Article

A socioecological measurement of homophobia for all countries and its public health impact

Abstract

Background Measuring homophobia at country level is important to guide public health policy as reductions in stigma are associated with improved health outcomes among gay men and other men who have sex with men. Methods: We developed a Homophobic Climate Index incorporating institutional and social components of homophobia. Institutional homophobia was based on the level of enforcement of laws that criminalise, protect or recognise same-sex relations. Social homophobia was based on the level of acceptance and justifiability of homosexuality. We estimated the Index for 158 countries and assessed its robustness and validity. Results Western Europe is the most inclusive region, followed by Latin America. Africa and the Middle East are home to the most homophobic countries with two exceptions: South Africa and Cabo Verde. We found that a 1% decrease in the level of homophobia is associated with a 10% increase in the gross domestic product per capita. Countries whose citizens face gender inequality, human rights abuses, low health expenditures and low life satisfaction are the ones with a higher homophobic climate. Moreover, a 10% increase in the level of homophobia at country level is associated with a 1.7-year loss in life expectancy for males. A higher level of homophobia is associated with increased AIDS-related death among HIV-positive men. Conclusion The socioecological approach of this index demonstrates the negative social, economic and health consequences of homophobia in low- and middle-income countries. It provides sound evidence for public health policy in favour of the inclusion of sexual minorities.
A socioecological measurement of homophobia for all countries and its public health
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impact
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Authors name
Degree
Affiliation
Full address
Erik Lamontagne
MSc
UNAIDS
Aix-Marseille School of
Economics
20 Ave Appia,
1211, Geneva
Switzerland
2, rue de la Charité
F-13236 Marseille cedex 2
France
Marc d’Elbée
Pharm.D.
MSc
London School of Hygiene
and Tropical Medicine
Keppel Street, London
WC1E 7HT
United Kingdom
Michael W. Ross
PhD MD
University of Minnesota
Department of Family Medicine and
Community Health
1300 South 2nd Street
Minneapolis, MN 55454
United States of America
Aengus Carroll
LL.M
The International Lesbian,
Gay, Bisexual, Trans and
Intersex Association (ILGA)
20 rue Rothschild
1202 Geneva
Switzerland
André du Plessis
LL.M
The International Lesbian,
Gay, Bisexual, Trans and
Intersex Association (ILGA)
20 rue Rothschild
1202 Geneva
Switzerland
Luiz Loures
MD, MpH
UNAIDS
20 Ave Appia
1211 Geneva
Switzerland
4
Corresponding author:
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Author name
Degree
Full address
Email and telephone
Erik Lamontagne
MSc
PhD
candidate
20 Ave Appia,
1211 Geneva, Switzerland
2, rue de la Charité
F-13236 Marseille cedex 2
France
lamontagnee@unaids.org
+41 22 791 4505
6
Disclaimers:
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All co-authors contributed to this article in their personal capacity. The views expressed are their own and do
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not necessarily represent the views of their respective organisation.
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Abstract
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Background: Measuring homophobia at country level is important to guide public health
13
policy as reductions in stigma are associated with improved health outcomes among gay men
14
and other men who have sex with men.
15
Methods: We developed a Homophobic Climate Index incorporating institutional and social
16
components of homophobia. Institutional homophobia was based on the level of enforcement
17
of laws that criminalise, protect or recognise same-sex relations. Social homophobia was
18
based on the level of acceptance and justifiability of homosexuality. We estimated the Index
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for 158 countries and assessed its robustness and validity.
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Results: Western Europe is the most inclusive region, followed by Latin America. Africa and
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the Middle East are home to the most homophobic countries with two exceptions: South
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Africa and Cabo Verde.
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We found that a one percent decrease in the level of homophobia is associated with a 10
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percent increase in the gross domestic product per capita. Countries whose citizens face
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gender inequality, human rights abuses, low health expenditures and low life satisfaction are
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the ones with a higher homophobic climate. Moreover, a 10 percent increase in the level of
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homophobia at country level is associated with a 1.7-year loss in life expectancy for males. A
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higher level of homophobia is associated with increased AIDS-related death among HIV-
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positive men.
