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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

      ObjectiveSubstantial 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.DesignData come from the European MSM Internet Survey (EMIS), which was administered between June and August 2010 across 38 European countries (N =174 209).MethodsCountry-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.ResultsMSM 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.ConclusionCountry-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 references 38

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      Global epidemiology of HIV infection in men who have sex with men.

      Epidemics of HIV in men who have sex with men (MSM) continue to expand in most countries. We sought to understand the epidemiological drivers of the global epidemic in MSM and why it continues unabated. We did a comprehensive review of available data for HIV prevalence, incidence, risk factors, and the molecular epidemiology of HIV in MSM from 2007 to 2011, and modelled the dynamics of HIV transmission with an agent-based simulation. Our findings show that the high probability of transmission per act through receptive anal intercourse has a central role in explaining the disproportionate disease burden in MSM. HIV can be transmitted through large MSM networks at great speed. Molecular epidemiological data show substantial clustering of HIV infections in MSM networks, and higher rates of dual-variant and multiple-variant HIV infection in MSM than in heterosexual people in the same populations. Prevention strategies that lower biological transmission and acquisition risks, such as approaches based on antiretrovirals, offer promise for controlling the expanding epidemic in MSM, but their potential effectiveness is limited by structural factors that contribute to low health-seeking behaviours in populations of MSM in many parts of the world. Copyright © 2012 Elsevier Ltd. All rights reserved.
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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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          A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people

          Background Lesbian, gay and bisexual (LGB) people may be at higher risk of mental disorders than heterosexual people. Method We conducted a systematic review and meta-analysis of the prevalence of mental disorder, substance misuse, suicide, suicidal ideation and deliberate self harm in LGB people. We searched Medline, Embase, PsycInfo, Cinahl, the Cochrane Library Database, the Web of Knowledge, the Applied Social Sciences Index and Abstracts, the International Bibliography of the Social Sciences, Sociological Abstracts, the Campbell Collaboration and grey literature databases for articles published January 1966 to April 2005. We also used Google and Google Scholar and contacted authors where necessary. We searched all terms related to homosexual, lesbian and bisexual people and all terms related to mental disorders, suicide, and deliberate self harm. We included papers on population based studies which contained concurrent heterosexual comparison groups and valid definition of sexual orientation and mental health outcomes. Results Of 13706 papers identified, 476 were initially selected and 28 (25 studies) met inclusion criteria. Only one study met all our four quality criteria and seven met three of these criteria. Data was extracted on 214,344 heterosexual and 11,971 non heterosexual people. Meta-analyses revealed a two fold excess in suicide attempts in lesbian, gay and bisexual people [pooled risk ratio for lifetime risk 2.47 (CI 1.87, 3.28)]. The risk for depression and anxiety disorders (over a period of 12 months or a lifetime) on meta-analyses were at least 1.5 times higher in lesbian, gay and bisexual people (RR range 1.54–2.58) and alcohol and other substance dependence over 12 months was also 1.5 times higher (RR range 1.51–4.00). Results were similar in both sexes but meta analyses revealed that lesbian and bisexual women were particularly at risk of substance dependence (alcohol 12 months: RR 4.00, CI 2.85, 5.61; drug dependence: RR 3.50, CI 1.87, 6.53; any substance use disorder RR 3.42, CI 1.97–5.92), while lifetime prevalence of suicide attempt was especially high in gay and bisexual men (RR 4.28, CI 2.32, 7.88). Conclusion LGB people are at higher risk of mental disorder, suicidal ideation, substance misuse, and deliberate self harm than heterosexual people.
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            Author and article information

            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
            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
            26035323
            4820755
            10.1097/QAD.0000000000000724
            NIHMS771807

            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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            concealment, msm, policy, sexual orientation, stigma

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