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. Author manuscript; available in PMC: 2023 Jan 1.
Published in final edited form as: Psychol Men Masc. 2022 Jan;23(1):26–34. doi: 10.1037/men0000374

Examining Stigmatizing Beliefs about PrEP Use among Black Sexual Minority Men: A Test of Explanatory Mechanisms

Redd Driver 1,2, Andrew C Cortopassi 2, Renee El-Krab 2, Lisa A Eaton 3, Seth C Kalichman 2
PMCID: PMC9802639  NIHMSID: NIHMS1858653  PMID: 36593763

Abstract

Stigma often is cited as a barrier to the uptake and use of pre-exposure prophylaxis (PrEP) to prevent HIV among Black sexual minority men (SMM). Socialized gender norms (i.e., restrictive emotionality) are associated with experiences and manifestations of stigma in men. However, the association between restrictive emotionality and the stigma surrounding PrEP use has received little attention in previous research. The present study examines the association between restrictive emotionality and holding stigmatizing beliefs about PrEP use with a theoretically informed serial mediation model testing internalized homophobia and LGBT community connectedness as mediators among a sample of 455 Black SMM in the Southeastern US. Results indicate that restrictive emotionality is associated with stigmatizing beliefs about PrEP use. Further, internalized homophobia and LGBT community connectedness were found to partially mediate the proposed relationship serially. Internalized homophobia, but not LGBT community connectedness, also independently mediated the association between restrictive emotionality and stigmatizing beliefs of PrEP use. This study provides important insights into how aspects of masculinity influence the manifestation of stigmatizing beliefs about PrEP use among Black SMM. The present findings have implications for reducing these beliefs, which are known to negatively impact uptake and use of the HIV prevention tool among Black SMM at elevated risk for HIV.

Keywords: HIV, PrEP, stigma, restrictive emotionality, Black sexual minority men

HIV, an epidemic spanning four decades in the United States (US), remains a public health issue, primarily among racial and sexual minority men. The Centers for Disease Control and Prevention (CDC) reports that Black sexual minority men (SMM) alone accounted for over a quarter (26%) of all new HIV infections in 2018; as well as a significant portion (37%) of the new HIV infections found among SMM (CDC, 2020a). However, this is an unnecessary burden for any group, given the current advances in HIV prevention. In particular, the development of pre-exposure prophylaxis (PrEP) has led to an expanded toolkit to curtail the spread of HIV. The current PrEP regimen, approved for use by the FDA in 2012, consists of a combination of oral HIV antiretroviral medications, which can be taken daily by HIV-negative people at elevated risk of acquiring HIV. Despite evidence that PrEP is as much as 99% effective at preventing HIV (Baeten et al., 2012; Grant et al., 2010), uptake remains low among Black SMM compared to SMM of other racial groups (Eaton et al., 2017; Finlayson et al., 2019). Yet, because PrEP can effectively reduce HIV incidence at the individual and population levels, it is an essential feature of the US national strategic plan of ending HIV by 2030 (Fauci, Redfield, Sigounas, Weahkee, & Giroir, 2019; Valdiserri & Holtgrave, 2018). Thus, this goal will not be feasible without substantial increases in PrEP use among Black SMM at elevated risk of HIV.

In light of low prevalence estimates of use among Black SMM (e.g., 5% - 8%), research indicates that stigmatizing beliefs about using PrEP is a significant factor impacting all facets of the PrEP continuum of care, including interest, uptake, and adherence (Biello et al., 2017; Driver et al., 2020; Eaton et al., 2017; Janulis, Phillips, Birkett, & Mustanski, 2018; Walsh, 2019). For instance, findings from a study among Black SMM who were not using PrEP indicated that these men often held negative perceptions of men who did use PrEP. Such perceptions included believing PrEP users were promiscuous or that users were attempting to hide a positive HIV status. Some men also perceived PrEP use as a means of unintentionally disclosing same-sex sexual behaviors. These perceptions were linked to participants engaging in othering – a phenomenon where individuals are defined and labeled as not fitting in within the norms of a social group – to distance themselves from PrEP users and the undesired associations linked to PrEP (Quinn et al., 2019). Given that previous research has established stigmatizing beliefs about using PrEP as a barrier to PrEP engagement, identifying amenable psychosocial factors that account for such beliefs is needed to reduce this barrier among Black SMM who are at risk of HIV.

