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Lifetime Prevalence and Sociodemographic Correlates of Multifactorial Discrimination Among Middle-Aged and Older Adult Men Who Have Sex with Men
Abstract
This study describes multifactorial discrimination (discrimination attributed to multiple social identities) among middle-aged and older adult MSM. MSM aged 40+ years (N = 1,193) enrolled in the Multicenter AIDS Cohort Study completed behavioral surveys ascertaining experiences of discrimination and their social identity attributions. Non-proportional odds regressions assessed multifactorial discrimination by age, race/ethnicity, HIV status, and covariates. Twenty-seven percent of participants reported multifactorial discrimination. Adjusted models indicated that middle-aged men were more likely to report multifactorial discrimination compared to older adult men. Racial/ethnic minorities were more likely to report multifactorial discrimination compared to non-Hispanic white participants. These same patterns emerged among the sub-sample of participants living with HIV. To our knowledge, this is the first assessment of multifactorial discrimination in middle-aged and older MSM. Our findings support the deleterious association between multiple-marginalization and multifactorial discrimination. Multilevel interventions targeting interconnected experiences of stigma may improve the health of MSM in transition to older age.
... There has historically been a disproportionate burden of the HIVepidemic on specific populations of older gay men who are subjected to intersecting oppressions, including aging gay-identified men of color (Rosenfeld et al., 2012). Moreover, there remains a heightened contemporary exposure to stigma and discrimination among older gay men who are racialized and affected by HIV (Meanley et al., 2019). Taken together, these findings suggest that barriers to sexual identity disclosure may be particularly prominent among aging gay men affected by multiple, intersecting systems of oppression. ...
... Originating in Black feminist scholarship and activism, intersectionality is increasingly adopted to conceptualize and interpret issues of sexual minority groups affected by interlocking forces of marginalization (Bowleg, 2008;Mink et al., 2014). These groups include older gay men, whose lives are often affected by their exposure to oppressive social processes involving the interplay of homophobia and heterosexism, agism, poverty, racism, and ableism, and other factors (Cronin & King, 2010;Meanley et al., 2019). Translocational analysis, which is sometimes used to frame intersectional inquiry (Anthias, 2008), highlights what is often the variable prominence of different facets of identity among subjects, particularly those affected by multiple systems of oppression, across different social contexts and situations. ...
... Given possible distinctions in the nature, frequency, and impacts of exposure to stigma and discrimination among older gay men who may be differentiated by race, class position, specific age, HIV status, ability, and other factors (Cronin & King, 2010;Meanley et al., 2019), we use a translocational frame to attend to the heightened or diminished salience of gay identity as it is constructed across older gay men's healthcare accounts. In particular, as sexual identity disclosure is closely related to past experiences of stigma and discrimination (Brooks et al., 2018;Lyons et al., 2021), we draw on this lens to examine intersectional differences in older gay men's experiences of marginalizationparticularly as they relate to sexual identity construction-in the context of healthcare. ...
Older gay men commonly conceal their sexual identity in healthcare settings due to past experiences and expectations of encountering stigma and discrimination in these contexts. Although insights on how older gay men construct their sexual identity in healthcare may help contextualize this phenomenon, this question remains under-explored. Accordingly, we present the findings of a secondary grounded theory analysis of individual interview data, which we originally collected to examine the healthcare experiences of 27 gay men ages 50 and over, to explore constructions of sexual identity among the group. Our findings broadly reveal that older gay men's varying exposure to intersecting systems of oppression, together with their perceptions of different healthcare settings, may be critical in shaping their constructions of sexual identity in these contexts. Our research supports the need for healthcare policies and practices that address stigma and discrimination as salient barriers to sexual identity disclosure among older gay men.
... Similar to the present study, Earnshaw and Chaudoir [23] found that enacted stigma may impact older adults similarly to younger adults, but older adults internalize that stigma less than younger adults. While longitudinal analyses are needed to better understand these results, others have commented that older MSM living with HIV may have had the opportunity to bolster personal resiliency in the process of reconciling experiences of stigma around HIV [59,60]. Alternatively, younger MSM may have greater stigma consciousness resulting in more identification of discrimination and subsequent internalization of related stigma. ...
... A second example is a multilevel stigmareduction pilot trial of MSM living with HIV in India, which demonstrated improvements in HIV and reductions in sexual behavior stigma alongside reductions in sexual risk behavior [74]. Our results echo others who have commented that age-related considerations should factor into the design of intersectional stigma reduction interventions given changes in experiences and perceptions of stigma across the life course [59]. Together these studies suggest that addressing intersecting stigmas and being cognizant of differences by age and year of diagnoses, may strengthen stigma-reduction efforts. ...
Discrimination and internalized stigma are barriers to engagement in HIV self-care among men who have sex with men (MSM) living with HIV. However, differences in perceptions of discrimination and internalized stigmas by age, year of HIV-diagnosis, and race are poorly understood. We assessed differences in reported discrimination related to HIV, race, sexual orientation, and substance use and internalized stigmas among 202 MSM living with HIV who use substances. Younger participants reported higher levels of all types of discrimination and internalized stigmas (p-values < 0.001–0.030). Those diagnosed after the advent of antiretrovirals reported higher levels of discrimination related to HIV, sexual orientation, and substance use, as well as internalized stigma related to HIV and substance use (p-values 0.001–0.049). We explored perceived community HIV stigma, which accounted for associations involving age and year of diagnosis. Age, year of diagnosis, and race should be considered when assessing and intervening with stigma.
Background. Across settings, individuals from populations that are multiply stigmatized are at increased risk of HIV and experience worse HIV treatment outcomes. As evidence expands on how intersecting stigmatized identities and conditions influence HIV outcomes, researchers have used diverse quantitative approaches to measure HIV-related intersectional stigma and discrimination. To date, no clear consensus exists regarding how to best quantitatively measure and analyze intersectional stigma and discrimination.
Objectives. To review and document existing quantitative measures of HIV-related intersectional stigma and discrimination to inform research, programmatic, and policy efforts.
Search Methods. We searched 5 electronic databases for relevant studies. References of included articles were screened for possible inclusion. Additional articles were screened on the basis of consultations with experts in the field.
Selection Criteria. We included peer-reviewed studies published between January 1, 2010, and May 12, 2021, that were HIV related and presented 1 or more quantitative measures of stigma and discrimination using an intersectional lens in measure design or analysis.
Data Collection and Analysis. Systematic methods were used to screen citations and abstract data via a standardized coding form. Data were analyzed by coding categories stratified according to 2 subgroups: (1) studies incorporating a single intersectional measure and (2) studies that examined intersectional stigma through analytical approaches combining multiple measures.
