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      Hidden from health: structural stigma, sexual orientation concealment, and HIV across 38 countries in the European MSM Internet Survey

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          Abstract

          Objective

          Substantial country-level variation exists in prejudiced attitudes towards male homosexuality and in the extent to which countries promote the unequal treatment of MSM through discriminatory laws. The impact and underlying mechanisms of country-level stigma on odds of diagnosed HIV, sexual opportunities, and experience of HIV-prevention services, needs and behaviours have rarely been examined, however.

          Design

          Data come from the European MSM Internet Survey (EMIS), which was administered between June and August 2010 across 38 European countries ( N =174 209).

          Methods

          Country-level stigma was assessed using a combination of national laws and policies affecting sexual minorities and a measure of attitudes held by the citizens of each country. We also assessed concealment, HIV status, number of past 12-month male sex partners, and eight HIV-preventive services, knowledge, and behavioural outcomes.

          Results

          MSM living in countries with higher levels of stigma had reduced odds of diagnosed HIV and fewer partners but higher odds of sexual risk behaviour, unmet prevention needs, not using testing services, and not discussing their sexuality in testing services. Sexual orientation concealment mediated associations between country-level stigma and these outcomes.

          Conclusion

          Country-level stigma may have historically limited HIV transmission opportunities among MSM, but by restricting MSM’s public visibility, it also reduces MSM’s ability to access HIV-preventive services, knowledge and precautionary behaviours. These findings suggest that MSM in European countries with high levels of stigma are vulnerable to HIV infection. Although they have less opportunity to identify and contact other MSM, this might change with emerging technologies.

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          Most cited references44

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          The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations.

          In this article, we attempt to distinguish between the properties of moderator and mediator variables at a number of levels. First, we seek to make theorists and researchers aware of the importance of not using the terms moderator and mediator interchangeably by carefully elaborating, both conceptually and strategically, the many ways in which moderators and mediators differ. We then go beyond this largely pedagogical function and delineate the conceptual and strategic implications of making use of such distinctions with regard to a wide range of phenomena, including control and stress, attitudes, and personality traits. We also provide a specific compendium of analytic procedures appropriate for making the most effective use of the moderator and mediator distinction, both separately and in terms of a broader causal system that includes both moderators and mediators.
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            HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for action.

            Internationally, there has been a recent resurgence of interest in HIV and AIDS-related stigma and discrimination, triggered at least in part by growing recognition that negative social responses to the epidemic remain pervasive even in seriously affected communities. Yet, rarely are existing notions of stigma and discrimination interrogated for their conceptual adequacy and their usefulness in leading to the design of effective programmes and interventions. Taking as its starting point, the classic formulation of stigma as a 'significantly discrediting' attribute, but moving beyond this to conceptualize stigma and stigmatization as intimately linked to the reproduction of social difference, this paper offers a new framework by which to understand HIV and AIDS-related stigma and its effects. It so doing, it highlights the manner in which stigma feeds upon, strengthens and reproduces existing inequalities of class, race, gender and sexuality. It highlights the limitations of individualistic modes of stigma alleviation and calls instead for new programmatic approaches in which the resistance of stigmatized individuals and communities is utilized as a resource for social change.
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              The psychological implications of concealing a stigma: a cognitive-affective-behavioral model.

              Many assume that individuals with a hidden stigma escape the difficulties faced by individuals with a visible stigma. However, recent research has shown that individuals with a concealable stigma also face considerable stressors and psychological challenges. The ambiguity of social situations combined with the threat of potential discovery makes possessing a concealable stigma a difficult predicament for many individuals. The increasing amount of research on concealable stigmas necessitates a cohesive model for integrating relevant findings. This article offers a cognitive-affective-behavioral process model for understanding the psychological implications of concealing a stigma. It ends with discussion of potential points of intervention in the model as well as potential future routes for investigation of the model.
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                Author and article information

                Journal
                8710219
                1493
                AIDS
                AIDS
                AIDS (London, England)
                0269-9370
                1473-5571
                27 March 2016
                19 June 2015
                19 April 2016
                : 29
                : 10
                : 1239-1246
                Affiliations
                [a ]Department of Chronic Disease Epidemiology, Social and Behavioral Sciences Division, Yale School of Public Health, Yale University, New Haven, Connecticut
                [b ]Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, New York, USA
                [c ]Sigma Research, Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, UK
                [d ]Department of Evidence Summaries, Norwegian Knowledge Centre for the Health Services, Oslo, Norway
                [e ]Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
                [f ]Communicable Diseases Division, Federal Office of Public Health FOPH, Bern, Switzerland
                Author notes
                Correspondence to John E. Pachankis, Laboratory for Epidemiology and Public Health, 60 College Street, Suite 316, New Haven, CT, 06520, USA. Tel: +1 203 785 3710; john.pachankis@ 123456yale.edu
                Article
                NIHMS771807
                10.1097/QAD.0000000000000724
                4820755
                26035323
                d6a9534d-43c7-4243-97e8-2ac212e6d722

                This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

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                Article

                concealment,msm,policy,sexual orientation,stigma
                concealment, msm, policy, sexual orientation, stigma

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