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									EXPOSING
Proceedings of the 5th Annual Gay Men’s Health Summit November 9 & 10, 2009 in Vancouver, BC




THE DETERMINANTS

                       Bacteria, Behaviour & Boyfriends


                       Is E-Health Secure?


The Difference Determinant

                       Our Invisible Population

                                                                                               HPV, Tushes
                                                                                               & Cancer
                       Gay Teen Wellness
2 EXPOSING THE DETERMINANTS 2009 GAY MEN’S HEALTH SUMMIT




CONTENTS
The 5th BC Gay Men’s Health Summit was held November 9 & 10, 2009. This summary of
the proceedings reviews highlights, key points and research needs.

The original recorded presentations are available online at www.cbrc.net.


3                      Introduction: Exposing The Difference Determinant

4-5                    Gay Teen Health and Wellness: how are we doing?

6-7                    Culture Eats Strategy for Lunch:
                       Where are the determinants data on gay men’s health?

8-9                    HPV: What are gay men’s vulnerabilities?                      Trussler, T. & Ferlatte, O. 2010. Exposing
                                                                                     the Determinants: Proceedings of the 5th
                                                                                     Gay Men’s Health Summit. Vancouver,
10-11                  Twelve Determinants of Gay Health
                                                                                     BC, November 9 & 10, 2009. Vancouver:
                                                                                     Community Based Research Centre.
12-13                  Creating Responsive Health Services

13                     The Trouble with E-health

14-15                  Concurrent Sessions

16-17                  Presenters

18                     Summary & Recommendations




Image: Ross Johnson, Steve Mulligan, Dr. Elizabeth Saewyc
                                                                                      2009 GAY MEN’S HEALTH SUMMIT EXPOSING THE DETERMINANTS 3



INTRODUCTION: Dr. Terry Trussler

EXPOSING THE DIFFERENCE DETERMINANT

CAN THERE BE ANY DOUBT, SINCE               By now it is increasingly clear that      tional appointments, hiring commit-
THE EMERGENCE OF HIV, THAT                  the disproportionate levels of HIV        tees, grant reviews, policy direction—
SEXUALITY IS A DETERMINING                  infection experienced by gay men          are a critical source of HIV vulnerability
FACTOR IN POPULATION HEALTH?                worldwide are the result of pervasive     for gay men. Why? Because it is so ap-
Yet,“sexual orientation” is absent from     moral panic over homosexuality that       parently easy to deny that gay men
Health Canada’s list of “population         results in denial of adequate services,   have health development needs in
                      .
health determinants” Why is that?           resources and support. As Elizabeth       spite of large, obvious truths in our ex-
Whatever we call it—homo-negativ-           Pisani has noted, the HIV prevention      perience with HIV. Again, right here in
ity, heterosexism, homophobia, hete-        money trail leads everywhere except       BC, we have seen sitting HIV communi-
ro-normativity, exclusion, denial, insti-   to the most affected groups. Rates of     ty program grant panels that, without
tutional neglect—social difference in       infection among gay men are at least      intervention, would have denied any
the environments where gay men live         a magnitude greater than the general      resources for gay men’s prevention in
and work is impacting our health and        population wherever you go, whether       their annual allocations.
well-being to a much greater extent         developed or developing nation.
than is generally recognized.                                                         What better description is needed of a
                                            Except in Australia and the UK, where     health determinant than a socially de-
HIV is gay men’s most studied health        gay men’s prevention has always           termined factor in a minority group’s
outcome and, as it turns out, a “lived”     been intense and focused, gay men         health outcomes that is beyond their
model of how health determinants            are commonly either absent or un-         control? The late Jonathan Mann—once
actually work in a minority popula-         der-represented in the places where       head of WHO’s Global Program on AIDS—
tion. Clearly, gay men are biologically     decisions are made about health in        observed more than 2 decades ago that
more vulnerable to HIV specifically          general or HIV specifically. Here in BC    the root cause of the worldwide HIV epi-
because commonplace male-male               it took us a decade to drive home a       demic was (and still is) stigma. Transmis-
sexual practices are an efficient route      simple truth that gay men are the         sible behaviour is merely the proximate
of viral transmission. Preventable? Of      most affected but least funded of HIV     cause of HIV infection. Proximate we can
course. But our experiences with de-        impacted groups.                          prevent. The root cause is another story.
veloping local prevention education                                                   Because it depends on the health de-
suggest it is more likely social than       Who decides the adequacy of a public      terminant of “other people’s decisions”
biological causes that sustain the HIV      health response? We have seen that        which are, in the main, out of gay men’s
epidemic in gay men.                        decision panels of every sort—institu-    control. Unless we change our tactics.


“Gay men are commonly either absent
or under-represented in the places where
decisions are made about health in general
or HIV specifically. “
4 EXPOSING THE DETERMINANTS 2009 GAY MEN’S HEALTH SUMMIT



PLENARY

GAY TEEN HEALTH AND WELLNESS:
A PICTURE OF HEALTH: GAY & BISEXUAL TEENS                                           HOMOPHOBIA CAN BE
IN BRITISH COLUMBIA                                                                 DEVASTATING FOR QUEER
Dr. Elizabeth Saewyc                                                                YOUTH: SO WHAT CAN
                                                                                    SCHOOLS DO ABOUT IT?
                                                                                    Steve Mulligan
BC Adolescent Health Surveys were conducted in 1992, 1998, 2003 and 2008. The
surveys involved more than 100,000 school based youth in grades 7 to 12 and
1,300 street-involved youth. The questionnaire included measures of sexual ori-     “68% of gay youth report
entation: accounting for 2,696 gay and bisexual teens.                              a lack of adult support at
                                                                                    school and never or almost
The surveys showed that persistent health disparities exist among gay and bi-       never feel safe in school.”
sexual teens compared to their heterosexual peers. Gay and bisexual teens are
more likely to experience hopelessness, sadness and suicidal thoughts or at-        His role as a diversity consultant
tempts. They are also more likely to be troubled by eating disorders (anorexia,     within Vancouver’s school system ad-
bulimia).                                                                           dresses homophobia and provides a
                                                                                    safer environment not just for sexual
Such disparities can be explained by a disproportionate experience of exclu-        minorities but all students. According
sion, harassment and outright violence in the family, school and community. Gay     to a 2008 “Social Responsibility Sur-
and bisexual teens often lack protective factors such as family and school con-     vey” 11% of Vancouver’s high school
                                                                                        ,
nectedness. However, those gay teens who had strong connections appeared to                                           ,
                                                                                    students identify as “lesbian” “gay”   ,
have much better health outcomes and reduced rates of mental disorder.                                    .
                                                                                    “bisexual” or “unsure” Still, “Homopho-
                                                                                    bia is the last bastion of discrimina-