Studies among Black SMM suggest that aspects of masculinity and components of minority stress are potential antecedents of developing stigmatizing beliefs about using PrEP (Brooks et al., 2020; Fields et al., 2015; Quinn et al., 2019). For example, one study suggests that the conflict between conforming to cultural conceptualizations of masculinity and homosexuality among Black SMM may influence HIV risk and prevention behaviors. Specifically, psychological stress and conflict from anti-homosexual expectations of male gender roles are implied to increase HIV risk and reduce engagement in prevention practices (Fields et al., 2015). With respect to sexual minority stress, studies also link internalized homophobia, discrimination, and social alienation to stigmatizing beliefs about PrEP use (Garcia et al., 2015). Thus, gender role conflict (GRC; O’Neil, 2008) and the minority stress model (Meyer, 2003) provide informative frameworks for explaining the manifestation of stigmatizing beliefs about PrEP use among Black SSM.

The primary implication of GRC is that adhering to socialized gender roles may result in experiencing a negative psychological state leading to stigma processes, including the restriction, violation, or devaluation of others or the self (O’Neil, 2008). One pattern of GRC in particular, restrictive emotionality – or “having restrictions and fears about expressing one’s feelings, and an inability to find words to express basic emotions” (O’Neil, 2008, p. 367), is related to stigmatizing beliefs towards health behaviors among men (Heath, Seidman, Cornish, & Wade, 2017). For instance, one study examining restrictive emotionality and psychological distress as predictors of stigma related to seeking help for mental health issues among male military members and veterans found that restrictive emotionality uniquely predicted stigmatizing beliefs regarding mental health services (Heath, Seidman, Cornish, & Wade, 2017) demonstrating the impact this norm may have on men’s beliefs about health-promoting behaviors.

Interestingly, SMM undergo the same gender socialization process, and thus, it is likely that they too restrict their emotions, which may influence their beliefs toward health behaviors. However, research has focused little on how aspects of masculinity, including restrictive emotionality, may influence stigmatizing beliefs regarding health behaviors among SMM. This may be partially due to findings that SMM are less affected by, or adherent to, male gender norms (Wester, Pionke, & Vogel, 2005). However, recent research indicates that of the affective patterns of GRC (e.g., restrictive emotionality and restrictive affective behavior between men), there is no significant difference in men’s restrictive emotionality based on their sexual orientation (McMahon, Tiernan, & Moane, 2020). Thus, restrictive emotionality may similarly influence stigmatizing beliefs about health behaviors, including PrEP use among Black SSM. Therefore, considering restrictive emotionality, a factor amenable to intervention, as an antecedent to developing stigmatizing beliefs about PrEP use may provide an avenue to enhance the uptake and use of PrEP among Black SMM.