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Conclusion: The socioecological approach of this index demonstrates the negative social,
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economic and health consequences of homophobia in low- and middle-income countries. It
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provides sound evidence for public health policy in favour of the inclusion of sexual
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minorities.
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Keywords: Homophobia; stigma and discrimination; HIV; homosexuality; economic
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INTRODUCTION
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Despite noticeable progress in terms of inclusion of sexual minorities in the vast majority of
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countries over the last 40 years, the stigma associated with gay men and other men who have
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sex with men (MSM) is still prevalent in most societies.
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Stigma applies when elements of labelling, stereotyping, separation, status loss, and
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discrimination co-occur in a power situation that allows the components of stigma to
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unfold(1). Stigma can occur at individual, interpersonal and structural levels(2, 3).
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Homophobia, a particular case of stigma based on sexual orientation and gender identity,
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affects primarily lesbian, gay, bisexual, transgender and intersex people (LGBTI). Several
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definitions focus on the clinical aspect of a phobia, describing homophobia as “an irrational,
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persistent fear or dread of homosexuals”(4). Here, we use the term homophobia to refer to
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any negative attitude, belief, or action toward persons of differing sexual orientation or
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gender identity. It includes laws and structural manifestations of that prejudice in institutional
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settings, such as the workplace(5). This working definition encompasses the three levels of
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stigma described earlier.
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The level of infringement of human rights, verbal and physical violence and denial of health
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services associated with homophobia is a public health issue. Stigma is a central driver of
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morbidity and mortality at a population level(6). Gay men facing enacted sexual stigma are
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more likely to engage in sexual risk behaviours(7, 8). They are less likely to adhere to their
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antiretroviral treatment(9) and have lower HIV testing rates(9-15). Finally, internalised
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homonegativity is associated with lower levels of HIV testing and lower levels of condom
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use in gay and bisexual men(16). A socio-ecological approach to health-related behaviour(17)
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allows for studies of stigma related to sexual orientation and gender identity in their broader
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structural and social dimensions(1, 6, 18). Most studies of homophobia focused at the
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individual level. Being able to identify the level of homophobia at country level is important
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to guide public health policies as recent evidence shows that reductions in the homophobic
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climate are associated with improved health outcomes among gay men and other MSM(19).
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This study aims to propose and validate a robust index to measure homophobia at country
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level, including in low- and middle-income countries (LMIC).
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METHODS
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Data sources
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The availability and reliability of data on stigma and discrimination related to gender identity
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and sexual orientation and gender identity is uneven from country to country. Data on HIV
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and on gay men and other MSM were obtained from AIDSinfo(20) an online repository of
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global AIDS data compiled and maintained by UNAIDS, as well as from scientific articles
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and grey literature. Economic and development indicators such as gross domestic product,
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health expenditures, proportion of seats held by women in parliaments, gender inequality,
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mean years of schooling and life expectancy were drawn from the IMF World Economic
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Outlook, the 2015 Human Development Report and the World Population Prospects
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published by the Department of Economic and Social Affairs of the United Nations
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Population Division. We used the individual data from the World Values Survey which we
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aggregated at country level. The information on laws and legislation comes from the
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International Lesbian, Gay, Bisexual, Trans and Intersex Association (ILGA). The rule of law
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index comes from the World Justice Project and the Cantril index from the Gallup World
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Poll. We used the data on homophobia made available by the Pew Research Center. We used
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STATA 14 for statistical analysis.
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Model and analytic strategy
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We propose a socio-ecological construct for measuring homophobia that translates the
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important role played by institutional but also interpersonal factors. Let the level of
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homophobia for a country (i) be the combination of institutional (IsH) and social (SoH)
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homophobia for each country (i).
