Future Life Goals of HIV-Positive Gay and Bisexual Male Emerging Adults

Abstract

This qualitative study explores the future life goals reported by a sample of HIV-positive gay/bisexual male emerging adults. Semi-structured interviews were conducted with 54 participants ages 17-24 at four geographically and demographically diverse adolescent HIV medicine programs to explore the content of participants’ goals, perceived obstacles and sources of resilience. We provide descriptive data on goals articulated by participants to begin to understand (1) how gay male emerging adults may differ from the heteronormative samples that have characterized most research on emerging adulthood to date, (2) how living with HIV/AIDS may impact the future life goals of this population, and (3) implications for HIV/AIDS service providers as HIV-positive emerging adults are transitioned from adolescent to adult care.

Keywords

emerging adulthood lesbians/gays/bisexuals/transgenders work identity issues HIV/AIDS

Introduction

The setting of life goals has been conceptualized as a key developmental characteristic of emerging adulthood (Kagitcibasi, 1996; Sneed et al., 2006), yet the vast majority of research in this area has been conducted through heteronormative lenses and with samples of heterosexual participants. What is less clear is how the future life goals of gay and bisexual male emerging adults may differ from their heterosexual counterparts. Further, the impact of HIV/AIDS on future life goals of HIV-positive young men has not been studied and merits consideration given the disproportionate impact of the HIV/AIDS epidemic on young gay and bisexual men (Centers for Disease Control and Prevention[CDC], 2008, 2009).

The concept of emerging adulthood has gained currency among developmental psychologists and social scientists as defining the postadolescent/preadulthood period of a young person’s life that is typified by identity exploration, instability in terms of residence and work, and the possibility of change. It is proposed that generally, from the age of 18 to mid-20s, emerging adults move out of parents’ homes and engage in diverse educational and occupational paths before entering into “enduring commitments,” such as long-term job and career, marriage, and parenthood (Arnett, 2004). What Erikson termed a psychosocial moratorium at the end of adolescence, in which upper- and middle-class American adolescents have the opportunity to experiment with a range of roles and responsibilities before assuming adult identities, has gradually expanded to include a distinct developmental stage that is typified by identity resolution before a commitment to intimacy in adult relationships (Arnett, 2004; Erikson, 1968).

For young gay and bisexual men, the identity-formation process can be complicated by experiences of heterosexism, homophobia, and prejudice (Harper, 2007; Harper & Schneider, 2003; Ryan & Futterman, 1998). Thus, gay and bisexual youth must juggle the developmental difficulties typically faced by a young person exploring various aspects of her or his identity along with the stigma associated with living in a heterosexist and homophobic society. The unique psychosocial/developmental needs of these youth and emerging adults should be understood within multiple social systems, especially the family, school, and peer networks (Bronfenbrenner, 1979; D’Augelli, Grossman, & Starks, 2005). Although these social institutions often provide support and guidance for the development of a healthy personal identity in heterosexual youth, gay and bisexual youth often find that their family, peers, and teachers do not accept, support, and/or nurture them as they develop their sexual orientation identity and may actually perpetrate harmful verbal and physical acts of violence against them (D’Augelli & Hershberger, 1993; Pilkington & D’Augelli, 1995; Ryan, Huebner, Diaz, & Sanchez, 2009; Savin-Williams, 1995). For some young gay men, the instability that characterizes emerging adulthood may occur earlier, as gay and lesbian adolescents have been documented to be at much greater risk for being runaways than straight adolescents (Kruks, 1991; Tenner, Trevithick, Wagner, & Burch, 1998).

