Stigma and its role in HIV prevention and care of gay and bisexual men
Kevin L. Nadal, PhD
John Jay College of Criminal Justice, City University of New York
David P. Rivera, MS
Teachers College, Columbia University
Recommendations for clinical and counseling practices
Previous studies have reported that stigma has been a key obstacle for individuals living with HIV/AIDS (Swendeman, Rotheram-Borus, Comulada, Weiss, & Ramos, 2006) and that stigma is a major barrier for HIV prevention (Chesney & Smith, 1999; Wolitski, Pals, Kidder, Courtenay-Quirk, & Holtgrave, 2009). Research has also demonstrated that gay and bisexual men living with HIV/AIDS (GBMLHA) are likely to experience both HIV stigma and gay-related stigma, which may cause significant psychological stress (Chenard, 2007). This “double stigma” may be traced back to the initial label of HIV/AIDS as the “gay cancer” or the “gay-related immune deficiency.” However, such stigma may also be influenced by individuals’ perceptions that gay and bisexual men who contract the disease are to “blame” for their own actions.
For example, a report of the Centers for Disease Control and Prevention (CDC, 2000) found that people who were most knowledgeable and educated about HIV infection were least likely to believe that people with HIV/AIDS “got what they deserved” (p. 1). Some studies have also shown that individuals are more likely to place blame and anger on GBMLHA than they are with other populations with HIV (Herek & Capitano, 1993; Schellenberg & Ben, 1998).
Given the findings that gay, lesbian and bisexual people with HIV/AIDS are more likely to possess symptoms of depression and engage in risky health behaviors (Lam, Naar-King, & Wright, 2007), it is important for counselors and clinicians to demonstrate cultural competence in working with this population. Furthermore, because there is a dearth of clinical and counseling services for people living with HIV/AIDS (Lam et al., 2007), it is necessary for practitioners to develop strong therapeutic relationships with their clients in order to prevent treatment dropout (Leeman et al., 2010). Finally, because gay-related stigma consciousness, or one’s ability to perceive heterosexist stigma, has been found to be a predictor of depressive symptoms (Lewis, Derlega, Griffin, & Krowinski, 2003), it is imperative that clinicians manage or eliminate such stigma in their counseling relationships in order to provide the most effective and optimal treatment for their clients.
The purpose of this article is to provide clinical and counseling recommendations regarding working most effectively with GBMLHA. Using the multicultural competence tripartite model developed by Sue, Arrendondo and McDavis (1992), which was later adapted for the APA’s (2003) Guidelines on Multicultural Education, Training, Research, Practice and Organizational Change for Psychologists (PDF, 235KB), we discuss how it is an ethical responsibility of psychologists to attain appropriate knowledge, awareness, and skills in working with all cultural minority groups, including GBMLHA.
It is paramount that when considering the tripartite model for developing cultural competence with this population, clinicians reflect on how their own attitudes and beliefs about gay and bisexual men developed, as well as their own biases or stereotypes about people living with HIV/AIDS. This introspective process begins by thoroughly examining one’s own cultural heritage, including how various aspects of identity (e.g., race, ethnicity, gender, sexual orientation, religion and spirituality, etc.) influence the development of one’s worldview. For example, a clinician with a strong Christian identity may not recognize her biases about samesex relationships and may inadvertently display judgmental facial expressions, thus damaging her rapport with a GLBMLHA client.
Traditionally, the model posited that people harbor biases toward those who are culturally different than themselves. While this is likely true, especially when considering the biases against gay and bisexual men harbored by heterosexuals, it is also important to emphasize that gay and bisexual individuals living without HIV/AIDS may also have biases against GBMLHA as a byproduct of learned HIV stigma (Courtenay-Quirk, Wolitski, Parsons, & Gómez, 2006) or their own internalized heterosexism (Szymanski, Kashubeck-West, & Meyer, 2008). For instance, a gay male therapist who is HIV-negative may have a bias that his GBMLHA client is sexually promiscuous or a drug abuser, thus placing blame on his client and failing to provide a safe, empowering environment for him. It is expected that culturally aware clinicians should recognize their limitations, which in turn will encourage clinicians to seek out educational experiences to address their shortcomings.
Gaining knowledge is the next component of the tripartite model for developing clinical cultural competence. This knowledge pertains to learning about gay and bisexual men as a unique social group, as well as their risk and protective factors with HIV/AIDS. The clinician must gain knowledge about the unique experiences of gay and bisexual men in general, which may include their developmental process (e.g., sexual orientation identity development and internalized heterosexism) and the social and political issues they face in everyday life (e.g., institutional and interpersonal discrimination).
For example, gay and bisexual men are not a monolithic group but are quite diverse in terms of life experience. A potential microaggression, or subtle form of discrimination, that may occur for an unaware clinician is to provide services based on the assumption that all gay and bisexual men have a common experience or that there is only one way for one to “come out of the closet” (Nadal, Rivera, & Corpus, 2010). Thus, the culturally competent clinician will recognize, through his or her acquisition of knowledge, that gay and bisexual men are diverse among themselves.
Furthermore, culturally competent clinicians will be well-informed about issues involving HIV/AIDS, so that time in the counseling session will be well spent on their clients’ emotional exploration. For example, a GBMLHA client may drop out of therapy because he feels that the majority of the time is spent on educating his counselor about HIV/AIDS instead of talking about his depression, which is what brought him to therapy.
