What guys say, and what they do

What guys say, and what they do Urban young men’s use of health and social services What guys say, and what they do Urban young men’s use of health ...
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What guys say, and what they do Urban young men’s use of health and social services

What guys say, and what they do Urban young men’s use of health and social services

Copyright 2013, Creative Commons 3.0 license. This report may be freely copied and distributed, without alterations, for non‑commercial purposes.

Project Team Dr. Elizabeth Saewyc Principal Investigator Dr. John Oliffe Co-Investigator Dr. Pam Hirakata Postdoctoral Fellow Dr. Laura MacKay Postdoctoral Fellow Jennifer Matthews Research Coordinator Bea Miller Research Coordinator Jayson Anderson Community Research Associate Kyle Flood-Sparks Community Project Assistant Cameron Parnell Community Project Assistant Wayne Saewyc Technology Consultant

A research project of the Stigma and Resilience Among Vulnerable Youth Centre University of British Columbia School of Nursing

Special thanks to our Advisory Group Richard O’Donnell Coordinator, Boys’R’Us Drop-in, Vancouver Coastal Health Authority Matthew Taylor Program Director, HUSTLE: How U Survive This Life Everday Jesse Brown Executive Director, YouthCO Camila Jimenez Program Manager, Onyx Program, PLEA Community Services Michelle Fortin Executive Director, Watari Ty Mistry Former Executive Director, PEERS Vancouver

Suggested citation

Dr. Genevieve Creighton Research Assistant

Saewyc E, Oliffe J, McMillan E, Miller B, Matthews J, MacKay L, Hirakata P, Roelofsen D, Rivers R, & Creighton G. (2013) What guys say, and what they do: Urban young men’s use of health and social services. Vancouver, BC: Stigma and Resilience Among Vulnerable Youth Centre, University of British Columbia.

Robert Rivers Research Assistant

Report layout by Stephanie Martin, McCreary Centre Society

Derek Roelofsen Research Assistant

iPod touch® is a registered trademark of Apple Inc.

Eva McMillan Research Assistant

Funding was provided by the Canadian Institutes of Health Research, Institute of Gender and Health. This project was approved by the University of British Columbia Behavioural Research Ethics Board, certificate #H09‑02441.

Inside this report 4

Why we did this research

5

Guys’ health and services use: Findings at a glance

6

About the study methods

8

Who were the guys?

10

How healthy were the guys?

19

Services guys use

23

Positive experiences with services

30

Negative Experiences with Services

34

Barriers or reasons for skipping services

42

Guys’ ideas for improving or changing services

43

Conclusions and recommendations

Why we did this research We wanted to understand how and why urban young men age 19–25 in British

Columbia use (or don’t use) health and social services. Generally in North America, young men tend not to use health and social services very often, especially compared to young women. But this doesn’t mean they don’t need services as often, they just don’t appear to access them. So we wanted to get a better under‑ standing of what young men need and want from health and social services. We also wanted to find out more about how they understand health and ill‑ ness. Hopefully our research will help services create or modify programs so that young men will feel more com‑ fortable using them. We were interested in young men’s opinions in general, but we also spe‑ cifically wanted to hear the opinions of young men who have traded sex, and those who are gay or bisexual. These are two groups who might experience stigma in health care and social ser‑ vices. We looked at similarities and dif‑ ferences between young men who had traded sex before or after they were 19 years old, compared with those who had never traded sex. We also looked at differences and similarities between the service use and opinions of gay, bisexual, and heterosexual young men.

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Why we wanted to focus on young men who traded sex We wanted to hear from young men who trade sex for money, drugs, food, shelter, or goods. If this happened before they turned 19 years old in BC, it is sexual exploitation under the law, although many young men don’t think of themselves as exploited. Recent research has shown that among youth who are street‑involved, boys are just as likely as girls to be sexually exploited. However, most research and programs focus on exploited girls because they are easier to find. Trading sex among youth has been linked with physical and mental health issues, including greater risks of experiencing violence, substance abuse, depression, self‑harm, and suicidal behaviours.

Why we wanted to focus on young men who were gay or bisexual Previous research has shown that lesbian, gay, bisexual, trans*, and queer (LGBTQ) youth are more likely than heterosexual youth to face violence and abuse, and as a result, to become homeless, to develop drug and alcohol problems, and to trade sex for money and/or goods. Society often treats these young men differently than heterosexu‑ al young men, which is unfair, and can lead to poorer health and lack of social support systems.

What guys say, and what they do

Guys’ health and services use: Findings at a glance We conducted a mobile device survey with 276 urban young guys age 19 to 25 in Vancouver and Victoria, and one‑on‑one interviews with 43 of the guys, to help us understand the variety of experiences. We asked them about their health issues, the kinds of health and social services they had used in the past year, and the quality of those services.

We found ◆◆ Just under half of guys in our study (45%) had been injured seriously enough in the past year to require medical attention. ◆◆ About half of the young men said they had been told by a health professional that they have a chronic condition; the most common ones were attention deficit hyperactivity disorder (ADHD) (24%), depression (21%), and substance abuse (15%). ◆◆ 1 in 5 young men did not have a care card. ◆◆ Almost all of the guys (89%) had used some health or social ser‑ vices in the past year; only 1 in 10 reported using no services. Most common services: walk‑in clinics and emergency departments.

◆◆ Even so, about 15% also said they didn’t get some services when they needed them. ◆◆ Most guys rated services positively, and had lots of reasons for positive experiences at different services, including caring and respectful staff, prompt access, and services located together, making it easier to access a variety of needed services at the same place. ◆◆ They also told us about negative experiences they or their friends had with services, including inaccurate care, rude or judgmental staff, or inconvenient hours and wait times. ◆◆ Young men shared reasons guys like them don’t get care, and a lot of those reasons had to do with “being a guy,” or masculine ideals; things like trying to tough it out, and only going if it’s serious, or waiting until it gets really bad; and trying to “do‑it‑yourself ” with on‑line information. ◆◆ Guys didn’t have any radical ideas for improving services, just the kind of things many other people want: caring and competent staff, prompt access, more convenient hours. Some wanted guy‑only services, and confidentiality was important.

