Anxiety Depression Strengths - GMSH

Anxiety Depression Strengths - GMSH

Social Anxiety, Depression, and

Psychological Strengths

Among Gay and Bi Men

Trevor A. Hart, Ph.D., C.Psych

Director, HIV Prevention Lab

Associate Professor

Department of Psychology

Ryerson University

Outline of Plenary

1. Prevalence of anxiety disorders and depression

among gay and bisexual men

2. Anxiety and risky sex

3. Social anxiety, depression, and risky sex

4. Anxiety and depression do not come out of a


• Distress may instead come from negative life experiences

5. Psychological strengths of gay and bisexual


• What we know and don’t know

Relevant Research Publications

• Calzavara, L. M., Burchell, A. N., Lebovic, G., Myers, T., Remis, R. S., Raboud, J.,

Corey, P., Swantee, C., & Hart, T. A. (2011). The impact of stressful life events on

unprotected anal sex among gay and bisexual men. AIDS and Behavior. doi:


• James, C. A., Schwartz, D. R., Roberts, K. E., Hart, T. A., Loutfy, M. R., Myers, T., &

Calzavara, L. (in press). Childhood emotional abuse and psychological distress in gay

and bisexual men. Journal of Aggression, Maltreatment, and Trauma.

• Hart, T. A., James, C.A., Roberts, K.E., Myers, T., Calzavara, L., & Loutfy, M. R. (2009,

August). Social anxiety predicts later risky sex: Mediation by fear of being rejected by

one’s partner. Paper presented at the 2009 U.S. National HIV Prevention Conference,

Atlanta, GA.

• Hart, T.A., James, C.A., Purcell, D.W., & Farber, E. (2008). Social anxiety and HIV

transmission risk among HIV-seropositive men. AIDS Patient Care & STDs, 22, 979-


• O’Cleirigh, C., Hart, T.A., & James, C.A. (2007). HIV and anxiety. In M. J. Zvolensky &

J. A. J. Smits (Eds.) Anxiety in health behaviors and physical illness (pp. 317-340). New

York: Springer.

• Hart, T.A., Roberts, K.E., Ghai, A., James, C.A., Myers, T., & Calzavara, L. (2007,

December). Psychological distress among HIV-positive and HIV-negative men who

have sex with men. Paper presented at the 2007 National HIV Prevention Conference,

Atlanta, GA.

• Hart, T.A., & Heimberg, R.G. (2005). Social anxiety as a risk factor for unprotected

intercourse among gay and bisexual male youth. AIDS and Behavior, 9, 505-512.

Thrust of This Talk





What is Sexual Health?

(WHO, 1992)

• Sexual health is a state of physical, emotional, mental

and social well-being in relation to sexuality; it is not

merely the absence of disease, dysfunction or


• Sexual health requires a positive and respectful

approach to sexuality and sexual relationships, as

well as the possibility of having pleasurable and safe

sexual experiences, free of coercion, discrimination

and violence.

• For sexual health to be attained and maintained, the

sexual rights of all persons must be respected,

protected and fulfilled.

Context of Sexual Health

(Wolitski & Fenton, 2011)

• Sexual health inequities experienced by gay and bisexual

men exist within a larger context, driven by social

marginalization and discrimination.

• Social marginalization is a cause of health inequities

experienced by a range of disadvantaged populations.

• Discrimination toward sexual minorities is a form of social

marginalization that is rooted in homophobia and is

reflected in laws, policies and interpersonal interactions

that affect the physical and mental health of gay and

bisexual men.

• Individual choices and behaviours affected by social


1. Prevalence of Anxiety and

Mood/Depression Disorders

Among Gay and Bisexual Men

First, what is a “Disorder”?

