The term syndemic was first developed in the 1990s by medical anthropologist Merrill Singer to describe the co-occurrence of multiple epidemics and their tendency to mutually reinforce the negative outcomes of one another. Originally, the syndemic theory was used to describe the simultaneous epidemics of HIV/AIDS, substance use and violence observed in Puerto Rican residents of Hartford, Connecticut. Later on, Singer went on to explain that syndemic theory can also address the co-existence of diseases and social problems, stating that “beyond the notion of disease clustering… the term syndemic also points to the critical importance of social conditions in disease concentrations, interactions and consequences” and that these health problems “commonly arise because of adverse social conditions… that put socially devalued groups at heightened risk.” Since then, the theory has been applicable to many culturally marginalized groups, including gay men.


syndemicAs of 2014, approximately 67% of all HIV diagnoses in the United States were attributable to gay and bisexual men. This alarmingly high HIV infection rate is comparable to what we see in Canada, where it is now estimated that more than half of HIV-infected people identify as men who have sex with men (MSM), and that approximately one in four MSM living in Toronto are infected with HIV. An interesting question, then, is whether HIV-infected gay men actually identify syndemic factors as important contributors to their infection status.

A research team in Chicago was interested in answering this very question and recruited HIV-infected, self-identified gay or bisexual men for extensive interviews. This qualitative examination covered topics such as safe sex knowledge, sexual history, drug and alcohol use, mental and emotional health as well as the very circumstance by which they became infected with HIV. They found that while participants did not identify poly-substance use as the main reason for their sero-conversion, they did identify other syndemic factors such as lack of familial and social support, and lack of mentorship, as having played a role in their HIV infection. Notably, with more than half of participants having come from families that did not accept their sexual orientation, sex was identified as providing a mental escape from feelings of depression. Moreover, participants stated that rejection by family members was a reason for their risky behaviour and their HIV-positive status. Overall, the research team supported the theory that syndemic factors play a synergistic role in having a negative impact on gay men’s health.

Another research team investigated syndemic conditions in black MSM by studying the following constituents: depression symptoms, sexual compulsiveness, substance use, intimate partner violence and stress. Men were categorized as syndemic if there were two or more existing health conditions, a category for which 54% of the participants qualified. According to the study, men in the syndemic group were significantly more likely to report stimulant use (including crack cocaine use), gay or non-gay-related victimization during their teenage years, and more internalized homophobia compared to men in the non-syndemic group. Of note, each psychosocial health condition was independently associated with at least one other psychosocial health condition, thus supporting the syndemic theory. For instance, depression symptoms were independently associated with sexual compulsiveness, while stress and substance use were independently associated with intimate partner violence. The team concluded that men who had three or more health conditions engaged in more unprotected anal intercourse compared to men who had two or fewer health conditions and that higher HIV transmission risk may be a consequence of such phenomena.

Because syndemic theory has consistently proven to be an acceptable explanation for gay men’s adverse health conditions, new studies are investigating the idea of syndemic analysis to understand other previously unexplored phenomena. For instance, a team in British Columbia sought to use syndemic theory to understand why gay men are four times as likely to attempt suicide as heterosexual men. In this study, they found that the likelihood of thinking about suicide was twice as high in people who reported three or more forms of anti-gay marginalization compared to those with no marginalization. These marginalization indicators included verbal and physical violence as well as anti-gay bullying, sexual violence and workplace discrimination based on sexuality. Psychosocial health problems were shown to have an additive effect on both suicide-related thoughts and suicide attempts in gay and bisexual men, even after removing depression and anxiety – the two strongest effectors of attempted suicide – from the mix.

syndemic3Taken together, these findings suggest that despite the fact that sexual minorities are protected from discrimination under the constitution, homophobia still exists and has a substantial impact on the physical health of gay and bisexual men. Such discrimination leads to clusters of adverse physical and mental outcomes, as explained by syndemic theory. Therefore, it is imperative that new policies are devised to advocate for the safety of sexual minorities and that educational programs are implemented to focus on gay-specific HIV education and foster HIV-positive mentor/educator to student relationships.


References:

  1. Dyer TP et al. Application of syndemic theory to black men who have sex with men in the Multicenter AIDS Cohort StudyJ Urban Health 2012; 89: 697-708.
  2. Ferlatte O et al. Suicide related ideation and behaviour among Canadian gay and bisexual men: a syndemic analysisBMC Public Health 2015; 15: 597. 
  3. Lyons T, Johnson AK & Garofalo R. “What Could Have Been Different”: A Qualitative Study of Syndemic Theory and HIV Prevention among Young Men Who Have Sex with Men. J HIV AIDS Soc Serv 2013; 20.
  4. Merrill S. Introducing Medical Anthropology: A Discipline in Action. HAB 2011; 204.

 

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Yoojin Choi

Yoojin is a graduate student in the Department of Immunology at the University of Toronto.

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