Guy’s health and services use: Findings at a glance

5

About the study methods

In order to get a picture of young men’s health and how they access health and social services, we used a multi‑ ple‑choice survey with 276 young men. We interviewed a smaller set of these young men to ask them questions in more detail. We were especially interested in hear‑ ing the experiences of guys who had traded sex or were gay or bisexual. However, inviting only guys to partici‑ pate if they trade sex or if they’re gay or bisexual means we would be outing them simply by participating in our research. So we would only get those guys who are comfortable with being out in public, and would miss those who don’t want to reveal such private information. Instead, we surveyed any and all young men who were interested. At the end of the survey, if a young man had answered “yes” to some of the activities we were interested in, the final message would read “You have been selected to complete an interview” with no infor‑ mation as to why they were selected. In order to have groups for comparing, though, we also interviewed young men who had not traded sex, or were not gay or bisexual.

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Some of the research team members were young men from the community who may have been sexually exploited themselves and/or who worked with other young men in the community.

Where we found participants In order to reach young men who trade sex, or are sexual minorities, we recruited from services for young men generally that they might access in Vancouver and Victoria, including drop‑in centres, employment services, a youth clinic, and shelters. We also recruited from other services specifi‑ cally designed for these young men, such as support groups. Finally, we recruited from other places guys hang out, like skate parks, gyms, malls, and Skytrain stations. We thought this could give a voice to young men who may not be already accessing services designed for them. This is in part what is unique about this project. Even though we usually work with at‑risk youth, we were surprised by how often young men in public spaces like skate parks reported that they’d traded sex or identified as gay or bisexual.

What guys say, and what they do

The Urban Young Men’s Survey Young men who looked like they were in the right age‑group were approached and asked their age. If they were the right age, they were then asked if they would like to participate in a voluntary and confidential UBC study about health and social services. The survey took about 20 minutes to complete. The surveys were done on iPod touch® mobile devices, and information was encrypted to keep all the information confidential. Researchers were on hand to answer any questions and for techni‑ cal support. Participants received a $15 gift card for participating. At the end of the survey a screen would show up with a unique identifier (3 numbers) for the researcher to write down so that the participant’s informa‑ tion was only linked to numbers and not to a name. If the participant was one of those selected for an interview, and they agreed to it, we linked their responses in the survey and the inter‑ view with that single code.

The interviews After the survey, if the invitation for an interview came up on the screen, then a researcher asked if they wanted to participate. Guys were given an addi‑ tional $20 gift card for participating in an interview. A trained UBC research team did the interviews. The interviews were recorded and transcribed so that the research team would have an accurate record of what the young men said. Quotes from these interviews are used throughout this report.

The numbers In this report, we provide percentages and numbers to describe survey results. However, we only report differences between groups when they are signifi‑ cant based on statistical tests.

About the study methods

7

Who were the guys?

We surveyed a total of 276 young men. Of these young men 9% had been sexually exploited, 17% had traded sex (age 19 or older) and 17% were gay or bisexual.

Age We surveyed men who were between the ages of 19 and 25. The average age was 23.

Cultural Background About half of the young men (48%) described their cultural background as “Canadian,” 23% as Aboriginal, and 15% as European.

Length of time in Canada Most guys had lived in Canada their whole lives (82%) and another (8%) had lived in Canada for 10 or more years. Only 10% were recent immigrants.

Languages 33% of the young men spoke a lan‑ guage other than English.

Schooling Two‑thirds (67%) were not currently attending school, college or university.

Work There were similar numbers of employed and unemployed men in our sample: 45% had a job. Of those with jobs, 42% worked 30 or more hours per week.

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What guys say, and what they do

Guys who Traded Sex

Guys who were Gay or Bisexual

◆◆ Those who first traded sex at 19 years or older were more likely to identify as gay or bisexual (39%) compared with guys who first traded sex younger than age 19 (13%).

There were no differences in age, cultural background, languages, school, or work status of gay/bisexual men and hetero‑ sexual men.

◆◆ Guys who first traded sex at 19 or older were also less likely to be employed (24% employed) when compared with guys who traded sex before age 19 (49% employed). ◆◆ Young men who first traded sex younger than 19 years of age were more likely to have a care card (92%) compared with guys who traded sex over the age of 19 (68%). ◆◆ Guys who first traded sex before age 19 were also less likely to speak a language other than English (8%) than guys who traded sex over the age of 19 (42%).

Who were the guys?

9

How healthy were the guys?

We asked the young men several questions about their health, how they found health information, and if they had health coverage. ◆◆ In general, most men described their health as good or very good (62%). ◆◆ 1 in 5 young men did not have a care card. ◆◆ 2 in 5 young men had extended health insurance such as pre‑ scription drug coverage, glasses, First Nations status etc. ◆◆ 3 in 5 young men either did not have extended coverage, or did not know if they had coverage. ◆◆ Most young men rated their cur‑ rent level physical fitness as good or very good (64%). ◆◆ Guys mostly got their informa‑ tion from health professionals (52%) followed by the internet (37%), and family (31%).

10

In general, how do you describe your health? 31% 31%

Description of Health

23%

10% 5% Fair Fair

Poor Poor

Good Good

Very Good Very

Good

Excellent Excellent

In general, how do you describe your health?

Physical fitness

In general, how do you describe your current level of physical fitness? 33%

32%

19% 13% 3% Poor Poor

Fair Fair

Good Good

Very Good Very

Good

Excellent Excellent

In general how do you describe your current level of physical fitness?

What guys say, and what they do

“I have friends that go on Wikipedia and search up their symptoms just to see what kind of medications they can go buy over the counter instead of having to go get a prescription drug for it.” Age 24,bisexual, never traded sex

52%

37% 31%

29% 21% 12%

Internet Health Health Internet professional Professional

Family Family

Friends Friends

Youth Youth Worker Worker

TV TV

10%

9%

7%

Magazines of Magazines Newspapers Newspapers None None of these these

Where do you get your health information?

