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. Author manuscript; available in PMC: 2022 Jul 1.
Published in final edited form as: Ethn Health. 2018 Dec 18;26(5):646–658. doi: 10.1080/13557858.2018.1557115

Discriminatory Distress, HIV Risk Behavior, and Community Participation among American Indian / Alaska Native Men Who Have Sex with Men

Matthew A Town a, Karina L Walters b, E Roberto Orellana c
PMCID: PMC6581640  NIHMSID: NIHMS1516342  PMID: 30560701

Abstract

Research regarding men who have sex with men (MSM) indicates that exposure to discrimination based on race and sexuality are positively associated with increased incidence of unprotected anal intercourse (UAI). In an effort to better understand this association, we assessed the associations of discriminatory distress with UAI among a sample of 183 American Indian and Alaska Native (AI/AN) MSM using survey data drawn from the HONOR Project. The HONOR Project examined the relationship between trauma, coping, and health behaviors among Two-Spirits (a contemporary name for gender and sexual minorities among American Indian and Alaska Native people). Using multivariable logistic regression techniques, our analysis showed participants reporting higher mean levels of distress from two-spirit discrimination had higher odds of reporting UAI (OR = 1.99, 95% CI, 1.19–3.32) compared to those reporting lower levels of distress. This analysis also showed lower odds of engaging in UAI among participants reporting higher levels of participation in LGBT specific online forums (OR = 0.86, CI = 0.75, 0.99; p < .05) and attending Two-Spirit events (OR = 0.82, CI = 0.71, 0.94; p < .01). Future prevention research and program designs should address the differential impact of discrimination and community participation on sexual behavior specifically among AI/AN MSM.

Keywords: American Indian / Alaska Native (AI/AN), Men Having Sex With Men (MSM), Discriminatory Distress, HIV Risk Behavior, Community Participation, Unprotected Anal Intercourse (UAI)

Introduction

As the HIV epidemic enters into its fourth decade, racial minority men who have sex with men (MSM), specifically American Indian and Alaska (AI/AN) MSM (hereinafter “AI/AN MSM”) experience high rates of infection and mortality from HIV. Though the seroprevalence of HIV among AI/ANs is low, there is growing concern regarding HIV within the AI/AN population as AI/ANs experience a significantly shorter time than any other racial group in the United States from initial diagnosis of HIV infection to AIDS-defining illness and experience one of the lowest survival rates after an AIDS diagnosis is made (Centers for Disease Control and Prevention (CDC). 2015). Additionally, male-to-male sexual contact, specifically unprotected anal intercourse (UAI), is the most common mode of exposure to HIV among AI/ANs (Bertolli, McNagthen, Campsmith, Lee, Leman, Bryan, & Buehler, 2004; McNaghten, Neal, Li, & Fleming, 2005). Finally, two recent studies report the prevalence of HIV infection among AI/AN MSM ranging from 18% to 34% as a result of UAI (Cassels, Pearson, Walters, Simoni, & Morris. 2011; Pearson, Walters, Simoni, Beltran, & Nelson. 2013), which is comparable to other samples of Asian, Black, Latino, and Pacific Islander MSM (Ayala, Bingham, Kim, Wheeler, & Millett. 2012; Bruce, Ramirez-Valles, and Campbell 2008; Chae and Yoshikawa 2008; Choi, Paul, Ayala, Boylan, & Gregorich. 2013).

Researchers still know very little about the predictors of UAI among racial minority MSM. To date, much of the research on HIV risk has relied upon theories that explain health disparities in HIV transmission using an individualistic paradigm that explain HIV transmission only at the level of individual agency (Cockerham 2005). However, the HIV behavioral research literature is documenting the important associations between HIV risk behavior and structural factors, such as discrimination, that take into account the contextual social forces that influence health behaviors (Ayala et al. 2012; Poundstone, Strathdee, and Celentano 2004). Increasingly, research studies have found that among racial minority MSM, experiences of race- and sexuality-based discrimination are associated with higher levels of UAI (Ayala et al., 2012; Mizuno, Borkowf, Millett, Bingham, Ayala, & Stueve, 2012; Yoshikawa, Wilson, Chae, & Cheng, 2004). Though situated within the experiences of Asian, Black, Latino, and Pacific Islander MSM, those research findings have important implications for understanding how racial and sexual discrimination may affect UAI among AI/AN MSM. The existing literature points to a need for identifying and understanding the different predictors that help explain the relationship between discrimination and UAI among racial minority MSM, and specifically among AI/AN MSM.

In addition to the characterization of risk factors at multiple levels (i.e., individual, interpersonal, and structural levels), there is also a need to better understand the role of protective factors against HIV risk. The research on the association of community participation and HIV risk behavior states that racial minority MSM who are more integrated into the gay community are less likely to engage in unprotected sex (Chng & Geliga-Vargas, 2000; O’Donnell, Agronick, San Doval, Duran, Myint-U, & Stueve, 2002). The rationale is that racial minority MSM who isolate themselves from the larger LGBT community, also isolate themselves away from an environment and a network that expose them to safe sex messages and discussions of HIV, resulting in increased HIV risk behaviors. This research provides some evidence that community participation, particularly in the gay community, has been conceptualized as having a protective or buffering effect regarding HIV risk behavior. Though, the research suggests that racial minority MSM who are more integrated into their racial communities are more likely to engage in HIV risk behaviors (Chng and Geliga-Vargas 2000), the recent literature argues that racial-minority MSM need a connection to their racial and ethnic communities as a means of maintaining strong racial and ethnic identities and improved self-esteem (Han 2007) in order to reduce their HIV risk behaviors. The research that specifically addresses community participation in relation to AI/AN MSM is missing. Given the importance of traditional values (relational ways of being, and the importance of connection to people) that are often shared among most American Indian and Alaska Native communities, it is important to examine community participation of AI/AN MSM in the LGBT community, the AI/AN community, and their intersection also known as the two-spirit community.

