Association of Discrimination-Related Trauma with Sexual Risk among HIV-Positive African-American Men Who Have Sex with Men

Abstract

Objectives

HIV disproportionately affects African-American men who have sex with men (MSM). High levels of traumatic stress among African American MSM may be associated with poor health behaviors, including sexual risk, and thus may be a promising target for HIV prevention. We investigated whether one form of traumatic stress, discrimination-related trauma (e.g., physical assault due to race), was associated with unprotected anal intercourse (UAI), especially when compared to non-discrimination-related trauma, among African-American MSM.

Methods

A convenience sample of 131 HIV-positive African-American MSM receiving antiretroviral treatment completed audio computer-assisted-self-interviews that covered UAI; interpersonal trauma; and whether trauma was due to discrimination based on race/ethnicity, HIV-serostatus, or sexual orientation.

Results

60% reported at least one interpersonal trauma; they attributed at least one trauma to being gay (47%), African-American (17%), and/or HIV-positive (9%). In a multivariate regression, experiencing discrimination-related trauma was significantly associated with UAI (AOR=2.4,95%CI=1.0-5.7,p=0.04), whereas experiencing non-discrimination-related trauma was not (AOR=1.3,95%CI=0.6-3.1,p=0.53).

Conclusions

HIV-positive African-American MSM experience high levels of discrimination-related trauma, a stressor that was associated with greater risk. HIV prevention interventions should consider the potential damaging effects of discrimination in the context of trauma.

Introduction

HIV disproportionately affects African-American men who have sex with men (MSM). Twenty-eight percent of African-American MSM are estimated to be HIV-positive, compared to 16% of white MSM¹ and 2% of the general African-American male population.² Young Black males (aged 13–29) who have sex with males have had a higher increase in HIV incidence in recent years than any other racial/ethnic subgroup in the US.³ Rates of unprotected anal intercourse (UAI) fail to account for racial/ethnic disparities in HIV prevalence.⁴ However, UAI remains the highest risk factor for HIV transmission among MSM. Understanding the socio-cultural variables associated with UAI among African-American MSM is likely to be important for developing appropriate HIV prevention strategies for this population. One such socio-cultural variable is interpersonal trauma, including childhood sexual abuse (CSA),⁵ intimate partner violence (IPV),⁶ forced sex,⁷ and other physical assault. African-Americans in general⁸ as well as MSM^{9, 10} are disproportionately affected by interpersonal violence. Although few studies have examined forced sex and physical assault among African-American MSM, several have reported a higher prevalence of CSA among African-American MSM than among white MSM.¹¹ Furthermore, MSM who experience trauma may be more likely to engage in sexual risk behaviors. For example, one study reported that MSM with a history of CSA had more sexual contacts and acts of UAI than MSM who had no history of CSA.¹¹

Other research suggests that African-American MSM are faced with multiple forms of discrimination associated with their HIV-serostatus, race, and sexual orientation,¹² and that such discrimination may sometimes be experienced as interpersonal trauma. A qualitative study of 87 African-American MSM reported that victims may perceive experiences of CSA to be related to their sexual orientation.¹³ A small quantitative study of a convenience sample of 56 HIV-positive patients recruited from an AIDS treatment clinic reported that of HIV-positive men of color and MSM who reported IPV, slightly more than a quarter believed that their abuse was related to their HIV serostatus.¹⁴

The minority stress model posits that social discrimination leads to excess stress among minority persons that may be more damaging than other types of stressors, because discrimination based upon one’s social group may threaten individuals’ core sense of identity.^15–18 Consistent with this model, a survey of lesbians and gays found that those who had experienced a bias-related crime showed worse mental health consequences (i.e., symptoms of depression, anxiety, anger, post-traumatic stress) than did those who had experienced non-bias-related crimes.¹⁹ The effect of social discrimination on mental health outcomes has been well documented across various populations, including people living with HIV.^{12, 20} Further, some research indicates a relationship between perceived social discrimination and sexual risk among MSM, ^21–28 but none has included an examination of the distinct relationship between discrimination-related trauma and sexual risk behavior, beyond the effects of other types of trauma. The minority stress model suggests that social discrimination-related trauma would have a greater association with sexual risk than would trauma alone. Although prior research has indicated an association between sexual risk and both trauma^5–7 and chronic discrimination,^21–28 the effects of trauma resulting from discrimination on sexual risk do not appear to have been investigated in the literature.

