There is increasingly recognition that environmental factors impact health and wellness. However, few theoretical perspectives and limited research data have emerged to incorporate these environmental factors. One theoretical perspective that foreground the social production of adverse health outcomes and health inequalities is syndemics.
Syndemics holds that social disparity heightens the risk of epidemics amongst “socially devalued groups”, and that epidemics in these contexts are often mutually reinforcing. Merrill Singer first used the term syndemics in the 1990s, and one of the earliest examples of a syndemic was the simultaneous epidemics of substance abuse, violence and AIDS, in communities of Puerto Ricans living in Hartford, Connecticut.
"social disparity heightens the risk of epidemics amongst ‘socially devalued groups'"
Ron Stall, Perry Halkitis, Brian Mustanski, Trevor Hart, and the Community-Based Research Centre have contributed to the emerging literature on syndemics in gay men, which began in the early 2000s. These researchers have used quantitative datasets from various studies with gay men to identify experiences of marginalization, health outcomes and HIV indicators. One definition of syndemics used is, “co-occuring epidemics that additively increase negative health consequences” (Mustanski et al., 2007, p. 38). The research with gay men has focused on the ways psychosocial health and HIV epidemics are mutually reinforcing.
Development of syndemics
Stall et al. (2003) developed a model that depicts the ways syndemic conditions develop across gay men’s lives. In boyhood and adolescence, gay men are socialized to enact traditional masculine gender norms, and are often exposed to dominant homophobic attitudes. As they develop a gay identity and proto-gay social skills, they may also be struggling with internalized homophobia acquired throughout these early life experiences.
At the point where gay men begin to develop their identities, they may initiate contact with the gay community, and this may lead to migration into these gay communities. In this context, cultural homophobia is an ongoing stressor and gay men gain access to strengths and weaknesses associated with their minority grouping. Over time, psychosocial health problems develop, and the result is physical health outcomes, including HIV/AIDS.
Research has shown that increases in the number of psychosocial health problems are consistent with higher levels of reported HIV risk behaviours, and in some cases, HIV infection rates. Much of the current syndemics research focuses on the additive nature of psychosocial health problems and their impact on health outcomes amongst gay men. Using syndemics to contextualize the causes of ill health amongst gay men draws attention to heterosexism and may support new ways of framing interventions to strengthen gay men’s health.
Evidence of syndemics
Syndemics research in gay men’s health has looked at the ways multiple psychosocial health problems (for example, depression, suicidality, emotional distress) impact HIV risk behaviour and HIV infection rates. Research from these authors suggest that 20-25% of gay men experience multiple, co-occuring psychosocial health issues.
Data from the 2010 Sex Now Survey shows that men who report more experiences of lifetime marginalization (harassment, physical violence, forced sex, career impact, and suicidality) were more likely to report psychosocial health issues (emotional distress, social isolation, substance abuse, care for depression, care for other mental health issue). Each of the psychosocial health issues were positively associated with unprotected anal intercourse with an unknown status partner (UAIU), and those men who reported two or more psychosocial issues were significantly more likely to report UAIU.
Strengths of syndemics theory
Syndemics theory is a crucial alternative to an individual model, which focuses on changing individual behaviour and/or treating individual illness. It decidedly emphasizes the connections between social context and health outcomes, and extends the discussion of social production of health beyond the social determinants of health to include forms of structural oppression. By contextualizing the life experiences of gay men with heterosexism, syndemics illustrates the ways oppression may impact health directly and indirectly. For example, heterosexism has direct impacts when gay men receive sex education in schools and from health care practitioners that assumes heterosexuality. Indirect experiences of heterosexism include school bullying reducing educational achievement and subsequent employment opportunities. These types of indirect and direct examples of heterosexism are key contributors to the production of health outcomes and health inequalities.
Opportunities for syndemics research
Research informed by a syndemics perspective to date foregrounds gay-related factors. As discussed in an earlier blog on the challenges of the term ‘men who have sex with men’, sexuality is not the only aspect of gay men’s lives and simultaneous aspects of gay men’s lives, including gender and gender expression, also influence health outcomes. Gay men’s health research, including syndemics research, must account for the ways structural factors beyond sexuality impact the health and well-being of this population.
Syndemics theory shows a clear connection between indicators of marginalization and increased psychosocial health problems. It demonstrates that as the number of psychosocial health problems increases, so too do levels of reported risk behaviours, and in some cases, levels of poor health outcomes. Whether or not oppression leads to psychosocial health problems, and whether or not these psychosocial health problems impact HIV risk behaviours, the heterosexism that shapes the lives of gay men throughout their life course is a significant social justice issue.
- Ron Stall: http://www.veomed.com/va031058712011
- Trevor Hart: http://www.ohtn.on.ca/Conference/2012/Presentations/138.pdf
- Olivier Ferlatte: Youth Sex Now Survey