Main Results. Sixteen articles met the inclusion criteria, 7 of which explicitly referenced intersectionality. Ten studies were from the United States. All of the studies included participants living with HIV. Among the 4 studies incorporating a single intersectional stigma measure, 3 explored race and gender stigma and 1 explored gender and HIV stigma. Studies involving analytic approaches (n = 12) mostly examined intersectional stigma via interaction terms in multivariate regression models. Three studies employed structural equation modeling to examine interactive effects or latent constructs of intersectional stigma.
Conclusions. Research on the measurement of HIV-related intersectional stigma and discrimination is currently concentrated in high-income settings and generally focuses on the intersection of 2 identities (e.g., race and gender). Efforts are needed to expand appropriate application of intersectionality in the development, adaptation, and use of measures of HIV-related intersectional stigma and discrimination. The use of context-, identity-, or condition-adaptable measures should be considered. Researchers should also carefully consider how to meaningfully engage communities in the process of measurement development.
Public Health Implications. The measures and analytic approaches presented could significantly enhance public health efforts in assessing the impact of HIV-related intersectional stigma and discrimination on critical health outcomes. (Am J Public Health. 2022;112(S4):S420–S432. https://doi.org/10.2105/AJPH.2021.306639 )
Objectives. To determine whether intersectional stigma is longitudinally associated with biopsychosocial outcomes.
Methods. We measured experienced intersectional stigma (EIS; ≥ 2 identity-related attributions) among sexual minority men (SMM) in the United States participating in the Multicenter AIDS Cohort Study. We assessed longitudinal associations between EIS (2008‒2009) and concurrent and future hypertension, diabetes, dyslipidemia, antiretroviral therapy adherence, HIV viremia, health care underutilization, and depression symptoms (2008‒2019). We conducted causal mediation to assess the contribution of intersectional stigma to the relationship between self-identified Black race and persistently uncontrolled outcomes.
Results. The mean age (n = 1806) was 51.8 years (range = 22–84 years). Of participants, 23.1% self-identified as Black; 48.3% were living with HIV. Participants reporting EIS (30.8%) had higher odds of hypertension, dyslipidemia, diabetes, depression symptoms, health care underutilization, and suboptimal antiretroviral therapy adherence compared with participants who did not report EIS. EIS mediated the relationship between self-identified Black race and uncontrolled outcomes.
Conclusions. Our findings demonstrate that EIS is a durable driver of biopsychosocial health outcomes over the life course.
Public Health Implications. There is a critical need for interventions to reduce intersectional stigma, help SMM cope with intersectional stigma, and enact policies protecting minoritized people from discriminatory acts. (Am J Public Health. 2022;112(S4):S452–S462. https://doi.org/10.2105/AJPH.2022.306735 )
1. Abstract This article examines the results of a 2010 sample of HIV+ African Americans in Louisiana within the larger context of health, educational, economic and incarceration disparities in the state. Similarities and differences between the sample and the general population of African Americans in the state were noted with the numbers incarcerated in the sample being the most dramatic difference. Over half of the sample had been incarcerated in a state recognized for its penchant for using the police and incarceration to control African Americans. The article concluded with attempts to connect the dots between vulnerability to HIV due to childhood trauma, a weathering from racism from an early age, educational deprivation, and policy choices such as abstinence-only sex education that raise the risks for young African Americans in Louisiana. 2.
Purpose:
The everyday lives of unemployed people with mental health problems can be affected by multiple discrimination, but studies about double stigma-an overlap of identities and experiences of discrimination-in this group are lacking. We therefore studied multiple discrimination among unemployed people with mental health problems and its consequences for job- and help-seeking behaviors.
Methods:
Everyday discrimination and attributions of discrimination to unemployment and/or to mental health problems were examined among 301 unemployed individuals with mental health problems. Job search self-efficacy, barriers to care, and perceived need for treatment were compared among four subgroups, depending on attributions of experienced discrimination to unemployment and to mental health problems (group i); neither to unemployment nor to mental health problems (group ii); mainly to unemployment (group iii); or mainly to mental health problems (group iv).
Results:
In multiple regressions among all participants, higher levels of discrimination predicted reduced job search self-efficacy and higher barriers to care; and attributions of discrimination to unemployment were associated with increased barriers to care. In ANOVAs for subgroup comparisons, group i participants, who attributed discrimination to both unemployment and mental health problems, reported lower job search self-efficacy, more perceived stigma-related barriers to care and more need for treatment than group iii participants, as well as more stigma-related barriers to care than group iv.
Conclusions:
Multiple discrimination may affect job search and help-seeking among unemployed individuals with mental health problems. Interventions to reduce public stigma and to improve coping with multiple discrimination for this group should be developed.
There is a clear, persistent association between poverty and HIV risk and HIV infection. Low educational attainment, neighborhood disadvantage, and residential instability are ways in which poverty is instrumentally experienced in urban America. We investigated the role of lived poverty at both the individual and neighborhood levels in transactional sex behavior among African American men who have sex with men (MSM) residing in urban neighborhoods. Using population-averaged models estimated by generalized estimating equation (GEE) models, we identified individual-level and neighborhood-level factors that are associated with exchanging sex for drugs and/or money. We tested the association between neighborhood and individual-level socioeconomic status and HIV risk behavior by combining area-based measures of neighborhood quality from the US Census with individual survey data from 542 low-income African American MSM. The primary outcome measure was self-reported transactional sex defined as exchanging sex for drugs or money. Individual-level covariates included high school non-completion, income, and problem drug use. Neighborhood-level covariates were high school non-completion and poverty rates. The findings suggested that educational attainment is associated with both the individual level and neighborhood level. Participants were more likely to engage in transactional sex if they did not complete high school (OR = 1.78), and similarly if their neighbors did not complete high school (OR = 7.70). These findings suggest potential leverage points for both community-level interventions and advocacy for this population, particularly related to transactional sex and education, and will aid HIV prevention efforts that seek to address the contextual constraints on individual risk behavior.
Background
The theory of fundamental causes explains why health disparities persist over time, even as risk factors, mechanisms, and diseases change. Using an intersectional framework, we evaluated multifactorial discrimination as a fundamental cause of mental health disparities. Methods
Using baseline data from the Project STRIDE: Stress, Identity, and Mental Health study, we examined the health effects of discrimination among individuals who self-identified as lesbian, gay, or bisexual. We used logistic and linear regression to assess whether multifactorial discrimination met the four criteria designating a fundamental cause, namely that the cause: 1) influences multiple health outcomes, 2) affects multiple risk factors, 3) involves access to resources that can be leveraged to reduce consequences of disease, and 4) reproduces itself in varied contexts through changing mechanisms. ResultsMultifactorial discrimination predicted high depression scores, psychological well-being, and substance use disorder diagnosis. Discrimination was positively associated with risk factors for high depression scores: chronic strain and total number of stressful life events. Discrimination was associated with significantly lower levels of mastery and self-esteem, protective factors for depressive symptomatology. Even after controlling for risk factors, discrimination remained a significant predictor for high depression scores. Among subjects with low depression scores, multifactorial discrimination also predicted anxiety and aggregate mental health scores. Conclusions
Multifactorial discrimination should be considered a fundamental cause of mental health inequities and may be an important cause of broad health disparities among populations with intersecting social identities.
