Tuesday, December 19, 2006

Homophobia, Stigmatization and the AIDS Epidemic: A Psychosocial Critique of a Public Health Intervention Failure - Stephanie E. Baker

Although the rate of HIV infection had declined in the United States between the mid-1980s and the mid-1990s, evidence now suggests that the number of HIV cases, mainly due to high risk sexual practices, is on the rise (CDC. Increases in HIV diagnoses, MMWR, 2003). The current HIV epidemic disproportionately affects men who have sex with men (MSM) by afflicting nearly half a million MSM in the United States alone, a startling figure which represents nearly half of all people living with HIV and 70% of all HIV infected male adults and adolescents (CDC HIV/AIDS fact sheet: HIV/AIDS among men who have sex with men. July, 2006). One way in which public health has responded to this epidemic, through sectors ranging from governmental agencies to religious advocacy groups, is through the implementation of a “use a condom every time” intervention. Given the dire, bleak state of the epidemic, wrought with rising statistics, it is clear that this behavioral change initiative has not been successful in alleviating the problem. Explaining this public health failure using reasons such as “AIDS burnout,” which results from years of exposure to prevention messages and safer sex practices (Ostrow, D.G., Fox, K., et al., 2004), is overly simplistic and could very well lead to an abandonment of the effort to help this at-risk population. Given that public health’s main goal is to promote health, prevent disease and prolong life through organized societal efforts, it is clear that a new approach is now necessary to intervene effectively in the problem. Both in content and delivery, the public health message to “use a condom every time” to reduce the spread of HIV/AIDS through high risk sexual behavior among homosexual men has been ineffective not only through individualizing the problem, but more so, in failing to address the fundamental psychosocial effects of homophobia and stigmatization in society.

One reason why the public health intervention of “Use a condom every time” is failing to reduce high-risk sexual behavior and the spread of HIV/AIDS among homosexuals is due to the message’s emphasis on individual- level risk elimination rather than on fundamental, more deeply routed societal factors. By focusing on total risk elimination rather than a more reasonable and attainable risk reduction strategy, the message lays out unrealistic goals and essentially sets the stage for the individual to fail (Siegel, 2004). If a homosexual has already engaged in sex without using a condom, the moment he hears this message, he views himself as a failure who has already put himself at great risk for HIV or AIDS. The homosexual recipient of this message adopts the fatalistic attitude that he has nothing more to lose and thereby continues to engage in high risk sexual practices. A facet of communication theory that the message to use a condom every time does not uphold is that the message must not cause harm or be offensive to the audience by blaming the victim (McGuire, 2001). By responding to the question of “What do I do if I think I am infected with HIV?” with “Remember, you must have engaged in behaviors that place you at risk for HIV infection…. those behaviors include unprotected sexual intercourse with an infected person,” not only reiterates the point that contracting the disease is the victim’s fault, but also could be perceived as having a parental tone of disappointment and condescension (“Learn about Safer Sex,” http://members.aol.com/gayjews/safer.html). In addition, stating such an obvious fact about sex and condom use is an insult to a homosexual’s intelligence, as most all are certainly aware of the dangers unsafe sex poses. Even more detrimental than insulting homosexuals on an intellectual and emotional level, using the individual-level message to use a condom every time runs the serious risk of blaming the victim, which thereby clouds the more powerful issues of homophobia and stigmatization which need to be addressed. The underlying factors of homophobia and stigmatization in influencing high risk sexual behavior wouldn’t even cross one’s mind after reading intervention materials such as the CDC HIV/AIDS Fact Sheet (2006), which lists solely individual level factors such as “complex sexual decision making, seeking sex partners on the internet, and failure to practice safer sex,” as reasons for the current increase in unprotected anal intercourse. When developing an effective public health intervention, it is important to remember that complicated behaviors are not always simple personal choices but rather are deeply intertwined within a person’s environment, making them difficult to change on one’s own accord. In order to be effective, public health messages must recognize and respond to the influence of a stigmatizing social environment on the behavior of homosexual men and move away from focusing on the individual’s risk eliminating behaviors.

