about building up resiliencies, building up the mechanisms that support risk reduction, these are skill sets that can be exercised even after you’ve forgotten all about the intervention, and even when you’re in a risky environment.
Stall presents a slide defining resilience as “the process of overcoming the negative effects of risk exposure, coping successfully with traumatic experiences, and avoiding the negative trajectories associated with risk.” The definition is attributed to Fergus (2005).
So this got us into resilience. Well, in public health we’re far better at defining illness than health. In fact, we’re really lousy at it. And so, the resilience definitions are kind of fake. This is probably one of the better ones, but what we decided to do was, in collaboration with Fenway Health, was to throw a big meeting like this. We had about 200 people and we sat for two days talking about what are gay men’s resiliencies? And so, it’s not resilience, its resiliencies — the multiple ways we access strengths.
So, we’re not saying people are strong because people are strong. We’re saying people are strong because they can create a family. People are strong because they can connect with community in good ways. People are strong because they can deal with internalized homophobia better, and on and on. So we ended up with 200-300 ways the gay men are strong. It was a lot of fun. And we had a qualitative person go back and boil everything down to a whole set of mechanisms that we think should be incorporated into intervention design.
Stall presents a slide listing MSM resiliencies. At the individual level, they include internal homophobia management & shame, self monitoring & goal setting, and adaptability and coping. At the dyadic level, they include relationship building and dyadic support. At the family level, they include biological family resolution and social bonding. A second slide shows the community level, including connection to community, institutional support, community building, commitment to community building, homophobia management, and external monitoring.
So, they’re clumped at the individual level, the dyadic, the family, and the community. So, these are some examples of the ways that we are strong. And that, I think, explain how we’ve survived the AIDS epidemic as a community.
Stall presents a three-column table with the headings factor, risk, and protective. In row one, the factor self-esteem maps onto low self-esteem for risk and high self-esteem for protective. In row two, the factor friends maps onto non-supportive friends (bad influences) for risk and supportive friends for protective. In row three, the factor community involvement maps onto high community involvement for risk and high community involvement for protective.
The other thing about the flipping the variables thing is that a lot of people, when they’re doing this, they think, “Well, shoot. I’ll just declare that somebody who’s not depressed is resilient and and just flip the analysis that way.” That’s a parlor game that won’t get you very far. We believe that all of the variables having to do with resiliency, the things that you would define as being weaknesses, have very different content than the things you would have as strengths.
So, like, community involvement. If your community involvement is involved in a soccer team or a sports team and your connection with the gay community is at four o’clock on a Saturday afternoon, the content of your high level of community involvement is going to be very, very different than if your connection with the gay community is at in the morning. And so, how — the content of this and the qualitative meaning of these things have not been very well explored. But, to just flip the variables is not going to get us very far. We have to understand the differential meaning of these things as variables.
And so, my point here being, to the gay men in the group or any of us who have risk-reduction issues, which intervention would you rather go to? An intervention where they tell us we need to improve our condom skills and show us how to put a condom on a banana, or sitting around with a group of gay men talking about what our internalized homophobia issues are and working with other gay men to deal with that? Mine would be getting in drag and going and arguing with the guy at the grocery store about the high price of lettuce these days. So, I can’t do that. But if I do that I will be zero on internalized homophobia, I guarantee you.
Stall displays the quote, “There is nothing more practical than a good theory” attributed to K Lewin (1952) from the publication Field theory in social science: Selected theoretical papers by Kurt Lewin.
So, on a useful theory. I just, you know, we need to get better — interventions are intensely theoretical. If I tell you AIDS is going to get you if you don’t look out, and hand you a condom, my theory is “Fear and condom availability reduce risk.” Everything that we do is an intense theoretical test. So, the smartest thing we can do around raising levels of health in our communities is come up with a better theory.
So what should it include? We need to do better than flipping the deficit-based variables. We need to understand the content of strength and how to measure the stuff and incorporate it in interventions. Obviously, we need to capture more variance. We need to find variables that are conducive to intervention design. So, if we do think that building families and building relationships is good for our health, then we need to figure out how to support that kind of stuff in our community for men who want to achieve that. If we think that reducing internalized homophobia is good for our health, we can come up with really cool interventions, I bet, that would do just that and probably have bigger effect sizes than the condoms on the banana interventions.
We need to include variables beyond the individual level. Saying you’re strong because you’re strong isn’t helpful. Saying you’re strong because you can connect to community in helpful ways, that’s helpful, and we can show men how to do that.
So, final thing is, you know, our communities have exhibited extraordinary resilience during a horrifying epidemic. We’ve been through a war. We have done really well. And in it’s a remarkable historical story. And that the overarching trope of what’s going on with our community should not be vulnerabilities, but should be about resiliency and heroism, in my opinion. I would argue strengths-based approaches are understudied, and that you need to do — and that, if we’re going to take that seriously, we’ve got to do multi-level interventions. And that it’s time to address weaknesses and tap strengths in raising levels of health in our community. And that’s it.
Sounds of applause followed by piano chords as the OHTN media logo appears.
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