“It is important to recognize                                                       tion that needs to be addressed in a
                                                                                    meaningful way in schools.”


that a healthy adolescence                                                          In general, the survey shows that ac-
                                                                                    ceptance of diversity appears to be

for gay and bisexual teens                                                          improving and teachers are seen to
                                                                                    be more responsive in addressing
                                                                                    abuse. Still, about 68% of gay youth
is the foundation for the                                                           report a lack of adult support at
                                                                                    school and never or almost never feel

long term health of gay and                                                         safe in school. By contrast, those who
                                                                                    perceive the adults at school to be
                                                                                    supportive, report feeling safe most
bisexual men.”                                                                      or all of the time. GSAs (Gay-Straight
                                                                                    Alliances) seem to promote a safer
                                                                                    learning environment for all students.
“We know that a lot of risks related to heart disease and cancer start in adoles-   However, there are numerous ways
cent years. The stress of exposure to violence and stigma have long term health     in which curriculum, school activities
impacts and influence people’s health well into their 60s and 70s. It is important   and special events can be made more
to recognize that a healthy adolescence for gay and bisexual teens is the foun-     inclusive of queer youth and positive
dation for the long term health of gay and bisexual men.”                           learning experiences for all.
                                                                               2009 GAY MEN’S HEALTH SUMMIT EXPOSING THE DETERMINANTS 5




HOW ARE WE DOING?
YOUTH VOICES AND THE SOCIAL IMPACT OF CREATIVE DISCOURSE
Ross Johnson

A project of Vancouver’s Queer Film Festival known as Out in Schools has
reached as many as 5,000 secondary school students by engaging them in
 video-making competitions. The students create public service announcements
featuring anti-homophobia messages and the best are chosen to be shown in
the annual Queer Film Festival.


KEY POINTS
• Personal Health and Coping Skills: Gay and bisexual teens are more likely than other teens to have
  tried tobacco, marijuana and street drugs; to have had their first sexual experience before the age of
  14; to use alcohol and drugs before sex and to have a greater number of sex partners.

• Mental Health disparities: Gay and bisexual teens are more likely to report hopelessness, sadness and
  suicidal thoughts or attempts.

• Cultural Context: 60% of gay and bisexual youth report discrimination related to their sexual orientation.
  They are more likely to experience bullying, exclusion and assault at school—to have been exposed to
  physical and sexual abuse.

• Social Support Networks: Family and school connectedness, when present, strongly reduce the odds
  of health disparities.

• Physical and Social Environments: 33.5% of all students report being called homophobic names in
  school even though 85% of them are straight.

• Healthy Child Development: a healthy adolescence for gay and bisexual teens is the foundation for
  the long term health of gay and bisexual men.

RESEARCH NEEDS
• Research is needed to evaluate interventions attempting to make a safer social environment for
  queer youth (policy and programs).

• Evidence is needed to determine whether the experience of stigma and discrimination in adoles-
  cence shapes the health of gay men as adults (Life-course theory).

• The important role of social support from family has been shown but the role of other gay friends
  remains to be determined and may be of greater value than currently recognized.
6 EXPOSING THE DETERMINANTS 2009 GAY MEN’S HEALTH SUMMIT



KEYNOTE: Dr. Verlé Harrop

CULTURE EATS STRATEGY FOR LUNCH:

The National Collaborating Centres                         population. Of course there are many       gay men at the population level. To
for Public Health were conceived as                        other “social determinants” and many       bring about change, gay men face a
a mechanism to encourage interpro-                         other “rogue” determinants like “hous-     real challenge without “gender/ori-
vincial sharing of information and                             .
                                                           ing” A concern, though, with treating      entation” evidence in the Canadian
evidence across provincial boundar-                        “heterosexism and homophobia” as           Census. “How can it be possible that
ies. Each has a specific focus but also                     special determinant is to miss an op-      in 2009 gay men, lesbians, bisexuals
a national mandate to synthesize                           portunity to leverage the federal gov-     and transgendered are statistically
evidence, identify gaps and get the                        ernment’s current population health        invisible in Canada?” Having a ques-
information to researchers and front                       policy in support of gay men and           tion about gender/orientation on
line health practitioners. Early inves-                    marginalizing gay men as a special in-     the census would open up a wealth
tigations on gay men at the National                       terest group.                              of information about gay men and
Collaborating Centre on Determi-                                                                      their health status.
nants of Health at St. Francis Xavier                      When Health Canada moved from a
University are showing that the evi-                       health promotion approach to a pop-
dence gaps around the determinants
of gay men’s health are profound.
                                                           ulation health approach there were
                                                           negative consequences for gay men.
                                                                                                      “How can it be
                                                           Health promotion had a fabulous
                                                           fit with gay men’s community initia-        possible that
“The evidence                                              tives. However, when Canada shifted
                                                           to Population Health its focus shifted
                                                           from communities to the health of
                                                                                                      in 2009 gay
gaps around the                                            entire populations.
                                                                                                      men, lesbians,
determinants                                               Population Health is evidence based
                                                           and requires population level data to
                                                           move forward. Statistics Canada is the
                                                                                                      bisexuals and
of gay men’s                                               primary source of that evidence. Gay
                                                           men, who may constitute anywhere           transgendered
health are                                                 from one, to four, to ten percent of
                                                           the population, have been left out of
                                                           that giant data base. This is a critical
                                                                                                      are statistically
profound.”                                                 problem because Statistics Canada
                                                           is the primary population level data       invisible in
Public Health Agency of Canada’s                           source used by politicians, academics,
(PHAC) framework of twelve determi-
nants of health is unlikely to change.
                                                           researchers and policy makers alike to
                                                           frame their understanding of health
                                                                                                      Canada?”
While there may be many more can-                          and the effectiveness of the health
                                                                                                      “When I asked my data analyst why
didate determinants, the current ones                      care system.
                                                                                                      Statistics Canada does not collect
are easy to grasp for their impact on
                                                                                                      gender/orientation data she said,
health and, importantly, for the con-                      From a population health point of view,
                                                                                                      ‘We’re Canadian we don’t talk about
nections between them. They are use-                       gay men are invisible. We lack crucial
                                                                                                      things like that’. When I asked my
ful in parsing out data for an entire                      data to show the burden of disease in
                                                                                                      colleague at Statistics Canada why
                                                                               2009 GAY MEN’S HEALTH SUMMIT EXPOSING THE DETERMINANTS 7