Sexual identity development among young gay men may also be viewed within shifting historical contexts. During the 1970s and 1980s, gay and lesbian people became increasingly more visible in public life in the United States, yet gay and lesbian adolescents were largely invisible or stigmatized as “high-risk” (Cohler, 2009; Savin-Williams, 2005). Gay/lesbian identity development models developed during this time (Cass, 1979; Coleman, 1982; Troiden, 1989) assumed a stage-based process that drew on the experiences of gay men and lesbians who “came out” as adults. Today, gay and lesbian adolescents are increasingly visible in their schools and communities, which appears to carry both risks as well as opportunities for normative development that their lesbian and gay forebears did not experience (D’Augelli, 2006; Savin-Williams, 2005). Developmental milestones such as sexual activity and same-sex relationships among gay and lesbian adolescents appear to be occurring now at younger ages than in previous generations (D’Augelli, 2006; Savin-Williams, 2005). Many lesbian and gay youth now have the opportunity of “living out” as adolescents and experiencing developmental milestones “on time,” rather than “off time” as did earlier generations of lesbian and gay adults who were not able to come out and live openly during adolescence. In contrast to previous generations of gay and lesbian persons who came out later in life, today’s lesbian and gay youth are developing their sexual identities while their adolescent cognitive, emotional, and social development is still occurring (D’Augelli, 2006). The development of their sexual identities would appear to entail more diverse and varied processes than the “coming-out” stages that were affixed to previous generations of gay or lesbian individuals.

Goal setting has been described as a key developmental characteristic of emerging adulthood, through which young persons exhibit instrumentality or agency in taking responsibility for one’s own actions, specifically in areas of finance and romance (Kagitcibasi, 1996; Sneed et al., 2006). Studies among college students have explained goals as life tasks, which may vary by scope and source, and serve to organize in salient ways “daily life activity” (Cantor & Kihlstrom, 1987; Cantor & Langston, 1989). Other theorists have framed goals in terms of possible selves, emphasizing identity or self-concept as the referent of motivational behavior and instrumental action (Markus & Nurius, 1986). While a range of possibilities may open up during emerging adulthood in terms of education, career/vocation, and romance, instability may also accompany such explorations (Arnett, 2004). The uncertainty that may characterize these areas of emerging adults’ lives during this period may be associated with psychological risks. Emerging adults often experience negative affect when working toward goals that challenge their self-concepts (Cantor & Langston, 1989). For example, research on emerging adulthood has revealed that young people between the ages 18-25 have the highest reported cases of depression and substance use in the United States (Park, Mulye, Adams, Brindis, Irwin, 2006).

In addition to theories regarding the role of goal setting during emerging adulthood, the pursuit of goals has been theorized to have importance in maintaining and enhancing resiliency while experiencing adversity (Bandura, 2000; Maes & Karoly, 2005). Research investigating the adjustment of children and adolescents living with a chronic illness has utilized a risk and resistance framework applied to stress and coping theory (Wallander & Varni, 1992). Adjustment to living with a chronic disease or health condition has been shown to impact goal setting among emerging adults who survived cancer during childhood or adolescence and among emerging adults with cystic fibrosis (Schwartz & Drotar, 2009). Health-related hindrance (i.e., the impact of health on goals) was found have a stronger relationship to psychological outcomes than health-related quality of life (HRQOL), emphasizing the impact that health has on goal pursuit and well-being among this population (Schwartz & Drotar, 2009). Chronic illness, bodily changes, and fear of future sickness can affect the process of forming identity goals (Charmaz, 1995).

Research into identity transformation among adults living with HIV has noted milestones of “biographical disruption” including testing, diagnosis, and disclosure of one’s status to others (Tewksbury & McGaughey, 1998). Studies examining the incorporation of an HIV-positive identity into persons’ array of identities have revealed a shift in the salience with which HIV-positive persons view themselves since the introduction of effective antiretroviral therapy (ART) in the late 1990s. Prior to the introduction of ART, HIV was claimed to be a central identity of many adults living with HIV, as other identities such as a work identity diminished over time due to worsening health (Baumgartner, 2007). After ART became widespread and its life-extending effects apparent, HIV came to be described as one of one of many identities that an individual may incorporate into the self, along with other identities, such as identities as worker, caretaker, advocate, or person in recovery (Baumgartner & David, 2009).

The impact of HIV/AIDS on the future goals of HIV-positive persons has not been studied extensively. Previous research has documented several areas that HIV-positive gay men may need assistance in achieving their goals including health-related concerns, stigma reduction, intimate relationships, employment and financial security, and personal skills and fulfillment (Harding & Molloy, 2008). Adolescents and young adults living with HIV must contend with a range of psychosocial stressors as they navigate the usual developmental tasks of adolescence, such as consolidating aspects of their identity and increasing their independence from parents, while also coping with the demands of living with a highly stigmatized chronic illness. Research exploring various chronic illnesses has consistently shown negative effects on developmental issues during adolescence (Gavaghan & Roach, 1987; Harper & Hosek, 2003; Sayer, Hauser, Jacobson, Willett, & Cole, 1995). Other research has proposed that the stigmatization of HIV may cause HIV-positive youth to postpone educational or vocational goals for fear of discrimination or accidental disclosure (Hosek, Harper, & Robinson, 2002). What impact living with HIV has on the future life goals of emerging adults is not well known.

