Sexual Identity, Mental Health, HIV Risk Behaviors, and Internalized Homophobia Among Black Men Who Have Sex With Men

Thirty-three years after HIV was first documented in gay White men, HIV has increasingly become a disease of color, with African Americans disproportionately represented. African Americans make up less than 14% of the U.S. population but account for 44% of new HIV cases (Centers for Disease Control and Prevention [CDC], 2009). According to the National HIV/AIDS Strategy, African Americans compose the greatest proportion of HIV/AIDS cases across transmission categories, including among women, adolescents, heterosexual men, individuals who inject drugs, infants, and older adults (The White House Office of National AIDS Policy, 2010). Although most segments of Black communities were affected by this epidemic, Black men who have sex with men (MSM) have experienced the negative consequences of the epidemic disproportionately. All races of MSM represent about 4% of the male population in the United States yet account for 78% of new HIV infections among men and 63% of all new infections (CDC, 2012). Black MSM have the highest rates of unrecognized HIV infection, the highest HIV prevalence and incidence rates, and the highest AIDS mortality rates among MSM in the United States (CDC, 2009). One study of five major cities found that nearly 50% of all Black gay and bisexual men were HIV positive (CDC, 2005). According to the CDC (2006) and other researchers (e.g., Laurencin, Christensen, & Taylor, 2008), reducing the incidence of HIV/AIDS among men of color who have sex with men is one of the major HIV prevention challenges in the United States. Internalized Homophobia The CDC (2009) linked homophobia and internalized homophobia to an increased risk of infection by HIV in Black MSM. Homophobia is classified as a risk factor for AIDS along with poverty, high unemployment, and poor access to health care services. In Black communities, internalized homophobia, specifically in Black MSM, may be a contributing factor to the disparity in HIV rates. Internalized homophobia is an identity, cognitive, emotional, and behavioral process that involves the personal adoption of negative attitudes and beliefs about homosexuality (Maylon, 1982). Sexual identity distress may result from internalized homophobia and was identified as a substantial factor affecting the mental health of gay and lesbian individuals (Dean et al., 2000). Low self-esteem and depression, in particular, were linked to internalized homophobia (Huebner, Davis, Nemeroff, & Aiken, 2002). HIV Risk Behaviors Internalized homophobia can affect sexual risk behaviors of Black MSM in several ways. According to Wilson, Kastrinakis, D'Angelo, and Getson (1994), African American MSM who do not disclose their sexual orientation have a prevalence of HIV infection that is nearly three times higher than that of nondisclosing MSM from all other races combined. Confirming previous research, the study by Wilson et al. of 5,589 men who had sex with male adolescents ages 15 to 19 years in six U.S. cities found that African American MSM were more likely not to disclose their sexual orientation compared with White MSM. HIV-infected nondisclosing MSM were less likely to know their HIV status and were more likely to have had recent female sexual partners. Wilson et al. postulated that the prevalence of African American nondisclosing MSM might be due to higher levels of internalized homophobia in African American communities, although they did not present any empirical evidence to support the assertion. Herek and Glunt (1995) asserted that internalized homophobia was negatively associated with feelings of self-efficacy for safe sex and positively associated with perceptions of interpersonal barriers to engaging in safe sex. Williamson (2000) conducted a systematic review of the literature and found a positive relationship between HIV risk behaviors and internalized homophobia based on three factors: (a) Gay and bisexual men with high levels of internalized homophobia are likely to be more isolated from the gay community and have less access to safer sex information and resources; (b) higher levels of internalized homophobia have consistently been shown to be associated with lower levels of self-esteem, which may lead to less condom use; and (c) higher levels of internalized homophobia may be associated with more substance use and alcohol consumption, which could impair decision-making processes (Newcomb & Mustanski, 2011). …