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 
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Institutional homophobia
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Institutional homophobia, , relates to the formal codes, such as laws and legislations that
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societies adhere to. Some of these codes may establish an institutional construct for inclusion
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or discrimination against people based on their sexual orientation or gender identity. These
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laws in their turn influence people’s behaviour and thoughts towards persons of differing
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sexual orientations and gender identities(21-24). First, we considered a set of eleven laws that
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characterise the level of institutionalised of homophobia of a country. For each country, those
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eleven laws are individually valued from 1 to 3 whether it is inexistent, existent and in force,
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or in force only in parts of its territory. The level of implementation is the one reported by the
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International Lesbian, Gay, Bisexual, Trans and Intersex Association(25).
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Second, we estimated the coefficients for these eleven laws globally. To ensure a transparent
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and objective weighting system, we considered the way all countries are combining (or not) a
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said law with the ten other laws considered here. By doing so, we reflect the choice of
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countries to enforce laws favouring inclusion and protection or, a contrario, laws
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criminalising same-sex relationships. To do so, we built polychoric correlation matrices as
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these variables are categorical and ordinal. Our methods demonstrated high internal
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consistency with an ordinal alpha of 0.92 and 0.83 for the inclusion and the criminalising
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laws respectively. The weight of each law was then estimated by a factor analysis. Laws and
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their coefficients are presented in annex 1. Institutional homophobia is expressed as
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 

 
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where are the factor loadings for the each law n
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and  is the level of enforcement of law n in country i , with  and   
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Social homophobia
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Social homophobia, , relates to interactions between communities or groups and
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individuals. A key characteristic is the direct reaction of individuals towards gay men and
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other MSM.
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Social homophobia reflects societal norms and behaviours based on moral, religious and
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cultural beliefs. It encompasses interpersonal processes as well as physical reactions such as
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avoidance or aggression, whether sexual, verbal or physical. These reactions take form in
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social networks such as family, workplace or friends. It can also be found within
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communities, whether ethnic, cultural, moral or religious ones.
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Markers of social homophobia are difficult to measure, particularly at country level. We
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focus on the interpersonal reactions, assuming it reflects the ultimate degree of societal
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penetration. We considered two representative questions asked to more than 460,000
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individuals in 91 countries within the three most recent waves of World Values Survey(26),
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the 2008 European Values Survey(27) and the Afrobarometer(28). The first question is “On
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this list are various groups of people. Could you please mention any that you would not like
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as neighbours?” This is a dichotomised answer whether respondents selected ‘homosexuals’
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or not. The second question was, “Do you think [homosexuality] can always be justified,
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never be justified, or something in between?” Answers were given on a scale from 1 to 10,
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with 1 meaning never justifiable and 10 meaning always justifiable. For each question, we
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considered the answers from all respondents for each country and calculated a country-
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specific value. Following a factor analysis, we weighted these two variables equally. We
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performed multiple imputations and predicted values for the remaining 45 countries with
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missing values for social homophobia, representing slightly more than a quarter (28%) of the
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total number of countries studied (158). The social homophobia component can be expressed
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as:
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
 
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Where n= number of respondents for country i and   
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We also considered homophobic violence. Unfortunately, only a minority of countries,
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essentially the least homophobic ones, systematically record homophobic violence and hate
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crimes. Reporting homophobic violence requires that the victims reveal their sexual
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orientation which, in too many countries still, may expose him/her to additional risks of
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violence and retaliation. It is worth noting that there has been remarkable progress by non-
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State actors in reporting hate crimes in several countries. Despite these advancements, data
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are still scarce, often limited to capital cities or large urban areas. If more data become
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available in the future, homophobic violence can be integrated in equation (3).
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We developed the homophobic climate index by compiling institutional and social
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homophobia data. Both components are weighted equally as confirmed with a factor analysis,
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i.e. in equation (1).
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Reliability and validity of the homophobic climate index
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We measured the internal consistency of the index with a reliability coefficient, measured by
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the Cronbach’s alpha. We also performed a confirmatory factor analysis to confirm that the
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scale in question is unidimensional.
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In order to assess the validity of the HCI, we first controlled the results from regressions of
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the HCI for two subsamples of countries randomly selected, with independent social and
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economic variables such as income, gender equality, human rights, satisfaction in life, health
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expenditures, and compared with the results obtained with the whole set of countries.