Emerging adulthood theory should be expanded to other emerging adult populations that have not been studied extensively, including gay and lesbian emerging adults. Research to date on goal setting during emerging adulthood has been conducted through a heteronormative lens, focusing primarily on marriage and parenthood, in addition to career and educational goals. While today’s gay and lesbian emerging adults may view marriage and parenthood as more attainable than previous generations in light of changes in laws and policies in parts of the United States, the extent to which gay male emerging adults may be distinct from their heterosexual peers in terms of their future life goals is not well understood. The majority of emerging adults living with HIV are gay and bisexual young men (CDC, 2008, 2009).

This article describes an exploratory study of future life goals reported by a sample of HIV-positive gay and bisexual male emerging adults as well as perceived obstacles and sources of resilience in the achievement of such goals. We provide descriptive data on goals articulated by participants in our sample to begin to understand (a) how gay male emerging adults may differ from the heteronormative samples that have characterized research on emerging adults to date, (b) how living with HIV/AIDS may impact the future life goals of this population, and (c) implications for HIV/AIDS service providers as HIV-positive emerging adults are transitioned from adolescent to adult care.

Method

Study Design

The data discussed in this article are derived from the first phase of a two-phase study investigating associations among young HIV-positive gay and bisexual men’s racial identities, sexual orientation identities, and identities as HIV-positive young men with their stressors, coping mechanisms, and health behaviors (ATN070). Qualitative data collection was conducted at four geographically and demographically diverse sites (Baltimore, Chicago, Memphis, and San Francisco) that were part of the Adolescent Trials Network for HIV/AIDS Intervention (ATN). The sites were outpatient adolescent medicine clinics that provided HIV primary care and supportive services to HIV-positive adolescents and emerging adults (up to age 24). Attempts were made to recruit a purposive sample that consisted of equal numbers of young men ages 16-19 and 20-24, as well as was evenly divided among three ethnic categories: African American/Black, Latino/Hispanic, and Other (including White, Asian American/Pacific Islander, Native American). The study team specified the sampling frame and ethnic categories in an attempt to assure adequate numbers of African American/Black and Latino/Hispanic young men, two groups that have historically been underrepresented in studies of men who have sex with men (MSM).

Recruitment

Young HIV-positive men ages 16-24 who were receiving care within clinic settings at one of the four sites were approached by study coordinators to assess study eligibility. In order to allay any concern by potential participants that they had been “identified” by the study coordinators, they were informed that all men in the clinic setting who appeared to be between the ages of 16-24 were approached and screened for the study. Inclusion criteria for the study was (a) biologically male at birth and identifies as male at time of study participation; (b) HIV-infected as documented by medical record review or verbal verification with referring professional; (c) HIV infection occurred through sexual or substance use behavior of the participant; (d) between the ages of 16 and 24 years at the time of informed consent/assent; ability to understand both written and spoken English; and (e) history of at least one sexual encounter involving either anal or oral penetration (either receptive or insertive) with a male partner during the 12 months prior to study enrollment. Study coordinators conducted a brief screening interview in a private room in order to determine eligibility; upon verification of eligibility, study coordinators then obtained signed consent/assent from participants.

Study Procedures

As the population of interest for this study was young MSM, the institutional review boards of each study site were requested to grant a waiver of parental permission to participate in the study for participants under the age of 18. This was done to avoid the selection biases present in recruiting only youth whose parents are both aware of and comfortable with their sexual orientation. The research protocol was approved the institutional review boards at DePaul University, Children’s Hospital of Chicago, St. Jude Research Hospital, the University of Maryland Medical Center, and the University of California, San Francisco.

