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HIV/STD prevention that targets gay men seldom meets the needs of young men who have sex with men (YMSM*). Some YMSM do not relate to gay-specific messages because they do not self-identify as gay. Many fear the social stigma and violence—sometimes intensified by culture and religion—directed at those identified as homosexual. Others identify themselves as bisexual and do not internalize gay-specific messages. Some young men, unsure of their sexual orientation, view same-sex sexual behavior as experimental and temporary. Since they seldom identify as gay, these YMSM may not recognize unsafe behaviors that put them at risk for HIV/STD.^1,2

On the other hand, HIV/STD prevention programs that target adolescents often exclude YMSM. Most school-based prevention efforts attempt to convince all adolescents that they are susceptible to HIV/STD, and, in so doing, they often inadvertently exclude messages specifically targeting YMSM. School-based curricula which contain messages like "AIDS is not a gay disease" may lead YMSM who identify as gay to believe they are not at risk. Some school-based programs deliberately ignore the existence of youth who identify as gay as well as YMSM who do not self-identify as gay. These short-comings in prevention messages underscore the need for programs that focus on YMSM, regardless of self-identification, and that incorporate messages which recognize and reflect the diversity among YMSM.

Many YMSM Engage in Behaviors that Put Them at Risk of HIV/STD Infection

In several studies, between 27 and 48 percent of YMSM had engaged in unprotected anal sex within six months of the surveys.^3,4,5 In one study, 63 percent of YMSM were at "extreme risk" for prior exposure to HIV through unprotected anal sex and/or use of injection drugs.⁶ Like other teens, many YMSM experience a phase of sexual experimentation marked by multiple sexual partners. HIV/STD risk increases with the number of sexual partners, and, in one study, 43.6 percent of surveyed YMSM reported at least 10 sexual partners.⁵ Some YMSM explore their feelings or attempt to conceal or change their sexual orientation by having sex with young women as well. One study found that YMSM who have sex with women are up to twice as likely to have unprotected sex with their male partners as those who have sex only with men.⁷

Assertive communication with partners about safer sex is often difficult for teens who lack role models or adequate sexuality education yet are exploring same-sex intimate relationships.⁶ Because adolescents are 10 to 17 times more likely to use condoms if they are comfortable communicating about AIDS with their partners, YMSM who lack support and skills are at risk for unsafe sex.⁸ One study found that YMSM discussed condom use with fewer than one-third of their last three partners and HIV serostatus with even fewer.⁶ Not being well acquainted with partners may also preclude easy communication about safer sex. Indeed, one study found that, next to sexual assault, meeting a sexual partner at an anonymous location was the strongest predictor of unprotected intercourse among YMSM.⁷ Conversely, some YMSM believe steady relationships will protect them from HIV and use condoms less within those relationships.^3,6,9

Lacking social support in a homophobic society, many YMSM turn to alcohol and drugs. Compared to heterosexual youth, gay, lesbian, bisexual, and transgender (GLBT) youth are twice as likely to use alcohol, three times more likely to use marijuana and to show signs of serious substance abuse, and eight times more likely to use cocaine.^9,10 Drug or alcohol use may make negotiating safer sex more difficult and increase the likelihood of unprotected sex."^11,12

Sexual risk behaviors are more likely to result in HIV transmission in populations where high rates of infection are already present.¹³ A study in six urban counties found that five to nine percent of surveyed YMSM were infected with HIV.⁴ Nationwide, same-sex sexual behavior is the leading HIV exposure category for males ages 13 to 19, accounting for 46 percent of cumulative HIV cases and 34 percent of cumulative AIDS cases.^l4 Among men ages 20 to 24, the figures rise to 55 and 63 percent, respectively.^l4 In one survey among YMSM tested for HIV, 70 percent of those found HIV-positive had been unaware of their infection.³

Societal Homophobia Puts YMSM at Higher Risk

Up to 80 percent of GLBT youth report feeling severely isolated socially and emotionally.¹⁵ Physical and psychological changes put many adolescents at risk of HIV/STD infection, but youth questioning their sexual orientation face greater risk because they "uniquely…grow up both different and alone.''¹⁶ GLBT youth usually lack peer support and often face verbal and physical attacks because of their sexual orientation. One in four YMSM is forced to leave home because of his sexual orientation; up to half of these youth resort to prostitution to support themselves—greatly increasing their risk for unprotected sex.¹⁷ YMSM often lack positive adult role models because fear keeps many gay adults from disclosing their sexual orientation.

Like other young people, YMSM need intimacy; but they must usually achieve it without social support or approval. Hiding their identities and desires, many YMSM have a desperate need for affection that overrides other concerns, including health. Societal hostility toward same-sex intimate relationships may make sex for YMSM the "only way to…escape the desperate social and emotional isolation."¹

YMSM may internalize pervasive homophobia, and some may believe the myths that gay men cannot maintain relationships and are destined to die of AIDS.¹⁸ Internalized homophobia often causes low self-esteem and depression. In fact, YMSM are seven times more likely to report attempting suicide than are heterosexual youth.^l9 While heterosexual youth frequently envision their futures to age 50, many gay teens do not imagine life past 33.^l9 Many YMSM believe there is nothing good about being an older gay man. As one YMSM stated, "many gay youth [believe] HIV…means I'm not going to be around 10 to 15 years from now, and I don't want to be around [then].''^l9

