Hidden from health

Abstract

Objective Substantial country-level variation exists in prejudiced attitudes towards male homosexuality and in the extent to which countries promote the unequal treatment of MSM through discriminatory laws. The impact and underlying mechanisms of country-level stigma on odds of diagnosed HIV, sexual opportunities, and experience of HIV-prevention services, needs and behaviours have rarely been examined, however. Design Data come from the European MSM Internet Survey (EMIS), which was administered between June and August 2010 across 38 European countries (N =174 209). Methods Country-level stigma was assessed using a combination of national laws and policies affecting sexual minorities and a measure of attitudes held by the citizens of each country. We also assessed concealment, HIV status, number of past 12-month male sex partners, and eight HIV-preventive services, knowledge, and behavioural outcomes. Results MSM living in countries with higher levels of stigma had reduced odds of diagnosed HIV and fewer partners but higher odds of sexual risk behaviour, unmet prevention needs, not using testing services, and not discussing their sexuality in testing services. Sexual orientation concealment mediated associations between country-level stigma and these outcomes. Conclusion Country-level stigma may have historically limited HIV transmission opportunities among MSM, but by restricting MSM’s public visibility, it also reduces MSM’s ability to access HIV-preventive services, knowledge and precautionary behaviours. These findings suggest that MSM in European countries with high levels of stigma are vulnerable to HIV infection. Although they have less opportunity to identify and contact other MSM, this might change with emerging technologies.

Anti-LGBT and Anti-immigrant Structural Stigma: An Intersectional Analysis of Sexual Minority Men's HIV Risk When Migrating to or Within Europe

“…27 Third, we used a measure of anti-immigrant attitudes to capture structural variation in anti-immigrant stigma across receiving countries, whereas we used legislation to represent anti-gay structural stigma, because population-based studies of attitudes toward sexual minorities do not exist for all countries. However, the fact that anti-gay legislation in Europe is strongly correlated with anti-gay attitudes in those countries 2 strengthens the validity of our measurement approach. Fourth, because we only examined national forms of structural stigma, future research should consider the role of local laws that might reinforce or protect against structural stigma at the country level.…”

“…3,25,26 Further, the mechanisms linking structural stigma to MSM’s HIV risks remain largely unknown, although emerging research suggests MSM living in more homonegative countries report more sexual orientation concealment, which predicts some HIV-related risks. 2 Future research might explore additional mechanisms linking early and current structural stigma to HIV-prevention outcomes, including learned behavioral responses to stress, lack of access to HIV-prevention knowledge during sensitive developmental stages, and perceptions of stigma in healthcare and other more proximal institutions. 12 …”

“…This research has shown, for example, that MSM living in more (vs. less) structurally stigmatizing locales experience critical gaps in HIV-prevention service coverage, knowledge, and behavior. 2 …”

The mental health of sexual minority adults in and out of the closet: A population-based study.

“…Finally, several personal and environmental factors might moderate associations between outness and mental health, including structural stigma, cohort, socioeconomic status, race/ethnicity, family support, and religiosity. While investigating these contextual influences is beyond the scope of the present investigation, recent research is beginning to reveal the importance of considering the influence of such factors on sexual orientation concealment and health (e.g., McGarrity & Huebner, 2014; Pachankis et al, 2015). An intersectionality perspective could usefully extend this research beyond statistical tests of interaction to capture the nuanced meaning and mental health consequences of possessing multiple stigmatized identities, both concealable and visible, in contexts of inequality across the life course (Carbado, Crenshaw, Mays, & Tomlinson, 2013; Clark & McCall, 2013; Cole, 2009).…”

Mortality in HIV-infected women, heterosexual men, and men who have sex with men in Rio de Janeiro, Brazil: an observational cohort study

“…Additionally, MSM remain a vulnerable population for HIV-infection in Latin America (24) with a 14·2% estimated point prevalence of HIV-infection in Brazil (25) that drastically contrasts with the 0·6% HIV-infection prevalence in the Brazilian general population (11). Beyond increased risk of HIV-infection, MSM are subject to stigma that operates at several levels including internalized, interpersonal and structural, all of which stand as barriers to access and utilization of HIV prevention and treatment services (26, 27). Though not HIV-specific, a recent systematic review found that prejudice against nonheterosexual orientation is prevalent in diverse regions of Brazil (28).…”