CONTEXTUALIZING TWO- SPIRITS

Working with American Indian and Alaska Natives requires knowledge and understanding of the relevant historical, political, cultural, and social context that have and continue to influence these communities. Historically, American Indian and Alaska Native communities included diverse gender and sexual identities beyond the binaries of male and female and heterosexual and homosexual (Walters, Evans-Campbell, Simoni, Ronquillo, & Bhuyan. 2006). Individuals with diverse gender and sexual identities were integrated into communities, often holding highly respected positions, as communities valued the fulfilment of one’s roles and responsibilities over one’s gender or sexuality (Walters et al. 2006).

Centuries of colonization have had devastating effects on American Indian and Alaska Natives communities that can be assessed today not only in terms of the loss of culture, land, and knowledge (Duran, Firehammer, and Gonzalez 2008; Gone 2008), but also in the loss of traditional conceptions of diverse gender and sexual identities (Walters et al. 2006). Colonizing practices that have led to the loss of traditional conceptions of gender and sexuality, have also influenced the overwhelming disparities in physical and mental health including HIV and AIDS (Gilley 2006). Examining disparities within the context of colonizing practices, frames HIV infection among American Indian and Alaska Natives as a structural phenomenon and an issue of social justice.

The contemporary term signifying diverse gender and sexual identities among American Indian and Alaska Native people is “two-spirit” (Anguksuar [LaFortune R] 1997). In addition to providing a space for gender and sexual minority American Indian and Alaska Native people, the term two-spirt also provides a pathway to enculturate (Bersamin, Wolsko, Luick, Boyer, Lardon, Hopkins, Stern, & Zindenberg-Cherr, 2014) and reclaim a cultural practice of valuing diverse gender and sexual identities and the corresponding social and ceremonial roles (Jacobs, Thomas, and Lang 1997), as a means of decolonizing the lived experience and celebrating one’s traditional authentic self. The process of enculturation bolsters the self-esteem among two-spirit people thereby protecting against adverse health outcomes (Walters, 1998) and is posited here as a protective factor against HIV sexual risk behavior.

Therefore, it is important to consider both AI/AN community participation as well as two-spirit community participation when examining the protective effect of community participation as AI/AN MSM belong to various communities. Therefore, the present study sought to address the following questions: 1) is discriminatory distress associated with HIV risk behavior among AI/AN MSM, and if so, to what extent? and 2) is community participation associated with HIV risk behavior among AI/AN MSM, and if so, to what extent?

METHODS

Participants and Procedures

This study used a sample of AI/AN MSM from the HONOR Project, a study designed to examine the relationship between trauma, coping, and health behaviors among two-spirit individuals (Cassels et al. 2011; Chae and Walters 2009; Nelson and Simoni 2011; Pearson et al. 2013). The HONOR Project was conducted in partnership with community-based agencies serving urban AI/ANs located in seven metropolitan areas in the U.S.: Seattle-Tacoma, Washington; San Francisco-Oakland and Los Angeles, California; Denver, Colorado; Tulsa, Oklahoma; Minneapolis—St Paul, Minnesota; and New York, New York. Each agency was responsible for conducting participant recruitment and participant interviewees.

The HONOR Project used a combination of targeted, partial network, and respondent-driven techniques to recruit participants, while minimizing non-coverage, overrepresentation, and other selection biases (Cassels et al. 2011; Chae and Walters 2009; Lehavot, Walters, and Simoni 2009). Full recruitment procedures of the HONOR Project have been published elsewhere (Cassels et al. 2011; Chae and Walters 2009; Lehavot et al. 2009; Nelson and Simoni 2011; Pearson et al. 2013). Participation in the HONOR Project was open to individuals who a) self-identified as American Indian, Alaskan Native, or First Nations and either enrolled in one’s tribe or had at least one-quarter in total American Indian blood quantum; b) self-identified as gay, lesbian, bisexual, transgender, or two-spirit or had sexual relations with someone of the same sex during the past 12 months; c) resided, worked, or socialized in the study area; d) were 18 years of age or older; and e) spoke English (Chae and Walters 2009; Lehavot et al. 2009).

The HONOR Project used computer assisted interview software to conduct interviews. Interviews lasted approximately 3 to 4 hours. Participants received $65.00 for completing their interview. A total of 447 participants were interviewed between July 2005 and March 2007.

Data access for this study was granted in collaboration with the HONOR Project team, the Indigenous Wellness Research Institute, and the University of Washington. The inclusion criteria used to generate a sample of AI/AN MSM from the HONOR Project included participants a) self-identified as male b) who have had sex with a man at least once in their life-time and c) those that completed the Two-Spirit discrimination scale (n=183). All data preparation and analyses were conducted using STATA (version 12.0). The study protocol was approved by the Institutional Review Boards at the University of Washington and Portland State University, as well as by each of the community-based partners.

Measures

Discriminatory Distress.

