Stigma and negativity from within the community increases HIV risk-taking by gay men

Stress levels and sexual risk-taking in gay men are at least as much influenced by stigma and rejection by other gay men as they are by stigma and discrimination by the non-gay community, according to a series of studies conducted by Dr John Pachankis and colleagues from the LGBT mental health unit at Yale University.

Stress, depression and rejection from the community

Unusually for a study on gay men's mental health, a previous paper by Pachankis attracted national press attention when The Guardian newspaper published a piece called Pressure to keep up: status imbalance a major factor in stress in gay men. This study found that the documented high rates of stress and poor mental health among gay men did not just correlate with discrimination and the perception of stigma from people outside the community – so-called 'minority stress' – but also with experiences and perceptions of rejection and stigma from other gay men – 'intraminority stress'. In fact, poor mental health in gay men was more strongly correlated with how they felt about other gay men’s focus on sex, status, competition and exclusion of diversity, than it was with distress about stigma and rejection from outside the gay community.

One strength of this study was that the researchers involved did not just quiz gay men about how they felt affected by intraminority stress, subjectively. It also conducted a practical experiment to see if a situation where it appeared they were being rejected by other gay men affected their mental functioning.

Participants were told they were being recruited for a study of how the profiles in gay dating sites worked and the factors that made them attractive or unattractive to other gay men. They were briefly admitted to a communal chatroom in which their profile was apparently being discussed by others. In reality, the other discussants were chatbots – standardised computer response programmes – that were programmed to either say positive things about the profile (e.g. “I hope we get the chance to meet this guy”) or negative ones (“I hope we won’t have to meet this guy”).

Glossary

stigma

Social attitudes that suggest that having a particular illness or being in a particular situation is something to be ashamed of. Stigma can be questioned and challenged.

sensitivity

When using a diagnostic test, the probability that a person who does have a medical condition will receive the correct test result (i.e. positive). 

risky behaviour

In HIV, refers to any behaviour or action that increases an individual’s probability of acquiring or transmitting HIV, such as having unprotected sex, having multiple partners or sharing drug injection equipment.

multivariate analysis

An extension of multivariable analysis that is used to model two or more outcomes at the same time.

sample

Studies aim to give information that will be applicable to a large group of people (e.g. adults with diagnosed HIV in the UK). Because it is impractical to conduct a study with such a large group, only a sub-group (a sample) takes part in a study. This isn’t a problem as long as the characteristics of the sample are similar to those of the wider group (e.g. in terms of age, gender, CD4 count and years since diagnosis).

Exposure to negative reactions tended to reinforce the despondency participants felt about sex, status, competition and the exclusion of diversity within the gay community.

Intraminority stress and sexual risk

As reported in the new paper in Annals of Behavioral Medicine, Pachankis' team continued these experiments to see if intraminority stress within the gay community impacted on gay men’s sexual health risk behaviour. In short, it did – affecting even gay men’s willingness to take risks that had nothing to do with sex.

The paper reports on two related studies. In the first study, the researchers recruited a group of 937 US gay men from the Grindr dating app.  They were selected to be from a variety of geographical backgrounds.

The make-up of the group reflected fairly well the demographics of the US, with a slight under-representation of white men (68% versus 72% nationally) and a slight over-representation of other races and Hispanic whites. Their average age was fairly young, at 31. Nearly a quarter (24%) defined as bisexual and most of the rest gay. Eighty-six per cent said they were HIV negative and 8.6% HIV positive – the rest were unsure. Half of the group earned more than $30,000 a year. One difference from some other surveys of gay men was that 68% of men in this study said they had a primary partner, whereas other studies have tended to find that slightly over half of gay male participants are single.

Firstly, the researchers established the stress levels of participants. They asked about general stress level with an often-used set of 14 questions such as “"In the last month, how often have you felt that difficulties were piling up so that you could not overcome them?”

They then asked about four different aspects of minority stress, i.e. stress coming from the non-gay community. This covered:

  • Discrimination and homophobia (sample question: “How often have you been called names or insulted?”)
  • Sensitivity to social rejection (“How concerned would you be if a colleague failed to invite you to their birthday celebration?”)
  • Internalised homophobia (“How often have you wished you weren’t gay?”)
  • How “out” participants were to friends, family and colleagues.

Finally, they asked about four different areas of intraminority stress. They asked how stressed/bothered participants were by the gay community’s:

  • Focus on status (sample question: “In the mainstream gay community there is a lot of fighting and cattiness”)
  • Competitiveness (“The mainstream gay community is overly judgmental”)
  • Focus on sex (“The mainstream gay community values sex over meaningful relationships”)
  • Social exclusion (“The mainstream community sexually objectifies men of colour”).

These questions and their correlation with stress had been validated by work done in the previous project. Finally, these four areas were combined to create an over-arching index of perceived intraminority stress.

Going back to the survey, 156 of the participants (one in six) said they had engaged in at least one HIV-risk event in the last 90 days. This was defined strictly as anal intercourse excluding a) the use of a condom, b) the use of PrEP, and/or c) if one partner had HIV, with the HIV-positive partner having a detectable viral load. The most common number of such events in the 156 men was one, but the median number was four, indicating a minority with numerous high-risk events.

"Intraminority stress – experiences and perceptions of rejection and stigma from other gay men – had the strongest association with risky sex."

Now the researchers could relate the probability of a participant having an experience that risked HIV with their demographic characteristics. They found that Asian participants were considerably less likely to have risky experiences (72% less likely than white participants) and black participants somewhat less so (18% less likely). Education, perhaps surprisingly, was a risk factor (participants with a graduate degree or above were 73% more likely to have had a risky event) whereas identification as gay was protective; gay, as opposed to bisexual or other, men were 60% less likely to have had a risk experience.

