Sin How Lim, Amy Herrick, Thomas Guadamuz, Mark Friedman, Michael Marshal, Ron Stall Department of Behavioral and Com

1. Childhood sexual abuse, gay-related victimization, and syndemic production among men who have sex with men (MSM): Findings from the Multicenter AIDS Cohort Study Sin How Lim, Amy Herrick, Thomas Guadamuz, Mark Friedman, Michael Marshal, Ron Stall Department of Behavioral and Community Health Sciences

2. Key Finding In MSM, sexual violence and social shaming in early life are associated with psychosocial health problems in later life

3. Syndemic “two or more afflictions, interacting synergistically, contributing to excess burden of disease in a population”-- Centers for Disease Control and Prevention, USA. www.cdc.gov/syndemics

4. Background • Psychosocial epidemics of substance use, depression, intimate partner violence, are associated with HIV risk taking among urban MSM (Greenwood 2002, Paul 2002, Stall 2003, Mills 2004, Relf 2004) • Syndemic Theory (Stall 2008) • Cultural marginalization (Singers 1994, Myers 2003, Diaz 2001) • Homophobia • Stigma • Life-course perspective

5. Aim of Study To test part of the syndemic theory using empirical data from a prospective cohort study of MSM

6. Multicenter AIDS Cohort Study • A prospective, cohort study of HIV infection and risk factors among MSM • Analytic sample, n=1086 • Baltimore/Washington DC, Chicago, Los Angeles, and Pittsburgh • New set of measures between 2007-2008

7. Measures Childhood Sexual Abuse Gay-related Victimization (28.4%, age 12-14) Sense of Masculinity Failure Internalized Homophobia Current Gay-related Discrimination Current Stress

8. Syndemic Variables • Sexual Compulsivity- inability to control sexual urges, feelings, fantasy, etc • Intimate Partner Violence - physical, emotional, sexual violence • Depression - CES-D (Raldoff, et al. 1977), depressive symptoms in past week • Substance Use - poppers, crack cocaine, other forms of cocaine, methamphetamines, ecstasy, and binge drinking • Risky Sexual Behavior - Number of unprotected anal intercourse partners in past 6 months

9. Statistical Method Path analysis (EQS 6.1, Bentler) was conducted to test a model (N=1086) containing • childhood sexual abuse, gay-related victimization, sense of masculinity failure • discrimination, internalized homophobia, stress, sexual compulsivity • syndemic variables

10. Hypothesized Model Childhood Adulthood ‘Syndemic’ Outcomes Childhood Sexual Abuse Intimate Partner Violence Discrimination Gay-related victimization Unprotected Anal Sex Partners Internalized Homophobia Depression Sense of Masculinity Failure Substance Use Stress Sexual Compulsivity

11. Hypothesized Model Childhood Adulthood ‘Syndemic’ Outcomes Childhood Sexual Abuse Intimate Partner Violence Discrimination Gay-related victimization Unprotected Anal Sex Partners Internalized Homophobia Depression Sense of Masculinity Failure Substance Use Stress Sexual Compulsivity

12. Hypothesized Model Childhood Adulthood ‘Syndemic’ Outcomes Childhood Sexual Abuse Intimate Partner Violence Discrimination Gay-related victimization Unprotected Anal Sex Partners Internalized Homophobia Depression Sense of Masculinity Failure Substance Use Stress Sexual Compulsivity

13. Hypothesized Model Childhood Adulthood ‘Syndemic’ Outcomes Childhood Sexual Abuse Intimate Partner Violence Discrimination Gay-related victimization Unprotected Anal Sex Partners Internalized Homophobia Depression Sense of Masculinity Failure Substance Use Stress Sexual Compulsivity

14. Hypothesized Model Childhood Adulthood ‘Syndemic’ Outcomes Childhood Sexual Abuse Intimate Partner Violence Discrimination Gay-related victimization Unprotected Anal Sex Partners Internalized Homophobia Depression Sense of Masculinity Failure Substance Use Stress Sexual Compulsivity

15. Hypothesized Model Childhood Adulthood ‘Syndemic’ Outcomes Childhood Sexual Abuse Intimate Partner Violence Discrimination Gay-related victimization Unprotected Anal Sex Partners Internalized Homophobia Depression Sense of Masculinity Failure Substance Use Stress Sexual Compulsivity

16. Final Model (CFI = .975, GFI = .992, RMSEA = .049, 90% CI RMSEA (.036, .062) Childhood Adulthood ‘Syndemic’ Outcomes Childhood Sexual Abuse Intimate Partner Violence Discrimination Gay-related victimization Unprotected Anal Sex Partners Internalized Homophobia Depression Sense of Masculinity Failure Substance Use Stress Sexual Compulsivity

