Discrimination and homophobia fuel the HIV epidemic in gay and bisexual men

Despite clear evidence for the social determinants of HIV transmission, there have been limited efforts targeting these social inequalities

Perry N. Halkitis, PhD, MSPerry N. Halkitis, PhD, MS
Steinhardt School of Culture, Education and Human Development, New York University

Over the last 30 years, efforts to prevent new HIV infections among gay and bisexual men have been guided by paradigms that hold individuals responsible for their health behaviors. These approaches, rooted primarily in social-cognitive frameworks (Halkitis, 2010b), have resulted in maintaining new infections in the United States at a steady state for the last decade (Centers for Disease Control and Prevention [CDC], 2011b). In addition, the population of men who have sex with men (MSM) has continued to be the only risk category for which new infections are rising (Hall et al., 2008). In fact, gay, bisexual, and other MSM acquire HIV at rates 44 times greater than other men and 40 times greater than women (CDC, 2011a).

More recently, with the game-changing breakthroughs in the biomedical arena, attention has shifted to these biomedical prevention strategies, which include preexposure prophylaxis (PrEP) for gay, bisexual, and other MSM (Grant et al., 2010) and vaginal microbicides for women (Abdool et al., 2010). In this biomedical approach, the early detection and treatment of HIV have been recommended policy for the last several years (CDC, 2006; Workowski & Berman, 2006) as a way to decrease community viral load. Yet even these medical advances are fraught with their own complications, not least of which are matters of uptake and adherence.

In response to these alarming health disparities among gay and bisexual men, there has been a call to broaden the prevention lens to examine the influence of multiple social and contextual factors influencing health behaviors (Halkitis & Cahill, 2011). The CDC recently delineated the significance of social determinants of health, stating that “while effective interventions that address individual risk factors and behaviors exist, to ensure good health in all communities requires a broader portfolio that looks at social and environmental factors as well” (CDC, 2010, p. 11). Despite clear evidence for the social determinants of HIV transmission and the beneficial effects of structural interventions (Adimora & Auerbach, 2010), there have been limited efforts targeting these social inequalities, which place gay and bisexual men at greater risk for the acquisition of HIV disease.

Of particular relevance to HIV prevention among gay and bisexual men are the social conditions that place us at heightened risk for acquiring HIV as compared to our heterosexual counterparts. In this article, consideration is given to the manner through which discrimination and homophobia, which may have been heightened because of the AIDS epidemic (Halkitis, 1999), perpetuate HIV vulnerabilities for gay and bisexual men. Such health vulnerabilities driven by homophobia are often exacerbated for gay and bisexual men of color, who are often further burdened by the social circumstances of racism and poverty. Since discrimination based on sexual identity is critical to the ideas being put forth, and since the HIV prevention needs of gay and bisexual men differ widely from those of non-gay or bisexual MSM (Halkitis, 2010b), the focus of this issue of the newsletter is on gay and bisexual men, and not MSM in general. This topic will be considered from the theoretical perspective of minority stress theory, with attention to (a) how clinicians can effectively address these social burdens with their clients, (b) the work of AIDS service organizations, and (c) policy in light of the National HIV/AIDS Strategy for the United States (Office of National AIDS Policy, 2010).

HIV in the gay and bisexual population

In the now historic document, which recently reached its 30th anniversary, the CDC (1981) reported five cases of Pneumocystis carinii pneumonia in young gay men who otherwise should have been healthy. I first became aware of this phenomenon as I sat on the beach reading The New York Times the summer before my freshman year at Columbia University. With bewilderment and fear, I read Robert Altman’s (1981) account of “doctors in New York and California [who] have diagnosed among homosexual men 41 cases of a rare and often rapidly fatal form of cancer.” In the following years, I witnessed the eruption of the disease, which in its early years was given the name GRID (gayrelated immunodeficiency disease) because of its omnipresence in the gay population (Shilts, 2007; Weeks & Alcamo, 2010).

Two generations later, GRID has evolved into what we have come to know as HIV/AIDS. However, despite the fact that the disease no longer remains confined solely to gay and bisexual men, the reality is that this segment of the population is the one most affected by this epidemic. In the seminal 1998 American Psychologist article, Walter Batchelor warned that “AIDS still attacks homosexual and bisexual men in great numbers” (p. 854). It is truly alarming that 30 years later, HIV/AIDS continues to be predominantly a gay and bisexual disease in this country (Halkitis, 2010b). This burden becomes abundantly clear when we consider the epidemiological data. Despite the fact that gay and bisexual men constitute approximately 2–4 percent of the U.S. male population 18–44 years of age (Chandra, Mosher, Copen, & Sionean, 2011), MSM, primarily gay and bisexual men, account for more than 50 percent of all AIDS cases and all HIV infections and 57 percent all new HIV infections (CDC, 2011b).

