Ties that bind: community attachment and the experience of discrimination among Black men who have sex with men

Abstract

In the USA, the impact of psychological distress may be greater for Black men who have sex with men given that they may experience both racial discrimination in society at large and discrimination due to sexual orientation within Black communities. Attachments to community members may play a role in addressing psychological distress for members of this vulnerable population. This analysis is based on 312 Black men who have sex with men recruited for a behavioural intervention trial in New York City. Analyses were conducted using bivariate and multivariable logistic regression to examine the relationship of discrimination and community attachment to psychological distress. Most participants (63%) reported exposure to both discrimination due to race and sexual orientation. However, a majority of participants (89%) also reported racial and/or sexual orientation community attachment. Psychological distress was significant and negatively associated with older age (40 years and above), being a high school graduate and having racial and/or sexual orientation community attachments. Psychological distress was significantly and positively associated with being HIV-positive and experiencing both racial and sexual orientation discrimination. Similar results were found in the multivariable model. Susceptibility to disparate psychological distress outcomes must be understood in relation to social membership, including its particular norms, structures and ecological milieu.

Introduction

Emergent research of the social determinants of health among Black US residents increasingly examines the impact of psychological distress on overall health. The US Department of Health and Human Services, Office of Minority Health (2012) and the Centers for Disease Control (2012) report that Black US Americans are more likely to report serious psychological distress than their white counterparts. The relationship between psychological distress and repeated exposure to intentional and unintentional forms of individual, institutional and structural discrimination has received greater attention in the literature (Brooks 1981; Kessler, Mickelson, and Williams 1999; Krieger, Williams, and Moss 1997; Loiacano 1989). Unlike Black men who have sex exclusively with women, Black men who have sex with men may experience discrimination in several contexts: (1) from the general population (due to being Black and having a gay sexual orientation), (2) from the white gay community (by being Black) and (3) from the Black community (by being gay and because of perceptions of HIV status) (Bonilla and Porter 1990; Brooks 1981; DeMarco 1983; Harris 1988; Icard 1986; Loiacano 1989; Pettiway 1996). Thus, examining predictors of wellbeing among Black men who have sex with men may offer substantial evidence to support building effective community interventions.

In this study, we explored how sociodemographic factors, discrimination due to race and sexual orientation and to community attachment contribute to psychological distress. Using baseline data from a behavioural intervention trial among Black men who have sex with men (Koblin et al. 2012), the study first examined the relationships between experiences of discrimination due to racial and sexual orientation to psychological wellbeing. Next, it examined the relationship of community attachment to psychological wellbeing.

Discrimination and wellbeing

Discrimination has been associated with various negative outcomes (Burgess, Diana et al. 2009; Edwards 2008; Gatchel et al. 2007; Karlsen and Nazroo 2002; Krieger 1999; Mays, Cochran, and Barnes 2007; Williams and Mohammed 2009; Williams and Williams-Morris 2000). Specifically, multiple studies demonstrate that discrimination is associated with decreased help seeking behaviour (Boyce et al. 2012) substance and alcohol use and psychological distress (Ajrouch et al. 2010; Schulz et al. 2006; Spikes, Willis, and Koenig 2010, Wagner et al. 2013). Furthermore, researchers (Bogart et al. 2011; Franklin 2004; Utsey 1997) have suggested that repeated exposure to cultural and racial/ethnic group invalidation (e.g., in the form of micro-aggression and insults) results in frustration, helplessness, self-depreciation and reduced capacity to initiate and sustain community institutions that enhance the group’s wellbeing.

Research findings have also demonstrated the relationship between discrimination and sexual orientation to psychological distress and wellbeing (Fingerhut, Anne Peplau, and Gable 2010; Lewis et al. 2002; Mays and Cochran 2001; Swim, Johnston, and Pearson 2009). The cumulative effect of discrimination and its association with poorer health outcomes and engagement in harmful behaviour may help explain the higher rates of psychological distress among gender and sexual minorities (Allman et al. 2007; Bing et al. 2001; Caughy, Murray Nettles, and Lima 2011; Cochran and Mays 2000; Cochran, Greer Sullivan, and Mays 2003; Diaz, Ayala, and Bein 2004; Hatzenbuehler, Nolen-Hoeksema, and Dovidio 2009; Huebner, Rebchook, and Kegeles 2004; Meyer 2003). This is particularly significant given that researchers such as Bogart et al. (2011) have described the compounding effect for co-occurring forms of stigma. The authors posited that discrimination due to race, sexual orientation and HIV status was associated with more depressive symptoms than racial discrimination alone. Thus, Black men who have sex with men may experience the compounding effect for co-occurring forms of stigma linked to race and sexual orientation.

