This document summarizes and discusses three studies related to assessing the roles of place and mobility in gay men's health across the life course. The first study examined how migration decisions and mental/emotional health are linked for gay men in the United States and Canada. The second study looked at how rurality can impact HIV risk and prevention for gay men in Nova Scotia. The third study analyzed service providers' perspectives on the impacts of migration on sexual health for gay, bisexual and queer newcomer men in Ontario. Overall, the document discusses how place and mobility shape key aspects of gay men's lives and health over their life courses.

1. ‚Placing‛ Gay Men’s Health across
the Life Course: Assessing the Roles
of Place and Mobility
Nathaniel M. Lewis, PhD 1, 2
1 School of Geography, University of Nottingham
Nottingham, United Kingdom
(formerly School of Health and Human Performance, Dalhousie University
Halifax, Nova Scotia, Canada)
2
Population Health Intervention Research Network (PHIRNET) National Research Intern,
Department of Geography, University of Toronto Mississauga
Mississauga, Ontario, Canada
Faculty of
Health Professions
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2. The Life Course
A model for explaining life events and outcomes, and their ordering


Alternative to human development paradigms (Levinson 1978)
Instead, examines the confluence of:



Individual maturation
Social and institutional contexts
Historical time
Critical issues for the gay life course
Delays and interruptions of transitions
Coming out



HIV/AIDS
Differentials of support and acceptance compared with heterosexual
men in multiple contexts
Faculty of
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3. Place and Life Course/Health among Gay Men

Life course and health among gay men often presented as aspatial

Gay life course is presented as having different timing (e.g.,
interruptions and delays) but not different spatialities

But migration often emerges as central in gay men’s lives

Health outcomes (e.g., anxiety, depression, STIs) often explained
through individual-based, psycho-behavioural factors and
models (e.g., history of abuse, self-esteem)
 But minority stress is rooted in place

Therefore, health outcomes among gay men are linked with the
geographies of their lives
Faculty of
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4. The Uneven Landscape of Minority Stress
Distal Factors
Proximal Factors
Coping
Structures
Structural
Prejudice
Financial
Status
Prejudice
Events
Concealment or
Suppression
Informal
Prejudice
Internalized
Homophobia
SelfDevaluation
Stigma
Health Outcomes
Treatment/Care Availability
and Sensitivity
Anxiety/Panic
Disorder
Substance
Abuse
Depression
Suicide
Suicide
Ideation
Risky Sexual
Behaviors
HIV and
other
STDs
= place factor
Reproduced from: Lewis, Nathaniel M. 2009. Mental Health in Sexual Minorities: Indicators, Trends, and their
Relationships to Place in North America and Europe. Health & Place 15: 1029–1045.
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5. Seeing Health Disparities as Place-Based
Prevalence of suicide attempt, LGB youth, US and Canadian jurisdictions, 1987–2005
50
45
40
35
30
males only*
25
Gay
LGB
Hetero
20
males
only **
15
10
5
0
MN 1987 MN 2004 Seattle MA 1995 MA 2005 VT 1995 VT 2005 Boulder BC 2003
1995
Co.
* 52/25 split in
** 38/8 split
2003
females
in females
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6. Place and Mobility in the Gay Life Course
place b
place a
place c
Institutions encountered across the life course
Migration a, etc. …
Life
course
from
birth
Individual maturation
individual maturation
Historical time
place a
place b
Faculty of
Health Professions
place c
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7. Presentation Outline
3 case studies linking health and gay life course:
Moving ‚Out,‛ Moving On study (2009–2010)

Examines mental/emotional health and migration decision
making among gay men in the United States and Canada
(migration as self-care)
Placing HIV Risk & Prevention among Gay Men in NS (2012)

Links rurality with men’s life courses, and the implications for
HIV/AIDS risk and prevention outside MTV
Promoting Sexual Heath for GBQ Newcomer men in ON (2013)

Uses service providers’ perspectives to view immigrant men’s
sexual health through the lens of the migration experience
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8. Moving ‚Out,‛ Moving On Study (2009–2010)
Places moved from, 48 gay-identified men living in Ottawa and Washington, DC, as of 2009–
2010
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Health Professions
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9. Migration up and down the urban hierarchy
Origin of most recent migration, by age at time of migration and city type
Number of respondents
Large
metropolis
Mid-sized
but larger
Ottawa or
Washington
Mid-sized
but smaller
1
3
2
5
4
7
6
Under 25
25–30
Over 30
Under 50,000
50000–500000
Mid-sized
Very small city
Very small city
Small city
Small city
500000–1000000
(Ottawa and Washington ≈ 650000)
Large metropolis Over 1000000
Faculty of
Health Professions
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10. Migration as Self-Care