Discrimination and homophobia as causes of HIV

Despite increased visibility, acceptance and recent sociopolitical advances, gay and bisexual men continue to live in a society that privileges heterosexuality while denigrating nonheterosexual relationships, behaviors and identities (Herek, Gillis, & Cogan, 2009). As a result, our population continues to face stigma rarely encountered by our heterosexual counterparts. Oppressive social structures and inequalities affecting gay and bisexual men have been implicated in perpetuating not only the HIV epidemic but also rates of anal cancer, Hepatitis B, human papillomavirus (HPV) and lymphogranulma vernreum (LGV) infections, syphilis, gonorrhea and Hepatitis C (Wolitski & Fenton, 2011).

These structural conditions, which take the form of discrimination and homophobia (Wolistki & Fenton, 2011; Wolitski, Stall, & Validiserri, 2008), are further compounded by racism and economic disparities for gay and bisexual men of color. Exposure to and experiences of homophobia have been implicated in substance abuse, risky sexual behaviors, negative body image, suicide attempts, increased stress and limited social support among gay and bisexual men (Halkitis, Fischgrund, & Parsons, 2005; Mayer, Bradford, Makadon, Stall, & Goldhammer, 2008; Wolitski, Stall, Valdiserri, 2008). Moreover, experiences with homophobia have been shown to interfere with the ability of gay and bisexual men to establish and maintain longterm same-sex relationships, which protect against HIV acquisition (Diaz, Ayala, Bein, Henne, & Marin, 2001). The experiences of homophobia may exert their effects on sexual risk taking indirectly by exacerbating mental health burden (Halkitis, 2010b; Johnson, Carrico, Chesney, & Morin, 2008).

Experiences with oppression and homophobia, which tend to pervade family, school and community settings, are especially relevant for gay and bisexual young men, who are in the process of establishing their personal identities. Unlike other marginalized groups (e.g., immigrants) who grow up with people like themselves and who receive the support of their families, gay and bisexual youth frequently have more complicated and often abusive family dynamics (D’Augelli, Hershberger, & Pilkington, 1998; Pilkington & D’Augelli, 1995). In a seminal study, Ryan, Huebner, and Sanchez (2009) showed the powerful effects of homophobia perpetrated by family members. These researchers compared lesbian, gay and bisexual (LGB) young adults who were rejected with those who were supported by their families. Rejected LGB youth were 8.4 times more likely to have tried to commit suicide, 5.9 times more likely to report high levels of depression, 3.4 times more likely to use illegal drugs, and 3.4 times more likely to have risky sex. For young gay and bisexual men, this form of nonacceptance starts in childhood and adolescence within the contexts of families.

The effects of discrimination are likely moderated by numerous factors, including the intensity of the discriminatory experience, the duration over which these experiences occur, as well as the relationship between the victim and the perpetrator(s) (Raymond Chen, Stall, & McFarland, 2011). For example, the lifelong health risks may be even greater if the family victimization takes the form of sexual abuse; Mimiaga et al. (2009) demonstrated that gay and bisexual men with histories of childhood sexual abuse were more likely to report both unprotected anal intercourse, to derive fewer benefits from participation in prevention programs, and to be at an overall greater risk for HIV infection.

Project Desire is an NYU Center for Health Identity, behavior and Prevention study that documented the risks and resiliencies of young gay and bisexual men ages 15–29. These images appeared in New York City subway stations.

Recently our research team at the Center for Health Identity, Behavior and Prevention Studies (CHIBPS) at New York University documented the risks and resiliencies of young gay and bisexual men ages 13–29 in a study named Project Desire. Using Gilligan’s (1982) Listening Guide for Psychological Inquiry (see Camic, Rhodes, & Yardley, 2003), we recorded these young men’s fears, hopes, and dreams in relation to emerging adulthood, dating, sex and HIV. Some spoke very clearly about experiences of homophobia in their lives (Halkitis, Moeller, & Siconolfi, 2010a, 2010b). An 18-year-old Latino who was HIV-negative expressed how he experienced homophobia from his own sister:

The way she talks about gay people it’s, it’s not right. Like she’ll be watching a movie and be like oh my god that... faggot.