In the present study, we examined the association of prior trauma with sexual risk among African-American MSM living with HIV. In multivariate models, we examined the distinct effects of discrimination-related and -unrelated interpersonal trauma on sexual risk. We were especially interested in assessing whether experiences of discrimination-related interpersonal trauma had a unique relationship with UAI beyond variables related to sexual risk in prior research. We were also interested in whether there was a distinct relationship between UAI and discrimination-related interpersonal trauma beyond any relationship with interpersonal trauma in general (including discrimination-related and –unrelated interpersonal trauma). Such findings would suggest a need to focus on the added effects of discrimination from interpersonal trauma in both research and secondary HIV prevention interventions targeting this population.

Methods

Participants and procedures

Two hundred fourteen African-American men living with HIV participated in this study. Eligible participants provided informed consent and then completed an audio computer-assisted self-interview (ACASI) containing several measures relevant to the present analyses (described below). Participants received a $30 honorarium.

The sample for the present analyses was restricted to men who reported having sex in the past three months (n=131). Men were recruited using flyers at an HIV medical clinic and three HIV social service agencies in Los Angeles, CA, from January 2007 to February 2009. Details of the recruitment process have been described previously.^{12, 29–32} Men responding to the fliers were screened via telephone for the following eligibility criteria: 1) Black/African-American identity; 2) self-identification as male; 3) HIV-positive serostatus; 4) 18 years or older; and 5) taking antiretroviral treatment (because medication adherence was relevant to another study goal).

Institutional review board approval was provided by all study institutions, and the National Institutes of Health issued a Certificate of Confidentiality.

Measures

Trauma and Discrimination

Participants were asked whether they experienced any of the following interpersonal traumatic events in their lifetime: physical assault; sexual assault; or sexual contact when younger than age 18 with someone 5 or more years older.³³ For each traumatic event, follow-up items designed for the present study were used to capture trauma due to Black/African-American race/ethnicity, HIV-positive serostatus, and gay sexual orientation (e.g., To what extent do you think that this happened because you are Black or African-American?). Two measures were derived from these questions. The first measure, discrimination-related trauma, was coded based on attributing any reported traumatic experience to discrimination based on the aforementioned personal characteristics. The second measure, interpersonal trauma not related to discrimination, was coded based on experiencing any of the aforementioned events and responding that they were not due to Black/African-American race/ethnicity, HIV-positive serostatus and/or gay sexual orientation (e.g. physical assault not believed to have been perpetrated against the participant because he was Black, gay or HIV-positive).

Socio-demographic characteristics

Participants were asked their age, education level, income, employment, sexual orientation, transgender identity, housing accommodations, date of HIV diagnosis, and history of imprisonment. Variables that were not initially dichotomous (e.g. transgender identity and history of incarceration) were dichotomized based on their distributions; distribution of variables with some categories that were less represented than others were combined with other similar categories. Education was dichotomized into high school diploma or less versus greater than high school diploma; annual income into <$5,000 versus ≥$5,000 annually based on a median split; employment into employed full/part-time versus unemployed, on disability, retired, or in school; sexual orientation into heterosexual versus other categories (i.e., gay/same-gender loving, bisexual, not sure or in transition, something else, or don’t know); and housing into stable (rent or own home or apartment, subsidized housing) versus not stable (homeless, living rent-free with friend/relative, residential treatment facility, temporary/transitional housing). We calculated the length of time since diagnosis from the interview date and the age at diagnosis.