The HONOR project collected information on stress attributable to routine experiences of discrimination. The HONOR project utilized the Two-Spirit Microaggression Scale, consisting of 32 items, designed to assess distress due to discrimination based on the unique standpoint of two-spirit people. Microaggressions are conceptualized as the “everyday verbal, nonverbal, and environmental slights, snubs, or insults, whether intentional or unintentional, that communicate hostile, derogatory, or negative messages to target persons based solely upon their marginalized group membership” (Sue, Capodilupo, Torino, Bucceri, Holder, Nadal, & Esquilin, 2007). Participants were asked how “distressed” or “bothered” they were over their lifetime with experiences of: “feeling that you have to leave or stay away from your reservation in order to express yourself as two-spirit”; “encountering white people who identify as two-spirit”; “hearing from other Natives that two-spirits did not historically exist in their tribe or your own tribe”; “seeing stereotyped imagery of two-spirit people such as the Village People.” Responses categories used a Likert scale ranging from 0 (not at all distressed or bothered) to 4 (extremely distress or bothered). The Cronbach’s alpha for the Two-Spirit Microaggression Scale is 0.95. Using the ‘rowmean’ function in STATA, the scale was operationalized using the mean score, whereby higher mean scores are associated with increased levels of distress related to discrimination.

HIV Risk Behavior.

The HONOR project collected information on sexual behavior and HIV risk within the past 12 months from date of interview. From these data, HIV risk behavior was measured as unprotected anal intercourse (UAI), a binary variable (yes = 1) indicating whether or not a participant engaged in this behavior at least once within the past 12 months.

Community Participation.

Community participation data was collected within three specific communities: AI/AN, LGBT, and the two-spirit communities. AI/AN community participation was assessed using the frequency of ceremonial and cultural activities. Participants were asked a series of 8 questions on how often they participated in traditional ceremonies and cultural events. Responses varied from 0 (never) to 5 (once a day or more). The mean score was used for analysis in which higher scores indicated higher frequency of participation. LGBT community participation was assessed using two indicators: how often participants attended LGBT events (i.e. support groups, meetings, political rallies, and parades) that were not specifically for two-spirit people and how often they participated in or visited LGBT online forums (i.e. websites, online chat rooms or email discussion groups). Two-Spirit community participation was assessed using two similar indicators: how often participants attended events such as support groups, meetings, sweats and drum groups that were specifically for two-spirit people and how often they participated in or visited two-spirit specific online forums (i.e. websites, online chat rooms or email discussion groups). Response categories for all LGBT and two-spirit indicators ranged from 0 (never) to 7 (at least once per day).

Correlates.

The HONOR Project collected known correlates of HIV risk behavior including age (years old at time of interview), self-reported HIV serostatus (positive = 1), and whether participants had a current romantic or sexual partner (yes = 1). Socioeconomic status variables included education (less than high school, high school or GED, some college or vocational training, and college degree or more), household monthly income (<$1,000, $1,000 - $2,000, >$2,000), and employment status (working or not working). Behavioral variables included depressive symptoms, alcohol use, and substance use. Depressive symptoms were measured using the total score from the Center for Epidemiologic Studies Short Depression Scale (CES-D 10). Alcohol use was assessed using a measure of frequency over the past 12 months (had not had a drink in the past 12 months; drank within the past 12 months, but not within the past 30 days; drank within the past 30 days, but not within the past 7 days; and drank within the past 7 days). The substance use measure assessed the number of different drugs participants had used within the past 12 months (including methamphetamine, stimulants, ‘club’ or ‘designer’ drugs, any form of cocaine, opiates, hallucinogens, inhalants, any form of marijuana, tranquilizers, and erectile dysfunction medication used recreationally).

Data Analyses

Descriptive statistics were calculated for all variables. Pearson’s chi-square (χ2) tests and t-tests were used to identify differences in levels of reported distress, community participation and correlates by whether or not participants had engaged in UAI within the past 12 months, see Table I. Logistic regression techniques were used to assess the unadjusted magnitude of two-spirit discriminatory distress on UAI, see model 1 in Table II. The remaining models adjusted for demographic (respondents’ age at time of interview, HIV status, and whether or not they had a current partner), socioeconomic status indicators (education, monthly household income, and employment status) and behavioral variables (depressive symptoms, alcohol use, and substance use). Model 3, 4, and 5 adjusted for AI/AN community participation, LGBT community participation, and two-spirit community participation, respectively. All data preparation and analyses were conducted using STATA (version 12.0). To determine which microaggressions were associated with UAI, we also ran a series of t-tests comparing the average levels of distress between those who had engaged in UAI and those that had not.

Table I.

Distribution of Demographic and Psychosocial Characteristics of American Indian / Alaska Native Men Who Have Sex With Men, by Unprotected Anal Intercourse

