Gay Men: Overview
Abstract and Keywords
This entry explains who gay men are, how gay identity constructions have evolved since their inception, and how they continue to evolve. It also describes the health and mental health problems that gay men may present to social work practitioners. In addition, it identifies several social policies that are relevant to gay men. The entry argues that a systemic perspective that takes into account the social, political, and cultural influences on gay men is necessary for understanding the problems that such men commonly experience.
The Oxford English Dictionary (1989) defines “gay” as a synonym of “homosexual,” that is, a person whose “sexual desires are directed wholly or largely toward” persons of the same sex. However, explicating what is meant by “gay men” is more difficult than this definition would suggest. For example, can a man who fantasizes about sexual contact with other men be gay if he has never acted on his fantasies? Is a man gay if he has sexual contact with both men and women? Is a man gay if he has sexual contact with other men but does not identify himself as gay? Is a man gay if he had sexual contact with other men several years ago but is now celibate?
Defining “gay men” is so difficult because the concept “gay” is an emergent social construction; the concept is constructed differently across cultures and historical periods. In addition, “gay” sometimes indicates a sexual orientation (as in the dictionary definition) and at other times a sexual identity. Finally, as a self-identifier, “gay” is likely to have personal or idiosyncratic meaning for those who endorse it. Thus, it is probably appropriate to define “gay men” as men who self-identify as gay. This definition encompasses a variety of meanings and behavioral patterns. However, it does exclude men who have same-sex sexual contact but do not identify themselves as gay.
Diversity in Gay Identities and Experiences
The great majority of writing about gay men focuses on those who are white and middle-class or affluent; thus popular conceptualizations of gay identities and experiences do not take into account the identities and experiences of men of color (Diaz, Bein, & Ayala, 2006; Poon, 2004; Wheeler, 2003) and men who are less affluent or poor (Masovsky, 2002). In addition, the literature on gay men contains strong urban and age cohort biases. Less is known about gay men living in small towns and rural areas (Williams, Bowen, & Horvath, 2005) and those who are elderly (Berger & Kelly, 2001).
Social workers' knowledge about gay identities and experiences is likely to be limited because of these biases. For example, it is commonly believed gay men progress through a series of stages in developing an integrated gay identity. This belief is based on stage models of identity development, such as those proposed by Troiden (1979) and Cass (1984), which begin with a gradual awareness of one's “true” sexual orientation and end with a positive and integrated identity as a gay individual. However, the studies that tested and found support for these models used samples that were almost entirely white (see Morrow, 2006). Because stage models such as these have an ethnocentric bias, the identity constructions they describe should not be used as normative standards against which divergent constructions are evaluated. For example, Latino immigrant men who have sex with other men may not consider themselves to be gay as long as they take a dominant role in sexual intercourse (Zea, Reisen, & Diaz, 2003). The adjustment of men to identity constructions such as these cannot be evaluated adequately in a cultural vacuum.
In addition, social workers should be careful not to essentialize gay men's identities and life course trajectories. The identities and life courses of today's gay adolescents are likely to be different from those of men 25 or more years ago on whom the popular stage models were based (Martin & D'Augelli, in press). New gay identities and life course templates continue to emerge because of ongoing changes in the social environment in which gay people live. For example, young gay men today typically become aware of their same-sex attractions by late childhood and self-identify as gay during middle adolescence, and many come out to others before age 20. In contrast, among older cohorts, gay men more typically became aware of their attractions around puberty, and self-identified as gay and came out after age 20 (Floyd & Bakeman, 2006). Coming out earlier has both positive and negative implications for the life course. On the positive side, individuals are likely to suffer fewer negative consequences from hiding in the closet. On the negative side, they are more likely to be victimized by peers because of their sexual orientation (D'Augelli, 2006).
An additional aspect of diversity among gay men concerns the extent to which they have liberationist or assimilationist views about being gay. Such views include men's beliefs about the nature of sexual orientation and their aspirations regarding social and political change. Those with liberationist views are more likely to believe that gay men have unique contributions to make to society (Warner, 1999), same-sex desire is the fundamental aspect of their identity, and freedom of sexual expression is important to defend (for example, Rofes, 1998). Those with assimilationist views are more likely to believe that gay men are not fundamentally different from other men, sexuality is just one aspect of their identity (for example, Bawer, 1993), and fitting into mainstream society is an important goal (see Goldstein, 2002). According to Vaid (1995), liberationism was dominant among gay, lesbian, bisexual, and transgender (GLBT) communities only for a short time following Stonewall.