Social support and health outcomes

There is also a growing body of literature that examines the relationship between social support and HIV risk and health outcomes (Kippax et al. 1993; Lemelle and Battle 2004; Lye Chng and Géliga-Vargas 2000; O’Donnell et al. 2002). Social support has been associated with reducing psychological distress among various populations (Ajrouch et al. 2010; Cohen and Wills 1985; Kawachi and Berkman 2001; Tate et al. 2006). Socially supportive relationships may offer resources that counter or reduce disparate rates of negative health outcomes related to racial and sexual orientation discrimination (Antonucci, Ajrouch, and Janevic 2003; James 1999; Schulz et al. 2006). The research exploring social support suggests that support ameliorates distress associated with exposure to discrimination. However, given that Black men who have sex with men may experience discrimination from society at large and from within the Black community, more attention to individuals’ attachment to diverse communities may offer greater insight into the levels of support they provide. Because of this, exploration must include examining attachments to diverse communities and how these affect mental health.

This paper employs a process model of stress and coping. In this model coping represents a transaction between the individual and their environment. That is, the individual manages the stress within the limits of their ability depending on factors such the type of stress, available resources and attributes of the involved actors. (Antonucci and Jackson 1990; Bott 1971; Lazarus and Folkman 1984; Lepore 1997). The authors posit community attachment as a resource for this examination into the lives of Black men who have sex with men. Community attachment is defined as the perception by individuals that they and select others share mutual interests and potentially exchange resources (Ellemers, Spears, and Doosje 1997; Lawler, Thye, and Yoon 2008). Examining community attachment adds depth to the discussion of exposure to discrimination among Black men who have sex with men and psychological distress. For such men, attachment based on sexual orientation may differ from that based on ethnic/racial identity. Several researchers (Lemelle and Battle 2004; O’Donnell et al. 2002) reported that among US men of colour, ethnic attachment was more predictive of safer sex behaviour than attachment based on sexual orientation. Black men who have sex with men may also face discrimination within their ethnic communities due to their sexual orientation. Furthermore, attachment to communities based on sexual orientation or race/ethnicity are not exclusive of each other. Black men who have sex with men, may find attachments in Black communities and among Black gay communities. Given the extant literature, we hypothesise that exposure to discrimination will increase the odds of psychological distress. We also hypothesise that those men with both Black and Black gay community attachments will experience decreased odds of psychological distress than those with few or no community attachments.

Methods

Participants and procedures

Details of the study procedures have been previously published (Koblin et al. 2012). Briefly, between May 2008 and June 2009, Black men who have sex with men, were recruited through outreach at street and venue locations throughout New York City, referrals from local organisations and study participants, recruitment flyers and study cards placed in locations accessed by Black men who have sex with men and advertisements placed in local gay press and on websites.

Men were eligible to participate in the study if they: were 18 years or older; lived in the New York City metropolitan area; understood and read English; self-identified as male and as African American, Black, Caribbean Black, or multiethnic Black; had at least two sexual partners (male or female) in the past three months; reported unprotected anal intercourse with a man in the past three months; and were available for the duration of the study. Men were ineligible if they self-identified as a transgender woman or refused HIV testing. Men newly diagnosed with HIV infection at baseline testing were not eligible to participate enrol for six months, after which time they were eligible to rescreen. The institutional review boards at the New York Blood Center, the New York Academy of Medicine and the US Centers for Disease Control and Prevention approved the study.

