Experiences of Stigma by Gay and Bisexual Men in Rural Oklahoma

Stigma, Mental Health, and Health care Use Among Rural Sexual and Gender Minority Individuals

Sexual and gender minorities (SGM) frequently experience depression and health care-related stigma. Health care satisfaction is important for seeking care, but little is known about SGM health care satisfaction, and especially as it relates to depression among rural SGM. From May 25 to July 2, 2021, we surveyed rural Illinois (IL) individuals aged ≥18 years on the topics of demographics, depression, health care satisfaction, past health care experiences, internalized stigma, and victimization. Among the 398 respondents, the gender identity distribution included cisgender males and females (171 and 203, respectively) and transgender males and females (8 and 7, respectively), while sexual orientation included heterosexuals (114), gay/lesbians (143), and other orientations (141). Analyses were conducted with respect to both identity and orientation (and their interaction). In univariate analysis, transgender individuals were more likely than cisgender to screen positive for depression and less likely to report feeling accepted by their medical provider. Compared to heterosexual respondents, gay/lesbians and other orientations were more likely to screen positive for depression. In logistic regression, factors associated with increased risk of depression included nonheterosexual orientation and past poor health care experiences. In linear regression, factors most commonly associated with the seven satisfaction subscales include: sexual orientation, past poor experiences, and employment. There were significant differences in depression across both sexual orientation and gender identity, and in health care satisfaction by sexual orientation. Rural SGMs are more vulnerable to depression and less likely to report satisfactory care. As health care engagement is critical for screening and care adherence, engaging rural SGM in a routine and satisfactory fashion is needed.

Mpox knowledge, behaviours and barriers to public health measures among gay, bisexual and other men who have sex with men in the UK: a qualitative study to inform public health guidance and messaging

BACKGROUND

The 2022-23 mpox epidemic is the first-time sustained community transmission had been reported in countries without epidemiological links to endemic areas. During that period, the outbreak almost exclusively affected sexual networks of gay, bisexual, or other men who have sex with men (GBMSM) and people living with HIV. In efforts to control transmission, multiple public health measures were implemented, including vaccination, contact tracing and isolation. This study examines knowledge, attitudes, and perceptions of mpox among a sample of GBMSM during the 2022-23 outbreak in the UK, including facilitators for and barriers to the uptake of public health measures.

METHODS

Interviews were conducted with 44 GBMSM between May and December 2022. Data were analysed using reflexive thematic analysis. Positive and negative comments pertaining to public health measures were collated in a modified version of a 'table of changes' to inform optimisations to public health messages and guidance.

RESULTS

Most interviewees were well informed about mpox transmission mechanisms and were either willing to or currently adhering to public health measures, despite low perceptions of mpox severity. Measures that aligned with existing sexual health practices and norms were considered most acceptable. Connections to GBMSM networks and social media channels were found to increase exposure to sexual health information and norms influencing protective behaviours. Those excluded or marginalized from these networks found some measures challenging to perform or adhere to. Although social media was a key mode of information sharing, there were preferences for timely information from official sources to dispel exaggerated or misleading information.

CONCLUSIONS

There are differential needs, preferences, and experiences of GBMSM that limit the acceptability of some mitigation and prevention measures. Future public health interventions and campaigns should be co-designed in consultation with key groups and communities to ensure greater acceptability and credibility in different contexts and communities.

Behaviors associated with HIV transmission risk among rural sexual and gender minority and majority residents

Multiple rural states and communities experience elevated rates of human immunodeficiency virus (HIV), often associated with diminished healthcare access and increased drug use. Though a substantial proportion of rural populations are sexual and gender minorities (SGM), little is known of this group regarding substance use, healthcare utilization, and HIV transmission behaviors. During May-July 2021, we surveyed 398 individuals across 22 rural Illinois counties. Participants included cisgender heterosexual males (CHm) and females (CHf) (n = 110); cisgender non-heterosexual males and females (C-MSM and C-WSW; n = 264); and transgender individuals (TG; n = 24). C-MSM participants were more likely to report daily-to-weekly alcohol and illicit drug use prescription medication misuse (versus CHf; aOR = 5.64 [2.37-13.41], 4.42 [1.56-12.53], and 29.13 [3.80-223.20], respectively), and C-MSM participants more frequently reported traveling to meet with romantic/sex partners. Further, more C-MSM and TG than C-WSW reported healthcare avoidance and denial due to their orientation/identity (p < 0.001 and p = 0.011, respectively); 47.6% of C-MSM and 58.3% of TG had not informed their provider about their orientation/identity; and only 8.6% of C-MSM reported ever receiving a pre-exposure prophylaxis (PrEP) recommendation. More work is needed to explore the substance use and sexual behaviors of rural SGM, as well as their healthcare interactions, to better target health and PrEP engagement campaigns.