In addition, the hypothesized relationship between restrictive emotionality and stigmatizing beliefs about PrEP use may be accounted for by psychosocial factors associated with the stress of being a sexual minority. For example, consistent with the assumption that anti-homosexual expectations of gender roles may influence Black SMM’s HIV risk and prevention behaviors (Fields et al., 2015), one component of minority stress, internalized homophobia, likely accounts for the association between restrictive emotionality and stigmatizing beliefs about PrEP use. This is because internalized homophobia, or the experience of negative feelings towards oneself because of same-sex sexual attraction, is linked, in part to adherence to masculine norms (Warriner, Nagoshi, & Nagoshi, 2013). Several studies have demonstrated a direct link between aspects of masculinity and homophobia in men (Sánchez, Westefeld, Liu, & Vilain, 2010; Thepsourinthone, Dune, Liamputtong, & Arora, 2020). For example, one study among SMM showed that valuing masculinity and holding concerns about violating masculine ideals (e.g., restricting emotions) was positively associated with negative feelings about being gay (Sánchez et al., 2010). Further, internalized homophobia has been implied to link to negative views of PrEP among Black SMM. In a qualitative study examining how recognizing diversity in gender and sexuality among Black SMM could shape and inform expanded HIV prevention programs, internalized homophobia (e.g., PrEP is only for gay men) was a common theme reported as a reason for not using PrEP by Black SMM (Garcia et al., 2016). Thus, these studies support the hypothesis that internalized homophobia may account for the association between restrictive emotionality and stigmatizing beliefs about PrEP use.

Feeling connected to the LGBT community is another factor that may further mediate the relationship between restrictive emotionality and holding stigmatizing views about PrEP use. As emphasized by the minority stress model, individuals belonging to stigmatized groups may experience prolonged stress from prejudice, discrimination, and social alienation (Meyer, 2003), which may affect how connected one feels to the communities that are a source of stigma. Research shows that feeling connected to the broader LGBT community, or LGBT community connectedness, can serve a supportive role for Black SMM (Miller, Forney, Hubbard, & Camacho, 2012; Strauss et al., 2017). LGBT community connectedness also is linked to greater knowledge of PrEP and participation in health promotion programs (Hotton, Keene, Corbin, Schneider, & Voisin, 2018). However, feeling alienated from the LGBT community may negatively influence Black SMM’s perceptions of PrEP due to its close association with gay men in the US. Further, LGBT community connectedness has been shown to mediate the association between homophobia and healthcare-related factors such as having a health care provider (Anderson-Carpenter, Sauter, Luiggi-Hernández, & Haight, 2019). This finding, in particular, suggests that internalized homophobia may mediate the association between restrictive emotionality and stigmatizing beliefs about PrEP use through LGBT community connectedness. If so, this would help explain how cultural conceptualizations of masculinity influence stigmatizing beliefs about PrEP use that lead to othering among some Black SMM.

Present Study

Informed by gender role conflict (O’Neil, 2008) and the minority stress model (Meyer, 2003), the present study examines the association between restrictive emotionality and stigmatizing beliefs about PrEP use. Further, this study tests potential explanatory mechanisms of this association: internalized homophobia and LGBT community connectedness. We first hypothesized that restrictive emotionality is positively associated with holding stigmatizing beliefs about using PrEP. Second, we hypothesized that internalized homophobia and LGBT community connectedness serially mediate the restrictive emotionality – stigma relationship. Specifically, we predict that restrictive emotionality is associated with greater internalized homophobia. In turn, greater internalized homophobia is linked to lower LGBT community connectedness, with lower connectedness associated with stigmatizing beliefs about PrEP use (see Figure 1).

Figure 1.

Figure 1

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Conceptual serial Mediation Model of the Association between Restrictive Emotionality and Stigmatizing Beliefs about PrEP Use

Methods

Participants and Procedures

Four hundred fifty-five participants were enrolled in an hour-long online study of Black SMM’s sexual health. Participants were recruited from April to June of 2020 throughout the southeastern US. We recruited participants using advertisements that were geographically targeted to Facebook users, as well as snowball sampling. All potential participants phoned a study screener for a brief interview to determine eligibility. To be included in the study, participants had to report: (1) being 18 years of age or older, (2) assigned male sex a birth, (3) identifying as Black/ African American, (4) having at least one consensual male sex partner in the previous year, and (5) an HIV negative or unknown HIV status, as having an HIV positive status would preclude one from initiating PrEP. Participants who met the study’s inclusion criteria, and provided informed consent, received a link via email or text message to the online questionnaire hosted by RedCap. Participants were compensated $55 for completing all study procedures. The university’s IRB approved all study and consent procedures.

