Structural stigma and sexual minority men's depression and suicidality: A multilevel examination of mechanisms and mobility across 48 countries.

Sexual minority men are at greater risk of depression and suicidality than heterosexuals. Stigma, the most frequently hypothesized risk factor for this disparity, operates across socioecological levels-structural (e.g., laws), interpersonal (e.g., discrimination), and individual (e.g., self-stigma). Although the literature on stigma and mental health has focused on interpersonal and individual forms of stigma, emerging research has shown that structural stigma is also associated with adverse mental health outcomes. However, there is limited data on whether changes in structural stigma, such as when a stigmatized person moves to a lower stigma context, affect mental health, and on the mechanisms underlying this association. To address these questions, we use data from the 2017/18 European Men-who-have-sex-with-men Internet Survey (n = 123,428), which assessed mental health (i.e., Patient Health Questionnaire) and psychosocial mediators (i.e., sexual orientation concealment, internalized homonegativity, and social isolation). We linked these data to an objective indicator of structural stigma related to sexual orientation-including 15 laws and policies as well as aggregated social attitudes-in respondents' countries of origin (N = 178) and receiving countries (N = 48). Among respondents who still live in their country of birth (N = 106,883), structural stigma was related to depression and suicidality via internalized homonegativity and social isolation. Among respondents who moved from higher-to-lower structural stigma countries (n = 11,831), longer exposure to the lower structural stigma environments of their receiving countries was associated with a significantly: 1) lower risk of depression and suicidality; 2) lower odds of concealment, internalized homonegativity, and social isolation; and 3) smaller indirect effect of structural stigma on mental health through these mediators. This study provides additional evidence that stigma is a sociocultural determinant of mental health. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Changes in the prevalence of self-reported sexually transmitted bacterial infections from 2010 and 2017 in two large European samples of men having sex with men-is it time to re-evaluate STI-screening as a control strategy?

BACKGROUND/OBJECTIVES: Many European countries reported increased numbers of syphilis, gonorrhoea and chlamydia diagnoses among men who have sex with men (MSM) in recent years. Behaviour changes and increased testing are thought to drive these increases. METHODS: In 2010 and 2017, two large online surveys for MSM in Europe (EMIS-2010, EMIS-2017) collected self-reported data on STI diagnoses in the previous 12 months, diagnostic procedures, STI symptoms when testing, number of sexual partners, and sexual behaviours such as condom use during the last intercourse with a non-steady partner in 46 European countries. Multivariate regression models were used to analyse factors associated with diagnoses of syphilis, gonorrhoea/chlamydia, and respective diagnoses classified as symptomatic and asymptomatic. If applicable, they included country-level screening rates. RESULTS: Questions on STI diagnoses and sexual behaviours were answered by 156,018 (2010) and 125,837 (2017) participants. Between 2010 and 2017, overall diagnoses with gonorrhoea/chlamydia and syphilis increased by 76% and 83% across countries. Increases were more pronounced for asymptomatic compared to symptomatic infections. The proportion of respondents screened and the frequency of screening grew considerably. Condomless anal intercourse with the last non-steady partner rose by 62%; self-reported partner numbers grew. Increased syphilis diagnoses were largely explained by behavioural changes (including more frequent screening). Gonorrhoea/chlamydia increases were mainly explained by more screening and a change in testing performance. A country variable representing the proportion of men screened for asymptomatic infection was positively associated with reporting symptomatic gonorrhoea/chlamydia, but not syphilis. DISCUSSION/CONCLUSION: The positive association of country-level screening rates with the proportion of symptomatic infections with gonorrhoea/chlamydia may indicate a paradoxical effect of screening on incidence of symptomatic infections. Treatment of asymptomatic men might render them more susceptible to new infections, while spontaneous clearance may result in reduced susceptibility. Before expanding screening programmes, evidence of the effects of screening and treatment is warranted.

Sexual and Mental Health Inequalities across Gender Identity and Sex-Assigned-at-Birth among Men-Who-Have-Sex-with-Men in Europe: Findings from EMIS-2017.