‚In *Ontario town+, I had panic
attacks on occasion. I’ve had like one
or two since I’ve moved here, so …
anxiety’s gone down … In high
school, because there was a lot—it
was a very kind of narrow-minded,
homophobic high school—I … I
developed ulcers … like I got really,
really bad migraines, and just a lot of
kind of stress-related health issues
that were kind of having a really,
really big impact on me … so, uh,
once I kind of left the area, I felt a lot
better.‛
⁻
Luke, 24, white, French-Canadian,
moved to Ottawa in his teens
Faculty of
Health Professions
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11. Migration as Self-Care

‚I had walked to the crest of the
MacDonald Bridge and I stood
there for—or was it the MacKay? I
don’t remember which, it doesn’t
really matter, they’re both high and
they’re both over the harbor—and I
stood there—it was rush hour—and
I stood there until it got dark—
waiting for myself to throw myself
over. And I knew if I stayed in
Halifax, one day I would throw
myself over. So I had to get out, I
had to leave.‛
⁻
Randall, 45, black/Aboriginal, moved to
Ottawa from Halifax in his late 20s
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12. ‚Operating without a safety net‛: migration/risk

‚I think there is some, um, disappointment—true disappointment—
when you figure out that maybe you don’t fit the mold and you’re not
welcomed over here and you’re not welcomed over there ... that’s a hard
lesson to learn, you know?‛

‚When I first came out [in D.C.], I dropped 60 pounds, I was running 21
miles a week, uh, you know, got myself into shape ... just coming
screaming out of the closet, and just being like ... if I’m gonna do this,
then I’m gonna be ... the best that I can be.‛

‚I kind of do *know when I contracted HIV+ ... I think there’s probably
some self-esteem issues there ... I think that trying to fit in thing that we
talked about ... I think that always plays into things ... just trying to fit in
... you may not *use protection during sex+ because you don’t want to be
rejected ... so you would just conform or just not say anything ...‛
⁻
Joseph, 38, white, moved from the Florida panhandle to DC in his late 20s
Faculty of
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13. AGGREGATE, N = 48, NEXT
MIGRATION
Migration & well-being later in the life course
Destination of next planned migration, by age at time of interview and city type
Number of respondents
Large
metropolis
Mid-sized
but larger
Ottawa or
Washington
Mid-sized
but smaller
1
3
2
6
4
9
Under 30
30–40
Over 40
Very small city
Not planning to move: 12 (Under 30: 3, 30–40: 3, Over 40:6)
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Very small city
Under 50,000
Small city
Small city
50000–500000
Mid-sized
500000–1000000
(Ottawa and Washington ≈ 700000)
Large metropolis Over 1000000
dal.ca

14. Migration & well-being later in the life course

In the 1980s: ‚What I sought [in moving to Ottawa], of course, was, you
know, acceptance and a community ... but at that time when I moved
here ... it was starting to grow. So I grew with it, and the things that I
probably expected or sought were the things that I was creating or
helping create‛
⁻
Adrian, 56, moved from Nova Scotia to Ottawa in his 20s

Later in life and later in historical time: ‚the social and existential
meaning of homosexual identity becomes less clear‛ (Kertzner 2001, 88).

In the 2000s: ‚It’s very comfortable to have [gay men] working without
any issues in just about every federal agency [in Washington, DC] ... I
didn’t get a sense of that in Ohio.‛
⁻
Adam, 34, moved from northern Ohio to DC in his 30s
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15. ‚Placing‛ HIV in NS Study (2012)

Looks purposefully at a the place-health link in terms of HIV

Interviews with individual gay-identified men and service
providers

One of the first studies to examine risk and prevention in a rural
region (as opposed to PLWHAs)
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16. Masculinities Messages: Growing up Gay in NS

‚Just trying to fit into … that rural culture and all the
masculinity sort of driving the truck, going mud
bogging and you know those types of things and
you know I think [younger gay men] fear—I think
it’s an irrational fear—but I think they fear, you
know, people not liking them because they’re gay‛
⁻
Justin, 30s, Colchester County
Also a strong historic & institutional components:





Eric Smith (1991) & Lindsay Willow (2006) cases
Banning of the sex book (2006)
Truro pride flag refusal (2007)
Intermittent banning of GSAs (up to 2012)
Lack of investment in prevention structures
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The ‚sex book‛
banned in some NS
schools
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17. Individual Effects: Risk Behaviour & Perception