Similarly, a 25-year-old Black, HIV-positive man described his family’s reaction to his coming out as follows:

I came here [NYC], I never had worked. I went to high school one year here just to get the high school diploma and went to Hofstra University. My scholarship was paid for by my family and I was given a car for my graduation and everything was good and as soon as I told them I was gay . . . all of that was . . . taken back because they think I brought disgrace to the family.

These realities extend to school environments, which, as a microcosm of society, are often filled with victimization and oppression of those who do not present with heterosexual identity (Espelage & Swearer, 2008; Kosciw, Greytak, Diaz, & Bartkiewicz, 2010). In their qualitative study of masculinity, Phoenix, Frosh, and Pattman (2003) found that boys as young as 11 years of age have found it critically important to present themselves as masculine in order to avoid being bullied and labeled as gay. In fact, when it comes to traditional gender expression, boys tend to be watched very closely because of the high value assigned to hegemonic masculinity, which is the most honored way of being a man in our culture (Connell & Messerschmidt, 2005; Pascoe, 2007).

Unfortunately, the cultural perception of gay and bisexual males as less masculine may lead to their assertions of masculinity through engagement in unprotected sexual behaviors (Halkitis, Green, & Wilton, 2004; Harper, 2007). Scientific evidence shows that gay men’s doubts about their masculinity as well as endorsement of masculine characteristics are associated with frequent risky sexual behaviors, which increase exposure to HIV (Connell, 1995; Diaz, 1998).

Life experiences with oppression and homophobia often become internalized and can have detrimental effects on the development of positive sexual identity (Rowen & Malcolm, 2002). Positive attitudes toward one’s sexual identity have been shown to be protective against risky sexual behaviors (Rosario, Hunter, Maguen, Gwadz, & Smith, 2001), while elevated rates of internalized homophobia have been linked to exacerbated sexual risk taking and other health risks.

This is how a 25-year-old HIV-negative White male participant of Project Desire described his struggles with internalized homophobia:

I grew up in such a heterosexual environment where that was just the norm. So maybe the fact that it [being gay] wasn’t normal. And I’m a very by-the-book person where I feel like, I’m always trying to do right... I was always the child that was given... rules to follow, to abide by and... I felt like that’s what I would strive for... [Being gay] wasn’t by the book. And it was outside the lines... I’m not completely comfortable with being gay but I’m still so much more comfortable than I was so it’s just a process.

Others nested their experiences of homophobia in relation to organized religion, as demonstrated in the comments of one 28-year-old HIV-negative Black man:

On a Sunday we’d be going to church; my dad would go to church very frequently and I accepted God into my life — Jesus Christ into my life at an early age. But like with a lot of men who have sex with men, especially men who have sex with men of color, it’s like — like the internalized issue — the homophobia with our cultures — the whole issue with being an abomination to God. So that definitely was a brain bender.

Project Gold is an NYU CHIBPS study that examines the life experiences, risks, and resiliencies of HIV-positive men ages 50 and older. These images appeared in NYC subway stations.

Gay and bisexual men experience homophobia throughout the course of their lives. Thus, it is critical that we consider the well-being of gay and bisexual men by using a life course perspective (Institute of Medicine, 2011). Last year at CHIBPS, we enacted a program of study named Project GOLD, which examines the life experiences, risk, and resiliencies of HIV-positive men 50 years of age and older (Halkitis, 2010a). Many of the men with whom we have spoken are long-term survivors of the disease, having lived with AIDS for over 20 years. Yet even those older men vividly describe how the experience of homophobia shaped their lives in the past and how it continues to affect their lives. Johnson et al. (2008) demonstrated that among 465 HIV-positive men, internalized homophobia was associated with unprotected receptive anal intercourse with partners who were HIV-negative or of unknown HIV status and was also associated with poorer adherence to antiretroviral therapy. A 51-year-old Latino man, who has been living with HIV for 24 years, described it as follows:

I think that being a gay person, even today we are being kicked around. And it’s hard to accept yourself very well when society seems to be, you know, kicking your ass a lot.

Another, a 53-year-old Black man living with HIV for 21 years, described his experiences in this manner:

Because society will keep telling you that something is wrong with you. And then you would hear very negative things, including even within my family; they’re very homophobic.