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Finally, we examined the stability of the correlation between the HCI and a control index to
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assess whether our instrument measures what we want to measure. We used the Gallup(29)
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question on homophobia “is the city or area where you live a good place or not a good place
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for gay or lesbian people” as control index and performed iterated regressions.
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RESULTS
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The model and data available enabled the estimation of the homophobic climate index (HCI)
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for 158 countries. The index shows good internal consistency, with a Cronbach’s alpha of
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0.82, and the control regressions with subsamples countries as well as with the control index
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enable us to consider the HCI a statistically reliable and valid index to measure homophobia.
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Regression and statistical tests are presented in annex 2.
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Figure_1
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The index ranges from 0 to 1, with higher values for more homophobic countries. Figure 1
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presents the map of the homophobic climate (See Annex 3 for the ranking of 158 countries).
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Table 1 presents the 10 most inclusive countries, globally (1a) and among low- and middle-
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income countries (1b). The 10 most homophobic countries are also listed (1.c).
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Table 1
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The most inclusive countries are essentially in Western Europe and Uruguay. Among the
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LMIC, Latin America appears as a leading region in promoting inclusion and fighting
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homophobia. It is worth noting that two African countries, South Africa and Cabo Verde are
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among the top ten most inclusive LMIC. The case of South Africa is particularly interesting
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as it paves the way to a more comprehensive and successful response to the HIV epidemic
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that could serve as an example in other countries of the region.
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Homophobia and socioeconomic determinants
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Figure_2:
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We performed multivariate regressions, using the country level of homophobia as
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explanatory variable to predict the value of key socioeconomic and public health outcome
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variables. It should be reminded that results of these regressions represent correlation and do
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not necessarily imply causal relationships. Descriptive statistics of the variables are presented
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in annex 4. We found a clear negative relationship between the level of homophobia and
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income. A ten percent change in GDP per capita is associated with a 1 percentage point
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reduction in the mean homophobic climate index (table 2, model 1). In addition, gender
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inequality, measured by the share of parliamentary seats held by women, is strongly
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correlated with higher homophobic climate. One can also note the statistically robust
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association between the level of homophobia and abuses of human rights. There is a strong
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negative relationship between the level of homophobia of a country and the level of
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satisfaction in life of its citizens, measured by the Cantril ladder.
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Table 2
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It appears from table 2 that homophobia is also negatively associated with the share of MSM
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among total population; meaning that a larger share of gay men and other MSM among the
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population is associated with lower degree of homophobia.
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We found that a 10-percentage point reduction in public health spending as a share of GDP is
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associated with an increase in the homophobic climate of 9-percentage points (table 2 model
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2). Moreover, AIDS-related deaths among men living with HIV is associated homophobia
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(table 2 model 3).
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Finally, even after controlling for markers of economic and social inequalities, the level of
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homophobia at country level is strongly associated with premature death among men. This
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translates into a 1.7-year reduction in life expectancy among its male population for a 10-
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percentage point increase of the level of homophobia. See annex 5. It should be reminded
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here that the correlations we identified between the level of homophobia at country-level and
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different markers of health, social and economic development do not necessarily imply a
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causal relationship.
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DISCUSSION
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In this study, we developed a statistically robust and valid index that translates institutional
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and social homophobia in most low- and middle-income countries across the globe. This
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socioecological approach provides a holistic picture of sexual orientation related stigma. We
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showed that homophobia is associated with lower economic output at country level.
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Furthermore, the level of homophobia appears to be closely related to lower investment in
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health and to social inequalities, such as lack of recognition of human rights and gender
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inequality. We found a negative relationship between the level of homophobia and life
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expectancy among males and showed that AIDS-related deaths among HIV-positive men are
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associated with higher level of homophobia.
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We also found that homophobia is negatively associated with the share of MSM among the
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total population. This finding raises two caveats: first, a correlation does not imply causality.
