The Influence of Internalized Stigma on the Efficacy of an HIV Prevention and Relationship Education Program for Young Male Couples

  • Brian A. Feinstein
  • Emily Bettin
  • Gregory Swann
  • Kathryn Macapagal
  • Sarah W. Whitton
  • Michael E. Newcomb
Original Paper

Abstract

Young MSM are at increased risk for HIV, especially in the context of serious relationships, but there is a lack of couples-based HIV prevention for this population. The 2GETHER intervention—an HIV prevention and relationship education program for young male couples—demonstrated promising effects in a pilot trial. However, there is evidence that internalized stigma (IS) can influence treatment outcomes among MSM. The current study examined the influence of IS on the efficacy of the 2GETHER intervention among 57 young male couples. The intervention led to decreases in percentage of condomless anal sex partners and increases in subjective norms regarding HIV prevention for those with low/average IS, but not high IS. The intervention also led to increases in motivation to get tested with one’s partner and decreases in alcohol consumption for those with high IS, but not low/average IS. In contrast, IS did not moderate intervention effects on other motivational constructs, dyadic adjustment, or alcohol problems. In sum, IS influences the extent to which young male couples benefit from HIV prevention and relationship education depending on the outcome. Research is needed to understand how IS influences treatment outcomes.

Keywords

Internalized stigma HIV prevention Relationship education Same-sex couples Young men who have sex with men 

Notes

Acknowledgements

We would like to acknowledge the various individuals who served as facilitators for this project (in addition to the authors): Ryan Coventry, David Drustrup, John Frank, Kelsey Howard, Darnell Motley, Jae A. Puckett, and Tyson Reuter. We would also like to acknowledge Samuel McMillen and Brian Mustanski for their support. Finally, we would like to thank the couples that participated in this study for their time.

Compliance with Ethical Standards

Conflict of interest

Brian A. Feinstein declares that he has no conflict of interest. Emily Bettin declares that she has no conflict of interest. Gregory Swann declares that he has no conflict of interest. Kathryn Macapagal declares that she has no conflict of interest. Sarah W. Whitton declares that she has no conflict of interest. Michael E. Newcomb declares that he has no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

