Emotional support for gay men

1. Emotional support for gay men A resource for healthcare professionals

2. Objectives This slide set aims to enable healthcare professionals (HPC) to: • Appreciate that there is an elevated risk of emotional and mental health problems among gay men than the general population • Understand that HIV and its treatment can pose additional mental and emotional problems for gay men living with HIV • Recognise some of the common triggers and consequences of mental and emotional issues, including stigma, homophobia, serophobia, behaviour and health outcomes • Be better informed about the needs of gay men in general, including the needs of younger and older gay men, and men who have sex with men (MSM) • Enhance the patient–professional relationship and use appropriate interventions, support tools and strategies to support the mental and emotional well-being of gay men • Recognise the importance of support networks and the role they can play in supporting gay men, including those who are HIV-positive

3. Contents Introduction Etiology Emotional and physical issues Younger and older gay men Support tools and strategies Case studies

4. Introduction

5. Different levels of severity and incidence of mental health issues It can be difficult to identify ‘generalised’ or ‘reactive’ symptoms: Symptom presence may be below diagnostic criteria Patients may experience single episodes or chronic symptoms The spectrum of severity, incidence and duration of symptoms Severe Moderate Reactive Generalised

6. Gay men are at higher risk of ‘emotional health’ problems than heterosexuals Among 571 gay men in Switzerland nearly half fulfilled the criteria for at least one of the five mood or personality disorders (DSM-IV) 19.2% had major depression 21.9% had specific and/or social phobia 16.7% had an alcohol and/or drug dependence disorder >25% of the cases had more than one disorder 35.7% consulted a HCP in the past 12 months for mental health Wang et al (2007) Soc Psychiatry Psychiatr Epidemiol

7. Emotional health issues in gay men Netherlands Mental Health Survey and Incidence Study (NEMESIS): Lifetime Prevalence of DSM-III-R Disorders by Sexual Behaviour in Preceding Year Sandfort TGM et al (2001) Arch Gen Psychiatry

8. Emotional triggers in gay men External homophobia and bullying Expectations of rejection Age Ethnicity History of abuse Heterosexism Internalised homophobia HIV and other diseases and medical issues, e.g. side effects Multiple AIDS-related bereavement

9. HIV in Europe (2008) In the EU/EEA (in 2008), the predominant mode of transmission for HIV infection is sex between men European Centre for Disease Prevention and Control/WHO Regional Office for Europe (2008)

10. Worldwide prevalence of HIV among men who have sex with men • Worldwide, it is estimated that sex between men accounts for 5–10% of HIV infections • Prevalence ranges widely across regions • United States 15% • United Kingdom 7–13% • Sub-Saharan Africa 12–43% • Latin America 8–26% • Asia 19% • Eastern Europe and Central Asia 0–23% • Caribbean 11–32% • Middle East and North Africa 1–9% UNAIDS (2000) Report on AIDS and men who have sex with men (2000); Jenness SM et al (2011) Public Health Rep; Fox J et al (2010) AIDS; UNAIDS (2009) AIDS epidemic update

11. HIV-associated mental and emotional problems can be burdensome in their own right They merit treatment and care Effective interventions are available Vulnerability Diagnosis Adjustment Relationships Prevention Health seeking Risk behaviours Treatment Adherence Suicide Adaptation Resilience Coping Mental and emotional problems in HIV 1. Bravo Pet al (2010) AIDS Rev

12. HIV and emotional distress in gay men Introduction of antiretroviral therapy (ART) means life expectancy of people with HIV is approaching that of general population1 As treatment has improved, emotional/social support may have declined as attitudes towards HIV change Despite effective treatment, gay men living with HIV continue to experience significant emotional distress2 1. Battegay et al (2009) Swiss Med Wkly; 2. Chuang HT et al (1989) Am J Psychiatry

13. Emotional health is important for HIV prevention and treatment Associated with outcome Adherence Side effects Switching Decision making Disease progression Clinical markers Bereavement • Associated with adaptation to HIV status • Coping • Adjustment • PTSD • Depression • Symptoms • Treatment • Disclosure • Support • Risk behaviour • Associated with risk of HIV infection • Drug use • Risk behaviour • Multiple partners • Low mood • Diagnosed mental illness/ vulnerability Harding R et al (2006) Int J STD AIDS; Johnson MO et al (2005) J Pain Symptom Manage; Sherr L et al (2008) AIDS