‚… and then I just got to 30 and realized I had no sexual confidence, I
had no sexual, like I don’t even really know what I like or what’s kind
of weird, or what I want and so it was just a beautiful revolving door
for like three years, hundreds [of sexual partners] I feel like, I just went
totally crazy … it was fun and I’m just so thankful I came out of that
and then now I’m in a place of comfort and pick and choose, and date,
and do what I want.‛
⁻

Mark, 30s, HIV-negative, Halifax County
‚They’re doing things that may be riskier because perhaps they don’t
even want to really talk about it … if they’re not talking, they’re not
comfortable talking to partners or going and getting condoms … I
suppose you’re doing things a little bit more spur of the moment that
you hadn’t planned on …‛

HIV nurse, Halifax County
Faculty of
Health Professions
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18. Individual Effects: Mobilities and Risk

To Halifax: ‚There is no place close to them … they may not be out or
they may have you know pent up energy or whatever—and they come
[to Halifax] and all hell breaks loose sometimes. So [STIs] may not be
the first thing on people’s minds and then they’re going home … they’re
going back and they’re living their lives whether that’s gay relationships
or … married to the opposite gender and potentially the spread.‛
⁻

youth outreach worker, Halifax County
To other cities: I’ve had many conversations with … gay men that might
be around the 30, 32 in age, who have spent a number of years … in the
Toronto, Vancouver area, who talk about the minute they got there … it
was like fantasy land, right? And they took every advantage they could
of course and nothing wrong with that, but we’re not at all prepared for
the emotions, the responsibilities or any of that associated with it.‛
⁻
ASO director, Halifax County
Faculty of
Health Professions
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19. Community Effects: Sexual Speakability

This sort of unwillingness to be comfortable with their own sexuality,
and just hating the gays that are *comfortable+… it’s more prevalent
here I feel … ‘cause maybe there’s this undercurrent or this tone in our
community where we’re still striving to be—either for their families or
their dads—you know, somewhat masculine and not want to change.‛
⁻

Mark, 30s, HIV-negative, Halifax County
‚… There’s sort of this badge of honor for normal gays like … I want a
monogamous relationship and I want to get married. [My HIV-positive
friend] was an example of what they could be and by sort of casting him
aside … it allowed them to sort of look back to their sort of cocoon of …
we’re all in open relationships, we all fuck around with everybody, we
do engage in unprotected sex … like if we dismiss it and push it away
… then we can keep on going and living our lives.
⁻
Jason, 30s, HIV-negative, Halifax County
Faculty of
Health Professions
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20. Ontario Newcomer Sexual Health Study (2013)

Focuses on post- (international) migration shifts in sexual health

Shifts focus to the when of the life course

Systematic review, plus interviews with service providers serving
newcomer men in London, Ottawa, Mississauga, and Toronto

One of the first studies to look specifically at GBQ immigrants
rather than GBQ ‚ethnic minority‛ groups
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21. Risk in GBQ immigrants and non-immigrants
12-month prevalence (%) of unprotected anal intercourse (UAI), nonimmigrants, Latin American immigrants, and other
immigrants, Catalonia, Spain, 2008 (Folch, 2009)
Group
UAI Prevalence
Adjusted Odds Ratio
Spain (non-immigrant)
26.4
1.00
Latin Amer. immigrants
45.1
2.10 (significant at .01)
Other immigrants
40.9
1.86 (significant at .05)
3-month prevalence (%) of unprotected anal intercourse (UAI), recreational drug use, and
lifetime prevalence of getting an HIV test, full study sample, white non-immigrants, Latin
American immigrants, and Eastern European immigrants, United Kingdom, 2007-2008
(Elford et al. 2012)
Group
UAI Prevalence
Drug Use prevalence
HIV Test Prevalence
Full study sample
41
50
66
White British men
42
50
65
Latin Amer. Immigrants (~6 yrs. since arrival)
44
60
90
E. European Immigrants (~3 yrs. since arrival)
45
49
75
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22. 6-month prevalence (%) of (1) cocaine, (2) marijuana, and (3) ecstasy use, select Asian/PI and
Latino studies, San Francisco (SF) Chicago/SF, and Miami, 2000–2005
Mean/median years since arrival
Marijuana
13
13
≤6 (60%)
Ecstasy (E)
8.3
Cocaine
≤6 (60%)
≤6 (60%)
8.3
13
8.3
% of immigrants in the sample
20–39%
40–59%
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60–79%
80–99%
100%
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23. 3-month prevalence of any unprotected anal intercourse (UAI)*, select studies, New York
City (NYC)/Los Angeles (LA), UK, San Diego (SD)/Seattle, United Kingdom, Northeastern
US, Miami, and rural North Carolina, 2002–2008
Mean/median years since arrival
9
15
6
3
9
* Where reported, rates for UAI w/ “casual partners” were 17–34%
% of immigrants in the sample
20–39%
40–59%
Faculty of
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60–79%
80–99%
100%
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24. Challenging the Acculturation Thesis