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This point is important to prevent misinterpretation to justify or promote homophobia in
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order “to contain” the number of men having sex with men. Second and paradoxically, it does
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not imply that homophobic countries have fewer gay men and other MSM. Instead, it may
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mean that in these settings, this population group is underreported and underestimated(30-
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32). Cultural, moral, religious beliefs may prevent men in some countries from coming out of
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the closet(33). In addition, individuals expecting negative reactions from others due to their
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differing sexual orientation or gender identity are less likely to report their sexual activity. In
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highly homophobic countries, gay men and other MSM cannot disclose their sexual
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orientation without exposing themselves to severe prejudices. Gay men and other MSM may
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conceal their sexual orientation, or have heterosexual behaviour(34), leading to additional
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under-reporting. Finally, the definition of homosexuality varies among different settings. In
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many countries the insertive male partner is not labelled or considered homosexual, only the
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receptive partner is(35).
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Two limitations should be noted. First, modelling homophobia at country level implied trade-
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offs in the identification of variables and proxies that adequately translate the different
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dimensions of homophobia, in addition to being available for all countries. Country-level
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analysis also means that variations within countries cannot be captured. The level of
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homophobia may vary from one city to another and from urban to rural areas. State and non-
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State actors at country level play a key role in filling these gaps and ensuring that no sexual
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minority is denied its rights and its access to care. Second, even though we controlled for
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collinearity, one should keep in mind that the institutional and social homophobia are
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interrelated to some extent: individuals may live in an environment where social, religious
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and cultural norms deeply interact with legislation. In other settings, laws and policies may
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implicitly favour stigma and discrimination against some minorities. Finally, the social
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homophobia experienced by individuals in some closed societies may provide ground for
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internalised homonegativity. This favours arguments for a holistic approach when identifying
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interventions aiming to reduce sexual-orientation related stigma and discrimination.
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Recent epidemiological evidence shows the increasing incidence of HIV among gay men and
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other MSM in most countries; new HIV infections rose by almost 12% between 2011 and
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2015 (36). There is growing evidence that homophobia impedes access to prevention, care
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and treatment by gay men and other MSM(16, 37-40). The availability of this index of
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homophobia at country level enables the better understanding of the determinants of
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vulnerability to HIV infection among gay men and other MSM in low- and middle-income
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countries.
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The socioecological model developed here provides a robust and valid measure of
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homophobia that can inform public health decision-making. Increased availability of data in
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low- and middle-income countries could enable future development of the socioecological
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approach to measuring homophobia. For example, internalised homonegativity and
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homophobic violence are important variables that could be considered if more data are made
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available at country level.
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Too many people are victims of stigma and discrimination related to sexual orientation and
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gender identity. Countering homophobia is part of public health policy and all actors with
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influence, including civil society and policy-makers should promote more inclusive societies.
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Acknowledgments
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We thank Michel Sidibé and Peter Ghys for making this study possible and for supporting it.
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We also thank Carole Siani and Bruno Ventelou for their invaluable technical inputs. The
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views expressed in this article are those of the authors and do not necessarily reflect those of
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their respective institutions.
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Conflicts of interest
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None declared
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Funding:
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None
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Keypoints
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There is a significant negative correlation between economic development and
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homophobia.
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Homophobia is associated with lower life expectancy for males at country level.
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Males living with HIV are more likely to die from AIDS in homophobic countries.
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Countering homophobia and other stigma related to sexual orientation and gender identity
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should be part of public health policy.
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25. International, Lesbian, Gay, Bisexual, Trans and Intersex Association, Carroll A.
