1. PROMOTING THE HEALTH OF MEN WHO HAVE SEX WITH MEN WORLDWIDE A training curriculum for providers

2. Module 3: Barriers to Health 2

3. Learning Objectives 3 1 2 3 Identify barriers, facilitators, and critical enablers that impact access to and utilization of healthcare services Describe how stigma undermines the health of gay men and other MSM Identify provider advocacy roles in mitigating barriers to healthcare access

4. Module Overview 4 1 2 3 Definitions, terminology, and causes of stigma and discrimination toward gay men and other MSM HIV-related and multi-layered stigma The link between social discrimination and health 4 The role of health professionals in advocacy on behalf of gay men and other MSM

5. Introduction 5 Gay men and other MSM experience stigma and discrimination Outside the health system o Laws, policies, other factors Inside the health system Stigma and discrimination Exacerbate vulnerability Decrease access to healthcare 2 3 1 Providers can help overcome stigma and discrimination

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7. Framework: Structural Factors Barriers Homophobia Social norms/heteronormative attitudes Provider stigma and insensitivity Poverty Criminalization of same-sex behaviors Facilitators Safe spaces Mental health and psychosocial services Comprehensive healthcare 2 1 7

8. Framework: Community Factors Barriers Social exclusion by families and friends, from cultural and religious activities, and from health institutions Extortion and blackmail Ridicule Eviction Job termination Violence Facilitators Community engagement Family support Stable relationships 2 1 8

9. Framework: Individual Factors Barriers Fear of being recognized as gay or MSM Poor self-worth Depression Anxiety Suicidality Facilitators Financial resources Sustainable work Education 2 1 9

10. Stigma and Discrimination 10 Stigma – An attribute that shames an individual or group in the eyes of others Three types: o Enacted o Felt o Internalized 1 2 3 Discrimination – When behaviors or actions are perpetrated that lead to inequality, inequity, or unfairness based on belonging to a particular group Homophobia – The irrational hatred, fear, or intolerance against homosexuality or against gay men and other MSM

11. Group Activity Rotational Brainstorm Naming Stigma and Discrimination Toward MSM 11

12. Stigma against MSM 12 Stigma occurs due to: Sexual orientation (being gay) Sexual behavior (having multiple partners or having anal sex) Engagement in sex work (being a sex worker) Diseases (having HIV or other STIs) Gay men and other MSM can be stigmatized for more than one reason Gay men and other MSM can stigmatize each other 2 3 1

13. Stigma within MSM Stigma within MSM can be based on: Ethnicity Rural background Religion Perceived socioeconomic status Perceived engagement in sex work Perceived promiscuity HIV status Gender expression 13

14. HIV-related Stigma HIV is often linked to negative perceptions of certain behaviors for e.g. Promiscuity Sex Work Injection drug use 14 2 1 HIV-related stigma is caused by Lack of knowledge and misperceptions about HIV Exaggerated fears of HIV infection Negative representations of people living with HIV in the media Association of HIV with illegal or immoral behavior

15. 15 Discrimination Family and CommunityHealthcare Sector Workplace IsolationLoss of social and family support Self-stigmatizationLoss of employment and income Suicidal thoughtsDecreased access to healthcare DepressionFewer job opportunities Fear of HIV Transmission Negative representations of PLHIV in the media and public health messages Association of HIV with illegal and immoral behavior Schematic diagram of stigma and discrimination against people living with HIV (PLHIV) in Ho Chi Minh City: Causes, effects, and relationships Misperceptions about HIV transmission risk STIGMA against PLHIV in the community Negative attitudes about PLHIV

16. Group Activity Addressing Stigma Targeted Against Gay Men and other MSM 16

17. Criminalization of Same-sex Behavior 77 of 193 countries currently criminalize same-sex behavior 17 Criminalization: Increases stigma and discrimination against gay men and other MSM Decreases representation in program and policy development Decreases health surveillance of gay men and other MSM Decreases uptake and provision of HIV-related services Limits the ability of health workers to provide services to gay men and other MSM Limits resources devoted to gay men and other MSM health 2 1

18. Social Discrimination and Health Stigmatizing attitudes do not always result in discrimination, but the effects are still harmful Mental health issues, anxiety, stress, and depression Riskier sexual behavior Increased risk for HIV and other STIs 18 It is estimated that less than one in ten gay men and other MSM globally are reached by HIV prevention services

19. Homophobia and the Health System MSM often utilize mainstream healthcare settings Gay- or MSM-specific services are not available everywhere Many providers lack specialized knowledge of unique needs May intentionally or unintentionally express disapproval and prejudice against gay and other MSM clients Homophobia in the health system has a negative impact on the health of MSM MSM who face stigma in the health system are: Less likely to openly discuss their sexuality Less likely to provide complete or accurate sexual histories More likely to avoid the health system altogether 1 2 3 4 19

20. Health Professional Advocacy Roles Health professionals play a central role in reducing stigma and discrimination Education for providers about gay men and other MSM is critical In the health setting, health professionals can: Promote a welcoming atmosphere Educate co-workers to ensure respect and dignity for gay men and other MSM Outside of the health setting, health professionals can: Treat families and communities equally and with respect Empower MSM to participate in community activities Lobby local authorities to support gay men and other MSM 1 2 3 4 20

21. Case Study Chike, 17 year old male from Nigeria Questions for Discussion: 1. What types of issues is Chike facing in his life? 2. Identify the barriers preventing Chike from receiving the care he needs. 3. Are there ways in which the clinic could improve Chike’s experience? Describe. 21

22. Summary MSM face barriers at all levels, from structural to individual to engaging with the health system Stigma and discrimination underlie the majority of barriers Criminalization of homosexuality has a highly negative effect on MSM health Gay men and other MSM may experience multi-layered stigma, such as with HIV Health professionals play a central role in reducing stigma and discrimination 1 2 3 4 5 22