Anxiety Disorders Among Gay/Bi Men

(Sandfort, de Graaf, Bijl, and Schnader, 2001)

Type of Anxiety Disorder





Adjusted Odds


(95% CI)

All Anxiety Disorders 13.2% 31.7% 3.11 (1.91- 5.05)

Panic Disorder 1.7% 7.3% 4.21 (1.65-10.77)

Agoraphobia (w/o panic) 1.8% 7.3% 4.54 (1.79-11.53)

Simple Phobia 6.0% 18.3% 3.61 (1.94- 6.74)

Social Anxiety Disorder 5.5% 14.6% 2.29 (1.17- 4.50)

Generalized Anxiety Disorder 1.5% 3.7% 2.88 (0.82-10.18)

Obsessive-Compulsive Disorder 0.7% 6.1% 6.20 (2.03-18.90)

Example of An Anxiety Disorder That

May Be Higher Among Gay/Bi Men

• Social Anxiety Disorder

– Marked and persistent fear of 1+ social or performance

situations in which the person is exposed to unfamiliar people

or to possible scrutiny by others. Person fears that he/she will

act in a way that will be humiliating or embarrassing.

– Exposure to the feared social situation almost invariably

provokes anxiety, which may take the form of a situationally

bound or situationally predisposed panic attack.

– Person recognizes that the fear is excessive or unreasonable.

– Feared situations are avoided or else are endured with intense

anxiety or distress.

– Interferes with the person's routine, functioning, or

relationships, or there is marked distress

Mood Disorders Among Gay/Bi Men

(Sandfort, de Graaf, Bijl, and Schnader, 2001)

Type of Mood Disorder





Adjusted Odds


(95% CI)

All Mood Disorders 13.3% 39.0% 2.35 (1.39- 3.97)

Major Depression 10.9% 29.3% 2.35 (1.39- 3.97)

Dysthymia 3.5% 7.3% 2.33 (0.94- 5.75)

Bipolar Depression 1.2% 8.5% 7.27 (2.85-18.52)

Psychological Strengths We Can See

From This Study

• Gay and bi men don’t have higher rates of

drug or alcohol use disorders.

• This is despite the facts that

– It is really easy to have access to drugs and

alcohol in the gay community

– Many gay men have tried multiple drugs

– Gay men may have additional stresses that

straight men do not have

2. Anxiety and Risky Sex

Why Anxiety?

• Gay and bi men are often characterized by the

media and homophobic people as:

– Reckless

– Irresponsible

– Living for the moment

• Not much attention to how gay and bi men

experience their lives

– Negative outcomes of gay and bi men’s oppression

– How gay and bi men survive and thrive despite


Need to Be Specific When Talking

About Anxiety

• Pretty weak associations between anxiety and sexual

risk behaviours across studies (r = .003)

– Also weak associations for depression and sexual risk


• High anxiety as a personality trait was even

associated with less likelihood of having unprotected

anal sex among 550 gay and bisexual men

• However, anxiety can be about anything

• Need for more specific questions – what is the anxiety


– Fears of washing dishes?

– Fears of not being liked by other people?

PTSD and Other Anxiety


• PTSD associated with

– 1.7 times more likely to have had anal sex

– 1.6 times more likely to have engaged in sex work

• However, might be just that people who suffered

trauma also were survivors of childhood sexual and

physical abuse

– Having lived through child abuse leads to adult risky sex

• We don’t know if other anxiety disorders are

associated with risky sex or other poor sexual health


3. Social Anxiety and HIV Risk

Among Gay and Bi Men

Defining Social Anxiety

• Fear about being evaluated in social

situations (Leary & Kowalski, 1995)

• A common experience (e.g., Ishiyama, 1984)

– Differentiated from Social Anxiety Disorder

• Social fears may be exacerbated in members

of stigmatized groups (Buss, 1980)

Social Anxiety and

Related Impairment

• Related to psychosocial impairment

(Schneier et al., 1994)

– school and work situations

– peer relationships

– romantic or sexual relationships

• Related to low social support, especially from

peers (La Greca & Lopez, 1988)

What Does Social Anxiety

Have to Do With HIV and AIDS?

• 32% of gay men reported being less likely to use

condoms when they:

– did not wish to offend their partner

– were concerned partner would react negatively (Offir,

Fisher, Williams, & Fisher, 1993)

• Adolescents who were embarrassed to use

condoms were 2.4 times less likely to use them

(Hingson, Strunin, Berlin, & Heeren, 1990)

Social Anxiety as a Risk Factor for

Unprotected Intercourse Among

Gay and Bisexual Male Youth

Trevor A. Hart, Ph.D.

Richard G. Heimberg, Ph.D.