Medical Mistrust Among a Racially and Ethnically Diverse Sample of Sexual Minority Men

Purpose: Medical mistrust is a barrier to health care utilization and is associated with suboptimal health outcomes. Research on mistrust among sexual minority men (SMM) is limited and largely focuses on Black SMM and HIV, with few studies assessing mistrust among SMM of other race/ethnicities. The purpose of this study was to examine differences in medical mistrust among SMM by race. Methods: From February 2018 to February 2019, a mixed-methods study examined the health-related beliefs and experiences of young SMM in New York City. The Group-Based Medical Mistrust Scale (GBMMS) was used to measure medical mistrust related to race, and a modified version of the scale assessed mistrust related to one's "sexual/gender minority" status (Group-Based Medical Mistrust Scale-Sexual/Gender Minority [GBMMS-SGM]). With an analytic sample of 183 cisgender SMM, a one-way multivariate analysis of variance was used to examine differences in GBMMS and GBMMS-SGM scores by race/ethnicity [Black, Latinx, White, "Another Racial Group(s)"]. Results: There were significantly different GBMMS scores by race, with participants of color reporting higher levels of race-based medical mistrust than White participants. This finding is supported by effect sizes ranging from moderate to large. Differences in GBMMS-SGM scores by race were borderline; however, the effect size for Black and White participants' GBMMS-SGM scores was moderate, indicating that higher GBMMS-SGM scores among Black participants is meaningful. Conclusion: Multilevel strategies should be used to earn the trust of minoritized populations, such as addressing both historical and ongoing discrimination, moving beyond implicit bias trainings, and strengthening the recruitment and retention of minoritized health care professionals.

Factors associated with quality of life, depressive symptoms, and perceived stress among rural older adults living with HIV in the United States

PURPOSE

Rural older people living with HIV (PLH) in the United States are a population of growing size and significance. A better understanding of factors associated with quality of life (QOL), depressive symptoms, and stress in this population-especially modifiable factors-could inform future interventions.

METHODS

Online or on paper, we surveyed 446 PLH aged 50+ residing in rural counties across the United States (Mage = 56, 67% male, 67% White, and 23% Black). Associations between social support, HIV stigma, satisfaction with medical care, discrimination in health care settings, and structural barriers and health-related QOL, depressive symptoms, and perceived stress were assessed using multiple linear regressions.

FINDINGS

Controlling for demographics, greater social support was associated with better QOL, fewer depressive symptoms, and less stress. Greater HIV stigma was associated with more depressive symptoms and stress. Satisfaction with care was associated with better QOL and less stress. Discrimination in medical settings was associated with lower QOL and more depressive symptoms and stress. Finally, experiencing more structural barriers was associated with lower QOL and more depressive symptoms and stress.

CONCLUSIONS

In addition to engagement in care and viral suppression, QOL and mental health are also critical considerations for rural older PLH. Increasing social support, reducing or providing skills to cope with HIV stigma, improving quality of care, reducing discrimination and stigma in medical settings, and reducing or mitigating the impact of structural barriers present potential targets for interventions aiming to improve the well-being of older rural PLH.