14. Additional challenges faced by gay men living with HIV Living with a chronic disease HIV diagnosis Guilt/shame Coping with acute illness Feelings of ‘prevention’ failure Stressors for HIV-positive gay men Alcohol and substance abuse ART and side-effects Access to medical, social and emotional support Relationships, family and friends HIV stigma Guilt/shame/ stigma/failure ideation

15. Etiology of emotional health issues among gay men

16. Forms and consequences of stigma and isolation Stigma is defined as an: “attribute of an individual that is undesirable or discrediting in the eyes of society, thus reducing that individual’s status” MINORITY STRESS The excess stress to which people from stigmatized social categories are exposed as a result of their social ‘minority’ position Associated with damage to self-esteem, self-image and self-hatred Linked with guilty feelings, depression, PTSD, increased risk behaviour Can be directly experienced or perceived • Expectations of rejection • Concealment • Internalised homophobia • Impact on physical, mental/emotional wellbeing • Fear of mental and physical attack Minority status based on sexual orientation, HIV status or race Adapted from Meyer IH (2003) Psychol Bull

17. Stigma, prejudice and discrimination Lifetime victimization directly attributed to sexual orientation is strongly linked to emotional health problems1,2 In one study, 34% of gay youths reported perceived discrimination based on their sexual orientation vs. 4% in heterosexual youths3 Gay men are significantly more likely than lesbians or bisexuals to experience violence and property crimes4 In a study of gay men, lesbians and bisexual adults ~20% experienced a personal or property crime based on their sexual orientation4 More than 10% reported having experienced employment or housing discrimination4 Fears associated with disclosure of being gay predict job attitude, psychological strain, work environment and career outcomes5 1. D’Augelli AR et a; (2006) J Interpers Violence; 2. D’ Augelli AR et al (2002) School Psychology Monthly; 3. Almeida J et al (2009) J Youth Adolesc; 4. Herek G M (2009) J Interpers Violence; 5. Ragins BR et al. (2007) J Appl Psychol

18. Stigma and the ‘coming out’ process Benefits of coming out Disadvantages of coming out Rejection Perceived stigma Acceptance Physical/ verbal abuse Discrimination Community Disappointment of family/friends Shame Happiness Non-conformity Comfort Risk of persecution Corrigan PW et al. (2009) Community Ment Health J

19. The role of shame • Concealment of sexual identity is one of the primary reasons why men may experience mental health problems • Individuals may hide their sexual identity out of shame and guilt • Among gay men, shame is elevated among those who see themselves breaching social norms • The emotion of shame draws attention to real or imagined deficiencies of the self • Greater feelings of shame are linked with suicide, drug and alcohol abuse, and depression Bybee JA et al (2009) J Adult Dev

20. The role of guilt • Chronic guilt is associated with mental health problems • Sources of chronic guilt may include: • being betrayed or betraying others • ongoing problems in maintaining intimate relationships • hurting relationship partners • Harmful chronic guilt may result among gay men if disclosure of gay identity resulted in a betrayal or severing of a relationship or if their family members are ashamed, disappointed, or emotionally hurt by revelations of sexual identity Bybee JA et al (2009) J Adult Dev

21. HIV-related stigma • Stigma is a severe problem that affects the daily lives of gay men living with HIV1 • Stigma can occur in any setting, including within the gay community and the healthcare sector1 • HIV-related stigma can negatively impact: • social relationships2 • access to resources2 • social support provision2 • psychological well being and self-esteem2 • effective HIV prevention activities2 • voluntary HIV counselling and testing2 • HIV treatment adherence2 1. Stutterheim SE et al (2009) AIDS; 2. Stutterheim (2008) Aids Fonds

22. Factors that may impact cognitive functioning HIV-related (neuro)cognitive impairment Occurrence, end stage disease, effects of treatment, manifestation Memory HIV action in the brain and central nervous system Predisposing personality Pre-morbid psychological/psychiatric factors Neuropsychiatric effects of HIV medications Psychological impact of HIV diagnosis and treatment

