Resilience pathways,childhood escape routes,and mentors reported by gay and bisexual men affected by syndemic conditions

Abstract

Investigation of the social and psychological antecedents of the HIV epidemic has identified a syndemic of conditions associated with risk behavior and seroconversion. This study inquires into the resilient practices and developmental processes of gay and bisexual men at the nexus of syndemic conditions to understand the pathways that lead to health problems or well-being. Interviews with 40 men identified branching pathways from home environments into schools that either offer refuge or a regime of gender discipline and bullying. Some found escape routes from hostile environments in worlds of books, pop culture, or internet chat. In adolescence, one set of men identified the development of sexual relationships with older men as a lifeline that brought a measure of emotional growth. This study points to resilience pathways and social resources that could make a difference in the lives of those deemed to be “high risk.”

Keywords

Gay men HIV risk resilience school bullying sexual mentor syndemic

Over more than 30 years, intensive investigation into HIV risk among gay, bisexual, and other men who have sex with men has identified a subset of men at elevated risk for condomless sex and seroconversion. Out of a great many studies, a small set of characteristics have emerged that have strong statistically significant predictive power for risk. Applying the notion of syndemics to these characteristics, Ron Stall and colleagues noted that depression, childhood sexual abuse, poly-drug use, and partner violence tend often to occur together and to be associated with risk behavior (Stall et al., 2003; Stall et al., 2007). In the ensuing decade, the syndemics idea has been reconfirmed in a growing research literature that has extended into a number of related conditions. The reliance of syndemics research on categories of psychological deficiency and the production of general tendencies described in statistical language has led to calls for investigation not only of the predictors of risk but of resilient practices and developmental processes that show how people navigate and overcome syndemic problems (Herrick et al., 2011; Herrick et al., 2014).

It is with this objective in mind that this study conducted life-history interviews with 40 gay men to identify pathways through the stresses and challenges underlying syndemic indicators. Interviews explored the ways in which gay and bisexual men had dealt with the challenges they experienced and their capacity “to navigate their way to health-sustaining resources, including opportunities to experience feelings of well-being” and to examine the larger capacity of the “individual's family, community and culture to provide these health resources and experiences in culturally meaningful ways” (Ungar, 2010: 405). Many of the men interviewed here had inconsistent or blocked access to the social determinants of good health widely identified in the research literature as family, peer, or school support or “community services, sports and artistic opportunities, cultural factors, spirituality and religion, and lack of exposure to violence” (Herrman et al., 2011: 260). Among the men participating in this study, many had unsatisfactory, conflictual, or unsupportive families of origin. Only a few traced syndemic indicators to other arenas such as challenges experienced from international migration or major difficulties in transitioning from home to college or work (Adam et al., 2017). Home and school are the primary life spheres available to children and adolescents and going from home to school offered a supportive alternative for some but additional pain for others. In other words, some found school to be a refuge from a difficult home life while others encountered bullying and rejection. Given these life histories, we became particularly interested in the few remaining pathways to resilience that emerge from the narratives of youth and young men in coping with often problematic home and school environments. What we dub childhood escape routes and protectors and mentors were identified as lifelines that provided a degree of safety or solace in the midst of troubling environments. The narratives from these interviews also suggest a link between these resilience pathways and likelihood of lower risk sexual practices in adulthood.

The multiple lines of research on resilience and adversity

There are a number of different, somewhat disconnected bodies of research that take up aspects of the question of navigating syndemic conditions with a focus on resilience, but very little that treats the nexus of all of these issues together. These different strands of research focus on such organizing concepts as: resilience, post-traumatic growth, adverse childhood experiences, minority stress, protective factors, sexual minority resilience, as well as syndemics. These research strands have kinship with sizeable research traditions on the coping strategies and collective mobilizations of a range of populations subordinated through repression and discrimination by environing societies. Just a few studies try to explore questions of syndemics, resilience, health, and HIV risk together.

