The association between internalized homophobia and risky sexual behavior among HIV positive men

Background: Throughout the world, as in Israel, men who have sex with men (MSM hereafter) are among those at high risk for contracting HIV, the virus that causes AIDS. For most of these MSM, risky sexual behavior is the main risk factor for HIV infection. Therefore, many studies have focused on identifying and understanding demographic, interpersonal, emotional, and behavioral factors that explain risky sexual behavior.

The current study aims to broaden existing knowledge using a theoretical framework based on the Theory of Social Action, according to which the individual’s processes of self-regulation exist in a context of social factors that together are related to health behavior (Ewart, 1991). In the current study, internalized homophobia, the independent variable, represents an outcome of a social atmosphere of discrimination and negative attitudes toward homosexuals, that together with the individual’s self-regulation processes - emotional situations (depression), and abilities (self-efficacy in engaging in protected sexual relations) are related to risky sexual behavior among HIV-positive MSM, the dependent variable.

Study Objectives:

1.To examine the association between internalized homophobia and risky sexual behavior.

2. Exploring mediating effects: Do depression and self-efficacy mediate the association between internalized homophobia and risky sexual behavior, and does self-efficacy mediate the association between depression and risky behavior?

3. To examine which variables contribute the most to explaining risky sexual behavior.

Method: The participants in this study were 124 HIV-positive MSM who attend the AIDS clinic at Chaim Sheba Medical Center at Tel HaShomer, Ramat Gan. The study was approved by the hospital’s Helsinki committee. This is a quantitative, cross-sectional study.  After signing informed consent forms, the participants were asked to fill out a self-administered questionnaire during their visit to the clinic. The questionnaire included demographic background and medical variables, an internalized homophobia scale—IHP (Martin & Dean, 1987), depression - the CES-D questionnaire (Radloff, 1977; Shmotkin, 2003), self-efficacy in engaging in safe sex scale (Klonover, 2005; Misovich, Fisher & Fisher, 1999) and questions on sexual behavior with steady and casual partners. Risky sexual behavior was measured as the frequency of condom use during casual sex.

Data analyses included bivariate analysis and multivariate analyses using two-step hierarchical linear regression models on risky sexual behavior: background variables were included in the first step, and the study variables were added in the second step. Mediation effects were tested using the PROCESS procedure.

Main findings: No significant association was found between internalized homophobia and risky sexual behavior, while significant associations were found between depression or self-efficacy and risky sexual behavior in the bivariate analysis. Examination of mediation effects on the association between internalized homophobia and risky sexual behavior revealed a full mediation by depression (ind b= 0.22, 95% [CI= .003, .057]), but no mediation by self-efficacy. In addition, self-efficacy mediated the association between depression and risky sexual behavior (total indirect effect= 0.031, p= .01).

Finally, depression and self-efficacy were the only explanatory variables that contributed significantly (11%) to explaining the variance in risky behavior.

Conclusions, implications, and importance of the study: The findings of this study suggest that internalized homophobia is related only indirectly to risky sexual behavior among HIV-positive MSM, whereas the variables of self-regulation processes - depression, and self-efficacy, explain risky sexual behavior. The findings also indicate the role of depression in mediating the association between internalized homophobia and risky sexual behavior, along with self-efficacy as mediating the association of depression and risky behavior.

These findings offer a better understanding of the factors related to risky sexual behavior, but future research should expand them by including a combination of additional variables and other research methods (such as, for example, qualitative research).

The findings have important practice implications. In view of the increase in the rate of HIV infection among MSM in recent years, it is important to decrease this risk by future interventions. These might include creating programs that focus on identifying and targeting MSM who engage in risky sex, reducing the emotional distress in this population, training the care teams in hospitals and in the community, and creating an LGBTQ-friendly atmosphere in the healthcare system.