Public opposition to same-sex marriage associated with poorer sexual health and HIV outcomes

HIV and sexual health outcomes among gay and bisexual men in Australia are worse in areas where there is greater opposition to same-sex marriage, according to a recent study published in the Journal of Acquired Immune Deficiency Syndromes. Amongst other findings, it reported that a gay or bisexual man living with HIV in the district most strongly opposed to same-sex marriage was 8% less likely to be on ART than someone living in the district with the least opposition to same-sex marriage.

“This study is the first to provide empirical evidence that structural stigma is associated with reduced use and awareness of HIV-related healthcare among Australian gay and bisexual men,” claim the authors.

It seems logical that structural stigma – that is, anti-gay stigma institutionalised in society through laws, policies, practices, and public opinion – may lead to poorer health outcomes among gay, bisexual, and other men who have sex with men.

Structural stigma increases gay and bisexual men’s exposure to discrimination and may lead to internalised stigma. Individuals experiencing such stigma may experience mental distress, engage in risky health behaviours (such as substance use) to help them cope, and delay or avoid accessing healthcare for fear of being discriminated against by healthcare providers.

Although there is a growing body of evidence to support this theory, few researchers have evaluated how structural stigma specifically affects HIV and sexual health outcomes, and even fewer have measured the scale of its impact.

Therefore, Karinna Saxby from Monash University in Australia and colleagues sought to fill this gap by estimating the extent to which structural stigma was associated with STI and HIV testing; awareness and use of PrEP and PEP; and access to HIV care among gay and bisexual men in Australia.

Australian Marriage Law Postal Survey

Saxby and her colleagues identified a useful measure of structural stigma expressed as opposition to same-sex marriage in the Australian Marriage Law Postal Survey, conducted in 2017.

This survey was run by the Australian government as a referendum on the legalisation of same-sex marriage, with respondents only able to respond with “yes” or “no”. Although it wasn’t mandatory to vote, 79.5% of Australians eligible to vote took part. The results of the referendum showed that overall, 61.6% of voters thought same-sex marriage should be legalised.

The results of the vote can be broken down by electoral districts, which range in voter numbers from 65,752 (Lingiari) to 144,391 (Canberra). Support for same-sex marriage varied significantly between these districts. Generally, more rural parts of Australia had a higher share of votes against same-sex marriage but, perhaps surprisingly, some of the highest percentages of votes against same-sex marriage were found in metropolitan areas. For example, the highest proportion of votes against same-sex marriage (55.4%) was found in Greater Sydney.

The authors acknowledge that opposition to same-sex marriage is unlikely to provide a complete measure of the range of structural stigma experienced by gay and bisexual men. When assessing a complex social issue such as structural stigma, researchers will often use a combined measure of multiple indicators that capture different elements of structural stigma. However, they believe the survey results were more likely to be an accurate reflection of public opinion than typical public attitude surveys. This is because respondents would be less likely to modify their response for fear of what others might think when they knew it would directly influence legislation.

Behavioural surveys

Data on STI and HIV outcomes used in the analysis came from the Gay Community Periodic Surveys held between 2015 to 2019. These are annual repeated cross-sectional surveys of cis and trans gay and bisexual men over the age of 16 conducted across all of Australia’s states and territories (except the Northern Territory). They collect information on demographics, sexual behaviour, STI testing and diagnoses, and HIV prevention, testing, and treatment. Participants were recruited online as well as via clinics and gay community events and organisations.

Analysis

Using the results of the Australian Marriage Law Postal Survey, the authors categorized the 150 electoral districts as low stigma (less than 25.7% votes against same-sex marriage); low-medium stigma (25.7-29.9% votes against same-sex marriage); medium-high stigma (29.9 to 33.9% votes against same-sex marriage); or high stigma (more than 33.9% votes against same-sex marriage). Responses to the behavioural surveys were then mapped onto these districts based on the respondent’s postcode.