How healthy were the guys?

11

Chronic health conditions ◆◆ About half of the young men reported having been told they have a chronic condition by a health professional. ◆◆ Most common chronic conditions were Attention Deficit Hyperactivity Disorder (ADHD) (24%), depression (21%), and substance abuse (15%). ◆◆ 78% responded that they had expe‑ rienced some negative health condi‑ tions in the past month.

◆◆ Guys most commonly experienced headaches (45%), had difficulty sleep‑ ing (41%), or had a cough, cold or flu (40%). ◆◆ Despite having these conditions most men rate their overall health good to excellent. This means young men may not see some of these conditions as health related, and may not seek help for these.

Have you ever been told by a health professional that you have any of the following? 41%

24%

21% 15%

14%

13%

11% 4%

None None of of these these

ADHD ADHD

Depression Substance Learning Learning Depression Substance Abuse Abuse Disability

Anxiety Anxietyor orPanic Panic Attacks

PTSD Posttraumatic Stress Disorder

FASD Fetal Alcohol Spectrum

Have you been told by a health professional that you have any of the following?

12

What guys say, and what they do

“‘Cause I don’t really got any problems. Knock on wood, you know? Stay healthy. Just don’t get sick.” – Age 21, heterosexual, traded sex

In the past month, have you had or felt the following? 45%

41%

40%

36% 30% 23% 17%

Headache Difficulty Cough cold Headache Difficulty Cough Sleeping flu flu Sleeping cold

Backache Stomachache Dizziness Backache Stomach- Dizziness ache

13%

None ofof Rashes/Skin Rashes/Skin None these problem these problem

In the past month, have you had or felt the following?

How healthy were the guys?

13

Injuries and other health risks ◆◆ Slightly under half of guys in our study (45%) had been injured seriously enough in the past year to require medical attention. ◆◆ 19% had been injured 1 time in the past year, 14% had been injured twice, and 12% had been injured 3 or more times. These are injuries the young men felt were bad enough to require medical care. Some may have had many more injuries that may have required medical attention and not got it (see “Services Guys Use”).

◆◆ Young guys tend not to seek care, or feel they need care, even when professionals might say they should. ◆◆ 1 in 4 of the young men had ever shared or used needles or gear after someone else had used it (23%), and about 1 in 5 had ever used tattoo or body piercing equip‑ ment or shaving razors after someone else used it (18%).

“Guys don’t wanna go into the emergency room for a busted nose, or a possible concussion because it’s like … [they] think they’ve got better things to do than making sure that they’re alright.” – Age 22, bisexual, never traded sex

14

What guys say, and what they do

Sexual activity ◆◆ Most of the young men were sexually active (87%). ◆◆ 15% of guys who’d had sex reported that they’d had an STI at some point. ◆◆ About 17% of the young men we sur‑ veyed had traded sex for money or other things. ◆◆ They most commonly traded sex for money (51%), drugs or alcohol (47%) and a place to stay (43%).

Have you ever traded sex for any of these reasons? 9% 8%

7%

3%

2%

2% 1%

Money Money

Drugs or Drugs or Alcohol Alcohol

AA Place to to Stay Place

Stay

Material Material Things Things

Food Food

Transportation Clothing Clothing Transportation

Have you ever traded sex for any of these reasons?

How healthy were the guys?

15

Sexual exploitation ◆◆ Sexual exploitation occurs when youth under age 19 in BC trade sexual activities for resources such as money, drugs, food, shelter, gifts, transporta‑ tion or other material considerations. It is illegal to give youth money or any other things in exchange for sex. ◆◆ We asked young men who had traded sex how old they were when they first exchanged sex for any of these things. ◆◆ Most of the young men in our sample who had traded sex had first traded sex before age 19 (63%).

Comparing guys who have ever traded sex with guys who’ve never traded sex ◆◆ Young men who had traded sex were more likely to have been told by a health professional that they had a chronic condition. ◆◆ Most common chronic conditions include Attention Deficit Hyperactiv‑ ity Disorder (ADHD) (42% vs. 20%), substance abuse issues (36% vs. 11%), and depression (32% vs. 18%).

“I know I come here to Boys R Us, I get the HIV test, which is really cool because you get to find out under a minute.” – Age 25, gay, traded sex under 19 years of age

How old were you the first time you ever traded sex?

37%

22% 15% 10% 5%

5%

5%

2% 12 years years or 13 13years years 12 younger younger

14years years 14

15years years 15

16 years

17years years 17

yearsor 18 years years 1919years orolder older

How old were you the first time you ever traded sex?

16

What guys say, and what they do

◆◆ Young men who had ever traded sex were no more likely to have ever had an STI compared to those who had never traded sex.

◆◆ Those who had ever traded sex were more likely to have been injured badly enough to require medical care twice in the past year, compared with men who had never traded sex (40% vs. 24%).

◆◆ Young men who ever traded sex were more likely to use sexual health clinics than those who had never traded sex (see “Services Guys Use”), which may help account for these positive results.

◆◆ Guys who’d ever traded sex were more likely to use a needle after someone else used it, compared to young men who have never traded sex (59% vs. 15%).

“I might suffer from post traumatic stress disorder, but you can’t tell it… I suffer from a substance abuse addiction, but you wouldn’t be able to tell it… I have trauma, I have … massive anxiety…and I think that maybe the only thing you could notice…if I was in a… bad place… I hyperventilate and I just, I don’t youI just ever been told health professional that you reallyHave speak… seem, what we by call,asketchy.”

have any of the following? – Age 24, gay, traded sex

Have you ever been told by a health professional that you have any of the following? 47% 42% 36%

Traded Sex Traded Sex

32%

Never Traded Never TradedSex Sex

23% 20% 12%

Learning Disability Learning Learning Disability Disability

21%

21%

11%

ADHD

ADHD ADHD

Traded Sex

18%

Depression Anxiety or Panic Attacks

PTSD

9%

11%

13%

Never Traded Sex

Substance None of Abuse These

None of of PostDepression Anxiety Anxiety or Substance None Depression or PTSD Substance these Panic Attacks traumatic Abuse Panic Abuse These Stress Attacks Disorder

Have you ever been told by a health professional you have any of the following?