WHERE ARE THE DETERMINANTS DATA ON GAY MEN’S HEALTH?


they don’t collect gender data he said
they were concerned that people
                                          RESEARCH NEEDS
would be “disgusted” and end up not       • Inclusion of gender identity/sexual orientation on census and popula-
filling out the census. When I told my       tion health surveys is critical.
kids about this, they were incredulous.
One asked, ‘Didn’t they grow up with      • Audits of grant programs such as CIHR, SSHRC to evaluate the extent of
Madonna?’.”                                 exclusion of gay men’s health research.
Imagine the power of normalizing          • Culture investigated as a determinant of gay men’s health.
gender identity/sexual orientation
through the census. What is asked in      • Gender identity studied as a determinant of gay men’s health.
the census becomes a de facto na-
tional conversation. In the beginning     • How does the stress of living in a homo-negative society shape gay
people might hesitate to fill in those
                                            men’s lives?
blanks, but, over time they would
become more candid. Data equals
                                          • Multiple, synergistic impacts of health determinants on gay men.
accountability and can’t be ignored.
Census data forms the substrate
upon which you can design sets of
questions around gay men’s health.
Indeed, one has to ask if the exclusion
of gender/orientation on the Census       “Indeed, one has to ask if
of Canada is discriminatory.

When examining the list of PHAC’s
                                          the exclusion of gender
                                          identity/ sexual orientation
social determinants of health, two
determinants are of particular impor-
tance to gay men: Gender and Culture.
Unpacking “gender” as a determinant
of health suggests “gender identity”
which has a natural fit with sexual
                                          on the Census of Canada is
orientation. In terms of “culture” as a
determinant, there is little doubt that   discriminatory.”
the attitudes of homophobia and het-
erosexism within Canadian culture
contribute to the marginalization and
stigmatization of gay men.

Finally, health determinants do not
exert their influence independent-
ly of each other. Connections and
synergies between them need to
be described.
8 EXPOSING THE DETERMINANTS 2009 GAY MEN’S HEALTH SUMMIT



PLENARY

HPV: WHAT ARE GAY MEN’S
VULNERABILITIES?
This plenary explored a large-scale issue emerging in gay men’s sexual health. Studies show that gay men are more
widely affected by HPV infections, including types that pose a higher risk of developing into cancer, than is generally
understood. A dearth of data on gay men underlies an absence of prevention and treatment programs. As such, rou-
tine anal pap smears are currently neither recommended nor offered to gay men even though their risk of anal cancer
is elevated compared to the general population. The HPV vaccine program, the only preventive, has been unavailable
to men. (update: HPV vaccine Gardasil is currently available in BC but with a cost.)

HPV: WHAT IS IT? WHAT DOES IT DO?
Dr. Natasha Press                                                                   HPV INFECTION AND
                                                                                    ANAL DYSPLASIA IN
Human papilloma virus (HPV) appears in about 100 different strains, 30 are sex-     VANCOUVER:
ually transmitted. The virus infects skin and mucosal linings of mouth or anal      PRELIMINARY FINDINGS
canal. When HPV causes disease it causes either warts or cancer. Common skin
                                                                                    FROM THE MANCOUNT
warts are caused by HPV types 1 or 2.
                                                                                    SURVEY
Anogenital warts, caused by HPV types 6 and 11, are transmitted through sexual
                                                                                    Dr. Mark Gilbert
activity. Oral sex can transmit HPV among different body parts. The wart types of
HPV are considered low risk for cancer. The high risk types – 16 and 18 – cause     Dr. Gilbert described the proce-
oral, anal and penile cancers.                                                      dures used in ManCount, a dry
                                                                                    blood sample HIV surveillance
Pre-cancerous lesions are known as dysplasia and named by location. Anal dys-       survey, to study HPV in a random
plasia or AIN can be mild (AIN 1) to severe (AIN 3) without showing any symp-       sample of gay men in Vancouver’s
toms. People can clear an HPV infection that causes only mild dysplasia but if      bars, baths and cafés. A sub-sam-
the infection persists it may go on to moderate or severe dysplasia. HIV positive   ple of participants provided self-
people with less active immune systems have difficulty clearing HPV infections.      collected rectal swabs to test for
Where the virus persists, more severe dysplasia develops, which may result in       HPV, Chlamydia, Gonorrhea and
cancer.                                                                             anal cancer. A total of 252 swabs
                                                                                    were collected, however, about
HPV is very common and about 75% of people have had it at some point in
                                                                                    38% were found insufficient for
their lives but most people eventually clear the infection on their own. However,
                                                                                    anal cancer screening.
while only 15 % of the general population have HPV at any moment in time, it is
active in about 60% of gay men. Because of immune deficiencies, close to 100%
of HIV positive men have HPV.                                                       Overall, the Vancouver study
                                                                                    found similar results to those
Historically, about 40/100,000 women developed cervical cancer from HPV. With       found elsewhere. About 62% of
the introduction of the cervical pap smear those rates dropped 80%. In recent       gay men were positive for HPV:
years the rate of anal cancer in men has increased significantly. In HIV negative    79% HIV positive men and 57%
gay men the rate of anal cancer from HPV is currently 35/100,000 (very similar to   HIV negative. Cancer screening
pre pap cervical cancer) and twice that rate in HIV positive men.                   showed cell abnormalities in 34%
                                                                                    of HIV negative men and 64% of
If the pap smear was so effective in women, is there a screening test for men       HIV positive men.
that could reduce anal cancer? Anal pap smears are available and lab readings
can help identify the HPV type and extent of disease.
                                                                                        2009 GAY MEN’S HEALTH SUMMIT EXPOSING THE DETERMINANTS 9