Drug Use

Participants were asked about how frequently they used any of four illicit drugs (i.e., cocaine powder, crack cocaine, heroin, or amphetamine/methamphetamine) in the past 30 days. Responses were collapsed into a dichotomous variable indicating “any” or “no” drug use.

Alcohol use

Problematic drinking was measured with the RAPS4-QF,³⁴ which contains four screening items for alcohol problems over the past year and two quantity-frequency (QF) items. A dichotomous variable was created to represent whether or not a participant was engaged in problematic drinking defined as response of ‘yes’ to any of the initial four items or both of the QF items.

Depression

Depression was measured using the 8-item depression scale from the Medical Outcomes Study.³⁵ A positive screen on this instrument indicates a high probability of major depression. A dichotomous variable was created to cover whether the participant screened positive for depression.

Sexual Risk Behavior

Participants were asked about sexual behavior in the past three months. Those who reported any male sexual partners were asked the frequency of protected and unprotected (i.e., with and without condoms) insertive and receptive anal intercourse. Separate questions assessed each type of sexual behavior with HIV-positive, HIV-negative, and unknown HIV-serostatus male and female partners.

Sexual risk was defined in three ways, as reported engagement in any unprotected intercourse with male partners; in any unprotected intercourse with HIV-negative or unknown-status male partners (a measure of HIV transmission risk behavior); and reported engagement in any unprotected intercourse with HIV-positive male partners (a measure of risk for exposure to new infections and/or different strains of HIV).

Statistical Analysis

Descriptive statistics were computed for all study variables. Means and standard deviations were examined for continuous variables, and frequencies were examined for categorical variables. Bivariate tests were conducted to examine whether discrimination-related interpersonal trauma and non-discrimination-related interpersonal trauma, as well as potential covariates (socio-demographic characteristics, sexual identity, time since HIV diagnosis, depression, imprisonment, and drug use), were related to the UAI outcome variables. These potential covariates were chosen based on their association with unprotected anal intercourse in prior studies.^36–38 Multivariate models testing the simultaneous effects of discrimination-related interpersonal trauma and non-discrimination-related interpersonal trauma were used to adjust for covariates that were related to unprotected sex at an alpha level of 0.20 in bivariate tests (sexual orientation, drug use, time since diagnosis, stable housing, low education, transgender identity, and history of incarceration). Including these covariates in the model allowed us to determine whether interpersonal trauma functioned as an additional unique factor related to sexual risk, beyond the effect of variables that have been associated with sexual risk in the literature.^39–45

Results

Sample Description

The average age of the sample was 42 (SD 8.7; range 20–67), and a substantial percentage had low socioeconomic status, with 81% not employed, nearly 43% with very low incomes, and nearly 20% with less than a high school degree (Table 1). Nearly half (47%) were housing situations that were not stable (e.g., homeless). Most (91%) identified as gay, bisexual, or another non-heterosexual category; 16% were transgender. On average, participants were diagnosed with HIV approximately 13 years before the study at an average age of 30. Half of the sample screened positive for depression, and 35% engaged in drug use in the past month. Over a fourth (28%) had been incarcerated. Nearly half (47%) reported having unprotected anal intercourse with a male partner in the past three months.

Table 1.

Characteristics of the Sample of 131 African American Men who have Sex with Men (MSM) with HIV

Sample Characteristics	M (SD) or %
Socio-demographic characteristics
Age	42.4 (8.7)
Employed	19%
Heterosexual	9%
Transgender	16%
Income (≤$5,000 annually)	43%
Education (≤ high school degree)	19%
Not in stable housing	47%
Depression (positive screen)	50%
Drug use (any in past 30 days)	35%
Ever incarcerated	28%
UAI with any male partner in the past 3 months	47%
Time since HIV diagnosis (years)	12.7 (6.5)

