YOUTH AT RISK
In a 1991 study of 601 men attending urban STD clinics, one fourth of participants had, during the previous four months, engaged in unprotected anal sex. More than 20% reported engaging in 23 or more episodes. A higher frequency of anal sex was associated with lower condom use rates. The researchers found that among those interviewed in San Francisco:
those who began sexual activity with men at a younger age were more likely to engage in unprotected anal sex. (Doll 1991)
While these findings might have been viewed as suggesting that efforts should be undertaken to prevent or at least delay young men from beginning involvement in homosexual behavior or actively adopting a homosexual lifestyle, none of the researchers drew that conclusion.
Those promoting support groups for "gay youth" in high school and even earlier have argued that these are necessary to save lives since once identified the youth could receive support and AIDS prevention education. The book Children of the Horizon was written to report on one such program and to recommend the creation of similar programs. It was clear from the text that the goal of the program was to bring young men and women into the homosexual community. According to the authors:
For gays and lesbians to succeed in constructing a culture in competition with other groups in the United States has required three fundamental steps: (1) the creation of institutions such as Horizons through which to socialize and affirm values and lifeways; (2) the integration of the older homosexual generation into the new gay and lesbian cohort, or at the least, the provision of cultural means to deal with the alienation of the older generation from the young; and (3) the training of the young, who will transmit social values and cultural rules and beliefs the utopian ideology across time and space into the future. (Herdt p.101)
While the teens involved in the group had a very high knowledge of what constitutes "safe sex," they did not always practice safe sex. The counselors were concerned:
some advisors at Horizons are hard pressed to handle variations among the youth in sexual risk-taking, especially among the small number of kids involved in what the adults consider "marginal" practices, such as sadomasochism. How does one instill a value of accepting "diversity" among gay and lesbian teens while teaching that sexual practices associated with such "marginal lifestyles" are dangerous? (Herdt p.143)
The Horizon group was designed to protect the adolescents from various problems and promoted as a prototype for school-based programs, but even though the group was very small, problems were evident. One of the members had died of AIDS, one was chronically mentally ill, one was a prostitute, another committed suicide, and others were already socializing at "gay bars."
AIDS educators have yet to prove that even the most intensive prevention programs will protect at-risk young men from infection. A longitudinal study of 68 gay men who had attended AIDS-prevention sessions and were followed for 16 months suggests that encouraging boys to come out early may actually increase the risk. The researchers found that:
risk behavior relapse is strongly predicted by earlier history of frequent high-risk practices, especially unprotected receptive anal intercourse, high levels of sexual activity with multiple partners, high subjective gratification derived from past risky sexual practices, sexual activity when intoxicated, and younger age. (Kelly 1991b)
They also found that the more "out" a homosexual was the more likely he was to engage in high risk behaviors. They concluded:
The significant influence of self-rated degree of homosexual "outness" and lower levels of depression may reflect increased sexual contact with other gay men. (Kelly 1991b)
Anyone with even a modicum of experience with adolescent boys knows that they are prone to risk-taking, pleasure seeking, alcohol abuse, refusing to follow good advice, and, in general, impulsive behavior. Educational programs, even when accompanied by social sanctions and threats of punishment, are rarely effective at completely curtailing these behaviors. Putting boys who have homosexual inclinations into an environment, such as the gay community where giving in to impulses is the rule rather than the exception and where the adults show little ability at impulse control could only be expected to have negative health consequences. It is not surprising therefore that "outness" is related to risk taking and to an increased risk of HIV infection.
At a meeting of the American Association for the Advancement of Science in 1996, Dr. Linda Valleroy of the CDC presented the findings of a survey of 1,781 men, 15 to 22, from Florida and California. Valleroy stated:
HIV prevalence is very high among young men who have sex with men, compared with the general population of youths in the US. . . The prevalence of unprotected anal sex is alarming, given that these young men grew up in an era of HIV awareness.
The study found that 38% of those surveyed reported unprotected anal sex within the previous six months. Among those 20 to 22 the rate of HIV infection was 9%.("Seven" 1996)
Concern over the increased incidence of HIV infection in young homosexual men motivated several studies focusing specifically on this age group. In 1994, George Lemp and associates published a study of 425 homosexual and bisexual men ages 17 to 22. The young men were contacted in public locations such as street corners and dance clubs in San Francisco and Berkeley CA. Of the 425, 9.4% tested HIV positive. Among those 20 to 22, the rate was 11.6%; and among African Americans, in the group the rate was 21.2%. The cause of the high infection rate was obvious: "Approximately one third (32.7%) of the participants reported unprotected anal intercourse and 11.8% reported injecting drug use in the previous 6 months." HIV disease was not the only health problem: 19.8% showed evidence of infection with hepatitis-B. (Lemp 1994)
Of the 139 reporting unprotected anal sex, 39.4% admitted alcohol intoxication during sex in the last 6 months, 60% reported nitrite intoxication during sex in last 6 months, and 41.4% reported at least one occasion (lifetime) of forced sex. The researchers concluded: "it is disturbing that the prevalence of risk behaviors is so high in a city known for its large array of prevention programs within the gay community." (Lemp 1994)
Because the previous studies targeted boys in public places, a household survey of unmarried men 18 to 29 was conducted in San Francisco by Osmond and associates. Of the 380 homosexual/bisexual men identified and tested, 17.9% tested HIV-positive. However, if the 52 bisexual men who reported no date of first regular sex with men and who were all HIV-negative were removed from the analysis, the seroprevalence for the rest jumped to 20.1%. Seroprevalence increased with age. Among those 27 to 29, the rate was 28.9%. Among those who had engaged in receptive anal intercourse with 10 or more partners in the previous 12 months, 54.5% were HIV-positive. (Osmond 1994) A follow-up HIV test on the 256 initially HIV-negative subjects found an estimated annual seroconversion rate of 2.6%. Osmond and associates predicted that:
At the observed infection rate, seroprevalence in this cohort, which has a median age of 25 years will be 35% in 9 years. . . Thus, the AIDS epidemic threatens to continue in the younger generation of homosexual men in San Francisco at a level not far below the epidemic in the older generation. (Osmond 1994)
Charts Band C summarize the studies on HIV risk and infection rates among young men who have sex with men.