“The long term best answer to the problem of anal cancer
is to prevent the HPV infection in the first place. And that is
through vaccination.”
EVERYTHING YOU EVER
WANTED TO KNOW                             annual digital anal exam. “Anal cancer       KEY POINTS
ABOUT TUSHES & HPV                         screening can be done as a “two-for”         • Data from the Mancount study show
AND THEN SOME…                             along with annual prostate screening.”         that 79% of HIV positive gay men and
Dr. Joel Palefsky                                                                         57% of HIV negative gay men have
                                           Unfortunately there is no specific HPV          anal HPV infection (compared with
We have known for a number of years        treatment so all we can do is remove           15% in the general population).
that among HIV positive men virtually      the tissue. Clinicians have a number         • Anal cancer rate among HIV nega-
everybody has anal HPV infection –         of options including liquid nitrogen,          tive MSM is 35/100,000 while cer-
usually with multiple HPV types and        electro-cauterization or infrared co-          vical cancer in women is about
at least one, sometimes two, three or      agulation. The long term best answer           8/100,000 (rates of cervical cancer
four, cancer causing types. Rates of       to the problem of anal cancer is to            were 40-50/100,000 prior to routine
HPV infection are also high among HIV      prevent the HPV infection in the first          pap screening).
negative men.                              place. And that is through vaccina-          • HIV positive gay men are particu-
                                           tion.                                          larly at risk of HPV infections and
If we had rates of cervical cancer in                                                     anal cancer.
San Francisco at 75/100,000 – the rate     Gardasil, the vaccine, has been shown        • Rates of anal cancer are 10 times
of anal cancer in HIV positive men –       to be almost perfectly effective in girls      higher among HIV positive gay
there would be a Congressional in-         but its application to boys has been           men than cervical cancer is among
vestigation. And yet, this has not been    controversial. It should be applied to         women and twice the rate of HIV
considered an important health prior-      boys because men can transmit HPV              negative gay men.
ity. We should not accept that.            to women and those risks would be
                                           reduced. Importantly, it would also          RESEARCH NEEDS
The anal pap smear is generally avail-     reduce the burden of HPV disease in          • Health Literacy: What level of knowl-
able, but the next step in the diagno-     MSM. That disease burden is not neg-           edge exists among gay men con-
sis of an abnormal screen – high reso-     ligible. The total of all HPV related can-     cerning their exposure to HPV and
lution anoscopy – is scarce. Given the     cers in men add up to nearly 10,000            anal cancer?
scarcity and the time it takes people      cases per year in the US. Recent stud-       • Health services: What are gay men’s
to become proficient in using the de-       ies have shown the vaccine to be ef-           HPV and anal cancer information
vice, the most effective screening is      fective in boys and it is now available        needs in terms of screening, treat-
for all HIV positive gay men and all HIV   but for a cost as opposed to free for          ment, and prevention? A digital rectal
negative men over the age of forty         girls. We have made progress but we            exam can detect anal cancer, but how
should be screened for AIN with an         are still only part of the way there.          many gay men are getting this test?
TWELVE DETERMINANTS
The Public Health Agency of Canada’s Determinants of Population Health framework and its language can be applied to inform
research perspectives on gay health. Such research may eventually disclose disparities with respect to the general population or
other men. A decade of surveys of gay men conducted by the Community Based Research Centre appear to indicate negative
impacts from many of PHAC’s health determinants. Whether they are true health disparities with respect to other men is an open
question without comparative data. Key comparison variables such as “gender identity” and “sexual orientation” are currently
absent in population level research. The Canada Census and the Canadian Community Health Survey must include gender identity
and sexual orientation to facilitate appropriate population level comparison studies.


          Income and social status
   Health status improves at each step up the income and social hierarchy.
 No income/risk gradient has been found in prevention research on Canadian
 gay men but gay men are by far the most HIV a ected population in Canada.



                            Social support networks
               Support from families, friends and communities is associated with better health.
Surveys of BC’s gay men have shown that 62% are ‘starved for company’ at times, 28% quite often.



                                          Education and literacy
                                                        Health status improves with level of education.
           At 72% tertiary level education, BC’s gay men have twice the rate of higher education than the
                                            general population, and yet, as a Statistics Canada study has
                                                             indicated, poorer mental health outcomes.



           Employment and working conditions
               Unemployment, underemployment, stressful or unsafe work are associated with poorer health.
          While 72% of gay men complete tertiary level education, 55% earn less than $50K per year. About 25% of
                     gay men say their career has been negatively a ected by being identi able in the workplace.



                                                  Social environments
                                       The array of values and norms of a society in uence in varying
                                       ways the health and well being of individuals and populations.
                              While measures of internet connections among gay men have been soaring,
                                                             community involvement has been declining.



                                  Physical environments
       Factors related to housing and the design of communities and transportation systems
                         can signi cantly in uence our physical and psychological well-being.
                                    Surveys indicate 71% dissatisfaction with places and spaces
                                                 where gay men can meet, socialize or organize.
OF GAY HEALTH

                 Personal health and coping skills
                 There is a growing recognition that personal life "choices" are greatly in uenced by the
                 socioeconomic environments in which people live, learn, work and play.
                 A decade of surveys have shown that young gay men are inadequately educated about sexual
                 health issues speci c to gay men. In the last 5 years, the proportion of gay men under 30 who
                 have never tested for HIV has expanded signi cantly.



            Healthy child development
            The e ects of early experiences on brain development, school readiness and health in later life has
            sparked a growing consensus about early child development as a powerful determinant of health.
            Roughly a third of gay men have had experiences of unwanted or forced sex prior to the age of eighteen.



  Biology and endowment
  Genetic endowment provides an inherited predisposition to a wide range of individual responses that a ect
  health status – in some circumstances to predispose individuals to particular diseases or health problems.
  It is well established that gay men are predisposed to HIV because background prevalence is excessively high
  and commonplace male-male practices highly e cient routes of viral transmission.
  71% of gay men report feeling oppressed at times by society’s marginalizing values, 30% quite often.