The notion of resilience contains within it the idea of an adversity, challenge, or trauma and the ability to cope with, manage, or overcome it. Though some have sought to reduce resilience to an a priori psychological state, resilience studies have increasingly focused on an interactive dynamic between the subject and “the quality of social relationships, processes, networks and communities and the mutuality and circularity of such” (Aranda et al., 2012: 550). As Kay Aranda and colleagues (2012: 552) contend, “Well-being and resilience are therefore argued to result from the ongoing iterative and interactive navigations and negotiations between selves, communities and environments.” The implications of this re-focus are to move from psychological states per se to “practical knowledge or routinised dispositions, or networks and assemblages of activities and things or in processes of embodied performativity” (Aranda and Hart, 2014: 358) and thus from a therapy-facilitated adjustment of individuals to their social environment to a critical assessment of those environments as essential elements in the resilience of individuals and populations (Bottrell, 2009). Related to the idea of resilience is a small research literature on post-traumatic growth, defined by Richard Tedeschi and Lawrence Calhoun (2004: 1) as “positive psychological change experienced as a result of the struggle with highly challenging life circumstances.” While sharing an interest with resilience studies in the ways in which people successfully overcome adversity, the focus of this literature has been more on singular or episodic trauma and its aftermath rather than structural or chronic adversity.

A well-developed research literature on adverse childhood events has identified a range of household problems that affect the health of children growing into adulthood. The presence of: mental illness, incarceration, or substance abuse among household members, parental divorce, domestic violence, physical or emotional abuse or neglect, and sexual abuse all prove to be associated with later physical and mental health problems (Dong et al., 2004; Felitti et al., 1998). These kinds of adverse childhood events appear to lead to elevated rates of depression, anxiety, eating disorders, suicide attempts, cigarette smoking, alcoholism, and multiple sexual partners (Dube et al., 2003: 274; Norman et al., 2012) and to a range of physical conditions such as obesity, diabetes, asthma, arthritis, cardiovascular disease, lung disease, and sexually transmitted diseases (McCrory et al., 2015; Monnat and Chandler, 2015).

Several of the health outcomes identified in the adverse childhood events research literature, such as depression, anxiety, suicidality, and substance abuse, appear to have somewhat elevated levels among lesbian, gay, bisexual, and transgender (LGBT) people compared to the general population (Hsieh, 2014). A growing body of research traces these conditions to various forms of discrimination and social exclusion such as sexual-minority-specific victimization and a heightened sense of insecurity experienced in unsupportive or hostile social environments. Ilan Meyer (2003: 676) argues that LGBT people face minority stress, that is an additional level of chronic and socially based stress beyond that experienced by the general population. Those who directly experience these forms of exclusion more often manifest these psychological conditions and LGBT people experience higher rates of exclusion compared to the general population (Brewster et al., 2013; Burton et al., 2013; Feinstein et al., 2013; Goldbach et al., 2014; Meyer, 2013, 2012; Lea et al., 2014; Wight et al., 2012). Damien Riggs and Gareth Treharne (2017: 600) call this the problem of decompensation when people “have been inadequately resourced and supported and … have experienced considerable and repeated marginalization, so much so that one's protective resources no longer work.”

It is perhaps not surprising then that a similar nexus of preconditions and health outcomes has emerged from the study of HIV risk behavior and vulnerability to sero-conversion among gay and bisexual men in particular. Ron Stall and colleagues (2003) applied the idea of co-occurring syndemics to a burgeoning HIV research literature that repeatedly confirmed the role of depression, childhood sexual abuse, and polydrug use in heightened HIV risk behavior, a set of factors that has extended to such indicators as social isolation, social anxiety, sexual compulsivity, and internalized homophobia among others (Bruce et al., 2011; Dyer et al., 2012; Hart et al., 2008; Mimiaga et al., 2015; Parsons et al., 2012; Tulloch et al., 2015; Vanden Berghe et al., 2014). These findings have further stimulated investigation into larger socio-historical contexts (Adam, 2016; Siconolfi et al., 2014), circuits and social networks (Adam et al., 2008; Egan et al., 2011), and local cultures (Aggarwal and Gerrets, 2014; Kurtz, 2005; Moeller et al., 2011; Stall et al., 2007) that generate and reproduce the social conditions that heighten these psychological indicators.

