Qualitative research published in the July issue of Social Science & Medicine by Dr Katherine Quinn and colleagues at the Center for AIDS Intervention Research highlights how intersectional stigma contributes to low pre-exposure prophylaxis (PrEP) uptake for black men who have sex with men (MSM) in the US. Mistreatment in healthcare services, racism, homophobia and structural inequalities all intersect to deter black MSM from seeking out PrEP as a means of preventing HIV infection.
HIV infection in the US continues to disproportionately affect black MSM when compared to white and Hispanic MSM, despite black men consistently reporting fewer sex partners and less risk behaviours. Half of all black MSM are projected to acquire HIV in their lifetime, compared to 25% of Hispanic MSM and 9% of white MSM. There are major disparities in PrEP use: of the 1.1 million estimated to benefit from PrEP, 45% are black MSM, yet of those currently using PrEP, only 11% are black MSM, compared to 13% Latino men and 69% white men.
Low PrEP uptake among black MSM may be attributed to intersectional stigma. This type of stigma is experienced as a result of discrimination based on multiple identities, such as being black and gay.
As the authors explain, “Intersectional stigma can occur at multiple levels of influence (interpersonal, community, and structural levels), and is based upon co-occurring and intersecting identities or conditions (e.g. HIV status, race, age, disability, sexual orientation). An important distinction to make is that it is not an individual’s intersecting identities that contribute to marginalization, but rather the social positions, privileges, power, and oppression (e.g. racism, classism, heterosexism) associated with those identities that contribute to inequalities.”
Intersectional stigma and PrEP use has not been widely studied. However, it may have similarities to intersectional stigma and HIV risk.
Six focus groups were held with 44 black MSM, in Milwaukee, Wisconsin from late 2017 to early 2018. This city has racial disparities in terms of HIV diagnoses for black men (four times higher than white men), is one of the most racially segregated cities in the US and has high rates of incarceration for black men.
All participants identified as black or African American, were aged 18-25, assigned male sex at birth, identified as MSM or having had sex with a man in the last two years, and were of HIV-negative or unknown HIV status.
Seventy-five per cent of participants identified as gay, 48% had a high school diploma or equivalent, with only four participants having a college degree. Over two-thirds were working full- or part-time, but half earned less than $10,000 per year. Two participants were former PrEP users and eight were currently taking PrEP. There was at least one PrEP user in each focus group.
The focus groups covered: 1) introduction to PrEP, 2) willingness to take PrEP or support a partner’s PrEP use, 3) perceptions and stereotypes of PrEP users, 4) perceived barriers to PrEP use, and 5) healthcare utilisation patterns and barriers. Participants were also asked how they perceived their experiences to differ from those of black heterosexual men or white gay men. The following themes emerged.
Mistreatment within the healthcare system
One of the most prominent barriers to accessing PrEP was anticipated and experienced stigma from healthcare providers based on race, sexuality or both. Participants expressed that, as black MSM, they tended to receive sub-standard healthcare services, which contributed to hesitancy accessing PrEP. This is seen in the following exchange:
Participant: We don’t have the same experiences of others because we don’t open up to our doctors.
Participant: The judgment. Even though they’re healthcare professionals and not supposed to judge, some people still judge, and the fear of being judged by a doctor is, … yeah.
Facilitator: And that is, you think that’s kind of like something culturally with us?
Participant: It’s culturally in, not only the fear of already being Black plus the fear of being gay.
As black men, participants face race-based judgements from healthcare providers and this erodes trust. As gay men, they are expected to disclose their sexual orientation in order to access services such as PrEP but there is a breakdown in the relationship between provider and client.
Some participants conformed to a more traditional masculine identity as a means of concealing sexuality (“…I can go in there and be a straight man if I want to…”). While this may minimise discrimination based on sexuality, it also limits access to PrEP.
PrEP as a marker of sexuality
Participants also shared stigmatising experiences as a result of PrEP being considered a marker of sexual identity.
Participant: It’s just like, known as a gay pill.
Facilitator: And do you think that creates a barrier?
Participant: Of course.
Participant: Yes! The stigma. Because it isn’t advertised to other identities and stuff. Someone who may not be LGBT-identified or gay may have to hide [PrEP] because they don’t want to explain to their parents what it is…
This aspect of PrEP use may be particularly problematic for younger men who do not identify as gay and whose sexuality could be discovered through their PrEP use. Participants also referred to “downlow” men who were seen as not wanting to lose their straight privilege despite having sex with other men.
