Association of Enacted Stigma with Depressive Symptoms Among Gay and Bisexual Men Who Have Sex with Men: Baltimore, 2011 and 2014

Comparing Men Who Have Sex With Men Only and Men Who Have Sex With Men and Women Visiting a Public Sexually Transmitted Infection Clinic

BACKGROUND

Men reporting same-sex behaviors are disproportionately impacted by sexually transmitted infections (STIs). Differences in clinical characteristics and STIs in men who have sex with men only (MSMO), with men and women (MSMW), and with women only (MSW) are not well described.

METHODS

First visits to 2 Baltimore City STI clinics 2011-2016 from MSMO and MSMW compared with an age-matched random sample of MSW were analyzed. Acute STI (aSTI) included chlamydia, gonorrhea, nongonococcal urethritis, and primary or secondary syphilis. χ2 Tests and logistic regression examined associations.

RESULTS

Among N = 1226 MSMO, N = 491 MSMW, and N = 1717 MSW, most identified as Black/African American; mean age (29.8 years) was similar across groups. The percentages of MSMW, MSMO, and MSW who reported ≥2 partners in the last 6 months were 73.5%, 67.2%, and 60.3%, respectively. "Always" condom use was reported by 20.4%, 17.4%, and 14.1% of MSMW, MSMO, and MSW. Overall HIV prevalence was 13.8%. Among those tested, urogenital chlamydia prevalence rates were 21.7%, 8.3%, and 3.9% ( P ≤ 0.01) in MSW, MSMW, and MSMO. Urogenital gonorrhea prevalence was 11.6%, 7.7%, and 8.3% in MSMW, MSW, and MSMO, respectively. Extragenital STI (range, 2.7%-21.9%), nongonococcal urethritis (25.2%), and primary or secondary syphilis (5.3%-5.7%) positivity was similar in MSMW and MSMO. Older age was inversely associated with STI diagnosis in MSW and MSMO only; consistent condom use was protective against aSTI in MSW (adjusted odds ratio, 0.60; P < 0.01) and MSMW (adjusted odds ratio, 0.54; P = 0.03) only.

CONCLUSIONS

Differences in behaviors and clinical characteristics associated with aSTI suggest that MSMO, MSMW, and MSW have diverse sexual health needs and may require tailored interventions to improve sexual health outcomes.

Assessing associations between stigma and mental health among pre-exposure prophylaxis users in Guatemala

Introduction

The mental health of gay and bisexual men (GBM) who use pre-exposure prophylaxis (PrEP) may be negatively impacted by experiences of stigma.

Methods

To assess the relationship between stigma and mental health among GBM who use PrEP in Guatemala, we conducted a survey with 162 PrEP users recruited in a community-based PrEP clinic.

Results

In multiple linear regression analyses, greater internalized (ß=1.94, SE=0.85, p=0.023) and enacted sexual orientation stigma (ß=0.50, SE=0.12, p<0.001) were associated with greater depressive symptoms. Greater internalized (ß=1.82, SE=0.80, p=0.023) and enacted sexual orientation stigma (ß=1.33, SE=0.11, p=0.003) were also associated with greater anxiety symptoms. Additionally, individuals with high social support and high anticipated PrEP stigma had fewer depressive symptoms than individuals with low social support and high anticipated PrEP stigma (ß=-3.25, SE=1.40, p=0.022). This relationship was marginally significant for anxiety (ß=-2.54, SE=1.31, p=0.055).

Conclusion

Sexual orientation and PrEP stigma may affect PrEP users' mental health. Interventions addressing stigma are needed to support uptake and sustained PrEP use in this population.

Longitudinal effects of sexual minority stigma on depressive symptoms among young men who have sex with men: Distinguish between and within person effects

BACKGROUND

Young men who have sex with men (YMSM) may experience high levels of sexual minority stigma (SMS) and depressive symptoms (DS) over the world and in China. However, there is a lack of studies investigating the longitudinal effects of SMS on DS of YMSM, especially focusing on YMSM and separating the between-person and within-person effects. This study aimed to fill the said gaps.

