The Role of Gay-Related Stigma in HIV-Risk Behavior Among Sexual Minority Men in Europe
Sexual orientation stigma stems from discriminatory social contexts and may ultimately impact the behavioral health of stigmatized individuals through stress-related pathways. Sexual minority stigma is of particular concern in Europe given the diversity of social contexts on the continent and sexual minority men’s rapidly increasing risk of HIV infection, especially in Central and Eastern Europe, potentially rooted in stigma. This study assesses whether stigma in the ubiquitous social contexts surrounding sexual minority men (e.g., family, workplace, government) may place them at higher risk for HIV contraction across six countries. We utilized a large cross-sectional survey sample of HIV-negative sexual minority men (N = 2087; mean age = 31.6, SD = 9.7) from six European countries to test whether those who reported sexual orientation stigma also engaged in more HIV risk-related behaviors, including condomless sex with casual partners (in the absence of PrEP) and substance use before and during sex. Regression analyses were performed in Mplus. We found that a one standard deviation increase in reported sexual orientation stigma was significantly associated with the following during the last sexual encounter: a 19% increase in odds of sex under the influence of alcohol, 27% increase in odds of sex under the influence of cannabis, 49% increase in odds of sex under the influence of illicit drugs, an 11% increase in odds of condomless sex with casual partners in the past 6 months, and a 26% increase in odds of knowing where to receive an HIV test. Sexual minority men who reported perceiving greater sexual orientation-related stigma within their ubiquitous social contexts were significantly more likely to report sexual risk and alcohol and drug use during their last sexual encounter, yet reported more knowledge of preventive services. Contextual stigma might serve as a precursor to behavioral risks of HIV infection, generating maladaptive stress responses capable of being modified through individually-focused interventions. Structural interventions are also needed to ultimately reduce stigma at its source.
KeywordsSexual minority men HIV risk Sexual orientation-related stigma Drug use Alcohol use
We gratefully acknowledge all the participants and project staff who have dedicated their time to this research.
This article is based on the findings from the SIALON project, co-funded by the European Commission under the Public Health Programme 2003–2008 (GA 2007309). The sole responsibility lies with the author of the publication, and the Commission is not responsible for any use that may be made of the information contained therein.
Compliance with Ethical Standards
Conflict of interest
The authors have no conflicts of interest to declare.
Research Involving Human Subjects
Informed consent was obtained from all individual participants included in the study. Study protocols were approved by each study site’s ethics committee, and are in compliance with the 1964 Declaration of Helsinki for ethical principles for conducting research with human subjects.
- 1.ILGA Europe. Rainbow Europe package. Annual Review and Rainbow Europe Map. https://rainbow-europe.org/country-ranking. Accessed 19 July 2016.
- 2.Beyrer C, Baral SD, editors. MSM, HIV, and the law: the case of gay, bisexual and other men who have sex with men (MSM). Working paper for the Third Meeting of the Technical Advisory Group of the Global Commission on HIV and the Law. July 7–9, 2011.Google Scholar
- 3.Mahajan AP, Sayles JN, Patel VA, Remien RH, Ortiz D, Szekeres G, et al. Stigma in the HIV/AIDS epidemic: a review of the literature and recommendations for the way forward. AIDS. 2008;22(Suppl 2):S67–79.Google Scholar
- 4.Millett GA, Peterson JL, Wolitski RJ, Stall R. Greater risk for HIV infection of black men who have sex with men: a critical literature review. J Inf. 2006;96(6):1007–19.Google Scholar
- 5.Millett GA, Peterson JL, Flores SA, Hart TA, Jeffries WL, Wilson PA, et al. Comparisons of disparities and risks of HIV infection in black and other men who have sex with men in Canada, UK, and USA: a meta-analysis. Lancet. 2012;380(9839):341–8.Google Scholar
- 6.Jeffries WL IV, Marks G, Lauby J, Murrill CS, Millett GA. Homophobia is associated with sexual behavior that increases risk of acquiring and transmitting HIV infection among black men who have sex with men. AIDS Behav. 2012;17(4):1442–53.Google Scholar
- 7.Oster AM, Wiegand RE, Sionean C, Miles IJ, Thomas PE, Melendez-Morales L, et al. Understanding disparities in HIV infection between black and white MSM in the United States. AIDS. 2011;25(8):1103–12.Google Scholar
- 8.Lelutiu-Weinberger C, Pachankis JE, Golub SA, Walker JJ, Bamonte A, Parsons JT. Age cohort differences in the effects of gay-related stigma, anxiety and identification with the gay community on sexual risk and substance use. AIDS Behav. 2013;17(1):340–9.Google Scholar
- 9.European Center for Disease Prevention and Control/WHO Regional Office for Europe. HIV/AIDS surveillance in Europe. 2015. https://ecdc.europa.eu/sites/portal/files/media/en/publications/Publications/HIV-AIDS-surveillance-Europe-2015.pdf. Accessed 15 Jan 2017.