23. HIV-associated (neuro)cognitive disorder (HAND) • As many as 40% of HIV-positive patients suffer from HAND1 • It is progressive, but with a variable course • Patients may develop ambulation or gait problems, mania, panic, psychosis, social isolation, or anxiety • Disruptions in ability to perform activities of daily living can impact on psychosocial functioning • Patients aware of their deterioration may develop an adjustment disorder characterized by profound fear, anxiety, or depression 1. Sacktor N (2002) J Neurovirol

24. Emotional and mental well being and the impact of HIV and its treatment are interlinked HIV HIV Treatment +ve • New life purpose • Feeling part of a new community • Immune reconstitution • Viral suppression • Resolution of symptoms • “Feel” better • Confidence in self management • Confidence in treatment Impact • Depression and anxiety of being sick • Fear of disclosure • Concerns about work/money • Anxiety and depression • Visible side-effects can lead to fear of disclosure and low self-esteem and decreased confidence • CNS side-effects including mood disturbances can affect social relationships • Sexual dysfunction -ve

25. Emotional issues among gay men

26. Emotional issues among gay men Higher levels of psychological distress1 Greater likelihood of diagnosis of depression or anxiety1 Higher risk of suicidal ideation2 Higher risk of deliberate self-harm2 Higher prevalence of panic attacks3 Greater perceived mental health needs and greater use of mental health services1 Greater risk for eating and body image disorders4 More substance abuse1 Higher risk of conduct disorders5 1. Burgess D et al (2007) J LGBT Health Res; 2. King M et al (2008) BMC Psychiatry; 3. Cochran SD et al (2003) J Consult ClinPsychol; 4. McCreary DR et al (2007) Am J Men’s Health; 5. Mustanski BS et al (2010) Am J Public Health

27. Depression and anxiety • Prevalence of major depression in gay men is over 17%1 • Prevalence of distress and major depression in gay men is around 30%1 • Risk for anxiety is two-fold greater in gay/bisexual men compared with heterosexual men2 • Gay men are 4.7 times more likely to meet the criteria for a panic disorder3 1. Mills TC (2004) Am J Psychiatry; 2. King M et al (2008) BMC Psychiatry; 3. Cochran SD et al (2003) J Consult Clin Psychol

28. Vulnerability of gay men to depression Risk for depression is at least two-fold greater in gay/bisexual men compared with heterosexual men* Lifetime prevalence 12-month prevalence *relative risk [RR] range, 2.41–2.58 King M et al (2008) BMC Psychiatry

29. Factors associated with depression • Lack of a domestic partner1 • Not identifying as gay1 • Experiencing multiple episodes of homophobic violence1 • Very high levels of community alienation1 • Histories of attempted suicide1 • Child abuse1 • Recent sexual dysfunction1 • Adopting denial and isolation as coping strategies2 • Less social support2 • Less gay community involvement2 • Socio-economic hardship2 • HIV stigma3 • Hepatitis C virus (HCV) infection and treatment4 • Compromised health resulting from co-morbidities 1. Mills TC et al (2004) Am J Psychiatry; 2. Mao L et al (2009) Aust N Z J Public Health; 3. Grov C et al (2010) AIDS Care

30. Depression and HIV • Rate of depression is significantly higher in HIV-positive gay men than HIV-negative gay men1 • Unclear whether HIV and depression are correlated • 38% of men with HIV meet criteria for an acute stress disorder2 • Some ART drugs and regimens are associated with a higher prevalence of depressive symptoms3 • Untreated depression among HIV patients is associated with reduced adherence to ART4 • Chronic depression may negatively affect HIV disease progression5 1. Mao L et al (2009) Aust N Z J Public Health; 2. Israelski DM et al (2007) AIDS Care; 3. Marcellin F et al (2008) AIDS 2008, XV11 International AIDS Conference; 4. Kacanek D et al (2010) JAIDS; 5. Leserman J (2008) Psychosom Med