Once consent/assent was received, participants were enrolled in the study utilizing a confidential code that contained no identifying person information. Interviews were scheduled by study coordinators at each site and conducted by interviewers trained by the study’s principal investigator and project director. All interviews were digitally recorded and transcribed. Original recordings and transcribed interviews were stored on a secure server with access restricted to key research staff at DePaul University.

Interview Guide

The disability-stress-coping model (Wallander & Varni, 1992) was used as a framework to develop questions that would investigate stressors and coping mechanisms related to the participants’ future life goals. The model is structured around a risk-resistance (or resilience) framework in which illness parameters and psychological stress resulting from chronic disease may be associated with individual or socioecological sources of risk and resilience (Wallander & Varni, 1992). A semistructured interview format was developed to explore goals, obstacles, and resiliencies among this population. The first subsection focused on goals over the following three periods: the next 12 months, the next 5 years, and beyond the next 5 years. The second subsection addressed obstacles to these goals, challenges that participants expect to have to overcome on their own, and expected difficulties due to others (“What difficulties do you think you will have achieving your life goals because of other people in your life?”), and their own personality traits. The final subsection explored sources of resilience within the participants themselves (“What do you think are some of the specific qualities or characteristics about you that will motivate you to achieve your future life goals?”), among other individuals (“How do you think other people in your life may assist you in achieving your future life goals?”) and organizations. The semistructured format gave interviewers a guide with which to investigate the domains of interest while allowing for participants to determine the context of the interview’s questions through their own narratives. Each interview lasted approximately 1 ½-2 hours.

Data Analysis

Participant responses to question areas relating to their future life goals were summarized across interviews in the following categories: content of goals, perceived obstacles, and sources of resilience. A diverse team of analysts (in terms of gender, ethnicity, and sexual orientation) met weekly to perform content analysis and discuss findings. Inductive coding procedures allowed for indigenous concepts and typologies to emerge from the participants’ descriptions of their own experiences. Codes were then refined until all subthemes were identified. An iterative process of data reduction and consolidation allowed for a summary of emergent themes. Finally, we performed cross-case analyses by constructing matrices to compare the aggregate themes and subthemes across cases.

Results

Participants were African American/Black (n = 31), Latino/Hispanic (n = 12), White (n = 7), and mixed race/ethnicity (n = 4) male adolescents and emerging adults living with HIV who identified as gay or homosexual (n = 45) or bisexual (n = 9). While we did not meet the exact proportional goals of the sampling frame, the final sample did racially approximate the current HIV/AIDS epidemiology among adolescent MSM (CDC, 2008, 2009). Ages of participants ranged from 17 to 24 years (M = 21.0 years, SD = 2.2).

Data are presented in three subsections: content of future life goals, obstacles to achieving goals, and sources of resilience in achieving goals. Participants provided their stated goals using multiple time points (1 year, 5 years, beyond 5 years), and distinctions among the content of goals across time points are noted.

Content of Future Goals

Most goals clustered within one of four areas: education, work and career, domiciles, and significant relationships (partners, families, children). Health-related goals were cited by very few participants, and those persons who did cite health-related goals saw them as concerns for 5 years and beyond, but not in the immediate (next 12 months) future. In addition, making an impact in the community was a commonly cited goal for beyond 5 years.

Pursuing education and obtaining degrees were the most frequently cited goals among the sample, with almost one-half of the sample citing “finishing” or “getting back into” school as a primary goal for the next year. These responses included both working toward a GED and beginning and/or continuing undergraduate studies. At 5 years, finishing school (whether GED, professional school, or undergraduate degree) was the most common goal, and pursuing a graduate degree was mentioned by several participants. By the beyond-5-year mark, educational goals were not mentioned among the sample.

Goals relating to work included obtaining a job or a better-paying position in the immediate future (1-year goals), and having a career with a meaningful job or one which gave participants a sense of fulfillment (typical of respondents’ long-range goals). Work-related goals were often expressed in combination with educational outcomes and as means to financial security, such as by one young man:

I want to hopefully be done or back in school finishin’ my pharmacy tech [degree] . . . Hopefully if not an apartment in a house, hopefully by 5 years . . . working for something I enjoy doing, comfortable economy-wise, not have to livin’ from check to check. (African American gay man, 21 years old)

For some participants, getting better work was related to being able to provide for others besides themselves (“I’m hoping to get a job that has insurance, and I’m hoping to be able to support my mom financially”), while others expressed the desire to work in fields that would directly benefit others (“. . . get into [the] social work industry, working with troubled kids, troubled children, because I wouldn’t be doin’ it for the pay”).