While this entry is specifically about gay men, the development of GLBT identities and communities are intertwined.
Although there is evidence that men have engaged in sexual contact with each other throughout history and across cultures (for example, Herdt, 1997), the construction of a male identity based on sexual object choice came about in the United States within the past 100 years (Chauncey, 1994). The forerunner of this construction originated in Germany, where industrialization and urbanization during the second half of the 19th century led to an increasingly urban concentration of homosexual men who had previously lived in rural isolation (Steakley, 1975). Such men developed ritualized forms of interaction to facilitate mutual recognition. In 1862 Karl Heinrich Ulrichs, a well-known lawyer and scholar, first declared his same-sex desires and, for the next 17 years, fought for the decriminalization of sexual behavior between men. Ulrichs formulated the first theory about sexual orientation, that men who had same-sex desires constituted a third sex in which a female soul is contained within a male body. He called such men urnings (Steakley, 1975).
The same process of industrialization, urbanization, and concentration of homosexual men in cities also occurred in England, and eventually in the United States. A third sex-based identity became popular in these countries too, as Ulrich's ideas were brought to the English-speaking world by John Addington Symonds and Havelock Ellis (Steakley, 1975).
Consistent with this identity construction, men in early 20th century New York City tended to organize their sexual identities around their gender identification (Chauncey, 1994). The most common identities, especially among the working class, were fairies and men. Fairies acted and thought of themselves as women, and they often adopted women's names (Chauncey, 1994). Because working class sexual identities during this era were not organized around sexual object choice, “men” could have sexual relations with “fairies” or other “men” without being considered abnormal as long as their gender identification was conventionally masculine. Men who would consent to sex with “fairies” were sometimes called trade. Identities such as these were embedded in life course templates that bear little resemblance to those of contemporary urban American gay men (Chauncey, 1994), especially those who are white.
Sexual identities organized around sexual object choice became increasingly common among middle-class men in early 20th century New York City (Chauncey, 1994). Many such men called themselves queer. Some considered their sexual desires to be an expression of inverted (that is, female) gender even though they did not behave or think of themselves as women. Others considered their desire for men to be an expression of heightened masculinity. In either case, middle-class men tended to be more concerned about avoiding marginalization and stigma than were working-class men, and the expression of their sexual identities was more private. However, casual physical affection between men was tolerated more than it is today, because there was little awareness among the general public of divergent sexual identities other than “fairies” and such behavior had no connotation of sexual identity (Chauncey, 1994).
Many large American cities had concentrations of homosexual men in the first half of the 20th century. In New York City, Harlem and Greenwich Village were magnets for them (Chauncey, 1994). The Harlem drag balls, which reached their height in the 1920s and 1930s, brought together homosexual African American men in great numbers. The Hamilton Lodge Ball, perhaps the most famous of them, drew white spectators and participants from far and wide. There were similar events in other major cities, such as Chicago and New Orleans. By bringing together so many men who shared same-sex desires and gender-nonconforming identities, these events allowed for the development of a sense of communal identity. Chauncey (1994) noted that “it was at the drag balls, more than any place else, that the gay world saw itself, celebrated itself, and affirmed itself” (p. 299). But in smaller towns and rural areas many men harbored same-sex desires and fantasies in secret, not imagining that there were others like themselves.
The military deployment of great numbers of young men from all walks of American life during the Second World War also played an important role in the construction of contemporary gay identities and communities. The war brought men who had previously kept secret their same-sex desires together. When the war ended, many such men (especially those who were discharged because they were gay) chose to remain in port cities such as San Francisco and New York (Bérubé, 1990).
As gay men gravitated to the major cities, they developed a thriving underground culture that was relatively invisible to outsiders. While such men tended to live in a manner that today would be considered secretive, the “closet” afforded them a space within which they could develop a highly elaborated gay culture (Seidman, 2002). The first gay organization, the Mattachine Society, was established in Los Angeles in 1951. Chapters were later formed in major cities across the United States, and the first American gay publication, ONE, began circulation in 1953. A second publication, Mattachine Review, was established in 1955. In addition to its publications, Mattachine provided education, referral, peer counseling, and other services (Meeker, 2001). Mattachine and other organizations like it were important elements in the development of a shared gay identity and sense of community, but they did not encourage their members to come out of the closet or engage in direct political action. Rather, their primary focus was on helping gay men to adjust to the conditions in which they lived (D'Emilio, 1983).