Total No UAI UAI
N=183 N=102 N=81
Two-Spirit Discrim., mean (SD) 0.82 (0.85) 0.70 (0.80) 0.98 (0.89) t = −2.36*
AI/AN Participation, mean (SD) 14.60 (84.37) 17.86 (101.89) 10.50 (55.30) t = 0.58
LGBT Participation, mean (SD)
LGBT Events
LGBT online forums
3.36 (2.35)
4.87 (2.40)
3.47 (2.37)
5.14 (2.35)
3.23 (2.32)
4.53 (3.44)
t = 0.67
t = 1.71
Two-Spirit Participation, mean (SD)
Two-Spirit Events
Two-Spirit online forums
4.61 (2.63)
4.98 (2.45)
5.06 (2.50)
5.28 (2.35)
4.05 (2.69)
4.59 (2.53)
t = 2.62**
t = 1.91
Age, mean (SD) 39.44 (10.85) 40.45 (11.42) 38.17 (10.00) t = 1.41
HIV-seropostive, no. (%)
 No
 Yes
123 (67.21)
60 (32.79)
74 (72.55)
28 (27.45)
49 (60.49)
32 (39.51)		 χ2 = 2.98
Has a Current Partner, no. (%)
 No
 Yes
118 (64.48)
65 (35.62)
71 (69.61)
31 (30.39)
47 (58.02)
34 (41.98)		 χ2 = 2.64
Education, no. (%)
 < High School (<12yrs)
 High School (12yrs)
 Some College (13–15yrs)
 College Grad (16+yrs)
18 (9.84)
52 (28.42)
68 (37.16)
45 (24.59)
10 (9.80)
27 (26.47)
40 (39.22)
25 (24.51)
8 (9.88)
25 (30.86)
28 (34.57)
20 (24.69)		 χ2 = 0.57
Employment Status, no. (%)
 Not Working
 Working
98 (53.55)
85 (46.45)
55 (53.92)
47 (46.08)
43 (53.09)
38 (46.91)		 χ2 = 0.01
Monthly Household Income $ (%)
 < 1000 per month
 1001–2000 per month
 > 2000 per month
95 (51.91)
43 (23.50)
45 (24.59)
46 (45.10)
29 (28.43)
27 (26.47)
49 (60.49)
14 (17.28)
18 (22.22)		 χ2 = 4.78
Depressive Symptoms mean (SD) 10.17 (6.69) 9.99 (7.24) 10.40 (5.95) t = −0.43
Alcohol Use, no. (%)
 Not within past 12 months
 Within past 12 months
 Within past 30 days
 Within past 7 days
36 (19.67)
20 (10.93)
27 (14.75)
100 (54.64)
23 (22.55)
16 (15.69)
14 (13.73)
49 (48.04)
13 (16.05)
4 (4.94)
13 (16.05)
51 (62.96)		 χ2 = 7.75
Substance Use mean (SD) 1.71 (1.89) 1.47 (1.64) 2.01 (2.13) t = −1.94
Open in a new tab
a

Test statistics comparing UAI to No UAI are derived using Pearson Chi-square and t-tests

*

b p < .05

**

p < .01

***

p < .001 (Two-Sided Test)

Table II.

Logistic Regression Models of American Indian / Alaska Native Men Who Have Sex With Men, Predicting Effects of Heterosexist and Racial Discrimination on Unprotected Anal Intercourse (N=202)

Variable Model 1 Model 2 Model 3 Model 4 Model 5
Two-Spirit
Discrimination		 1.53*
(1.06, 2.22)		 1.82**
(1.18, 2.78)		 1.82*
(1.18, 2.79)		 1.85**
(1.19, 2.89)		 1.56
(0.99, 2.44)
AI/AN Participation 1.00
(0.99, 1.00)
Attend LGBT Events 0.96
(0.83, 1.10)
Visit LGBT
online forums		 0.86*
(0.75, 0.99)
Attend Two-Spirit Events 0.82**
(0.71, 0.94)
Visit Two-Spirit online forums 0.94
(0.81, 1.10)
Constant 0.56 0.28 0.30 0.59 0.89
Pseudo R2 0.0214 0.0970 0.0978 0.1162 0.1392
Open in a new tab
a

Logistic regression odds ratios with 95% confidence intervals in parentheses.

b

Model 1 consists of the unadjusted odds ratio, all other models adjust for demographic, socioeconomic status, and behavioral variables.

*

c p < .05

**

p < .01

***

p < .001 (Two-Sided Test)

RESULTS

Descriptive Statistics

The descriptive statistics in Table I indicate the average age of the sample was 39.4 years (range:20–67 years). Thirty-three percent of the individuals reported being HIV-positive. Thirty-six percent reported having a partner at the time of interview. Twenty-eight percent had a high school diploma, while 25% had a college degree. The majority (54%) reported they were currently not working and 52% had a monthly household income of less than $1,000 (i.e., <$12,000 per year). Bivariate analysis indicated that those who had engaged in UAI within the past year had significantly higher levels of distress attributed to Two-Spirit discrimination, t(181) = −2.36, p < .05, higher prevalence of having consumed alcohol within the past week, χ2 (3)=7.75, p < .05, where significantly more likely to have used more substances in the past year, but significantly less likely to attend Two-Spirit events t(181) = 2.62, p < .05 compared to those that had not engaged in UAI within the past year.

Multivariable Analyses

The results of Model 1 in Table II indicate that the unadjusted odds ratio for two-spirit discriminatory distress is significantly associated with UAI (odds ratio [OR] = 1.53, 95% confidence interval [CI] = 1.06, 2.22; p < .05), indicating that distress from two-spirit discrimination increases the odds of engaging in UAI by 53%. The results of Model 2, shown in Table II, indicate that the association between two-spirit discrimination and UAI is stronger (OR = 1.82, CI = 1.18, 2.78; p < .01) after adjusting for correlates. It is important to note that in models 2 through 5 in Table II, individuals self-reporting an HIV positive status had statistically higher odds (ranging from 2.18 to 2.68) of engaging in UAI. Similarly, those with a current partner also reported significantly higher odds (with odds ratios ranging from 1.95 to 2.39) of engaging in UAI. Table 2 indicates a suppression effect for two-spirit discriminatory distress. This finding suggests the correlates account for some of the variance and adjusting for them allows for a more true and robust association between two-spirit discriminatory distress and UAI to be shown.

