Stigma and MSM: A Barrier to Prevention
Stigma and discrimination against men who have sex with men (MSM) have been well documented around the world. The challenges they face can vary from everyday personal hardships to high-level factors such as hostility from civil society organizations, religious bodies, government, and law enforcement. In many cases, homophobia is perpetuated by policies that criminalize MSM or neglect their basic human rights. Harassment, rejection, and violence lead many MSM to actively hide their feelings and relationships, denying themselves the social support that could improve their health and quality of life.
Discrimination and High-Risk Behavior
Studies have shown that MSM who experience discrimination and harassment are more likely to engage in risky sexual behavior. Violence and threats from family members and other sources have been linked with heightened risk behaviors, such as unprotected anal sex. Hostile behaviors directed against Latino gay men in the U.S. -- including harassment from their families and the need to pretend to be heterosexual -- have also been linked with high-risk sexual behavior.
In many cultures, the pressure to marry and have children can also place enormous stress on gay men. Studies in China have revealed that expectations of male gender roles contributed to higher levels of stigma, which may be linked to higher rates of unprotected anal intercourse. When gay men succumb to pressure and enter into heterosexual marriage, they often maintain sexual relationships with male partners. This can result in unseen sexual networks, increasing HIV risk and making it difficult to reach them with prevention information.
A growing body of evidence links discrimination and poor mental health in gay men. Stress research has shown that expectations of rejection and actual events of discrimination and violence contribute to mental health problems. In the U.S., gay men who live in states with laws that discriminate against same-sex couples have been found to exhibit hopelessness, chronic worry, and hypervigilance, common psychological responses to perceived discrimination. Social discrimination directed at gay, bisexual, and transgender high school students has been shown to lead to a greater risk of self harm, suicidal thoughts, risky sex, and substance use.
Nearly 80 countries criminalize same-sex acts, with penalties ranging from fines to imprisonment, and in seven nations, death. Facing such laws, MSM cannot disclose their sexual behavior to a health care provider without risking criminal sanctions. This can hinder provision of vital prevention information, testing, and care. Furthermore, outreach workers providing HIV prevention information and services to MSM may be accused of supporting illegal activities, such as "promoting homosexuality," and be subjected to fines, imprisonment, harassment, or violence.
Over 20 countries in Asia criminalize homosexuality, in a region where higher HIV prevalence rates have been recorded among MSM compared with the general population. In Africa, MSM are 3.8 times more likely to be HIV-positive than the general population. Yet a majority of African countries punish same-sex behavior with criminal sanctions. Several countries have recently shown renewed interest in same-sex criminalization by expanding criminal penalties or putting forward new laws. For example, in 2009, legislation was introduced in Uganda that would increase existing same-sex criminal penalties to include life imprisonment and, in some cases, the death penalty.
Criminalization of homosexuality can worsen HIV epidemics. HIV prevalence data from the Caribbean offers a striking example. As the following chart illustrates, countries that criminalize homosexuality demonstrate higher rates of HIV among MSM than those that do not. This is a pattern that can be found across regions around the world.
Stigma and Health Care
Hostile conditions push MSM underground, making them extremely difficult to reach. A recent survey of MSM in low- and middle-income countries found that only about half used a condom the last time they had anal sex with another man, and fewer than a third had tested for HIV in the last year. Because HIV resources are often offered at sites that provide other health services, homophobia in these settings can make it particularly difficult for MSM to get care. Even health care workers who declare acceptance of homosexuality have been known to display homophobic attitudes when providing services, breaching ethics standards and compromising the care of sexual minorities.
In recent decades, many governments and global institutions have emphasized primary health care, but many primary care providers still lack specialized knowledge about caring for MSM. They may, intentionally or unintentionally, express disapproval, driving them away. These behaviors can range from nonverbal gestures to disparaging remarks or ridicule. This makes MSM less likely to openly discuss their sexuality and more likely to provide inaccurate sexual histories.
An HIV diagnosis in itself can lead to significant stigma and discrimination, even from the systems that deliver HIV care. In Vietnam, nearly 100% of people with HIV in a recent study had experienced some form of discrimination because of their HIV status. In South Africa, HIV-positive men of all sexual orientations reported considerable emotional distress and discrimination. In Tanzania, people living with HIV reported "name calling, mocking and pointing fingers at those infected, and abusive language."
The root causes of stigma against people with HIV are many and varied. Lack of knowledge about HIV is an important factor, leading to misperceptions and fear of contracting the virus. Negative images of people with HIV in the media and linking HIV with illegal or "immoral" behavior (including sex between men) increase stigma. The growing trend toward criminalizing HIV transmission heightens the stigma. This stigma is realized through various forms of discrimination, including loss of family and community support, loss of housing, and loss of employment. The resulting isolation can be devastating. In India, for example, one study found an unwillingness to buy food from or share a meal with people with HIV. The dual stigma against MSM with HIV can hamper involvement in prevention efforts, decrease the chance of early intervention, and reduce quality of life.
It is estimated that HIV prevention services reach fewer than one in ten MSM globally. One recent study reported that fewer than half of MSM in low- and middle-income countries have access to information about HIV. It is not surprising then that MSM end up bearing the bulk of the epidemic's burden in many countries.
