Stigma, discrimination, and homophobia harm efforts to prevent HIV and to care for those living with the virus. HIV stigma consists of prejudice, discrimination, and harassment directed at people thought to have HIV. HIV stigma and discrimination show themselves in large part because of antigay bias and homophobia, particularly in communities of color. Homophobia is the irrational fear of, or aversion to, people who are thought to be homosexual. Both homophobia and HIV stigma can be expressed in a multitude of harmful and detrimental ways. This can be verbal or emotional abuse, rejection, ridicule, isolation, or physical violence.
Homophobia and HIV stigma often lead to a lack of participation by people of color in HIV prevention services, a reluctance to test for HIV or to use condoms, and difficulty talking about HIV and sex. Addressing homophobia and HIV stigma is critical to decreasing the spread of HIV in communities of color.
Whether through the media or casual conversation, discrimination against gay and lesbian people remains socially acceptable throughout the U.S. Anti-gay sentiment can be especially strong in communities of color, which leads to both homophobia in the community and the internalized homophobia experienced by lesbian, gay, bisexual, or transgender (LGBT) people. This antigay bias is rooted in community and family norms, attitudes, and values.
In the Latino community, for example, homosexuality is equated to weakness and is perceived to run counter to notions of machismo (community norms on what it means to be a man). As such, homosexuality in the Latino community is thought to hurt or embarrass the family. The African-American community sees homosexuality as an embarrassment to the African-American race as a whole, as well as to the family structure. More specifically, homosexuality in the African-American community is often perceived as conflicting with gender roles and community norms about sexuality, and even to being sinful and unnatural.
Rejection and discrimination by family and friends can lead to loss of employment, dropping out of school, or young people having to leave their homes. This may cause LGBT people to feel as if they have no options and are no longer part of their community. Some young people who are forced out of their homes end up living on the street. Over 40% of homeless youth are LGBT and many turn to sex work. This not only puts them at a higher risk for HIV, but may also increase their feelings of helplessness and loss of community. (Of course, some people who engage in sex work feel empowered and want to be seen as legitimate businesspeople.) The stigma surrounding sex work makes reaching out to them with HIV education, prevention, and service provision even more challenging.
LGBT people who feel shunned by their community because of homophobia often internalize those negative feelings. They may experience hatred toward gays before they become aware of their own attraction to the same sex. When they do recognize it, they begin to see themselves as different and socially unacceptable, which can damage their own sense of self-worth. Low self-esteem and depression often follow suit. When coupled with isolation, the foundation for long-lasting self-hatred is laid, making it difficult to move beyond negative attitudes toward both homosexuality and themselves. Stigma also prevents conversations about bisexual behavior. Homophobia can lead to low self-esteem, anxiety, depression, isolation, and loss of self-efficacy among LGBT people. Many turn to substance use to ease the pain and lessen anxiety.
Fear of Contagion
Another contributor to HIV stigma is the fear of contagion, an irrational fear of contracting HIV through casual contact. Many people are fearful of getting HIV through sex, but several studies show that fear of contagion is one of the key contributors to HIV stigma for both children and adults.
For example, a national survey that measured HIV stigma in the U.S. in 2002 found that, while most people do not advocate the segregation of people with HIV from the general public, many still believe that HIV can be transmitted through casual contact. This is shown by some parents' fear of sending their children to school with an HIV-positive child. These parents explained that they were concerned that HIV could be transmitted through sneezing and coughing, which is scientifically untrue. Similarly, young people who were uncomfortable with HIV-positive students in their schools thought that the children with HIV were responsible for contracting the disease. In addition, inaccurate HIV education contributed to the students' fear of contracting HIV through casual contact.
Despite this fear of contagion, HIV stigma and discrimination relates most closely with homophobia in the U.S. Because gay men were the hardest hit at the beginning of the epidemic, and because 57% of new infections in 2006 were among gay and bisexual men, there is still a strong belief that HIV is a gay disease. As such, many communities of color equate HIV with a variety of behaviors considered unacceptable. Men who have sex with men or with both sexes, drug users, and those who have multiple partners are those whose behaviors are most commonly linked with HIV infection in black and Latino communities.