How healthy were the guys?

17

Comparing guys who traded sex at 19 or older with guys who first traded sex before age 19

Comparing heterosexual with gay or bisexual guys ◆◆ Young men who were gay or bisexual were more likely to have been diagnosed with ADHD (36% vs. 21%), substance abuse (27% vs. 14%) and anxiety or panic attacks (22% vs. 11%).

◆◆ Young men who had traded sex before age 19 were less likely to rank their physical fitness as good to excellent (72% vs. 95%). ◆◆ Young men who had traded sex before age 19 were more likely to report having felt dizzy (35% vs. 10%) and more likely to have had a cough, cold or flu (54% vs. 24%) in the past month compared to those who had traded sex at 19 or older.

◆◆ Gay and bisexual young men were more likely to share needles after someone else had used them (36% vs. 19%) than het‑ erosexual young men were.

◆◆ Guys who traded sex were much more likely to identify as gay and bisexual. Have you ever been told by a healthTrading professional you sex appearedthat to affect guys’ health outcomes more than sexual orientation. have any of the following?

Have you ever been told by a health professional that you have any of the following? 46% 36%

Traded Sex Gay/Bisexual

27% 21%

18% 13%

Learning Disability

ADHD Learning Learning Disability Disability

Depression 1% Anxiety or Panic Attacks ADHD Fetal

Heterosexual Never Traded Sex

Gay/Bisexual

11%

9%

24%

22%

PTSD

14%

Heterosexual

Substance None of Abuse These

Anxiety or Substance None of Anxiety or Substance None of Panic Attacks Abuse these Panic Abuse these Attacks Have you ever been told by a healthcare professional you have any of the following?

18

FAS

Alcohol Spectrum

ADHD

What guys say, and what they do

Services guys use

Research shows that young men access ser‑ vices less often than young women do, and we wanted to know why. This can help us understand why guys might be using certain services, and how we can make services more appropriate for them. We were surprised: almost all of the young men (89%) used some health or social

services in the past year, only 1 in 10 report‑ ed using no services. By far, the number one service for young men to use in the past year was walk‑in clin‑ ics, followed by the Emergency Room (ER) and Employment Services. We don’t know how often guys used these services in the past year, only whether they did or didn’t use these services at least once.

What services have you used in the past year? 66%

47%

47%

43%

38% 22%

Walk‑in Walk-in Clinic Clinic

Emergency Employment Family Family Emergency Employment Room Services Doctor Room Services Doctor

Housing Housing Services Services

Mental Mental Health Health Services Services

19%

18%

Alcoholor or Street Street Nurse Alcohol Drug Use Nurse Drug Use Services Services

17%

Sexual Sexual Health Health Services Services

What services have you used in the past year?

Services guys use

19

The services young men felt they needed but did not access Only a small number of young men (between 5% and 15%) reported they needed services that they did not get in the past year. Among these guys, three health services were most commonly identified by young men as something they needed, but did not access: family doctors, walk‑in clinics, and the ER.

“The ID thing, that’s what I wanted to mention, I mean because … I’ve had good intentions of getting my ID back, but just when I get my money I went and spent it because my addiction or something like that.” – Age 25, heterosexual, sexually exploited

“Interviewer: What would be the process through which you decide whether or not to go? Participant: I guess cost always; that’s one of the first ones, obviously.” – Age 21, gay, never traded sex

“But yea, cost is a problem for some of the guys.” –Age 22, bisexual, never traded sex

20

What guys say, and what they do

“I just find it easier to get access to walk‑in clinics. In family doctors, mine’s completely booked up all the time it seems.” – Age 19, gay, never traded sex

Were there any services you felt you needed in the past year, but didn't access? 35%

18%

Family Family Doctor Doctor

16%

Walk In Walk‑in Clinic Clinic

15%

Emergency Employment Employment Emergency Room Services Room Services

12%

12%

Mental Mental Health Health Services Services

11%

Alcohol Nurse Street Alcoholor or Street Nurse Drug Use Use Services Services

10%

9%

Housing Housing Services Services

Sexual Sexual Health Health Services Services

Were there any services you felt you needed in the past year, but didn`t access? (among young men who didn’t get services they needed; they could choose more than one)

Services guys use

21

Comparing guys who ever traded sex and guys who never did There were very few differences in accessing services between groups: ◆◆ In the past year, young men who ever traded sex (when compared to those who never traded sex) were more likely to have: ›› Accessed housing services (56% vs. 35%) ›› Seen a street nurse (33% vs. 15%) ›› Accessed sexual health services (29% vs. 14%). ◆◆ Those who had traded sex were more likely than those who have never traded sex to say they needed to go to, but did not go to: ›› Alcohol or drug use services (38% vs. 8%) ›› A walk‑in clinic (36% vs. 14%) ›› The emergency room (33% vs. 13%).

Comparing guys who first traded sex at 19 or older with guys who first traded sex before age 19 ◆◆ Young men who traded sex before age 19 were more likely to visit the ER than young men who first traded sex over 19 years of age (68% vs. 35%) ◆◆ Guys who first traded sex before age 19 were less likely to see a street nurse (15% vs. 60%.)

Comparing heterosexual and gay or bisexual guys There were very few differences in service use by sexual orientation: ◆◆ Guys who were gay or bisexual were more likely than heterosexual guys to: ›› Have accessed a street nurse (30% vs. 16%). ›› Use sexual health services (41% vs. 12%). ›› Say they needed employment services but did not access them, (30% vs. 10%).