Measures

Demographic and health characteristics.

We collected data on participants’ age, race/ethnicity, education, income, employment, sexual identity and openness, and the frequency of anal sex acts with and without a condom. To assess sexual identity, participants responded to two items from the sexual identity sub-scale of the Sell Assessment of Sexual Orientation Scale (Sell, 1996). The two items of the sexual identity sub-scale assess how much a person identifies as (1) gay and (2) straight on a 7-point scale (1 = not at all, 7 = extremely). Participants also reported the number of times they ever tested for HIV and their awareness of PrEP.

Restrictive emotionality.

To assess men’s restrictions and fears about expressing feelings and restrictions in expressing basic emotions around sex, participants completed the 5-item restrictive emotionality subscale of the Gender Role Conflict/Stress Scale (Gottert et al., 2018). The Gender Role Conflict/Stress Scale was developed from two scales: the Gender Role Conflict Scale (O’Neil et al., 1986) and the Masculine Gender Role Stress Scale (Eisler & Skidmore, 1987). The measure was developed to assess restrictive emotionality as it relates to HIV-related outcomes among South African men. Items include; “I have difficulty telling others I care about them,” and “Talking about my feelings during or after sex is difficult for me.” Responses were provided on a 6 point scale (0 = strongly disagree, 5 = strongly agree). Responses were averaged across items with higher scores indicating higher levels of restrictive emotionality (α = .85).

Internalized homophobia.

Internalized homophobia was assessed using 8 items of the Internalized Homophobia (IHP) Scale (Herek, Cogan, Gillis, & Glunt, 1997). The IHP measures the experience of negative feelings about oneself because of same-sex sexual attraction. Items include; “I have tried to stop being attracted to men in general,” and “I feel alienated from myself because of my sexuality.” Responses were provided on a 6 point scale (0 = strongly disagree, 5 = strongly agree). Responses to items were averaged with higher scores indicating greater levels of internalized homophobia (α = .87).

LGBT community connectedness.

Participants responded to 7 items adapted from the LGBT People of Color Microaggressions Scale (Balsam, Molina, Beadnell, Simoni, & Walters, 2011) to assess the degree of feeling connected to the LGBT community based on one’s race. Items include, “I am angry at the way the Gay community treats Black men,” and “I have felt rejected by the LGBT community because of my racial identity.” Responses were provided on a 6 point scale (0 = strongly disagree, 5 = strongly agree). Responses were averaged across items with higher scores indicating greater feelings of LGBT community connectedness (α = .74).

Stigmatization of PrEP Use.

To examine men’s stigmatizing beliefs about PrEP use, participants responded to 7 items adapted from the PrEP Stigma Scale (Klein & Washington, 2019). Items assessed participants’ perceptions 1) that using PrEP means one is promiscuous, 2) concerns that one’s sex partner(s) would think that one was engaging in risky sex with other men, and 3) concerns that one’s friends or family members would think less highly of him if they were to discover that he used PrEP. Items include, “Someone taking PrEP should keep their pills hidden,” and “Someone taking PrEP would be seen by others as slutty.” Responses were provided on a 6 point scale (0 = strongly disagree, 5 = strongly agree). Responses to items were averaged to create a composite score, with higher scores indicating greater stigmatizing beliefs about using PrEP (α = .85).