HIV forces us to talk about sex and sexuality, which is rife with morality issues. Since HIV is transmitted primarily through sexual contact or sharing needles, people with the virus are often viewed as morally inferior or shameful. Today, much stigma is directed toward the person who "should have known better" or who "brought it on himself." The young child, on the other hand, is seen as an innocent victim, as are women with cheating husbands.
HIV-positive sex workers are also considered responsible for their HIV status. Indeed, some people assume that having multiple sexual partners automatically leads to HIV infection. This is scientifically untrue; HIV transmission is purely a function of biology. Although the risk for getting HIV increases with the number of partners, the chances are greatly influenced by the availability and consistent use of safer sex tools like condoms.
Ignoring, or being ignorant of, how the virus is actually transmitted, some community members judge people with HIV based on personal characteristics: being gay, a substance user, black or racially different, poor, or uneducated, or having multiple partners.
Stigma and Public Health
Negative attitudes toward HIV and homosexuality in communities of color can hamper HIV prevention and treatment efforts. The social isolation that homophobia and HIV stigma cause results in silence around HIV. Many Latino and African-American men refuse to get tested, as they equate taking an HIV test with an admission of risky behavior, most commonly having sex with other men. In African-American communities, a condom is sometimes seen as a threat to masculinity, as admission of having sex outside a relationship, or as having a sexually transmitted infection (STI). People who don't know their HIV status often avoid HIV testing, and some begin to deny that they can get HIV or that it poses any health risk.
Public health efforts in communities of color would fare better if homophobia and HIV stigma did not exist. If individuals were more willing to get tested for HIV, more people would know their status and be more likely to obtain care and protect their partners. If more people were able to disclose their status without fear of rejection, their partners would be much more likely to use protection. If people with HIV had easier access to treatment, they would be more likely to adhere to their regimens and their viral loads would drop, reducing (but not eliminating) the risk of transmission. This could reduce the overall transmission rates in black and Latino communities. If gay and/or HIV-positive men felt supported in their families, at work, at school, at church, and on the street, they would be more likely to care about their health and the health of others.
What Can We Do?
We need to counter homophobia and HIV stigma by doing away with all expressions of stigma, subtle and overt, if we want to reduce HIV transmission in communities of color. What is needed are meaningful interventions that address the love, acceptance, and intimacy that gay men seek -- interventions that look to shift community attitudes and encourage support and dialogue. Service providers should not be afraid to deal with these issues directly. Whatever forms the interventions take -- social marketing, support groups, or community events -- HIV prevention should expressly address these factors. There is a tremendous need for increased education and for efforts to raise awareness of HIV stigma in communities of color. Culturally competent and appropriate images that allow members of communities of color to identify themselves are more successful in transmitting the prevention message. Relatable role models also have a positive effect on an audience's ability to embrace a campaign's message.
A recent study of New York City black men concluded that stigma surrounding both HIV and homosexuality may ensure that non-heterosexual preferences and practices remain hidden. Other research has found the same to be true for Latinos. HIV stigma and homophobia are rooted in fear, lack of information, and prejudice. As if the shame of having HIV or the feeling of being "damaged goods" is not enough, HIV stigma and homophobia affect the mental, physical, and spiritual health of HIV-positive men of color. If we look deeper, we will find that preventing HIV and other STIs requires initiatives that go beyond campaigns promoting safer sex and HIV testing. Although these are crucial, addressing homophobia and HIV stigma can have a profoundly positive impact on HIV transmission and public health.
We still live in a pervasively homophobic society, one that erects high barriers to community health, especially among people of color. When gay men live with the shame, isolation, and self-hatred they have picked up from those around them, they often stop caring about themselves enough to want to engage in safer sex. When gay men live with depression, anxiety, and anger caused by being denied a job or promotion, being constantly harassed at school, or being rejected by family, they stop seeing themselves as worthy of a loving relationship with supportive friends, of maintaining healthy habits, and of caring about their sexual partners. Even more worrisome, homophobia and discrimination can lead to addiction, abuse, and violence. Greater risk of HIV is just one of the many public health costs.
Jaime Gutierrez has an MPH from John Hopkins University. Giovanni Koll has worked for GMHC's Institute for Gay Men's Health.
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