After written informed consent had been obtained, participants completed a baseline behavioural assessment using audio computer-assisted self-interview technology. Following completion of the assessment, all participants received HIV prevention risk-reduction counselling and a rapid HIV antibody test if they self-reported being HIV-negative, had never been tested or did not know their current HIV status. Participants who reported being HIV infected did not undergo HIV testing if they were able to provide documentation of their HIV-positive status. Participants were referred to medical and social services as needed. At the next visit, participants were randomised to intervention or control arms and scheduled for their three-month follow-up visit.

Measures

Sociodemographic characteristics included age, education (i.e., highest degree earned), income and HIV status. Education and annual income were dichotomised into high school diploma or less versus greater than high school and < $10,000 annually versus > $10,000 annually. Participants’ age was divided into three categories, 18–29 years, 30–39 years and 40 years and over. HIV serostatus was collected at baseline.

Experience of discrimination due to race was derived from a three-item scale. Items covered verbal, physical and employment forms of discrimination (i.e., ‘As an adult, how often have you been treated rudely or unfairly because of your race or ethnicity’, ‘As an adult, how often have you been hit or beaten up because of your race or ethnicity’ and ‘How often have you been turned down for a job because of your race or ethnicity’) (α = 0. 63). The score for each experience of discrimination due to race ranged from 0 to 3, where score ‘0’ indicated that the participant had not experienced discrimination due to race, to ‘3’, experiencing it many times. Scores from 1 to 3 indicated the participant had experienced discrimination due to race and were subsequently recoded as ‘1’. A dichotomous variable was created where score ‘0’ indicated that the participant had not experienced discrimination due to race and score ‘1’ indicated the participant had experienced discrimination due to race.

Experience of discrimination due to sexual orientation and was also derived from a three-item scale, with items on verbal, physical and employment forms of discrimination (i.e., ‘As an adult, how often have you been made fun of or called names because others thought you were homosexual or not manly enough’, ‘As an adult, how often have you been hit or beaten up because others thought you were homosexual or not manly enough,’ and ‘As an adult, how often have you lost a job or career opportunity because others thought you were homosexual?’) (α = 0. 63). The score for each experience of discrimination due to sexual orientation ranged from 0 to 3, where score ‘0’ indicated that the participant had not experienced discrimination due to sexual orientation. Scores from 1 to 3 indicated the participant had experienced discrimination due to sexual orientation and and were subsequently recoded as ‘1’. A dichotomous variable was created where score ‘0’ indicated that the participant had not experienced discrimination due to sexual orientation ‘1’ indicated the participant had experienced discrimination due to sexual orientation.

Experience of neither, only one or both forms of discrimination was derived by summing the dichotomous variables created for ‘experience of discrimination due to race’ and ‘experience of discrimination due to sexual orientation.’ A score of 0 indicated the participant had not experienced discrimination due to either race or sexual orientation and was subsequently recoded as ‘0’. A score of 1 indicated the participant had experienced discrimination due to either race or sexual orientation and was subsequently recoded as ‘1’ for those who had experienced discrimination due to race or ‘2’ for those who had experienced discrimination due sexual orientation.

Psychological distress was measured by the validated Kessler Psychological Distress Scale (K10). Items include cognitive symptoms (e.g., ‘In the last month, how often did you feel nervous?’, ‘In the last month, how often did you feel tired for no good reason?’) (α = 0. 92). Respondents rated the frequency of symptoms from 1, none of the time, to 5, all of the time, in the past month. The possible range of scores was 10–50 for 10 items. Scores of less than 20 indicated that the participant was ‘Likely to be well’, scores 20–24 indicated that the participant was ‘Likely to have mild distress’, scores 25–29 indicated that the participant was ‘Likely to have moderate distress’ and scores greater than 30 indicated that the participant was ‘Likely to have severe distress’. An additional dichotomous variable was created where scores 0–19 were coded ‘0’, indicating that the participant was likely to be well, and scores 20 or greater were coded ‘1’, indicating that the participant had experienced some psychological distress.