Statistical analysis

We conducted descriptive analyses to examine participants’ demographic and health characteristics. Continuous variables were examined using means and standard deviations, and categorical variables using frequencies and percentages. Next, to examine significant relationships among study variables, zero-order correlations were conducted. We also examined the mediators’ partial correlation to test for support of the theoretically proposed association of the mediators. Specifically, multiple mediators are assumed to be correlated due to their shared relationship with the predictor variable, and as such, should be uncorrelated after accounting for the shared cause. After accounting for the predictor, partial correlations that remain significant suggest that one mediator affects another (Hayes, 2013). Study hypotheses were then tested via a serial mediation analysis using the SPSS macro PROCESS version 3.2.01. Hypothesis testing included only those participants who reported previous knowledge of PrEP as our outcome was participant’s stigmatization of PrEP use. In the model (model 6), internalized homophobia and LGBT community connectedness were included as mediators (PROCESS model: restrictive emotionality – internalized homophobia – LGBT community connectedness – stigmatizing beliefs; Figure 1). We used 10,000 bootstrap samples and 95% bias-corrected confidence intervals to identify significant indirect effects. Significant indirect effects were determined by examining for confidence intervals that do not include zero. SPSS version 26 was used for all analyses.

Results

Demographic characteristics

Table 1 shows the demographic and health characteristics of the sample. The majority of men (94%) reported prior awareness of PrEP. The sample reported a strong gay/same-gender-loving identification indicated by a score of 5.4 (SD = 1.6, range 1–7) on the Sell Assessment subscale. Identifying as straight was low among participants with a score of 1.9 (SD = 1.5, range 1–7). The average age across the sample was 29.4 (SD = 5.4, range 18 – 41). A large minority reported completing some college (44%) and reported earning between $26,000 – $50,000 annually (35%). On average, men were open about their sexual identity 2.42 (SD = .58, range 1–3), reported an average of 3.5 (SD = 1.4) lifetime HIV tests, and engaged in 5.1 (SD = 2.7) condomless sex acts over the previous 12 months.

Table 1.

Demographic Characteristics

Characteristics
N = 455
M(SD)/N(%)
Gay/SGL
identity 5.4(1.6)
Heterosexual identity 1.9(1.5)
Age 29.4(5.4)
PrEP awareness 404(94%)
Education
< HS graduate 7(1%)
High school grad/GED 82(18%)
Some college 199(44%)
College grad 167(37%)
Income
< $10,000 107(24%)
$10,000 - $25,000 131(28%)
$26000 - $50,000 157(35%)
>50,000 60(13%)
Employment
Working 299(66%)
unemployed 119(26%)
other 37(8%)
Sexual orientation
openness 2.42 (.58)
HIV testing frequency 3.5 (1.3)
Condomless sex acts 5.1 (2.6)
PrEP stigma 1.12 (1.14)
RE 2.12 (1.53)
IH 1.47 (1.28)
LGBT CC 2.62 (1.13)
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Note. RE = restrictive emotionality, IH = internalized homophobia, LGBT CC = LGBT community connectedness.

*

p < .05,

**

p <. 01,

***

p <.001.

Zero-order and partial correlations of model constructs

Table 2 shows the correlations, means, and standard deviations of the mediation model constructs. Stigmatizing beliefs about PrEP use was positively associated with restrictive emotionality (r = .35, p < .001) and internalized homophobia (r = .45, p < .001). Stigmatizing beliefs about PrEP use demonstrated a negative association with feelings of LGBT community connectedness (r = −.24, p < .001). Restrictive emotionality was positively associated with internalized homophobia (r = .31, p < .001) and negatively associated with feelings of LGBT community connectedness (r = −.19, p < .001). Internalized homophobia was also negatively associated with feelings of LGBT community connectedness (r = −.21, p < .001). Examining the partial correlation between the mediators controlling for restrictive emotionality, a significant negative association remained (r = −.16, p < .001). The pattern of associations supported testing the proposed theoretical serial mediation model.

Table 2.

Correlations, Means, and Standard Deviations of the Mediation Model Variables

Variable Mean SD Stigma RE IH Partial correlation with IH
Stigma 1.16 .91 1 --
RE 2.12 1.53 .35** 1 --
IH 1.47 1.28 .45** .31** 1 --
LGBT CC 2.73 .89 −.24** −.19** −.21** −.16**
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Note. Stigma = stigmatizing beliefs about PrEP use, RE = restrictive emotionality, IH = internalized homophobia, LGBT CC = LGBT community connectedness.