Despite continued advances in HIV prevention and treatment, gay and bisexual men and other men who have sex with men (MSM) remain the population most impacted by HIV/AIDS in the US and many other Western countries. Additionally, MSM are disproportionately affected by various psychological problems, including depression, distress, trauma and substance use. These challenges frequently co-occur, and are associated with higher rates of behaviours related to HIV acquisition and transmission, HIV infection, and, for those living with HIV/AIDS, lower levels of treatment engagement. Moreover, racial disparities exist among MSM in the US; for example, young African American MSM bear a disproportionate burden of the continuing HIV epidemic, likely related to disparate HIV prevalence in partner pools as well as long-standing structural inequities. In this review, the mental health challenges facing MSM primarily in the US, related to HIV and STI prevention and across the HIV care cascade, including HIV diagnosis, engagement and retention in care, and antiretroviral adherence, are illustrated. Disparities among MSM including racial and ethnic, age-related and structural barriers associated with HIV prevention and treatment, as well as current interventions, are also described. Moving forward towards 2020, resources will be needed to assess and implement scalable intervention strategies to address psychological and social barriers to HIV and STI risk reduction and treatment for MSM, with a particular focus on the most vulnerable subpopulations. As access to prevention and treatment strategies expand, and new breakthroughs continue to emerge, behavioural strategies will continue to be needed to reduce risk and increase uptake and engagement among MSM most at risk through 2020 and beyond.
There are approximately one million older lesbian, gay, bisexual, and transgender (LGBT) adults in the USA. Their mental health issues result from interactions between genetic factors and stress associated with membership in a sexual minority group. Although advancements in acceptance and equal treatment of LGBT individuals have been occurring, sexual minority status remains associated with risks to physical and mental well-being. Older LGBT adults are more likely to have experienced mistreatment and discrimination due to living a majority of their lives prior to recent advancements in acceptance and equal treatment. All LGBT adults experience one common developmental challenge: deciding if, when, and how to reveal to others their gender identity and/or sexual orientation. LGBT individuals have higher rates of anxiety, depression, and substance use disorders and also are at increased risk for certain medical conditions like obesity, breast cancer, and human immunodeficiency virus (HIV). Improved education and training of clinicians, coupled with clinical research efforts, holds the promise of improved overall health and life quality for older LGBT adults.
Introduction:
Self-rated health is demonstrated to vary substantially by both personal socio-economic status and national economic conditions. However, studies investigating the combined influence of individual and country level economic indicators across several countries in the context of recent global recession are limited. This paper furthers our knowledge of the effect of recession on health at both the individual and national level.
Methods:
Using the Life in Transition II study, which provides data from 19,759 individuals across 26 European nations, we examine the relationship between self-rated health, personal economic experiences, and macro-economic change. Data analyses include, but are not limited to, the partial proportional odds model which permits the effect of predictors to vary across different levels of our dependent variable.
Results:
Household experiences with recession, especially a loss of staple good consumption, are associated with lower self-rated health. Most individual-level experiences with recession, such as a job loss, have relatively small negative effects on perceived health; the effect of individual or household economic hardship is strongest in high income nations. Our findings also suggest that macroeconomic growth improves self-rated health in low-income nations but has no effect in high-income nations. Individuals with the greatest probability of "good" self-rated health reside in wealthy countries ($23,910 to $50, 870 GNI per capita).
Conclusion:
Both individual and national economic variables are predictive of self-rated health. Personal and household experiences are most consequential for self-rated health in high income nations, while macroeconomic growth is most consequential in low-income nations.
This study uses General Social Survey data to compare gender and homosexuality across American religious groups from the 1970s to 2014, examining three possible patterns for how evangelical attitudes relate to those of other groups: (1) they are similar; (2) they are different, but move together over time; (3) they are different and converge or diverge over time. Evangelical gender attitudes regarding work and family issues are more conservative than those of all other groups, but are adaptive to broad trends, changing at a rate similar to those of other groups. Evangelical attitudes toward the morality of homosexuality and same-sex marriage are more conservative than those of all other religious groups, and their rate of change is slower over time. Separate trends on the two issues suggest that gender and sexuality attitude change is decoupled, especially among evangelicals who are adapting more on gender while increasingly distinguishing themselves on same-sex relationships. A three-stage process of religious tension appears to characterize evangelical identity-building: (1) similarity, (2) distinction, and (3) adaptation.
Discrimination against sexual minorities is widespread and has deleterious consequences on victims' psychological and physical wellbeing. However, a review of the psychometric properties of instruments measuring lesbian, gay, and bisexual (LGB) discrimination has not been conducted. The results of this review, which involved evaluating 162 articles, reveal that most have suboptimal psychometric properties. Specifically, myriad scales possess questionable content validity as: 1) items are not created in collaboration with sexual minorities; 2) measures possess a small number of items and, thus, may not sufficiently represent the domain of interest; and 3) scales are "adapted" from measures designed to examine race- and gender-based discrimination. Additional limitations include: 1) summed scores are computed, often in the absence of scale score reliability metrics; 2) summed scores operate from the questionable assumption that diverse forms of discrimination are necessarily interrelated; 3) the dimensionality of instruments presumed to consist of subscales is seldom tested; 4) tests of criterion-related validity are routinely omitted; and 5) formal tests of measures' construct validity are seldom provided necessitating that one infer validity based on the results obtained. The absence of "gold standard" measures, the attendant difficulty in formulating a coherent picture of this body of research, and suggestions for psychometric improvements are noted.
This study examined the association between attributing self-reported discrimination to weight and diabetes outcomes (glycemic control, diabetes-related distress, and diabetes self-care). A community dwelling sample of 185 adults (mean age 55.4; 80 % White/Caucasian 65 % female) with poorly controlled type 2 diabetes (HbA1c level ≥7.5 %) provided demographic and several self-report measures (including diabetes-related distress, diabetes self-care activities, discrimination, and attributions of discrimination), and had height, weight, and glycated hemoglobin (HbA1c) assessed by trained research staff as part of a larger research study. Individuals who attributed self-reported discrimination to weight had significantly higher HbA1c levels, higher levels of diabetes-related distress, and worse diabetes-related self-care behaviors (general diet, exercise, and glucose testing). These relationships persisted even when controlling for BMI, overall discrimination, depressive symptoms, and demographic characteristics. Results indicate that the perception of weight stigma among individuals with type 2 diabetes is strongly associated with a range of poor diabetes outcomes. Efforts to reduce exposure to and/or teach adaptive coping for weight stigma may benefit patients with type 2 diabetes.