(Hart & Heimberg, 2005, AIDS and Behavior)


• 100 gay and bisexual male youth and 89

heterosexual male youth

• After school programs, university residence

halls and LGBT student organizations

• Between the ages of 16 and 21 (Mean 18.8,

SD = 1.4)

• 53% youth of colour


• Anonymous self-administered questionnaires

• Demographics

• Two types of social anxiety

– Social Interaction Anxiety Scale (SIAS; Mattick & Clarke,


– Social Phobia Scale / Social Performance Anxiety (SPS;

Mattick & Clarke, 1998)

– Data confirm that measures assess different aspects of

social anxiety (E. J. Brown et al., 1997; Heimberg et al.,

1992; Ries et al., 1998)

Social Anxiety in the Two Samples





21.97 *









Social Interaction Anxiety


Social Phobia Scale

SPS and Unprotected

Insertive Anal Intercourse

Regression Variables χ 2 df OR 95% CI

Step 1: 6.08 4

Discuss Condom Use 0.66 0.43 – 1.02

Refuse Unprotected Intercourse 1.01 0.69 – 1.49

Number Social Supports 0.84 0.62 – 1.12

Social Support Satisfaction 1.14 0.68 – 1.91

Step 2: 7.21** 1

Social Phobia Scale 3.82* 1.38 – 10.52

Note: OR = odds ratio; CI = confidence interval; n = 90

* p < 0.05 ** p < 0.01



• High social anxiety is associated with greater likelihood

of unprotected insertive anal sex among young MSM

– No effect for heterosexual populations

– May reflect gender role differences among MSM vs.

heterosexual males

• Social anxiety exerts its effects above and beyond the

other variables assessed in the literature

– Discussing condom use

– Refusing unprotected sex

– Social support

Limitations and Future Directions

• Limitations

– Cross-sectional

– Is it really social anxiety or is it any kind of psychological

distress, like depression?

• Needed to replicate findings in other


– HIV+ men

– Adult MSM of any HIV status

Social Anxiety as a Risk Factor

For HIV Transmission

The HIV-Seropositive Men Study

(Hart, James, Purcell, & Farber, 2008,

in AIDS Patient Care and STDs)


• HIV-seropositive men at a public city hospital

– Sample N = 138

– 84 men who have sex with men (MSM)

– 54 behaviorally heterosexual men

• Age M = 41.86 (SD = 6.62)

• Mostly ethnic/racial minority (70% African-American, 20%

Caucasian, 10% Latino or other)

• 61.7% had high school or less educational level

• 85% unemployed (51% on disability)

• 88.6% had income < US$20,000

• 94% with AIDS diagnosis (CD4 M = 226)

Overview of Method

• Initial nonspecific recruitment to reduce effect of

anti-gay stigma

• Audio-Computer Assisted Self Interview (ACASI)

– Better for individuals with low literacy

• Brief Clinical Interviews

– Liebowitz Social Anxiety Scale

– Hamilton Depression Scale

• Participants paid $10 as reimbursement for their

time and effort


Proportion Engaging in Unprotected

Insertive Intercourse

Social Anxiety And Unprotected Insertive

AI with Non-HIV+ Partners – MSM

Measure Odds Ratio 95% Confidence



SIAS 1.75 0.51 - 6.04 .37

LSAS-Social 4.71 1.17 - 18.92 .03


7.41 1.51 - 36.34 .01


SPS 15.39 1.89 - 125.64 .001

Predictors of Unprotected Insertive Anal

Sex With Non-HIV+ Partners:

Step 1 of Logistic Regression


Odds Ratio 95% Confidence





Club Drug


6.07 1.17 – 31.51 .03

2.54 0.63 – 10.26 .19

Regression Model: Simultaneous

Predictors of Insertive Anal Sex


Odds Ratio 95% Confidence





Club Drug


2.94 0.73 – 11.75 .13

2.42 0.47 – 15.21 .27

SPS 15.02 1.08 – 88.19 .04


Limitations and Future Directions

• Need for further exploration of this association in

longitudinal analyses

– Does baseline social anxiety predict later HIV risk


– How does social anxiety exert its putative effects on risky

sexual behaviour?

– With which types of partners does social anxiety exert its

putative effects? Longer-term partners? Casual


• How about HIV- MSM?