Communication theory (McGuire, 2001) has shown that utilizing a message that instills a sense of fear and dread in the audience has the exact opposite effect that it intends- it completely turns the recipient off, not only to hearing the message, but also to heading the content or advice contained within that message. The World Health Organization, which states as its main objective “the attainment of the highest possible level of health for all people,” induces this fear to a large extent not only through incessant repetition of the message to use a condom every time (eight times within a six page presentation), but also through the use of capital letters and bold font to strongly and forcefully drive the message home (http://w3.whosea.org/LinkFiles/Flip_chart_14_condoms.ppt.) Inducing fear without providing a way to alleviate such fear or anxiety could lead some homosexual men to engage in unprotected sex more frequently and more often than they would have prior to hearing this message. Admonishing a homosexual to use a condom every time could be perceived as a warning that his sexual partner could very well have HIV/AIDS already, so therefore wearing a condom each and every time for protection is an absolute necessity. In a public health message geared toward homosexual orthodox Jews, the very first sentence states, “Many people think that they won’t get AIDS, but anyone who in engages in sexual behavior with a person infected with HIV can get AIDS” (“Learn about Safer Sex,” http://members.aol.com/gayjews/safer.html). For some homosexuals, this statement could form the fatalistic mindset that the risk of contracting HIV is so great, that they are bound to contract the disease at some point in their life anyway, regardless of how much protection they use and how often they use it. In addition, by bluntly stating that there virtually is no way to tell if the person they are dating has been infected with HIV, and by highlighting the fact that even condom use isn’t fool proof (“…on rare occasions, they can break”), this message heightens the level of fear that it has already begun to convey and leaves the recipient hopeless and understandably confused. Perhaps if a message is conveyed that utilizes softer tactics and provides realistic information which alleviates, rather than induces, fear, the audience would be more apt to comply with the health protection strategies contained within it.

Although most individual level behavior models are not adequate in and of themselves in getting to the root, fundamental causes of public health problems, the Theory of Self-Efficacy (Bandura, 1970) could help to explain part of the failure of the “use a condom every time” message. According to the Theory of Self-efficacy (Bandura, 1970), the extent to which a person believes they can master or be successful a certain behavior, they will perform that behavior. The theory outlines two types of expectancies that exert strong influence over a behavior: perceived outcome expectancy, which states that a certain behavior will lead to a certain outcome, and perceived self efficacy expectancy, which states that one can successfully execute the behavior to bring about the outcome. Any individual, regardless of sexual orientation, could very well not believe or have faith that he is capable of using a condom during every single sexual encounter. Therefore, this person would have a very low level of self-efficacy, and hence, will not perform the behavior of wearing a condom. In addition, if a homosexual’s potential partner dislikes or refuses to engage in sexual interaction using a condom, one perceived outcome of such a behavior could be the lack of an outlet to fulfill a homosexual’s sense of love and belonging, which is often negated within the homophobic surrounding in which he lives. Given that this outcome is far from a desirable one, he knowingly does not engage in the behavior of wearing a condom. It is easy to understand how one wouldn’t heed such an unrealistic, unattainable message as “a condom can’t do you any good if you don’t have one when you need it, so have plenty around where you could have sex” given the fact that a person knows that he isn’t capable such a task (OrthoGays. “Learn about Safer Sex,” http://members.aol.com/gayjews/safer.html, www.OrthoGays.com). In reality, sex can occur in almost all locations, so exhorting someone to be sure they have plenty of condoms around for such times is impractical. By failing to be realistic and making extreme claims which few human beings, gay or straight, could achieve, the likelihood of the message to “use a condom every time” being successful in reducing high risk sexual behavior and HIV infection is minimal at best.