ABSTRACT In the last four decades, we have witnessed vast and important transitions in the social, economic, political and health contexts of the lived experiences of gay men in the United States. This dynamic period, as evidenced most prominently by the transition of the gay rights movement to a civil rights movement, has shifted the exploration of gay men's health from one focusing primarily on HIV/AIDS into a mainstream consideration of the overall health and well-being of gay men. Against this backdrop, aging gay men in the United States constitute a growing population, for whom further investigations of health states and health-related disparities are warranted. In order to advance our understanding of the health and well-being of aging gay men, we outline here a multi-level, ecosocial conceptual framework that integrates salient environmental, social, physical, and psychosocial factors into sets of macro-, meso- and micro-level constructs that can be applied to comprehensively study health states and health care utilization in older, gay men.
Exposure to heterosexist discrimination may vary by a person's place of residency. Utilizing a minority stress perspective, an online survey of self-identified lesbian, gay, and bisexual (LGB) individuals (n = 285) examined whether rural and small town inhabitants experienced greater exposure to six types of enacted stigma. After comparing the frequency of enacted stigma by community type, findings demonstrated that rural LGBs reported experiencing more homophobic statements, property damage, and employment discrimination than urban LGBs. Small town LGBs also encountered additional amounts of housing discrimination and were more often chased by strangers compared with urban sexual minorities. Finally, disclosure practices and hierarchies based on race and social class also influenced exposure to discrimination. The importance of spatial factors often intensified when respondents disclosed their sexual identity more publicly. When exploring racial and class differences, affluent sexual minorities experienced less employment discrimination and white sexual minorities were less likely to experience several forms of heterosexist events (especially being punched and kicked).
Health disparities among sexual minority groups, particularly mental health disparities, are well-documented. Numerous studies have demonstrated heightened prevalence of depressive and anxiety disorders among lesbian, gay, and bisexual groups as compared with heterosexuals. Some authors posit that these disparities are the result of the stress that prejudice and perceived discrimination can cause. The current study extends previous research by examining the associations between multiple types of discrimination, based on race or ethnicity, gender, and sexual orientation, and past-year mental health disorders in a national sample of self-identified lesbian, gay, and bisexual women and men (n = 577). Findings suggest that different types of discrimination may be differentially associated with past-year mental health disorders. Notably, sexual orientation discrimination was associated with higher odds of a past-year disorder only in combination with other types of discrimination. These findings point to the complexity of the relationship between discrimination experiences and mental health, and suggest that further work is needed to better explicate the interplay among multiple marginalized identities, discrimination, and mental health. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
Discrimination has been linked to negative health outcomes among minority populations. The increasing evidence regarding health disparities among sexual minorities has underscored the importance of addressing sexuality discrimination as a public health issue. We conducted a web-based survey between May and September of 2012 in order to obtain a diverse sample of young men who have sex with men (ages 18-29; N = 397; 83% gay; 49% Black, 27% White, 15% Latino) living in the Detroit Metro Area (Michigan, USA). Using multivariate regression models, we examined the association between overall health (self-rated health, days in prior month when their physical or mental health was not good, limited functionality) and experiences of sexuality-based work discrimination. Fifteen percent reported at least one experience of sexuality-based work discrimination in the prior year. Recent workplace discrimination was associated with poorer self-rated health, a greater number of days when health was not good, and more functional limitation. We discuss the importance of addressing sexuality-related discrimination as a public health problem and propose multilevel intervention strategies to address these discriminatory practices.
In 2 meta-analyses, we examined the relationship between perceived discrimination and psychological well-being and tested a number of moderators of that relationship. In Meta-Analysis 1 (328 independent effect sizes, N = 144,246), we examined correlational data measuring both perceived discrimination and psychological well-being (e.g., self-esteem, depression, anxiety, psychological distress, life satisfaction). Using a random-effects model, the mean weighted effect size was significantly negative, indicating harm (r = -.23). Effect sizes were larger for disadvantaged groups (r = -.24) compared to advantaged groups (r = -.10), larger for children compared to adults, larger for perceptions of personal discrimination compared to group discrimination, and weaker for racism and sexism compared to other stigmas. The negative relationship was significant across different operationalizations of well-being but was somewhat weaker for positive outcomes (e.g., self-esteem, positive affect) than for negative outcomes (e.g., depression, anxiety, negative affect). Importantly, the effect size was significantly negative even in longitudinal studies that controlled for prior levels of well-being (r = -.15). In Meta-Analysis 2 (54 independent effect sizes, N = 2,640), we examined experimental data from studies manipulating perceptions of discrimination and measuring well-being. We found that the effect of discrimination on well-being was significantly negative for studies that manipulated general perceptions of discrimination (d = -.25), but effects did not differ from 0 when attributions to discrimination for a specific negative event were compared to personal attributions (d = .06). Overall, results support the idea that the pervasiveness of perceived discrimination is fundamental to its harmful effects on psychological well-being. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
This study aims to provide empirical evidence regarding whether attitudes, beliefs, and intentions of elder-service providers can be positively affected as a result of attending cultural competency training on the unique challenges of sexual and gender minorities. Stigmatization throughout the lifespan may have a causal influence on barriers to care, social isolation, and concomitant health disparities. Data were collected for this study at 4 Massachusetts training events to pilot a cultural competency workshop on lesbian, gay, bisexual, and transgender (LGBT) aging for mainstream elder service providers. This quasi-experimental study included the analysis of pre- and posttest surveys completed by the service-provider attendees (N = 76). The analytic strategy included descriptive statistics, paired t tests, chi-square analyses, and repeated measures analyses of variance. Findings revealed statistically significant improvement in numerous aspects of providers' knowledge, attitudes, and behavioral intentions subsequent to the training sessions. These included (p = .000) awareness of LGBT resources, policy disparities, spousal benefits for same-sex couples, and the intention to challenge homophobic remarks. This study concludes that mainstream elder-service provider training on LGBT aging issues results in positive change. Recommendations include long-term follow up of participants, the inception of agency-level surveys to appraise institutional culture change, and increased curriculum on transgender older adults.