METHODS

Study data were derived from a prospective cohort of 349 YMSM from central China (Wuhan, Changsha, Nanchang), the baseline survey was started in 2017 with one follow-up visit every year. SMS and DS were measured three times using valid and reliable instruments. The cross-lagged panel model (CLPM) and the random intercept CLPM (RI-CLPM) were used to examine the between-person and within-person concurrent and lagged effects, respectively.

RESULTS

Findings of CLPM revealed bidirectional associations between SMS and DS over time. RI-CLPM suggested that at the between-person level, SMS was significantly associated with DS, echoing the results of CLPM. However, this reciprocal relationship has not been found at the within-person level.

CONCLUSION

The associations between SMS and DS among YMSM at the population level is more significant than that at the individual level. We suggest that interventions should be against the adverse effects of cultural marginalization and systemic change the social concepts to reduce the amount of SMS in society.

Violence, Discrimination, and High Levels of Symptoms of Depression Among Adolescent Men Who Have Sex With Men and Transgender Women in Brazil

PURPOSE

This study aimed at describing the prevalence of symptoms of depression among 15-19 year old adolescent men who have sex with men (aMSM) and transgender women (aTGW), who were recruited in an HIV pre-exposure prophylaxis cohort study in three Brazilian capital cities. The study also examined potential associations, including violence and discrimination, with severe symptoms of depression among aMSM.

METHODS

This is a cross-sectional study of baseline data among 730 aMSM and 56 aTGW recruited between February 2019 and February 2021. Sociodemographic and behavioral data were collected. The 20-item Center for Epidemiologic Studies Depression scale was used to screen for symptoms of depression. Scores of ≥22 points indicate the presence of severe symptoms associated with major depression. Logistic regression was used to assess independent associations among aMSM, adjusting for sociodemographic variables.

RESULTS

Our findings indicate a high prevalence of symptoms of depression (overall prevalence = 58.5% and 69.6%; 21.2% and 25.0% for mild/moderate, and 37.3% and 44.6% for severe) among these aMSM and aTGW, respectively. Psychological violence (aOR = 1.74; 95% CI = 1.12-2.70), sexual violence (aOR = 1.79; 95% CI = 1.07-2.98), and discrimination due to sexual orientation (aOR = 1.71; 95% CI = 1.23-2.38) were independently associated with severe symptoms of depression in aMSM.

DISCUSSION

The high prevalence of severe symptoms of depression and its association with psychological and sexual violence and discrimination creates cycles of vulnerability and carries important public health implications. Thus, our findings indicate public policies should consider assessing depression, psychological and sexual violence, as well as discrimination, especially in populations that will be targeted by interventions, such as the use of pre-exposure prophylaxis.

Grit is associated with psychological health among older sexual minority men

Objectives: Studies have shown that grit-defined as perseverance and passion for achieving one's long-term goals-is associated with improved health outcomes, including lower levels of psychological distress. However, the psychometric properties of the original Grit Scale (Grit-O Scale) has not been validated among sexual minority men (SMM). The present study aimed to validate the Grit-O Scale among a sample of older SMM and assess the relationships between the Grit-O Scale factors and symptoms of psychological distress.Method: We used data from a single visit of participants in the Multicenter AIDS Cohort Study (MACS) Healthy Aging longitudinal study. The sample included 981 older SMM (mean age = 61, SD = 8.5) with and without HIV. We conducted confirmatory factor analysis (CFA) to identify the two factors of the Grit-O Scale: consistency of interest and perseverance of effort. We also conducted a latent profile analysis (LPA) to identify distinct profiles of psychological distress from self-reported scales of depression, anxiety, and perceived stress.Results:The Grit-O Scale showed acceptable reliability estimates for the items with Cronbach's alpha reliability coefficients ranging from 0.77 to 0.82. The CFA identified the two factors of the Grit-O Scale with acceptable model fit (root mean square error of approximation = 0.058 [95% CI = 0.050, 0.067], comparative fit index = 0.95, Tucker-Lewis Index = 0.93, standardized root mean square residual = 0.07). The LPA yielded three mutually exclusive profiles of psychological distress (profile 1: low stress, anxiety, and depression; profile 2: high stress and depression and low anxiety; and profile 3: high stress, anxiety, and depression). In adjusted multinominal logistic regression analysis, we found that both higher levels of consistency of interest and perseverance of effort factors of the Grit-O Scale were significantly associated with decreased odds of being in profiles 2 and 3 compared with being in profile 1.Conclusion: Our findings support the use of the Grit-O Scale among older SMM. Grit factors could explain variability in the negative psychological symptoms among older SMM and warrant further investigation.Supplemental data for this article is available online at http://dx.doi.org/10.1080/13607863.2022.2032594.

