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Hidden from health: structural stigma, sexual orientation concealment, and HIV across 38 countries in the European MSM Internet Survey

Pachankis, John E.a; Hatzenbuehler, Mark L.b; Hickson, Fordc; Weatherburn, Peterc; Berg, Rigmor C.d; Marcus, Ulriche; Schmidt, Axel J.c,f

doi: 10.1097/QAD.0000000000000724
Epidemiology and Social

Objective: Substantial country-level variation exists in prejudiced attitudes towards male homosexuality and in the extent to which countries promote the unequal treatment of MSM through discriminatory laws. The impact and underlying mechanisms of country-level stigma on odds of diagnosed HIV, sexual opportunities, and experience of HIV-prevention services, needs and behaviours have rarely been examined, however.

Design: Data come from the European MSM Internet Survey (EMIS), which was administered between June and August 2010 across 38 European countries (N = 174 209).

Methods: Country-level stigma was assessed using a combination of national laws and policies affecting sexual minorities and a measure of attitudes held by the citizens of each country. We also assessed concealment, HIV status, number of past 12-month male sex partners, and eight HIV-preventive services, knowledge, and behavioural outcomes.

Results: MSM living in countries with higher levels of stigma had reduced odds of diagnosed HIV and fewer partners but higher odds of sexual risk behaviour, unmet prevention needs, not using testing services, and not discussing their sexuality in testing services. Sexual orientation concealment mediated associations between country-level stigma and these outcomes.

Conclusion: Country-level stigma may have historically limited HIV transmission opportunities among MSM, but by restricting MSM's public visibility, it also reduces MSM's ability to access HIV-preventive services, knowledge and precautionary behaviours. These findings suggest that MSM in European countries with high levels of stigma are vulnerable to HIV infection. Although they have less opportunity to identify and contact other MSM, this might change with emerging technologies.

aDepartment of Chronic Disease Epidemiology, Social and Behavioral Sciences Division, Yale School of Public Health, Yale University, New Haven, Connecticut

bDepartment of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, New York, USA

cSigma Research, Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, UK

dDepartment of Evidence Summaries, Norwegian Knowledge Centre for the Health Services, Oslo, Norway

eDepartment of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany

fCommunicable Diseases Division, Federal Office of Public Health FOPH, Bern, Switzerland.

Correspondence to John E. Pachankis, Laboratory for Epidemiology and Public Health, 60 College Street, Suite 316, New Haven, CT, 06520, USA. Tel: +1 203 785 3710; e-mail:

Received 18 February, 2015

Revised 7 April, 2015

Accepted 13 April, 2015

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