Social Anxiety as a Risk Factor

for HIV Transmission Behaviour:

Mechanisms of Action

Trevor A. Hart, Ph.D. 1,2 , Carolyn A. James,

M.A. 1,3 , Karen E. Roberts, M.A. 1,3 , Ted

Myers, Ph.D. 2 , Liviana Calzavara, Ph.D. 2 , &

Mona R. Loutfy, MD, MPH 4


Ryerson University, Toronto, Ontario


Dalla Lana School of Public Health, Toronto, Ontario


York University, Toronto, Ontario


Women’s College Research Institute, Toronto, Ontario


• Funded by an Operating Grant (2005-2009) and

a New Investigator Salary Award (2006-2011)

from the Canadian Institutes of Health Research


• Staff of the:

– Polaris Seroconversion Study

– The Maple Leaf Medical Clinic

– The HIV Prevention Lab at Ryerson University

• A special thank you to Massimo Di Domenico and Bojana


• The many men who participated in our study

What is this Study About?

• Examines mechanisms by which social anxiety

impacts HIV transmission risk among MSM

– fear of rejection for insisting on condom use (presented


– fear of AIDS stigma

– sexual performance anxiety

• Examines relations longitudinally

– Baseline assessment of social anxiety

– Follow-up assessment of risky sex

• Completed enrolment = 238 MSM

Social Anxiety and Risky Sex:

Proposed Mechanism of Action



Fear of Being

Sexually Rejected

by Partner


Sex at




• N = 238 men who have sex with men (MSM)

– 124 HIV-negative MSM

– 114 HIV-positive MSM

• Age M = 44.22 (SD = 9.72)

• Mostly (76.8%) Caucasian

• 67.6% had at least some college education

– 19.7% had high school or less educational level

• 60.3% have an income of < CDN$40,000

• 25.4% were on disability, 19.9% were unemployed,

53.8% were employed either full- or part-time

Overview of Method

• Recruitment from the Polaris Seroconversion Study,

Maple Leaf Medical Clinic, AIDS Service

Organizations and gay/bisexual media

• Participants completed

– A brief clinical interview (LSAS) and an Audio-Computer

Assisted Self Interview (ACASI) containing self-report

measures at baseline and

– ACASI at a 6-month follow-up

• Participants were paid $50 at baseline and $30 6-

month follow-up as reimbursement for their time

and effort

Self-Report Measures

• Specific Sexual Fears

– If I insisted on condom use, I would be concerned:

• My partner would not want to have sex with me

• UAI in the past six months with

– Longer-term partners (≥ 6 months)

– Casual partners (< 6 months)

– Interested in UAI with unknown serostatus or

serodiscordant status


Social Anxiety Predicts

Later Risky Sex

Further Findings With HIV+


Social Anxiety Predicts UAI

with Non-HIV+ Casual Partners




95% CI P-value

LSAS-Social Interaction 1.72 1.07 - 2.75 .02

LSAS-Social Performance 1.59 1.08 – 2.52 .049

Fear partner will not want

to have sex with me

2.15 1.20 – 3.88 .01

Simultaneous Predictors of UAI with

Non-HIV+ Casual Partners




95% Confidence





Fear partner

won’t want to

have sex with


1.06 0.97 – 1.16 .18

2.02 1.15 – 3.55 .01

Social Anxiety and Risky Sex With

Casual Partners:

Mechanism of Action

Higher Social


Fear of Being


Rejected by


Risky Sex



• Gay and bi men with higher social anxiety are

more likely to have subsequent risky sex

– May be because they are concerned that they

will be rejected by their partners for insisting on

condom use

– Need for better mental health promotion and

support for gay and bisexual men

Sexual Health Implications

• Prevention workers may wish to attend to social anxiety

among gay and bisexual men, which predicts

subsequent risky sex

• Interventions that integrate fear of being rejected in

sexual situations with evidence-based HIV prevention

are warranted

• Many empirically supported HIV prevention

interventions can be adapted to include social anxiety

– Healthy Relationships uses a social cognitive model

– Social anxiety treatment uses a social cognitive model

4. Anxiety doesn’t come

out of a vacuum!