- 10.SIALON II. City Profiles. Recommendations on HIV prevention gaps and opportunities for health promotion among men who have sex with men. 2015 http://www.sialon.eu/data2/file/133_Sialon%20II_City%20Profiles_Recommendations%20on%20HIV%20prevention%20gaps%20and%20opportunities%20for%20Health%20Promotion%20among%20Men%20who%20have%20Sex%20with%20Men.pdf. Accessed 12 Jul 2016.
- 11.Ferrer L, Furegato M, Foschia J-P, Folch C, González V, Ramarli D, et al. Undiagnosed HIV infection in a population of MSM from six European cities: Results from the Sialon project. Eur J Public Health. 2015;25(3):494–500.Google Scholar
- 12.ACCEPT Association of Romania. ILGA Europe. Documentation of discrimination in the field of LGBT heath in Romania. General overview, legal framework, findings and recommendations. 2014. http://www.ilga-europe.org/sites/default/files/Attachments/romania.pdf. Accessed 3 March 2017.
- 13.Nachescu V. Hierarchies of difference: National identity, gay and lesbian rights, and the church in postcommunist Romania. In: Coleman E, Sandfort T, editors. Sexuality and gender in postcommunist Eastern Europe and Russia. New York: Haworth Press; 2005. p. 57–78.Google Scholar
- 14.Turcescu L, Stan L. Religion, politics and sexuality in Romania. Eur-Asia Stud. 2005;57(2):291–310.Google Scholar
- 15.Krishnamoorthy N. Romanian activists call for ban on same-sex marriages in the country. International Business Times. http://www.ibtimes.co.uk/romanian-activists-call-ban-same-sex-marriages-country-1561657. Accessed 14 July 2016.
- 16.Morgan J. Three million people want to ban same-sex marriage in Romania. Gay Star News. http://www.gaystarnews.com/article/three-million-people-want-ban-sex-marriage-romania/#gs._EsgV2U. Accessed 14 July 2016.
- 17.Moraru A. Social perception of homosexuality in Romania. Proc Soc Behav Sci. 2010;2(2):5726–30.Google Scholar
- 18.Holzhacker R. State-sponsored homophobia and the denial of the right of assembly in Central and Eastern Europe: the “boomerang” and the “ricochet” between European organizations and civil society to uphold human rights. Law Policy. 2013;35(1–2):1–28.Google Scholar
- 19.Takács J, Kuhar R, editors. Beyond the pink curtain. Everyday life of LGBT people in Eastern Europe. Ljubljana: The Peace Institute of Contemporary Social and Political Studies; 2007.Google Scholar
- 20.Van den Akker H, Van der Ploeg R, Scheepers P. Disapproval of homosexuality: comparative research on individual and national determinants of disapproval of homosexuality in 20 European countries. Int J Public Opin Res. 2013;25(1):64–86.Google Scholar
- 21.Crocker J, Major B, Steele C. Social stigma: the psychology of marked relationships. Handbook Soc Psychol. 1998;2:504–53.Google Scholar
- 22.Pachankis JE, Hatzenbuehler ML, Wang K, Burton CL, Crawford FW, Phelan JC, et al. The burden of stigma on health and well-being: A taxonomy of concealment, course, disruptiveness, aesthetics, origin, and peril across 93 stigmas. Pers Soc Psychol Bull. 2018;44(4):451–74.Google Scholar
- 23.Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol. 2001;27(1):363–85.Google Scholar
- 24.Bos AE, Pryor JB, Reeder GD, Stutterheim SE. Stigma: advances in theory and research. Basic Appl Soc Psychol. 2013;35(1):1–9.Google Scholar
- 25.Ragins BR, Cornwell JM. Pink triangles: antecedents and consequences of perceived workplace discrimination against gay and lesbian employees. J Appl Psychol. 2001;86(6):124412–61.Google Scholar
- 26.Ryan C, Huebner D, Diaz RM, Sanchez J. Family rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics. 2009;123(1):346–52.Google Scholar
- 27.Pachankis JE, Bränström R. Hidden from happiness: structural stigma, concealment, and life satisfaction among sexual minorities across 28 countries. J Consult Clin Psychol. 2018;86:403–15.Google Scholar
- 28.Leluțiu-Weinberger C, Pachankis JE. Acceptability and preliminary efficacy of an LGBT-affirmative mental health practice training in a homophobic national context. LGBT Health. 2017;4(5):360–70.Google Scholar
- 29.Pachankis JE, Hatzenbuehler ML, Hickson F, Weatherburn P, Berg RC, Marcus U, et al. Hidden from health: structural stigma, sexual orientation concealment, and HIV across 38 countries in the European MSM internet survey. AIDS. 2015;29(10):1239–46.Google Scholar
- 30.Centers for Disease Control and Prevention. HIV surveillance report. Diagnoses of HIV infection in the United States and dependent areas, 2015. https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-2015-vol-27.pdf. Accessed 15 Nov 2016.