Community attachment was measured with two items assessing connection to Black and Black gay communities. Items were ‘How connected do you feel to the African American or Black community?’ and ‘How connected do you feel to the African American or Black community of gay/bisexual men?’ Respondents rated connection from 0, not at all connected, to 8, extremely connected. Total score ‘0’ indicated that the participant was not at all connected to the African American/Black community or Black gay/bisexual men community. Scores from 1 to 8 for each variable indicated that the participant was connected to the African American/Black community or Black gay/bisexual community. A new variable was created if participants reported having attachments to both African American/Black community and black gay/bisexual community attachment (recoded as ‘1’). For the multivariate analyses, any attachment (race exclusive, sexual orientation exclusive and racial and sexual orientation inclusive) were combined into one variable (recoded as ‘1’). A score of ‘0’ indicated the participant reported no attachment.

Data analysis

Data from the baseline visit were used for these analyses. The analysis was limited to 312 men who self-identified as bisexual, homosexual, gay, same-gender loving or queer. Sixteen participants who identified as heterosexual or straight, not sure, questioning or other were excluded from the analysis. We controlled for HIV status in line with Ciesla and Roberts’ (2001) meta-analysis finding that people living with HIV are more likely to receive a major depressive disorder diagnosis than are those who are HIV-negative. Analyses were carried out using the statistical software IBM SPSS Statistics 20. The statistical analyses of data included univariate analysis to measure the distribution of all the variables used in this study within the sample population and bivariate correlations and chi-square tests. Logistic regression analysis was then performed to examine the association between discrimination and community attachment with psychological distress (dependent variable), controlling for demographics and HIV status; p-values under 0.05 were considered to indicate statistical significance.

Results

Table 1 displays frequencies for the total sample. The sample was predominantly men 40 years of age and older (56.4%) and HIV-positive (61.5%). Participants who had at least a high school education represented 84.6% of the sample, and those with annual income less than $10,000 represented 61.5% of the sample. The majority of participants (63.1%) reported experience of both race and sexual orientation discrimination, only 9.6% reported no exposure to discrimination, 18.3% reported exposure to discrimination due to race alone and 9.0% reported exposure to discrimination due to sexual orientation alone. Most participants (72.5%) reported attachment inclusive of Black communities and Black men who have sex with men communities; only 11% reported no community attachment. Over half of the participants (59.7%) score within the ‘likely to be well’ range using the K10 and 40.3% score within the ‘Likely to have Mild, Moderate or Severe Distress’ range.

Table 1.

Demographic characteristics, community attachment, exposure to discrimination and psychological distress among Black men who have sex with men (n = 312).

	n	%
Age (years)
18–29	72	23.1
30–39	63	20.5
40 +	175	56.4
HIV status
Negative	116	38.5
Positive	186	61.5
Education
< Grade 12	48	15.4
Grade 12 or GED (General Educational Development) +	262	84.6
Income
< 10,000	189	61.5
10,000 +	118	38.5
Discrimination
No experience	30	9.6
Experienced racial discrimination	56	18.3
Experienced sexual orientation discrimination	28	9.0
Experienced racial and sexual orientation discrimination	196	63.1
Community attachment
No attachment	34	11.0
Racially exclusive	41	13.3
Sexual orientation exclusive	10	3.2
Racial and sexual orientation inclusive	224	72.5
Psychological distress
Likely to be well	185	59.7
Likely to have mild distress	55	17.7
Likely to have moderate distress	35	11.3
Likely to have severe distress	35	11.3

In the bivariate analyses (Table 2) across the three age groups, men between the ages of 30 and 39 years experienced the highest percentage of psychological distress. The percentage of men with psychological distress were significantly lower for men who were at least 40 years of age than for men who were 18–29 years of age (31.4 versus 50.0% –Odds Ratio [OR] = 0. 46; 95% Confidence Interval [CI]: 0.26, 0.80) and for men who had additional education beyond high school compared with men who did not (37.0 versus 58.3% – OR = 0.42; 95% CI: 0.23, 0.79). HIV-positive men had greater odds of experiencing psychological distress than HIV-negative men (OR = 1.97; 95% CI: 1.10, 3.53). Participants who reported experience of both racial and sexual orientation discrimination had greater odds of psychological distress (OR = 2.68; 95% CI: 1.10, 6.53) than those with no reported experience of discrimination. Men who reported any type of community attachment had lower odds of experiencing psychological distress than men who did not have attachments (OR: 0.28; 95% CI: 0.13, 0.61).

Table 2.

