There’s a growing body of research showing that Black gay, bisexual, and other sexual-minority men experience vast health inequities compared with their white counterparts. But much of that research looks at outcomes through the lens of individual drivers rather than structural ones. A new study published in April in the American Journal of Preventive Medicine takes a more intersectional approach.
A team of researchers surveyed a U.S. national sample of 1,379 Black and 5,537 white sexual-minority men—all over age 16 and who identified as male (including cisgender and transgender men) and were HIV-negative or unaware of their status—on their psychological health and behavioral health. The study measured structural racism based on an index assessing state-level Black-white inequities in incarceration rates, educational attainment, economic indicators, employment status, and residential segregation.
It measured anti-LGBTQ policies using an index that grades each state based on how its laws affect LGBTQ communities, like permitting hate crimes and discrimination in housing and employment.
The study found that, for Black men, structural racism was associated with higher levels of anxiety, perceived burdensomeness (seeing oneself as a burden to others), and heavier drinking. Also for Black men, anti-LGBTQ policies were associated with these three as well as lower HIV-testing frequency. The links between structural racism and health inequities were stronger for Black men living in states with anti-LGBTQ policies in place. Strikingly, significant associations were not seen for white sexual-minority men.
While deeply concerning, the study’s findings are critical in pushing the research, medical, and policy communities to focus on “indicators of structural racism that we have in these states as key intervention [areas] in HIV, in suicide, in psychological health, and in general,” said Devin English, Ph.D., an assistant professor at Rutgers School of Public Health and the study’s lead author.
A Map of Anti-Black, Anti-LGBTQ Policies
Terri Wilder: Can we start off by talking about how and why your research study on inequities came about? What was the idea behind it, and what sparked the interest?
Devin English: Yes, absolutely. This study comes from a larger study called the UNITE study, from Drs. Jon Rendina and Ali Talan at Hunter College. The focus of that larger study is to measure predictors of HIV seroconversion among sexual-minority men. It is a national dataset. The goal was originally over 8,000 men. At baseline, we ended up having over 10,000.
Having a dataset like that from all 50 states, there was a unique opportunity to focus on some of the structural differences between those states. So much of the HIV research that we have focuses on individual-level predictors and outcomes, but with this dataset there was a really important opportunity to focus on the effects of policies and the effects of different state environments. That’s generally where it came from.
For all of us, we are very much steeped in critical race theory and intersectionality approaches, which are critical approaches that challenge us to focus on structural drivers of inequities, rather than orienting oppression within individuals. That is, I think, an important driver for this study, in particular.
Wilder: Much of the article talked about, in particular, structural racism and the anti-LGBTQ policies around the country. One of the graphics that really knocks you in the head (for lack of a better phrase) is the graphic of the United States, where it showed that if the state was yellow, it had anti-LGBTQ policies, and if it was a white state, it didn’t necessarily have those. And the United States is a very yellow country.
What was it like for you as the researchers to map that out and say, “Wow, that’s a lot of yellow”?
Riko A. Boone: I wasn’t directly involved in producing that map, but what I will say is that I wasn’t surprised by that. Even when you think about what that map looks like, in terms of structural racism, it also wouldn’t be very surprising, considering the fact that a lot of folks kind of think about racism just at the individual level—how people are interacting and being discriminated against by other people—and not recognizing enough that discrimination based on race goes well beyond the individual interactional level. It also plays out within systems and structures and is baked into the foundation of this country.
So, when you think about the Trump executive order that was issued shortly before he left office around not addressing structural racism, pretending as if structural racism doesn’t exist—we know that it does exist. Many of us, in our families, our relatives, etc., we’re only one or two generations removed from Jim Crow. That obviously is also the case with anti-LGBTQ policies.
We, up until last year, were still fighting for Title VII protection against discrimination based on sexual identity and sexual orientation. So, living and breathing this every day, that map probably looks like that for the near future, I can imagine, unfortunately.
Wilder: When we say structural racism, what does that mean? And when we say anti-LGBT policies, what does that mean? What definitions did you, as researchers, use?
English: The metrics that we used in this study, the structural racism index, is a relatively new index that was published by Mesic and colleagues in 2018. What it does is it takes census data for each state and it looks at indicators of Black and white racial segregation, inequities in incarceration, education, economic indicators, and employment. So it’s a summary measure of those inequities.
For the anti-LGBTQ policies measure, we actually used the Human Rights Campaign’s State Equality Index, which is an index that they publish yearly that assesses the policies within each state and specifically those that restrict rights to LGBTQ communities or don’t provide protections.