- 31.European Center for Disease Prevention and Control. EMIS 2010: The European men-who-have-sex-with-men internet survey: findings from 38 countries. http://ecdc.europa.eu/en/publications/Publications/EMIS-2010-european-men-who-have-sex-with-men-survey.pdf. Accessed 28 Aug 2016.
- 32.Mayer KH, Beyrer C. HIV epidemiology update and transmission factors: risks and risk contexts—16th International AIDS Conference epidemiology plenary. Clin Infect Dis. 2007;44(7):981–7.Google Scholar
- 33.Folch C, Muñoz R, Zaragoza K, Casabona J, Pujol UGT. Sexual risk behaviour and its determinants among men who have sex with men in Catalonia, Spain. Euro Surveill. 2009;14(47):24–30.Google Scholar
- 34.Amirkhanian YA, Kelly JA, Takacs J, Kuznetsova AV, DiFranceisco WJ, Mocsonaki L, et al. HIV/STD prevalence, risk behavior, and substance use patterns and predictors in Russian and Hungarian sociocentric social networks of men who have sex with men. AIDS Edu Prev. 2009;21(3):266–79.Google Scholar
- 35.Mirandola M, Gios L, Davis J, Furegato M, Breveglieri M, Folch C, et al. Socio-demographic factors predicting HIV test seeking behaviour among MSM in 6 EU cities. Eur J Public Health. 2017;27(2):313–8.Google Scholar
- 36.Mirandola M, Gios L, Sherriff N, Pachankis J, Toskin I, Ferrer L, et al. Socio-demographic characteristics, sexual and test-seeking behaviours amongst men who have sex with both men and women: Results from a bio-behavioural survey in 13 European cities. AIDS Behav. 2017;21(10):3013–25.Google Scholar
- 37.Mirandola M, Folch TC, Krampac I, Nita I, Stanekova D, Stehlikova D, et al. HIV bio-behavioural survey among men who have sex with men in Barcelona, Bratislava, Bucharest, Ljubljana, Prague and Verona, 2008–2009. Eur Commun Dis Bull. 2008;14(48):1424–7.Google Scholar
- 38.Stanekova D, Mirandola M, Gios L, Botsi C, Habekova M, Gonzales-Soler V, et al. Validation study of a conventional enzyme immunoassay to detect HIV antibodies in oral fluid. Bratisl Lek Listy. 2016;117(1):19–21.Google Scholar
- 39.UNAIDS Joint United Nations Programme on HIV/AIDS. Global AIDS response progress reporting 2014: construction of core indicators for monitoring the 2011 UN political declaration on HIV/AIDS. Joint United Nations Programme on HIV/AIDS (UNAIDS), WHO Library Cataloguing-in-Publication Data; Geneva: Switzerland; 2014.Google Scholar
- 40.Williamson LM, Hart GJ. HIV prevalence and undiagnosed infection among a community sample of gay men in Scotland. J Acquir Immune Defic Syndr. 2007;45(2):224–30.Google Scholar
- 41.Halkitis P, Parsons J, Stirratt M. A double epidemic: Crystal methamphetamine drug use in relation to HIV transmission among gay men. J Homosex. 2001;41(2):17–36.Google Scholar
- 42.Colfax G, Mansergh G, Guzman R, Vittinghoff E, Marks G, Rader M, et al. Drug use and sexual risk behavior among gay and bisexual men who attend circuit parties: a venue-based comparison. J Acquir Immune Defic Syndr. 2001;28(4):373–9.Google Scholar
- 43.Clatts M, Goldsamt L, Yi H. Club drug use among young men who have sex with men in NYC: a preliminary epidemiological profile. Subst Use Misuse. 2005;40(9):1317–30.Google Scholar
- 44.Celentano DD, Valleroy LA, Sifakis F, MacKellar DA, Hylton J, Thiede H, et al. Associations between substance use and sexual risk among very young men who have sex with men. Sex Transm Dis. 2006;33(4):265–71.Google Scholar