17. Final Model(CFI = .975, GFI = .992, RMSEA = .049, 90% CI RMSEA (.036, .062) Childhood Adulthood ‘Syndemic’ Outcomes Childhood Sexual Abuse Intimate Partner Violence Discrimination Gay-related victimization Internalized Homophobia Unprotected Anal Sex Partners Depression Sense of Masculinity Failure Substance Use Stress Sexual Compulsivity

18. Discussion • Gay-related victimization is common in young gay men • Childhood sexual abuse, Sense of masculinity failure -> Sexual Compulsivity -> Substance use -> NUAI • Early Sense of Masculinity Failure -> Depression • Violence, discrimination occur in gay youth • Internalized by gay youth • shame

19. Implications • Prevention: life course perspective, early life Structural intervention to reduce gender norm-based violence Effective interventions need to address multiple interrelated psychological and sexual sequelae • Future research: longitudinal study of heterosexual and homosexual adolescents • Subpopulations: racial minority, rural

20. Acknowledgements • Participants of the Multicenter AIDS Cohort Study (MACS) • NIH grant R01-DA022936 (“Long-term health effect of Methamphetamine use in the MACS”, PI: Ron Stall) • The Center for Research on Health and Sexual Orientation, University of Pittsburgh

21. Email: shl18@pitt.edu Danke schön

22. Measures • Childhood Sexual Abuse • forced sex • before 18 years old • moderately or extremely upsetting experience • prevalence 9.3% • Gay-related Victimization • age 12-14 • verbal insults • threatened with physical violence • targets of thrown objects • physical assault (punched/kicked/beaten) • threatened by knife, gun, or weapon • Any victimization, prevalence 28.4%.

23. Measures • Sense of Masculinity Failure • 15-18 years old • Experience of shame related to not achieving masculine norms (Andrew 2002) • e.g.,“How often do you feel ashamed about your ability to act like a man” • Internalized Homophobia • In the past 12 months • 5-point response scale (disagree strongly to agree strongly) • e.g., “I tried to stop being attracted to men in general”

24. Measures • Current Discrimination -past 12 months-verbally insulted, or threatened physically, targeted with a thrown object, punched/kicked/beaten, or threatened with a knife/weapon because respondent was gay or bisexual • Current Stress -past 12 months-finances, job satisfaction, death/illness/injury of close ones, housing, physical health • Sexual Compulsivity-past 5 years-condition characterized by sexual fantasies and behaviors that interfere with personal, interpersonal, or vocational pursuit “I had trouble controlling my sexual urges”

25. Strengths and Limitations • Measures have shown fairly good psychometric properties and thus path analysis is appropriate • Could examine moderator and interaction effects • Childhood adverse experience are retrospective • May only be generalized to urban MSM in the United States

26. Direct Effects from Hypothesized Path Model b=conefficient of each predictor in its raw unit z = z value of the standard error of each predictor, B = standardardized coefficient

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28. Contextual Stressors: Socioeconomic, Racial/Ethnic Family of Origin (Abuse, Parental Psychopathology/Substance Abuse)General Stressors of Urban Life: Higher Costs of Living, Relative Anonymity Gay Identity Development First Awareness of Same Sex Sexual Attraction-Wonder if I’m Gay-First Same Gender Sexual Activity-Decide I’m Gay-Disclosure of Being Gay to Others • Access to Minority Weaknesses • Continued Sexual • Shaming/Silence • Stress of Being Openly Gay • in a Heterosexual Context • Social Disconnect • Increased Target for Abuse • High Background Prevalence • Rates of Substance Abuse, • Violence, MH Problems, • STDs, and HIV Development of a Psycho-Social Health Problem • Development of Internalized Homophobia • Devalue Other Gay Males Hide • Self /Monitor Behaviors • Withdrawal from Active Social Life • Assume Marginalized Group Identity Substance Abuse SYNDEMIC HIV VULNERABILITY Depression • Access to Minority Strengths • Increased Opportunity for: • Social Bonding • Sense of Community • Romantic Partners • Healthy Sense of • Being Male • Healthy Sense of • Being Gay • Economic • Protogay Social Skills • Ambivalent Attachment to Mainstream • Social Cliques • Possible Delayed Identity Attachment to • Any Social Clique • Possible Attachment to Non- • Mainstream Social Cliques • Possible Development of Ability to • Thrive in Adversity • Possible Development of Vulnerability • to Psychosocial Health Problems Violence Victimization HIV Sexual Risk Behavior Masculine Socialization Stress: Shaming and Other Punishment of Gay Males for Failing to Achieve Masculine Ideals Cultural Homophobia: Cultural Norms and Institutional Policies that Discriminate Against Gay Men (e.g. Marriage, Adoption, Tax Laws, Military Service, “Glass Ceiling” in Professional Settings)