Intersecting Sexual Behavior and Gender Identity Stigmas Among Transgender Women in the United States: Burden and Associations with Sexual Health.

In the United States, a context of multiple marginalization shapes sexual health disparities experienced by transgender women. Using data from 396 transgender women with negative or unknown HIV status, we performed exploratory factor analysis on responses to gender identity and sexual behavior stigma items and regressed sexual health outcomes on extracted factors via modified Poisson regression with robust variance estimation. Overall, 97.2% of participants endorsed ≥ 1 gender identity stigma; 67.2% endorsed ≥ 1 sexual behavior stigma; and 66.9% endorsed ≥ 1 of each. Extracted factors included gender-identity social stigma, reflecting experiences related to family, fearfulness in public, and verbal harassment (α = 0.68); gender-identity institutional stigma/violence, reflecting experiences related to healthcare, police interactions, and interpersonal violence (α = 0.73); and global sexual behavior stigma, reflecting experiences related to family, friends, and healthcare, as well as police interactions, fearfulness in public, verbal harassment, and interpersonal violence (α = 0.83). Gender-identity social stigma was significantly, positively associated with testing for HIV and testing for sexually transmitted infections. Gender-identity institutional stigma/violence and global sexual behavior stigma were both significantly, positively associated with condomless anal sex, sex work, testing for HIV, testing for sexually transmitted infections, and use of HIV pre-exposure prophylaxis. Stigma-mitigation remains critical to improve quality of life and sexual health for transgender women in the United States.

Metrics of Sexual Behavior Stigma Among Cisgender Men Who Have Sex With Men in 9 Cities Across the United States.

Men who have sex with men (MSM) in the United States are stigmatized for their same-sex practices, which can lead to risky sexual behavior, potentiating risk for human immunodeficiency virus (HIV) infection. Improved measurement is necessary for accurately reporting and mitigating sexual behavior stigma. We added 13 sexual behavior stigma items to local surveys administered in 2017 at 9 sites in the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance system, which uses venue-based, time-sampling procedures to survey cisgender MSM in US Census Metropolitan Statistical Areas. We performed exploratory factor analytical procedures on site-specific (Baltimore, Maryland; Denver, Colorado; Detroit, Michigan; Houston, Texas; Nassau-Suffolk, New York; Portland, Oregon; Los Angeles, California; San Diego, California; and Virginia Beach-Norfolk, Virginia) and pooled responses to the survey items. A 3-factor solution-"stigma from family" (α = 0.70), "anticipated health-care stigma" (α = 0.75), and "general social stigma" (α = 0.66)-best fitted the pooled data and was the best-fitting solution across sites. Findings demonstrate that MSM across the United States experience sexual behavior stigma similarly. The results reflect the programmatic utility of enhanced stigma measurement, including tracking trends in stigma over time, making regional comparisons of stigma burden, and supporting evaluation of stigma-mitigation interventions among MSM across the United States.

Metrics of sexual behavior stigma among cisgender men who have sex with men in Mexico: exploratory and confirmatory factor analyses.

Cisgender gay, bisexual, and other men who have sex with men (MSM) in Mexico experience disparities in sexual health outcomes, perhaps most notably in HIV prevalence, HIV testing and status awareness, and condom use. Sexual behavior stigma, underpinned by socio-structural factors specific to Mexico (e.g., machismo), uniquely shapes these sexual health disparities. However, few reliable, valid measures are available to document, track, and ultimately mitigate sexual behavior stigma in this context. Exploratory and confirmatory factor analyses were performed on responses to a 13-item sexual behavior stigma scale from 15,681 MSM recruited online across Mexico. Associations with extracted factors were tested to assess construct validity. Three subscales were identified in exploratory factor analysis and validated in confirmatory factor analysis: "stigma from family and friends" (α = 0.65), "anticipated healthcare stigma" (α = 0.84), and "general social stigma" (α = 0.70). External construct validity was indicated through each subscale's strong association (all p < 0.001) with perceived community intolerance of MSM and perceived community discrimination toward people living with HIV. These subscales show promise as reliable, valid measures for assessing sexual behavior stigma among MSM in Mexico, and as tools for documenting and tracking sexual behavior stigma trends, comparing regional burdens of sexual behavior stigma, and tracking the progress of stigma-mitigation interventions among MSM in Mexico. Future research is needed to understand the extent to which each subscale is differentially associated with sexual (and other) health outcomes, which can inform the development and implementation of uniquely tailored stigma-mitigation, HIV-prevention, HIV-care, and other needed interventions for MSM in Mexico.

Characterizing Cross-Culturally Relevant Metrics of Stigma Among Men Who Have Sex With Men Across 8 Sub-Saharan African Countries and the United States.