    Health services
    Health services, particularly those designed to maintain and promote health, to
    prevent disease, and to restore health and function contribute to population health.
    Recent surveys of BC’s gay men have shown only 50% satisfaction with the HIV
    prevention e orts of regional health agencies.



        Gender
        "Gendered" norms in uence the health system's practices and priorities. Many health issues are a
        function of gender-based social status or roles.
        According to recent surveys, roughly 50% of gay men are single, 26-36% partnered with
        another man, 6% married to another man, and as many as 8-16% married to a woman.



   Culture
   Some persons or groups may face additional health risks largely determined by dominant cultural values
   that contribute to the perpetuation of conditions such as marginalization, stigmatization, and
   lack of access to culturally appropriate health care and services.
   At least 51% of gay men have been a target of anti-gay hate talk and/or violence.
12 EXPOSING THE DETERMINANTS 2009 GAY MEN’S HEALTH SUMMIT



PLENARY

CREATING RESPONSIVE HEALTH SERVICES

EXTENDING                                                   COUNSELING                                HETERONORMATIVITY
ADVANCED TESTING                                            APPROACHES FOR                            AND STI TESTING IN BC
SERVICES TO                                                 NEWLY DIAGNOSED                           Rod Knight
DIAGNOSE EARLY                                              GAY MEN TESTING HIV
                                                            POSITIVE IN BC:                           Hetero-normative biases in the sexu-
HIV INFECTION IN                                                                                      al health and STI clinics of the Fraser
GAY MEN IN BC:                                              LEARNING FROM THOSE
                                                                                                      Health Region were described. The
EARLY EXPERIENCES                                           ALREADY INFECTED                          very existence of gay men in the popu-
Michael Kwag                                                Olivier Ferlatte                          lation is largely denied by the region’s
                                                                                                      institutions. The result has negatively
Testing options for gay men have                            The needs of gay men at the time of       impacted access to quality care for
improved with the introduction of                           an HIV diagnosis are much greater         young gay men.
the NAAT test – an “early” HIV test                         than recognized. Receiving an HIV di-
with a dramatically reduced win-                            agnosis is a traumatic life-changing
dow period of only ten days follow-                         event. Yet, very little psycho-social
ing risk. “One of the challenges in                         support is generally offered to help        RESEARCH NEEDS
bringing new HIV testing technolo-                          such men cope with the emotional            • Diffusion of Innovation: How
gies to gay men has been the diffu-                         fall-out. Especially those with recent        does the diffusion process
sion of information about them.”                            HIV infections need specific help to           occur in gay communities?
                                                            deal with their acute contagiousness          What is the best way to pro-
Slow proliferation of knowledge                             – a critical moment in preventing on-         mote new prevention technol-
through the community has been                              ward transmission.                            ogies and testing programs?
evident in slow to change testing                                                                       • Health Services: What is the
patterns among gay men. Informa-                                                                          experience of gay men with
                                                            ENGAGING PHYSICIANS                           their physicians? How do
tion campaigns – featuring new                              PROJECT
HIV testing technologies – could                                                                          homophobia, heterosexuality
                                                            Kevin Saya-Moore and Daryle Roberts
shift these trends. But, health mes-                                                                      and hetero-normativity impact
sage campaigns directed toward                              A project to engage physicians for bet-       the quality of health services of
gay men have been limited by inad-                          ter service to gay men in the Okanagan        gay men?
equate funding of HIV prevention                            region was undertaken by the Living         • Social Support Network: What
programs for gay men.                                       Positive Resource Centre. Homophobia          are the impacts on gay men of
                                                            and heterosexism among health care            having friends with HIV in their
                                                            professionals were identified as ma-           social networks? How does
                                                            jor obstacles to adequate health care         having HIV positive friends
                                                            for gay men in this region. “Our health       influence behaviour and atti-
                                                            professionals do not even want to talk
                                                                                                          tudes related to HIV?
                                                            about the men who have sex with men
                                                            in their practices.”
                                                                               2009 GAY MEN’S HEALTH SUMMIT EXPOSING THE DETERMINANTS 13



                                     SUMMIT FORUM: Micheal Vonn, LLB

                                     THE TROUBLE WITH E-HEALTH

                                     An enormous threat to personal privacy is emerging with e-health. The “inad-
KEY POINTS                           vertent security” of paper health records is that stacks of files are difficult to
• When new prevention technol-       move. With medical files, stored in one place, in one giant database, the poten-
  ogies are being introduced it is   tial security threat is much greater. Too many people know how to access elec-
  critical to inform the popula-     tronic files and can move millions of them with a touch of a button. The security
  tion so people can modify their    side of e-health has not been openly discussed while the convenience side has
  health practices accordingly.      been oversold.
• Gay men often identified
  themselves differently in pub-     A centralized system would put the government in charge of private informa-
                                     tion between patient and doctor, including who has access to it. “We should
  lic than in private in a survey
                                     be horrified by what is being put forth as the “modernization” of health infor-
  of MSM in the Okanagan. MSM
                                     mation systems.” Alberta has advanced further than other provinces and they
  were more likely to identify as
                                     appear to be proud that their electronic record system is a “consent free” zone
  “straight” in public.
                                     – no patient permission required to access files. A growing number of Alberta’s
• Health care providers often        citizens are not so sure.
  confuse sexual identity with
  sexual practices.                  The most advanced e-health system in the world is in the UK where even the
• Many physicians are unable to      Prime-Minister’s health records have been illegally accessed. Governments are
  collect a sexual history of MSM    allowing individual lockdowns of personal files but they are not telling people
  properly; are uncomfortable        unless asked that such lockdowns are even available.
  talking about sex, and more
  particularly about gay sex.        There is no empirical evidence that centralized electronic records either im-
• Doctors are generally not good     prove health outcomes or save money. What we do have evidence about is that
  at making referrals to appro-      at least 50% of people would not seek sexual health services if they knew their
  priate services for gay men.       records were being held in a central database.
• The psycho-social needs of gay
  men newly diagnosed with           The government has interests in providing access to centralized medical infor-
  HIV are poorly addressed.          mation for “research” purposes such as that done by insurance and pharmaceu-
• Gay men who have HIV posi-         tical firms – who seem to be major proponents of the e-health scheme. How-
                                     ever, such large databases are becoming unwieldy and there is some potential
  tive individuals in their social
                                     that the current models of e-health will implode.
  support networks feel less
  stigma at the time of diagnosis
                                     Internet technologies have caught up and exceeded the capacities of the origi-
  and have less difficulty access-
                                     nal software that e-health started with. After spending billions on developing
  ing community services.            e-health more effective solutions are available using internet resources for free.
                                     Australia, once in the vanguard of e-health, has dropped it because it was be-
                                     coming so unmanageable.