The evidence cumulated on the adversity side of the ledger has also revealed some of the protective factors that diminish these kinds of health outcomes both for large population-based samples and for LGBT people. Protective factors tend to fall into a few broad categories: psychological traits, social support, and socio-economic status (Woodward et al., 2017). Psychological traits like self-esteem, internal locus of control, and positive affect may themselves be embedded in personal histories of social support (Fergus and Zimmerman, 2005; Lawson, 2009; Thoits, 2011). Social support in the form of family and personal relationships, strong social networks, school connectedness, satisfactory neighborhoods and communities all appear to mitigate negative health outcomes predicted by adverse childhood events (Fergus and Zimmerman, 2005; Hart et al., 2017; Luthar and Brown, 2007; Nurius et al., 2015). Also, higher income, education, and employment status of a person reduce the effects that adverse childhood events once had on that person (Monnat and Chandler, 2015). Research on gay and bisexual men, while finding many of these same conditions to be operative, find having close friends, feeling connected to the gay community, feeling the larger community to be supportive of LGBT people, having no recent experiences of discrimination, and low internalized homophobia all help contribute to greater well-being (Colpitts and Gahagan, 2016; Lyons et al., 2013; Lyons et al., 2016; Reed and Miller, 2016; Shilo et al., 2015). Work on sexual minority resilience has extended this inquiry beyond looking for countervailing protective factors to see how LGBT people may grow and thrive over time in the face of adversity. Like the post-traumatic growth literature, it documents benefits from learning to cope with and overcome adverse conditions (Wang et al., 2016). Finally, all of these bodies of research stand alongside other major arenas of investigation into the subjectivity of subordination and oppression (Adam, 1978, 2005; Foucault, 1988; Kardiner and Ovesey, 1972; Memmi, 1969; Sartre, 1973), and socio-historical studies of the ways in which subordinated peoples have over time found ways through adverse circumstances to develop sufficient personal and collective resilience to transform the adverse conditions around them.

The challenge, then, is to study how “men with multiple syndemic conditions remain sexually safe and HIV negative over time or how community mobilization can strengthen community interactions and supports [that] will likely improve health promotion efforts among gay men” (Herrick et al., 2011: S28). Much of the research on adverse childhood events, syndemics, and protective factors relies heavily on large databases with measures made meaningful through finding statistical significance. The developmental and social interactive processes that underlie these indicators remain opaque. To identify resilience pathways requires examination of social practices (Reckwitz, 2002), that is the ways in which individuals deal with adverse events and chronically difficult environments, often as children or adolescents. These processes may indeed be narratives of abuse and neglect, depression, and sometimes life-threatening substance use, but they are also stories of lifelines found, refuge, turnarounds, and growth. Matt Mutchler and colleagues (2005), for example, have documented how young gay men navigate divergent social scripts to piece together safer practices by combining discourses from partners, mentors, and other sources. To that end, this study seeks not to distinguish those who have experienced adverse childhood events from those who have not, or those caught in syndemic conditions from those who are not, but rather to look inside the life histories of those experiencing syndemic conditions to see how some find their way to “the activities, places and relationships in which they find well-being, belonging, and power” (Bottrell, 2009: 325).

Methods

Interviewees for this study were drawn from the larger Gay Strengths study, which recruited 470 gay, bisexual, and other men who have sex with men in Toronto. Participants in that study had to report being HIV-negative and to have engaged in sexual activity with another man in the past six months. They were recruited through posters at community organizations and local businesses, distribution of flyers at community events such as the Toronto Pride festival, and advertisements on social media sites and a website oriented to gay men. Particular attention was given to enhancing the diversity of the sample through outreach to black, south Asian, and east/southeast Asian communities. The study was reviewed by the research ethics boards of Ryerson University and the University of Windsor.

Study participants were screened in a one-hour initial assessment session and provided written informed consent. They then completed a computer-assisted self-interview questionnaire which included the following syndemic indicators:

1. Depression:

Symptoms of depression were measured using the 20-item Centre for Epidemiologic Studies – Depression scale (CES-D) (Radloff, 1977). Participants report on their feelings and behavior over the past week on a 4-point Likert-type scale ranging from rarely or none of the time (less than 1 day) to most or all of the time (5–7) days. Sample items include “I thought my life had been a failure” and “I felt sad.” Participants with a CES-D score of 16 or more screened positive for this syndemic indicator.

2. History of childhood sexual abuse:

Childhood sexual abuse was measured using the sexual abuse subscale of the Childhood Trauma Questionnaire – Short Form (CTQ-SF) (Bernstein et al., 2003). Participants with a score of 6 or more on the sum of items 20, 21, 23, 24, 27 on the CTQ-SF screened positive for this syndemic indicator. A score of 5 indicates that the participant indicated that none of the following occurred during childhood:
Someone tried to touch me in a sexual way, or tried to make me touch them.

Someone threatened to hurt me or tell lies about me unless I did something sexual with them.

Someone tried to make me do sexual things or watch sexual things.

Someone molested me.

I believe that I was sexually abused.