The confluence of homophobia, racism, and economic inequalities

For gay and bisexual men of color, the effects of sexual orientation discrimination on HIV risk may be confounded and exacerbated by other powerful structural factors, including racism, lack of access to economic means, and poverty (Williams, Wyatt, Resell, Peterson, & Asuan-O’Brien, 2004). HIV in the United States has disproportionately affected racial/ethnic minorities and the poor for decades (Brooks, Rotheram-Borus, Bing, Ayala, & Henry, 2003; Karon, Fleming, Steketee, & De Cock, 2001). Thus, the synergistic social conditions of homophobia, racism, and poverty likely explain the even higher incidence of new HIV infections among racial ethnic minorities, particularly Black and Latino gay and bisexual men (CDC, 2011b). In a study of Latino men, Diaz et al. (2001) identified positive relations between risky sexual behaviors and the participants’ experiences of homophobia, racism, and financial instability. Mays, Cochran, and Zamudio (2004) revealed similar findings in a study of gay, bisexual and other MSM.

Poverty has been identified by the United Nations Population Fund (2003) as a critical factor in the spread and treatment of HIV. For many gay and bisexual men of color, economic inequalities add to the pernicious effects of oppression and homophobia. For example, in a seven-city study of HIV prevalence among young gay and bisexual men, Harawa et al. (2004) found prevalence rates of 16 percent for Black men, 6.9 percent for Latinos, and 3.3 percent for Whites, despite the fact that the White men reported potentially risky sex and drug-using behaviors with greater frequency. In this sample, however, such indicators of socioeconomic status as unemployment and lack of formal education were highly associated with HIV infection, suggesting socioeconomic inequalities suffered by the racial and ethnic minority men.

Perhaps the effects of economic standing on HIV prevalence among gay and bisexual men can also be understood in relation to contextual factors, particularly the roles played by residential neighborhoods (e.g., Frye et al., 2006). Certainly person-level variables interact with sociopolitical variables to shape HIV risk-taking behavior among gay men. Yet it is a likely hypothesis that those who have access to and navigate environments where there are high levels of gay presence are also likely to be exposed to HIV prevention messaging through publications and advertisements, as well as through interactions with other gay men in social venues. In addition, living in impoverished neighborhoods may bestow additional burdens on gay and bisexual men. According to Ellen, Mijanovich, and Dillman (2001), the impact of neighborhoods may be manifested through (a) short-term influences on behavior, attitudes, and access to health care, which affect immediate well-being; and (b) long-term effects associated with poor environmental quality and limited resources experienced over numerous years and known as “weathering.”

For those young gay men of color who are socioeconomically disadvantaged, access to gayrelated health resources may be more limited because their neighborhoods of residence tend to be outside the exclusive city center, where many gay cultural, health, and social establishments tend to be located (Halkitis, Moeller, & Siconolfi, 2009a, 2009b). In effect, risk may be exacerbated by the fact that these men must negotiate the reality of their sexual identities within residential neighborhoods that reject and stigmatize people with non-heterosexual identities (Mays, Chatters, Cochran, & Mackness, 1998; Mays, Cochran, & Zamudio, 2004). This situation is compounded by the lack of access to other services in poor communities where some African American men reside, increasing their likelihood of HIV seroconversion (Crosby & Grofe, 2001).

The confluence of neighborhood factors, socioeconomic factors and access to services not only exacerbates HIV risk but also the comorbid conditions of substance use, including injection drug use (Crosby & Grofe, 2001; Shafer et al., 2002), and mental health burden (e.g., Truong & Ma, 2006), which in turn elevate vulnerabilities. Frye et al. (2010) examined the relation between gay neighborhood presence and sexual risk taking of young gay men and found that gay neighborhood presence was positively associated with consistent condom use during anal intercourse. These matters are of particular concern in relation to homeless and unstably housed youth (Marshall et al., 2009), who may reside in a variety of different neighborhood environments including parks and public spaces, vehicles, shelters and hostels (Daly, 1996).

Conclusions

Taken together, the extant literature suggests that the perpetuation of the HIV epidemic in gay and bisexual men is not directed solely by person-level behaviors but is influenced by a range of contextual factors, rooted in cultural, historical, and political structures in this country. These findings suggest that HIV prevention efforts must be embedded within a larger framework of gay men’s lives, identities and health. A holistic approach to the well-being of gay men (Halkitis, 2010b; Safren, Resiner, Herick, Mimiaga, & Stall, 2010) should collectively consider the biomedical, psychological and social factors that create these health disparities in this segment of the population.