**

p <. 01.

Test of restrictive emotionality - PrEP stigmatization serial mediation model

Figure 2 shows all path coefficients for the full serial mediation model examining the association between restrictive emotionality and stigmatizing beliefs about PrEP use. Tables 3 and 4 present the full model effects. Results of our first hypothesis, testing the total effect of restrictive emotionality on stigmatizing beliefs about PrEP use, indicated a significant effect (β = .16, t = 5.25, p < .001, 95%CI 0.10 – 0.21). As predicted, greater restrictive emotionality was associated with holding stigmatizing beliefs about using PrEP. Examining the second hypothesis, that internalized homophobia and LGBT community connectedness serially mediated the relationship between restrictive emotionality and stigmatizing beliefs about PrEP use, we found a significant indirect effect (β = .01, SE = .003, 95%CI 0.003 – 0.02; Table 4). As predicted, restrictive emotionality was associated with greater internalized homophobia. Internalized homophobia was associated with feeling less connected to the LGBT community, and less LGBT community connectedness was associated with stigmatizing beliefs about using PrEP. We also found that internalized homophobia independently mediated the association between restrictive emotionality and stigmatizing beliefs about PrEP use (β = .05, SE = .02, 95%CI 0.03 – 0.09; Table 4). Here restrictive emotionality was associated with greater internalized homophobia, which in turn was associated with holding stigmatizing beliefs about using PrEP. The final model explained 22% of the variance in participants’ stigmatizing beliefs about PrEP use (see Table 3).

Figure 2.

Figure 2

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Serial Mediation Model of the Association between Restrictive Emotionality and Stigmatizing Beliefs about PrEP Use

Serial mediation diagram; a, b, c, c’ and d are path coefficients representing unstandardized model estimates and standard errors (in parentheses). The c path coefficient represents the total effect of restrictive emotionality on stigmatizing beliefs about PrEP use, while the c’ path coefficient represents the direct effect of this relationship. The serial indirect effect through internalized homophobia and LGBT community connectedness is represented by the path coefficients a1d21b2. The a2 and b1 path coefficients were not central to our hypotheses. The a2 coefficient represent the restrictive emotionality/LGBT community connectedness association and the b1 coefficient represents the association between internalized homophobia and stigmatizing beliefs about PrEP use. Solid lines indicate significant paths. ** p <.01, *** p <.001.

Table 3.

Mediation Analysis of the Associations between Restrictive Emotionality, Internalized Homophobia, LGBT Community Connectedness, and Stigmatizing Beliefs about Using PrEP

M1 (IH) M2 (LGBT CC) Y (Stigma)
variable β SE p 95% CL β SE p 95% CL β SE p 95% CL
Intercept 0.92 0.11 <.001 0.71, 1.13 3.15 0.08 <.001 2.99, 3.31 1.04 0.18 <.001 0.70, 1.39
RE a 1 0.24 0.04 <.001 0.16, 0.32 a 2 −0.05 0.03 n.s. −0.11, 0.01 c 0.09 0.03 .003 0.03, 0.14
IH – – – – – – – – d 21 −0.23 0.04 <.001 −0.30, −0.14 b 1 0.23 0.04 <.001 0.16, 0.30
LGBT CC – – – – – – – – – – – – – – – – B 2 −0.15 0.05 .002 −0.25, −0.05
R2=0.08 R2 = 0.13 R2 = 0.22
F(1, 363) = 32.98, p <.001 F(2, 362) = 26.97, p <.001 F(3, 361) = 33.13, p <.001
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Notes. Stigma = stigmatizing beliefs about PrEP use, RE = restrictive emotionality, IH = internalized homophobia, LGBT CC = LGBT community connectedness. M1 and M2 = mediator variables, Y = outcome variable

Table 4.