Willingness to Participate in and Preferences for Studies of mHealth HIV Prevention Interventions: Cross-Sectional Study Among Sexual and Gender Minority Groups in the Southern United States

A number of mobile HIV prevention interventions have been developed to increase uptake of HIV prevention services such as HIV testing and pre-exposure prophylaxis (PrEP). Most of these interventions have been tested among urban populations. However, sexual and gender minority (SGM) groups in rural areas might also benefit from mobile HIV prevention interventions. These groups have heightened experiences of stigma and discrimination and have limited access to culturally competent healthcare. We conducted a survey of SGM participants in the southern United States to assess willingness to use the common features of mobile HIV prevention interventions and to participate in research studies of these interventions and to compare the results between rural and non-rural respondents. We found few differences in willingness to use common features of mobile HIV prevention interventions based on rurality and high levels of cellular connectivity across participants. Based on these results, rural residence is not a barrier to using mobile HIV prevention interventions.

Qualitative and Artificial Intelligence-based Sentiment Analyses of Anti-LGBTI+ Hate Speech on Twitter in Turkey

The aim of this study was to evaluate hate speech in Turkish LGBTI+-related tweets during a one-month period of artificial intelligence-based sentiment analyses. Turkish tweets related to LGBTI+, were retrieved using Python library Tweepy and were evaluated by sentiment analysis. The researchers then performed a qualitative analysis of the most frequently liked and retweeted tweets (n = 556). Sentiment analysis revealed that 69.5% of tweets were negative, 23.3% were neutral, and 7.2% were positive. The qualitative analysis was grouped under seven themes: LGBTI+ Club; Terrorism and Terrorist Organization Membership; Perversion, Illness, Immorality; Presence in History; Religious References; Insults; and Humiliation. The results of this study show that anti-LGBTI+ hate speech in Turkey is significant in terms of both quality and quantity. As LGBTI+ individuals are at risk for excess mental distress and disorders, it is important to understand the risks and other factors that ameliorate stress and contribute to mental health in social media.

Do Spirituality, Rurality, and LGBTQ Support Increase Outness and Quality of Health in Gay and Bisexual Men?

Although the existing research suggests that spirituality may positively affect health outcomes for gay and bisexual men, it is unclear to what extent it improves the quality of health over and above sociodemographic factors. Furthermore, there remains conflicting evidence regarding the role of residential location on levels of outness for gay and bisexual men. To that end, the present study used hierarchical linear regression analyses to examine the role of spirituality, rurality, and LGBTQ connectedness in outness and quality of health. The sample comprised 2,202 self-identified gay and bisexual men aged 18 and older who responded to the Social Justice Sexuality Project survey; participants represented all 50 states and Puerto Rico. The results indicate that whereas spirituality was positively associated with a greater quality of life, there was no significant difference in outness between rural versus nonrural participants. Moreover, bisexual men endorsed significantly lower levels of outness compared to their gay counterparts. Implications for future research regarding the role of spirituality and rurality in sexual minority health are discussed.

Engagement with HIV and COVID-19 prevention: a national cross-sectional analysis of users on a geosocial networking app (Preprint)

Background

Objective

Methods

Results

Conclusions

Well-Being of Lesbian, Gay, Bisexual Youth: The Influence of Rural and Urban Contexts on the Process of Building Identity and Disclosure

The study investigates how the territorial community can influence the individual and social well-being of lesbian, gay, bisexual (LGB) youth and especially the recognition of their feelings and the construction of their own identity as well as their needs to be socially recognized. This research focuses on the experiences of 30 LGB individuals (23 males and 7 females), with a mean age of 25.07 years (SD = 4,578), living in urban and rural areas of Southern Italy. Focalized open interviews were conducted, and the Grounded Theory Methodology, supported by the Atlas.ti 8.0 software, was used for data analysis. The textual material was first coded, and then codes were grouped into five macro-categories: Freedom of identity expression in the urban and rural context, identity construction and acceptance process, need of aggregation and identification with the LGB community, role of the interpersonal relationship in the process of identity acceptance, socio-cultural context, and LGB psychological well-being. The results showed a condition common to the two contexts that we can define as “ghettoization.” The young LGB is alone in the rural area due to a lack of places and people to identify with and greater social isolation. On the contrary, although there are more opportunities in the urban area, young people feel stigmatized and ghettoized because “their places” are frequented exclusively by the lesbian, gay, bisexual, transexual, queer (LGBTQ) community. The work will extensively discuss the limitations of the research, future proposals, and the practical implications of the results.

