Worth a Thousand Words

Worth a Thousand Words

By Rachael Strecher

Love and art have no business in the world of hard science, some believe. And yet love plays a crucial role in sexual and emotional safety, as studies by the University of Michigan Center for Sexuality & Health Disparities (SexLab) have indicated. The lab's findings, in fact, suggest that love may be a critical factor in both the emotional well-being and sexual health of certain population groups.

To further examine the role of love in preventing disease, researchers in the Center for Sexuality & Health Disparities recently undertook a 24-month "Photolove" study using a Photovoice-inspired methodology developed by former U-M SPH faculty member Carolyn Wang. Wang developed Photovoice in the 1990s as a community-based participatory research and empowerment methodology through which participants create their own images and discuss them with each other and with researchers. The technique allows researchers to delve deeper into a topic than they're able to do with alternative methods, such as in-depth interviews.

As a first-year MPH student working in the SexLab, I designed the Photolove study starting in September 2010 with the help of Jose Bauermeister, director of the lab and an assistant professor of health behavior and health education at U-M SPH. Our hope was to collect qualitative data to better understand some of the lab's previous findings about sexual and partner-seeking behaviors among young men who have sex with men (YMSM). In one earlier study, for example, researchers found that YMSM who could envision a future with a committed, loving relationship-love-reported fewer sexual partners with whom they had unprotected sex. These data suggested a need to understand what romantic love meant to these men.

When we asked them in earlier studies how they defined romantic love, the young men we interviewed were often understandably baffled. Providing language to explain the concept of love is something poets, storytellers and songwriters have been attempting for hundreds of years, often with poor results.

Given these challenges, we sought through Photolove to give our study population the opportunity to explain their perspectives on love, using both words and images. If they met the study requirements (between the ages of 18 and 24 and identifying as gay, bisexual, queer, or questioning), participants could choose either to create a collage or take photographs that represented their conception of romantic love. Once they sent us the creative portion of their project, we scheduled an in-depth interview.

  • Everything in the middle is something I would look for in the beginning of a relationship.

    Everything in the middle is something I would look for in the beginning of a relationship.

  • The last row was, sort of, I saw the progression of a relationship, ideally.

    The last row was, sort of, I saw the progression of a relationship, ideally.

  • Love is when you make the decision to support a person so completely that you would be willing to mount any level of resources and sacrifice anything in your life for their well-being.

    Love is when you make the decision to support a person so completely that you would be willing to mount any level of resources and sacrifice anything in your life for their well-being.

  • I am really proud of myself, and I don't care what people think or say.

    I am really proud of myself, and I don't care what people think or say.

  • Love should be fun.

    Love should be fun.

  • For me, my entire goal in life is to start a family, no matter what it takes.

    For me, my entire goal in life is to start a family, no matter what it takes.

For the majority of the men interviewed, love followed a traditional, Western, heteronormative trajectory of dating, marriage, children, and growing old together. While sex was an important component of love—a component that many of our interviewees highlighted—it wasn't the only element, and was often far down on their list of important relationship aspirations, if not absent entirely.

So how do these conceptions of love play out in the sexual behaviors of young men who have sex with men, and how can such conceptions contribute to HIV/AIDS prevention? As any good public health student will tell you, our sample was small and not representative of any broader population, but the depth of insight we gained through the study was profound in a way that surveying thousands of the same population about condom use would not be. We found that our study participants faced the same web of complications and insecurities that most young people deal with in the realm of love and sex, and that this web was even more complicated in the face of expectations from inside and outside the gay community about how they, as YMSM, should act.

In public health, we too often focus on disease prevention rather than on the promotion of health and well-being. But this is gradually changing. In 2012, the United Nations placed "happiness" on the global agenda, and economists like Jeffrey Sachs and Joseph Stiglitz are now talking more about a country's "happiness indicators" than its GDP. These ideas have been brewing in our culture for a long time, as indicated by the World Health Organization's 1948 definition of health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." Yet the (admittedly crucial) process of vaccinating people, for example, can be easier than creating the conditions for health as defined by WHO, and such obvious interventions are often promoted over deep environmental and cultural changes that can/could lead to better health.

As Professor Bauermeister points out, we can show young people images of death and disease, implore them to use condoms at all times, and—most ineffectually—tell them to abstain from sex until marriage all we want, but it won't work, and hasn't worked. Is it time for a paradigm shift? It might be more useful to understand YMSM as complex beings navigating a challenging environment of lust, love, discrimination, self-image, and other cultural and personal expectations for how to be a "gay man." Our hope is that public health policies will shift to promote commitment and love between same-sex couples, and to develop programs that will allow YMSM to have the skills and self-acceptance to navigate relationships in a way that is safe, both emotionally and physically, whether they are looking for romantic love or not.

Rachael Strecher, MPH '12, is a program associate in the Global Health and Development Department of the Aspen Institute and a former health communications fellow at the National Cancer Institute.

Dreaming of Tomorrow

HIV infection rates in the United States have stabilized in every population group except one: young men who have sex with men. In the Detroit Metro area, for example, young men between the ages of 20 and 29 account for 16 percent of all new HIV cases in Michigan. "If you include younger adolescents, the number is even larger," says SPH Assistant Professor Jose Bauermeister, director of the U-M Center for Sexuality & Health Disparities.

Bauermeister is trying to identify the behavioral patterns that may underlie the relatively high rates of HIV transmission in this population. Through a series of studies on "virtual love," begun in 2009, he and his research team are working to understand what happens when 18-to-24-year-old gay and bisexual men go online to meet partners and date, and how that information can help health professionals design and implement effective safe-sex interventions.

Health professionals have tended to focus more on risk factors associated with HIV transmission than on healthy behaviors, Bauermeister says, and he thinks that's a mistake. "From a public health standpoint, if we're always measuring risk, we miss the opportunity of increasing what works for people. In the context of HIV, I can talk to young men about condom use until I lose my voice, or I can understand that they're looking for love and equip them with tools that can help them negotiate condoms with their partners."

Through their Virtual Love project, Bauermeister and his team are using surveys, interviews, and Photovoice methodology to learn how young gay and bisexual men conceptualize love and dating—including things like how they distinguish between a hookup and a date, how they know when they're falling in love, and how they characterize and define love. Having recently concluded a pilot Photolove study in southeastern Michigan, Bauermeister and his colleagues are now embarking on a nationwide survey of 1,500 to 2,000 young men who have sex with men. The aim, Bauermeister explains, is to understand the romantic desires of this population and how those desires can either protect young men or put them at risk for HIV and other sexually transmitted infections. "A lot of what we're doing is finding out how love protects kids. When they can envision a future for themselves, for example, they tend to take better care of their bodies."

Key findings from Bauermeister's research are:

  • Among young men who have sex with men, sex is tied to intimacy, and therefore the act of foregoing a condom is often a nonverbal expression of interest in a partner.
  • Youth who are able to envision a committed relationship in the future report fewer unprotected sex partners in the present.
  • Youth who experience "romantic obsession" can be so thirsty for love that it overruns their safer-sex decision-making, and so love isn't always a good thing.

The public health implications of such findings are significant. "If all we do as public health professionals is keep talking about using condoms, we'll fail," Bauermeister says. "The literature has been very clear that condom use is partner-dependent. The way someone negotiates condoms with a casual partner is very different from a partner with a romantic interest. If we don't understand how people process love or romance, how can we build interventions for them?"