Some men who have sex with men (MSM) were assigned female at birth (AFB) and/or identify as trans men. Little is known about how these men differ from other MSM. We compared sexual and mental health indicators from the European MSM Internet Survey (EMIS-2017), comparing men AFB and/or currently identifying as trans men with those assigned male at birth (AMB) who identified as men. EMIS-2017 was an opportunistic 33-language online sexual health survey for MSM recruiting throughout Europe. We used regression models adjusting for age, country of residence and employment status to examine differences across groups. An analytic sample of 125,720 men living in 45 countries was used, of which 674 (0.5%) were AFB and 871 (0.7%) identified as trans men. The two sub-groups were not coterminous, forming three minority groups: AFB men, AFB trans men and AMB trans men. Minority groups were younger and more likely unemployed. Anxiety, depression, alcohol dependence and sexual unhappiness were more prevalent in sex/gender minority men. Conversely HIV and STI diagnoses were less common. AMB trans men were most likely to have sexual risk behavior with steady partners and to have unmet health promotion needs, and were least likely to be reached by interventions. Sex assigned at birth and trans identification were associated with different sexual and mental health needs. To facilitate service planning and to foster inclusion, sex-assigned-at-birth and current gender identity should be routinely collected in health surveys.

Estimating the 'PrEP Gap': how implementation and access to PrEP differ between countries in Europe and Central Asia in 2019.

In 2019, only 14 European and Central Asian countries provided reimbursed HIV pre-exposure prophylaxis (PrEP). Using EMIS-2017 data, we present the difference between self-reported use and expressed need for PrEP in individual countries and the European Union (EU). We estimate that 500,000 men who have sex with men in the EU cannot access PrEP, although they would be very likely to use it. PrEP's potential to eliminate HIV is currently unrealised by national healthcare systems.

Structural Validation and Multiple Group Assessment of the Short Internalized Homonegativity Scale in Homosexual and Bisexual Men in 38 European Countries: Results From the European MSM Internet Survey.

Internalized homonegativity (IH) is the internalization of negative attitudes and assumptions about homosexual people by homosexual people themselves. To measure IH, Smolenski, Diamond, Ross, and Rosser (2010) and Ross, Rosser, and Smolenski (2010) revised the Reactions to Homosexuality Scale (RHS) to develop the Short Internalized Homonegativity Scale (SIHS) with eight items. Using the European Men Who Have Sex With Men Internet Survey (EMIS) data, with an analytic sample of 130,718 gay and bisexual men in 38 European countries, we confirmed the validity of the SIHS scale in both training and validation data, in strata of Ross, Berg, et al.'s (2013) three "homosexual discrimination" country clusters, of age, and of education level. However, the performance was less adequate in comparison of gay versus bisexually identified individuals. The latent SIHS structure contains only minor variations across these three strata. The seven-item scale performed as well as the eight-item scale. The SIHS is a promising candidate for standard IH measures, which is invariant across cultural, age, and educational strata.

Increased incidence of syphilis in men who have sex with men and risk management strategies, Germany, 2015.

In Germany, the number of reported syphilis cases increased between 11% and 22% per year between 2010 and 2014. We analysed syphilis surveillance data and data of four behavioural surveys on men who have sex with men (MSM) in Germany (2003, 2007, 2010, 2013) to assess if this rise is ongoing and to find possible explanations for it. Syphilis notifications increased in 2015 by 19% to a total of 6,834. This was mainly due to increasing notifications in MSM of all age groups in larger German cities. Data from the behavioural surveys on MSM in Germany showed a simultaneous increase of selective condom use as HIV-status-bases risk management strategy and the number of syphilis cases. MSM diagnosed with HIV reported condomless anal intercourse with non-steady partners more frequent than MSM not diagnosed with HIV or untested for HIV, but the latter also reported higher frequencies of this behaviour in the more recent surveys. Transmission in HIV-positive MSM probably plays an important, but not exclusive role, for the syphilis dynamics in Germany. A risk adapted routine screening for sexually active MSM and potentially innovative approaches to increase early screening and treatment of syphilis such as internet counselling, home sampling, home testing and broadening venue-based (rapid) testing, should be critically evaluated to effectively reduce syphilis infections.