Impact of Stigma on Clinician Training for Opioid Use Disorder Care: A Qualitative Study in a Primary Care Learning Collaborative

PURPOSE

We undertook a study to examine how stigma influences the uptake of training on medication for opioid use disorder (MOUD) in primary care academic programs.

METHODS

We conducted a qualitative study of 23 key stakeholders responsible for implementing MOUD training in their academic primary care training programs that were participants in a learning collaborative in 2018. We assessed barriers to and facilitators of successful program implementation and used an integrated approach to develop a codebook and analyze the data.

RESULTS

Participants represented the family medicine, internal medicine, and physician assistant fields, and they included trainees. Most participants described clinician and institutional attitudes, misperceptions, and biases that enabled or hindered MOUD training. Perceptions included concerns that patients with OUD are "manipulative" or "drug seeking." Elements of stigma in the origin domain (ie, beliefs by primary care clinicians or the community that OUD is a choice and not a disease), the enacted domain (eg, hospital bylaws banning MOUD and clinicians declining to obtain an X-Waiver to prescribe MOUD), and the intersectional domain (eg, inadequate attention to patient needs) were perceived as major barriers to MOUD training by most respondents. Participants described strategies that improved the uptake of training, including giving attention to clinician concerns, clarifying the biology of OUD, and ameliorating clinician fears of being ill equipped to provide care for patients.

CONCLUSIONS

OUD-related stigma was commonly reported in training programs and impeded the uptake of MOUD training. Potential strategies to address stigma in the training context, beyond providing content on effective evidence-based treatments, include addressing the concerns of primary care clinicians and incorporating the chronic care framework into OUD treatment.

What triggers depressive symptoms among gay and bisexual men? A sequential mediation model of sexual minority-related stigma and self-criticism

A growing number of studies has shown that gay and bisexual men are more likely to experience adverse mental health status than their heterosexual counterparts. Stigma-related stress and self-criticism are believed likely to exacerbate depressive symptoms among gay and bisexual men. This research used cross-sectional findings to illustrate the mediating role of internalized self-stigma and self-criticism in the association between perceived public stigma and depressive symptoms. A total of 317 Chinese gay and bisexual men (267 gays and 50 bisexuals with a mean age of 25.29) were invited to participate in this study from October to November 2021. Sociodemographic characteristics, perceived public stigma, internalized self-stigma, self-criticism and depressive symptoms were measured through self-reported online questionnaires. The results indicated that the association between perceived public stigma and depressive symptoms was sequentially mediated by internalized self-stigma and self-criticism. The findings indicated that public stigma, as a distal stressor, was perceived and internalized as self-stigma by gay and bisexual men. This self-stigma may pose a risk for depressive symptoms via self-criticism (a maladaptive consequence of their attempts to reduce cognitive dissonance). These results highlight the necessity of reducing sexual minority-related stigma and self-criticism to reduce depressive symptoms. Our findings appeal to society to further decrease prejudice and stigma, increase tolerance, and focus on the negative mental health status of gay and bisexual men.