Childhood Emotional Abuse

Might Lead to More

Psychological Distress

Variables in


Why Gay Men Might Have

Higher Social Anxiety

(Roberts et al., 2008)

Adjusted R 2 F df Semipartial r

Full Model .48 27.63** 5, 141

Education -.16*












Depression .17*

Psychological Strengths of

Gay and Bisexual Men


There is a lot missing from the

research literature!

Strengths We Need To

Focus More On

• The literature is full of what makes gay men at “risk” for

unprotected anal sex

– Hardly any studies focus on strengths

• 54% of gay and bi men had no unprotected anal sex in the

past 6 months (Calzavara et al., 2011)

• Why is it that most gay men haven’t had unprotected anal

sex recently?

• How do gay men protect themselves in ways other than

avoiding unprotected anal sex?

– Getting tested for HIV and/or Sexually Transmitted Infections

– Taking HIV medications regularly

Part of the Solution: New Research

The Gay Men’s Strengths Study

• Will ask 400 HIV-negative gay and bi men

about their mental and sexual health

• Will ask men about their health at 3 different


– Baseline when they start the study

– 3 months after baseline

– 6 months after baseline

Social-level Strengths

• Engagement in the gay/bi men’s community

– Beyond just bars

– Social, athletic, activist activities

• “Social capital”

– The resources and support gay/bi men get

– From one’s friendship and family networks

– From the community (e.g., organizations,


Individual-level Strengths

• Personal beliefs about the need to protect oneself

and others from HIV and STIs

• Hope

– Having goals for the future

– Positive expectations about the future

• How connected gay/bi men feel toward others

• How gay/bi men cope with stress

– Stress in general (e.g., work, daily hassles)

– Gay-specific stress (e.g., feeling less valued than others,

overt homophobic experiences)

Another Part of the Solution:

Innovative Programs

• Need for more HIV prevention and sexual health

promotion programs that build on STRENGTHS

• Gay Poz Sex (GPS)

– 7 session program for HIV+ Gay and Bi Men

– Offered by ACT, and eventually Positive Living BC

– Participants to identify own personal sexual health goals

– Assumes that men are capable of making their own decisions

– Builds on each participant’s personal strengths and successes

– Well-received by participants

• see Rick’s talk on GPS at the breakout sessions on Tuesday at 1:30pm

• This work is a part of a large and exciting new way of

thinking across ASOs across Ontario


What Can We Take From This Talk?


• Some kinds of anxiety disorders are higher among

gay and bi men

• Social anxiety and risky sex

– Social anxiety is higher among gay men

– Social anxiety leads to risky sex among gay men

• Social anxiety and other kinds of anxiety come out of

homophobic and other negative experiences

• Most gay and bi men are still highly functioning and

thriving despite negative experiences

– We need more data showing just how well gay and bi

men do thrive

Social Anxiety Doesn’t

Come Out of a Vacuum

• HIV stigma

• Childhood emotional abuse

• Childhood bullying

• Many other life problems

– From childhood

– From adulthood

What We Don’t Know

• Biological sexual outcomes

– Does social anxiety predict STIs?

• How about other anxiety problems?

• How does anxiety affect other aspects of


– Immune functioning

– Substance use

What Health Providers Can Do

• Assess for anxiety disorders

• Google “Liebowitz Social Anxiety Scale” and use

it in your clinic or case management setting

• Pay attention to social anxiety and trauma

among people at risk for STIs

• Acknowledge that anxiety may come from a

difficult life history

• Treat anxiety disorders if possible

• Refer to mental health providers

What Prevention Workers Can Do

• Assess for anxiety disorders

• Find out if social anxiety and/or trauma are

factors in your client’s lives

• Use your case management and counselling

skills to support clients living with higher


• Refer when useful for the client

What Gay/Bi Men Can Do

• Identify if anxiety has affected your life

– Acknowledge that it probably came out of your life history

– Don’t blame yourself

• Read more about anxiety and anxiety disorders, if relevant

to you

• Is your anxiety level too high for you?

– Talk about it with your health and service providers

– Don’t blame yourself – it probably came out of real life


– Know that high anxiety is a treatable problem!

– Acknowledge that what how gay men feel about themselves

also affects what gay men do sexually






Thank You

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