This article sheds new light on policy diffusion by exploring policy complexity in state-level lesbian, gay, bisexual, and transgender (LGBT) antidiscrimination policies. The multiple component event history approach taken in this research allows for the concurrent study of both policy content and the factors that affect policy adoption. Results reveal that the factors influencing policy adoption vary depending on both the content and scope of the policy in question. In addition to addressing laws that protect gay people from discrimination, this article is one of the first studies in the political science and policy literature to empirically investigate the spread of transgender inclusive laws. Despite combined advocacy and public conflation of identities, gay and transgender-inclusive laws appear to be influenced by different internal and external factors.
Most victims of antigay/lesbian hate crimes never report these crimes to police for fear of hostility and abuse. Similarly, lesbian/gay officers fear a negative response if they come out at work. Research assumes but has not shown that dislike of lesbians and gay men translates into negative behavior. This article employs original survey data to examine the relationship between attitudes and behavior toward lesbians and gays among subsets of sworn officers. We employ the concept “sexual project” to argue that this relationship is shaped by experiences that determine respondents' relationship to (homo)sexuality, masculinity, and civil rights. We conclude by outlining implications of homophobic attitudes within law enforcement.
Objective:
This article considers how the social psychology of intergroup processes helps to explain the presence and persistence of health disparities between members of socially advantaged and disadvantaged groups.
Method:
Social psychological theory and research on intergroup relations, including prejudice, discrimination, stereotyping, stigma, prejudice concerns, social identity threat, and the dynamics of intergroup interactions, is reviewed and applied to understand group disparities in health and health care. Potential directions for future research are considered.
Results:
Key features of group relations and dynamics, including social categorization, social hierarchy, and the structural positions of groups along dimensions of perceived warmth and competence, influence how members of high status groups perceive, feel about, and behave toward members of low status groups, how members of low status groups construe and cope with their situation, and how members of high and low status groups interact with each other. These intergroup processes, in turn, contribute to health disparities by leading to differential exposure to and experiences of chronic and acute stress, different health behaviors, and different quality of health care experienced by members of advantaged and disadvantaged groups. Within each of these pathways, social psychological theory and research identifies mediating mechanisms, moderating factors, and individual differences that can affect health.
Conclusions:
A social psychological perspective illuminates the intergroup, interpersonal, and intrapersonal processes by which structural circumstances which differ between groups for historical, political, and economic reasons can lead to group differences in health.
In 2006, Millett published a seminal literature review that examined 12 hypotheses to explain the high rates of HIV among black MSM. This paper augments Millett's article by reviewing the recent literature on behavioral, biomedical, structural, social contextual, psychosocial, and social network factors that affect HIV rates among black MSM. We searched three databases: PubMed, Scopus, and Google Scholar. First we searched all articles that included black or African American and MSM and HIV. We then searched the following terms for each area: behavioral (drug use during sex, crack cocaine use, and serosorting); biomedical (circumcision, STDs, and STIs); structural (access to care, HIV care, ART, HAART, patient-provider communication, HIV quality of care); social contextual (stigma, discrimination, internalized homophobia, internalized heterosexism, medical mistrust, social isolation, and incarceration); psychosocial (peer support and mental health); and social network (sexual mixing, partner characteristics, and social networks) factors. We identified 39 articles to include in this review. We found inconclusive evidence that incarceration, stigma, discrimination, social isolation, mental health disparities, or social networks explain the elevated rates of HIV among black MSM. We found evidence that the differences in rates of HIV between black and white MSM may be explained by differences in STIs, undiagnosed seropositivity, access to care and treatment services, and use of HAART. There is an overwhelming need for HIV testing, linkage to care, retention in care, and adherence programs for black MSM.
People with HIV infection are subjected to prejudice, discrimination and hostility related to the stigmatization of AIDS. To manage the stigma of their disease, they mount complex coping strategies. This paper reports results from a qualitative study that examined gay/bisexual men's experiences of living with HIV infection. Unstructured interviews from a diverse sample of 139 men were analyzed to examine how men coped with AIDS-related stigma. We discerned a variety of stigma management strategies that could be arranged along a continuum from reactive to proactive based on the extent to which they implicitly accepted or challenged the social norms and values that underlie the stigmatization of HIV/AIDS. Reactive strategies to cope with stigma involve defensive attempts to avoid or mitigate the impact of stigma, but imply acceptance of the underlying social norms and values that construct the stigma. Examples of reactive strategies include hiding one's HIV status, presenting one's illness as a less stigmatizing one (e.g., cancer), or distancing one's self from more damaging aspects of AIDS-stigma (e.g., attributing infection to blood transfusion). Proactive strategies challenge the validity of the stigma and imply disavowal and resistance of the social norms and values that underlie the stigma. Examples of proactive strategies include engaging in public educational efforts that address misperceptions about HIV transmission and social activism to change the social and political conditions that affect PWA/HIV.
Three broad themes that emerge from the social psychological research on unconscious or implicit prejudice and stereotypes are highlighted in this article. First, individuals who belong to socially advantaged groups typically exhibit more implicit preference for their ingroups and bias against outgroups than do members of socially disadvantaged groups. This research suggests that intergroup preferences and prejudices are influenced by two different psychological forces—people's tendency to prefer groups associated with themselves as a confirmation of their high self-exteem versus their tendency to prefer groups valued by the mainstream culture as a confirmation of the sociopolitical order in society. Second, these inplicit prejudices and stereotypes often influence people's judgements, decisions, and behaviors in subtle but pernicious ways. However, the path from implicit bias to discriminatory action is not inevitable. People's awareness of potential bias, their motivation and opportunity to control it, and sometimes their consciously held beliefs can determine whether biases in the mind will manifest in action. Finally, a new line of research suggests that implicit biases exhibited by individuals who belong to socially disadvantaged groups towards their own group may have unintended behavioral consequences that are harmful to their ingroup and themselves.
The exclusion of lesbian, gay, bisexual, and transgender (LGBT) elders from queer and gerontological theories has resulted in the silencing of LGBT older adults and their experiences. Historically, this silencing has left LGBT elders without adequate social or material supports and has isolated them from both the LGBT and the older-adult communities, as well as the agencies serving those communities. The author defines this silencing as a rhetorical move rendering elders invisible in queer theory and queerness invisible in gerontological theory and argues that the producers of queer and gerontological theory, from a position of power within these discourses, silence and ignore LGBT elders' rhetorical activities. The author further argues that although many LGBT elders have worked to arrange material and social supports for themselves and their peers, their activities have become audible only relatively recently, due to the activism of middle-aged and older LGBT members of human service and academic networks.