Securing new or improved living situations characterized a number of the respondents’ goals. Regarding the next year, these goals tended to focus on improving their current conditions, such as “I want to move out of my friends’ place,” or “I want to move to another apartment.” Five years out, that focus had shifted for many participants to owning their own homes.

Some participants viewed their life goals as centered in areas of education, career, and relationships, with the specific goals in those areas developing over time, such as this young man articulated:

Finishing school within a year, so gonna get my bachelor’s, which is exciting . . . and getting a new job, I need money, so I need a better job . . . Then, finishing my master’s, being a social worker, probably working [at community-based organization]. Hopefully I’ll be still in a relationship with my partner. My goals for beyond ten years, having a career. Beyond ten years, I would hope to have my private practice. Not that far away, not that far along. Shoot. Be married. We’re getting there. I would love, I would really love to have kids but I don’t know. (Latino gay men, 21 years old)

A variety of goals articulated by participants related to intimate relationships and family. Having children was the most frequently reported goal beyond the next 5 years. Being in a relationship, both within the next 5 years as well as beyond, was reported as a goal by a few respondents. Working through problems with existing significant others was mentioned by several participants as a 12-month goal. Revealing their HIV status to family members was mentioned as a goal by several participants, although the estimated time frame in which this would be accomplished varied by participant. Some saw it as an immediate goal to work on within the next 12 months, while others saw it as something to address in the distant future. One participant described his hesitancy in revealing his HIV status to his family while acknowledging it as an important goal of his:

Being out to my family, HIV status-wise. That was my goal two years ago but I kind of delayed it. I figure by the age I’m 30 or 27 they should know. My deadline was the end of this year but there’s no way I’m doing it. (Latino gay man, 23 years old)

Obstacles to Achieving Goals

The obstacles that participants perceived as impediments to their successful attainment of their goals fell into two main groups: financial/credit issues, and the challenges of maintaining a healthy lifestyle. In general, most participants viewed these types of obstacles as outgrowths of their previous behavior patterns and issues to resolve through behavior change. One participant noted that “getting used to a new lifestyle” posed an obstacle for him to overcome in that he needed to change his previous habits and begin “exercising, eating right, taking care of myself.” Another noted the significant debt that he had accumulated by overspending was going to be an obstacle to his future goals:

I think that I’m going to have work to do with my debt from shopping and being wild and spending all this money that I didn’t even have. I have a lot of debt that I’m going to have to make some sacrifices and pay that off. (African American gay man, 24 years old)

Obstacles which participants anticipated having to overcome specifically on their own included a range of interpersonal issues: disclosing their HIV status to their family, working on their intimate relationships, time management, choosing friends. Other obstacles they perceived they would have to overcome on their own included money and financial issues, medication adherence, and substance use reduction or cessation.

When asked which obstacles they anticipated having to overcome due to other persons, a majority of participants responded that other persons did not pose obstacles to their goals. Most of these maintained that they did not allow others to act as obstacles to their goals (“I don’t give people that much power”), while others stated the persons in their life provided support and did not pose obstacles (“I hang around people that want me to do well in life and that are going to promote me living healthy”). Of participants who did report expected obstacles due to others, most described expectations of having to end some friendships due to their own desired health-behavior changes. One participant noted:

A lot of my friends are really big partiers, they want to keep the party going . . . they want to go that extra mile, and some friends I’m gonna have to let go in order to get to where I want to. (African American gay man, 20 years old)

Another participant mentioned similar motivations for ending certain friendships, and was considering about moving to another city in order to avoid previous behaviors:

They’re probably still using and that’s triggering [me] to want to do it again. So it’s like you probably have to quit hanging around them . . .I thought about moving to another city where I can move out to another environment where I can get to doing better things with myself. (African American bisexual man, 24 years old)

Other participants stated that they felt actively sought out people who would be supportive of their health promoting behavior:

For the most part, like I hang around with people that want me to do well in life and that are going to promote me living healthy or are going to promote me wanting to do well with myself. (White gay man, 22 years old)

Most participants maintained that their personal characteristics did not pose obstacles to their goals. Of those that did report their own feelings or personal characteristics as potential obstacles, the issues included depression, being “overly emotional,” narcissism, or being too “self-critical.”

