Community-based approaches to HIV prevention that address antigay stigma
Sean Cahill, PhD
Health Policy Research, Fenway Health, Boston, Mass.
Robert Valadéz, MSW
Gay Men’s Health Crisis, New York, N.Y.
Despite 3 decades of advances in HIV testing technologies and medications, HIV continues to burden gay and bisexual men disproportionately, especially within communities of color in the United States. One key structural driver of vulnerability to HIV infection is antigay stigma. To counter the detrimental effects of pervasive antigay stigma, widespread implementation of innovative and replicable HIV prevention interventions that affirm and cultivate the healthy formation of gay identities is strongly needed. This article outlines current community-based HIV prevention approaches addressing antigay stigma being used in the field, often with little or no funding.
LGBT-affirming school-based interventions
Antigay bias is rampant in schools and in urgent need of redress. Several studies show that lesbian, gay, bisexual and transgender (LGBT) youth experience higher rates of harassment and violence from their peers because of their actual or assumed sexual orientation (Bontempo & D’Augelli, 2002; Espelage, Aragon, Birkett, & Koenig, 2008; Swearer, Turner, Givens, & Pollack, 2008; Rivers, 2004). Many LGBT students feel unsafe at school and report higher rates of social isolation, depression, suicidal ideation and unprotected sex (Russell, Ryan, Toomey, Diaz, & Sanchez, 2011).
A number of school-based, LGBT-affirming and antibullying interventions are emerging across the country. One such program is the Gay Straight Alliance (GSA). GSAs are support groups where LGBT students, those questioning their sexual orientation or gender identity, and their straight friends can gather to discuss issues associated with their sexual orientation or gender identity and foster communication with others (Ginsberg, 1999). Currently, 4,000 GSAs are registered throughout the United States. The spate of suicides that occurred in late 2010 among gay men who were victims of anti-gay harassment and bullying underscores the importance of GSAs. Research shows that these interventions are a key resiliency factor for gay youth; young gay and bisexual men in schools with pro-gay interventions report fewer risky behaviors associated with HIV transmission, including unprotected sex (Goodenow, 2007).
One study in Salt Lake City found that students’ academic performance improved, their sense of belonging to the school community was enhanced, and their school attendance increased if they were involved with the GSA (Lee, 2002). Replicating programs such as these is critical to preventing the development of risk behaviors that increase vulnerability to HIV among young gay and bisexual men and transgender women.
Social marketing campaigns promoting family acceptance of gay sons and challenging antigay stigma
Family acceptance of LGBT persons is also central to addressing HIV. Research shows that the greater the extent to which one experiences family rejection because of one’s sexuality during adolescence, the poorer the health outcomes for LGBT young adults (Ryan, Huebner, & Sanchez, 2009). In addition to exhibiting higher rates of substance use, depression, and attempted suicide, participants in the study who were rejected by their families were 3.4 times more likely to report having engaged in unprotected sexual intercourse, compared with peers who reported little to no experiences of family rejection (Ryan et al., 2009).
Gay Men’s Health Crisis (GMHC) has implemented a series of social marketing campaigns that draw on a strength-based intervention model. Strength-based campaigns are effective in changing an individual’s behavior (Detweiler, Bedell, Salovey, Pronin, & Rothman, 1999; Devos-Comby & Salovey, 2002; Rothman, Salovey, Antone, Keough, & Martin, 1993). One 2008 campaign, titled “My Son Is My Life,” models behavior in which a Black father supports his gay son. Informational palm cards and ads in print media and in bus shelters highlight reactions parents can have when they learn their son is gay and illustrate steps they can take to provide support and love. “I know he is gay, and I don’t always understand, but that doesn’t change my love for him,” the image reads.
Another campaign, titled “I Love My Boo,” depicts young Black and Latino men in loving, affectionate embraces in public settings — a portrayal of gay men of color rarely seen in mainstream media. “We’re about trust, respect and commitment,” the image reads. “We’re PROUD of who we are and how we LOVE.” The campaign ran in 1,000 subway trains and 150 subway stations in New York City in 2010 to promote positive, strength-based images of Black and Latino gay men, encourage gay men to aspire to committed, long-term relationships, and counter antigay stigma.
A 2008 campaign titled “I know my rights... Do you?” focuses on combatting the stigma transgender women experience in public accommodations by explaining a New York City nondiscrimination ordinance passed in 2002 covering gender identity. Palm cards addressed access to health care, homeless shelters and employment. Research to date on public health issues affecting men who have sex with men (MSM) has largely neglected transgender persons. There are no national data on transgender women and HIV. However, independent studies report that transgender women are among the most vulnerable to HIV infection (Clements-Nolle, Marx, Guzman, & Katz, 2001). Addressing HIV among transgender women requires better surveillance and culturally competent and effective HIV prevention campaigns.