Beginning in the mid-1960s, the civil rights and other activist movements began to influence the aspirations of gay men. Small pickets demanding equality were organized by the umbrella group East Coast Homophile Organizations (ECHO) in Washington, Philadelphia, and New York. Male picketers wore ties and jackets; women wore dresses (D'Emilio, 1983). At the same time, gay organizations began to proliferate in other parts of the country, including the more conservative south (Sears, 2001).
The Stonewall Riots, which occurred in New York City over the course of six days in the summer of 1969, are usually considered the beginning of the contemporary gay rights movement (Carter, 2004). However, it should be clear from this historical overview that the development of contemporary gay communities and identities did not begin with Stonewall. What did begin with Stonewall was the gay liberation movement. Perhaps not surprisingly, the riots were “instigated and led by the most despised and marginal elements of the…community” (Carter, 2004, p. 262), especially gender-nonconforming homeless gay youths who had little to lose. The Gay Liberation Front (GLF), which sought the total transformation of society's oppressive institutions regarding sexuality, was formed one month after the riots. The youthful members of GLF viewed themselves as revolutionaries, and they reviled the more conservative and assimilationist views of older gays and lesbians (Carter, 2004).
But within a few months the less revolutionary Gay Activists Alliance (GAA) was formed, and it eventually eclipsed the GLF. However, the GAA was hardly a conservative organization. The preamble to its constitution identified its members as “liberated homosexual activists” (Carter, 2004, p. 235), and it articulated the demand for an end to oppression of homosexuals and recognition of their basic rights (Carter, 2004).
One year after the Stonewall Riots, 20 organizations, including thousands of gay men, lesbians, and other sexual minorities, participated in the first Christopher Street Liberation Day march. Carter (2004) described the extraordinary importance of this event as follows: “…many stopped and cried tears of joy in a moment they would never forget, as they looked out at the vast numbers of gay men and lesbians who had turned out to support each other by marching proudly in the open” (p. 255).
Throughout the 1970s gay men's communities exploded in the major cities, and bars and other commercial institutions that catered to a gay clientele proliferated. The number and variety of gay-related organizations grew exponentially. The synergy of these communities fostered exuberant celebration of gay sexuality and experimentation with new forms of relationships (Moore, 2004). Unfortunately, the party was to end by the early 1980s with the arrival of AIDS.
Impact of HIV and AIDS
Gay men and other men who have sex with men have always constituted the greatest number of Americans with HIV and AIDS. The devastating impact of the AIDS epidemic on gay men, and the transformation of their communities that it caused, has been well documented by empirical research (for example, Gluhoski, Fishman, & Perry, 1997; Oram, Bartholomew, & Landolt, 2004) and other written materials (for example, Herek & Greene, 1995; Odets, 1995; Shilts, 1987). In response to the AIDS crisis, gay men significantly increased their avoidance of risky behaviors and decreased the number of their sexual partners. According to Becker and Joseph (1988), this was one of the most profound changes in behavior made by any community in response to a health problem. However, gay men lost friends and loved ones to AIDS. Some experienced the loss of their entire support system. Traumatic stress, depression, survivor guilt, and sexual dysfunction were reported by many gay men (Dupras & Morriset, 1993; Nord, 1996).
Because the U.S. government ignored AIDS during the early years of the epidemic (Shilts, 1987), gay communities mobilized to develop their own prevention strategies and systems of care. Outrage about government inaction, discrimination, and profiteering by pharmaceutical companies led to a radicalization of many gay men. The organization AIDS Coalition to Unleash Power (ACT-UP), which advocates direct and provocative political action, was formed in 1987 to channel this energy.
Although the rate of HIV infection declined among gay men for a number of years, there is evidence that it is increasing again Incidence of HIV infection is especially high among African American men who have sex with men (including those who identify as gay) and young gay men (CDC, 2005). Because prevention strategies currently in use are not sufficiently effective with these populations at highest risk, there is a great need for new strategies based on more complex conceptualizations of sexual behavior (Martin, 2006).