3. Multiple substance use:

Use of two or more substances within the last three months, not including tobacco or cannabis: Alcohol use to the point of drunkenness; heroin; methadone; cocaine (including crack); speedball; crystal methamphetamines or “Tina”; ecstasy or “X”; GHB or “G”; other amphetamines, uppers, or speed; ketamine or K; other barbiturates, downers, or sleeping pills; erectile enhancing drugs (e.g., Viagra, Levitra, Cialis)

4. Homophobic harassment:

Indicating more than once on the question: “Before age 18, how many times were you made fun of, picked on, pushed, shoved, hit, or threatened with harm because you were gay/bisexual?”

Those scoring above the cut-off of two or more syndemic indicators became eligible to be invited for a follow-up life history interview. Interviewees were subsequently provided $30 to compensate for time and travel to the interview.

Once half of the study participants had been recruited to the larger study, recruitment for the qualitative interviews began by inviting those whose scores indicated three or four syndemic categories, followed by those who scored on at least two syndemic categories, until 40 interviews were achieved. Semi-structured interviews explored the life histories of study participants by inquiring into the family, school, work, and neighborhood relationships in childhood, adolescence, and adulthood (Halkitis et al., 2008; Séguin et al., 2007). Interviewers were particularly interested in exploring coping strategies to life challenges, sources of stress and social support, and participants' own assessments of adversity and resilience (Friedman et al., 2008; Friedman et al., 2011). Interviews were transcribed and coded to capture a wide range of themes concerning moving into and out of childhood sexual abuse and homophobic harassment, depression, and substance use, along with personal reflections and strategies on pathways through these challenges. Narratives were examined to identify the range of views associated with each topic using constant comparative analysis with the assistance of NVivo10 software, then discussed intensively by the co-authors to identify salient themes and excerpts indicative of the range of views (Smith et al., 2009).

Results

The types of syndemic indicators represented in the interview sample were as follows:
28 (70%) indicated having experienced childhood abuse of which 13 indicated sexual abuse, 9 emotional abuse, and 6 more than one form of abuse

39 (97.5%) indicated childhood homophobic harassment

30 (75%) scored greater than 16 for depression (CES-D)

18 (45%) indicated use of two or more substances in the past 3 months.

Sexual risk behavior was assessed in terms of receptive condomless anal sex with a positive or serostatus-unknown male partner in the past three months (Adam et al., 2017). At the time of the study, Truvada had not yet been approved as a pre-exposure prophylaxis in Canada and its use was still rare (Wilton et al., 2016).

The average age of the 40 interviewees was 38. They indicated their sexual identity as: 34 gay, 2 bisexual, 2 two-spirit, 1 queer, and 1 pansexual. Educational levels were relatively high with 3 having just high school education, 19 two years of post-secondary education, 10 four years, and 8 post-graduate training. They reported their ethnic origins as: 17 British, 12 other European, 5 African and/or Caribbean, 2 Asian, and 1 each of Latin American, Middle Eastern, Aboriginal, or mixed black and white backgrounds.

Pathways to resilience

These life history interviews point toward branching pathways, some that lead in more supportive directions and others in less supportive ways. Examining current sexual risk practices in adulthood suggests that those who found their way along more supportive pathways were less likely to report higher risk sexual behavior compared to those who did not. Though a qualitative study of this kind does not have the numbers to compute statistical significance, these pathways raise hypotheses worthy of further exploration.

From home to school

Rates of childhood abuse are high among men experiencing syndemic conditions. When they go to grade school as children, their experiences tend to fall into two contrasting modes. First, for 8 of the men interviewed, school was experienced as a refuge and lifeline from an often problematic family environment: 6 of these 8 report current low risk sexual behavior. Second, 14 report experiencing considerable bullying in school. Just 6 of these 14 report current low risk sexual behavior. For these boys, the school experience often compounded their sense of living in a cold or hostile world both at home and at school.

Childhood escape routes and protectors

Eight men talked about childhood escape routes, that is finding personal refuges where they were able to feel safer. Of these eight, four also reported school bullying. Seven of these eight reported current low-risk sexual behavior. Nine of the interviewees identified having had childhood protectors, often a relative or friend who could provide them some sense of support outside of family and school. Just four of these nine reported current low-risk sexual behavior.

Sexual mentorships

Finally, six reported having had older male lovers in adolescence. Only one of these six falls into the current high-risk sexual category, suggesting that having these male partners may have had some protective effect in the personal development of the men interviewed here.

In sum then, this examination of childhood and adolescent pathways to resilience suggests hypotheses worth exploring further with large samples:
School bullying appears to increase likelihood of later risk.

Childhood escape routes and school experienced as a place of refuge and validation appear to offer some protective value.