Rural College Students' Amenability Toward Using At-Home Human Immunodeficiency Virus and Sexually Transmitted Infection Testing Kits

BACKGROUND

College students residing in rural areas of the United States have limited access to human immunodeficiency virus (HIV) and sexually transmitted infection (STI) screening programs; yet, have increased rates of infection.

METHODS

Students (N = 326), attending a state university located within a rural community, completed an online survey containing open-ended questions that gauged their perceptions and experiences with HIV/STI testing, amenability to at-home testing technology, and preferences for obtaining at-home testing kits. Inductive coding was used to create themes for each open-ended question.

RESULTS

Students encounter a number of perceived barriers to accessing clinical HIV/STI testing venues including cost, utilization of parents' medical insurance, and stigma. Students desired screening paradigms that allow for a greater sense of privacy and the ability to be empowered through self-sampling methods. This includes the use of at-home testing kits, which could be accessed via mail, campus, or the local community. Although students were overwhelmingly amenable to using at-home testing, students discussed concerns with potential user error that could impact testing accuracy.

CONCLUSIONS

Study findings suggest the importance of developing less clinically oriented systems of HIV/STI screening, which allow students to choose from an array of screening options. Removing perceived barriers, notably access and privacy concerns, to HIV/STI testing by leveraging at-home testing is one potential method to increase screening uptake among this at-risk population.

A review of top performing rural community and critical access hospitals' web resources for transgender patients in the United States

OBJECTIVE

This cross-sectional study examined the prevalence of "LGBT" and "transgender" terminology and type of resources available to transgender patients on the websites of top performing rural/community hospitals and critical access hospitals in the U.S. The effect of hospital control (e.g. type of operating parent organization) on the presence of transgender resources on these websites was also evaluated.

METHODS

The rural and critical access hospitals selected for inclusion in this study were those published on the Chartis Group's 2020 "top performing" hospital lists. Each hospital website was reviewed for the presence of "transgender" and "LGBT" terminology, as well several control terms commonly found on hospital websites.

RESULTS

Findings suggest a lack of resources for sexual and gender minorities among rural community and critical access hospitals within this sample; the term "transgender" appeared on 26% of rural community hospitals and 21% of critical access hospitals (N = 200). There was no significant relationship between hospital classification and the type of transgender resources offered by the hospitals (p = 0.248). There was a significant relationship between hospital control and presence of the term "transgender" on the websites of critical access hospitals (p = 0.002, Fisher's Exact Test).

CONCLUSIONS

Few facilities provided links to external resources for transgender patients, advertised LGBT-friendly providers, or provided any information pertaining to gender-affirming healthcare. Additional research is needed to determine what barriers or social forces prevent these hospitals from using their websites to create a more inclusive environment for transgender patients within the communities they serve.

Perceived Confidentiality Risks of Mobile Technology-Based Ecologic Momentary Assessment to Assess High-Risk Behaviors Among Rural Men Who Have Sex with Men

Although men who have sex with men (MSM) within rural communities are disproportionately impacted by HIV, limited HIV research and programmatic resources are directed to these communities within the U.S. There is a need for improved behavioral data collection methods to obtain more detailed information on the relationship between rural environments, sexual behavior, and substance use. Utilization of mobile health (mHealth) technologies, such as ecologic momentary assessment (EMA), has been advocated for; however, limited research has evaluated its utility among rural MSM. Forty MSM residing in rural Oklahoma were recruited to complete in-depth interviews related to participating online/mobile-based HIV prevention research. Men described a willingness to participate in HIV and substance use studies that use EMA methodologies for data collection; however, they raised various research-related concerns. In particular, participants indicated potential privacy and confidentiality concerns related to the use of the mobile technology-based EMA in public and the storage of data by researchers. Given the varying degree of sexual orientation and substance use disclosure by participants, rural MSM were largely concerned with being inadvertently "outed" within their communities. Men described the various strategies they could employ to protect private information and methods to minimize research risk. Study findings suggest that EMA is an acceptable research methodology for use among rural MSM in the context of HIV and sexual health information, when privacy and confidentiality concerns are adequately addressed. Input from community members and stakeholders is necessary to identify potential areas of concerns for participants prior to data collection.