31. Survival, depression and adherence to ART Lima VD et al (2007) AIDS

32. Substance use in gay men • Risk for alcohol or drug dependence over 12 months were 1.5-fold higher compared with heterosexual men1 • In the US, use of methamphetamine has been estimated to be 5–10 times more than in the general population2 • Methamphetamine has been shown to predict depressive symptoms among gay/bisexual men3 • Youths reporting same-sex attraction have been shown to be at higher risk for substance use and abuse4 1. King M et al (2008) BMC Psychiatry; 2. Shoptaw S (2006) Top HIV Med; 3. Peck JA et al (2005) J Urban Health; 4. Russell ST et al (2002) Am J Public Health

33. Suicide • Significantly greater lifetime prevalence of suicide attempts among gay/bisexual (GB) men than heterosexual men King M et al (2008) BMC Psychiatry

34. Suicide • 4-fold excess in suicide attempts (lifetime risk) among gay/bisexual men versus heterosexual men1 • 2-fold increase in self-harm1 • Period of greatest risk for suicidal ideation/attempts is period of ‘coming out’ to immediate family2 • People attempting or considering suicide often do not ‘seek death’ but simply cannot ‘face life’ 1. King M et al (2008) BMC Psychiatry; 2. Wichstrøm L (2007) Acta Sociologica;

35. Predictors of suicidal ideation and suicide attempts Predictors of suicidal ideation and attempts include:1–5 • Hopelessness1 • Family rejection2–4 • Other psychiatric symptoms2 • Drug/alcohol abuse1 • Internalized homophobia2 • HIV diagnosis5 1. Walls N et al (2008) Soc Work; 2. Igartua KJ et al (2003) Can J CommunMent Health; 3. Wichstrøm L (2007) ActaSociologica; 4. Ryan C et al (2009) Pediatrics 5. Badiee J et al (2011) J Affect Disord

36. Post-Traumatic Stress Disorder (PTSD) • The lifetime risk of PTSD in the general population is 4% for men and >9% for gay men1 • 16–54% of HIV patients suffer from PTSD2 • If untreated, PTSD may be associated with:2 • poor medication adherence • HIV risk behaviour • drug and alcohol abuse • depression • difficulties with relationships and employment 1. Roberts AL et al (2010) Am J Pub Health; 2. Whetten K et al (2008) Psychosom Med

37. Pervasive personality disorders • Young gay men score higher in both measures of narcissism and lower on the self-esteem measure, compared with their heterosexual counterparts1 • Narcissistic personality disorder may be related to defences against shame2 • Individuals with Borderline Personality Disorder (BPD) are more likely to report homosexual or bisexual orientation3 1. Rubinstein G (2010) Sex Marital Ther ; 2. Wurmser L (1987) Shame the veiled companion of narcissism, in The Many Faces of Shame; 3. Reich DB et al (2008) J Pers Disord

38. Body dissatisfaction and eating disorders • Compared with heterosexual men, gay/bisexual men: • Have significantly higher prevalence estimates of eating disorders1 • Are more likely to report both binge eating and purging2 • Are more likely to view their bodies as sexual objects and may be more vulnerable to experiencing body dissatisfaction3 • Consequences of HIV, such as lipodystrophy, place increased risk on a group highly vulnerable to body dissatisfaction and eating disorders 1. Feldman MB et al (2007) Int J Eat Disord; 2. Austin SB et al (2009) J Adolesc Health; 3. Siever MD (1994) J Consult Clin Psychol

39. Younger and older gay men

40. Younger gay men • Homophobic abuse, bullying, isolation and invisibility in adolescence can result in:1,2 • increased truancy/drop-out • lower examination results • higher levels of mental health problems: • panic attacks • eating disorders • suicide attempts • The key risk indicator for suicide among adolescents is sexual minority status3 • Isolation and fear of discovery in adolescence interferes with self-esteem, identity and intimacy4 1. Takács J (2006) ILGA- Europe and IGLYO; 2. Bridget J on behalf of GALYIC (2003) GALYIC; 3. Russell ST (2003) Am Behav Sci; 4. Frankowski BL (2004) Pediatrics