In this case, the State Equality Index measures things such as HIV criminalization; the lack of prohibitions against hate crimes; discrimination in housing, employment, and public services; the allowance of conversion therapy; and other forms of hate that are geared towards LGBTQ communities.
Unraveling the Precursors to Suicidality
Wilder: What were the study’s significant findings?
Boone: One of the main findings was that we found that Black gay, bisexual, and queer men living in states with high levels of structural racism—like inequities in housing, education, incarceration—and who lived in states with anti-LGBTQ policies—for instance, places that permitted hate crimes or discrimination in housing, employment, and public services—I call it a miasma of policy environments—they showed worse psychological outcomes. So, higher anxiety and higher perceived burdensomeness. Heavy drinking outcomes and HIV testing outcomes were also impacted by these toxic policy environments.
The second point was kind of counterintuitive: White gay, bisexual, and queer men living in these states with high levels of either form didn’t show these worse health outcomes in the same way.
Wilder: “Perceived burdensomeness” is a phrase that most people might not understand—it indicates a psychological precursor to suicide. Can you say more about what that means?
Can you also talk about how your findings, particularly around HIV testing, could impact efforts to end the HIV epidemic in the U.S.?
English: Absolutely. Perceived burdensomeness might be someone seeing themselves as a burden to others around them and to the people who are important to them. It is an interpersonal risk factor for suicidality. That was really concerning for us, too. We know that suicide rates are increasing among Black adolescents—and, in particular, preteens—at higher rates than any other racial/ethnic group.
Those rates are even higher among sexual-minority youth.
As we were thinking, “Where do we go with this?” we actually decided, “Well, let’s dig more into this, into looking at suicidality among younger men, in particular.” That’s what we are focusing on now. We’ve submitted a paper that focuses on some of these precursors to suicidality. We measure a couple of them: perceived burdensomeness and heavy drinking.
We measured depression, as well, and we also are looking at suicidal ideation, self-harm, and suicide attempts.
Unfortunately, we’re seeing many of the same patterns as we see in this study: States with higher levels of anti-LGBTQ policies and structural racism are predictive of these life-and-death outcomes.
Boone: And then taking it a step further to think about how this work then connects to the Ending the HIV Epidemic [EHE], your second question: That is a really important and critical question. The Ending the HIV Epidemic plan, as we know, stems from prior work under the Obama administration around the National HIV/AIDS Strategy and taking it to the next level and focusing in on 50 jurisdictions. Rather than focusing on one city or one location, it’s this 50-[county] approach, which is similar to how we were looking at anti-LGBTQ policy environments and structural racism environments. You have to consider the whole.
EHE focuses on treatment, prevention, and rapid responses to outbreaks, which are all great strategies and key pillars. But we have to also acknowledge the fact that those strategies and how well they’ll succeed hinges on this larger social structural context in which they’re implemented. The way that these strategies are going to be implemented in, say, New York City will look very, very different than how it may look in rural Mississippi or in Chicago or Puerto Rico. They’ll look very different.
There’s this miasma of toxic policy environments that will make or break our ability to successfully implement the Ending the HIV Epidemic plan, locally and nationally. We really can’t separate EHE from the policy work that needs to be done on this front.
English: We can’t treat HIV without treating inequities in housing and wealth and incarceration.
White People Benefit From Inequities
Wilder: We’ve talked about how anti-LGBT policies of structural racism impact Black minority men and sexual-minority men. We should also talk about how it benefits white people. In the last year with what’s happening about police murdering Black people and the Black Lives movement, I think people are hopefully starting to realize what is happening. But I also think that people still don’t get (especially if you’re a white person) how you have benefited from this forever.
Boone: I was just going to say this. My mentor talks about this willful ignorance as it relates to acknowledging how discrimination impacts people’s lives. I don’t think that the past year, for instance, in terms of all the police killings, is pivotal, from the sense of it being new—or it being more likely to spark people’s investment in addressing these issues.
These police killings have been going on for decades. If you ask any Black person, they’ll tell you that this is nothing new. There hasn’t been a break since the beating of Rodney King, and even beforehand, in how police brutality has been playing out. There hasn’t been a real break.
I think what we see now is that it’s captured on social media more. The news coverage of it is more so than it has been in the past. A part of that is just the fact that it’s inescapable. It’s almost become a spectacle at this point.
