HIV/STD Prevention and Young Men Who Have Sex with Men

hiv aids in background with pills sitting on top of the wordsHIV/STD prevention that targets gay men seldom meets the needs of young men
who have sex with men (YMSM*). Some YMSM do not relate to gay-specific messages
because they do not self-identify as gay. Many fear the social stigma and
violence—sometimes intensified by culture and religion—directed at those
identified as homosexual. Others identify themselves as
bisexual and do not internalize gay-specific messages. Some young men, unsure of
their sexual orientation, view same-sex sexual behavior as experimental and
temporary. Since they seldom identify as gay, these YMSM may not recognize
unsafe behaviors that put them at risk for HIV/STD.

On the other hand, HIV/STD prevention programs that target adolescents often
exclude YMSM. Most school-based prevention efforts attempt to convince all
adolescents that they are susceptible to HIV/STD, and, in so doing, they often
inadvertently exclude messages specifically targeting YMSM. School-based
curricula which contain messages like “AIDS is not a gay disease” may lead YMSM
who identify as gay to believe they are not at risk. Some school-based programs
deliberately ignore the existence of youth who identify as gay as well as YMSM
who do not self-identify as gay. These short-comings in prevention messages
underscore the need for programs that focus on YMSM, regardless
of self-identification, and that incorporate messages which recognize and
reflect the diversity among YMSM.

Many YMSM Engage in Behaviors that Put Them at Risk of HIV/STD

In several studies, between 27 and 48 percent of YMSM had engaged in
unprotected anal sex within six months of the surveys. In one study, 63 percent
of YMSM were at “extreme risk” for prior exposure to HIV through unprotected
anal sex and/or use of injection drugs. Like other teens, many YMSM experience a
phase of sexual experimentation marked by multiple sexual partners. HIV/STD risk
increases with the number of sexual partners, and, in one study, 43.6 percent of
surveyed YMSM reported at least 10 sexual partners. Some YMSM explore
their feelings or attempt to conceal or change their sexual orientation by
having sex with young women as well. One study found that YMSM who have sex with
women are up to twice as likely to have unprotected sex with their male partners
as those who have sex only with men.

Assertive communication with partners about safer sex is often difficult for
teens who lack role models or adequate sexuality education yet are exploring
same-sex intimate relationships. Because adolescents are 10 to 17
times more likely to use condoms if they are comfortable communicating about
AIDS with their partners, YMSM who lack support and skills are at risk for
unsafe sex. One study found that YMSM discussed condom use with fewer
than one-third of their last three partners and HIV serostatus with even
fewer.  Not being well acquainted with partners may also preclude
easy communication about safer sex. Indeed, one study found that, next to sexual
assault, meeting a sexual partner at an anonymous location was the strongest
predictor of unprotected intercourse among YMSM. Conversely, some YMSM believe
steady relationships will protect them from HIV and use condoms less within
those relationships.

Lacking social support in a homophobic society, many YMSM turn to alcohol and
drugs. Compared to heterosexual youth, gay, lesbian, bisexual, and transgender
(GLBT) youth are twice as likely to use alcohol, three times more likely to use
marijuana and to show signs of serious substance abuse, and eight times more
likely to use cocaine. Drug or alcohol use may make negotiating safer sex more
difficult and increase the likelihood of unprotected sex.”

Sexual risk behaviors are more likely to result in HIV transmission in
populations where high rates of infection are already present. A
study in six urban counties found that five to nine percent of surveyed YMSM
were infected with HIV. Nationwide, same-sex sexual behavior is the
leading HIV exposure category for males ages 13 to 19, accounting for 46 percent
of cumulative HIV cases and 34 percent of cumulative AIDS cases. Among men ages 20 to 24, the figures rise to 55 and 63 percent,
respectively.  In one survey among YMSM tested for HIV, 70 percent of
those found HIV-positive had been unaware of their infection.3

Societal Homophobia Puts YMSM at Higher Risk

Up to 80 percent of GLBT youth report feeling severely isolated
socially and emotionally.
Physical and psychological changes put
many adolescents at risk of HIV/STD infection, but youth questioning their
sexual orientation face greater risk because they “uniquely…grow up both
different and alone.’ GLBT youth usually lack peer support and often face verbal
and physical attacks because of their sexual orientation. One in four YMSM is
forced to leave home because of his sexual orientation; up to half of these
youth resort to prostitution to support themselves—greatly increasing their risk
for unprotected sex. YMSM often lack positive adult role models
because fear keeps many gay adults from disclosing their sexual orientation.

Like other young people, YMSM need intimacy; but they must usually achieve it
without social support or approval. Hiding their identities and desires, many
YMSM have a desperate need for affection that overrides other concerns,
including health. Societal hostility toward same-sex intimate relationships may
make sex for YMSM the “only way to…escape the desperate social and emotional

YMSM may internalize pervasive homophobia, and some may believe the myths
that gay men cannot maintain relationships and are destined to die of AIDS.
Internalized homophobia often causes low self-esteem and depression. In fact,
YMSM are seven times more likely to report attempting suicide than are
heterosexual youth. While heterosexual youth frequently envision their futures
to age 50, many gay teens do not imagine life past 33. Many YMSM believe there
is nothing good about being an older gay man. As one YMSM stated, “many gay
youth [believe] HIV…means I’m not going to be around 10 to 15 years from now,
and I don’t want to be around [then].’

Many older gay men became acquainted with AIDS through the deaths of friends,
and their sense of personal loss created an unprecedented change in risk
behaviors within the adult gay male community. Although YMSM who practice
consistent safer anal sex perceive themselves to be susceptible to HIV, few YMSM
today have witnessed the deadly consequences of unsafe behavior, and many do not
feel particularly susceptible to HIV. Although peer support for safer sex is
among the strongest predictors of condom use, YMSM often lack peer support. Some
YMSM may associate HIV with older gay men and assume young, apparently healthy
partners are HIV-negative. Lacking older HIV-negative role models, some YMSM
even view HIV infection as a rite of passage into the adult gay
community. Perceived invulnerability is characteristic of youth but is
especially problematic for YMSM, considering their risk for HIV and their lower
rates of safer sex as compared to older gay males.

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