Note: UAI = unprotected anal intercourse

Experience with Interpersonal Trauma

Sixty percent of participants reported experiencing at least one interpersonal trauma; 45% experienced childhood sexual abuse (N=58, average age = 8.8, SD = 3.9), 8% adult sexual assault (N=10, average age = 23.4, SD = 5.0), and 36% physical assault (N=47, average age = 23.1, SD = 10.9). Of those who experienced any interpersonal trauma, 47% attributed at least one trauma experience to being gay (average age at first gay-related trauma experience= 13.8, SD = 9.2), 17% to race (average age at first race-related experience = 14.7, SD = 8.8), and 9% to HIV-serostatus (average age at first serostatus-related experience = 19.9, SD = 14.6).

Relationships between Interpersonal Trauma and UAI

In bivariate analyses, discrimination-related interpersonal trauma was associated with a higher likelihood of reporting UAI with any male partners in the past three months (odds ratio (OR)=2.78, 95% confidence interval (CI)=1.26–6.13, p= 0.01) and, reporting UAI with HIV-positive male partners in the past three months (OR=2.83, 95% CI=1.29–6.22, p= 0.009) (Table 2). There was no significant association between discrimination-related interpersonal trauma and UAI with HIV-negative/unknown male partners. Interpersonal trauma not related to discrimination was not significantly related to any of the UAI outcome variables.

Table 2.

Bivariate and Multivariate Regressions Predicting Unprotected Anal Intercourse (UAI) in Past Three Months with Interpersonal Trauma among 131 African American Men who have Sex with Men (MSM) Living with HIV

	Unadjusted OR (95% CI)	Adjusted OR (95% CI)†
UAI with Any Male Partner
Non-discrimination-related Interpersonal Trauma	1.28 (0.61–2.68)	1.31 (0.56–3.08)
Discrimination-related Interpersonal Trauma	2.78 (1.26–6.13)*	2.44 (1.05–5.71)*
UAI with HIV Positive Male Partner
Non-discrimination-related Interpersonal Trauma	1.29 (0.60–2.77)	1.17 (0.48–2.85)
Discrimination-related Interpersonal Trauma	2.83 (1.29–6.22)**	3.49 (1.42–8.61)**
UAI with HIV Negative/Unknown Male Partner
Non-discrimination-related Interpersonal Trauma	1.03 (0.37–2.86)	1.23 (0.35–4.28)
Discrimination-related Interpersonal Trauma	1.86 (0.68–5.12)	1.48 (0.47–4.72)

Note: UAI = unprotected anal intercourse; CI = confidence interval; OR = odds ratio

^*p<.05

^**p<.01

^†Adjusted for heterosexual sexual identity, transgender identity, time since HIV diagnosis, stable housing, low education, imprisonment, and drug use (in past 30 days)

Multivariate regressions indicated that participants who had experienced discrimination-related interpersonal trauma were more likely to have engaged in UAI with any male partner (OR=2.44, 95% CI=1.05–5.71, p= 0.04), and UAI with HIV-positive male partners (OR=3.49, 95% CI=1.42–8.61, p= 0.007) (Table 2).

In the multivariate regression for UAI with any male partner, none of the covariates remained significant. Transgender identity remained the only covariate significantly associated with UAI with HIV- negative or unknown male partners (OR=5.32, 95% CI=1.22 to 23.08, p= 0.03). In the multivariate regression for UAI with male partners who are HIV-positive, transgender identity (OR=0.15, 95% CI = 0.03 to 0.69, p=.02) and heterosexual identity (OR=9.03, 95% CI = 1.62 to 50.31, p=.01) remained significant predictors.

Discussion

In our convenience sample of 131 African-American MSM living with HIV, we found a high prevalence of interpersonal trauma, including sexual assault, childhood sexual abuse, and other physical assault. About half of those who had experienced trauma attributed that trauma to discrimination based on their being Black/African-American, HIV-positive or gay. We also found a high prevalence of sexual risk, with 47% reporting UAI with a male partner in the previous three months.