22

What guys say, and what they do

Positive experiences with services

In the interviews, guys were asked to think about a time within the past 3 years when they had a positive experi‑ ence with either health or social services. Some young men found BC had many resources, while others felt there was a shortage. There weren’t clear differences

between groups; both young men who traded sex and those who hadn’t described positive experiences, as did gay, bisexual, and heterosexual guys. Overall, guys liked services that were convenient and free, provided quality care, caring staff, food, resources, and a positive environment.

“I keep coming back here because of my experience here is very good.” – Age 21, gay, never traded sex

“In BC, I found the most resourceful out of any province I’ve been in so far. Maybe it’s just like I was given the right guidance and the right, I was shown where to go.” – Age 21, heterosexual, traded sex

Positive experiences with services

23

Convenience Guys tend to like services that are easy to access, whether that be location or hours. They also liked services that met many needs at once, including “one‑stop shops” that could see them right away. Guys also really liked fast services.

“Location’s number one though. How far I have to go to travel to get it.” –Age 21, heterosexual, never traded sex

“It was quick, reliable, and I was like, I don’t know I was just, it was quick and reliable… I was in and out in 20 minutes.” – Age 19, heterosexual, traded sex “I find them extremely helpful because I have all services in one down there. I have social worker there. I have my dietitian there. I have my doctor there, my family doctor. All in the same clinic as well as a psychiatrist if I need to see one. Counselors, drug and alcohol counselors… It’s a one stop shop.” –Age 25, chose not to answer about sexual orientation, never traded sex

“The service was fast and that was probably my most positive experience.” – Age 20, bisexual, traded sex

“They’re pretty useful… they’re nice and quick…like you just walk‑in, talk to ‘em, that’s about it.” –Age 21, heterosexual, never traded sex

24

What guys say, and what they do

Quality Care & Considerate Staff Many of the young men talked about when staff were great at their job. For the guys, this meant staff were well educated, had years of experience, were constantly improving services, kept aware of the latest research, and had life experience to relate to. Expert care was one of the top reasons young men chose a specific service.

“I mean they are pretty knowledge‑ able. Any questions I’ve had, asked, they have been pretty helpful.” – Age 19, heterosexual, never traded sex

“They don’t just give you bible verses… they give you their own life experiences …because … some of them have been really hardcore gangsters and …. they can tell some good stories.” – Age 25, heterosexual, traded sex

“How long the doctors been inform[ed], you know, I mean about HIV services. How long they’ve been studying on it. What area of research they’ve done. Basically, I investigate the doctor through thick and thin. Talk to friends that have seen that doctor… Talk to people that left that doctor and ask them why. … And just get both sides of the story before I make a decision.” – Age 25, chose not to answer about sexual orientation, never traded sex

Positive experiences with services

25

Service providers sometimes use complicated language, and some guys found it difficult to understand what providers meant. They found this frustrating. Guys preferred simple language that is easy to understand, and wanted to be given clear instructions on how to care for themselves.

“They have to be competent for one thing. Well‑spoken—they can simplify com‑ plex terms or whatever.” – Age 21, gay, never traded sex “The staffs were extremely helpful… they knew what they were talking about and able to describe in plain language that I can understand. And in doing that, that helps me, I need to know what’s happening, otherwise I don’t normally do it.” – Age 19, gay, never traded sex

Many positive experiences were due to good staff. Staff who were friendly, kind, non‑judgmental, were often a major factor in the young men’s positive experiences.

“It has like a mellow kind of vibe. And if you say something you’re not supposed to talk [about] …they’re not like, rude…They talk to you in a cool manner, so you’re not embarrassed because you’re an adult…Shoot full respect and you get it back.” – Age 22, heterosexual, traded sex

“They’re just willing to talk or listen, you know, they don’t see a stereotype when they’re talking with you, they actually see a person.” – Age 22, not sure of own sexual orientation, chose not to answer about trading sex

26

What guys say, and what they do

The staff can be the difference between a good and bad experience. Some guys described both good and bad experiences at the same service, depending on the staff. Guys liked it if the service provider spent more time focusing on the individual.

“It wasn’t as bureaucratic as it’s always been whenever I went to a hospital and I appreciate that. Like, where the people were concerned about you and your issues rather than your information …it was just they really made an effort to make you feel comfortable and I appreciated that.” – Age 21, gay, never traded sex

“The last time I went there it was pretty good because I did a little bit too much ecstasy, it was my first time. I was really paranoid at the time, so the staff seemed to be very, how should I say? Understanding. Of my situation.” – Age 25, gay, traded sex

Many guys liked services which consider their abilities and readiness. Young men facing mental health issues, learning disabilities, or substance abuse issues appreci‑ ated staff who would take extra time to support them, and would allow them to work at their own pace.

“They’re doing their job I guess, basically. And looking into each circumstance and figuring out what is his or her best needs or their interests or wants or whatever. And then going from there.” – Age 22, not sure of own sexual orientation, chose not to answer about trading sex

“That one is for like alcoholics or drug addicts and so the staff is more understanding towards that, like helping you find a job at your own pace.” –Age 24, heterosexual, traded sex

Positive experiences with services

27

Positive Environment Many guys went to places that were recom‑ mended by friends. Guys said they liked programs that offered fun activities, chances to make new friends, and provided resources. Guys appreciated youth‑run programs, which made them feel like their opinions mattered. Some liked programs designed for a specific group, like gay, bisexual and trans* services, or Aboriginal services.

“Sometimes there’s games even too. … Me and my friends were playing, which kept us happy while we were waiting.” – Age 23, heterosexual, never traded sex

“The main program that I’m doing … is the jujitsu program….And, it’s just, just a great program… they have an awesome instructor… and, everything’s brought together in a very, not traditional but respectful way. It’s teaching discipline, it’s teaching all these things that a lot of people do need.” –Age 19, bisexual, never traded sex

“That’s why so many kids come back [here] is because … it’s youth run. The youth are who make what programs happen here and what programs we decide to enforce.” – Age 23, bisexual, traded sex

“They have a program that’s available to like, transgender or gay bisexual groups… I think that’s something that people can identify with easier… ‘Cause I felt a little bit more comfort‑ able being with people who were on my level …” – Age 25, gay, traded sex

28

What guys say, and what they do

ID Many young men do not have ID, and this can be a barrier to accessing services. Some young men found and liked services that would help them find IDs.