Dyadic effects of enacted stigma, internalized homophobia, and communal coping on depressive symptoms among cisgender sexual minority male couples

The present study investigated the dyadic direct and indirect effects of enacted stigma on depressive symptoms via internalized homophobia and whether communal coping moderated the effects of enacted stigma on internalized homophobia and depressive symptoms. Hypotheses were tested using actor-partner interdependence models with a sample of 543 cisgender sexual minority male couples. Results showed both partners' enacted stigma experiences were associated with elevated levels of internalized homophobia via actor and partner effects. Internalized homophobia was only associated with elevated depressive symptoms via actor effects. Indirect effects analysis suggested that internalized homophobia mediated the actor and partner influence of enacted stigma on depressive symptoms. Communal coping moderated the direct effects of enacted stigma on internalized homophobia and attenuated the conditional indirect actor and partner effects of enacted stigma on depressive symptoms. Findings underscore the role of intimate relationship processes in understanding the impacts of enacted stigma on depressive symptoms.

Health Inequalities by Sexual Orientation: Results from the 2016-2017 Barcelona Health Survey

Purpose: The aim of this study was to assess health inequalities by sexual attraction in the 2016-2017 Barcelona population, stratifying by sex. Methods: Data came from the 2016-2017 Barcelona Health Survey, where 3362 adults answered among other instruments the EuroQol-5 dimensions-5 levels (EQ-5D-5L), which measures five dimensions and summarizes health-related quality of life into a single utility index score. To assess health differences by sexual attraction, we constructed Tobit models for the EQ-5D index score and Poisson regression models for the EQ-5D dimensions. Nested models were constructed to examine the mediating role of discrimination and health-related variables. Results: After adjusting for sociodemographic variables, women feeling attraction to more than one sex showed a lower EQ-5D index score (worse health) than those with only other sex attraction (-0.042, p = 0.012), and higher prevalence of problems with mobility, usual activities, and anxiety/depression with the following adjusted prevalence ratios (aPR) and confidence intervals (CIs): 1.79 (95% CI 1.05-3.05), 1.84 (95% CI 1.05-3.21), and 1.76 (95% CI 1.27-2.43). Women feeling attraction only to their same sex also presented higher prevalence of anxiety/depression (aPR = 1.46, CI 95% 1.10-1.92). In contrast, differences were not observed for men. Conclusion: Women, but not men, feeling attraction to more than one sex and only same-sex attraction in Barcelona in 2016-2017 presented worse health than those feeling only other sex attraction, with discrimination playing a mediating role in explaining such inequalities. These results among women indicate the need to develop public health strategies in Barcelona addressed to lesbian and bisexual women, considering the intersection of gender and sexual orientation.

mHealth to reduce HIV-related stigma among youth in the United States: a scoping review

Multiple intersecting stigmas and discrimination related to sex, gender, HIV, and race/ethnicity may challenge HIV prevention and treatment service utilization, particularly among youth. This scoping review describes recent and ongoing innovative mobile health (mHealth) interventions among youth in the United States that aim to reduce stigma as an outcome or as part of the intervention model. To identify examples of stigma-mitigation via mHealth, we searched peer-reviewed published literature using keyword strategies related to mHealth, HIV, stigma, and youth (ages 10 to 29). We identified eleven articles that met our inclusion criteria, including three describing data from two randomized controlled trials (RCTs), five describing pilot studies, one describing the process evaluation of an ongoing intervention, one describing formative work for intervention development, and one published study protocol for an ongoing intervention. We review these articles, grouped by HIV prevention and care continuum stages, and describe the mHealth approach used, including telehealth, simulation video games, motion comics, smartphone applications (apps), social media forums, online video campaigns, video vignettes, and a computerized behavioral learning module. Four studies focused on preventing primary acquisition through individual-level behavior change (e.g., reducing condomless anal intercourse), three focused on increasing HIV testing, three focused on linking to prevention services [e.g., pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP)] and one focused on promoting adherence to antiretroviral therapy (ART). Our review did not identify any published studies using mHealth with a primary aim to reduce stigma as a way to improve care engagement and increase viral suppression among youth in the United States. Additional RCTs and implementation studies examining the effectiveness of mHealth stigma-reduction interventions on HIV-related outcomes are needed to end the HIV epidemic among youth. mHealth offers unique advantages to address the complex intersecting stigma barriers along the HIV continuum to improve HIV-related outcomes for youth.