Different cohorts of gay/bisexual men experience unique developmental factors given their distinct socio-historical contexts. This study examined the moderating effects of age on three psychosocial predictors of HIV risk behavior and substance use. Analyses drew on data from a study of substance using HIV-negative and unknown status gay/bisexual men (N = 302) at risk for HIV infection. Anxiety was a strong independent predictor of sexual risk and substance use, and its effects on the sex risk outcomes were moderated by age, such that older and more anxious participants had more frequent instances of sexual risk. Identification with the gay community protected against HIV risk, and its effects on sex risk outcomes were moderated by age, such that younger participants who identified with the gay community reported less sexual risk. Understanding HIV risk within socio-historical contexts is essential in tailoring prevention by taking into account recipients' ages.
Mental health problems are prevalent among HIV-infected individuals, with some estimates that 50% likely meet criteria for one or more psychiatric disorders. The mental health of HIV-infected individuals is important not only for quality-of-life concerns, but also in regard to HAART adherence and biological disease progression. The current review focuses on research published between 2009 and April of 2011, exploring mental health, coping, and stress in relation to HIV care behaviors including HAART adherence, quality of life, treatment retention, health care utilization, and disease progression amongst HIV-infected individuals. Specifically, we reviewed the most prevalent and interfering concerns among HIV-infected individuals-depression, post-traumatic stress disorder, interpersonal violence, stigma and shame, and body image concerns. Despite advances over the last 2 years documenting the deleterious effects of mental health on important HIV self-care behaviors, there is continued need for developing and disseminating evidence-based psychosocial interventions that integrate treating mental health problems with improving self-care behaviors for those living with HIV.
Bullying is a form of violence characterized as an aggressive behavior that is unprovoked and intended to cause harm. Prior studies have found that lesbian, gay, bisexual, and transgender (LGBT) youth experience high levels of bullying related to their sexuality and this harassment can lead to engagement in risk behaviors, depression, and suicide. Ethnic/racial minority young men who have sex with men (YMSM) may experience dual levels of stigma and maltreatment due to both their sexuality and their race. The aim of the current study was to assess the prevalence and perceptions of racial and sexual identity-based abuse among a sample of minority YMSM, and whether this maltreatment plays a role in the emotional distress of these youth. We found that overall 36% and 85% of participants experienced racial and sexuality-related bullying, respectively. There was a significant association between experiencing a high level of sexuality-related bullying and depressive symptomatology (p=0.03), having attempted suicide (p=0.03), and reporting parental abuse (p=0.05). We found no association between racial bullying and suicide attempts. In a multivariable logistic regression model, experiencing any racial bullying and high sexuality-related bullying were significant predictors of having a CES-D score ≥16; adjusted odds ratio (OR) 1.83 and 2.29, respectively. These findings contribute to the existing literature regarding the negative experiences and daily stressors facing LGBT youth with regard to both their minority status and LGBT identities. Future interventions for racial/ethnic minority YMSM should provide assistance to achieve a positive view of self that encompasses both their racial and sexual identities.
Adopting socioecological, intersectionality, and lifecourse theoretical frameworks may enhance our understanding of the production of syndemic adverse health outcomes among gay, bisexual and other men who have sex with men (MSM). From this perspective, we present preliminary data from three related studies that suggest ways in which social contexts may influence the health of MSM. The first study, using cross-sectional data, looked at migration of MSM to the gay resort area of South Florida, and found that amount of time lived in the area was associated with risk behaviors and HIV infection. The second study, using qualitative interviews, observed complex interactions between neighborhood-level social environments and individual-level racial and sexual identity among MSM in New York City. The third study, using egocentric network analysis with a sample of African American MSM in Baltimore, found that sexual partners were more likely to be found through face-to-face means than the Internet. They also observed that those who co-resided with a sex partner had larger networks of people to depend on for social and financial support, but had the same size sexual networks as those who did not live with a partner. Overall, these findings suggest the need for further investigation into the role of macro-level social forces on the emotional, behavioral, and physical health of urban MSM.
Men who have sex with men experience high rates of psychosocial health problems such as depression, substance use, and victimization that may be in part the result of adverse life experiences related to cultural marginalization and homophobia. These psychosocial health conditions interact to form a syndemic which may be driving HIV risk within this population. However, MSM also evidence great resilience to both the effects of adversity and the effects of syndemics. Investigating and harnessing these natural strengths and resiliencies may enhance HIV prevention and intervention programs thereby providing the additional effectiveness needed to reverse the trends in HIV infection among MSM.
This article reports diagnosis disclosure decision comments arising serendipitously in five focus group discussions with 34 HIV-infected New Yorkers over age 50. Three overarching disclosure themes demonstrate the complexity of diagnosis disclosure decision-making: (a) hiding or selectively disclosing, or stigma management; (b) partial disclosure because of the perception of partial control of the information; and (c) widespread or complete voluntary diagnosis disclosure, representing stigma resistance. Social workers and other human services practitioners should remember the diversity in the HIV population, the aging population, and the HIV-positive aging population. Experiences of HIV stigma and choices about diagnosis disclosure and stigma management or resistance are individual, reciprocal, and dynamic.
Using a social stress perspective, the authors studied the mental health effects of added burden related to socially disadvantaged status (being African American or Latino, female, young, and identifying as bisexual vs. gay or lesbian) in a community sample of 396 self-identified lesbian, gay, and bisexual (LGB) adults. Mental health outcomes were social and psychological well-being contrasted with depressive symptoms. When mental health deficiencies by disadvantaged social status were detected, the authors examined whether LGB community connectedness and positive sexual identity valence played a mediating role, reducing the social status disparity in outcome. The authors found different patterns when looking at social versus psychological well-being and positive versus negative mental health outcomes. Bisexuality and young age, but not gender and racial/ethnic minority status, were associated with decreased social well-being. In bisexuals, this relationship was mediated by community connectedness and sexual identity valence. Although no differences in social or psychological well-being were found by gender, female gender was associated with depressed mood. The authors conclude that there is limited support for an additive stress model.
Families and social support systems have been found to be instrumental for the physical and psychological well-being of older adults. However, the majority of research on families has assumed that all members within a family are hetero sexual. This chapter discusses families and social support systems for lesbian, gay, bisexual, and transgender (LGBT) older adults. The chapter initially provides an overview of the research on social networks and social support systems of the general older adult population. The discussion on LGBT older adults' families and social support systems highlights families of choice, LGBT communities, and the impact of disclosing one's sexual orientation on social network relationships. The chapter concludes with recommendations for future research and best practices that focus on addressing the unique needs and concerns of LGBT elders.
Purpose
The purpose of this paper is to summarize the limited body of research that focuses on the efficacy of sexual orientation anti-discrimination legislation in reducing discrimination.