                                     “What we do have evidence about is that at least 50% of
                                     people would not seek sexual health services if they knew
                                     their records were being held in a central database.”
 14 EXPOSING THE DETERMINANTS 2009 GAY MEN’S HEALTH SUMMIT




CONCURRENT SESSIONS
BACTERIA, BEHAVIOURS,                                        • Social support networks: Gay men’s      TWO-SPIRIT PEOPLE AND
BOYFRIENDS AND BEYOND –                                        relationships have been under           DETERMINANTS OF HEALTH
EMERGING ISSUES IN SEXUAL                                      studied. What are the health out-       Robert Hong
HEALTH                                                         comes/risks of being in a gay rela-
                                                               tionship?                               Two-spirit people, as part of the larger
1) Burden of Enteric Infections                                                                        aboriginal community, have seen their
Among MSM in Vancouver                                       GAY MEN’S HEALTH AND                      health impacted by the history of col-
Jason Wong                                                   SUBSTANCE USE                             onization and residential schooling. In
                                                             Brent Astle, JP Grimard and Bob Martel    addition, the history of two-spirit cul-
Rates of enteric infections (infections of                                                             ture has been lost among aboriginal
the gut, including Shigella, Cryptospo-                      Addiction is often intertwined with       people, leading to the oppression of
ridium and Giardia) among gay men                            other mental health issues such as        gay individuals within their own com-
appear to be disproportionately high                         depression or anxiety. Addiction in       munities. As a result, many two-spirit
when compared to heterosexuals.                              gay men is closely connected to sys-      aboriginal men have been forced to
                                                             temic heterosexism and homophobia         flee their communities, often to Van-
2) The Boyfriend Study                                       experienced in youth. Specific pro-        couver’s Downtown Eastside. There
Jason Mitchell                                               grams for gay men are working. Offer-     many face harsh street-life conditions.
                                                             ing services ‘for gay guys by gay guys’   Despite major health disparities, no
                                                             promotes a culture of acceptance and      funding is available for two-spirit pro-
Despite a vast literature on HIV relat-                                                                grams.
ed behaviour gay men’s relationships                         increased chances of recovery. Such
have been under-studied. Surveil-                            services provide a safe space for gay
lance research indicates that gay men                        men to explore issues impacting their     Research Needs
are more likely to get HIV infected in                       addiction.                                • How do aboriginal status, two-spirit
a relationship than from casual sex.                                                                     and homosexuality interact to cre-
Yet, few studies have examined the                           Research Needs                              ate health disparities among two-
dynamics of gay relationships from                           • Health services: What are the ben-        spirit people? (Intersectionality).
both sides. Researching relationship                           efits of peer based health services?
“diads” is important not only for HIV                          What is the level of homophobia in      HOW IS THE INTERNET CHANGING
prevention but many other factors                              addiction services and the impact       OUR COMMUNITY: EXPLORING
affecting gay men’s health and well                            on gay men with addictions?             HEALTH INFORMATION NEEDS OF
being.                                                       • Culture: How can we explain the link    HIV POSITIVE MEN
                                                               between homophobia and addic-           Zoran Stjepanovic, Adriann de Vries
                                                               tion problems in gay men?               and Harpreet Kahlon
3) Dirty Pictures/Healthy
Outcomes: using art to create
                                                                                                       This workshop reviewed an assess-
community
Ted Kerr                                                     “Addiction in gay                         ment of the treatment information
                                                                                                       needs of HIV positive men. Contrary
Art can be a powerful tool to engage
                                                             men is closely                            to the assumption that people would
community and increase dialogue
about health and other related is-
                                                             connected                                 prefer to receive treatment informa-
                                                                                                       tion on the internet, results from the
sues. Polaroid and digital photogra-                         to systemic                               assessment concluded that individu-
                                                                                                       als prefer a face-to-face conversation.
phy documenting ordinary life was
described as a way to create dialogue                        heterosexism                              Physicians were the preferred source.
                                                                                                       Information on the internet was not
among gay men about the nature
and meaning of gay culture.                                  and homophobia                            seen as consistently trustworthy
                                                                                                       though accessed by many.
Research Needs
                                                             experienced in
• Health services: Do gay men re-
  ceive appropriate screenings?
                                                             youth.”                                   Research Needs
                                                                                                       • Health literacy: How knowledgeable
                                                                                   2009 GAY MEN’S HEALTH SUMMIT EXPOSING THE DETERMINANTS 15