Meeting Basic Needs Young men often described a positive experience as one in which their practi‑ cal needs were met, especially when they were offered free of charge. Guys used employment services, which they felt were services that give very practical advice for something young men actively need.

“Well I was hungry the other day, so I went to [a drop‑in] and I ate some food… It was amazing.” –Age 25, heterosexual, never traded sex

“They helped me get a forklift ticket. They helped me do a lot. They helped me look for a job. I couldn’t find a job anyways but [laughs]… But they got me certificates and stuff like that.” –Age 24, heterosexual, traded sex

Resources & Referrals Many guys accessed services for the resources they provided, including programs, information, referrals to other services, and places to stay.

“[This place] is a great place to find a shelter or to find housing, all those different things. They’re really helpful because they’ve got tons of resources. And information is important too and they’ve got a lot of that.” – Age 20, bisexual, traded sex

“The fact that they did everything I ever asked for… [I asked for] referrals to like, treat‑ ment centres and shit.” – Age 25, heterosexual, never traded sex

Positive experiences with services

29

Negative Experiences with Services

In the interviews, the guys were asked to think about a time within the past 3 years when they had a negative experience with either health or social services. Overall, guys disliked services which were inconvenient, or whose staff were judgmental or environments were unwelcoming.

Inconvenience One of the most common frustrating experiences that guys reported was dealing with long wait times. This ranged from waiting for hours in a waiting room, weeks for a doctor’s appointment, or months for housing. Hours of operation could also make services difficult to access.

After participant said that housing services were useless: “I shouldn’t say useless. It’s just a very long wait… I have been waiting for like, few months.” – Age 22, heterosexual, never traded sex

“I know a lot of people that can’t access this one because they’re working during the day. Or else they have like 12 to 8 shift or something.” – Age 19, heterosexual, never traded sex

Interviewer: “What has your experience been with the welfare system?” “… A lot of hoops to jump through with them. And sometimes it’s frustrating.” –Age 23, heterosexual, never traded sex

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What guys say, and what they do

Bureaucracy in the different systems can be difficult to navigate, especially when deal‑ ing with staff that the young men may view as judgmental and non‑supportive. Guys found ways to work the system which weren’t always honest, and described this as a negative experience.

“I did my job searching program, that wasn’t enough. I filled out 5 pages of going, I went to every business … I’m like, nobody’s called me back!… For 8 months they refused to give me income assistance so I just took the shortcut around it and got these guys to fill out a medical form for me, just a bullshit lie, just so I could get on friggin’ assistance… ’Oh you have this form saying you’re crazy, oh you can have the money now.’” –Age 24, bisexual, never traded sex

“I applied for Ministry help, but they were actually very rude to me… They wanted like millions of questions out of me. They wanted like to know every little detail about me, … just so they can give me a small amount of money to live. I was just like, OK, I’ll just go find some other way to do this… It was kind of like, you know, kind of blaming, kind of rudeness, I didn’t really wanna put up with.”

– Age 21, heterosexual, traded sex

Incompetent Staff Many guys explained their most negative experience was when receiving services from a professional who made a bad diagnosis, or did not appear to be good at their job. A number of guys said that their worst experience was being put on medication that made them throw up, but did not help their symptoms. Others were disappointed in the psychological care they received, or found social services unable to provide them information they did not already have.

Participant: “I broke my elbow and I went to a walk‑in clinic and they like, told me it wasn’t broken … and then eventually when I went to the hospital they had to like, re‑break it.” Interviewer: “So what made that a bad experience for you?” Participant: “‘Cause the doctor didn’t know what he was talking about.” – Age 20, heterosexual, traded sex

[When accessing a social service] “The information they gave me was basically the same stuff I could have found on the website as well, so, they basically told me what I already knew.” – Age 21, gay, never traded sex

Negative experiences with services

31

Guys described sometimes feeling judged by or discriminated against by staff. Young men also described feeling uncomfortable or accused when staff asked too many questions. Guys thought they may have been treated poorly because of their drug use, sexual orientation, gender identity, ethnic background, or information in their file. This happened even when services claimed to be non‑discriminatory. Guys will choose not to use the service if they feel they are treated poorly. Some guys talked about choosing where to go based on peer recommendations, and also about letting their friends know a service is “bad.”

“He did the doctorly things and just looked at me like with contempt because, …the look of like, you’re just a drug addict… why am I here attending to you when, you know, there could be a burn patient coming through the door? Or I could be doing something else more important than, you know, attending to somebody who doesn’t, who’s flushing their life away… [laughs slightly]” –Age 22, gay, chose not to answer about trading sex

“They admitted me and then just left me sitting there in the IV chair for 3 or 4 hours while I’m, you know, just blatantly ignoring me … [I feel they discriminate against people because of] the drugs they use or the labeling, the stereotyping that they give certain people.” – Age 22, not sure of own sexual orientation, chose not to answer about trading sex

“There’s been a few times where I’ve been dressed female, right, where I’ve had to go in … like at the walk‑in clinics and stuff, and they’ve completely made me feel like I was being inappropriate just ‘cause of the way I dressed… They’re like, ‘oh I thought you were male’, and I’m like ‘no.’ I’m, like, I don’t like having to explain to people that I’m transgendered” –Age 23, bisexual, traded sex

“There was this [health nurse] … she’s pretty rude all the time… I just walked away.” –Age 24, bisexual, chose not to answer about trading sex

32

What guys say, and what they do

“I was actually in a First Nations establishment… and a First Nations lady I think, I could kind of sense that she was being rude to me… because I’m only half native… I got choked. I just left… I got upset, I left. And I just didn’t go back… I didn’t make a big deal about it… I just told, I got word of mouth, told my friends.” – Age 25, heterosexual, traded sex

“I had just lost my best friend, right? So I wasn’t all there, and the report that they did totally demonized me as like a complete freak, creep person … and I went to go see the same, the same program again like a couple years later and they pulled out the report and he started listing off all the stuff in the report and I was like well you know, I had just lost my best friend, you really expect me to be all there?” –Age 23, bisexual, traded sex

Negative Environment Some services were viewed as being imper‑ sonal or not taking into account individual stories and needs, including the specific needs of youth. Some guys found that some services did not invest enough individualized time, which meant they could be moved out of the service too quickly for their needs.