With respect to community participation measures, the results from model 3 in Table II, indicate that AI/AN participation is not associated with UAI (OR = 0.86, CI = 0.99, 1.00; ns). However, model 4 indicates that participation in LGBT specific online forums is associated with UAI (OR = 0.86, CI = 0.75, 0.99; p < .05), in that this type of participation decreases the odds of risk behavior by 14%. Model 5 suggests that participating in two-spirit specific events is associated with an 18% decrease in the odds of engaging in UAI (OR = 0.82, CI = 0.71, 0.94; p < .01). Furthermore, model 5 also indicates that two-spirit discriminatory distress (OR = 1.56, CI = 0.99, 2.44; ns) is not significantly associated with UAI after adjusting for two-spirit community participation.

Individual Microaggression Analyses

A series of t-tests were used to compare those that had engaged in UAI and those that had not on their reported levels of distress from each of the microaggressions. The results in Table III show that on 30 of the 32 microaggression items, those who engaged in UAI had higher distress level than those without UAI report. However, only10 of the 32 microaggressions were significantly associated (p < .05) with outcome.

Table III.

Two-Spirit Microaggression Scale – Individual Analysis of Each Item by UAI in the Past 12 Months

Please indicate how much you were distressed or bothered by the following experiences EVER in your life… Total No UAI UAI
N Mean SD Mean SD Mean SD t
1. encountering white people who identify as two-spirit? 179 0.85 1.22 0.63 1.05 1.13 1.35 −2.79**
2. hearing people use tribal two-spirit terms (e.g. winte, nadle) in a pejorative way? 178 0.92 1.32 0.93 1.37 0.91 1.25 −0.09
3. non-Native LGBT people assuming that you are spiritually gifted? 180 0.91 1.27 0.77 1.26 1.08 1.26 −1.61
4. non-Native people assuming that you can speak for all two-spirit people? 179 1.23 1.50 1.09 1.48 1.42 1.51 −1.46
5. non-Native people stating that they feel a “spiritual connection” to two-spirit people? 179 1.08 1.43 0.96 1.44 1.23 1.41 −1.24
6. non-Native people appropriating two-spirit names? 179 1.06 1.47 0.83 1.33 1.35 1.58 −2.39*
7. being excluded from LGBT groups, events, or programs because you are two-spirit? 179 0.41 0.96 0.42 0.98 0.39 0.93 0.25
8. your tribe or Native community denying your existence? 178 0.08 1.28 0.73 1.24 0.87 1.33 −0.76
9. being told that being LGBT is a “White thing”? 178 0.58 1.09 0.55 1.12 0.62 1.06 −0.40
10. being excluded or asked to leave ceremonies because you are two-spirit? 175 0.22 0.69 0.19 0.65 0.25 0.73 −0.51
11. your tribe not allowing you to participate in ceremonial roles relates to being two-spirit? 174 0.28 0.83 0.26 0.82 0.32 0.85 −0.48
12. being asked to educate non-Native people about two-spirit roles and history? 179 0.60 1.09 0.53 1.07 0.68 1.12 −0.93
13. being sexually objectified by non-Native LGBT people? 179 0.72 1.21 0.61 1.16 0.85 1.26 −1.31
14. encountering racism in the LGBT community? 181 1.27 1.51 1.13 1.52 1.44 1.48 −1.40
15. encountering homophobia in the Native community? 182 1.46 1.52 1.39 1.56 1.56 1.47 −0.75
16. seeing stereotyped imagery of two-spirit people such as the village people? 182 1.13 1.43 1.11 1.34 1.15 1.51 −0.18
17. feeling that you have to leave or stay away from you reservation in order to express yourself as a two-spirit person? 177 0.83 1.29 0.64 1.16 1.06 1.41 −2.18*
18. not being allowed to go home when sick? 178 0.47 1.02 0.27 0.75 0.72 1.25 −2.97**
19. people assuming that you must be HIV-positive because you are two-spirit? 179 0.85 1.27 0.72 1.27 1.04 1.26 −1.66
20. people saying that you are not a “real” Indian because you are two-spirit? 179 0.58 1.16 0.48 1.08 0.72 1.24 −1.40
21. being the “token” two-spirit person in LGBT and/or Native groups or organizations? 179 0.74 1.17 0.52 0.99 1.01 1.33 −2.83**
22. people assuming that you are not or could not be a good parent because you are two-spirit? 178 0.87 1.33 0.78 1.28 0.97 1.39 −0.98
23. other Native people avoiding you because they are afraid you will try to “recruit” them? 178 0.56 1.11 0.57 1.16 0.54 1.06 0.13
24. other Native LGBT persons appropriating a tribal-specific term such as Winkte for themselves when it is not their tribal term? 177 0.66 1.21 0.47 1.07 0.88 1.34 −2.26*
25. heterosexual Natives do not acknowledge or say “hello” to you because you are two-spirit? 179 0.70 1.19 0.57 1.15 0.88 1.22 −1.74
26. heterosexual Natives stopped speaking to you when they find out you were two-spirit? 180 0.66 1.15 0.53 1.15 0.83 1.14 −1.71
27. not being able to speak freely about being two-spirit in your home community or rez? 180 0.81 1.26 0.64 1.20 1.01 1.32 −2.00*
28. being told by a non-Native sexual partner the he or she is excited or happy to sleep with an Indian? 181 0.73 1.21 0.60 1.21 0.90 1.21 −1.67
29. a tribal community member refusing burial or ceremonial rites because an Indian person has AIDS or HIV? 178 0.81 1.45 0.62 1.25 1.06 1.65 −2.05*
30. hearing from other Natives that two-spirits did not historically exist in their tribe or your own tribe? 180 1.02 1.50 0.75 1.32 1.35 1.64 −2.73**
31. being rejected as a romantic or steady partner because you are Native? 177 0.62 1.13 0.50 1.07 0.77 1.20 −1.56
32. being selected as a sexual partner solely based on your being a Native two-spirit? 180 0.64 1.13 0.46 0.98 0.88 1.26 −2.49*
Open in a new tab
a

