1. Cultural Competence: Silent Population Welcome! Harold Thomas, MS August 5, 2015 Austin, TX

2. National Community Health Partners (NCHP) Through funding from the Centers for Disease Control and Prevention (CDC), we work nation- wide and in the U.S. territories to provide capacity building assistance to community-based organizations. Our mission is to educate and assist in identification and correction of social and health issues associated with the threat and outbreak of communicable disease and social dysfunction.

3. Community High-Impact Prevention (CHIP) An initiative to extend High-Impact Prevention (HIP) to directly funded community-based organizations. HIP has emphasized sustainable, high-impact HIV testing and screening programs, linkage to and engagement in care & services, scalable and effective interventions and public health strategies for high-risk populations and Persons Living with HIV/AIDS.

4. Overall Presentation Goal To provide knowledge, awareness and skills to enhance the capacity of service providers to work effectively with men who publicly maintain heterosexual relationships as well as discreetly engage in same-gender sex - hereafter referred to as individuals in the “silent” population

5. Training Objectives Identify how the social, psychological, and behavioral characteristics of the silent population affect HIV and other health risks Understand how cultural norms and values impact experiences and behaviors. Provide a foundation of knowledge, skills, and strategies to effectively address the unique challenges associated with the silent population

6. Presentation Agenda Cultural Competency Profile of Individuals in the Silent Population Stigma HIV and Health Risks Cultural Considerations Strategies for Working Effectively with the Silent Population

7. Profile of Individuals in the “Silent” Population

8. What is the “Silent” Population? Individuals who self-identify as heterosexual and publicly maintain heterosexual relationships while engaging in discreet same- gender sex

9. Why not just say “MSM” or “gay”? Avoiding the use of labels, especially “gay”, “bisexual” or “MSM” is important in reaching the silent population The terms “MSM” or “gay” ignore the unique social and emotional context and risk of HIV among silent populations Further, the use of “MSM” or “gay” may constitute a barrier to prevention efforts when they are perceived as insulting or inappropriate

10. Outward Characteristics In heterosexual relationships Some are married Exhibit traditionally masculine behaviors and appearances (i.e. don’t “look gay”) May subscribe to homophobic or erroneous beliefs about same-gender sex, and may participate in homophobic or sexist remarks, discriminatory behaviors Often conceal same-sex relationships even from close family and friends

11. Internal Characteristics May feel homosexuality, homosexuals, homosexual relationships, etc. are vile Generally do not identify as “gay” or “bisexual” due to their own shame associated with homosexuality and/or their concern about being rejected by social alliances who stigmatize homosexuals

12. Perceptions Individuals in the silent population may subscribe to beliefs that (for example) : Gay and bisexual people are promiscuous Homosexuals do not want and are not capable of having long-term monogamous relationships In same-sex relationships, one partner plays the “male” role and the other the “female” role

13. Perceptions (cont.) Same-sex relationships are unhealthy/abnormal Same-sex relationships consist of an older gay person who psychologically manipulates a younger, vulnerable person

14. Stigma

15. Stigma We all Stigmatize Insufficient knowledge, disbeliefs and fears about: 1)How HIV is transmitted; and 2)The life potential / capacity of PLWHA Moral judgments about people who we assume have been sexually promiscuous Fears about death and disease Lack of recognition of stigma

16. Stigma Individuals in the silent population: May subscribe to HIV-related fear and discrimination, and therefore distance themselves from the disease and persons associated with it (i.e. outwardly gay and bisexual individuals) May hide the fact that they engage in same-gender sex out of fear of losing the support of loved ones Thus, addressing HIV-related stigma and fear is key to working with the silent population

17. Homophobia Individuals who engage in homosexual behavior while holding negative attitudes toward homosexuality often experience emotional distress and engage in destructive behaviors that undermine the ability to practice safer sex Source: Jarma, et al. 2005; Garcia 2005

18. Addressing Stigma It is important for providers to understand how these social, emotional, and behavioral characteristics impact the silent population’s unique and complex HIV (and other health) risks

19. HIV & Other Health Risks

20. Health/HIV Risk Determinants The key to working effectively with individuals in the silent population is to understand their unique Perceived Risks Social Support Actual Risks SaferBehavior Service Access Factors associated with: Limitations in: Barriers to:

21. Perceived Risks Self-perception of risk is impacted by: Societal Attitudes Knowledge Skills Personal Beliefs Perceived Risks

22. Scenario # 1 Tell your wife

23. Scenario # 2 Inside information

24. Scenario # 3 Outreach-a-go-where?

25. Environmental & Structural Factors Structural Factors Laws, ordnances, policies, etc. Partner notification mandates Culture and individual experiences interact with structural conditions that affect the environment in which a person may encounter HIV risk(s) Environmental Factors People Places Things

26. Strategies for Working Effectively with the Silent Population

27. Working with the Silent Population 1.Avoid using labels such as “gay” or “MSM” 2.Correct erroneous beliefs about same-sex behaviors, relationships, and identities 3.Help individuals understand the individual, cultural, structural and environmental factors that shape and / or limit their sexual choices 4.Help individuals examine how their beliefs and behaviors contribute to negative self-esteem and self-destructive behaviors

28. Working with the Silent Population 5.Encourage individuals to seek intimacy in the context of safer sex practices 6.Create an open environment where sexual identity and sexual behavior can be discussed openly and independently. For example: Men who identify primarily or strictly as heterosexual can talk about having sex with other men Men who have same-gender sex can appear / be “masculine”

29. Working with the Silent Population 7.De-stigmatize homosexuality 8.De-stigmatize condom use… 9.Consider the impact of culture… 10.All individuals - e.g., not just openly “gay” men - should be educated about HIV risk related to same-gender sex

30. National Community Health Partners Training and Technical Assistance: Organizational Development & Management (ODM) Public Health Strategies (PHS) Prevention with Positives

31. Grant Writing Board Development Leadership Development ARTAS CHTC SNS Medication Adherence Social Media Motivational Interviewing EXAMPLES OF TRAININGS WE OFFER Organizational Development Management Public Health Strategies Prevention with Positives

32. E-Learning Center National Community Health Partners is building e-learning courses to help health departments and community based organizations implement Community High-Impact Prevention practices while working with both the HIV+ and at-risk populations

33. E-Learning Center Current Courses Community High-Impact Prevention Motivational Interviewing Medication Adherence Condom Distribution Asset Mapping Biomedical Strategies for HIV Prevention Cultural Capacity for Transgender For more information: http://www.nchponline.org/nchp-elearning

34. Thank you! Harold Thomas hthomas@nchponline.org Project Director 3365 N. Campbell Avenue, Suite 141 Tucson, AZ 85719 www.nchponline.org (520) 795-9756 (520) 887-0432 fax Toll Free 877-749-3727