For people with non-conforming gender identities and sexual orientations, stigma rarely comes as a surprise. Funny looks, whispers and awkwardness still come standard in 2016, as does the occasional threat of unpredictable physical or sexual violence.
But for public health experts, harassment and exclusion on the basis of sexual identity and orientation are more than social ills—they're major obstacles to eradicating HIV. Decades worth of data have shown stigma leads to lower rates of HIV testing, increased risk for HIV infection, and lower rates of accessing care among people who are HIV-infected, all of which increase HIV transmission.
Although the United States is often seen as a relatively progressive place, it is also the setting for a steady pace of hate crimes targeting LGBTQ populations, including this June's Pulse nightclub shooting in Orlando, in which 49 people were gunned down at what they had assumed was a safe gay space. It's not consolation, exactly, to imagine that it's much harder to be a gay or bisexual man in other parts of the world, but it's an assumption many Americans make.
According to a study published this July, however, that assumption might be wrong: Men who have sex with men (MSM) living in the US and in sub-Saharan Africa experience stigma in surprisingly similar ways.
The study's authors looked at stigma-related questions from 12 years' worth of interviews conducted with MSM living in West and Central Africa. By asking the same questions of American men, using an online questionnaire deployed on a variety of gay-interest websites, they were able to make comparisons between the experiences of gay men living in two very different parts of the world. And although multiple studies show stigma based on sexual behavior does exist, no yardstick has yet been developed for measuring stigma (and understanding its impact) in countries with different cultures, healthcare systems, and legal structures, something the study's authors hope to change.
Respondents were asked whether they had disclosed their sexual orientation to a family member or a healthcare worker, and questions were asked about their experiences with family, healthcare, public safety, violence, and blackmail. What's remarkable about the findings are the similarities shown: In all three cultures, family gossip and exclusion from family activities were worse for men who were out to family, and men who were out to a healthcare provider were less likely to avoid seeking care. It's not a huge surprise to hear these experiences reported by American MSM; seeing them echoed widely among African MSM confirmed they're part of a widespread pattern.
Most strikingly, in their answers to all but two questions, American respondents reported more stigma than their African counterparts (African MSM reported more blackmail and rape).
"While we feel that caution should be applied in the comparisons, the similar trends in stigma observed across these settings highlight... similarly negative experiences," said Stefan Baral, a study author and epidemiologist at the Johns Hopkins School of Public Health (JHSPH).
Some of the differences between the groups' reports may be related to differences in methodology, said Shauna Stahlman, another author and former JHSPH epidemiologist: people responding to sensitive questions online (as American participants did) often respond differently than they would in person, and some meaning might have changed when translating questions into local African languages.
Indeed, it might be hard to imagine that MSM living in the US feel more stigmatized than those living in countries like Nigeria, where even supporting "the registration, operation and sustenance of gay [institutions]" is punishable by a 10-year prison sentence. (Of the five West African countries sampled for the study, three—Nigeria, Togo, and Senegal—have laws that punish homosexual activity with imprisonment and fines.)
However, because homosexuality is criminalized or socially unacceptable in many parts of Africa, African men are much less likely to disclose their sexual preferences publicly—that is, to live uncloseted—than American men are. (In this study, 82% of American men were out to their families and 72% were out to a healthcare worker, while only 12-36% of African men were out.) Non-disclosure makes being the target of harassment or exclusion less likely.
But the study authors accounted for differences in disclosure in one of their analyses, and found that regardless of family disclosure, American MSM reported family exclusion and poor healthcare treatment two to four times as often as men living in Africa.
Some of that might be due to socio-economics. American MSM answering questions online are likely wealthier and better-educated than the global MSM population as a whole. This might lead to a better understanding of human rights and higher sensitivity to violations thereof.
But studies have also shown that living in a country with frequent and vociferous public opposition to LGBTQ civil rights increases what researchers call "internalized homonegativity"—basically, internalized stigma—even if that country has relatively liberal laws.
Stigma contributes to HIV transmission by reducing the likelihood that at-risk men will access healthcare. However, says Baral, whether a man's report of stigma is a matter of fear or actual violence is irrelevant to that effect. "One of the biggest determinants of limited engagement in care is people's perception, and not what actually happened," he says.
In that sense, understanding whether stigma reports are related to perceptions or actual experiences helps public health authorities design appropriate interventions. If a person feels stigmatized because they were treated poorly by a healthcare provider, providers might need training about LGBT health.
"[In the case of perceived stigma], it doesn't matter that you did some health care training or you engaged with the doctors or the nurses or the allied health professionals," Baral concluded. "You actually have to engage with the community to build resilience and try to change perceptions."