There are a lot of individual and regional factors that can affect HIV and sexual health outcomes, so the research team used statistical methods to control for as many of these as possible in their analysis. Individual factors included age, education, ethnicity, employment status, being born overseas, and sexual behaviour (such as condomless anal sex with casual partners and number of partners in the last 6 months). Regional factors included level of socioeconomic disadvantage, density of medical practitioners per population, state/territory fixed effects, and local support for Australia’s major conservative political party, the LNP (Liberal-National Party).

Finally, the authors tested the robustness of their estimates in several ways, including matching the high and low stigma districts on a number of characteristics so the estimation was restricted to districts which were similar, apart from their level of stigma.

Results

The final sample included 43,811 responses from gay and bisexual men between 2015 and 2019, including 4836 (11%) living in electoral districts with high stigma and 26,047 (59%) living in districts with low stigma.

"A gay or bisexual man living in a district with the highest reported level of stigma was 7% less likely to have used PrEP."

Compared to those living in low stigma districts, gay and bisexual men living in high stigma districts were slightly younger, had fewer sexual partners, were less likely to be employed and had fewer years of education.

High stigma districts also had less access to healthcare with fewer medical practitioners per person, and higher levels of socioeconomic disadvantage.

Compared to those living in low stigma districts, gay and bisexual men living in high stigma districts were less likely to know their HIV status, have ever been tested for HIV or to have heard about PrEP or PEP. They also reported fewer clinical HIV appointments and were less likely to be on combination antiretroviral therapy.

For every 10% increase in votes against same-sex marriage, there was a:

• 1.56% reduced likelihood of being diagnosed with an STI but a 1.33% reduced likelihood of receiving an STI test in the previous year.
• 1.72% reduced likelihood of having used PrEP within the previous 6 months and a 1.6% increase in the likelihood of never having heard about PrEP.
• 1.8% reduced likelihood of having tested for HIV in the previous year and 0.07 fewer HIV tests per year.
• 1.16% reduced likelihood of being tested HIV positive but a 0.72% increase in the likelihood of individuals not being aware of their HIV status.

To put some of these numbers into context, this translates into a gay or bisexual man living in a district with the highest reported level of stigma (56% votes against same-sex marriage) being 5.5% less likely to have received an STI test in the previous year than a gay or bisexual man living in a district with the lowest reported level of stigma (13% votes against same-sex marriage).

He’d also be 7.2% less likely to have used PrEP, 7.6% less likely to have tested for HIV, and 3.0% more likely to not know his HIV status.

Among those diagnosed with HIV, for every 10% increase in votes against same-sex marriage there was:

• 0.06 fewer HIV-related clinical visits per year.
• 2.00% reduced likelihood of being on ART.

This translates into an individual living with HIV in a district with the highest reported level of stigma having, on average, 0.29 fewer HIV-related clinical visits per year and being 8% less likely to be on ART than an individual living with HIV in a district with the lowest structural stigma.

Those who identified as gay or queer were generally worse affected by stigma than those who identified as bisexual or heterosexual. While the impact of structural stigma on sexual health and HIV outcomes tended not to vary by education and employment status, those with more education appeared to be particularly negatively affected by stigma in relation to PrEP/PEP awareness and reduced HIV testing.

The authors also found that in some cases, outcomes worsened more substantially when stigma reached a critical level. For example, in districts with more than 29.9% votes against same-sex marriage, there was particularly lower use of HIV prevention interventions.

Conclusion

At first glance, these findings may seem to suggest that the impact of stigma is not very large. However, it should be noted that these are the effects of stigma after controlling for other factors affecting HIV and sexual health outcomes. Since higher stigma areas were also more likely to be socio-economically deprived and have fewer medical practitioners, stigma serves to compound poorer health outcomes for gay and bisexual men living in these areas and puts them at further disadvantage.

Altogether, the results suggest that stigma may be undermining HIV prevention strategies as well as the provision of appropriate care and treatment for gay and bisexual men living with HIV. The authors recommend that efforts to improve uptake of testing, PrEP, PEP and ART among gay and bisexual men should be targeted to high stigma districts if Australia is to reach its goal of eliminating HIV transmission.