“[Services here are] alright. It’s just a lot of them aren’t geared for youth.” – Age 19, heterosexual, never traded sex

“They want to push you out the door faster than trying to help you. By seems of it. Yeah, that’s basically about it. Shelter systems can be a problem.” – Age 25, chose not to answer about sexual orientation, never traded sex

“I found that a lot of the time they…mainly prescribe something to get you off a bit. But then you’d be hooked on something or whatever. They wouldn’t really counsel you, so you went to counseling. Like I learned a lot when I went to the addictions thing, but I didn’t learn anything when I went to the hospital….And [the hospital] knew that I had the past of drugs…and they gave me more drugs [Laughs] which is completely silly.” – Age 22, gay, never traded sex

Negative experiences with services

33

Barriers or reasons for skipping services

Barriers are conditions or situations that guys say are the reason they don’t access services or return to services even when they need to. Among young men in the survey, very few said they missed out on care they felt they needed (between 5% and 15%, depending on the type of care). The two most common reasons for not getting care when they needed it was staff had been unhelpful before, and they were afraid of being judged—this was the case for both heterosexual and gay/ bisexual guys. In the interviews, the main

34

barriers to accessing services that guys talked about were bad fit with the service, unavailable programs, location, wait times, language barriers, gender and age man‑ dates, lack of information about services, and maintaining a masculine image.

Bad Fit Some guys said they do not identify with other participants at services, and this may prevent them from accessing the services. It can be hard for some guys to ask for help or support, and to identify as a person who needs these things.

What guys say, and what they do

“I didn’t feel comfortable.…when you walk‑in there, there’s a lot of differ‑ ent, you, like, just, visually…. Seeing the different types of mental health. Right? And it’s like, I look at myself and it’s like, I’m not like one of these people.” – Age 24, gay, sexually exploited

“They’ll give you food and if you say ‘thank you,’ they don’t say ‘you’re wel‑ come’…at first I feel, I feel angry when I think about it…but it’s like, well, they just gave me a free meal…[but] it kind of really makes me look to myself. You know, I wasn’t always like this.” – Age 25, heterosexual, traded sex

Barriers or reasons for skipping services

35

Unavailable Services/Unable to Find Services Some services that guys said they need they also said did not exist; other services may be full because many people need them. Guys may have had trouble finding services that do not obviously market their programs. Many young guys we talked to had social workers who were involved in their lives and showed them where to go. However, not everyone was as lucky. Many guys were new to the community, or simply had never heard of some of the services. A field note from one our researchers was that many of the guys in community set‑ tings didn’t know what a street nurse was. After the researcher explained, they said they had never seen someone like that.

“A lot of times shelters are really, really full, and there are times people like myself have to go off to places [that’s] not a shelter but a place we can crash …that’s happened with me couple of times where I had [to]… stay …for two days on a floor, with no blanket, no pillow until I got into a shelter. You know what I mean? … There isn’t enough in the city to accommodate everybody that’s homeless or youth or anything else, right?” – Age 25, chose not to answer about sexual orientation, never traded sex

“There’s no website where, like, you hear about all these different sweats and stuff, but a lot of it is like, you gotta know somebody to get in. But it would be good if there’s like somewhere you can go and be like, well I’m kind of looking for a sweat …‘Cause a lot, it is just word of mouth.” – Age 19, heterosexual, never traded sex

36

What guys say, and what they do

Location and Waits Some guys would like services in more areas because it can be difficult to get to cer‑ tain locations. Other guys noted that it can be difficult to overcome addiction with long wait times to access rehabilitation services.

“So all these youth have to walk from each end of the town to get to these different places…[the city is like] ‘we’re already funding our place so there’s no need for us to fund this youth shelter at all.’ I’m like oh, wow. Thanks. You’re just pushing all the youth under the carpet and stuff. … I stayed [at an all‑ages shelter,] like it’s just full of junkies and guys and women that get out of jail …I was there for like 2 weeks and me and my friend got held up at knife point 5 times, and the staff are just like, ‘its not our problem, its your problem. You get stabbed? Not our problem.’” – Age 24, bisexual, never traded sex

“For an addict to see its going to take a week or more to get into treatment, that’s not going to be a thing that they’re going to do. On one hand they’re going to have their drug, and on the other hand their going to have like you know, ‘I gotta go through a week of saying no to this drug?’ You know, it should be a little more easier on somebody, you could just walk‑in and say ‘hey I need to get off, I need to get out of here now, ‘cause this is what I have—it’s in my hand right now and I don’t know if I can help it,’ because that’s how it is for some people. I’ve known quite a few people who’ve just don’t make it through, their, binge or whatever. Are no longer here… [when they are turned away] people just lose the, how should I say? The motivation … I guess there’s day‑tox and detox but there’s waiting list for those too right?” – Age 25, gay, traded sex

Barriers or reasons for skipping services

37

Language Not speaking English well can make accessing services very difficult.

“Sometimes I don’t feel very comfortable because I don’t speak very well the English. So that’s the thing that sometimes I feel nervous or, or some‑ times even frustrated because, I think is, is dif‑ ficult to, to be in a country that you don’t speak pretty well the language… Sometimes I struggle with that, but, I am trying to deal with it.” –Age 23, heterosexual, never traded sex

Exclusionary Rules Some young men would like to use services, but the program only provided services for people of a specific gender or age. Policies of services may seem random to some guys, and may prevent them from getting the help they need.