It is important to note that this difference in HIV prevalence is not unique to developing nations. The resurgence of the epidemic among MSM in high-income countries is well documented. According to UNAIDS, sex between men represents the dominant mode of transmission in Australia, North America, and the European Union. The CDC reports that the rate of new HIV diagnoses among MSM in the U.S. is more than 44 times that of other men. The National AIDS Trust estimates that MSM account for a third of new infections every year in the United Kingdom.
In low- and middle-income countries, MSM often do not have legal protections against hate crimes or other discrimination. This further limits their access to health information and services. The result can be seen in regions where MSM are at higher risk for HIV transmission and are also excluded from mainstream society. In Latin America for instance, male-to-male sex is the primary mode of HIV transmission. This region also has the largest number of homophobic crimes in the world, based on the reported number of murders due to sexual orientation.
Coordinated advocacy efforts are needed to change the attitudes of individuals, families, and communities. To maximize their effectiveness, these efforts must engage gay men and MSM, including those with HIV. Universal access to HIV treatment cannot be achieved unless social, legal, and policy environments protect the rights of gay men and other MSM.
Adopt a human rights-based approach to tackling social discrimination.
Governments should adopt these guidelines:
- International Guidelines on HIV/AIDS and Human Rights: These guidelines are consistent with fundamental human rights and should constitute the core of any national AIDS strategy.
- Yogyakarta Principles (Application of International Human Rights Law in Relation to Sexual Orientation and Gender Identity): A key policy tool for the advancement of legal reform toward full equality of all people, regardless of sexual orientation or gender identity.
- UN Statement on Sexual Orientation and Gender Identity: Reaffirms the universality of human rights, condemns human rights violations based on sexual orientation and gender identity, and calls on states to ensure that sexual orientation and gender identity are never grounds for criminal penalties.
Advocate for legal reform.
Communities must partner with global health bodies, human rights organizations, and legal institutions to repeal existing and emerging criminal laws and other policies targeting lesbian, gay, bisexual, and transgender people.
- Criminalization of same-sex acts must be repealed to create an environment that allows MSM free access to HIV services and information.
- Other laws that may be used to target MSM and other sexual minorities must be repealed, such as public assembly laws, loitering or public nuisance acts, public indecency laws, and age-of-consent laws that are stricter for same-sex acts.
- Antidiscrimination laws related to HIV, sexual orientation, and gender identity must be enacted to protect the rights of MSM and increase their use of social and health services.
Build capacity for responsive health service delivery systems.
MSM are typically "hard to find" by health systems, but this can be addressed by working with community-based organizations. Primary and specialized health care should be readily available to MSM. Creating awareness of the health and social care needs of MSM among health care providers must be part of strengthening health systems.
- Provider education on stigma can help MSM obtain care without fear of discrimination or harassment.
- Training programs must be organized to dispel myths that providers may have about working with MSM, including those with HIV.
- Guidelines for health care for MSM and professional education on their issues should be routinely made available to all health care providers, from doctors to lab technicians.
- Professional health care associations should ensure that their codes of conduct address sexual minorities and people with HIV, and that they include freedom from discrimination in health care settings and human rights protections. Health care associations should actively speak out against policies that result in negative health outcomes for MSM.
Ensure access to the legal system.
MSM in many countries have no recourse to justice when their rights are violated. In order to address their health care needs, they must be able to assert their rights through the legal systems that are available to the broader community.
- National governments, policy makers, and civil society must create an environment in which victims of discrimination or hate crimes may freely and confidentially obtain legal services.
- Advocates must be helped to create safe spaces where MSM can obtain support in their communities and can receive support from each other. This includes supporting the creation of MSM organizations.
Increase anti-stigma work.
Anti-stigma initiatives are critical to improving access to HIV services and enabling MSM to take charge of their own health.
- National governments and donors must finance programs that combat stigma, discrimination, and violence against MSM.
- Donors should provide funding to groups that support MSM. Such organizations are in a position to act as both watchdogs and service providers, and play a key role in empowering communities to take control of their lives and advocate for change.
Develop more evidence on stigma.
Limited data exist about interventions that lessen the impact of stigma and discrimination on MSM. The "People Living with HIV Stigma Index" is a significant development, gathering data from groups of people with HIV to better understand the nature of stigma. The Stigma Index will help evaluate trends in relation to interventions.
- A comprehensive study of stigma interventions must be done regularly, and "best practices" shared globally.
- Data on stigma, with attention to MSM, should be used to advocate for policy and funding changes that more effectively target the response.
- Resources must be used to scale up interventions that have been proven effective.
- Knowledge gained must be shared among all stakeholders involved in sexual rights and HIV policy.
Coordinate strategic communication.
Messaging strategies must be informed by the personal and collective experiences of MSM.
- The role of the media and its impact on public opinion and policy cannot be overestimated. Regional and global media should be engaged in raising public awareness and addressing hostile attitudes toward MSM.
- Educational strategies designed to promote reporting of discrimination, homophobia, and violence must be developed and implemented.
Adapted from "Social Discrimination Against Men Who Have Sex With Men (MSM): Implications for HIV Policy and Programs" by The Global Forum on MSM & HIV (MSMGF). Charts used with permission from MSMGF.