Community connectedness has also been proven to protect against HIV infection. Greater community involvement counters the negative effects of antigay bias on safer sex practices among gay men by providing social support, enhancing feelings of selfefficacy and positive self-identity, and reinforcing peer norms supporting safer sex practices (Ramirez-Valles, 2002). Greater emphasis on prevention among older adults is also necessary. The Centers for Disease Control and Prevention (CDC) reports that most new infections among White gay and bisexual men occur among those who are 30-49 years of age (CDC, 2008). In 2007, 16 percent of new HIV infections were among people 50 and older (CDC, 2007). Evidence suggests that in addition to experiencing anti-gay bias, older gay men also experience issues related to aging and self-esteem. Some older gay men experience aging differently than their heterosexual counterparts, a concept referred to as “accelerated aging” (Rosario, Schrimshaw, Hunter, & Braun, 2006). This experience of feeling older at an earlier age than one’s chronological age presents issues of social isolation for gay men over 40 who are single and equate physical attractiveness with youth. These men may put themselves at risk for HIV by meeting anonymous partners on the Internet and coupling these experiences with substance use.
Identifying the need for HIV prevention among older gay men in 2008, the Fenway Institute in Boston piloted a group intervention to reduce HIV sexual risk, depression-related withdrawal, and anxiety-related social avoidance in gay and bisexual men 40 and older. The intervention, titled “40 and Forward,” was a series of 2-hour weekly sessions that brought together groups of gay men, ranging from 49 to 71 years of age and of multiple races, to socialize and discuss topics like safer sex. Men who participated in the intervention reported a significant decrease in depressive symptoms, as well as a significant increase in condom use selfefficacy (Reisner et al., 2010). It is notable that the intervention also helped socially isolated older gay men develop social support networks, a critical resiliency factor against HIV.
Globally, public health specialists are also recognizing the importance of combatting antigay bias to stem the spread of HIV, especially among MSM. The full scope of the global HIV pandemic among MSM is unclear, as most countries fail to gather surveillance data for MSM. However, evidence suggests that the 86 countries which criminalize homosexuality render MSM highly vulnerable to HIV infection because they are forced underground and face multiple barriers to HIV prevention and treatment (amfAR, 2008). In many African countries, the exclusively heterosexual content of HIV prevention campaigns causes gay and bisexual men to think they are not at risk for HIV. A number of studies show a disproportionate impact of HIV on MSM in sub-Saharan Africa (Beyrer, 2008; Saavedra, zazola- Licea, & Beyrer, 2008). One study reported that in middle-and lower-income countries, MSM are 19 times more likely to contract HIV than the general population (Baral, Sifakis, Cleghorn, & Beyrer, 2007).
In 2008, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) was reauthorized and included language calling for prevention with MSM and research to understand the impact of HIV on MSM. Also in 2008, the former presidents of Zambia and Mozambique, chairing the United Nations’ Economic Commission for Africa, issued a report calling for HIV prevention with MSM and opposing legal discrimination against them. The Global Fund for HIV, Tuberculosis and Malaria is also promoting MSM concerns. In May 2011, the U.S. Office of the Global AIDS Coordinator issued field guidance on MSM (see U.S. President’s Emergency Plan for AIDS Relief, 2011). The guidance gives suggestions for providing HIV prevention to MSM in Africa, the Caribbean and elsewhere.
The alarming number of HIV infections among gay and bisexual men makes it imperative that U.S. and global agencies as well as state and local health departments combat antigay bias as a public health threat. School-based initiatives that affirm LGBT youth, social marketing campaigns that challenge family rejection and social isolation, and other gay-affirming interventions should be implemented on a broader scale to challenge antigay stigma and promote the health and well-being of gay and bisexual men and transgender women.
About the authors
Sean Cahill, PhD, is the director of health policy research at the Fenway Institute in Boston, Mass., where he oversees efforts to adapt Fenway’s LGBT health and HIV/AIDS research data and findings to better advocate for a progressive public health policy. He was the former managing director of public policy, research and community health at the Gay Men’s Health Crisis in New York and an adjunct assistant professor of public administration at New York University’s Robert Wagner School of Public Service. His policy priorities have included promoting a national HIV/AIDS strategy, advocating for LGBT elders and HIV-positive elders through the Older Americans Act reauthorization, repealing the HIV entry ban, and preventing HIV among gay and bisexual men in Africa and the Caribbean through the President’s Emergency Plan for AIDS Relief. He serves on the New York City Ryan White Planning Council.
Dr. Cahill directed the National Gay and Lesbian Task Force Policy Institute from 2001 to 2007, where he led research and policy analysis on demographics, poverty/homelessness, family recognition, aging, voting, the antigay movement, and other topics. He is the author of two books on LGBT family policy and the forthcoming "Lesbian, Gay, Bisexual and Transgender Youth in America’s Schools: Research, Policy, and Practice" (University of Michigan Press). His latest publication is “Black and Latino Same-Sex Couple Households and the Racial Dynamics of Anti-Gay Activism” in "Black Sexualities: Probing Powers, Passions, Practices, and Policies" (Rutgers University Press, 2010).