  are HIV positive gay men about         Research Needs                            ries public health authorities finally
  HIV treatment including alterna-       • How does supportive policy and insti-   recognized that sex among HIV posi-
  tives?                                   tutional change impact the health of    tive individuals was an emerging new
• Health services: What is the quality     gay men?                                form of HCV transmission. Despite
  of treatment information offered                                                 this recognition, however, there is no
  to HIV positive gay men?               WHAT DETERMINES GAY MEN’S                 surveillance or monitoring of sexually
• Social support networks: Are face-     HEALTH?                                   transmitted HCV in British Columbia.
  to-face programs building social       Dr. Verlé Harrop                          As a consequence, HIV positive gay
  support networks?                                                                men are poorly informed of their in-
                                                                                   creased HCV risks associated with un-
                                         Gender and sexual identity were
CREATING DIALOGUE FROM                                                             protected sex.
                                         recognized to be complex areas of
WITHIN THE GAY MEN’S HEALTH              research. However, it would be criti-
MOVEMENT                                 cal to include gender identity/sexual     Research Needs
Ted Kerr                                 orientation on the Canadian census        • Sexually transmitted HCV should
                                         for better data on the distribution of      be monitored in HIV-positive gay
Using Eric Rofes’ social theory and      gay men across communities. Having          men.
David Wojnarowicz’s fictional litera-     gender categories would facilitate        • Health literacy: Research should be
ture as a catalyst for conversation,     data comparisons indicating health          done among HIV positive gay men
the workshop engaged a discus-           disparities between gay and other           to assess their knowledge around
sion in which gay men could reflect       men—critical information needed to          HCV and how to prevent it.
on their own lived experiences with      advocate for better funding and pro-      • Personal Health and coping skills:
the idea that their identity has been    gramming.                                   Looking at the prevention strate-
shaped, knowingly or unknowingly,                                                    gies of gay men to protect them-
by its “outlaw” status. How does our     Research Needs                              selves from HCV and other STI in-
outlaw status impact on the way gay      • Canadian census should include            fections.
men perceive health promotion mes-         gender identity/sexual orientation
sages? How do gay men experience           to introduce population level data      PEER COUNSELING WITH GAY MEN:
“normal” when their very existence is      for gay men.                            AN INTERACTIVE WORKSHOP
seen to be transgressive?                • Disparities can only be demonstrat-     Dr. Bill Coleman and Elgin Lim
                                           ed with comparative data, there-
WE RECRUIT! HETEROSEXISM IN                fore we need studies that compare       This workshop explored the use of
THE CANADIAN MILITARY                      experience and health outcomes          peer counselors among gay men. Peer
Ephriam Herrit and Dr. Liam “Captain”      between gay and other men.              counseling is an alternative approach
Snowdon                                                                            to professional counseling which can
                                         SEX AND HEPATITIS C IN HIV                be expensive, inaccessible and not
As of 1992, gay men are allowed to       POSITIVE MEN: WHAT’S HOT?                 free of homophobia. Peer counsel-
serve openly in the military. To re-     WHAT’S SAFE? CAN THE TWO BE               ing has the advantage of focusing on
verse discrimination and harass-         RECONCILED?                               shared experiences and understand-
ment, the military created aggres-       Rob Gair, Dakota Descoteaux and Ian       ing of issues. It provides a safe place
sive anti-harassment policies which      Nelson                                    for the exchange of supportive infor-
include annual ethical training and                                                mation.
education for all members. This re-      Hepatitis C is now linked to sex be-
sulted in a significant drop in harass-   tween HIV positive gay men. However,      Research Needs
ment based on sexual orientation.        when these men were first diagnosed        • Health services: The experience
The military is now recruiting at gay    with HCV the infection was thought          of gay men in mainstream mental
pride festivals and other gay events     to be drug related. No one believed         health services.
around the country—demonstrating         that HCV was transmitted by sex. Such     • Evaluation of peer counseling and
a drastic shift in the ideology of the   men were thought to be lying about          comparative study of peer vs pro-
Canadian forces.                         their drug use. After many similar sto-     fessional counseling.
  16 EXPOSING THE DETERMINANTS 2009 GAY MEN’S HEALTH SUMMIT




PRESENTERS
Brent Astle and JP Grimard are coun-                          Robert Hong works for Vancouver              Steve Mulligan is the Anti-homopho-
selors with VAMP - Vancouver Addic-                           Coastal Health as an Outreach Worker in      bia and Diversity Consultant with the
tions Matrix Program at Vancouver                             the Aboriginal Wellness Program where        Vancouver School Board. His role in-
Coastal Health. Bob Martel was the                                                                .
                                                              he facilitates “Gay Warriors Talking”        cludes consulting on individual stu-
Program Coordinator for Addiction                                                                          dent issues, and supporting a network
Services at Vancouver Coastal Health                          Ross Johnstone is the Director of            of school contacts and Gay/Straight
before taking a position in Toronto.                          Youth Education for Out On Screen,           Alliance clubs.
                                                              organizers of the annual Vancouver
Dr. Bill Coleman is an independent                            Queer Film Festival. Ross coordinates        Daryle Roberts is the Executive Di-
consultant working with BC Centre                             the Out in Schools program, a unique         rector of the Living Positive Resource
for Disease Control. Elgin Lim is Direc-                      outreach initiative which uses youth-        Centre in Kelowna serving an area of
tor of Health Promotion at BC Persons                         made film to engage students on is-           approximately 48,000 square kilome-
With AIDS Society.                                            sues of homophobia and bullying.             ters of British Columbia’s interior.

Olivier Ferlatte graduated in Sexol-                          Ted Kerr is an independent artist living     Kevin Saya-Moore is the Project Co-
ogy, completed a Master of Public and                         and working in Edmonton Alberta.             ordinator of the Engaging Physicians
Population Health in 2008 and is cur-                                                                      Project with the Living Positive Re-
rently a Doctoral candidate with the                          Rod Knight is an MSc student in the          source Centre in Kelowna.
Faculty of Health Sciences at Simon                           School of Population of Public Health
Fraser University.                                            at the University of British Columbia.       Zoran Stjepanovic, Adriaan de Vries,
                                                                                                           Harpreet Kahlon work with the BC
Rob Gair is a pharmacist with St Paul’s                       Michael Kwag is the Research Project         Persons With AIDS Society.
Hospital and serves on the Board of                           Manager of the CIHR Team in the Study
Directors of the Health Initiative for                        of Acute HIV Infection in Gay Men at         Jason Wong is with the School of Pop-
Men. Dakota Descoteaux is with                                the BC Centre for Disease Control and        ulation and Public Health, University
Friends for Life. Ian Nelson works with                       Vice-Chair of the Board of Directors at      of British Columbia.
the BC Persons With AIDS Society.                             the Health Initiative for Men.

Dr. Mark Gilbert is a community                               Jason Mitchell is a doctoral student
medicine specialist and a physician                           with Oregon State University in Port-
epidemiologist in the Division of STI/                        land.
HIV Prevention and Control, at the BC
Centre for Disease Control, where he                          Dr. Natasha Press is a graduate of the
leads the HIV and STI surveillance pro-                       University of Toronto School of Medi-
gram.                                                         cine and of Internal Medicine and Infec-
                                                              tious Diseases at the University of Brit-
Ephraim Herritt is with the Canadian                          ish Columbia. She completed a research
Armed Forces. Dr. Liam “Captain”                              fellowship with the Canadian HIV Trials
Snowdon is Education Coordinator at                           Network and currently runs the anal
AIDS Vancouver Island.                                        dysplasia clinic at St. Paul’s Hospital.