Overcoming stigma affecting gay, bisexual, and other men who have sex with men (MSM) is a foundational element of an effective response to the human immunodeficiency virus (HIV) pandemic. Quantifying the impact of stigma mitigation interventions necessitates improved measurement of stigma for MSM around the world. In this study, we explored the underlying factor structure and psychometric properties of 13 sexual behavior stigma items among 10,396 MSM across 8 sub-Saharan African countries and the United States using cross-sectional data collected between 2012 and 2016. Exploratory factor analyses were used to examine the number and composition of underlying stigma factors. A 3-factor model was found to be an adequate fit in all countries (root mean square error of approximation = 0.02-0.05; comparative fit index/Tucker-Lewis index = 0.97-1.00/0.94-1.00; standardized root mean square residual = 0.04-0.08), consisting of "stigma from family and friends," "anticipated health-care stigma," and "general social stigma," with internal consistency estimates across countries of α = 0.36-0.80, α = 0.72-0.93, and α = 0.51-0.79, respectively. The 3-factor model of sexual behavior stigma cut across social contexts among MSM in the 9 countries. These findings indicate commonalities in sexual behavior stigma affecting MSM across sub-Saharan Africa and the United States, which can facilitate efforts to track progress on global stigma mitigation interventions.

A structural equation model of factors associated with HIV risk behaviors and mental health among men who have sex with men in Malawi.

BACKGROUND: Men who have sex with men (MSM) bear a disproportionate burden of HIV in Malawi. Early prevention efforts in Malawi have been largely focused on preventing heterosexual and vertical transmission of HIV, and MSM have rarely been the specific benefactors of these efforts, despite facing both higher prevalence of HIV coupled with multiple barriers to prevention and care. To better facilitate the design of culturally relevant HIV prevention programs and prioritize resources among MSM in resource limited settings, the objective of this analysis was to estimate the relationship between social factors and HIV related risk behaviors and mental health. METHODS: 338 MSM were recruited using respondent-driven sampling in Blantyre, Malawi from April 2011 to March 2012. Structural equation models were built to test the association between six latent factors: participation in social activities, social support, stigma and human rights violations, depression symptomatology, condom use, and sexual risk behaviors, including concurrent sexual partnerships and total number of partners. RESULTS: The mean age of participants was 25 years old. Almost 50% (158/338) of the participants were unemployed and 11% (37/338) were married or cohabiting with women. More than 30% (120/338) of the participants reported sexual behavior stigma and 30% (102/338) reported depression symptomatology. Almost 50% (153/338) of the participants reported any kind of HIV-related risk behaviors and 30% (110/338) participated in one of the recorded social activities. Significant associations were identified between stigma and risk behaviors (ß = 0.14, p = 0.03); stigma and depression symptomatology (ß = 0.62, p = 0.01); participation in social activities and depression symptomatology (ß = 0.17, p = 0.01). CONCLUSION: Results suggest MSM reporting stigma are more likely to report sexual risk practices associated with HIV/STI transmission and depressive symptoms, while those reporting participation in social activities related to HIV education are less likely to be depressed. Furthermore, interventions at the community level to support group empowerment and engagement may further reduce risks of HIV transmission and improve mental health outcomes. Taken together, these results suggest the potential additive benefits of mental health services integrated within comprehensive HIV prevention packages to optimize both HIV-related outcomes and general quality of life among MSM in Malawi.

Gender identity and sexual behavior stigmas, severe psychological distress, and suicidality in an online sample of transgender women in the United States.

PURPOSE: The objective of this study is to (1) quantify burden of perceived, anticipated, and enacted gender identity (GI) and sexual behavior (SB) stigmas and (2) explore associations between GI and SB stigmas with key mental health factors among transgender women in the United States. METHODS: We estimated associations between GI and SB stigmas with severe psychological distress, suicidal ideation, and suicide attempt using cross-sectional data from the Transgender Women's Internet Survey and Testing study from March to April, 2019. Modified Poisson regression produced prevalence ratios and 95% confidence intervals for severe psychological distress, suicidal ideation, and suicide attempt with GI and SB stigma items individually, as well as the GI and SB stigma items treated as two scales. RESULTS: Of 381 transgender women, 52% experienced severe psychological distress in the past month, whereas 59.3% and 13.12% reported suicide ideation and attempt in the past year, respectively. In adjusted models, GI and SB stigma scales were significantly, positively associated with severe psychological distress, suicidal ideation, and suicide attempt. CONCLUSIONS: Continued training for providers in trans-competent mental health care and the development of newer engagement and delivery strategies for stigma mitigation interventions are needed.