Is internalized homophobia protective against HIV for gay and bisexual African-American men?
That's the confusing question posed by a recent analysis of data from a multiethnic group of gay and bisexual men in San Francisco, Los Angeles, New York City and Chicago. The paper, published in December in the journal Sexually Transmitted Infections, was a further parsing of the data from the Project MIX multisite behavioral intervention study conducted in 2005 and 2006, on 1,069 gay and bisexual men.
In the analysis, researchers found no association between measures of internalized homophobia and condomless anal sex among the group as a whole. But when they looked more closely at the race and ethnicity of the participants, a different story emerged: HIV-negative gay and bisexual black men were more likely to use condoms than their white or Latino counterparts. HIV-positive gay and bisexual men who had higher levels of internalized homophobia also were less likely to have condomless receptive anal sex.
"African American men with higher internalized homophobia are using condoms," said Gordon Mansergh, Ph.D., senior behavioral scientist at the U.S. Centers for Disease Control and Prevention's Division of HIV/AIDS Prevention. "We didn't know what to suspect [when we went in to this research] but we had no basis to suspect that."
Diverging From the Norm
For almost as long as there has been an HIV epidemic, there has been research into the role of internalized homophobia on health. In 1981, researchers began looking into interventions to help gay men cope with external bias against their sexualities.
But the research is far from clear. In a 2011 meta-analysis of 16 recent studies on the effect of internalized homophobia on sexual risk behaviors, the authors found little relationship between the two -- and they found that the effect diminished rapidly as time went on. In other words, as civil rights for lesbian, gay, bisexual and transgender people have expanded, the impact of internalized homophobia has dissipated.
They even went so far as to advise their colleagues that they "would be well-served to consider abandoning the investigation of [internalized homophobia] as a predictor of risky sexual behavior in order to focus resources on more promising lines of research."
But the previous research has been limited by some very real factors -- namely, that much of the previous research on internalized homophobia and sexual risk behaviors was based on small sample sizes and largely white cohorts.
What the Project MIX data revealed was very different levels of internalized homophobia by race. Gay and bisexual black men, for instance, had nearly twice the rate of internalized homophobia as their white counterparts: 27%, compared to 14% for white men. While 24% of Latino men in the study reported high levels of internalized homophobia.
The study also found that men who had higher education levels reported less internalized homophobia than those with less education.
And then, the rub: HIV-negative gay and bisexual black men in the study who reported condomless anal sex had less internalized homophobia, and those with more internalized homophobia used condoms more than their white gay and bisexual counterparts.
And while black and Latino HIV-positive men were more likely to report internalized homophobia, those same HIV-positive black men were less likely to have receptive anal sex without a condom.
"We do know from early in the epidemic that fear-based interventions work," said Mansergh. "But that's obviously not the direction we want to go with prevention programs, because of other health effects of internalized homophobia."
Because it's the first study to show an inverse relationship between internalized homophobia and condom use, Mansergh is adamant that more research needs to be done to replicate Project MIX's findings. In addition, larger studies of a more diverse group of African-American and Latino men ought to be conducted. In order to participate in Project MIX's study, men had to have had condomless sex in the last six months, and they must have been high or drunk while doing it.
"We can't generalize beyond this group," he said. "Being that this is one of the first studies to look at this strata of race and ethnicity, the results really do need to be replicated in a broader population."
The other issue is that association is not causation. Black men in this study experienced greater levels of internalized homophobia and they also used condoms more, but that doesn't mean the two have anything to do with each other, said Seth Kalichman, Ph.D., professor of psychology at the University of Connecticut, where he studies sexual compulsivity and depression, among other things, among HIV-positive men.
"I do the same kind of research that Mansergh is doing here, and the thing that haunts us all is, 'What did we not measure?'" said Kalichman, who also edits the journal AIDS and Behavior. "What might account for this?"
Among other things, Kalichman proffered that it could be that internalized homophobia is part of a more complex web of stigma that includes racism and, if HIV-positive, anti-HIV stigma.
It could also be that African-American men, especially young gay and bisexual African-American men, know that they face some of the highest rates of HIV in the country, and are acting accordingly, said Mansergh.
"Maybe, in this particular situation, African American men are taking to heart their risk of HIV infection," said Mansergh.
In other words, maybe it's not about internalized homophobia at all; maybe it's a clear-eyed assessment of risk.
A Decade Later
The other caution Kalichman lays out is that this research was conducted nearly a decade ago, in 2005 and 2006. When he reviews research for AIDS and Behavior, he said, he seriously considers whether to include research conducted more than five years ago, because the science and the culture are changing so fast.
"Two-thousand and five is before a lot of the clinical trials on drugs. It was before HPTN 052, that showed that treatment prevents infection. Heck, it was before President Obama was elected," said Kalichman. "Just today, the Supreme Court decided it wouldn't stop gay marriages in Alabama. The question in, Is this still relevant? Because things are changing so fast."
Heather Boerner is a health care journalist based in San Francisco and author of Positively Negative: Love, Pregnancy and Science's Surprising Victory Over HIV.