Test statistics comparing No UAI to UAI are derived using t-tests (t)

b

N= Number of participants that answered, SD = Standard Deviation

*

c p < .05

**

p < .01

***

p < .001 (Two-Sided Test)

DISCUSSION

The impact of discrimination on HIV sexual risk has been documented in the literature. Our data extends previous research findings by (1) examining these relationships among AI/AN MSM, a population that is underrepresented in the literature; (2) investigating discriminatory distress in relation to HIV sexual risk within an indigenous perspective; thereby understanding the continued colonizing practices that undermine traditional conceptions of two-spirit identities; and (3) examining whether participation within various communities buffered the influence of discriminatory distress on HIV sexual risk behavior. This study and projects, like the HONOR project, demonstrate that U.S. studies of gender and sexual minorities are not only feasible among American Indian and Alaska Native populations but are also important, given the implications that discrimination based on race, gender, and sexuality has on health and health behavior of these populations.

Our findings indicate that exposure to discriminatory distress is associated with UAI. These results are consistent with previous studies (Ayala et al. 2012; Mizuno et al. 2012) among racial-minority MSM suggesting that discrimination is a pervasive factor in HIV risk. After accounting for known correlates of risk behavior, the association became stronger suggesting that not only do individual factors (such as HIV serostatus and having a current partner) matter, but structural factors, such as discrimination, matter as well.

We found the effect of discriminatory distress on UAI among AI/AN MSM was buffered by LGBT and Two-Spirit community participation. Our findings indicate that participation in LGBT specific online forums reduced the odds of engaging in UAI. This finding is consistent with the initial studies (Chng and Geliga-Vargas 2000; O’Donnell et al. 2002), suggesting AI/AN MSM gain knowledge and skills by participating in LGBT specific online forums that reduce their odds of engaging in UAI. However, this finding is inconsistent with more recent studies involving racial-minority MSM (Frye, Nandi, Egan, Cerda, Greene, Van Tieu, Ompad, Hoover, Lucy, Baex, & Koblin, 2015; Jeffries IV, Marks, Lauby, Murrill, & Millett, 2013; Warren, Fernandez, Harper, Hidalgo, Jamil, & Torres, 2008). Similarly, attending two-spirit events not only reduced the odds of engaging in UAI, but it also explained away the association between discriminatory distress and UAI. This suggests that this type of community participation acts as a buffer to both discriminatory distress and UAI. While this finding is promising, this relationship warrants further investigation.

LIMITATIONS

The HONOR Project is the first national study of AI/AN gender and sexual minorities. Though the HONOR Project data provide a national picture of the health and health behaviors of AI/AN MSM, this sample may not be fully representative of the nation’s AI/AN MSM. However, the HONOR Project was a seminal study in the US and continues to inform research, policy, and practice. In fact, this study and these data provide insights otherwise unavailable about the lives of AI/AN MSM at risk for transmitting or acquiring HIV. As part of a growing body of literature, this study and these data, provide important direction for HIV prevention programs for AI/ANs in general and AI/AN MSM specifically.

There are several caveats to our study. The findings rely on respondents’ self-reported behaviors, which cannot be independently verified. Although computer-assisted self-interviewing methods were used to reduce any bias of self-disclosing behaviors deemed as socially undesirable, the accuracy of participants’ responses cannot be determined (Cassels et al. 2011). As a result, the true prevalence of respondents’ risk behaviors may be underestimated and the findings are likely conservative estimates.

Due to the retrospective cross-sectional design of the study, the directional relationship between discrimination and sexual risk behavior cannot be confirmed. Longitudinally designed research is needed to better understand the directional relationship of this association. Additional research is warranted to further determine whether and how different types, sources, and frequency of discriminatory experiences might cause AI/AN MSM to engage in HIV risk behaviors. Similarly, using a measure that captures the frequency of UAI, would allow for a better understanding of risk. Furthermore, future research should examine more nuances of risk including knowledge of, access to, and utilization of pre-exposure prophylaxis (PrEP) among AI/AN MSM. Lastly, research should also pay attention to protective factors, such as two-spirit community participation, that might alleviate the negative effects of discrimination, specifically the types, frequency and the quality of the protective factors.

IMPLICATIONS.

Despite these limitations, this study has important implications for HIV prevention interventions and future research with AI/AN MSM. This study provides one of the first insights into the effects of discriminatory distress on HIV sexual risk behaviors among AI/AN MSM. This study supports and recognizes the importance of addressing structural factors in dealing with the HIV epidemic, indicating that addressing discrimination must be part of future HIV prevention interventions. Lastly, we highlight the importance of understanding colonization practices within a relevant historical, political, cultural, and social context that influences the lives of American Indians and Alaska Natives today.