Older male partners in adolescence appear to enhance resilience and self-care while childhood protectors such as friends, siblings and grandparents do not appear to offer much protective value in later life, at least as measured in terms of sexual risk behavior.

School as lifeline

For a sizeable set of the men interviewed here, school was described as a “sanctuary,” an “escape,” or a “reprieve” often in stark contrast to their experiences at home. Indicative of these experiences are the following excerpts from interview:
School was really positive because again I had a very dysfunctional home life and I was smart so I … integrated into the school situation. It was a reprieve – right? – from home. (50s, European ethnicity)

My school friends were my adopted family while struggling to find safety in my parents' home and my teachers were my guidance counselors … School was my sanctuary. (40s, Pacific Islander)

Especially in high school, I had some teachers that were role models because I never really confided in anybody about what was going on at home but … still I really appreciated the emotional stimulation and being able to escape … School was an escape for me. (20s, European)
For these men, school proved to be an alternative place where they could find encouragement, support, and the opportunity to flourish.
School for me was always a constant. It was always like the only place where I felt successful. (40s, French)

I can name specific teachers who were very, very helpful. You know you go to poor, relatively low-income schools and then, you know, if you're someone with a lot of potential, there's teachers that sort of glom on to you and encourage you in different ways … I was doing all advanced work, won national science fairs, Canadian Idol finalist, performing ensembles, musicals, travel. (20s, British)

Public school was wonderful. I mean, I had a few fights the same as any other kid does, arguments and stuff like that, but … I had friends and public school was great and I got along with the teachers. (40s, British)
For these boys, many of whom did not experience supportive home lives, school provided an alternative route to new horizons and opportunities that contributed to self-esteem and emotional well-being.

School bullying

A larger set of boys had a fundamentally different school experience. In their narratives, operative descriptors like “terrible,” “hate,” and “nightmare” apply to their recollections of going to school. For them, an often hostile home environment was reinforced by school mates and even teachers, many of whom engaged in campaigns of vilification against them, often labeling them as “gay” well before having any sense of their own sexuality.
At school, I was constantly informed by others that I didn't belong. I was very slight, like I was a tiny kid, so I was constantly picked on, and I was beat up more than once and when you lisp, you know in those days they caught on to it very quickly and also my choice of extra-curriculars, like gymnastics, and other things. I was a big target. (40s, French)

Especially now that everybody thinks you're gay, I got beat up at least once a week for the next few years … I hated to be at home and I hated to be at school. (40s, British)

Terrible, I hated it so much … I was I guess a loser you would call it, like grade 1 to grade 8, for sure. Yeah, I wasn't, I wasn't treated very nicely by other kids. (20s, British)

I was bullied by a female … I remember her throwing in sexuality as a jeer as one of the things, pretty much having the entire class to join in on it … She kind of made remarks about my sexuality based on my appearance and my presentation of self and what made matters worse was she made that situation even far different than everything else, she went out to physically attack me. (20s, Caribbean)
In a couple of particularly egregious instances, teachers and school administrators joined in the torment:
It was a nightmare. I had people laughing and throwing things … I went to a Catholic school – I was brought to the office because there was a disorder in the school. They decided to send me home for the week and then they allowed me to come back and I was forced to use the teachers' washrooms. I was forced to, not allowed to stand up for prayer. I was told that if I stand up for Oh Canada that I would have to leave the classroom for prayer … Going up to grade 9, 10, 11, I got teased everyday and made fun of everyday and I had the odd teacher that would stand up for me and some of the teachers that would always blame it on me and I would get suspended. I was suspended several times in school for standing up for myself but because the way I did it was so angry and reactive to the person, they said it was my fault. (20s, British-French)

Primary school, a terrible experience I had, I think it was my first, I felt immense mistrust in the world. I felt very, very scared … She [teacher] said, “Look, look at this little nancy-boy, look at this sissy. Look at him he's brought a doll.” … I remember a few days later, he [childhood friend] came to school and he said to me, “I cannot be your friend anymore because you're what we call … a nancy-boy or gay boy.” (40s, European)
In some instances, school bullying was further compounded by racist harassment.
Me and my brother were kind of stuck in the middle, being native, and the entire city was very racist towards natives … Everyone knew I was gay except for me, I guess. They were calling me names; I didn't even know what they meant … Absolutely horrible … If anyone picked on anyone, it was me. I was bullied. I was beat up. It was just relentless. (30s, Aboriginal)

I went to a Catholic school. My bottom still hurts from all the whips and my hands still hurt. Every time my hand hurt, I remember it well. I think I wore the dunce cap a lot and that was rough. I hated school, I hated school. I would skip school … Grade 5 … then the bullying started, the very first day. They called us Paki (laughs) … High school, I would be called gay, because I would be hanging around with the nerdy sort of, the nerd group would be called gay. (40s, Caribbean)
Unlike the boys who found school to be a lifeline and respite from home, this other sizeable group of boys use words like “horrible” and “relentless” to describe a regime of homophobic and racist bullying that further added to their distress.