Sources of Resilience in Achieving Goals

Personal qualities that participants believed would help them in achieving one’s goals, included the following: motivation and ambition; optimism and positive outlook, loyalty and regard for others; leadership and desire to educate others; and independent thinking and resistance to negative influences. Chief among the motivations mentioned by participants included acting as role models of persons living with HIV, either by defying others’ expectations or assumptions, or by actively engaging the community as a an agent of change:

I mean I want to be able to be a testament that addiction and HIV and leaving your parents’ house at 16 and like all the trials and tribulations that I have faced cannot —in the long run you can grow from that. You can build a life on that, you can make yourself better. I want it to be a testament to that and I’m gonna be. (White gay man, 22 years old)

I plan to be changing healthcare policies. Being active in the community, specifically in the African-American community dealin’ with children. Still with those who are HIV positive, but moreso on a more global disparity in African-American and Latino community, and minorities in general. (African American gay man, 19 years old)

Participants did not report a wide range of coping methods, and many stated that they did not possess effective coping strategies. Those that did report coping methods and resources cited their own artwork, writing, and journaling activities; prayer and belief in a higher power; and therapy and counseling. One participant explained how his journaling helped to reduce stress and was also directly connected with his future plans for self-actualization:

I think that my journaling is a way that I deal with stress, and I have these really intricate journals, collages, and I’ll try therapeutic exercises and stuff within them and songs and stuff, and they’re really helping me to discover my true self . . . and I think that at some point those are going to become very effective tools in me getting to where I want to be. (African American gay man, 24 years old)

Another young man explained how prayer helped him deal with the stress of starting his own business:

I pray about it [achieving goals]. I believe in a higher power—in God—and the ability to effectively release things that I can’t always control. (Black gay man, 24 years old)

Persons who were expected to assist participants in achieving their goals were most often family members, such as siblings, parents, grandparents. A few mentioned friends, boyfriends, and employers. Some participants mentioned family members, especially mothers, as providing general support and feedback on their decision making:

Like my mom, she gives me constructive criticism if she thinks what I’m doing is wrong. She’s gonna let me know. And if she thinks I’m making a good decision, she’ll let me know. (Black gay man, 19 years old)

Others viewed certain individuals having distinct roles in aiding them in achieving different goals, such as this young man:

Yes, my older sister is the only person in my family that knows my status. She’s the one person that’s going to help me for my second goal [disclosing to parents]. For my first goal it will just be my friends understanding that I’m not going to be out for the next year because I’m trying to finish [school]. (Hispanic gay man, 23 years old)

The primary care clinics where participants received their medical care and supportive services were most often viewed as the organizations that assisted in the pursuit of goals. Many participants reported receiving assistance from service providers, including case managers, social workers, nurses, and physicians where they receive their HIV care. Some participants mentioned providers as sources of information for specific goals, such as higher education:

Like so many things about the college experience and all this stuff that they [providers at clinic] know about that I have no clue or the energy or the time to try to search it all out. So I definitely plan on using them as a source of being able to help me figure it all out. (Black gay man, 18 years old)

Often, the interaction participants described between themselves and clinical staff went beyond clinical care and service delivery, and included discussions about personal goals, in general:

I personally like the one-on-one normal talking with [case manager] or [physician], because it’s like I can still talk about the things that I need to look at in my life, like you know, when they ask me like, “What are your goals? What do you want to do with your life?” (Biracial gay man, 18 years old)

Miss S~ [social worker at clinic], because she always ask me, “Now, what do you want to do, what you want to do? What you got planned in life and what you gonna end up doing? I know you don’t want to be at that hotel all your life.” She keeps me going. (Black gay man, 20 years old)

Discussion

This exploratory study describes the content of future life goals, and anticipated obstacles and sources of resilience in achieving such goals among a sample of HIV-positive gay/bisexual male emerging adults. It sheds light on a population that is often not included in studies of emerging adulthood: gay or bisexual and HIV positive.