Transactional Sex: Supply and Demand Among European Men Who have Sex with Men (MSM) in the Context of Local Laws.

Objectives: Transactional sex (TS) is generally defined as the trading of sex for material goods. Cast within the broader context of prostitution laws, we examined variations in the sociodemographic profile of men who have sex with men engaging in TS by payment direction (buying/selling). Methods: The data were collected as part of the 38-country European Men who have sex with men Internet Survey project, conducted in 2010. Results: About 12% of respondents reported engaging in TS in the past year. TS was associated with laws, age, education, employment, and residence. Conclusions: The striking sociodemographic differences in TS by payment direction suggest a power differential and a leading role of socioeconomic factors in TS.

Comparison of the performance of STI screening services for gay and bisexual men across 40 European cities: results from the European MSM Internet Survey.

OBJECTIVES: Sexually transmitted infections (STIs) such as anal/genital warts, syphilis and genital/rectal gonorrhoeal/chlamydial infections compromise the health of men who have sex with men (MSM). Rectal bacterial STIs increase the per-contact risk of HIV infection. Early detection of asymptomatic STIs requires regular screening including collection of clinical specimens (or, for warts: physical examinations) that allow for the detection of infections at sites common to men's same sex practices. METHODS: From June to August 2010, the European MSM Internet Survey recruited 174,209 men from 38 European countries to an anonymous online questionnaire in 25 languages. As sexual healthcare for MSM in most countries is organised locally, we chose cities for comparison. Multivariable regression models were used to compare accessibility of services and applied diagnostic procedures across 40 cities. RESULTS: The proportion of respondents tested for STIs in the last 12 months in the absence of symptoms ranged from 8.9% in Istanbul to 48.0% in Amsterdam. At city level, low STI screening correlated with inaccessible services (R2=44.1%). At individual level, anal/penile inspection and anal swabbing was most common in U.K. cities, Amsterdam, Dublin and Stockholm. Compared to London, MSM in 30 cities had an adjusted OR (AOR) of (0.02 to 0.18) for anal swabbing; and (0.06 to 0.25) for anal/penile inspection (p<0.001). CONCLUSIONS: Anal/genital warts and rectal infections are likely to be profoundly underdiagnosed among MSM in most European cities. This has implications for the sexual health of MSM, HIV prevention and comparing national surveillance data. There is an urgent need to improve sexual healthcare tailored to MSM at risk for STIs.

Internalised homonegativity predicts HIV-associated risk behavior in European men who have sex with men in a 38-country cross-sectional study: some public health implications of homophobia.

OBJECTIVES: Internalised homonegativity (IH) is hypothesised to be associated with HIV risk behaviour and HIV testing in men who have sex with men (MSM). We sought to determine the social and individual variables associated with IH and the associations between IH and HIV-related behaviours. DESIGN AND SETTING: We examined IH and its predictors as part of a larger Internet-delivered, cross-sectional study on HIV and health in MSM in 38 European countries. PARTICIPANTS: 181 495 MSM, IH data analysis subsample 144 177. All participants were male, over the age of consent for homosexual activity in their country of domicile, and have had at least one homosexual contact in the past 6 months. METHODOLOGY: An anonymous Internet-based questionnaire was disseminated in 25 languages through MSM social media, websites and organisations and responses saved to a UK-based server. IH was measured using a standardised, cross-culturally appropriate scale. RESULTS: Three clusters of European countries based on the level of experienced discrimination emerged. IH was predicted by country LGB (lesbian, gay and bisexual) legal climate, Gini coefficient and size of place of settlement. Lower IH was associated with degree the respondent was 'out' as gay to others and older age. 'Outness' was associated with ever having an HIV test and age, education and number of gay friends, while IH (controlling for the number of non-steady unprotected sex partners and perceived lack of control over safe sex) was associated with condom use for anal intercourse. CONCLUSIONS: IH is associated with LGB legal climate, economic development indices and urbanisation. It is also associated with 'outness' and with HIV risk and preventive behaviours including HIV testing, perceived control over sexual risk and condom use. Homonegative climate is associated with IH and higher levels of HIV-associated risk in MSM. Reducing IH through attention to LGB human rights may be appropriate HIV reduction intervention for MSM.