Through developing multicultural skills — the final component of the tripartite model of cultural competence — clinicians may learn that the most effective approaches or techniques in working with GBMLHA parallel the most effective skills in working with any client. Using humanistic techniques like empathy or unconditional positive regard is essential, particularly for clients who have internalized oppression, blame, or guilt as a result of their sexual orientation or HIV status. Existential approaches may be effective in exploring how clients understand their life span and mortality, while cognitive–behavioral techniques may be useful in examining faulty cognitions and unhealthy behaviors. Psychodynamic approaches may be used to reveal unconscious feelings about the client’s sexual orientation or to identify defense mechanisms related to the client’s coping with his HIV status.
Finally, counselors and clinicians must recognize that GBMLHA have other identities that must be accounted for that may influence their everyday lives in numerous ways. People of color, transgender people, persons with disabilities and individuals of diverse ethnicities, religions, ages and social classes may uphold an array of social identities that may need to be integrated into the treatment. For instance, an African American GBMLHA client may report experiencing discrimination and how it affects his mental health. In this case, a culturally competent counselor would be cognizant not just of exploring the client’s HIV status or sexual orientation but also of examining the client’s racial identity in order to provide a safe, nonjudgmental space for him. Using techniques that address a client’s intersectional identities may be vital in developing a strong therapeutic alliance and providing a safe space for clients while also demonstrating cultural competence.
About the authors
Kevin L. Nadal, PhD, is an assistant professor of psychology at the John Jay College of Criminal Justice—City University of New York, where he also serves as the deputy director of the forensic mental health counseling program. His research interests focus primarily on multicultural issues in psychology, particularly regarding issues related to race, sexual orientation and gender. He has published several works specifically on microaggressions toward LGBT people and Filipino American issues in psychology. Dr. Nadal is an executive board member of the Asian American Psychological Association, a national trustee of the Filipino American National Historical Society, a member of the APA Committee of LGBT Concerns, a psychologist-trainer for the New York Police Department, and a fellow of the Robert Wood Johnson Foundation.
David P. Rivera, MS, is a doctoral candidate in counseling psychology at Teachers College, Columbia University. He holds degrees in psychology and counseling from Johns Hopkins University and the University of Wyoming. His research focuses on issues impacting the marginalization and health of people of color and sexual minorities. His research has been published in the Counseling Psychologist, Cultural Diversity and Ethnic Minority Psychology, and the Journal of Counseling & Development. His therapeutic interests include working with college students and people with substance abuse issues. He will be completing his predoctoral internship at the University of Pennsylvania. He cohosts a blog — “Microaggressions in Everyday Life” — on Psychology Today’s website. Mr. Rivera has received multiple recognitions for his work, including national honors from the APA and the American College Counseling Association.
American Psychological Association. (2003). Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. American Psychologist®, 58, 377-402. doi:10.1037/0003-066X.58.5.377
Centers for Disease Control and Prevention. (2000). MVrelated knowledge and stigma. Journal of the American Medical Association, 284(A68768999).
Chenard, C. (2007). The impact of stigma on the self-care behaviors of HIV-positive gay men striving for normalcy. JANAC: Journal of the Association of Nurses in AIDS Care, 18(3), 23-32.
Chesney, M.A., & Smith, A.W. (1999). Critical delays in HIV testing and care: The potential role of stigma. American Behavioral Scientist, 42, 1162–1174.
Courtenay-Quirk, C., Wolitski, R.J., Parsons, J.T., & Gómez, C.A. (2006). Is HIV/AIDS stigma dividing the gay community? Perceptions of HIV-positive men who have sex with men. AIDS Education and Prevention, 18, 56-67.
Herek, G.M., & Capitano, J.P. (1993). Public reactions to AIDS in the United States: A second decade of stigma. American Journal of Public Health, 83, 574-577.
Lam, P.K., Naar-King, S., & Wright, K. (2007). Social support and disclosure as predictors of mental health in HIVpositive youth. AIDS Patient Care and STDs, 21, 20-29.
Leeman, J., Chang, Y.K., Lee, E.J., Voils, C.I., Crandell, J., & Sandelowski, M. (2010). Implementation of antiretroviral therapy adherence interventions: A realist synthesis of evidence. Journal of Advanced Nursing, 66, 1915-1930.
Lewis, R.J., Derlega, V.J., Griffin, J.L., & Krowinski, A.C. (2003). Stressors for gay men and lesbians: Life stress, gay-related stress, stigma consciousness, and depressive symptoms. Journal of Social and Clinical Psychology, 22, 716-729.
Nadal, K.L., Rivera, D.P., & Corpus, M.J. (2010). Sexual orientation and transgender microaggressions in everyday life: Experiences of lesbians, gays, bisexuals, and transgender individuals. In D.W. Sue (Ed.), Microaggressions and marginality: Manifestation, dynamics, and impact (pp. 217-240). New York: Wiley.
Sue, D.W., Arredondo, P., & McDavis, R.J. (l992). Multicultural competencies/standards: A pressing need. Journal of Counseling & Development, 70, 477-486.
Swendeman, D., Rotheram-Borus, M.J., Comulada, S., Weiss, R., & Ramos, M.E. (2006). Predictors of HIV-related stigma among young people living with HIV. Health Psychology, 25, 501-509. doi:10.1037/0278-6126.96.36.1991
Szymanski, D.M., Kashubeck-West, S., & Meyer, J. (2008). Internalized heterosexism: A historical and theoretical overview. Counseling Psychologist, 36, 510-524.
Wolitski, R.J., Pals, S.L., Kidder, D.P., Courtenay-Quirk, C., & Holtgrave, D.R. (2009). The effects of HIV stigma on health, disclosure of HIV status, and risk behavior of homeless and unstably housed persons living with HIV. AIDS and Behavior, 13, 1222–1232.