Estimates of the relationship between psychological distress, sociodemographic characteristics, HIV-status, community attachments, and exposure to discrimination among Black men who have sex with men, and multivariate results (N = 312).

Percentage reporting psychological distress	(%)	Unadjusted			Adjusted
		OR	95% CI	p	OR*	95% CI	p
Age (years)
18–29	50.0	1.00			1.00
30–39	54.0	1.17	0.60, 2.31	0.645	1.28	0.61, 2.72	0.52
40 +	31.4	0.46	0.26, 0.80	0.006	0.41	0.21, 0.81	0.01
Education
< Grade 12	58.3	1.00			1.00
High school graduate and above	37.0	0.42	0.23, 0.79	0.007	0.37	0.18, 0.74	0.01
Income
< $10,000	39.2	1.00
$10,000 +	42.4	1.14	0.72, 1.82	0.576
HIV status
Negative	37.5	1.00			1.00
Positive	59.9	1.97	1.10, 3.53	0.022	1.87	1.06, 3.31	0.03
Discrimination
No experience	23.3	1.00			1.00
Racial discrimination	30.4	1.43	0.52, 3.97	0.49	3.39	1.03, 11.13	0.05
Sexual orientation discrimination	46.4	2.85	0.92, 8.78	0.068	4.04	1.11, 14.73	0.03
Racial and sexual orientation discrimination	44.9	2.68	1.10, 6.53	0.03	4.56	1.61, 12.87	0.004
Community attachment
No attachment	67.6	1.00			1.00
Racial and/or sexual orientation attachment	37.2	0.28	0.13, 0.61	0.001	0.26	0.12, 0.59	0.001

^*Controlling for Age, Education, Income, and HIV status in adjusted model

In the multivariate adjusted model (Table 2), sociodemographic characteristics and HIV-status were entered as control variables. Age, education, HIV-status, discrimination and community attachment were all significantly associated with psychological distress and results were very similar to the bivariate results. Men at least 40 years of age (compared with men 18–29 years of age), having greater than a high school education (compared to those who did not) and having racial and/or sexual orientation community attachments (compared to those with no attachments) had lower odds of experiencing psychological distress. Participants who reported being HIV-positive (compared to HIV-negative participants), experiencing discrimination based on sexual orientation alone, and both racial/sexual discrimination (compared to reporting no discrimination experiences) had greater odds of experiencing psychological distress.

Discussion

The findings were consistent with the hypotheses and previous research that describes an association between exposure to discrimination and psychological distress (Pieterse and Carter 2007; Pieterse et al. 2012). As hypothesised, the analyses revealed that those men who reported exposure to discrimination due to their race or sexual orientation alone or a combination of both reported higher psychological distress. Men who reported exposure to discrimination due to sexual orientation had four times the odds of reporting psychological distress as men reporting no exposure to discrimination. Men who had attachment to both the Black and the Black men who have sex with men communities were less likely to report psychological distress compared to men who reported no attachment to either community.

In this sample of Black men, HIV-status was associated with psychological distress. Other studies show a similar pattern (Ciesla and Roberts 2001; Koblin et al. 2006). Findings concerning the association between HIV status and increased psychological distress were consistent with earlier studies suggesting that the presence of an illness may heighten an individuals’ experience of stress and vulnerability to mental illness (Belbase et al. 2013). Other studies have also identified high rates of mental illness such as anxiety, depression and other mood disorders among HIV-positive persons (Bottonari and Stepleman 2010; Galvan, Audrey Burnam, and Bing 2003; Grossman and Gordon 2010).

Younger African American men, between the ages of 18 and 29, who have sex with men had greater odds of experiencing psychological distress than men who were at least 40 years of age. A hypothesis for this finding may be related to older men having had more time to adjust to the adversities they have experienced in life than younger men. Older men may have also developed support systems to handle life stressors. Although both younger and older Black men may have received guidance from parents and the Black community concerning racial discrimination (Caughy, Murray Nettles, and Lima 2011) in their formative years and into adulthood, the same type of guidance may not have been available for handling homophobia for sexual minority youth. Rather, parents and community members may espouse negative attitudes towards same-sex behaviour and may not have the skills to teach their children about the dynamics of being in a same-sex relationship or coping effectively with homophobia.