Relaying the message of “wear a condom every time” to homosexuals also could be perceived as making a negative value judgment against the homosexual lifestyle. By clearly outlining in a bullet point that one of the ways in which men who have sex with men (MSM) could prevent the contraction of HIV is to be in a long-term mutually monogamous relationship, the CDC HIV/AIDS Fact Sheet is actually suggesting that not enough homosexuals are involved in a committed, monogamous relationships, in which condom use every time isn’t as necessary or vital to prevent the spread of HIV/AIDS (CDC HIV/AIDS fact sheet, January, 2006). Surely, most everyone is aware that having intercourse with solely one person (who is HIV free) drastically reduces or even eliminates the risk infection, so by actually reiterating that piece of common knowledge on a fact sheet geared solely toward homosexual men could very well leave the recipients with feelings of worthlessness and devaluation by society. Similarly, stating that “If MSM choose to have sex outside a steady relationship, they should always use a condom… (and) should know their HIV status and that of their partner(s),” is a loaded statement that suggests or hypothesizes infidelity and the inability of homosexuals to hold down a stable relationship. As Odets points out, public health, most likely, would not be so free in delivering the same message to heterosexuals due to the fact that society respects the values that heterosexuals place on committed relationships (Odets, 1995). In addition, the message to use a condom every time takes away a homosexual’s informed judgment and the ability to make his own decisions, leaving him with a sense of lack of control, hopelessness and self-doubt. Interventions should give control back to the homosexuals so that they may make informed decisions for themselves, rather than being told from outsiders, who have little understanding what it’s like to be gay in today’s society, what they should or should not do. As one gay activist had powerfully noted regarding HIV prevention messages, “we have been ‘educated’ to death. Under the rubric of ‘safer-sex,’ and ‘HIV prevention,’ we've been told what to do and what not to do, shamed and guilted incessantly. We have been messaged and marketed a million times. We have been directed, instructed, commanded, suggested, harangued and manipulated -- all by people who believe that if you tell people repeatedly what to do or not to do with their sex, they will comply,” (Rofes, 1999). Given the fact that, in this day and age, the majority of homosexual men are well informed of the risks of unsafe sex, having any prevention message which fails to respect this knowledge will, as Adam foresees, “surely fall on deaf ears” (Adam, 2005). In fact, communication theory tells us that one of the criteria that needs to be met in order to develop a persuasive message is that the messenger is seen by the audience as a credible source of information (McGuire, 2001). Although homosexuals may acknowledge that the messenger is knowledgeable in its statistical and scientific information, the two components that comprise credibility- perceived honesty and similarity to the target audience- are not met within the homophobic society in which its is transmitted. It is evident that all individuals must be viewed within their prospective social context so that we in public health can begin to better understand the attitudes and emotions and powerful extenuating circumstances underlying such high risk behavior.

A critical reason why the public health intervention message of “use a condom every time” is currently failing to alleviate the problem of high risk sexual behavior and the spread of HIV/AIDS among the male homosexual population is due to the fact that the message is being conveyed within a homophobic society and ignores the negative psychosocial effects of homophobia and stigmatization of gay men that have a significant impact on problem. Studies have shown that growing up with anti-gay messages and derogatory jokes against gays leads to an internalization of such negative attitudes and results in high levels of psychological distress (D’Augelli & Hershberger, 1993). The presence of anxiety and depression, coupled with low self-esteem, may very well drive homosexuals to engage in self-destructive risky behavior with causal partners in an effort to help validate their attractiveness and self-worth, a validation which they don’t receive within a homophobic society. Homosexual respondents in a study by Stokes & Peterson (1998) emphasized disenfranchisement and hopelessness as reason for their high risk sexual behavior. Given that sex was a way to affirm that they are loved, valued and accepted, the respondents didn’t hesitate to act impulsively and unsafely. A desperate urge to feel needed, coupled with the hope of gaining love through a solid relationship, helped fuel their self-destructive behavior. When one thinks so low of himself, the message to wear a condom each and every time one engages in intimate sexual contact, understandably, wouldn’t hold much weight. Within a hostile, homophobic environment, homosexuals are deprived of the basic human needs of safety and security, love and belonging, and status or self-esteem (Maslow, 1943). In addition to denying homosexuals a sense of safety through the threat of verbal and physical violence and aggression, homophobia denies homosexuals emotionally-based relationships, the need to love and be loved, and to be accepted as a valuable part of the community. If a person is viewed in a negative light, as a homosexual very frequently is, he becomes increasingly susceptible to social anxieties, depression and loneliness, all of which rob him of this basic human needs of security. Even worse, the locations where homosexuals could seek belonging, such as the church and family, are often the very places where homosexuals are made to feel threatened, demeaned and demoralized the most. In one study, gay males indicated higher levels of self esteem and comfort with their sexual orientation if their parents were seen as approving of their sexual orientation and were important in their lives (Savin-Williams, 1995).

