Internalised homophobia leads to sexual risk taking by HIV-positive gay men

Internalised homophobia is associated with sexual risk behaviour amongst HIV-positive gay and bisexual men, US research published in the journal AIDS Education and Prevention suggests. The investigators found that not being “out” as gay or bisexual was associated with non-disclosure of HIV status to non-primary sexual partners and that lower sexual comfort was associated with less confidence using condoms and unprotected anal sex with HIV-negative men or men of an unknown HIV status.

The concept of internalised homophobia (or internalised homonegativity) was developed in the 1970s and is described as a revulsion or hostility towards one’s own homosexuality or things homosexual.

Some research has suggested a link between internalised homophobia and unprotected sex. Investigators wished to gain a better understanding of the relationship between internalised homophobia and serodiscordant unprotected anal sex amongst a population of 675 HIV-positive gay men recruited through community-based organisations in six US cities.

The men had a median age of 42 years. Most (80%) identified as gay, the remaining 20% describing themselves as bisexual. Approximately 50% were African Americans and the median average income was low at a little under $11,000 per year. A third of the men were diagnosed with HIV before 1991, another third between 1991 and 1997 and the remaining third after 1998. Three-quarters of the men were taking antiretroviral therapy. Median CD4 cell count was 428 cells/mm³ and median viral load was 2800 copies/ml.

Using self-completed questionnaires, the investigators measured: internalised homophobia; self-assessed sexual orientation; comfort with one’s sexuality and one’s body; compulsive sexual behaviour; alcohol use; drug use; mental health; comfort using condoms; and unsafe sex. Measures of unsafe sex included non-disclosure to non-primary partners and unprotected anal sex with men of an unknown or different HIV status in the previous three months.

Overall, internalised homophobia was most common amongst African American men (p = 0.011) and men who ranked religion as important to them (p = 0.012).

There was also an association between internalised homophobia and depression (p = 0.02) and lower levels of education (p = 0.04).

The investigators found two relationships between internalised homophobia and unprotected sex.

Firstly, they found that men who were not “out” as gay or bisexual had lower levels of HIV disclosure to their secondary sexual partners, which in turn was associated with unprotected anal sex with men of unknown HIV status.

Secondly, a relationship was also demonstrated between lack of sexual comfort - comfort with one’s sexuality and body image - and poor condom efficacy, which in turn led to an increased risk of unprotected anal sex with men of a different or unknown HIV status.

“These data appear to confirm the previously hypothesized role of internalised homophobia as a precursor of unsafe sexual behavior in men who have sex with men,” comment the investigators.

Furthermore, the investigators also suggest that internalised homophobia could also be important to “understanding gay men’s higher rates of body dissatisfaction, eating disorders, eating-disordered behaviors, and insecure body image compared to their straight male counterparts.”

They conclude, “for HIV-seropositive men…these data do implicate internalised homophobia in risk behavior and suggest that its modification may be a useful adjunct to sexual risk reduction programs.”