We found that men who experienced discrimination-related interpersonal trauma in their lifetime were more likely than those who had not experienced such trauma to have engaged in UAI with a male partner in the past three months. This association was significant for two of the three UAI outcome variables – UAI with any male partner and UAI with an HIV-positive male partner – but not UAI with an HIV-negative/unknown male partner. In contrast, among men who experienced interpersonal trauma not related to discrimination, there was no significant association between their experience of trauma and UAI. Prior research has shown an association between trauma and sexual risk behavior. By separating out discrimination-related trauma from non-discrimination-related trauma, this study extends prior research by suggesting that discrimination could be driving this association.

These findings are consistent with studies based on the minority stress model, in which sexual minority individuals who experienced discrimination-related stressors showed greater adverse mental health outcomes (e.g., depressive symptoms and suicide ideation) than did sexual minorities not subjected to such stressors.¹⁹ Our findings extend prior research by showing an association between minority stress and a non-mental health outcome. Furthermore, biopsychosocial models^46–49 posit that social discrimination may lead to poor health outcomes by increasing detrimental physiological and psychological stress responses, including maladaptive coping and lower thresholds for coping with new stressors. Our findings and those of others^50–52 suggest that increased sexual risk behavior is a potential maladaptive avoidance/escape strategy for coping with stressors such as discrimination.

Decreasing maladaptive coping from discrimination-related trauma may be an important target for interventions in this population. However, little is known about the types and success of specific coping strategies used by African-American MSM in response to discrimination. Literature on resilience among African-Americans describes reliance on family and community networks for social support, religion and spirituality, and racial pride as adaptive strategies for coping with stress, including stress from racism.^53–56 Additional formative work is critically needed to develop interventions to strengthen use of adaptive coping strategies and reduce use of avoidance/escape and other maladaptive strategies. Furthermore, such interventions must take into account that African-American HIV-positive MSM experience compounded minority stress, as members of multiple stigmatized social groups. For instance, social support, although important, may be difficult to garner for these men due to stigmatization based on sexual orientation and serostatus in African-American communities and race in white gay communities.^{57, 58}

Limitations

These findings are not generalizable to the broad population of African-American MSM living with HIV, as the sample was not randomly selected and was limited to one geographical area in Southern California. In addition, causality cannot be inferred from our cross-sectional study regarding the positive association between discrimination-related trauma and sexual risk. Recent research on seroadaptive behaviors, in which MSM adapt their sexual behaviors based on the status of their partners^59–61 suggests that serosorting or strategic positioning (i.e. assuming a sexual position that lowers the risk of transmitting HIV) may in part explain our findings of differential behaviors with negative or unknown partners compared to positive partners. Because we did not specifically ask about seroadaptive behaviors, we cannot rule out such practices as a confounding factor. In addition, because of our small sample size, the study was not sufficiently powered to examine the effects of different types of interpersonal trauma. Nor were we able to examine the effects of discrimination-related trauma due to HIV-serostatus, sexual orientation, or race/ethnicity separately. Further, our measures of discrimination-related interpersonal trauma are self-reported and subject to the limitations of other self-reported measures. Of note, several studies suggest that discrimination is often underreported,^{62, 63} and thus our findings may be underestimates of the true effects.

Conclusions

The African-American MSM living with HIV in this study reported high levels of interpersonal trauma including child sexual abuse, sexual assault, and other physical assault, a substantial proportion of which they believe stemmed from discrimination based on their race, sexual orientation or HIV status. Discrimination-related trauma may be a sizeable and overlooked stressor, particularly in populations faced with multiple stigmatized identities or conditions. Future work is needed to identify intervention strategies sensitive to these multiple conditions in order to reduce the harmful psychological and behavioral effects of discrimination and ultimately reduce HIV-related health disparities among African-American MSM.