Both levels of self-esteem that Abraham Maslow (1943) outlines in his Hierarchy of Human Needs- the lower level comprising the need for respect from others, including positive recognition, attention and reputation, and the higher level consisting of the need for self-respect, including feelings of confidence, independence, and achievement- are also difficult for homosexuals to receive and maintain in today’s society. Low self-esteem and inferiority complexes, which ensue from a homophobic, stigmatizing society, were considered by Maslow to be at the root of most human psychological problems, such as depression. Because society doesn’t respect or value his lifestyle, a homosexual could very well begin to internalize those negative attitudes and feelings and develop self-loathing, which then leads to a search for respect and reassurance from others in order to validate oneself. When this validation isn’t received from outer societal outlets, but rather within the context of unprotected sexual relations, the vicious cycle continues. What’s worse, given that these needs are what Maslow has called deficiency needs, when a homosexual doesn’t receive them, he feels the need for them even more so. Studies have shown that unprotected anal intercourse is associated with high levels of depression and with low self-esteem and that there is clear progression from self-acceptance of homosexuality to increased self-esteem and decreased high risk sexual behaviors (Rotherman-Borus, Ried & Koopman, 1995, In: Stokes & Peterson, 286-287). Rather than leaving the message at “you need to use a condom every time you have sexual intercourse,” public health advocates should convey that they care about homosexuals as people and that they accept and value them for who they are (AVERT, http://www.avert.org/usecond.htm). Positive messages such as these would demonstrate that society wants what’s best for homosexuals and therefore would like them to engage in behaviors to protect their health and well-being. In addition, to maximize the effectiveness of the message, public health could transmit a more flexible, softer tactic that discounts the perceived benefits of the unhealthy practice of sex without a condom rather than solely focusing on negatively attacking the unhealthy behavior. For example, relaying the understanding that unsafe sex does not make someone desirable to their peers or is not the “cool,” or socially acceptable action to take, it could lessen its occurrence. By appealing to the values of the audience- values of love, acceptance and respect- the message is more likely to have a successful outcome. As one gay respondent in a Stokes & Peterson (1998) study aptly stated regarding the effort to decrease high risk sexual behavior among homosexuals, “If you can’t get them to improve on their own self-worth and help them to love themselves, it is a lost cause” (page 285). Lacking a sense of belonging and acceptance, along with adequate levels of self-esteem, the likelihood of a homosexual moving upwards on the hierarchy of human needs toward the human growth need of self-actualization and engaging in self health protection, especially through using a condom every time, is slim.