In place of building resources to cope with discrimination due to sexual orientation within the family, sexual minorities may be more likely to depend on social networks outside of the familial networks (Shippy, Cantor, and Brennan 2004). For example, family members may not be supportive of their son’s attraction to and sexual behaviour with other men. Locating friendship networks takes time (Van Sluytman et al. 2013) and younger Black men may be unable to access resources to form a protective community, resulting in increased distress and associated risk of engaging in high-risk behaviours.

Disparate health outcomes for Black US Americans, high HIV prevalence among Black men who have sex with men in general and elevated rates of new infections among young Black men who have sex with men (CDC 2012a, 2012b) have led to shifts in examining the factors that place them at increased risk for exposure for HIV. Although engaging in risk behaviour remains an important factor in understanding disease transmission, researchers have increasingly taken to examining the social determinants of disparate health outcomes among at-risk populations. Researchers (Corburn 2004; Krieger 2001; Parker 2009; Susser and Susser 1996) have asserted that social organisations, such as communities and neighbourhoods, influence the wellbeing of individuals and populations. Susceptibility to disparate health outcomes must be understood in relation to social membership, including particular norms, structures and ecological milieux. Many researchers (Franklin 2004, Franklin, Franklin, and Kelly 2006; Klonoff and Landrine 1999; Klonoff, Landrine, and Ullman 1999; Pieterse and Carter 2007) have suggested that exposure to discrimination results in psychological distress. However, diagnosing individuals who have encountered discrimination due to race or sexual orientation as having a psychiatric disorder may be an error; symptoms consistent with psychiatric diagnoses may actually be reactions in response to discrimination and not psychiatric abnormalities (Carter et al. 2013). In addition, psychiatric diagnoses may lead to individual treatment strategies that ignore the systemic, environmental and institutional factors of racism and heterosexism (Carter et al. 2004). These factors should be acknowledged and addressed.

Accordingly, it is important to examine the dynamic social interactions informed by micro-, meso- and macro-level processes. For example, for many Black Americans, discrimination is a regular occurrence on individual, institutional and structural levels (e.g., discrimination in employment, disparate rates of incarceration, exposure to urban decay). In addition to racial discrimination experiences, Black men who have sex with men face discrimination related to their sexual orientation as well. They develop multiple and possibly duelling identities. Several researchers found that exposure to discrimination has a cumulative effect that must be examined to further contextualise the experience of Black men over the lifecourse in both research and interventions (Taylor and Turner 2002). As community attachment is associated with reduced psychological distress, future research needs to identify the factors that facilitate community attachment and specific resources exchanged with these attachments towards designing effective and culturally appropriate intervention models.

Data were collected to assess the efficacy of a behavioural intervention and not specifically for the purpose of answering research questions for this paper. For example, data collection did not include measures of the quality of community attachment. As such, the findings do not assert that reduced risk of psychological distress was associated with community members affirming of racial or sexual orientation. Next, participants reporting experiencing exclusively racial or sexual orientation discrimination was not common in the sample. Similarly, few participants reported exclusively Black community or Black men who have sex with men community affiliation. As such, the researchers could not assess where these affiliation moderated the relationship between discrimination and psychological distress. Because this is a secondary analysis, variables may not be measured as accurately as with primary data collection. Low Cronbach’s alpha coefficients (α = 0. 63) of the measures of racial and sexual orientation may indicate that the items may not have high internal consistency. Furthermore, as with most cross-sectional data, the study reports associations without reference to causality.

Despite these limitations, the findings suggest that a large proportion of Black men who have sex with men experience racial and sexual orientation discrimination from society and within Black communities, and those experiences are associated with psychological distress. However, most men have attachments to the larger Black and/or Black gay communities, which may serve to decrease this distress. As such, our findings suggest several areas for further examination. They include identifying constituent members of the communities, their contribution to the experiences of discrimination, the moderating effect and mechanisms of community attachment on the relationship between discrimination on psychological distress and the specific resources exchanged through the attachment. Future research should explore the qualitative nature of these social processes within communities. Such inquiry would add significantly to the capacity to engage communities in developing effective intervention models grounded in their indigenous cultures and values.