As noted by the Institute of Medicine (2011) and as supported by the ideas presented in this article, an approach to the totality of gay men’s health must consider the role that social structures play in compromising gay men’s health. Specifically, we must combat the homophobia and discrimination that gay and bisexual men face from families, communities, and society at large. We must understand that such oppression not only perpetuates the HIV epidemic but also compromises the overall wellness of gay and bisexual men. In the end, our best hope for eradicating the HIV epidemic in gay and bisexual men will arise from the combined strength of biomedical, social, behavioral and legislative interventions. Finally, for preventive efforts to be meaningful and effective, such approaches must understand the lives of gay and bisexual men, support us in development of strong and healthy identities, and help us in the creation of strong communities in which we will not only be cared for but also able to take care of ourselves and support each other.

About the author

Perry N. Halkitis, PhD, MS, is an associate dean for research and doctoral studies, a professor of applied psychology, public health and medicine, and the director of the Center for Health, Identity, Behavior and Prevention Studies at the Steinhardt School of Culture, Education, and Human Development at New York University (NYU). He is also an affiliate of the Center for AIDS Research and the Center for Drug Use and HIV Research, also at NYU. He is internationally recognized for his work examining the intersection of HIV, drug abuse, and mental health and is well known as one of the nation’s leading experts on methamphetamine addiction and HIV behavioral research.

He is lead editor of two volumes: "HIV + Sex: The Psychological and Interpersonal Dynamics of HIVSeropositive Gay and Bisexual Men’s Relationships" (2005) and "Barebacking: Psychosocial and Public Health Perspectives" (2006). His book "Methamphetamine Addiction: Biological Foundations, Psychological Factors, and Social Consequences" was published in 2009, and he is currently working on a new manuscript examining the life experiences of gay men who are long-term survivors of HIV/AIDS. Author of over 120 peer-reviewed academic manuscripts, Dr. Halkitis’s research examines how sexual and drug-related risk taking, as well as mental health, are influenced by interpersonal, contextual, developmental and cultural factors.

Dr. Halkitis’s research has been funded by the National Institutes of Health (NIH), the CDC, the New York City Department of Health and Mental Hygiene, the New York State AIDS Institute, the United Way, the New York Community Trust and the American Psychological Foundation. He serves on the APA’s Committee on Psychology and AIDS, is a member of the advisory committee on HIV and STD prevention and treatment of the CDC and the Health Services Research Administration, and is a member of the College of Reviewers of the NIH Center for Scientific Review. He is the recipient of numerous awards from both professional and community-based organizations and is an elected fellow of the New York Academy of Medicine, the Society of Behavioral Medicine and APA. Dr. Halkitis received his PhD in 1995 from the Graduate Center of the City University of New York and is currently completing his MPH degree.

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2012 Institute of Medicine (IOM) Report

Monitoring HIV Care in the United States: Indicators and Data Systems

Washington, D.C.: The National Academies Press

Released: March 15, 2012

Morgan A. Ford and Carol Mason Spicer, Editors; Committee on Review Data Systems for Monitoring HIV Care; Institute of Medicine

In July 2010, the White House Office of National AIDS Policy (ONAP) released its National HIV/AIDS Strategy (NHAS), which includes goals to increase access to care, optimize health outcomes for people with HIV, and reduce HIV-related health disparities. At the same time, the Patient Protection and Affordable Care Act (ACA) is poised to bring millions of uninsured people — including many with HIV — into the health care system when it is implemented in 2014.

Monitoring HIV Care in the United States addresses existing gaps in the collection, analysis, and integration of data on the care and treatment experiences of people living with HIV/AIDS (PLWHA). This report identifies critical data and indicators related to continuous HIV care and access to supportive services, assesses the impact of the NHAS and the ACA on improvements in HIV care, and identifies public and private data systems that capture the data needed to estimate these indicators. This report also addresses a series
of specific questions related to the collection, analysis and dissemination of such data.

This is the first of two reports to be prepared by this study. In a forthcoming report, also requested by ONAP, the committee will address the broad question of how to obtain national estimates that characterize the health care of people living with HIV in the United States. The second report will include discussion of challenges and best practices from previous large-scale and nationally representative studies of PLWHA as well as other populations.