Other Health Problems
With respect to other problems, in recent times it has been argued that greater use of community organizations and health promotion activities is needed to support the broader health and well-being of gay men (Scarce, 2000).
Sexually Transmitted Diseases
Recent evidence suggests that men who have sex with men (MSM) are contracting sexually transmitted diseases (STDs), which include syphilis, gonorrhea, and chlamydia, at increasing rates (CDC, 2004; McFarland, Chen, Weide, Kohn, & Klausner, 2004). The median rate of syphilis seroreactivity among MSM tested at STD clinics in nine U.S. cities more than doubled from 1999 to 2004. The 2004 syphilis rates ranged from 5.7% in Denver, Colorado to 14% in Houston, Texas and Long Beach, California. Gonorrhea positivity rates increased in some cities but not others, ranging from 10.1% in Washington, DC to 17.3% in Philadelphia (CDC, 2004).
Chronic Illnesses and Disabilities
Although there are no epidemiological data on the number of gay men living with chronic illnesses other than HIV, Lipton (2004) estimated the number to be in the hundreds of thousands. Living with such illnesses, which include diabetes, cancer, and some forms of hepatitis, may be particularly challenging for gay men because of the lack of specialized services for them and their relative invisibility within gay communities (Lipton, 2004). Similarly, disabled gay men may lack validation of their experiences, role models, and both formal and informal sources of support (Hanjorgiris, Rath, & O'Neill, 2004).
Substance Abuse and Dependence
Although it has been commonly believed that gay men abuse alcohol and drugs at higher rates than other men (see Berger & Kelly, 1995), evidence from several large population-based studies has failed to support this belief. Cochran and Mays (2006) analyzed data from four such studies; in each case, no statistically significant differences in rates of alcohol or drug dependency were found between men who reported same-sex sexual partners and men who reported opposite-sex partners. The most comprehensive study of the health of American adolescents, Add Health, found no relationship between self-reported same-sex attraction and substance abuse indicators among young males (Udry et al., 2003). However, it is not clear whether these same findings would be obtained from men who self-identify as gay. In addition, since these studies specifically examined substance dependency, it remains unclear whether the rates of substance use or abuse among gay men differ from those of non-gay men. It may be that gay and non-gay men appear to have such problems at similar rates. Among gay men, however, substance abuse—especially injection drug use—is of particular public health concern because of its association with HIV infection (Gorman, Nelson, Applegate, & Scrol, 2004). In addition, gay men's use of club drugs, which include ecstasy, GHB (gamma-Hydroxybutyric acid), ketamine, and methamphetamine, is associated with risky sexual behavior (Hirshfield, Remien, Humberstone, Walavalkar, & Chiasson, 2004). The increasing popularity of methamphetamine among gay men is a special concern because of its strongly addictive qualities (Halkitis, Fischgrund, & Parsons, 2005). Participants in the Halkitis et al. (2005) study of gay men in New York City most commonly reported using methamphetamine to enhance sexual experiences, though some reported using it to increase their energy or to improve their mood. Kurtz (2005) found that escaping loneliness was a major reason for use of methamphetamine by gay men in Miami.
Traumatic victimization, including hate crimes, peer violence, and intimate partner and family-related violence, is disturbingly prevalent in the lives of gay men of all ages. From the reports of hate crimes in Los Angeles over the course of one year, Dunbar (2006) found that gay men were the victims in 30% of these incidents. Among all reported hate crimes against persons (as opposed to those against property), those based on sexual orientation were more severe than those based on race or religion. In another study (D'Augelli, Grossman, & Starks, 2006), 87% of a sample of 15 to 19 year old gay male youths reported having been victimized verbally, 15% physically, and 14% sexually. Victimization incidents occurred in schools, other public settings, and at home, beginning as early as at age 11. Gender-nonconforming males reported more verbal and physical victimization than those who were gender-conforming.
Among young adult gay and bisexual men in the American Southwest, ages 18–27, 37% reported incidents of verbal harassment during the previous six month period, and 4.8% reported physical violence within the same time frame (Huebner, Rebchook, & Kegeles, 2004). And in another study (D'Augelli & Grossman, 2001), 65% of gay male elders across the United States reported being verbally abused during their lives, 20% reported physical attacks, 34% reported being threatened with violence, and 15% reported threats with a weapon.