Childhood escape routes and sources of support

Perhaps most interesting in tracing the life pathways sketched out in interviews were the ways in which a set of men experiencing adverse conditions carved out safer spaces for themselves and made connections often in the absence of supportive home or school environments. One theme that recurred in the narratives was the world of books as one of those spaces:
I just focused on things I could control, like I was an avid reader, I read a lot. I would do, I painted. I would watch TV, just things that I knew. (40s, French)

School was very hard for me. I remember being picked on. I guess I was a bit of a fem and I expressed myself the way I felt comfortable doing … (I: Right, right. So were books a bit of a refuge for you?) Yes, totally. Totally, yeah. (40s, British)
Another found inspiration in the world of pop divas, identifying with the lives and lyrics of tragic or resilient women who themselves battled adversity.
I was bullied a lot before everyone knew I was gay because I was very quiet and very dorky and you know, I kept mostly to myself and then I came out and it just got worse because this kid that was always so invisible was like the center of relevance for 1200 students in school and it was just a lot of unnecessary attention and everyone was discussing my own personal life … I identified a lot, and I know this is going to sound ridiculous: through this time Britney Spears and Amy Winehouse were going through a lot of like stuff in their lives, like they were doing drugs and stuff, and I saw how people were attacking them and how they were just dealing with their own thing personally and just taking their own time to heal, and I thought that I should do the same. Just take all these negative things that people are throwing at me, analyze why they're doing it, and just take the best from that. Like, it wasn't my fault that I grew up in this patriarchal, horrible, colonial society, and they didn't really know how to deal with homosexuality. I always knew there wasn't anything wrong with me, there was something wrong with them, so there was nothing for me to change. (20s, Caribbean-Latin American)
For younger men whose formative experiences came about in the internet age, virtual worlds provided access to alternatives to home and school that were restricting their everyday lives:
I isolated myself and I talked to people on the computer as opposed to going out and my friends were older but the people I talked to were generally on the computer around the world. Ninety-five percent of those friends I've met, we're still in touch with today and it's amazing that we've been able to do that. (20s, British-French)

Ten years ago so I would go on the internet and I would go on these Latin websites and I would meet young guys, older guys or guys around my age and we would talk about our experiences or sensual experience or what not … It was interesting to hear about their experiences but that's the only way I could get information about the gay communities. (20s, Latin American)
Another found a childhood escape route in the virtual world of gamers.
I was a pretty flamboyant little kid; I was very girly so I never had too many friends. I was bullied a lot in New York. I did well in school, I excelled in school, I was gifted, but yeah I was bullied a lot … I gamed a lot; I played PS2 I think it was a lot. I watched a lot of TV. I didn't really have anyone I could go to. (20s, African)
The notion of childhood escape routes is an unexplored topic in social and health science studies of young gay men, but it is a topic that has had resonance in some work in the humanities. The place of the Broadway musical, divas, and movies in gay culture has been the subject of some reflection in cultural studies (Dyer, 2002; Miller, 1998) and perhaps exemplified in the novel, and subsequent play, of Manuel Puig's (1979) Kiss of the Spider Woman. David Halperin (2012) ruminates in How to be Gay about “the queer appeal of the Broadway musical – which takes the gay subject back to its presexual but ecstatic enjoyment of ‘kid stuff’ and to all the shameful, embarrassing emotional vicissitudes of its solitary childhood.” Interestingly enough, the Broadway musical per se does not appear in the life histories of these men dealing with syndemic conditions, but other childhood escape routes do, ones that fulfill many of the same impulses identified in cultural studies as roots of gay cultures. These refuges and escape routes help build a culture of resilient practices with emotional resonance and practical utility in facing hostile social environments.