41. Adolescence and school • Studies have reported that 65–75% of UK pupils experience homophobic bullying1 • 50% of young gay people feel that it is hard for people like them to be accepted at school and feel unable to be themselves1 • Over a third are unhappy at school1 • Among gay adults who had been bullied at school, 50% had contemplated suicide or self-harm2 • Lack of positive information about homosexuality/role models within schools mean negative messages about homosexuality go unchallenged 1. Hunt R et al (2007) The School Report: The experiences of young gay people in Britain’s schools; 2. Rivers I et al (2003) Children and Society

42. Coping skills in adolescence Normal stressors of puberty Additional stressors related to being gay • Hormonal changes • Changes to physical functioning • Changes to social functioning • Development of sexual orientation and identity • Initiation of romantic and sexual intimacy • Social stigma • Discrimination • Explicit victimisation (e.g. Bullying) • Implicit victimisation (e.g. Antigay messages from media, society, religion, etc) • Internalised homophobia Coping skills not fully developed Adolescents less able to protect themselves from stressors Unable to request adult support

43. Potential issues faced by older gay men Remaining closeted for all or much of their life History of psychiatric treatment to ‘cure’ them Gay scene geared towards younger people Multiple AIDS-related bereavement Multiple stigma of age, being gay, HIV positive, mentally ill, race Emotional health Older people’s organizations aimed at heterosexuals Neurocognitiveimpairment related to prolonged life with HIV and exposure to treatment ‘Cult of Youth’ – age generally depicted as unattractive and socially boring

44. Loneliness in older age • Older gay men appear to experience heightened feelings of loneliness compared with younger gay men1 • Those who had experienced or expected negative reactions had the highest levels of loneliness2 • Older gay men are more likely to have experienced divorce, have less intensive contact with their children and other members of their families, or be childless1 1. Fokemma T et al (2009) Arch Sex Behav; 2. Kuyper L et al (2009) Arch Sex Behav

45. Older gay men living with HIV • Have been described as being situated at the lowest rung of a contemporary gay social hierarchy1 • Feel devalued and marginalized, especially if not physically healthy2 • Are more socially isolated and lonely3 • Receive less compassion and sympathy from others regarding their disease than younger adults3 1. Dodds C (2006) J Community Appl Soc Psychol; 2. Schrimshaw EW (2003) J Health Psychol; 3. Siegel K et al (1998) Res Aging

46. Differences between younger and older gay men • Older gay men may experience less severe emotional symptoms than younger men1 • related to a lessening in shame • Sexual behaviour may differ among both younger and older gay men2 • Compared with their older counterparts, gay men aged <25 years reported:2 • fewer recent partners • less sex with casual male partners • less engagement in group sex 1. Bybee JA et al (2009) J Adult Dev; 2. Prestage G et al (2009) AIDS Care; 3. Prestage G et al (2008) Sexual Health

47. Managing mental and emotional issues among gay men

48. How to identify potential mental and emotional issues and risks Approaches in medical practice range from simple history taking techniques and questions, to more complex and formal screening instruments: • Simple history taking – consider asking routine questions such as: • How would you describe your sexuality? • Who are you out or open to about your sexuality? • What about alcohol/recreational drug use? • (If HIV-positive) Who have you told about your HIV status, do you have anyone to talk to about it? • Formal screening tools • Risk assessments

49. Individualizing HIV care is dependent upon a full understanding of the man’s history Socio-economic class Age Other transmittable infections Family issues Sexual issues Medical history Stage of ‘coming out’ Support Treatment should vary depending on the unique needs and personal circumstances of each man . . . Immigration Violence or sexual abuse Co-morbid problems (e.g. alcoholism, drug use, depression) Acceptance of sexual orientation Culture or religion Language and understanding Existing support network

50. Mental health screening and referral pathway for people living with HIV HIV diagnosis E.g. CDQ or HADS + IHDS prior to first medical appointment Emotional health screening Positive Negative • Discuss treatment and referral options with patient for the most appropriate services, e.g. • Psychology • Primary care • Memory clinic/ neuropsychologist • Pharmacist • Psychiatry • Always discuss consent with patient before disclosing their status to another professional Repeat emotional health screening annually and ask four pre-screening questions in every clinic consultation There may still be a need for appropriate emotional support and services