Dr. Sonya Arreola, PhD, MPH is the Director of Arreola Research and the Research Director for Openly Gray: Older Gay Men’s Health Study at the University of California San Francisco’s Division Prevention Science.
Your research focuses on the sexual health inequities that continue to impact Men who have Sex with Men (MSM) and how those inequities complicate efforts to end the HIV epidemic. What originally drew you to this line of work?
When my mother found herself raising her two youngest children alone, her best friend moved in to help raise us. We came to refer to him as uncle. My uncle is gay. In Mexico City at that time, there was a vibrant gay community that welcomed and nurtured my mother and us, and I felt safe and loved in that secret world. However, I can still taste the sour apprehension that arose when we were in general settings such as in schools, grocery stores, or doctor’s offices. My family all internalized the unspoken rule of silence. My mother and uncle then began to pretend they were married to explain why he was living with us, provide a barrier from the heterosexism that permeated society, and allow him to work and move freely throughout the world. When I turned nine, my uncle met his partner, and I gained a second uncle.
My uncles lived double lives. They were narrating two versions of themselves—quietly absorbing cruel jokes and publicly denying whom they loved just in order to survive. I witnessed the toll it took on their relationships with their families, friends, and on their own wellbeing.
Keeping up the front would sometimes lead to arguments, drinking, or depression for my uncles. In the 1980s HIV emerged, and heterosexist attitudes were emboldened across the whole world. I needed a way to cope with the injustice of it all. This experience helped me find my vocation in participatory action research that is focused on uncovering the lies and celebrating the various forms that a life can take.
The Gay Men and Aging Study will assess relationships among overall health, structural racism and discrimination, resources, and the biomarkers of health among African American, Asian American, Latinx, and White older gay men. Why is now an ideal time to conduct a study like this one? What are you hoping to learn?
In Queer Aging, a book by Jesus Ramirez-Valles, he noted that what he called “Gayby Boomers” are the first generation of gay men who came of age during the gay liberation, and that they were the hardest hit by the AIDS epidemic. As such, gay men over 50 offer a unique opportunity for insight on history, culture, and sociopolitical forces that shaped their experiences. How do they navigate social discourses and norms about sexuality, aging, race, ethnicity, and living with HIV, and what are the implications for public health? We do know that older gay men have poor access to resources like social support; and they experience disproportionately high levels of structural stigmatization, heterosexism, racism, et cetera.
Older gay men living with HIV face even greater health challenges than their HIV negative peers. However, little research exists focused on older gay men’s health and even less on gay men of color who are aging. Therefore, the “Openly Gray” Study, as we call it, will examine how structural racism, discrimination, local LGBTQ+ environments, stigmatization, ageism, HIV stigmatization, resources, and social support impact the lives of older gay men.
The health outcomes we are studying include cognitive function, physical health, depression, substance use, and adherence to antiretroviral treatment. In addition, we will collect biomarkers of health and aging. Our research studies a cross-section of 600 gay men in the San Francisco Bay area split evenly among African American, Asian American, Latino, and White gay men. We will also conduct in-depth interviews with some of the men who participate in the quantitative portion of the study. Using a life course perspective, we will interview 60 gay men across four racial/ethnic groups to get a deeper sense of and explanation for how these things are related to each other.
From 2021 to 2022 there was a 22% increase in the number of PrEP users aged 55 and over, but people in that age group still only represent around 11% of PrEP users. What sort of challenges do older men face when it comes to accessing PrEP?
Access to resources is determined by location, history, and factors like social class, race, ethnicity, and sociopolitical events across time. This is apparent in the inequitable distribution of PrEP by age and by race/ethnicity. Sexuality research is challenging to do because of discrimination, particularly with older gay men, which means there is a lack of research on the subject. We know that a significant proportion or older gay men engage in condom-less sex or sex without the use of PrEP, but perceived risk for HIV infection appears to decrease with age.
Why is not clear. I wonder how ageism and the invisibility of older people as sexual beings, as well as poor access to services together with social isolation, all contribute to poor access and utilization of PrEP. In addition, your own AIDSVu PrEP use data show that there is inequitable distribution and use of PrEP by race ethnicity. In 2021, African Americans represented 42% and Latinx represented 27% of new HIV diagnoses, but only 14% and 17% of PrEP users respectively in 2022. So inequitable access is evident, but how do ageism and structural racism and other forces influence PrEP uptake? These are some of the questions that we hope to answer in the Openly Gray Study.
Age-related stigma and discrimination are issues both in the HIV community and in the wider world. How can ageism and stigma impact HIV-related outcomes?
Both structural and social stigmatization, whether based on age, race, sexuality, or other socially determined factors influence health outcomes, including HIV-related health. And one of the mechanisms that accounts for the powerful impact across all of these is society’s determination of worth and belonging based on individuals or group’s positionality in society. At the structural level, these determinations lead to policies, programming, and practices that privilege some people and make other people invisible, or “others” them. At the social level, stigmatization leads to attitudes and norms that we all consume and that dehumanize those who are not deemed worthy.
In my opinion, it takes great effort to rehumanize people and it would be a lot easier just to accept and care for each other from the start. In addition, regarding gay men, the emphasis on physical attraction and sexual appeal in gay men communities tends to heighten ageism. About 30% of older LGBT people are concerned about age prejudice, and older African American men report even higher ageism than their White peers. So again, we hope to uncover more answers through engaging with older gay men in our study that will help to answer some of these questions.
Every year, the percentage of people living with HIV who are over 55 gets larger, growing from 39% in 2020 to 41% in 2022. What sorts of policy and programmatic efforts could help improve health equity among aging populations?
Eliminating stigmatization and discrimination is one of the keys. Even subtle forms of stigmatization need to be addressed. For example, even though PrEP does offer protection from HIV infection, its association with risk reduction inadvertently shames gay men. Beyond the narratives about gay sex as a sin, the discourse on risk reduction interprets gay men who have condomless sex—or who choose not to use PrEP—as risky. And gay men who are aging have been informed by this narrative for most of their adult lives.
Public health must move away from shaming gay men’s sexuality. We know that shaming, coercion, and othering only serve to isolate and create loneliness. The goal should be to embrace and support multiple expressions of human sexuality and consensual sex behaviors.
Fortunately, we know also that camaraderie, friendship, and community involvement are antidotes to shame and social isolation. The data to support these findings are robust and very clear. Gay men who are involved within their communities fare better than those who do not. As important as it is to create connection, gathering with other gay men also challenges the internalized sense of shame that society imposes, and it offers a more creative and robust lens through which to view oneself and each other and to imagine a life.
September 18 is National HIV/AIDS and Aging Awareness Day, a day to bring attention to the growing number of people living long and full lives with HIV and to their health and social needs. What message do you have for the community on this day?
We must prioritize addressing social and structural determinants of health that drive health disparities. Loneliness and isolation increase as we age, and this is especially true for gay men. We need to support community systems that strengthen gay communities and individuals and their wellbeing with a more holistic approach. At the individual level, start paying attention and seeing and embracing older gay men and challenge the social norms that tell us that some people are worth more than others. At a community level, create systems and support systems that allow people to come together in common cause. At the institutional level, create policies and programming that reject all forms of stigmatization and discrimination and, instead, support the health and wellbeing of gay men at all stages of their lives.
While there is a great deal more work to be done, there are small indicators that my uncles have aged in communities that begin to recognize them as whole people, including their sexuality, not despite it. My wish is for liberation, that they and all will be completely free to be openly gray.