Gay men may also experience traumatic victimization within their families of origin and in intimate relationships. In a study of siblings across the life span(Balsam, Rothblum, & Beauchaine, 2005), gay men reported much higher rates of childhood sexual abuse than heterosexual men. However, estimates of the rate of intimate partner violence among male couples range from 21% to 50%, which is similar to those for opposite-sex and female couples (Stanley, Bartholomew, Taylor, Oram, & Landolt 2006).
After the constructs of homosexuality and heterosexuality were developed, in the late 19th century, the belief that homosexuality was a medical problem (as opposed to a moral problem) became increasingly popular (Martin, 1997). By the early 20th century, the understanding and treatment of homosexuality became the domain of psychiatry. Homosexuality was officially classified as a mental illness (a sociopathic personality disorder) by the American Psychiatric Association in 1952, with the publication of the first Diagnostic and Statistical Manual (DSM). It was then declassified by the American Psychiatric Association in 1973. The American Psychological Association (APA) (2003) passed a resolution in 1975 supporting the psychiatric declassification, and the National Association of Social Workers followed suit with a policy statement in 1977 However, not all psychiatrists supported the declassification. Some members of the helping professions, including social work, continue to believe that homosexuality is a disorder that can, or should, be treated (Appleby & Anastas, 1998). Thus the conceptualization and treatment of gay men's mental health is fraught with considerable historical and political baggage.
When considering the question whether gay men have higher rates of mental disorders than other people, one must keep in mind that these disorders are themselves constructions that have sociopolitical meaning (Martin, 1997). For example, Ussher (1992) argued that mental illness is diagnosed in women more often than men because it is conceptualized in a way that equates “madness” with femininity.
There have been numerous attempts to estimate the relative prevalence of mental disorders among gay men. Several studies that were conducted during the late 20th century used convenience samples (for example, Bell & Weinberg, 1978; Saghir, Robins, Walbran, & Gentry, 1970; Pillard, 1988) and found no evidence of elevated prevalence among them. More recently, studies have used population-based samples, which are presumed to produce more accurate findings. Results from these studies are mixed, with some finding elevated prevalence of depression (Cochran & Mays, 2000; Cochran, Sullivan, & Mays, 2003) and panic disorders (Cochran & Mays, 2003) in gay men, and others finding no differences between gay and non-gay men (Gilman et al., 2001). A meta-analysis of 10 empirical studies conducted between 1970 and 2000 (Meyer, 2003) found gay men to have higher lifetime prevalence of mood and anxiety disorders than non-gay men.
There is some evidence that the rate of suicide attempts among gay male youths is higher than among non-gay male youths, though the evidence is not conclusive because of differences across studies in sampling and measurement. According to the Youth Risk Behavior Survey (CDC, 2006), 8.4% of male high school students in the Unites States (including those who are gay) attempted suicide at least once during 2005. An earlier study of Massachusetts high school students (Garofalo, Wolf, Kessel, Paltrey, & DuRant, 1998) found the rate of suicide attempts during the previous year was more than three times higher (35.3% vs. 9.9%) among those identifying as gay, lesbian, or bisexual. However, this study did not report rates broken down by gender. Two other studies (Remafedi, French, Story, Resnick, & Blum, 1998; D'Augelli et al., 2005) compared retrospectively measured lifetime rates of suicide attempts of gay and non-gay youths. Using a population-based sample of Minnesota junior and senior high school students, Remafedi et al. (1998) found the rate among gay and bisexual male youths to be more than six times that of heterosexual males. Using an ethnically-diverse nonprobability sample of lesbian, gay, and bisexual youths in the New York City area, D'Augelli et al. (2005) found that 13% of the gay males reported having made at least one suicide attempt. Among them, more than half reported that their attempts were related to their sexual orientation. This study also found that suicide risk was particularly high among gay youths whose gender role behavior was not traditionally masculine.