And so, we have to acknowledge that while Black communities have been living this, and Black LGBTQ people have been living through this for as long as we can remember, I think there’s a certain degree of conscientization that is happening amongst non-Black people. If you look at any points recently, in terms of acknowledging the importance of Black Lives Matter and the need for police reforms, you’re seeing some shift in non-Black people’s attitudes—but there is a certain degree of willful ignorance that still exists.
English: A refrain in this past year that a lot of white people have found comfort in is, we’re all in this together. We’ve heard that a lot around this time last year—the idea that we’re all in this together. The fact is, it’s just not true. Those of us who are white, we do benefit from hate. In terms of this study, we do benefit from inequities in incarceration. We do benefit from inequities in wealth and in housing. We do benefit from inequities in police murder. That is the uncomfortable truth.
We reviewed some research on the fact that, in states with higher levels of structural racism, white people have lower levels of heart attacks. The study that we actually got the structural racism index from showed that there were higher levels of Black/white inequities in police shootings. This is life-and-death stuff and it really, at the core of it, means that white communities live longer and white communities benefit on a day-to-day basis.
I think that the idea that, again, we are all in this together, is really the spotlight on anti-LGBTQ policies. This study is really important because the idea that anti-LGBTQ policies actually disproportionately target, in effect, Black communities—and what we are finding is it didn’t affect white communities at all. There was no association. The fact is these anti-LGBTQ policies—and many of them are anti-Black anti-LGBTQ policies—are not impacting communities within the LGBTQ community equally. It’s long been time that we acknowledge inequities within LGBTQ communities, and that the kind of racism that affects the country broadly absolutely is playing out within LGBTQ communities across the country.
Boone: What we’re really talking about also is how to make this work of social justice for LGBTQ communities more intersectional and the critical role that intersectionality has for our fight for certain policy reforms.
When we think about even the marriage-equality movement, there were Black and other communities of color, and LGBTQ activists pushing back and saying, “Yes, this is important.” At the same time, there is this whole other host of policy issues that are affecting our day-to-day lives. We can’t prioritize one over the other. We have to have this all-hands-on-deck, comprehensive approach to addressing the fight for marriage equality and all the other issues affecting LGBTQ people.
What we see with this study is basically what those activists were pushing back against a couple decades ago. Thankfully, we have marriage equality now. And that’s great. But then, at the same time, we’re still trying to play catch up with some of these other intersectional social policy issues.
A Call to Action for Medical Providers
Wilder: In terms of all hands on deck, your paper addresses something that I think is really important. The basis of your research was about looking at health outcomes. How do you see what you see in clinical practice—and you’re not an activist? You can be an activist physician. You can be an activist nurse. You can be an activist dentist. You can be an activist eye doctor.
I’m basically asking: How do we as a society, or as a group of people who care about the LGBTQ community—in particular, minority LGBTQ people—enroll medical providers as part of our activist team?
English: It’s such an important question, and I’ll speak from me and my experience. The work and the advocacy are connected, and so, it’s important that we have these conversations with coworkers and at home—and that we see our personal lives as fully part of our professional lives in many ways and our personal responsibility to confront systems of oppression. That does not stop when we clock out.
I’ve worked as a psychologist in city hospitals, and it’s not easy doing a full workday and seeing in many ways the products of structural oppression. I think the more that we can use that as motivation to confront those structures, to advocate against those structures, to advocate for housing for all, to advocate for the passage of the Equality Act—the more that we can engage in those activities, the less that we are going to see of these devastating outcomes.
Boone: I agree wholeheartedly with everything that was said. I will just add that I think that therein lies the beauty in the fact that this paper was published in the American Journal of Preventive Medicine. It really acknowledges and serves as a call to action for everyone involved in health care, be it medical providers, nurses, or social workers.
I’m a social worker by training and a social psychologist by training, and so I think about how all of these different disciplines need to be actively involved in the quest for social justice and equity as it relates to these issues and health outcomes, realizing that for some of us—myself, for instance, identifying as a Black gay man—our ability to clock out from structural oppression doesn’t exist.
I may be helping my clients through these things in practice, but then I go home and have to help my relatives, my brothers, my spouse, and my friends through these issues, as well. So, some of us never get to clock out from these issues. That really speaks to the need for physicians and other professional health care, mental health care, and physical health care providers to realize that maybe they should be not clocking out, as well.
English: I will say that it really does put an onus on those who are intersectionally privileged and empowered, those who are benefiting from these systems, to be agents of change. That is something that we really highlight.
Wilder: While centering the voices of people who are marginalized.