There were overarching similarities in the short-term and long-term goals among the sample to those emphasized in previous studies of emerging adults: school, work, home, relationships. In general, gay and/or bisexual identity did not appear to alter the developmental trajectories envisioned by the study participants. Further, the most commonly voiced long-term goal of our participants centered on having children. In light of recent advances in some U.S. jurisdictions in terms of marriage, adoption, and parental rights of LGBT persons this should not be particularly surprising; however, we believe it is significant that the desire to have children appears to be somewhat normalized among this sample despite historical and social interdictions against young gay men expecting to raise children during their lives. Recent findings have reported that among a sample of lesbian and gay adolescents, the overwhelming majority were interested in raising children (D’Augelli, Rendina, Grossman, & Sinclair, 2008).

The impact that living with HIV has on the desire of young gay and bisexual men to have children has not been well documented. Previous research has shown that substantial proportions of HIV-positive men who have sex with women want to have children in spite of their chronic illness (Paiva, Filipe, Santos, Lima, & Segurado, 2003). To our knowledge, this study is the first in the United States to document having children as stated goals of HIV-positive young gay and bisexual male emerging adults.

The evolution of HIV/AIDS into a chronic condition over the past decade and a half is reflected in its influence on the goal setting of these HIV-positive emerging adults. Specific health-related goals were cited by few participants and those that did tended to view them as long-term issues rather than goals to attain in the near future. Maintaining health tended not to be viewed as a goal in itself by most of the sample, but was viewed as a possible obstacle to their other goals. The most salient impact that living with HIV has on these young men’s goals appears to be the behavioral modification that many of them perceived necessary to achieve their future life goals. This emphasis on behavior applies not only to their own health-promotion approaches, but also extends to social interaction and choice of friends and supportive networks. Jessor (1991, 1993) conceptualized adolescent risk or problem behaviors as a constellation of behaviors, whereby involvement in one risk behavior increases the likelihood of involvement in other risk behaviors due to social linkages and opportunities to practice them with other adolescents. The social and relational nature of such clustered risk behaviors may have implications for health promotion and harm reduction among HIV-positive gay and bisexual young men. Many of our participants cited current or previous social networks as potential obstacles to promoting their own health while living with HIV.

The transition from pediatric to adult HIV care that occurs for HIV-positive emerging adults around age 24 serves as an opportunity for providers to guide the development of independence and responsibility for one’s health care among this population (Miles, Edwards, & Clapson, 2004; Valenzuela et al., 2011). It has been recommended that members of the adolescent medicine workforce support the reintegration of organ transplant recipients into vocational and educational paths as they progress through emerging adulthood, with the recognition that many such patients may have missed significant amounts of school and/or work in association with their transplant, hospitalization, and recovery (Bell et al., 2008). Effective transition planning for HIV-positive emerging adults should include an assessment of educational, vocational, career, and personal goals in order to support patient independence. The data presented in this study provide insight into the future life goals of HIV-positive emerging adults and may help frame future efforts of adolescent care providers in helping this population transition to adult care.

Providers should be prepared to discuss the possibility of positive as well as negative reactions to and outcomes of HIV-positive emerging adults’ disclosure of their status to family members. Studies of identity development among adults living with HIV have emphasized the critical importance of disclosure in the way it may alter others’ perceptions of and interactions with the HIV-positive individual (Baumgartner & David, 2009; Tewksbury & McGaughey, 1998). While previous research has documented disclosing to dating and romantic partners as a primary concern of HIV-positive adolescents (Wiener & Battles, 2006), our participants tended to focus on revealing their status to family members in the future as a more significant goal. While disclosing one’s status may be viewed as an on-going process that may become easier over time with repeated attempts, disclosing one’s status to individual family members is likely to be a one-time event with each individual. As such, disclosure to specific persons be a more intrinsic and identifiable goal as opposed to a process or approach with dating relationships over time.

Previous inquiry into future planning among HIV-positive adult gay men in the United Kingdom revealed areas in which service providers may provide assistance, including the development of personal goals, transition from welfare to employment, community involvement, and public education to reduce stigma and discrimination (Harding & Molloy, 2008). By contrast, our sample of HIV-positive gay/bisexual male emerging adults in the United States cited the following areas in which service providers may provide assistance: support for disclosure strategies, financial management, job training and professional development, and health-promotion approaches. Additionally, the perceived absence of coping methods reported by participants points to an additional domain in which providers may address this population’s needs.