Homophobic attitudes within society create a “don’t ask don’t tell” atmosphere and very often set the stage for some homosexuals to engage in quick, secretive encounters which occur without protection. According to Labeling Theory (Becker, 1963), the labels applied to individuals influence their behavior. Those who are labeled in a certain way actually take on the characteristics of those labels and live up to them as a self-fulfilling prophecy. Through homophobic stigmatization, homosexuals are labeled as deviant, abnormal and highly promiscuous; therefore, a small subset of the gay community actually confirms, and helps to define, that label through frequent and unsafe causal encounters. Viewing themselves as morally at odds with those members of the rule abiding, normative, and homophobic society in which they live, these homosexuals see themselves as different from the mainstream and thereby feel they have little choice but to conform to the essential meaning of the judgment placed upon them. Focusing attention on the act of the individual by admonishing him to always wear a condom is clearly ineffective in intervening in this problem due to the fact that certain homosexuals, albeit a small sub-population, actually seek out these unsafe sexual encounters- the polar opposite effect that the message intends to bring about. “Barebackers,” men who seek out other men for unsafe sex, have been portrayed within the gay media as rebels who break away from their conformist peers (Suarez, T & Miller, J., 2001). Engaging in such self-deprecating and self-destructive behavior not only affirms the label that has been applied to the gay population by society, but also reveals that these men are actively seeking out attention, love and a sense of belonging, albeit in a fleeting and dangerous manner that ultimately will fail to nourish and sustain such needs. This reckless behavior, which essentially is a game of Russian roulette, displays just how low these men think of themselves and just how little self-worth they hold within them. As Green (1996) appropriately states, “...ignoring the role homophobia plays in the psychology of AIDS means ignoring an element of a disease at least as powerful as biology. If we care about health, there is little choice but to care about people’s feelings, too” (page 84). Rather than endorsing the message of “use a condom every time,” which essentially admonishes homosexual men to behave a specific, predetermined way within their intimate, personal relationships, public health should instead focus on expressing their care, concern and respect of the homosexual lifestyle. This strategy would hold great promise in creating a comfortable atmosphere that fosters open discussion rather than one that dismisses homosexuals as deviant and abnormal. Because the deviant behavior here is labeled as such by persons in positions of power, or our homophobic, masculinized society, the change that is warranted lies with altering society’s views, not with homosexual men’s actions. Perhaps if society’s moral indignation is replaced with tolerance and respect, the desired outcome of less unsafe sexual relations and an alleviation of the AIDS epidemic would be seen.

By shifting our attention away from the current proscriptive message to use a condom every time and toward the more proactive approach of addressing and combating homophobia, perhaps we in public health can begin to see a decline in the high risk sexual behavior and consequential HIV/AIDS epidemic among the homosexual population. One way in which public health could help to diminish or alleviate society’s homophobic attitudes and beliefs is through educational programs geared toward young children. By targeting people at a young age, a time in human development when one’s beliefs, attitudes and values are formed, and shifting the focus away from the dominant, heterosexual norm through an early introduction to alternative lifestyles, children will be much more likely to grow up viewing their homosexual peers with respect and acceptance rather than with disdain or degradation. Given that it is human nature to fear the unknown or that which is different, bringing the homosexual lifestyle to the forefront and shedding light on the fact that homosexuals share the same needs and values as their heterosexual counterparts would be an effective tactic in addressing the problem. Storybooks or television programs which portray healthy, loving relationships within families with homosexual parents could help debunk the negative stereotypes that permeate our society and break down the barriers to foster insightful discussion, both within the classroom and without. It is within this supportive, welcoming atmosphere that strides could be made not only in building up a homosexual’s self-esteem and sense of self-worth, which would help him to refrain from engaging in the unhealthy, self-destructive behavior of unsafe sex, but also in displaying to the greater community that homosexuals are no different than their heterosexual counterparts in their basic human needs for love, protection and respect. In fact, studies have shown that social support plays a prominent role in a gay man’s psychological well-being. It has been found that homosexuals who perceive themselves as having low social support are likely to be depressed and have lower levels of self-acceptance than those with high social support (Vincke & Bolton, 1994). Procuring the assistance of gay role models to invest in an educational, informational intervention would provide them with the confidence and self-respect they need to engage in healthier sexual practices which involve protection rather than destruction. Utilizing an opinion leader within the population to communicate these positive images is a tactic that holds a better chance of a message being accepted and embraced by the homosexual community, as it is known that the more similar in values the communicator is to the audience, the more likely the audience is relate to the communicator and, hence, the more likely they are to comply with the content of the message (Rogers, 1983). Just as homosexuals themselves have been successful in utilizing peer outreach tactics to reduce the rate of unsafe sex among their peers, so can we in public health be successful in reducing society’s homophobic attitudes (Keagles, Hayes & Coates, 1996). Creating a non-stigmatizing environment that provides social support and social networks could aid in the fight against the HIV/AIDS epidemic among MSM and serve as a protective barrier to a homosexual’s societal-induced vulnerability and consequential unsafe sexual practices.

