Over the past year, my Under the Lens blog has featured seven theoretical topics. To date, my writing here has highlighted academic work of numerous researchers. These topics are just some of the theoretical perspectives that help to explain persistent inequities in gay men’s health outcomes at a population level:

• Rebecca Young and Ilan Meyer’s work on the limitations of the term ‘men who have sex with men’ (MSM)
• Jeffrey Aguinaldo’s arguments on the important distinctions between homophobia and heterosexism
• Ron Stall’s model of syndemics among gay men
• Barry Adam and Cindy Patton’s work on medicalization of HIV
• Innovative models of HIV prevention proposed by Patricia Hill Collins, Thomas Coates, and Len Tooley
• Intersectional analysis by Kimberlé Crenshaw and Mia Mingus,
• Phillip Hammack’s work on life course analysis.

In my blog this month, I will revisit these theories in an attempt to connect the dots between them, and share some of my reflections on these topics since first writing about each one. Through my ongoing work with gay men, and engagement with academic reading, I have continued to deepen my engagement with these theories. This month’s blog reflects my musings as to how these theories complement each other and some of the implications they have for our work in gay men’s health.

Intersectionality (1) has been front of mind in my own work as of late. First articulated by Black feminists in the United States, intersectionality highlights the simultaneous nature of multiple forms of oppression, and the need for social justice movements to be responsive to diversity within them. As such, intersectionality gives us pause to think about the limitations of framing this field as “gay men’s health”, when it is also tasked with meeting the needs of cis- and trans*-gender gay, bisexual, two-spirit and ‘other’ MSM.

As discussed in my first blog here at Under the Lens, ‘gay men’ is preferable over ‘MSM’ in some contexts. But, intersectionality begs the question as to the limitations of using the language of ‘gay men’ to include a plethora of men who, behaviourally, have sex with men, but may identify their sexuality as gay, straight, bisexual, two-spirit, down low, Radical Faerie, or any number of other ways. The way we describe our sexuality carries cultural significance, and often, reflects the social environments in which we live, and is something that must be self-determined. Intersectionality raises the possibility by talking about gay men’s health, we homogenize the needs of other men who are sometimes assumed to be included in this category.

Intersectionality raises the possibility that by framing our work as gay men’s health, we collectively pay less attention to the needs of men who identify their sexuality in another way, and the unique cultural and social aspects these identifiers represent. When programs are designed by and for cisgender gay men, they may not respond to the needs of trans gay men, two-spirit men, or any number of other groups of men in the behavioural category of MSM. For example, surveys designed to understand gay men’s experiences often ask about homophobia, but do not ask about transphobia or biphobia. It may not always be a bad thing to only focus on certain groups of people. However, when we erroneously assume that certain groups are included in our work, we often reproduce the very kinds of injustice we seek to overcome.

While intersectionally provides a challenge as to how we frame gay men’s health, intersectionality also offers a framework for recognizing the impact of institutional and social structures on people’s individual experiences. The attention to structural aspects of health and wellbeing in intersectionality is consistent with other theoretical paradigms discussed in the blog so far. For example, Aguinaldo argues that homophobia is an insufficient concept to reduce gay men’s health inequities and calls for attention to heterosexism (2). In another example, Ron Stall’s syndemics model focuses on masculine socialization stress and heterosexism as factors in health inequities and the continued transmission of HIV (3). Intersectionality also helps us to pay attention to the ways a person’s age and cumulative life experiences matter when trying to provide tailored and specific supports as in Philip Hammack’s life course model (4).

The gay men’s health theories highlighted here consistently point to the necessity of addressing structural aspects of gay men’s lives. Over and over again, these theoretical perspectives point to structural factors that affect gay men, the ways men are – or aren’t – recognized in service provision, and the variety of approaches taken to addressing their needs. Although structural interventions produce change over the long term, they may leave people who need change today with unmet needs. Thus, we have to include multiple approaches in our advocacy and service provision.

The work done by the AIDS Coalition to Unleash Power (ACT UP) in the United States throughout the 1980s and 1990s exemplifies the strengths of combining advocacy to change structural injustices with immediate alternatives to meet people’s current needs. ACT UP’s work included policy advocacy to improve legal and bureaucratic recognition of diverse relationships and people living with HIV. In addition to challenging systems that were failing their needs, ACT UP actively created new systems in the meantime. For example, while the Treatment and Data Committee of ACT UP was challenging the US Food and Drug Administration’s regulatory processes, and advocating for pharmaceutical companies to do what they could to make drugs available more quickly and at low cost, other members established an underground buyer’s club that imported drugs used in other countries to treat HIV. ACT UP’s ability to challenge structural injustices and inadequacies while simultaneously providing direct services to meet people’s existing needs is also a powerful reminder of the diversity of strategies needed to create change.

The insights in each of these theoretical perspectives illustrate the complexity and multiplicity of aspects to address in our collective efforts to support and strengthen the health and wellbeing of gay men. However, the challenge remains in effectively implementing the relevant aspects of these perspectives into the day-to-day work of gay men’s health in Canada and beyond.

Many of the theories and subsequent discussions here – the need to focus on gay men’s health and wellbeing beyond solely HIV, increasing the availability of culturally responsive services for gay men, and structural change to support gay men’s health and well being earlier in, and throughout, the life course – are not new. The ongoing nature of these conversations highlights the depth of these issues, the challenges we collectively face in trying to address them, the need to continue to learn with and from each other, and the importance of adopting diverse strategies to achieve shared goals. While theory can sometimes seem removed from day-to-day work and inaccessible, I think that these theories can help us to hold ourselves and each other accountable in working towards equity, strengthened health and wellbeing for gay men within and beyond HIV, and hopeful opportunities to move these crucial conversations forward.

(1) Read more at my blog, Thinking Intersectionally.

(2) Read more at my blog, ‘Homophobia is killing us’: Heterosexism and gay men’s health

(3) Read more at my blog, Understanding Syndemics and Gay Men’s Health

(4) Read more at my blog, History, human development, and health: looking at the life course model