The Legacy of the Past Gay Men in Mid-Life And the Impact of HIV/AIDS By Spencer Cox Executive Director The Medius Institute For Gay Men’s Health The Medius Institute is a non-profit organization dedicated to improving the health, well-being, and longevity of gay men. The author is deeply indebted to Dr. Robert Kerzner and Dr. Walt Odets for their insights into these issues. See Kerzner RM. The adult life course and homosexual identity in midlife gay men. Annu Rev Sex Res. 2001;12:75-92 and Odets W. Survivor Guilt in HIV-Negative Gay Men. Hath Cont Ed for Psych. 4:15. 1994. Special thanks to Founding Sponsor Broadway Cares/Equity Fights AIDS, David Corkery and The Corkery Group, GlaxoSmithkline, Mark M. Sexton & W. Kirk Wallace, and New York’s Lesbian, Gay, Bisexual & Transgender Community Center. Also thanks to: Lynda Dee, Dr. Alan Downs, Dr. Anthony Gaudioso, Dr. Perry Halkitis, Michael Isbell, Michael Joyner, Jay Laudato, Mark Leydorf, Jon-David Nalley, Catherine McBride, Christopher Murray, David Nimmons, Laura Pinsky, Michele Pronko, David Richwine, Michael Shernoff, John Sirabella, Tom Viola, John Voelcker, Dr. Barbara Warren, Dr. Ron Winchell, and Mark Woodcock. The Medius Institute for Gay Men’s Health. 305 W. 45th St. Suite 4I. New York, NY 10036. Phone: (646) 873-3550. e-mail: [email protected] web site: www.mediusinstitute.org 2 Our lifetime as gay men has been bewildering, to be honest. But we dealt with it through this terrible plague as well, this hideous illness that struck so many people down. And the current younger generation I don't think even understands what we went through, what we witnessed. For me that's the fuel. The ashes of all the people I loved who are dead keep me going. I promised one of my best friends that I would not give up. And that's still very much a part of my identity. I am a child of the plague and I will never, never forget that. For some of us, that changed us forever. It gave us a sort of intensity and drive that the younger generation cannot know because they are lucky enough to have escaped it. Writer Andrew Sullivan in Soul Searching: Andrew Sullivan’s Quest to Reclaim Conservativism. Metro Weekly. November 9, 2006 Introduction The current generation of American gay men in mid-life has experienced remarkable losses. From the late 1970s until the end of 1999, when effective anti-HIV regimens became widely available, the AIDS epidemic ravaged America’s gay communities: the Centers for Control and Prevention (CDC) estimate that more than 267,500 men who have sex with men died of AIDS in the United States during those early years.1 Following the terrorist attacks of September 11th, 2001, there was immediate recognition of the urgent need for immediate and ongoing mental health evaluation and treatment for those exposed to and/or affected by the event.2 In contrast, for gay men who lived for decades through an epidemic that killed hundreds of thousands of friends and family members, no systematic effort has been made to treat -- or even to identify -- the long-term psychological effects associated with such traumatic experiences and painful memories. Self-harming behaviors have been identified in other survivors of mass trauma, and have also been associated with AIDS-related bereavement.3,4,5,6 Specifically, a number of risks have been identified for gay men in mid-life, defined roughly as thirty-five to fifty-five years of age, that may be directly or indirectly associated with traumatic experiences, including: • Depression and anxiety • Drug and alcohol addiction • Sexual risk-taking • Partner violence • The inability to positively imagine or plan for the long-term future 1 Centers for Disease Control and Prevention. HIV/AIDS Surveillance Supplemental Report. Vol. 8, No 1. 2001. Includes MSM and MSM/IDU. 2 Resnick H, Galea S, et al. Research on Trauma and PTSD in the Aftermath of 9/11. PTSD Res Quart. 15(1) Winter 2004. 3 Krystal H & Danieli Y. Holocaust Survivor Studies in the Context of PTSD. PTSD Res Quart. 5(4) Fall 1994. 4 Martin, J., and L. Dean, "Effects of AIDS-Related Bereavement and HIV-Related Illness on Psychological Distress Among Gay Men: A 7-Year Longitudinal Study, 1985-91," Journal of Consulting and Clinical Psychology 61 (1993), pp. 94-103. 5 Pfefferbaum B & Doughty DE. Increased alcohol use in a treatment sample of Oklahoma City bombing victims. Psychiatry. 2001 Winter; 64(4):296-303 6 Bremner JD, Southwick SM et al. Chronic PTSD in Vietnam combat veterans: course of illness and substance abuse. Am J Psychiatry. 