- 45.Wilton L. Correlates of substance abuse use in relation to sexual behavior in black gay and bisexual men: Implications for HIV prevention. J Black Psychol. 2008;34(1):70–93.Google Scholar
- 46.Sarkar S, Panda S, Sarkar K, Hangzo CZ, Bijaya L, Singh NY, et al. A cross-sectional study on factors including HIV testing and counselling determining unsafe injecting practices among injecting drug users of Manipur. Indian J Public Health. 1995;39(3):86–92.Google Scholar
- 47.Ackers M-L, Greenberg AE, Lin CY, Bartholow BN, Goodman AH, Longhi M, et al. High and persistent HIV seroincidence in men who have sex with men across 47 US cities. PLoS ONE. 2012;7(4):e34972.Google Scholar
- 48.Sander PM, Cole SR, Stall RD, Jacobson LP, Eron JJ, Napravnik S, et al. Joint effects of alcohol consumption and high-risk sexual behavior on HIV seroconversion among men who have sex with men. AIDS. 2013;27(5):815–23.Google Scholar
- 49.Hatzenbuehler ML, Nolen-Hoeksema S, Erickson SJ. Minority stress predictors of HIV risk behavior, substance use, and depressive symptoms: results from a prospective study of bereaved gay men. Health Psychol. 2008;27(4):455–62.Google Scholar
- 50.Pachankis JE, Hatzenbuehler ML, Rendina HJ, Safren SA, Parsons JT. LGB-affirmative cognitive behavioral therapy for young adult gay and bisexual men: a randomized controlled trial of a transdiagnostic minority stress approach. J Consult Clin Psychol. 2015;83(5):875–89.Google Scholar
- 51.Pachankis JE. A transdiagnostic minority stress treatment approach for gay and bisexual men’s syndemic health conditions. Arch Sex Behav. 2015;44(7):1843–60.Google Scholar
- 52.Hatzenbuehler ML. How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychol Bull. 2009;135(5):707–30.Google Scholar
- 53.Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674–97.Google Scholar
- 54.Hatzenbuehler ML, McLaughlin KA, Keyes KM, Hasin DS. The impact of institutional discrimination on psychiatric disorders in lesbian, gay, and bisexual populations: a prospective study. Am J Public Health. 2010;100(3):452–9.Google Scholar
- 55.Herek GM, Gillis JR, Cogan JC. Internalized stigma among sexual minority adults: insights from a social psychological perspective. J Couns Psychol. 2009;56(1):32–43.Google Scholar
- 56.Ross MW, Rosser BS, Neumaier ER. The relationship of internalized homonegativity to unsafe sexual behavior in HIV seropositive men who have sex with men. AIDS Educ Prev. 2008;20(6):547–57.Google Scholar
- 57.Huebner DM, Davis MC, Nemeroff CJ, Aiken LS. The impact of internalized homophobia on HIV preventive interventions. Am J Community Psychol. 2002;30(3):327–48.Google Scholar
- 58.Wells BE, Golub SA, Parsons JT. An integrated theoretical approach to substance use and risky sexual behavior among men who have sex with men. AIDS Behav. 2011;15(3):509–20.Google Scholar
- 59.Weber G. Using to numb the pain: Substance use and abuse among lesbian, gay, and bisexual individuals. J Mental Health Couns. 2008;30(1):31–48.Google Scholar
- 60.Pachankis JE. Uncovering clinical principles and techniques to address minority stress, mental health, and related health risks among gay and bisexual men. Clin Psychol. 2014;21:313–30.Google Scholar
- 61.Miller W, Rollnick S. Motivational interviewing: preparing people for change. New York: Guilford Press; 2002.Google Scholar
- 62.Hatzenbuehler ML, Phelan JC, Link BG. Stigma as a fundamental cause of population health inequalities. Am J Public Health. 2013;103(5):813–21.Google Scholar