Trends and differences in sexual practices and sexually transmitted infections in men who have sex with men only (MSMO) and men who have sex with men and women (MSMW): a repeated cross-sectional study in Melbourne, Australia

OBJECTIVES

In the 2010s, there has been an increase in sexually transmitted infections (STI) in men who have sex with men (MSM) in Australia, and since 2015 also in urban heterosexuals. Men who have sex with both men and women (MSMW) have characteristics that may differ from both men who have sex with men only (MSMO) and heterosexual men. We aimed to compare the sexual practices and the trends in HIV/STI positivity between MSMO and MSMW.

DESIGN

Repeated cross-sectional study.

SETTING

A sexual health centre in Melbourne, Australia.

PARTICIPANTS

MSM aged 18 years and above who attended the Melbourne Sexual Health Centre for the first time between 2011 and 2018. This includes 12 795 MSMO and 1979 MSMW.

PRIMARY OUTCOME MEASURES

Demographic characterics, sexual practices and HIV/STI positivity.

RESULTS

Compared with MSMW, MSMO were more likely to practice anal sex and to have condomless receptive anal sex with casual male partners, and less likely to have a current regular relationship. Over the 8-year period, there was an increase in condomless receptive anal sex with casual male partners for both groups (MSMO: from 46.2% to 63.3%, ptrend <0.001; MSMW: from 41.3% to 57.9%, ptrend=0.011). Syphilis positivity increased in MSMO (from 5.5% to 7.9%, ptrend=0.012) and MSMW (from 0.9% to 6.4%, ptrend=0.004) and HIV remained stable. Gonorrhoea increased among MSMO from 2011 to 2014 (from 6.7% to 9.6%, ptrend=0.002), and remained stable from 2015 to 2018. MSMO had higher odds of testing positive for gonorrhoea (adjusted OR (aOR) 1.36, 95% CI 1.13 to 1.64), chlamydia (aOR 1.39, 95% CI 1.16 to 1.67), syphilis (aOR 1.74, 95% CI 1.37 to 2.22) and HIV (aOR 4.60, 95% CI 2.43 to 8.70) than MSMW.

CONCLUSIONS

MSMW have overall lower condomless sex and lower HIV/STI positivity. In the last years, changes in sexual practices in MSM have affected both MSMW and MSMO leading to an increased STI risk.

Characterizing the role of intersecting stigmas and sustained inequities in driving HIV syndemics across low-to-middle-income settings

PURPOSE OF REVIEW

In 2020, key populations around the world still have disproportionate risks for HIV acquisition and experiencing HIV-related syndemics. This review presents current data around HIV-related syndemics among key populations globally, and on the role of intersecting stigmas in producing these syndemics in low-to-middle-income settings.

RECENT FINDINGS

Sex workers, sexual and gender minorities, prisoners, and people who use drugs experience high burdens of tuberculosis, sexually transmitted infections, viral hepatitis, and violence linked to heightened HIV-related risks or acquisition. Adverse sexual, reproductive, and mental health outcomes are also common and similarly amplify HIV acquisition and transmission risks, highlighting the need for psychosocial and reproductive health services for key populations.

SUMMARY

Achieving the promise of biomedical interventions to support HIV care and prevention requires action towards addressing syndemics of HIV, and the stigmas that reproduce them, among those most marginalized globally.