It is clear that addressing the AIDS epidemic among homosexuals by utilizing an intervention which focuses solely on individual behavior modification distracts us, in public health, from seeing the deeper contributing issues of homophobia and stigmatization and their negative effects on homosexuals. Stigmatization and homophobia not only affect the perceptions and practices of individual homosexual men, they also hamper the provision of interventions that are effective, affirming, and tailored to meet the needs of the population (Valdiserri, RO; In Peterson & DiClemente, 2001). The public health message to “use a condom every time” exhorts gays to act safely in the present moment in order to maintain healthy selves for the future, but if life is perceived by them as not worth living in the here and now, the future is irrelevant. Although changing deeply entrenched homophobic attitudes and views is a daunting, difficult task at best, at least our effort to try to address them is a strong step in the right direction.


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Blogger Michael Siegel said...

This is an outstanding and thorough critique, and an excellent example of the use that the social and behavioral sciences can play in informing the development of more effective interventions.

I think you make a very insightful point that if people do not have a basic feeling of acceptance and self-worth in the here and now, that it is pointless to try to encourage them to adopt a health behavior to protect themselves years in the future. This is one of the most misunderstood points in public health practice.

I think this critique focuses our efforts exactly where they need to be. The difficulty of addressing homophobia is no excuse for failing to do what we need to do to address the AIDS epidemic.

8:12 AM  
Anonymous Anonymous said...

Stephanie, I was very glad to have the chance to read your paper as I spend much of my professional life working in HIV/AIDS prevention and treatment. You have a very well researched paper and I enjoyed reading it...despite not being in your seminar. Your hard work is clear.

One thing I would ask you to consider. Being referred to as a "homesexual" isn't how most of the community identifies. It is also not generally used synonomously with "men who have sex with men." Your arguement is that problems around HIV preveniton interventions are homophobia in our society and the lack of acceptance. I agree--and I guess that I would also say that cultural competency is essential when doing research with marganalized communities. A paper that doesn't feel culturally competent actually feels like it adds to the very problems you identify rather than helping out. I am sure this wasn't your intention, but thought it was important feedback for you to get--especially since the blog is "public."

Another thing to consider is that the messages may need to take identity into account -- men who identify as gay? bisexual men? What about men who engage in sex with men, but they identify as straight? Do some messages work bettter for different groups?

Again, thanks for your paper...I look forward to further converation about it. Rodney

3:49 PM  
Anonymous Anonymous said...

Hey Stephanie,
Just wanted you to know that I really enjoyed your paper. I found your suggestions for the future especially enlightening, as you brought up many intervention ideas I would not have previously considered. Great job!

11:26 AM  
Anonymous Anonymous said...

Hi Rodney,

Thanks for your feedback. I appreciate the time you took to read my paper and comment on it. Regarding your comment- for the sake of the length of the paper, I narrowed my focus on homosexual men (who self- identify as gay, although I did not explicitly state that or elaborate on that within the paper). Writing on "bisexual men" or "men who have sex with men but who self identify as straight" would have gone beyond the scope of the assignment, but they are definitely interesting areas to consider. In addition, I realize that members of the community itself don't refer to themselves as "MSM," but I wanted to cite the term as it was stated in the research articles I had utilized for support. I definitely agree that it's important for research to delve into the community and ask the members themselves what they feel would be effective interventions to successfully combat the epidemic. Cultural competency is clearly vital to coming up with solutions. Thanks again for your feedback.

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