Design/methodology/approach
Reviews past research that documents overt and subtle forms of workplace discrimination against gay, lesbian, and bisexual individuals and describes how legislation plays an important role in changing social norms and underlying attitudes.
Findings
Empirically demonstrates that legislation effectively can reduce discrimination.
Originality/value
Informs legislative debate and promotes the expansion and adoption of national, state, and local legislation on sexual orientation anti-discrimination legislation.
In addition to physical health challenges, older people living with HIV/AIDS (PLWHA) experience mental health burdens and challenges to their social well-being that diminish their overall health. These health states are synergistic and are driven by HIV and HIV treatments, the aging process itself, and psychosocial and structural conditions of their lives. However, resilience, which we understand as both a trait and a process, may serve to buffer the effects that HIV/HIV treatments, aging, and social/structural conditions may have on the overall well-being of the individual. In this chapter, we examine the extant literate on the mental health and psychosocial challenges experienced by older PLWHA as elements of the total health of the individual. We also provide a contextualization and conceptualization for understanding the significant role that resilience may play in empowering individuals to enact processes which buffer health from the stressors. In this perspective, the health of older PLWHA must be viewed through a lens of power and strength rather than one of deficit. We conclude by outlining a theoretical paradigm for the role of resilience in the health of older HIV-positive adults, which may serve as a guide to clinicians, public health practitioners, and researchers working with this population.
This essay offers a brief history of homosexuals’ rights in the United States, explains why same-sex marriage is the ultimate civil right for sexually marginalized persons, reviews prior public opinion research on attitudes toward homosexuals, and disentangles predictors of support for same-sex marriage. Consistent with prior research, we find greater support for same-sex marriage among Democrats, liberals, young people, more educated people, non-Blacks, and women. Contrary to expectations, we do not find that increased contact with homosexuals improves support for marriage equality. We explain these results and offer recommendations for future research at the nexus of race, age cohort, education, and religious affiliation.
We are more than 30 years into the HIV epidemic, and, although we have made many important scientific advances, there remains much to understand and implement to prevent new infections. The science of HIV prevention, although interdisciplinary, has relied heavily on psychological theories and research methods to address many key questions. In this paper, we briefly review some historical and epidemiologic considerations about the U.S. HIV epidemic and then present some key psychological concepts from HIV prevention. We make the case for continuing to focus efforts on gay, bisexual, and other men who have sex with men, who represent the sociocultural group with the highest incidence and prevalence of HIV in the domestic epidemic. We present a summary of the research support for, and limitations of, the three major psychosocial models that predict HIV risk behaviors – the information–motivation–behavioral skills model, the minority stress model, and the syndemics framework. We discuss the use of these models in the development and testing of HIV prevention interventions and end by highlighting a few novel research areas, including bio-behavioral approaches.
Why do municipal governments adopt lesbian, gay, bisexual, and transgender (LGBT) inclusive policies? The preponderance of literature suggests urbanism and social diversity are the most likely explanations for LGBT municipal policies. This research tests these assumptions using the morality politics model. Using rare-events logistic regression, municipalities in the state of Florida with LGBT antidiscrimination ordinances are compared with municipalities that do not have such policies. The results contradict theories of urbanism and highlight the shortcomings of the morality politics model. Specifically, the results indicate that even under highly salient conditions, LGBT advocacy resources play an important role in the policy adoption process.
The objective of this study is to determine associations between intertwining epidemics (syndemics) and HIV medication adherence and viral load levels among HIV-positive MSM and to test whether adherence mediates the relationship between syndemics and viral load.
We analysed participant data collected between 2003 and 2009 from the Multicenter AIDS Cohort Study, a prospective HIV/AIDS cohort study in four U.S. cities.
We conducted longitudinal analyses (repeated measures mixed models) to assess whether differences in viral load levels, undetectable viral load and self-reported HIV medication adherence were associated with count of syndemic conditions (substance use, depression symptoms and sexual risk behaviour, range 0-3), adjusting for race/ethnicity, age and income. Mediation analyses were conducted using structural equation modelling and the SAS %mediate macro.
Syndemics count was associated with higher viral loads (P < 0.0001) and lower adherence (P < 0.0001). Increased counts of concomitant syndemics were associated with viral load (P < 0.01), detectable viral load (P < 0.05) and adherence (P < 0.001). Black MSM experienced worse outcomes across domains than white MSM (P < .0001) and experienced higher overall rates of syndemics (P < 0.01). Adherence significantly mediated the relationship between syndemics and viral load, accounting for an estimated 32.3% of the effect (P < 0.05).
Effectively lowering viral load levels among MSM has implications for both HIV/AIDS prevention and care. Our findings suggest that integrating substance use interventions, mental healthcare and sexual risk prevention into standard HIV care may be necessary to optimize treatment and Treatment as Prevention (TasP) models.
Using a community sample of 197 people living with HIV/AIDS, we examined how awareness of societal stigma (felt stigma) and negative feelings toward oneself as a member of a stigmatized group (self-stigma) are related to psychological well-being. Both felt stigma and self-stigma were significantly correlated with symptoms of depression and anxiety, but controlling for felt stigma reduced self-stigma's association with depressive symptoms to nonsignificance. Global self-esteem and social avoidance fully mediated the associations between self-stigma and distress but only partially mediated the associations between felt stigma and distress. Felt stigma mediated the relationship between distress and HIV-related changes in physical appearance.
The theory of syndemics has been widely applied in HIV-prevention studies of gay, bisexual, and other MSM (men who have sex with men) over the last decade. Our investigation is the first to consider the applicability of the theory in a sample of aging (ages 50 and over) HIV-positive MSM, which is a growing population in the United States. A sample of 199 men were actively recruited and assessed in terms of mental health and drug-use burden, as well as sexual risk behaviors. Bivariate and multivariable analyses indicate a high level of association between psychosocial burdens (i.e., drug use and mental health) and same-sex unprotected sexual behaviors, providing initial support for the applicability of the theory of syndemics to this population. Further support can be seen in participants’ narratives. Findings suggest the mutually reinforcing nature of drug use, psychiatric disorders, and unprotected sexual behavior in older, HIV-positive, gay, bisexual, and other MSM, highlighting the need for holistic strategies to prevention and care among this population of older and sexually active individuals. In short, the generation of gay men who came of age in the late 1970s and 1980s, “the AIDS Generation,” are continuing to mature such that further efforts must be enacted to meet the multidimensional nature of these men's physical, mental, and sexual health needs.