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362
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363
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364
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365
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366
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367
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368
28. Dulani B, Gift S, Dionne KY. Afrobarometer Round 6. Updated 15 Sept. 2016.
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370
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371
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Table 1: Homophobic Climate Index 2017: Top 10 most inclusive and most homophobic countries
1a: Top 10 most inclusive countries
1b: Top 10 most inclusive low-and middle-
income countries (LMIC)
1c: Top 10 most homophobic countries
Rank
Country
HCI
Rank
Country
HCI
Rank
Country
HCI
1
Sweden
0.112
18
Colombia
0.321
149
Tunisia
0.870
2
Netherlands
0.131
20
Brazil
0.338
150
Burundi
0.873
3
Denmark
0.137
22
South Africa
0.352
151
Iraq
0.878
4
Norway
0.140
25
Mexico
0.369
152
Guinea
0.880
5
Spain
0.163
28
Ecuador
0.400
153
Nigeria
0.884
6
Finland
0.168
35
Romania
0.443
154
Qatar
0.897
7
Belgium
0.177
36
Costa Rica
0.444
155
South Sudan
0.905
8
France
0.180
41
Cabo Verde
0.474
156
Saudi Arabia
0.926
9
Uruguay
0.189
42
Serbia
0.482
157
Afghanistan
0.935
10
United Kingdom
0.206
43
Bolivia
0.489
158
Sudan
0.957
Table 2: Associations between homophobia and key socioeconomic and public health
outcome variables
Model 1
Model 2
Model 3
(95% CI)
(95% CI)
(95% CI)
Revenue per capita
(ln GDP pc )
-0.101
***
-0.033
**
-0.031
**
(-0.119
-0.083)
(-0.057
-0.010)
(-0.060
-0.003)
Share of parliament seats by
women (√x)
-0.26
**
-0.018
**
(-0.043
-0.008)
(-0.035
-0.001)
Human rights abuse (√x)
0.054
***
0.047
***
(0.036
0.072)
(0.029
0.064)
Satisfaction in life
-0.041
**
-0.050
***
(-0.069
-0.013)
(-0.079
-0.020)
Health expenditures
-0.009
**
(-0.016
-0.003)
Proportion of MSM among
total pop
-6.501
***
-5.644
**
(-8.669
-4.342)
(-7.918
-3.371)
Share of male AIDS death
among male HIV+ (√x)
0.507
**
(0.031
0.982)
Constant
1.481
***
1.246
***
1.086
***
(1.341
1.620)
(1.098
1.394)
(0.828
1.345)
Model fit indices
R2
0.49
0.79
0.81
R2 adjusted
0.49
0.78
0.80
F
125.09
100.65
110.27
Prob>f
0.0000
0.0000
0.0000
N
158
147
137
Note: Bootstrap jackknife regressions, CI Confidence Intervals. *p<0.05 **p<0.01 ***p<0.001
... In particular, previous research has demonstrated the impact of discrimination and perceived discrimination as a factor contributing to the higher instances of distress seen in sexual minority populations as compared with heterosexual populations (Douglass et al., 2017). Two reasons can explain why sexual minorities experience discrimination: Laws and legislations which impact the rights of sexual minorities, and social homophobia, where norms and acceptable behavior are influenced by moral, religious, and cultural beliefs (Lamontagne et al., 2018). While discrimination can affect sexual minorities individually, discrimination has been shown to also negatively impact same-sex couples, such as increasing feelings of shame or otherness felt by samesex couples and distress from the rejection of same-sex couple by family and friends (Douglass et al., 2017;Frost et al., 2016). ...
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... Prejudice against non-heterosexual, transgender, and/or non-normative gender groups or people remains a problem that is expressed in its classic (explicit/flagrant) or modern (implicit/subtle) form, despite the advances that include the creation of norms that inhibit its manifestation in Western societies (Bartos & Hegarty, 2018;Fleury & Torres, 2007;Goldberg & Allen, 2018). This phenomenon has been investigated in studies on homophobia (Lamontagne et al., 2018;Paternotte, 2015) and sexual prejudice (Herek, 2000(Herek, , 2004Bartos et al., 2014), and, although these terms can be understood as corresponding, for some authors it seems more coherent to refer to sexual prejudice to approach this problem at a more comprehensive level Herek, 2004). In investigations in this field, it is also important to consider studies on prejudice against sexual and gender diversity Costa et al., 2016;Herek, 2016). ...
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... Globalisation and favourable global cultural messages may have had some effect on changing negative attitudes and laws in some countries although the impact appears less pronounced in other more religious societies (Roberts, 2019). According to the estimated Homophobic Climate Index for 158 countries incorporating institutional and social components of homophobia, Western Europe is the most inclusive region, followed by Latin America, while Africa and the Middle East are home to the most homophobic countries with two exceptions: South Africa and Cabo Verde (Lamontagne et al., 2018). Some countries seem to be taking steps backwards which will increase stigmatisation and diminish the hard-won legal rights of sexual minorities (Guasti & Bustikova, 2020;ILGA World, 2020) along with worsening mental health which may contribute to poor physical health and increased mortality. ...