Given these studies it is not surprising that in 1994, epidemiologists estimated that 30% of all 20-year-old homosexually active men would be HIV-positive or dead of AIDS by the time they were 30.(Goldman 1994)
This information is in keeping with the predictions about the course of the AIDS epidemic. After an epidemic reaches saturation it burns itself out unless a new group of vulnerable individuals enters the at-risk population. Rotello points out that an epidemic among homosexuals differs from one among heterosexuals in that:
Each new homosexual generation is replenished by heterosexuals, whose production of gay sons is entirely unrelated to the dynamics of the epidemic. AIDS can therefore keep mowing down gay men, and rather than dying out, phalanx after phalanx will emerge from the trenches, ready to be mowed down anew. . . There won't be a small number of people who survived whether through genetic mutation or behavioral and cultural adaptation, and who then produce healthy and immune future generation, the epidemic could literally go on forever. (Rotello, p.208)
Several studies found a high incidence of forced sex among young homosexual men. A study of 196 homosexually active men found that 29% reported that they had been pressured at least once into having sex. Ot those pressured 97% said that one or more of these experiences involved unprotected anal intercourse. (Kalichman 1995) Lemp and associates found that, of the 425 homosexuals males, ages 17 to 22, they surveyed, 41.4% reported an occasion of forced sex. The Lemp study also found that 79 of the boys reported beginning anal sex with men when they were ages 3 to 14, of these 15.2% were already HIV-positive. (Lemp 1994) These young men would probably qualify as victims of sexual abuse.
The study by Osmond also found evidence of sexual child abuse: "some of these subjects reported that they had first engaged in regular sex with a male when they were as few as 4 years old." (Osmond 1994) The Remafedi study of the sexual behavior of 239 homosexually active boys 13 to 21 found that 42% had a history of sexual abuse/assault. (Remafedi 1994)
Sexual child abuse and sexual assault have been linked to lifelong psychological problems, including depression, sexual addiction, drug addiction, involvement in prostitution, and suicidal feelings. Those promoting in-school support groups for students who think they may be homosexual frequently point to the various problems among this group. Sexual child abuse and sexual assault must be considered as possible causes.
AIDS education, which provides children and adolescents with explicit information about various forms of sexual behavior which spread the disease, may create curiosity and encourage experimentation among young men. AIDS education has also been used as a vehicle for promoting positive attitudes toward homosexuality and it is possible that the number of young men experimenting with homosexuality will increase. As support groups in schools for boys who think that they might be homosexual are being set up, these boys will be encouraged to "come out." This "coming out" will probably include engaging in sexual activity at an earlier age and more often. These young men may also become part of the urban homosexual community, traveling to centers of homosexual activity where they are likely to encounter HIV-positive adults interested in engaging in sexual activity with attractive teenagers.
According to the book on the Horizons group, the end goal of the group membership is participation by the teenagers in a gay pride march:
The advisors generally praise the marchers' participation in the parade. . .
To be a full person in gay and lesbian culture is to have passed through each of these successive ritual passages that culminates in marching in the parade. That is their jumping-off point into society, following which the youth apply what the youth group experience has taught them. (Herdt p.237)
The authors reported that, when they took group members to such a march, adult homosexuals cheered their presence from the sidelines shouting, "Chicken" and "Fresh meat." (Herdt p.164)
Given the risks, it would appear advisable to delay or prevent young men from engaging in same-sex behavior. It is clear from the studies reported above that every month a young males' entry into the homosexual life style is delayed, his risk of infection is reduced.
In adolescence, some young men experiment with homosexual and heterosexual relationships. Boys who have visited the urban centers and engaged in unsafe homosexual sexual practices may return to their high schools HIV-positive and infect their male and female classmates.
Gary Remafedi's study of 239 homosexual and bisexual male adolescents, aged 13 to 21, found that 9% of the sexual encounters during the previous year were with female partners. Of the 239 subjects, 63% were considered at extreme risk for prior exposure to HIV, 25% at moderate risk. Only 40% had ever undergone HIV testing, but 4% knew they were already positive. In addition, 23% of the subjects reported being infected with other venereal diseases. (Remafedi 1994)
In addition, bisexual young men may take more risks. One study found that Among those under 24, "unprotected anal intercourse was reported by 50.0% of those who reported bisexual activity as compared to 24.4% of those who reported only having sex with men." (Myers 1992a)
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