Some study participants also identified other childhood protectors, usually in the form of siblings, grandparents, or friends who provided some alternative sources of support:
I was kind of safe because my older brother was usually ahead of me [in school], so nobody beat me up. I found out later he did beat up people and throw them out of windows for calling me a sissy. I was very effeminate and I think I, my voice is, was probably very effeminate, but I kind of didn't realize it because I think I had this little bubble of safety around me from my older brother. (50s, French)

We [siblings] did everything together. We protected each other and there was my cousin for example, and we would do bad things that would get us in trouble when we were kids (laughter) but we were really close. (20s, British-French)

My grandparents helped a lot without realizing it. They lived right around the corner and we saw them sometimes several times a day and I know I hid out there a lot without it ever really being acknowledged, so there was, that was kind of the safest place for me, and probably my siblings too, growing up. (40s, White)

Adolescent sexuality and older male mentors

Finally, six interviewees identified an older male partner as the source of safety and personal growth in high school and beyond. Because the topic of adult men and adolescent men together is largely silenced in contemporary culture, or subject to a totalizing discourse of sexual abuse (Lancaster, 2011), it is worthwhile quoting each of these narratives in their own words:
I don't really want to meet people my age … I've always, since the age of my coming out, related to older men and was able to sit down and have these conversations and tell them how I was feeling. (20s, British-French)

He eventually got a job in [city] just so that I could come back to [city] and he paid for a course I took and was really – he was an older person than I was. I was like twenty or twenty-one at this time and he was really, really good to me, and I miss him. (40s, British)

I, luckily at the age of fourteen, I met an older man whose, well he's twelve years older than me. He's still alive and he was a bit of a nut, but he, his name is B and he didn't abuse me or anything. There was never any abuse. It was always consensual because I wanted it. I was looking for it, I was looking for affection and I found it. I discovered sex and I realized it felt good, you know, for many reasons … He had a house and he had a stable bunch of friends and he sort of showed me you can be gay and lead a regular life. (40s, British)

I realized that I was searching for that physical and emotional and intellectual connection with men and that was a boy who was only four years older than me at the time, but that was quite clear to me when I was going into my late teens just before I was twenty, I desperately needed this love from an older figure or an equal, but it had to be male. (70s, European)

I went to [gay bar]. I didn't know why I was going, I was just going and then I met this guy named H … He was French, he was from Paris and he took me home and I lived with him for three years … He was lovely … He was fifty-five years old. (40s, Caribbean)

I was eighteen. It was someone I had met cruising. He was a flight attendant. He was thirteen years older than me. It was pretty, it was pretty drama laden because I was drinking a lot and he was actually being the responsible person. He had been in social work previously … I'm still in touch with him so we've stayed, I wouldn't say friends, but we've stayed contacts. He was pretty formative in helping me kind of identify as being gay. (50s, British)
Each of these narratives is quite strong in asserting the speaker's own agency in these relationships, in some instances anticipating and resisting the implication of abuse. Each of these narratives comes up in response to interviewers' questions about sources of support over the course of their lives and older male mentors are a recurring theme. Being taken in and supported by an older man was experienced by these youths as a healing and validating experience. These relationships provided immediate emotional and sometimes material support, as well as entry into social networks and spaces that gave them safety and new opportunity.

Conclusion

This study was particularly interested in examining sources of support and resilience among gay, bisexual, and other men who have sex with men who experience syndemic conditions. Set against research literatures that trace health problems to adverse childhood events and which identify protective factors leading to healthy outcomes, these life histories inquire into the resilience strategies developed in childhood and adolescence among those facing considerable adversity and limited protection. Some of these men found safety, encouragement, and reward in school but more encountered school environments that compounded their distress through a regime of gender discipline and bullying. Nevertheless, some succeeded in finding escape routes or refuges from cold or hostile home and school environments through immersion in worlds of books, pop culture, or internet chat. In adolescence, one set of men identified the development of sexual relationships with older men as a lifeline that brought a measure of emotional grounding, stability, and personal growth.