Many older gay men became acquainted with AIDS through the deaths of friends, and their sense of personal loss created an unprecedented change in risk behaviors within the adult gay male community.¹³ Although YMSM who practice consistent safer anal sex perceive themselves to be susceptible to HIV,²⁰ few YMSM today have witnessed the deadly consequences of unsafe behavior, and many do not feel particularly susceptible to HIV. Although peer support for safer sex is among the strongest predictors of condom use, YMSM often lack peer support.^3,21 Some YMSM may associate HIV with older gay men and assume young, apparently healthy partners are HIV-negative. Lacking older HIV-negative role models, some YMSM even view HIV infection as a rite of passage into the adult gay community.^l6 Perceived invulnerability is characteristic of youth but is especially problematic for YMSM, considering their risk for HIV and their lower rates of safer sex as compared to older gay males.²²

Racism Puts YMSM of Color at Higher Risk

YMSM of color face double discrimination—racism and homophobia—that may increase their risk for HIV.²³ Indeed, YMSM of color have higher HIV/AIDS rates than do white YMSM. In one study, as many as 7.8 percent of Latino, 12.5 percent of Asian and 14.3 percent of African American YMSM were HIV-infected—far more than the 3.9 percent among white YMSM ⁵ Some YMSM of color may also be more likely than white YMSM to misperceive their risk of HIV transmission.^l3,24 In one study, 64.3 percent of Native American YMSM reported unprotected anal intercourse, more than reported by any other racial/ethnic group.⁵

These differences are often due to the lack of culturally and linguistically appropriate interventions for communities of color. Because of the barriers posed by homophobia and racism, interventions for YMSM of color may need to focus on community-building approaches that reflect cultural nuances as well as on individual behavior change.^23,24 For example, one study suggests that interventions focus on increasing the collective capacity of African American YMSM to address HIV and on increasing tolerance for YMSM within African-American communities.²⁴

Effective Programs Must Build Skills and Affirm the Value of YMSM

Lack of information, misinformation, and homophobia are common in school-based sexuality education.²⁵ Some educators either choose or are required to teach that homosexual behavior is unacceptable. Many assume that all students are heterosexual and teach risk-reduction in terms of heterosexual contact only or teach abstinence-until-marriage—concepts frequently of little relevance to YMSM. Providing no risk reduction education for YMSM implies that they are nonexistent and denies them "…instruction on how to manage their sexual lives responsibly."^9,13

Homophobic inadequacies in HIV prevention education are particularly distressing because balanced, realistic HIV/STD prevention efforts can achieve behavior change. Following one intervention for YMSM,unprotected anal intercourse decreased by 60 percent and condom use for anal sex increased by 50 percent.²⁶

Although YMSM generally exhibit a good understanding of HIV transmission, too many engage in risky behaviors despite that knowledge.²⁶ This underscores that knowledge alone does not create behavior change. To be effective, HIV/STD prevention must address the developmental and social factors that lead to risk behaviors and build skills to translate knowledge into behavior change. The following critical components for HIV/STD prevention are drawn from research.

• Tailor programs to include YMSM. Programs developed for all young people should discuss sexual orientation and should include anal sex in HIV/STD risk reduction discussions. Programs should use inclusive language, such as "sexual partner" and "same-sex sexual behavior." In addition, YMSM need separate interventions that are developed specifically for them.
• Involve youth. Peer support groups provide non-sexual opportunities for YMSM to share their emotions and experiences, ease their feelings of isolation, and build support systems. Involving YMSM in program design and implementation reduces their risky behaviors and fosters their spirit of self-determination and selfworth.
• Foster a sense of personal worth. Prevention must affirm the value of YMSM and create a context that fosters responsible sexual behavior. One-on-one counseling sessions make effective beginnings for such interventions.
• Address the needs of youth. Focus on the needs identified by YMSM, not on those perceived by adults. This may include sponsoring support groups, building dating skills, and providing mentors and other role models.
• Teach skills. Programs must teach skills. The ability to use condoms, negotiate safer sex with partners, build relationships, communicate with steady and casual partners, make decisions, and say 'no' strengthens teens in making healthy choices.²⁷
• Provide sustained support. Since sustaining behavior change is difficult, populations at high risk require continuing support and reinforcement. To prevent relapse into unsafe behavior, prevention programs must address the changing needs of YMSM as they grow older.
• Start early. Since the most powerful predictor of HIV/STD risk behavior is a youth's sexual history, prevention is most effective before youth become sexually active.^28,29 Developmentally appropriate HIV/STD prevention should begin in earliest adolescence and should support both responsible sexual behavior and healthy self-concepts. School sexuality education can effectively reduce risky behavior without increasing sexual activity.
• Create programs specifically for YMSM of color. Studies indicates that programs need to address individual, community, and cultural factors pertinent to YMSM. Programs should address racism in the gay, white community while simultaneously supporting YMSM of color as they deal with decisions regarding sexuality, gay identity, culture, and race/ethnicity. YMSM also need safe environments for sharing their experiences.
• Address the needs of marginalized groups such as homeless youth and sexually abused youth. Programs must reach out to homeless youth, especially those involved in commercial sex, for they are unlikely to be in school. Outreach for homeless YMSM must first address their needs for food, clothing, and shelter. Only after these are met can YMSM focus on health considerations.

Pedro Zamora, who died in 1994 at age 22, said about the needs of YMSM, "I needed positive messages about my sexuality. I needed to know about condoms, how to use them correctly and where to buy them. I needed to know that you can be sexual without having intercourse. I needed to know how to say 'I don't want to have intercourse, I just want to be held."³⁰

*In this Issues at a Glance, YMSM is defined as men ages 22 and under who have sex with other men. This classification is inclusive of those self-identifying as gay, homosexual, bisexual, heterosexual, transgender, questioning, and queer.

Written by Deborah Roseman and Kent Klindera, February 1999

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