Indirect Effects of the Serial Mediation Model

Indirect effects
β SE 95% CI
RE ➝ IH ➝ stigma (H2) 0.05 0.02 0.03, 0.09
RE ➝ LGBT CC ➝ stigma (H3) 0.01 0.01 −0.002, 0.02
RE ➝ IH ➝ LGBT CC ➝ stigma (H4) 0.01 0.003 0.003, 0.02
Total indirect effect 0.07 0.02 0.04, 0.11
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Notes: Stigma = stigmatizing beliefs about PrEP use, RE = restrictive emotionality, IH = internalized homophobia, LGBT CC = LGBT community connectedness.

Discussion

To our knowledge, the present study is the first to examine the association between restrictive emotionality and stigmatizing beliefs about PrEP use among Black SMM. Consistent with theorizing that gender role socialization may influence stigma processes (Mahalik et al., 2003; O’Neil, 2008), our findings extend previous research investigating the association between restrictive emotionality and stigma. Previous research has primarily focused on the association between aspects of masculinity and stigma toward seeking mental health services (Heath et al., 2017; Pederson & Vogel, 2007; Steinfeldt et al., 2009; Wester et al., 2010). However, the results of our study suggest that restrictive emotionality may be related to the manifestation of stigmatizing beliefs regarding health-related behaviors more broadly.

Rigid adherence to the norm of restrictive emotionality may result in stigmatizing beliefs towards a range of behaviors that violate conceptualizations of masculinity. This result is likely because expressing emotions is viewed as a feminine behavior, and a central tenet of masculinity is the avoidance of femininity (O’Neil, 2008). As our findings suggest, greater emotional restriction may hinder some Black SMM’s ability to accept aspects of themselves that may be viewed as feminine, such as their same-sex sexual behavior. This lack of acceptance may further influence their beliefs towards health-promoting behaviors that are associated with same-sex sexual behavior. Thus, experiencing greater levels of restrictive emotionality may negatively affect some Black SMM’s beliefs about and acceptance of PrEP, providing a motive to engage in othering to avoid femininity (e.g., attempting to conform to anti-homosexual expectations of male gender roles).

We also examined internalized homophobia and LGBT community connectedness as explanatory mechanisms of the association between restrictive emotionality and stigmatizing beliefs about PrEP use. We found that these factors accounted for the predicted association. Consistent with previous work (McDermott et al., 2014; Sánchez et al., 2010; Thepsourinthone et al., 2020), restrictive emotionality was directly associated with internalized homophobia. This finding suggests that adhering to the norm of restricting one’s emotions may lead to the internalization of homophobic beliefs. Further, and informed by previous work (Anderson-Carpenter et al., 2019), the relationship through internalized homophobia was linked to stigmatizing belief about using PrEP through LGBT community connectedness, supporting our theoretically informed prediction. Our model also indicated that internalized homophobia may act as an independent mechanism accounting for the association between restrictive emotionality and stigmatizing beliefs about PrEP use. This finding is consistent with previous research (Sánchez et al., 2010) and highlights that PrEP may be strongly associated with gay men among Black SMM; thus, some Black SMM who experience greater internalized homophobia may view PrEP as an unacceptable form of HIV prevention.

Despite the novel findings presented, several limitations should be considered. First, the cross-sectional study design precludes the ability to make causal inferences. However, while the limitations of cross-sectional data in mediation analysis are well-known, our study hypotheses and directionality have intuitive appeal and were based on theoretical and empirical research conclusions. Future research should examine the direct influences of the model’s proposed relationships utilizing a longitudinal design. Second, study data was collected from Black SMM in the southeastern US and is not representative of all Black SMM. Thus, the present study’s results may not generalize to Black SMM in other geographic locations or SMM of different racial or cultural backgrounds. However, this study is the first that we are aware of to examine the link between restrictive emotionality and stigma in a sample of minority men at the intersection of race and sexuality. Finally, social desirability may have influenced how participants responded to some items. However, participants were informed of the study’s anonymity, reducing the likelihood of social desirability bias.