1996 Mar; 153(3):369-75 1 There is no question that, at the time, massive bereavement produced traumatic symptoms. In 1993, researchers at the Columbia School of Public Health attempted to quantify the psychological impact of AIDS-related bereavements. In a group of 746 gay men, scientists found “a direct dose-response relation between bereavement episodes and the experience of traumatic stress response symptoms, demoralization symptoms, and sleep disturbance symptoms.”7 In this study, recreational drug use and sedative use also increased in proportion to the number of bereavement episodes. Drug and alcohol use are common responses to trauma. For instance, after September 11, 2001, sustained increases were seen in use of cigarettes, alcohol and marijuana among residents of Manhattan living below 110th Street; these increases were associated with post-traumatic symptoms and depression.8 Researchers find very high rates of recreational drug use among urban gay men: more than 50 percent of respondents in the Gay Urban Mens’ Health Study said they used recreational drugs.9 Almost 20 percent reported recent “frequent” use of powder drugs (ecstasy, ketamine, cocaine).10 While frequent or heavy drug use is not confined to gay men in mid-life, these men use and abuse recreational drugs in substantial numbers.11,12,13 7 Martin, 1993. Ibid. 8 Resnick 2004. ibid. 9 Stall R, Paul JP et al. Alcohol Use, Drug Use and Alcohol-related Problems Among Men Who Have Sex With Men: The Urban Men’s Health Study. Addiction. 96(11). Nov 2001. p. 1589 10 Stall 2001. Ibid. 11 Sexual behavior patterns of methamphetamine-using gay and bisexual men. Subst Use Misuse. 2005;40(5):703-19 12 Patterson TL, Semple SJ et al. Methamphetamine-Using HIV-positive Men Who Have Sex With Men: Correlates of Polydrug Use. J Urban Health. 2005 Mar;82(1 Suppl 1):120-6. 13 Halkitis PN, Green KA & Mourgues P. Longitudinal investigation of methamphetamine use among gay and bisexual men in New York City: findings from Project BUMPS. J Urban Health. 2005 Mar;82(1 Suppl 1):i18-25. 2 In addition, there is evidence that, in gay men, traumatic bereavement is associated with risky sexual behavior. Men who have sex with men and who lost a friend or relative in the September 11th attacks were significantly more likely to report unprotected anal intercourse, and more sexual partners after the disaster than those who did not.14 And there is compelling evidence of ongoing, increased risky sexual behavior among gay men: since 1999, dramatic increases in rates of syphilis have been reported among American men who have sex with men.15 Rates of new HIV infections in men who have sex with men in the United States are rising, and studies show that risk-taking is frequent among middle-aged gay men. Of newly reported HIV cases among men who have sex with men in New York City in 2004, the majority were in men over 30, and more than a third were in men over 40. 16,17 The development of effective HIV therapy seems to have interrupted the study of the psychological impact of the AIDS epidemic: very little research is available from the late 1990s onward. However, these current data on risk behaviors among gay men in mid-life offer ample cause for questions and concerns. Gay men now in mid-life came of age before or during the dark early days of the epidemic, and have survived to see the dramatic amelioration of its effects in the United States. It would be surprising if such experiences did not have long-standing effects on the lives of survivors. While it is by no means certain that current high-risk behaviors are related to the traumatic survival of AIDS-related loss, the question certainly merits more detailed exploration than it has been given. 14 Chiasson MA, Hirshfield S et al. Increased high risk sexual behavior after September 11 in men who have sex with men: an Internet survey. Arch Sex Behav. 2005 Oct;34(5):527-35. 15 Division of STD Prevention. Sexually Transmitted Disease Surveillance 2004 Supplement: Syphilis Surveillance Report. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2005. Online at http://www.cdc.gov/std/Syphilis2004/SyphSurvSupp2004.pdf. Accessed 30 Jul 2006. 16 Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2004. Vol. 16. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2005 17 Torian L. Director, HIV Surveillance and Epidemiology Program, Department of Health and Mental Hygiene, City of New York. Personal Communication. Dec 7 2004 3 The History of Loss From 1979 until the late 1990s, urban gay men experienced unprecedented losses to HIV/AIDS. Unlike “normal” bereavements, these men often experienced multiple, repeated losses on an almost unimaginable scale: As of 1994, up to 60 percent of gay men reported annual losses, and a third of these bereaved individuals described the multiple loss of family, friends, and neighbors.