Robert Valadéz, MSW, is a policy analyst at the Gay Men’s Health Crisis, the world’s oldest HIV/AIDS service organization. He was a 2009 recipient of the Urvashi Vaid Fellowship of the Policy Institute of the National Gay and Lesbian Task Force. He previously held tenures at the Sexual Health and Rights Project of the Open Society Institute and the Family Services Program of the L.A. Gay & Lesbian Center. He received his master’s degree in social welfare policy from the Columbia University School of Social Work.
amfAR, the Foundation for AIDS Research. (2008). MSM, HIV, and the road to universal access—How far have we come? (PDF, 585KB)
Baral, S., Sifakis, F., Cleghorn, F., & Beyrer, C. (2007). Elevated risk for HIV infection among men who have sex with men in low and middle-income countries 2000–2006: A systematic review (PDF, 297KB). PLoS Med, 4(12), e339.
Beyrer, C. (2008). Hidden yet happening: The epidemics of sexually transmitted infections and HIV among men who have sex with men in developing countries. Sexually Transmitted Infections, 84, 410-412.
Bontempo, D.E., & D’Augelli, A.R. (2002). Effects of at-school victimization and sexual orientation on lesbian, gay, or bisexual youths’ health risk behavior. Journal of Adolescent Health, 30, 364-374.
Centers for Disease Control and Prevention. (2007). Cases of HIV infection and AIDS in the United States and dependent areas, 2007. HIV/AIDS Surveillance Report, 19.
Centers for Disease Control and Prevention. (2008). Subpopulation estimates from the HIV incidence surveillance system—United States, 2006. Morbidity and Mortality Weekly Report, 57(36), 985-989.
Clements-Nolle, K., Marx, R., Guzman, R., & Katz, M. (2001). HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: Implications for public health intervention. American Journal of Public Health, 91, 915-921. doi:10.2105/AJPH.91.6.915
Detweiler, J.B., Bedell, B.T., Salovey, P., Pronin, E., & Rothman, A.J. (1999). Message framing and sunscreen use: Gain-framed messages motivate beach-goers. Health Psychology, 18, 189-196. doi:10.1037/0278-6126.96.36.199
Devos-Comby, L., & Salovey, P. (2002). Applying persuasion strategies to alter HIV-relevant thoughts and behavior. Review of General Psychology, 6, 287-304. doi:10.1037/1089-26188.8.131.527
Espelage, D.L., Aragon, S.R., Birkett, M., & Koenig, B.W. (2008). Homophobic teasing, psychological outcomes, and sexual orientation among high school students: What influence do parents and schools have? School Psychology Review, 37, 202-216.
Ginsberg, R.W. (1999). In the triangle/out of the circle: Gay and lesbian students facing the heterosexual paradigm. Educational Forum, 64, 46-56.
Goodenow, C. (2007, December 4). Protective and risk factors for HIV-related behavior among adolescent MSM: Analysis of Massachusetts Youth Behavior Survey data. Paper presented at the National HIV Prevention Conference, Atlanta, GA.
Lee, C. (2002). The impact of belonging to a high school gay/straight alliance. High School Journal, 85(3), 13-26.
Ramirez-Valles, J. (2002). The protective effects of community involvement for HIV risk behavior: A conceptual framework. Health Education Research, 17, 389-403. doi:10.1093/her/17.4.389
Reisner, S.L., O’Cleirigh, C., Hendricksen, E.S., McLain, J., Ebin, J., Lew, K.,... Mimiaga, M.J. (2010, April). “40 & forward”: A pilot group intervention to reduce HIV sexual risk behavior and improve mental health outcomes among older age men who have sex with men. Poster session presented at the annual meeting of the Society of Behavioral Medicine, Seattle, WA.
Rivers, I. (2004). Recollections of bullying at school and their long-term implications for lesbians, gay men, and bisexuals. Crisis, 25, 169-174.
Rosario, M., Schrimshaw, E., Hunter, J., & Braun, L. (2006). Sexual identity development among lesbian, gay, and bisexual youths: Consistency and change over time. Journal of Sex Research, 43, 46-58.
Rothman, A.J., Salovey, P., Antone, C., Keough, K., & Martin, C.D. (1993). The influence of message framing on intentions to perform health behaviors. Journal of Experimental Social Psychology, 29, 408-433.
Russell, S., Ryan, C., Toomey, R., Diaz, R., & Sanchez, J. (2011). Lesbian, gay, bisexual, and transgender adolescent school victimization: Implications for young adult health and adjustment. Journal of School Health, 81, 223-230.
Ryan, C., Huebner, D., & Sanchez, J. (2009). Family rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics, 123, 346-352.
Saavedra, J., Izazola-Licea, J. A., & Beyrer, C. (2008). Sex between men in the context of HIV: The AIDS 2008 Jonathan Mann Memorial Lecture in health and human rights. Journal of the International AIDS Society, 11, 9.
Swearer, S.M., Turner, R.K., Givens, J.E., & Pollack, W.S. (2008). ”You’re so gay!”: Do different forms of bullying matter for adolescent males? School Psychology Review, 37, 160-173.
United Nations Economic Commission for Africa. (2008). Securing our future: Report of the Commission on HIV/AIDS and Governance in Africa (PDF, 5.42MB).
U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). (2011, May). Technical guidance on combination HIV prevention (PDF, 5.52MB).