The Role of Minority Stress
According to the minority stress model (Meyer, 2003), gay men's experience of stress associated with being members of a highly stigmatized minority contributes to negative mental health outcomes in them. Stress among gay men may derive from external events such as being attacked verbally or physically, expectations of events such as these, and internalization of society's negative attitudes toward them. However, identifying with a stigmatized gay identity can also be a source of resilience (Crocker & Major, 1989). Nevertheless, Meyer (1995) found that experiences of discrimination and violence, expectations of rejection and discrimination, and internalized homophobia predicted higher psychological distress among gay men. Martin, Pryce, and Leeper (2005) used a similar model in their proposition that some gay men might engage in impulsive and risky sexual behavior as a way of coping with stress that derives from sources such as these.
Challenges And Controversies
Although the American Psychiatric Association declassified homosexuality in 1973, it created the diagnostic category “ego-dystonic homosexuality.” This diagnosis could be applied to individuals who experienced extreme distress about their homosexuality and wished to become heterosexual. Thus, attempting to change a client's sexual orientation remained an acceptable clinical goal even though homosexuality was no longer considered a disorder. Ego-dystonic homosexuality was removed from the next edition of the DSM, in 1980 (Martin, 1997). However the acceptability of this goal continues to be debated. The National Association of Social Workers (1997), APA (1997), and American Psychiatric Association (2000) have issued policy statements that reject the use of conversion therapies, which focus on changing clients' sexual orientation, because of evidence that they are ineffective (Shidlo & Schoeder, 2002) and cause harm to recipients (Haldeman, 2001). In addition, focusing on individuals' sexual orientation or sexual behavior as the locus of change ignores sociopolitical sources of distress among gay men, such as experiences of victimization and discrimination. Thus conversion therapies run the risk of “blaming the victim.” Proponents of conversion therapies (for example, Yarhouse, 1998) claim that clients who wish to change their sexual orientation have the right to treatment for this goal.
Policies oriented toward ensuring the safety of GLBT people include anti-harassment policies in schools and state and federal policies on hate crimes. As described previously in this chapter, gay adolescents are frequently victimized in their schools. Especially following a 1996 federal appellate court decision (Nabozny v. Podlesny, 1996) that public schools are obligated to protect gay and lesbian students from abuse, a number of public school districts have instituted anti-harassment policies. In addition, some states have passed legislation that requires school personnel to protect gay and lesbian students when necessary (Messinger, 2006). Although anti-harassment policies may not be controversial in and of themselves, including sexual orientation in them has been contested. Most notably, the State College (Pennsylvania) Area School District adopted an anti-harassment policy in 1999 that included sexual orientation as a protected category. This policy was challenged in court on behalf of two students who claimed that it prevented them from voicing their belief that homosexuality is sinful. Subsequently, a three judge panel of the U.S. Circuit Court of Appeals struck down the policy on the grounds that it violated the First Amendment of the U.S. Constitution (Saxe v. State College Area School District, 2001). One result of this ruling was that it clarified how anti-harassment policies could be written so they protect the rights of GLBT students without abrogating free speech. The American Civil Liberties Union (ACLU) has issued recommendations for writing such policies (see ACLU, 2003).
Federal and state hate crime legislation involves the application of enhanced penalties for crimes motivated by prejudice or hatred based on race, religion, gender, and other characteristics. Most states have such laws, but not all of them include sexual orientation as a protected category. The federal hate crime law, passed in 1969, does not include sexual orientation (Messinger, 2006). The rationale for such legislation is that enhanced penalties would act as a deterrent to hate-motivated violence. In addition, proponents claim that perpetrators should receive harsher penalties for hate-motivated offenses because they are more damaging to victims than other offenses. Not everyone agrees that legislating enhanced penalties is sound policy. Jacobs (2002) argued that hate crime laws are mainly symbolic statements of support for minority groups, and that they are unlikely to provide enhanced deterrence. In particular, capital offenses may already be punishable by death and yet they still occur.
Social workers could encounter gay clients in almost any agency setting. Because of the evidence that mental health problems among gay men are associated with stigma-related stress, efforts to alleviate their distress should include attention to the experience of stigma and its sources in the social and political environment.
Trends and Future Directions
Men who self-identify as gay are one segment of a larger population of men who experience same-sex attractions and engage in sexual behavior with other men. Constructions of gay identity have changed significantly during the past century, and they continue to change. A systemic perspective is similarly needed to understand and respond to other problems that gay men may experience, including HIV/AIDS, substance abuse, and victimization.
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