Evidence-based behavioral interventions to prevent HIV transmission have been designed for Black MSM and Asian and Pacific Islander MSM and these interventions address discrimination through group discussions and demonstrate how the positive impacts of these interactions reduce sexual risk behaviors (Mizuno et al. 2012). As of today, however, no evidence-based behavioral interventions are available specifically for AI/AN MSM. Given the high prevalence of HIV infection and risk behaviors within this sample, more HIV prevention and intervention research is urgently needed for this population. Given HIV status and partner status were consistently associated with UAI, intervention research should address harm reduction and secondary prevention with AI/AN MSM as well as sexual agreements and overall dynamics of male couples in which one or both partners are AI/AN MSM.

The findings from this study and prior research on racial minority MSM, illustrate the importance of examining HIV risk behavior beyond the individual level and assess the effects of structural and protective factors associated with racial minority MSM. Innovative prevention programs should focus efforts on the specific needs and cultural characteristics of population to promote safer sexual practices. In the case of AI/AN MSM, it is essential to include the relevant historical, political, and social context in future research and prevention programs. Framing HIV infection in this way contextualizes AI/AN populations, and AI/AN MSM specifically, in relation to HIV infection as an issue of social justice and aligns it with the legacy of colonization.

ACKNOWLEDGEMENTS

The authors thank the entire HONOR project research team, the study participants, collaborating community-based partners, and community advisory board who contributed to the design and implementation of the HONOR project. Support for this study was provided by a grant from the National Institute of Drug Abuse (R01 DA037811–02S1). The HONOR Project was supported by the National Institute of Mental Health (R01 MH065821), the Office of Research on Women’s Health, The Office of AIDS Research, and the National Center on Minority Health and Health Disparities.

REFERENCES:

  1. Anguksuar LaFortune R. 1997. “A Postcolonial Perspective on Western [Mis]Conceptions of the Cosmos and the Restorationc v of Indigenous Taxonomies.” Pp. 217–22 in Two-spirit people: Native American gender identity, sexuality, and spirituality, edited by Jacobs S-E, Thomas W, and Lang S. Chicago, IL: University of Illinois Press. [Google Scholar]
  2. Ayala George, Bingham Trista, Kim Junyeop, Wheeler Darrell P., and Gregorio a Millett. 2012. “Modeling the Impact of Social Discrimination and Financial Hardship on the Sexual Risk of HIV among Latino and Black Men Who Have Sex With Men.” American Journal of Public Health 102 Suppl:S242–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Bersamin Andrea et al. 2014. “Enculturation, Perceived Stress, and Physical Activity: Implications for Metabolic Risk among the Yup’ik--The Center for Alaska Native Health Research Study.” Ethnicity & Health 19(3):255–69. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Bertolli Jeanne et al. 2004. “Surveillance Systems Monitoring HIV/AIDS and HIV Risk Behaviors among American Indians and Alaska Natives.” AIDS Education and Prevention : Official Publication of the International Society for AIDS Education 16(3):218–37. [DOI] [PubMed] [Google Scholar]
  5. Bruce Douglas, Jesus Ramirez-Valles, and Campbell Richard T.. 2008. “Stigmatization, Substance Use, and Sexual Risk Behavior Among Latino Gay and Bisexual Men and Transgender Persons.” The Journal of Drug Issues 38(1):235–60. [Google Scholar]
  6. Cassels Susan, Pearson Cynthia R., Walters Karina L., Simoni Jane M., and Morris Martina. 2011. “Sexual Partner Concurrency and Sexual Risk among Gay, Lesbian, Bisexual, and Transgender American Indian/Alaska Natives.” Sexually Transmitted Diseases 37(4):272–78. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Centers for Disease Control and Prevention (CDC). 2015. “Diagnoses of HIV Infections in the United States and Dependent Areas, 2015.” HIV Surveillance Report 27(27):1–114. [Google Scholar]
  8. Chae David H. and Walters Karina L.. 2009. “Racial Discrimination and Racial Identity Attitudes in Relation to Self-Rated Health and Physical Pain and Impairment among Two-Spirit American Indians/Alaska Natives.” American Journal of Public Health 99 Suppl 1:S144–51. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Chae David H. and Yoshikawa Hirokazu. 2008. “Perceived Group Devaluation, Depression, and HIV-Risk Behavior among Asian Gay Men.” Health Psychology : Official Journal of the Division of Health Psychology, American Psychological Association 27(2):140–48. [DOI] [PubMed] [Google Scholar]
  10. Chng Chwee Lye and Jesus Geliga-Vargas. 2000. “Ethnic Identity, Gay Identity, Sexual Sensation Seeking and HIV Risk Taking among Multiethnic Men Who Have Sex With Men.” AIDS Education and Prevention : Official Publication of the International Society for AIDS Education 12(4):326–39. [PubMed] [Google Scholar]
  11. Choi Kyung-Hee, Paul Jay, Ayala George, Boylan Ross, and Gregorich Steven E.. 2013. “Experiences of Discrimination and Their Impact on the Mental Health among Africian American, Asian and Pacific Islander, and Latino Men Who Have Sex with Men.” American Journal of Public Health 103(5):868–74. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Cockerham WC 2005. “Health Lifestyle Theory and the Convergence of Agency and Structure.” Journal of Health and Social Behavior 46(1):51–67. [DOI] [PubMed] [Google Scholar]
  13. Duran Eduardo, Firehammer Judith, and Gonzalez John. 2008. “Liberation Psychology as the Path Toward Healing Cultural Soul Wounds.” Journal of Counseling & Development 86(3):288–95. [Google Scholar]
  14. Frye Victoria et al. 2015. “Sexual Orientation- and Race-Based Discrimination and Sexual HIV Risk Behavior Among Urban MSM.” AIDS and Behavior 19(2):257–69. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Gilley Brian Joseph. 2006. Becoming Two-Spirit: Gay Identity and Social Acceptance in Indian Country. Lincoln: University of Nebraska Press. [Google Scholar]
  16. Gone Joseph P. 2008. “Mental Health Discourse as Western Cultural Proselytization.” Ethos 36:310–15. [Google Scholar]
  17. Han Chong-suk. 2007. “They Don’t Want To Cruise Your Type: Gay Men of Color and the Racial Politics of Exclusion.” Social Identities 13(1):51–67. [Google Scholar]
  18. Jacobs Sue-Ellen, Thomas Wesley, and Lang Sabine. 1997. Two-Spirit People: Native American Gender Identity, Sexuality, and Spirituality. edited by Jacobs S-E, Thomas W, and Lang S. Chicago, IL: Univerisity of Illinois Press. [Google Scholar]
  19. Jeffries IV, William L., Gary Marks, Jennifer Lauby, Murrill Christopher S., and Millett Gregorio A.. 2013. “Homophobia Is Associated with Sexual Behavior That Increases Risk of Acquiring and Transmitting HIV Infection among Black Men Who Have Sex with Men.” AIDS and Behavior 17(4):1442–53. [DOI] [PubMed] [Google Scholar]
  20. Lehavot Keren, Walters Karina L., and Simoni Jane M.. 2009. “Abuse, Mastery, and Health among Lesbian, Bisexual, and Two-Spirit American Indian and Alaska Native Women.” Cultural Diversity & Ethnic Minority Psychology 15(3):275–84. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. McNaghten AD, Neal Joyce J., Li Jianmin, and Fleming Patricia L.. 2005. “Epidemiologic Profile of HIV and AIDS among American Indians/Alaska Natives in the USA through 2000.” Ethnicity & Health 10(1):57–71. [DOI] [PubMed] [Google Scholar]
  22. Mizuno Yuko et al. 2012. “Homophobia and Racism Experienced by Latino Men Who Have Sex With Men in the United States: Correlates of Exposure and Associations with HIV Risk Behaviors.” AIDS and Behavior 16(3):724–35. [DOI] [PubMed] [Google Scholar]
  23. Nelson KM and Simoni JM. 2011. “‘I’ve Had Unsafe Sex so Many Times Why Bother Being Safe Now?’: The Role of Cognitions in Sexual Risk among American Indian/Alaska Native Men Who Have Sex with Men.” Annals of Behavioral … 42(3):370–80. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. O’Donnell Lydia et al. 2002. “Ethnic and Gay Community Attachments and Sexual Risk Behaviors among Urban Latino Young Men Who Have Sex with Men.” AIDS Education and Prevention : Official Publication of the International Society for AIDS Education 14(6):457–71. [DOI] [PubMed] [Google Scholar]
  25. Pearson Cynthia R., Walters Karina L., Simoni Jane M., Beltran Ramona, and Nelson Kimberly M.. 2013. “A Cautionary Tale: Risk Reduction Strategies Among Urban American Indian/Alaska Native Men Who Have Sex With Men.” AIDS Education and Prevention : Official Publication of the International Society for AIDS Education 25(1):25–37. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Poundstone KE, Steffanie A Strathdee, and Celentano David D.. 2004. “The Social Epidemiology of Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome.” Epidemiologic Reviews 26:22–35. [DOI] [PubMed] [Google Scholar]
  27. Sue Derald Wing et al. 2007. “Racial Microaggressions in Everyday Life: Implications for Clinical Practice.” The American Psychologist 62(4):271–86. [DOI] [PubMed] [Google Scholar]
  28. Walters Karina L. 1998. “Negotiating Conflicts in Allegiances among Lesbians and Gays of Color: Reconciling Divided Selves and Communities.” Pp. 47–59 in Foundations of Social Work Practice with Lesbian and Gay Persons, edited by Mallon GP. Binghamton, NY: Routledge. [Google Scholar]
  29. Walters Karina L., Evans-Campbell Teresa, Simoni Jane M., Ronquillo Theresa, and Bhuyan Rupaleem. 2006. “‘My Spirit in My Heart’: Identity Experiences and Challenges Among American Indian Two-Spirit Women.” Journal of Lesbian Studies 10(1–2):125–49. [DOI] [PubMed] [Google Scholar]
  30. Warren Jacob C. et al. 2008. “Predictors of Unprotected Sex among Young Sexually Active African American, Hispanic, and White MSM: The Importance of Ethnicity and Culture.” AIDS and Behavior 12(3):459–68. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Yoshikawa Hirokazu, Patrick Alan-David Wilson, Chae David H., and Cheng Jih-Fei. 2004. “Do Family and Friendship Networks Protect Against the Influence of Discrimination on Mental Health and HIV Risk Among Asian and Pacific Islander Gay Men?” AIDS Education and … 16(1):84–100. [DOI] [PubMed] [Google Scholar]

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