They could also relate the likelihood of HIV risk to the degree of stress participants registered. In terms of their general, non-specific stress level, for every one-point increase (on a zero-to-ten scale) in the degree of stress participants experienced, they were 5% more likely to have been involved in sex that risked HIV at least once in the last three months.

In terms of minority stress, the results were similar, at least for participants’ sensitivity to sexual and social rejection, and also to their degree of internalised homophobia; a 4% increase in the likelihood of sexual risk for every one-point increase on the scale. However, general experience of societal homophobia was not related to sexual risk, and 'outness', far from being protective, predicted more sexual risk: for every one-point decrease in the degree to which participants were less 'out', they were 11% less likely to have risky sex – not that surprising if you think about it, as less 'outness' may simply equate to less mixing with other gay men.

However, it was intraminority stress – experiences and perceptions of rejection and stigma from other gay men – that had the strongest association with sexual risk behaviour. For every one-point increase on the intraminority stress scale, the likelihood of having had risky sex in the last three months increased by 20%. This is a considerable degree of sensitivity to stress.

Staged acceptance and rejection

The researchers then staged a second study in which a different set of 99 participants were subject to the same staged acceptance or rejection of profiles which they had submitted to a mock-chatroom or focus group – which was in fact ‘populated’ by chatbots programmed to make positive or negative remarks.  

The demographic makeup of these 99 men, who were recruited by a marketing agency saying it was engaging in social research on profiles, was similar to the first participant group, with one significant difference: only 19% of these participants earned less than $30,000 a year compared with 50% of participants in the first study. There were also more black and fewer Asian and Hispanic participants than the previous study.

"Participants who had experienced simulated rejection from other gay men were more cynical about condoms and more reckless about risk."

The researchers measured three variables before, and after, the staged chatbot-group experiences.

(We should add that these were relatively brief – a minute’s exposure each – and that participants were told that their experiences of acceptance or rejection were in fact ‘programmed’ responses immediately after doing the second set of psychological tests.)

Firstly, they looked at emotions. Participants were asked to rate on a one-to-five scale the degree to which they were experiencing ten negative emotions such as distress or hostility. The second exercise looked at opinions about one measure of sexual risk: participants were asked to rate, again on five-point scales, their agreement with two lists of statements, one listing the advantages of condoms, the other their disadvantages.

The final and perhaps most interesting exercise looked at their behaviour: they were asked to play a solitaire game of cards in which they turned over cards that were either neutral, offered points, or subtracted points. The ‘gain’ cards were relatively frequent and offered moderate rewards – 10 or 30 points gained. The ‘loss’ cards exacted big penalties – 250 or 750 points subtracted – but there were only one to three in a pack. Participants could end the game whenever they want, but if they turned over a loss card, it ended the game. The game therefore directly measured people’s tolerance of risk.

One average, participants flipped over 239 cards in 24 games each – just shy of ten in each game. The range per participant was from zero (presumably a totally risk-averse participant) to 413.

The results for all three variables were measured before and after the experiences of acceptance or rejection. Participants who had the 'acceptance' chatbot experiences were unaffected emotionally – they had neither stronger nor weaker negative affect after the chatbot experiences. However, those who had the 'rejection' experiences recorded significantly increased negative affect afterwards. There was a marginal increase in these participants’ scores for the benefits of condom use too, though not for their costs.

However, the most interesting effects came out in a multivariate analysis that controlled for negative affect: in other words, the opinions on condoms, and also risk behaviour in the card game, were measured after factoring out the effects of conspicuously negative emotions – thus revealing effects the participants weren’t consciously aware of.

After their chatbot experience, participants who’d received 'rejection' experiences reported significantly fewer benefits of condoms, compared with before the experience, than participants who’d received 'acceptance'. (Their feelings about the disadvantages of condoms continued not to differ.) Note that participants with consciously negative affect change had reported more benefits of condoms after receiving rejection.

Regarding the card game: after receiving their 'rejection' experiences, and remembering that the average in 24 trials was 239 before the chatbot experience, participants in the 'acceptance' group flipped over fewer cards – an average of 206 in 24 games - and in the 'rejection' group they flipped over more – 271.

In other words, and without necessarily being conscious of feeling bad, participants who had experienced simulated sexual or social rejection from other gay men became somewhat more cynical about condoms – and more reckless about risk.

The researchers comment that these effects could impact disproportionately on gay men who are already perceived by other gay men, or perceive themselves as, of low status. They comment that they did not specifically investigate these factors, but that other studies have shown that gay men “who are Hispanic, single and younger, and those who have lower income and less educational achievement, perceive more gay community stress.” Indeed the perception of low status by self, and by others, may mutually reinforce each other.

The researchers emphasise that their studies do not contradict the fact that socioeconomic disadvantage also contributes objectively to HIV risk in many ways ranging from less access to health care, through to experience of violence and abuse, to poor housing and survival sex.

They also point out that membership of the gay community also contributes many benefits, ranging from love and companionship to political solidarity and even to cross-class cultural and learning opportunities.

However, they add, it’s important for further research to investigate the way that structural, societal and intraminority stress – to quote The Guardian article, the way that “gay men can be awfully hard on each other” – contributes to HIV, poor mental health, addictions, suicide and other health risks.

References

Burton CE, Clark KA, Pachankis JE. Risk from within – intraminority gay community stress and sexual risk-taking among sexual minority gay men. Annals of Behavioral Medicine, online ahead of print, 24 March 2020 (open access).

doi: https://www.doi.org/10.1093/abm/kaaa014