‚From arrival until 3 or 4 years *after arrival+, they have so many other
issues, that, you know, spending spare time, enjoying the life, it’s hard to
say if they’re getting included at the gay bar or whatever.‛
⁻

‚The priority is for them to integrate, and then as soon as they settle,
maybe then they would come out to me if they are closeted.‛
⁻

newcomer centre director, Mississauga
settlement counselor, London
‚ … back home I couldn’t be out and I’m glad to be here or we didn’t
have a bath house back home … It’s sort of this place where you are
guaranteed going to be meeting gay … you’re really being stressed and
that’s the kind of release you’re looking for, a bath house can be one of
those things … I don’t know anybody but at least I can go get laid.‛
⁻
sexual health counselor, London
Faculty of
Health Professions
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25. Post-Migration Vulnerabilities: Negotiating Sex

‚Some people are coming having experienced extreme violence and
extreme trauma … and for gay men … you’ve experienced some form
of shame-based trauma that goes undealt with; how trauma can
manifest, we can have voicelessness … we can have difficulty
negotiating safer sex or negotiating relationships.‛
-

gay men’s sexual health advocate, Toronto
‚*An immigrant colleague+ said that … because he visually looked so
different, he never felt empowered to insist on the kinds of sex that he
wanted to have because the message … was you should feel lucky that
the beautiful white boy wants to have sex with you … it caused him to
bend the rules where he otherwise wouldn’t or to avoid sex altogether.
Like I don’t want to rock the boat by insisting on condom use.‛
⁻
sexual health educator, London
Faculty of
Health Professions
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26. Conclusions

Gay men’s health continues to be affected by geographies of rights,
social inclusion, and service provision, that are uneven both
across space and over time:



Migration emerges as a personal self-care strategy:



Individuals carry forward personal trauma experienced earlier in
life, sometimes in other places
Communities—and gay communities within them—often perpetuate
historical traumas through ongoing behaviours and modes of being
That corrects interruptions and delays in the life course
That can create additional stress and upheaval during transitions
Clear points of entry into gay communities and gay-specific care
are central to promoting resilience among diverse GBQ groups,
including the recently arrived
Faculty of
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27. The Disavowal of Gay Space?

‚In Toronto, we’ve abandoned the Church
Wellesley Village … we vacation with our
boyfriends in fabulously rustic country
homes that belong to our parents, who don’t
mind us coming to stay as a couple. Hell, we
even marry our boyfriends, if we choose to,
on rooftops overlooking Queen West. Our
sexual orientation is merely secondary to our
place in society. We don’t need to categorize
or define ourselves as gay, and who we sleep
with—mostly men and, hey, sometimes
women—isn’t even much of a topic of
conversation anymore … say hello to the
post-modern homo. The post-mo, if you will.‛

Paul Aguirre-Livingston, ‚The Dawn of a New
Gay,‛ The Grid Toronto, 6/9/2011
Faculty of
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28. Problematizing Mobilities as Self-Correction
‚The IGB video is a mandate to fold into urban, neoliberal gay enclaves,
a form of … upward-mobility that echoes the now discredited ‘pull
yourself up from the bootstraps’ immigrant motto. [Dan] Savage
embodies the spirit of a coming-of-age success story. His message
translates to: Come out, move to the city, travel to Paris, adopt a kid, pay
your taxes, demand representation.‛
⁻
Jasbir Puar, ‚The Problem with It Gets Better,‛ The Guardian, 11/10/2010
Faculty of
Health Professions
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29. Community Investment as Alternative: Ottawa

‚. . . There’s a lot of gays who arrive here
from the [Ottawa] valley and from smaller
communities … their experiences are quite
different … whereas in Montreal … you
arrive on the bus terminal . . . you’re
practically in the Village already.‛
⁻

Sam, 44, Moving ‘Out’, Moving On Study
‚… the opportunity for people who live in
our area and the surrounding areas to …
understand where to access services . . . that’s
something that’s really … exciting and unique
about *the+ Ottawa *village+ … we have
organizations like the Centretown Citizens’
Association+ … the *Citizens’ corporation+‛
⁻
Glenn Crawford, 2009
Faculty of
Health Professions
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30. Acknowledgements




Social Sciences and Humanities Research Council Vanier
Scholarships
Association of American Geographers
Canadian Institutes of Health Research (CIHR)
CIHR Population Health Intervention Research Network
(PHIRNET)
Faculty of
Health Professions
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