- 63.Bruce D, Ramirez-Valles J, Campbell RT. Stigmatization, substance use, and sexual risk behavior among Latino gay and bisexual men and transgender persons. J Drug Issues. 2008;38(1):235–60.Google Scholar
- 64.Lelutiu-Weinberger C, Manu M, Lăscut F, Dogaru B, Kovacs T, Dorobănțescu C, et al. An mHealth intervention to improve young gay and bisexual men’s sexual behavioral and mental health in a structurally stigmatizing national context. J Med Internet Res. 2018. https://doi.org/10.2196/mhealth.9283.Google Scholar
- 65.Muessig KE, Nekkanti M, Bauermeister J, Bull S, Hightow-Weidman LB. A systematic review of recent smartphone, internet and web 2.0 interventions to address the HIV continuum of care. Curr HIV/AIDS Rep. 2015;12(1):173–90.Google Scholar
- 66.Lelutiu-Weinberger C, Pachankis JE, Gamarel K, Surace A, Golub SA, Parsons JT. Feasibility, acceptability and preliminary efficacy of a live-chat intervention to reduce HIV risk among young men who have sex with men. AIDS Behav. 2015;19(7):1214–27.Google Scholar
- 67.Schnall R, Travers J, Rojas M, Carballo-Diéguez A. eHealth interventions for HIV prevention in high-risk men who have sex with men: a systematic review. J Med Internet Res. 2014;16(5):e134.Google Scholar
- 68.Sullivan PS, Grey JA, Rosser BRS. Emerging technologies for HIV prevention for MSM: What we have learned, and ways forward. J Acquir Immune Syndr. 2013;63:S102–7.Google Scholar
- 69.Donker T, Petrie K, Proudfoot J, Clarke J, Birch M-R, Christensen H. Smartphones for smarter delivery of mental health programs: a systematic review. J Med Internet Res. 2013;15(11):e247.Google Scholar
- 70.Muessig KE, Pike EC, Fowler B, LeGrand S, Parsons JT, Bull SS, et al. Putting prevention in their pockets: developing mobile phone-based HIV interventions for black men who have sex with men. AIDS Patient Care STDs. 2013;27(4):211–22.Google Scholar
- 71.Pachankis JE, Eldahan AI, Golub SA. New to New York: ecological and psychological predictors of health among recently arrived young adult gay and bisexual urban migrants. Ann Behav Med. 2016;50(5):692–703.Google Scholar
- 72.Meyer IH. Prejudice as stress: conceptual and measurement problems. Am J Public Health. 2003;93(2):262–5.Google Scholar
- 73.Lyles CM, Kay LS, Crepaz N, Herbst JH, Passin WF, Kim AS, et al. Best-evidence interventions: findings from a systematic review of HIV behavioral interventions for US populations at high risk, 2000–2004. Am J Public Health. 2007;97(1):133–43.Google Scholar
- 74.Grossman CI, Forsyth A, Purcell DW, Allison S, Toledo C, Gordon CM. Advancing novel HIV prevention intervention research with MSM—meeting report. Public Health Rep. 2011;126(4):472–9.Google Scholar
- 75.Johnson WD, Diaz RM, Flanders WD, Goodman M, Hill AN, Holtgrave D, et al. Behavioral interventions to reduce risk for sexual transmission of HIV among men who have sex with men. Cochrane Database Syst Rev. 2008;3:1230.Google Scholar
- 76.Bull SS, Levine DK, Black SR, Schmiege SJ, Santelli J. Social media-delivered sexual health intervention: a cluster randomized controlled trial. Am J Prev Med. 2012;43(5):467–74.Google Scholar
- 77.Parsons JT, Lelutiu-Weinberger C, Botsko M, Golub SA. A randomized controlled trial utilizing motivational interviewing to reduce HIV risk and drug use in young gay and bisexual men. J Consult Clin Psychol. 2014;82(1):9–18.Google Scholar