With these limitations in mind, the study’s findings have important implications for interventions aimed at reducing the stigmatization of PrEP use among Black SMM at elevated risk for HIV, as well as practical implications for healthcare providers. Interventions targeting stigmatizing beliefs about PrEP may need to be tailored to address aspects of our conceptual model for Black SMM. The total effect suggests that addressing restrictive emotionality may be the most effective means of reducing stigmatizing beliefs about using PrEP. For instance, research shows that increasing men’s self-compassion can decrease the negative association between strict adherence to rigid gender roles and stigma (Heath, Brenner, Vogel, Lannin, & Strass, 2017). Research also indicates that the resolution of internalized homophobia is associated with positive health outcomes among SMM (Herrick et al., 2013). Thus, focusing on resolving internalized homophobia may be another effective way to reduce stigmatizing beliefs about PrEP and increase its use over time. This may be especially true given the finding that internalized homophobia independently accounted for the association between restrictive emotionality and stigmatizing beliefs about PrEP use. The results of the present study not only connect findings from previous research but also highlight the importance of considering social and network-level factors in conjunction with individual-level factors to address the disparate incidence of HIV and the uptake of prevention strategies among Black SMM (Millett, Flores, Peterson, & Bakeman, 2007; Millett et al., 2012). Our findings suggest that feeling connected to the LGBT community is likely a critical factor that affects how PrEP is viewed among this group. Thus, increasing Black SMM’s LGBT community connectedness may be a feasible and expedient means to reduce stigmatizing beliefs about PrEP use. Black SMM who feel connected to the broader LGBT community may be less inclined to engage in othering, facilitating the uptake of HIV prevention strategies. This intervention point may be highly effective given that LGBT community connectedness is associated with positive outcomes among Black SMM (Miller et al., 2012), including awareness and knowledge of PrEP (Hotton et al., 2018).

While future research should develop interventions that address the negative influence of gender norms in conjunction with minority stress factors to increase PrEP use among Black SMM, the present study highlight the critical need to focus on healthcare providers, who may be in a position to reduce the negative influence of the factors examined in the present study. Specifically, training in sexuality and the negative impact gender norms can have regarding Black SMM’s sexual health issues is needed (Komlenac & Hochleitner, 2019). Healthcare providers may be uniquely situated to reduce the stigmatization of PrEP by actively engaging Black SMM in their sexual health and providing an environment to correct misperceptions and stereotypes regarding PrEP use without imposing heteronormative ideas that may lead to othering and avoidance of the prevention tool.

The goal of ending the HIV epidemic in the US is within reach due to advancements in the tools used to treat and prevent the disease. However, reaching this goal will require a substantial increase in the use of bio-behavioral prevention strategies such as PrEP among groups most impacted by HIV. A complete understanding of the unique barriers Black SMM face is essential, as this group remains most affected by HIV. Failing to consider how aspects of masculinity may affect the sexual health of Black SMM not only reinforces heteronormative ideals but also fails to adequately identify areas of intervention that will ultimately bring an end to an epidemic that has devastated marginalized groups for decades.

Public Significance Statement.

Restrictive emotionality was associated with stigmatizing beliefs about using PrEP to prevent HIV among Black sexual minority men. Internalized homophobia and LGBT community connectedness partially mediated the association serially. Addressing restrictive emotionality among this population may be an effective strategy to reduce stigmatizing beliefs about PrEP and increase the use of the prevention tool.

Acknowledgments

  • The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article. The project described was supported by Award Number T32 MH019139 (Principal Investigator, Theodorus Sandfort, Ph.D.). from the National Institute of Mental Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of National Institute of Mental Health or the National Institutes of Health. This work was supported also by the National Institute of Mental Health [T32MH074387] and [R21MH121314]. The authors declare that there is no conflict of interest.

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