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Substantial country-level variation exists in prejudiced attitudes towards male homosexuality and in the extent to which countries promote the unequal treatment of MSM through discriminatory laws. The impact and underlying mechanisms of country-level stigma on odds of diagnosed HIV, sexual opportunities, and experience of HIV-prevention services, needs and behaviours have rarely been examined, however. Data come from the European MSM Internet Survey (EMIS), which was administered between June and August 2010 across 38 European countries (N = 174 209). Country-level stigma was assessed using a combination of national laws and policies affecting sexual minorities and a measure of attitudes held by the citizens of each country. We also assessed concealment, HIV status, number of past 12-month male sex partners, and eight HIV-preventive services, knowledge, and behavioural outcomes. MSM living in countries with higher levels of stigma had reduced odds of diagnosed HIV and fewer partners but higher odds of sexual risk behaviour, unmet prevention needs, not using testing services, and not discussing their sexuality in testing services. Sexual orientation concealment mediated associations between country-level stigma and these outcomes. Country-level stigma may have historically limited HIV transmission opportunities among MSM, but by restricting MSM's public visibility, it also reduces MSM's ability to access HIV-preventive services, knowledge and precautionary behaviours. These findings suggest that MSM in European countries with high levels of stigma are vulnerable to HIV infection. Although they have less opportunity to identify and contact other MSM, this might change with emerging technologies.
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Anti-discrimination laws on the basis of sexual orientation have been adopted by many states to counteract perceived discrimination in the labor market. However, we find the evidence of earnings disparities between homosexual and heterosexual men to be extremely sensitive to the choice of reference group. Relative to married heterosexual men, gay men earn less, and, over time, anti-discriminatory laws lessen this gap. Relative to unmarried, coupled heterosexual men, however, gay men experience similar levels of earnings. The choice of reference group leads to opposite conclusions regarding the effectiveness and necessity of an anti-discriminatory law for homosexual men, which highlights the need to construct reference groups with care. We also find that homosexual women experience similar earnings to their heterosexual female counterparts, and the law has no effect on these relative wages.
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Population size estimation of key populations at risk of HIV is essential to every national response. We implemented population size estimation of men who have sex with men (MSM) in Ghana using a three-stage approach within the 2011 Ghana Men's Study: during the study's formative assessment, the larger integrated bio-behavioral surveillance (IBBS) survey; and during the stakeholder meeting. We used six methods in combination within the three-stage approach (literature review, mapping with census, unique object multiplier, service multiplier, wisdom of the crowd, and modified Delphi) to generate size estimates from 16 locations (4 IBBS survey sites and 12 other locations) and used the estimates from the 16 sites to extrapolate the total MSM population size of Ghana. We estimated the number of MSM in Ghana to be 30,579 with a plausible range of 21,645-34,470. The overall estimate suggests that the prevalence of MSM in Ghana is 0.48 % of the adult male population. Lessons learned are shared to inform and improve applications of the methods in future studies.
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Purpose: The purpose of this study is to estimate the population size of men who have sex with men (MSM) in Kazakhstan and their HIV testing history. Methods: We conducted structured interviews with MSM in four geographically disparate cities-N = 400 (n = 100/city)-to implement four population estimation methods and ascertain HIV testing history. Results: Approximately 3.2% of men-corresponding to ∼154,000 individuals-in Kazakhstan aged 18-59 are MSM. The 49.9% of the sample who reported taking an HIV test far exceeds the <1% reported as MSM in surveillance data. Conclusion: HIV testing surveillance in Kazakhstan has underestimated the number of MSM. This underscores the need to redress social and structural barriers to HIV testing and disclosure of sexual behavior experienced by MSM in Kazakhstan. Recommendations include promoting cultural sensitivity among testing staff through quality assurance and regular training, and increasing protection and public awareness through antidiscrimination policy development.
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