“I get discriminated against because I’m old. I’m like almost to that point where I’m not eligible for anything anymore.” –Age 24, bisexual, never traded sex

38

What guys say, and what they do

“When you turn 18, you basically, a lot of people get cut off from stuff like youth agree‑ ments, so many services are just closed to you… Once you turn 18, you can’t access a lot of the shelters. And a lot of them really do help people. …And especially if you’ve been like in institutional and you used to that kind of stuff, and it’s just like well you’re 19, good bye… You’re not their problem anymore. You’re the police and the govern‑ ment’s problem.”

– Age 19, heterosexual, never traded sex

“There’s not a lot of stuff for males only, a lot of its only females and so I’ve gone through like lots and lots of different services and stuff where …I could use that service, oh, its female only… like rape support groups. [I am female‑identified but]… they won’t let me … I just recently was able to get into the girls group … because I argued, … I see myself as female, why can’t I go into the girls’ group?” –Age 23, bisexual, traded sex

“[My friends] were having trouble getting the EI, and getting things set up because they might have a five–hour a week job, and because they were able to work just a little bit they got it taken away from them. And then because of that they didn’t have the money to pay for rent and because… And it was this big chain reaction …just from trying to support themselves with a side job.” –Age 19, bisexual, never traded sex

Barriers or reasons for skipping services

39

ID/ Care Card Issues Some guys know where to get help without an ID, but many young people do not. Most services will not provide support without the proper ID.

“[I know where to get help] without coverage. But a couple of my friends, they don’t really know. … one of my friends was sick for six months because she didn’t … she didn’t have any ID… she tried going to these places, but they turned her away… It’s just the lack of information …Like all these services are out there. It’s just connecting with them, right?” – Age 19, heterosexual, never traded sex

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What guys say, and what they do

“Toughing it Out” We interviewed several young men who talked about not accessing care as “typi‑ cal guy behaviour.” This was explained as just toughing out pain, being brave, and sucking it up until things got really bad. “Toughing it out” included being brave when physically hurt and not asking for emotional support. We heard this from all the different groups of young men. Some of this had to do with “male pride,” being proud of not showing pain or needing help. Another thing a lot of young men said was most guys wouldn’t get care until it was really serious. Others talked about going on‑line and figuring out what to do for themselves, rather than getting health care or services.

“I was pretty scared that I was going to lose my leg because I ignored it for, like, a couple months, so it got really bad… ‘cause it started out as rug burn and, like I dunno, I’m a guy. I never thought that rug burn would get infected…. I just assumed it would heal on its own… somebody was like, you need to go the doctor… My mom was like, [you’re going to] … get your leg chopped off.” —Age 20, heterosexual, traded sex

“Guys are just like, pfff, I can deal with it, I’ve been sicker than this.” —Age 24, bisexual, never traded sex

“ ‘cause men are less demanding and they kind of like to take care of things on their own… It’s a guy thing.” —Age 20, bisexual, traded sex

Pretty much all the reasons for missing out on care were talked about by both heterosexual and gay or bisexual guys, and guys who had traded sex and guys who hadn’t.

Guys`ideas for improving or changing services

41

Guys’ ideas for improving or changing services

We asked guys to tell us what their ideal services would look like, but most guys had trouble coming up with anything really different, just more of the things

they found positive: quick service, located in the same place, convenient hours, no wait times, non-judgmental staff.

“And hours, definitely not ‘til six like all the other walk‑in clinics are. Try to go later on because when you come out of work and stuff, other people get paid by the hour, so they want to stay ‘till the end and not leave early or just not go to work for that day.” —19 years old, heterosexual, never traded sex

“Services for like, men only, or services where people can, where guys can go to where other guys will be there, rather than going to services where like most of it’s female.” –23 years old, bisexual, traded sex

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What guys say, and what they do

Conclusions and recommendations Even though they accessed services, some of them still had unmet needs, or waited a long time, until things got worse, before getting care. And though they accessed care and were positive about it, nearly all of them had stories from friends or their own past expe‑ riences about why guys don’t access services, or only go when it’s serious, and negative experiences they or their friends had at services.

The urban young men we surveyed in Vancouver and Victoria had definite health care and social service needs, but contrary to what we expected, most of them actually accessed some form of services in the past year. And most of them had positive things to say about the services they received. They liked services that were quick and confidential, and offered a lot of differ‑ ent services in one place; at the same time, they wanted providers who were caring and non‑judgmental, and were willing to talk to them in language they understood.

Most of their descriptions of good care, and what they wanted, were the same kinds of things other people talk about wanting from health care, and they gave many of the same reasons other groups of guys give for not getting care. Some of their comments clearly suggest there is a traditional “guy code” out there that shapes ideas about men getting health care, or even recognizing they need care, although what these guys said, and what they actually did, didn’t always match up. Our research suggests that, at least in Vancouver and Victoria, a lot of young urban guys actually do access care, although it is more likely to be emer‑ gency or walk‑in clinic care, rather than ongoing services. They are, for the most part, satisfied with the care they receive. And young men who might have specific concerns, like gay or bisexual guys, or those who trade sex, find the services meet their needs, too.

Conclusions and recommendations

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In the face of this overall access and positive assessment, it is hard to offer recommendations for improving services, beyond paying attention to quality: ◆◆ Ensure staff are well‑trained and knowledge‑ able, non‑judgmental and clear when they communicate ◆◆ Co‑locate different services, for ready access in convenient locations (near transit stops) ◆◆ Offer guy‑inclusive or guy‑focused confi‑ dential services in an environment that isn’t solely female‑focused. What might health and social services do differ‑ ently? The guys in our study couldn’t envision anything radically different: just a little more prompt, a little more confidential, and a little more caring, than their current services.

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What guys say, and what they do

University of British Columbia School of Nursing T201-2211 Wesbrook Mall Vancouver, BC Canada V6T 2B5 www.saravyc.ubc.ca

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