This article explores how theories of diversity and intersectionality can improve our understandings of the lives of older lesbian, gay and bisexual (LGB) adults. In so doing, it argues that theories of diversity help us to understand both the structural constraints and the advantages that may arise from being an older LGB adult. However, these theories are unable to fully account for differences that may exist within this social group. In order to address this omission, we argue that we need to move beyond a focus on diversity per se, to incorporate the multiplicity of identities suggested by intersectionality theory. We conclude by assessing the implications of this debate for policy and research. Throughout the article we draw on existing research as well as our own empirical studies with older LGB adults.
Lesbian, gay, bisexual, and transgender (LGBT) people have experienced a long and pervasive history of employment discrimination. Today, more than eight million people in the American workforce identify as LGBT, but there still is no federal law that explicitly prohibits sexual orientation and gender identity discrimination against them.
This Article begins by surveying the social science research and other evidence illustrating the nature and scope of the discrimination against LGBT workers and the harmful effects of this discrimination on both employees and employers. It then analyzes the existing legal protections against this discrimination, which include constitutional protections for public sector workers, court interpretations of Title VII’s ban on sex discrimination, state and local antidiscrimination laws, and corporate policies. This Article determines that, while these laws and policies provide important protection, the current system is incomplete, confusing, and inadequate. This Article next considers empirical research showing that employers do not offer employees with a same-sex spouse or partner the same access to family benefits that they offer to employees with a different-sex spouse, and it examines court decisions finding that a denial of equal benefits is unlawful employment discrimination.
Based on this research and legal analysis, the Article concludes that a federal law like the Employment Non-Discrimination Act (ENDA), a bill pending in Congress that would prohibit sexual orientation and gender identity employment discrimination, is needed. To serve its purpose consistently, however, the bill’s current exemption of employee benefits should be removed. To be sure, ending all forms of unequal treatment based on sexual orientation or gender identity is warranted and feasible, and doing so will have positive effects for both employees and employers.
This article discusses the impact that coming of age in the Pre-Stonewall era has had on older gays and lesbians. Anti-gay hate and violence, within a historical context of homophobia and heterosex-ism, are examined. Risk factors, as well as coping capacities, for older lesbians and gays are explored. Research on the psychological adjustment and well-being of older gays and lesbians is reviewed, and suggestions for intervention with this population are proposed.
Early research on ethnicity focused on the stereotyped thinking, prejudiced attitudes, and discriminatory actions of Euro-Americans. Minority-group members were viewed largely as passive targets of these negative reactions, with low self-esteem studied as the main psychological outcome. By contrast, recent research has increasingly made explicit use of stress theory in emphasizing the perspectives and experiences of minority-group members. Several ethnicity-related stressors have been identified, and it has been found that individuals cope with these threats in an active, purposeful manner. In this article, we focus on ethnicity-related stress stemming from discrimination, from stereotypes, and from conformity pressure arising from one's own ethnic group. We discuss theory and review research in which examination of ethnicity-related outcomes has extended beyond self-esteem to include psychological and physical well-being.
Bodies of research pertaining to specific stigmatized statuses have typically developed in separate domains and have focused on single outcomes at 1 level of analysis, thereby obscuring the full significance of stigma as a fundamental driver of population health. Here we provide illustrative evidence on the health consequences of stigma and present a conceptual framework describing the psychological and structural pathways through which stigma influences health. Because of its pervasiveness, its disruption of multiple life domains (e.g., resources, social relationships, and coping behaviors), and its corrosive impact on the health of populations, stigma should be considered alongside the other major organizing concepts for research on social determinants of population health. (Am J Public Health. Published online ahead of print March 14, 2013: e1-e9. doi:10.2105/AJPH.2012.301069).
When does a common group identity improve efficiency in coordination games? To answer this question, we propose a group-contingent social preference model and derive conditions under which social identity changes equilibrium selection. We test our predictions in the minimum-effort game in the laboratory under parameter configurations which lead to an inefficient low-effort equilibrium for subjects with no group identity. For those with a salient group identity, consistent with our theory, we find that learning leads to ingroup coordination to the efficient high-effort equilibrium. Additionally, our theoretical framework reconciles findings from a number of coordination game experiments. (JEL C71, C91, D71)
Despite evidence that discrimination within the health care system may play an important role in perpetuating health disparities, instruments designed to measure discrimination within the health care setting have not been adequately tested or validated. Consequently, we sought to test the psychometric properties of a modified version of the Everyday Discrimination scale, adapted for medical settings.
Cross-sectional study.
Academic medical center in Chicago.
Seventy-four African American patients.
We measured factor analysis, internal consistency, test-retest reliability, convergent validity and discriminant validity.
Seventy-four participants completed the baseline interviews and 66 participants (89%) completed the follow-up interviews. Eighty percent were women. The Discrimination in Medical Settings (DMS) Scale had a single factor solution (eigenvalue of 4.36), a Cronbach's alpha of 0.89 and test-retest reliability of .58 (P<.0001). The DMS was significantly correlated with an overall measure of societal discrimination (EOD) (r=.51, P<.001) as well as two of its three subscales (unfair: r=-.04, P=.76; discrimination: r=.45, P<0.001; worry: r=-.36, P=.002). The DMS was associated with the overall African American Trust in Health Care Scale (r=.27, P=.02) as well as two key subscales (racism: r=.31, P<.001; disrespect: r=.44, P<.001). The DMS scale was inversely associated with the Social Desirability Scale (r=.18, P=.13). The DMS scale was not correlated with the Center for Epidemiologic Studies Depression Scale (r=.03, P=.80).
The Discrimination in Medical Settings Scale has excellent internal consistency, test-retest reliability, convergent validity and discriminant validity among our sample of African American patients. Further testing is warranted among other racial/ethnic groups.
Stigma may mediate some of the observed disparity in HIV infection rates between black and white men who have sex with men (MSM).
We used data from the General Social Survey to describe race-specific trends in the US population's attitude toward homosexuality, reporting of male same-sex sexual behavior, and behaviors that might mediate the relationship between stigma and HIV transmission among MSM.
The proportion of blacks who indicated that homosexuality was "always wrong" was 72.3% in 2008, largely unchanged since the 1970s. In contrast, among white respondents, this figure declined from 70.8% in 1973 to 51.6% in 2008 with most change occurring since the early 1990s. Participants who knew a gay person were less likely to have negative attitudes toward homosexuality (relative risk, 0.60; 95% confidence interval, 0.52 to 0.69). Among MSM, twice as many black MSM reported that homosexuality is "always wrong" compared with white MSM (57.1% versus 26.8%, P = 0.003). MSM with unfavorable attitudes toward homosexuality were less likely to report ever testing for HIV compared with MSM with more favorable attitudes (relative risk, 0.50; 95% confidence interval, 0.31 to 0.78).
US attitudes toward homosexuality are characterized by persistent racial differences, which may help explain disparities in HIV infection rates between black and white MSM.