Structural and environmental factors are associated with internalised homonegativity in men who have sex with men: findings from the European MSM Internet Survey (EMIS) in 38 countries.

Internalised homonegativity refers to a gay person's negative feelings about homosexuality and is believed to stem from negative societal stereotypes and attitudes towards homosexuality. Surprisingly, little research has centred on this link. In this research, we aimed to examine the associations between internalised homonegativity and structural forces, cultural influence, and access to sexual health promotion measures among a sample of 144,177 men who have sex with men (MSM) in 38 European countries. Participants were recruited as part of the European MSM Internet Survey (EMIS) during 2010. It was a self-completion, multilingual Internet-based survey for men living in Europe who have sex with men and/or feel attracted to men. Assumed causal relations were tested through multiple regression models. Variables at the structure of rule-systems (macro-level) that were significantly and negatively associated with internalised homonegativity were the presence of laws recognising same-sex relationships and same-sex adoption. In the meso-level model, greater proportions of the population expressing that they would not like to have homosexuals as neighbours predicted higher internalised homonegativity. In the last model, five variables were significantly and negatively associated with internalised homonegativity: being exposed to HIV/STI information for MSM, access to HIV testing, access to STI testing, access to condoms, and experience of gay-related hostility. In turn, men who had tested for HIV in the past year evidenced lower internalised homonegativity. This is the largest and certainly most geographically diverse study to date to examine structural and environmental predictors of internalised homonegativity among MSM. Our results show that one insidious consequence of society's stigma towards homosexuals is the internalisation of that stigma by gay and bisexual men themselves, thus, drawing attention to the importance of promoting social equity for self-acceptance around gay identity in building a positive sense of self.

HIV serosorting among HIV-positive men who have sex with men is associated with increased self-reported incidence of bacterial sexually transmissible infections.

BACKGROUND: We aimed to quantify the frequency of HIV serosorting among men who have sex with men (MSM) in Germany, and evaluate the association of serosorting with other sexual risk management approaches (RMA) and with the frequency of bacterial sexually transmissible infections (STI). METHODS: An anonymous, self-administered questionnaire was distributed through German online sexual networking sites and medical practices in 2006. The analysis was based on 2985 respondents who reported an HIV test result. Based on two questions on RMA, serosorting was classified as tactical (an event-based decision) or strategic (a premeditated search for a seroconcordant partner). The analysis was stratified by HIV serostatus and seroconcordant partnership status. RESULTS: HIV serosorting patterns were different for HIV-positive and HIV-negative participants. Tactical serosorting ranked second after RMA based on condom use (HIV-positive: 55.1%, HIV-negative: 45.1%; P < 0.001). While the overlap of strategic and tactical HIV serosorting among HIV-positive MSM was substantial (58.0%), HIV-negative strategic and tactical serosorting were more distinct (18.1% overlap). Among HIV-positive and HIV-negative respondents, tactical serosorting was associated with reduced condom use. Compared with respondents using RMA other than serosorting, HIV-positive men reporting serosorting had a three-fold increased risk for bacterial STI (strategic: odds ratio (OR) = 2.62; 95% confidence interval (CI): 1.76-3.89; tactical: OR = 3.19; 95% CI: 2.14-4.75; both for respondents without HIV seroconcordant partners). CONCLUSIONS: HIV serosorting has emerged as a common RMA among MSM. For HIV-positive MSM, it may contribute to high rates of bacterial STI that may lead to elevated per-contact risks for HIV transmission.