Sexual Health and the LGBTQ+ Community

Expand at first use ("lesbian, gay, bisexual, transgender, queer (or questioning), and others"? Sexual health is a state of physical, emotional, mental, and social well-being in relation to sexuality. Factors that contribute to the sexual health of an LGBTQ+-identified patient include not only the physical state of the patient but also cultural and contextual factors that influence other aspects of well-being. To be effective in promoting sexual health, providers must maintain an attitude of accepting the patient's sexual orientation and gender identity as core aspects of sexual health. Providers need to examine paperwork, office space, and cultural competence in providing a safe medical home for the LGBTQ+ community.

Use of Geosocial Networking Applications Is Associated With Compulsive Sexual Behavior Disorder in an Online Sample

BACKGROUND

Geosocial networking applications (GNAs) are relatively new outlets through which individuals may find partners for sexual encounters. There has been a paucity of research on the associations between use of these platforms and measures of mental health and compulsive sexual behavior disorder (CSBD).

AIM

To examine associations between use of GNA, anxiety, and CSBD.

METHODS

Using data from a large nontargeted Web-based sample (N = 4,203), we examined demographics associated with the use of GNAs. Using multivariable logistic regression adjusting for demographic differences between users and non-users, we examined associations between GNA use, anxiety, and CSBD.

OUTCOMES

The outcomes are Generalized Anxiety Disorder-7 and a modified Hypersexual Behavior Inventory-19.

RESULTS

The percentage of participants that reported they used GNAs was 12.3%. Those who reported using the applications compared with those who did not were more likely to be young, male, and nonheterosexual. After adjusting for demographic variables, GNAs use was associated with CSBD (adjusted odds ratio = 1.62, 95% confidence interval: 1.09-2.37, P = .015) but not anxiety.

CLINICAL IMPLICATIONS

This study is an initial foray into the relationships between GNA and mental health, establishing a relationship between GNA use and CSBD. Future research is needed to better understand the relationships between GNA use, psychopathology, and CSBD.

STRENGTHS & LIMITATIONS

Strengths of the study include its large sample size and nontargeted recruitment design, which minimizes confirmation bias. Limitations include the cross-sectional nature of this study, which precludes determination of the direction of causation.

CONCLUSION

Use of GNAs was prevalent among our sample and associated with CSBD. GNA use may represent an important platform through which CSBD manifests. Conversely, GNA use may drive CSBD. Turban JL, Passell E, Scheuer L, et al. Use of Geosocial Networking Applications Is Associated With Compulsive Sexual Behavior Disorder in an Online Sample. J Sex Med 2020;17:1574-1578.

Interface of Internalized Homophobia and Community Connectedness on Frequency of Doctor's Visits for Rural and Urban MSM in Oklahoma

PURPOSE

Men who have sex with men (MSM) face persistent risk of stigma, with past studies showing unequal treatments of MSM in health care settings. Contextual factors, such as internalized homophobia and connectedness to one's community, have shown to serve as a barrier or facilitator (respectively) with regard to MSM's decisions to seek preventative treatment. These studies, however, predominately feature urban populations, with less consideration given to rural MSM. The current study comparatively investigates these contextual factors between rural and urban MSM to detect differences in the frequency of doctor's visits.

METHODS

A 2-by-2 (rural/urban × doctor visit yes/no) multivariate analysis of variance (MANOVA) was conducted to investigate if significant differences and/or interactions existed for internalized homophobia and community connectedness.

FINDINGS

Results show a significant interaction between rurality and doctor's visits in our sample of predominantly white, self-identified gay men. Higher levels of internalized homophobia and lower levels of community connectedness were seen in rural individuals who had visited a doctor in the past 12 months and in urban individuals who had not seen a doctor in the past 12 months.

CONCLUSIONS

Study findings have implications for future public health research and for health promotion interventions, practices, and policies for MSM in rural areas. Social exclusion reinforces the invisibility of lesbian, gay, bisexual, and transgender (LGBT) populations, particularly in rural areas. Stigma and marginalization of MSM promote structural barriers inhibiting care. Our results give evidentiary support for programs which inform the work of clinicians on mechanisms to create LGBT-inclusive practice settings.