As a result of limited PrEP access, some men – mainly current PrEP users – expressed the need for black MSM to advocate for and educate other black MSM, especially younger men, about PrEP. Limited knowledge was one of the reasons cited for making men feel uncomfortable asking about PrEP.
“I just feel like, it’s mainly with us [hand motion to indicate the young black MSM in the room]. It’s like we have to educate ourselves, make everybody aware and just educate them so that they don’t feel ashamed, ostracized, when they go to these clinics.”
Societal racism and inequality
A common theme was the racism and social inequality experienced by all participants at multiple levels. This was compounded by sexuality-based discrimination and created a unique situation in which black MSM had specific concerns when accessing PrEP.
“…I think it’s also more [stigma] in African American community because, like, I just feel like just being African American, being gay, like just that stuff that happened throughout my past, like being judged and battered and stuff, it kinda made me tough…”
Social racism intersects with homophobia and this contributes towards feelings of anxiety, defensiveness and low self-worth. This stigmatisation happens at multiple levels: within their own communities, broader society and from the largely white, gay male community.
Regarding racial disparities in PrEP uptake, men cited structural barriers and competing priorities such as poverty, unemployment and racial segregation as contributors. They resulted in PrEP dropping down black MSM’s priority list.
“That’s why [white people] are able to be on PrEP. Because they have access, they have the money, they have the families for this stuff.”
Othering and HIV stigma
Stigma surrounding PrEP use was closely linked to HIV-related stigma for many black MSM. Fear of being stigmatised for taking PrEP was often based upon participants’ own stigmatisation of men living with HIV. Men with HIV were described as “sick” and were not seen as potential sexual or romantic partners. Many participants attempted to actively distance themselves from those living with HIV.
There was a disconnect in terms of how PrEP users were described (“responsible” and “mature”) versus who men thought should be taking PrEP (“the trades, the hoes,” and individuals who “just don’t have value of themselves. . . just out here, no condoms.”). Here, the associations between those who were HIV positive and those who should be taking PrEP had great overlap: they were seen as irresponsible, promiscuous and engaging in condomless sex.
HIV stigma and its consequences were so profound that even being considered at risk for HIV and using PrEP to prevent infection was seen as problematic. Thus Truvada, which can be used for both prevention and treatment, was stigmatised (referred to as the “sick pill”).
Most participants still saw condom use as normative and the “correct” way to gain protection from HIV. Those who chose not to use condoms and opt for prevention such as PrEP were seen as irresponsible and in violation of a long-standing social norm. PrEP users were closely linked to those who had become infected with HIV as a result of having condomless sex.
“Don’t be like ‘I don’t care, I don’t need no condom.’ Uh, you need that for your life, ‘cuz, you know, you look bad.”
The research highlights the importance of acknowledging intersectional stigma when considering limited PrEP uptake among black MSM in the US. This approach goes beyond individual-level risk factors and considers the broader social and structural factors that make black men more vulnerable to HIV infection; many of these are the same factors that pose barriers to PrEP uptake and adherence.
Men experienced both racism and homophobia within a context of inequalities in healthcare access, socioeconomic status, education and HIV infection. PrEP use has also become stigmatised as it is linked to being gay, sexual promiscuity and irresponsibility. The intersection of being gay, black and HIV positive had the most negative impact on perceptions of PrEP use, as men wanted to distance themselves from this intersectional identity.
As the authors argue, this necessitates the need for multi-level interventions that are able to mitigate intersectional stigma and its consequences. This could be in the form of supportive youth spaces and implementing resiliency-focused interventions to reduce negative associations of being gay and black. Public health interventions also need to work to normalise PrEP use and to break the association between PrEP use and sexual deviance. Awareness and knowledge of PrEP reduces stigma and works to increase positive attitudes.
Quinn K, Bowleg L and Dickson-Gomez J. “The fear of being Black plus the fear of being gay”: The effects of intersectional stigma on PrEP use among young Black gay, bisexual, and other men who have sex with men. Social Science & Medicine 232:86-93, 2019. doi: https://doi.org/10.1016/j.socscimed.2019.04.042.