                                                                                                          Olivier Ferlatte
                                                                                        2009 GAY MEN’S HEALTH SUMMIT EXPOSING THE DETERMINANTS 17




KEYNOTES

Dr. Verlé Harrop graduated from           Dr. Joel Palefsky is Professor of Medi-          Dr. Elizabeth Saewyc is a Professor
MIT with an Interdisciplinary PhD in      cine at UCSF School of Medicine; com-            at the University of British Columbia
Medical Informatics. She returned to      pleted his undergraduate degree and              in the School of Nursing and Division
Canada in 2002 to head up the Na-         Internal Medicine residency at McGill            of Adolescent Medicine; Senior Sci-
tional Research Council’s e-Health        University and a fellowship in Infec-            entist in the Child Family Research
research. In 2009, Dr. Harrop was ap-     tious Diseases at Stanford University.           Institute at BC Children’s Hospital;
pointed Senior Scientist for the Na-      He is an internationally recognized ex-          and Research Director for McCreary
tional Collaborating Centre for the       pert on the biology, treatment, patho-           Centre Society, a community-based
Determinants of Health At St. Francis     genesis and natural history of anogen-           youth health research and youth
Xavier University.                        ital HPV infection.                              empowerment organization.

Dr. Terry Trussler is the Research        Micheal Vonn is a lawyer; Policy
Director of the Community Based           Director of the BC Civil Liberties Associa-
Research Centre and lead investiga-       tion; and adjunct professor at the Univer-
tor of Sex Now, a periodic survey of      sity of British Columbia in the Faculty of
gay men’s health and well being.          Law and the School of Library, Archival
                                          and Information Studies,where she teach-
                                          es civil liberties and information ethics.




Dr. Joel Palefsky, Dr. Mark Gilbert, Dr. Natasha Press
    18 EXPOSING THE DETERMINANTS 2009 GAY MEN’S HEALTH SUMMIT




SUMMARY & RECOMMENDATIONS
TOWARD KNOWING WHAT DETERMINES GAY HEALTH
Overall, the Summit did as much to expose the invisibility of gay men in Canada’s health policies as it did to further knowl-
edge about the impact of health determinants on gay men. Ultimately, health impacts are studied by comparison. Without
                                                                           ,
key comparative variables such as “gender identity” or “sexual orientation” much needed population studies of gay men
are impossible.

Summit presentations detailed the many ways in which gay men’s invisibility in health policy affects gay men’s health:
inadequately resourced HIV prevention for the size and involvement of the affected population; slow public health accep-
tance of evidence pointing to the sexual transmission of HCV; little if any attention to elevated levels of cancer in gay men.
These observations suggest that important parts of the developing gay health agenda lie beyond direct approaches to
improving the lives of gay men. Some gay health work must aim to change society, or, at least the social structures that are
currently impeding gay men’s health development at the population level.


1. Canada Census                                           2. Canadian Community                    3. Institutional Audits
    Without a place in the Census of                          Health Survey                           Institutional audits are likely to
    Canada gay men are an invisible                             Sexual orientation is currently       demonstrate funding inequities
    population of unknown size and                              studied as an indirectly “con-        that deny adequate research on
    spread. Because it is critical for                          structed” variable in the Cana-       gay men’s health. As examples,
    future population studies, gender                           dian Community Health Survey          the CIHR Gender Institute and
    identity and sexual orientation
                                                                (CCHS). Gay health develop-           the Community Based Research
    must be addressed in the Census
                                                                ment activities should promote        Program of the Infection and
    of Canada. Some dimension of
                                                                refinements to future CCHS             Immunity Institute should be
    gay health development activities
    should include education and col-                           questionnaires which would            assessed for the adequacy and
    laboration to achieve this end.                             facilitate population level stud-     equity of their support for gay
                                                                ies of gay men.                       men’s health research.




                                                                                                      O
4. Gay Health                                              5. HPV Vaccination
   Determinants Survey                                          In view of the elevated preva-
    A national survey of gay men                                lence of HPV infection in gay
    should be conducted to probe                                men and subsequent cancer
    questions related to the determi-                           risks exposed by clinical re-
    nants of health. The survey could                           search, gay health development
    be modeled on the success of the                            activities should include efforts
    Sex Now Survey conducted on the                             to achieve the full inclusion
    internet. The survey should have                            of teenage boys in the public
    a new name related to its specific                           vaccination program currently
    purpose. Groups across Canada                               offered only to girls.
    could collaborate on promoting
    local participation.
                     2009 GAY MEN’S HEALTH SUMMIT EXPOSING THE DETERMINANTS 19




                   5TH GAY MEN’S HEALTH
                   SUMMIT 2009
                   ORGANIZED BY THE
                   COMMUNITY-BASED
                   RESEARCH CENTRE IN
                   PARTNERSHIP WITH THE
                   HEALTH INITIATIVE FOR MEN
                   AND THE BC CENTRE FOR
                   DISEASE CONTROL

                   Proceedings Report
                   Olivier Ferlatte & Terry Trussler

                   Summit Planning Group
                   Phillip Banks
                   Rick Marchand
                   Mark Gilbert
                   Terry Trussler

                   Rapporteurs
                   Olivier Ferlatte, Justin Go & Jody Jollimore

                   Registration Desk
                   Jim Sheasgreen, HIM

                   Report Design & Layout
                   Rachel Thompson, Bluemuse Media

                   Funded by
                   Public Health Agency of Canada
                   Canadian Institutes of Health Research
                   Province of British Columbia
                   Burst Creative Group
                   ManCount Survey

                   See and hear the original conference
                   presentations online www.cbrc.net


                   Celebrating
                   COMMUNITY BASED
                   RESEARCH CENTRE’S
                   10 ANNIVERSARY
                       TH

                   a decade of creating and sharing knowledge




Dr. Verlé Harrop
Suite 310 - 1033 Davie Street Vancouver BC V6E 1M7

              www.cbrc.net

								
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