The role of school as an alternative source of support and esteem for gay men growing up has been noted by John Pachankis and Mark Hatzenbuehler (2013: 186) who argue that “compared to others’ acceptance of a presumably devalued stigmatized self, academics, appearance, and competition may be safer domains in which young sexual minority men can invest their self-worth.” Reliance on alternative childhood escape routes from home and school has been taken up primarily in a few works in cultural studies but has yet to be studied systematically by the social and health sciences. Finally a few studies have inquired into the role of mentorship in the lives of LGBT youth, but for the most part they have skirted the issue of sexual mentorship in providing protection and nurturing resilience (Johnson and Gastic, 2015; Sheran and Arnold, 2012). One of the few to raise the role of sexual mentorship is the work of Sonya Arreola and colleagues (2013: 398) who also found through life history interviews with Latino gay men that “social structures in childhood limited agency through symbolic forms of structural hostility, such as the recurrent homophobic messages of unworthiness and humiliation, and physical manifestations of structural violence, such as forced sex” but that voluntary youthful sexual exploration actually improved later resiliency and well-being. Both supportive family members and same- or older-aged men discovered through sexual exploration contributed to “a sense of self and a quality of agency when describing both their childhood and adult sexual episodes, even in the face of virulent homophobic environments.” While the health research evidence is strong concerning the deleterious effects of child sexual abuse, these findings point to the need for an analytic distinction to be made for adolescent sexuality where older male mentors may play a part in pathways to resilience.

This study, then, points to some of the social resources that can mitigate the harm caused by family and school abuse and that could contribute to the longer-term health and well-being of gay and bisexual men. School anti-bullying programs and gay-straight alliances may constitute structural reforms with very practical consequences for the immediate security of school children (demonstrated, for example, by Taylor and Peter (2011)) but also for the long-term health of these same children as they emerge into adulthood. Both schools and alternative spaces to home and school can provide additional avenues to well-being by providing safe spaces for self-expression, communication, and social connection by supporting childhood escape routes from hostile social environments. For these 40 men, such alternatives as sport and religion – whether Protestant, Catholic, or Islamic – which often appear in the biographies of heterosexual men as places of support or relief, figure in their narratives as additional enforcers of deprecation, harassment, and rejection. Rather, intellectual, artistic, and internet pursuits offered a measure of solace for these narrators. Finally, adolescent romantic and sexual connection, almost entirely discouraged if not punished for gay youth, opened a path to direct emotional support and access to the cumulative wisdom of gay cultures, experienced by a sizeable set of these men as healing and beneficial. From a psychological perspective, these resilience pathways may contribute to decreasing social isolation, improving self-esteem, increasing internal locus of control, and increasing emotional self-regulation. They also point to arrays of social interaction and social capital that could make a difference for those often deemed as “high risk” by health science and practice. This cumulating research on resilience among gay men suggests, then, several avenues by which the social capital of young gay men could be enhanced, avenues that very likely mitigate the effects of syndemics on HIV and other health risks. Work on these kinds of social structures and environments is a necessary complement to appeals for individual behavior change that have been the primary strategy for doing HIV prevention.

Footnotes

Acknowledgements

We would like to thank the other members of the Gay Strengths research team, David J Brennan, Syed Noor, Sandra Gardner, Winston Husbands, and Ted Myers for their assistance. We would also like to thank the volunteer research assistants of the HIV Prevention Lab for transcribing the interviews, including Aidan Ablona, who also contributed to the coding of interviews.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Canadian Institutes for Health Research.

Barry D Adam is Distinguished University Professor Emeritus of Sociology at the University of Windsor and Senior Scientist at the Ontario HIV Treatment Network. He has an extensive research record on the dynamics of domination and empowerment, LGBT studies, and HIV prevention. In recent years, he has received the Simon-Gagnon award for a distinguished career in the study of sexualities, the Sociologists' AIDS Network Career Award for outstanding contributions to the sociology of HIV, the Community Partners Award of the Ontario AIDS Network, the Anselm Strauss award for qualitative research on family relations, and the Queen's Diamond Jubilee Medal.

Trevor Hart is Professor of Psychology at Ryerson University. He holds a Chair in Gay and Bisexual Men's Health from the Ontario HIV Treatment Network. Dr. Hart's research examines factors associated with HIV transmission, and interventions to reduce HIV transmission risk and to promote sexual health among gay and bisexual men.

Jack Mohr is a health researcher, currently based at St Michael's Hospital in Toronto. His interests include health promotion, HIV prevention, health policy and implementation science. He holds an MA in Sexuality Studies from San Francisco State University.

Todd Coleman is an Assistant Professor of Health Sciences at Wilfrid Laurier University. He has worked on several Canadian community-based research projects with gay, bisexual, and other men who have sex with men, and other sexual and gender minority populations. In addition to his research with sexual and gender minority communities, his research interests include population health, epidemiology, research methods, HIV, and sexual health.

Julia Vernon studied Psychology and International Development Studies at McGill University, where she earned a Bachelor of Arts degree in 2013. Julia has worked at the HIV Prevention Lab in the Department of Psychology at Ryerson University since 2013, and served as coordinator for the Gay Strengths Study.

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