Future studies focused on intervention approaches for future life goals among HIV-positive gay/bisexual male emerging adults may benefit from an assessment of the cognitive development of participants. Goal attainment strategies may be broken down into steps, in order to encourage participants to realistically describe how they will go about planning and implementing goal-attainment strategies. The overarching research objectives of our study did not allow for us to examine this cognitive domain with depth, and future research with this population may benefit from such data.

We also did not differentiate between participants who had experienced a relatively recent (within the past year) HIV diagnosis with others who had been living with HIV for a longer time. Psychosocial adjustment to an HIV diagnosis has been shown to improve over time, as measured by HIV disclosure and individual coping styles among young HIV-positive gay men (Goggin, 1993). More recent research has proposed that many young people diagnosed with HIV deal with multiple layers of stressors for 12 months after diagnosis that may inhibit adjustment (Hosek, Harper, Lemos, Martinez, & the Adolescent Medicine Trials Network for HIV/AIDS Interventions, 2008). How the future orientation of young men living with HIV may be affected by psychosocial adjustment to diagnosis is a subject for further research.

The findings from this study were derived from qualitative data collected from a purposive sample of 54 HIV-positive gay/bisexual male emerging adults, and as such they should not be considered necessarily as generalizable to the population. In order to establish patterns and explore variations among the future life goals of HIV-positive gay/bisexual male emerging adults, future studies should consider statistically powered samples that allow for statistical comparisons among subgroups by such characteristics as race/ethnicity, education level, socioeconomic background, and age. While our findings do not allow us to draw such comparisons among our sample, they do contribute to the literature on emerging adulthood by describing the future life goals, as well as obstacles to and resiliencies in achieving such goals, reported by an understudied and often marginalized group.

Footnotes

Acknowledgements

The authors would like to thank Rob Garofalo, MD and staff at Childrens Memorial Hospital (Julia Brennan, ANP; Eric Cagwin, BSN), Patricia Flynn, MD and staff at St. Jude Childrens Research Hospital (Mary Dillard, BSN), Ligia Peralta, MD and staff at University of Maryland School of Medicine (Reshma Gorle, MPH) and Barbara Mosicki, MD and staff at University of California at San Francisco (Lisa Irish, BSN; Kevin Sniecinski, MPH). ATN070 has been scientifically reviewed by the ATN’s Behavioral Leadership Group. They also like to thank individuals from the ATN Data and Operations Center (Westat) including Julie Davidson, MSN and Jacqueline Loeb, MBA; and individuals from the ATN Coordinating Center at the University of Alabama including Craig Wilson, MD; Cindy Partlow, MEd; and Marcia Berck, BA. Additionally, they would like to acknowledge the thoughtful input given by participants of our national and local Youth Community Advisory Boards. Finally, they express their deep gratitude to the participants in this study whose thoughtful input and willingness to share their stories made this study possible.

This paper is dedicated to the memory of J.B. Molaghan.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) is funded by grant Nos. 5 U01 HD 40533 and 5 U01 HD 40474 from the National Institutes of Health through the National Institute of Child Health and Human Development (Bill Kapogiannis, MD; Sonia Lee, PhD) with supplemental funding from the National Institutes of Drug Abuse (Nicolette Borek, PhD) and Mental Health (Susannah Allison, PhD). Additional support from the National Institute of Mental Health was funded by grant No. K01 MH 089838.

Bios

Douglas Bruce, PhD, MSW, is a research scientist at the Adolescent Community Health Research Group, Master of Public Health Program, DePaul University. His research interests are in HIV/AIDS treatment and prevention, stigmatization, and marginalization, and health promotion among gay and bisexual male adolescents and emerging adults.

Gary W. Harper, PhD, MPH is professor of psychology, and director of the Master of Public Health Program at DePaul University. Dr. Harper’s research is focused on developing community-based HIV prevention interventions for adolescents and young adults who are marginalized in society, with a focus on gay/bisexual male youth and inner-city ethnic-minority youth (primarily African American and Latino/a). He also conducts research on the development of psychosocial interventions for adolescents living with HIV, with a focus on youth newly diagnosed with HIV and gay/bisexual male youth living with HIV.

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