References

  1. 1.
    CDC. HIV Surveillance Report, 2015. 2016. http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Accessed 4 Jan 2017.
  2. 2.
    CDC. Diagnoses of HIV infection among adolescents and young adults in the United States and 6 dependent areas 2010–2014. 2016. https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Accessed 4 Jan 2017.
  3. 3.
    Goodreau SM, Carnegie NB, Vittinghoff E, et al. What drives the US and Peruvian HIV epidemics in men who have sex with men (MSM)? PLoS ONE. 2012;7(11):e50522.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Sullivan PS, Salazar L, Buchbinder S, Sanchez TH. Estimating the proportion of HIV transmissions from main sex partners among men who have sex with men in five US cities. AIDS. 2009;23(9):1153–62.CrossRefPubMedGoogle Scholar
  5. 5.
    Newcomb ME, Macapagal KR, Feinstein BA, Bettin E, Swann G, Whitton SW. Integrating HIV prevention and relationship education for young same-sex male couples: a pilot trial of the 2GETHER intervention. AIDS Behav. 2017;21(8):2464–78.CrossRefPubMedGoogle Scholar
  6. 6.
    Millar BM, Wang K, Pachankis JE. The moderating role of internalized homonegativity on the efficacy of LGB-affirmative psychotherapy: results from a randomized controlled trial with young adult gay and bisexual men. J Consult Clin Psychol. 2016;84(7):565–70.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Huebner DM, Davis MC, Nemeroff CJ, Aiken LS. The impact of internalized homophobia on HIV preventive interventions. Am J Community Psychol. 2002;30(3):327–48.CrossRefPubMedGoogle Scholar
  8. 8.
    Mustanski B, Newcomb ME, Clerkin EM. Relationship characteristics and sexual risk-taking in young men who have sex with men. Health Psychol. 2011;30(5):597–605.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Newcomb ME, Ryan DT, Garofalo R, Mustanski B. The effects of sexual partnership and relationship characteristics on three sexual risk variables in young men who have sex with men. Arch Sex Behav. 2014;43(1):61–72.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Perez-Figueroa RE, Kapadia F, Barton SC, Eddy JA, Halkitis PN. Acceptability of PrEP uptake among racially/ethnically diverse young men who have sex with men: the P18 study. AIDS Educ Prev. 2015;27(2):112–25.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Greene GJ, Andrews R, Kuper L, Mustanski B. Intimacy, monogamy, and condom problems drive unprotected sex among young men in serious relationships with other men: a mixed methods dyadic study. Arch Sex Behav. 2014;43(1):73–87.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Mitchell JW, Petroll AE. Patterns of HIV and sexually transmitted infection testing among men who have sex with men couples in the United States. Sex Transm Dis. 2012;39(11):871–6.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Chakravarty D, Hoff CC, Neilands TB, Darbes LA. Rates of testing for HIV in the presence of serodiscordant UAI among HIV-negative gay men in committed relationships. AIDS Behav. 2012;16(7):1944–8.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    CDC. HIV among gay and bisexual men. 2015. https://www.cdc.gov/hiv/group/msm/index.html. Accessed 4 Jan 2017.
  15. 15.
    Grov C, Starks TJ, Rendina HJ, Parsons J. Rules about casual sex partners, relationship satisfaction, and HIV risk in partnered gay and bisexual men. J Sex Marital Ther. 2014;40(2):105–22.CrossRefPubMedGoogle Scholar
  16. 16.
    Hoff CC, Beougher SC. Sexual agreements among gay male couples. Arch Sex Behav. 2010;39(3):774–87.CrossRefPubMedGoogle Scholar
  17. 17.
    Hoff CC, Beougher SC, Chakravarty D, Darbes LA, Neilands TB. Relationship characteristics and motivations behind agreements among gay male couples: differences by agreement type and couple serostatus. AIDS Care. 2010;22(7):827–35.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Mitchell JW. Characteristics and allowed behaviors of gay male couples’ sexual agreements. J Sex Res. 2014;51(3):316–28.CrossRefPubMedGoogle Scholar
  19. 19.
    Parsons JT, Starks TJ. Drug use and sexual arrangements among gay couples: frequency, interdependence, and associations with sexual risk. Arch Sex Behav. 2014;43(1):89–98.CrossRefPubMedGoogle Scholar
  20. 20.
    Mustanski B, Newcomb M, Du Bois SN, Garcia SC, Grov C. HIV in young men who have sex with men: a review of epidemiology, risk and protective factors, and interventions. J Sex Res. 2011;48(2–3):218–53.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Jiwatram-Negron T, El-Bassel N. Systematic review of couple-based HIV intervention and prevention studies: advantages, gaps, and future directions. AIDS Behav. 2014;18(10):1864–87.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Allen S, Meinzen-Derr J, Kautzman M, et al. Sexual behavior of HIV discordant couples after HIV counseling and testing. AIDS. 2003;17(5):733–40.CrossRefPubMedGoogle Scholar
  23. 23.
    World Health Organization. Guidance on couples HIV testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples. Geneva: WHO; 2012.Google Scholar
  24. 24.
    Allen S, Tice J, Van de Perre P, et al. Effect of serotesting with counselling on condom use and seroconversion among HIV discordant couples in Africa. BMJ. 1992;304(6842):1605–9.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Wagenaar BH, Christiansen-Lindquist L, Khosropour C, et al. Willingness of US men who have sex with men (MSM) to participate in couples hiv voluntary counseling and testing (CVCT). PLoS ONE. 2012;7(8):e42953.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Stephenson R, Sullivan PS, Salazar LF, Gratzer B, Allen S, Seelbach E. Attitudes towards couples-based HIV testing among MSM in three US cities. AIDS Behav. 2011;15(Suppl 1):S80–7.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Wu E, El-Bassel N, McVinney LD, et al. Feasibility and promise of a couple-based HIV/STI preventive intervention for methamphetamine-using, black men who have sex with men. AIDS Behav. 2011;15(8):1745–54.CrossRefPubMedGoogle Scholar
  28. 28.
    Wu E, El-Bassel N, Donald McVinney L, Fontaine YM, Hess L. Adaptation of a couple-based HIV intervention for methamphetamine-involved African American men who have sex with men. Open AIDS J. 2010;4:123–31.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Newcomb ME, Mustanski B. Moderators of the relationship between internalized homophobia and risky sexual behavior in men who have sex with men: a meta-analysis. Arch Sex Behav. 2011;40(1):189–99.CrossRefPubMedGoogle Scholar
  30. 30.
    Hatzenbuehler ML, Dovidio JF, Nolen-Hoeksema S, Phills CE. An implicit measure of anti-gay attitudes: prospective associations with emotion regulation strategies and psychological distress. J Exp Soc Psychol. 2009;45(6):1316–20.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Hofmann W, Gawronski B, Gschwendner T, Le H, Schmitt M. A meta-analysis on the correlation between the implicit association test and explicit self-report measures. Pers Soc Psychol Bull. 2005;31(10):1369–85.CrossRefPubMedGoogle Scholar
  32. 32.
    Jellison WA, McConnell AR, Gabriel S. Implicit and explicit measures of sexual orientation attitudes: in group preferences and related behaviors and beliefs among gay and straight men. Pers Soc Psychol Bull. 2004;30(5):629–42.CrossRefPubMedGoogle Scholar
  33. 33.
    Safren S, Otto MW, Worth JL. Life-steps: applying cognitive behavioral therapy to HIV medication adherence. Cogn Behav Pract. 1999;6(4):332–41.CrossRefGoogle Scholar
  34. 34.
    Puckett JA, Newcomb ME, Ryan DT, Swann G, Garofalo R, Mustanski B. Internalized homophobia and perceived stigma: a validation study of stigma measures in a sample of young men who have sex with men. Sex Res Soc Policy. 2017;14(1):1–16.CrossRefGoogle Scholar
  35. 35.
    Nungesser LG. Homosexual acts, actors, and identities. New York: Praeger; 1983.Google Scholar
  36. 36.
    Ramirez-Valles J, Kuhns LM, Campbell RT, Diaz RM. Social integration and health: community involvement, stigmatized identities, and sexual risk in Latino sexual minorities. J Health Soc Behav. 2010;51(1):30–47.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Shidlo A. Internalized homophobia: conceptual and empirical issues in measurement. In: Greene B, Herek GM, editors. Psychological perspectives on lesbian and gay issues. Thousand Oaks: Sage; 1994. p. 176–205.Google Scholar
  38. 38.
    Mustanski B, Starks T, Newcomb ME. Methods for the design and analysis of relationship and partner effects on sexual health. Arch Sex Behav. 2014;43(1):21–33.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Misovich SJ, Fisher WA, Fisher JD. A measure of AIDS prevention information, motivation, behavioral skills, and behavior. In: Davis C, Yarber R, Bauserman R, et al., editors. Handbook of sexuality-related measures. Thousand Oaks: SAGE; 1998. p. 328–37.Google Scholar
  40. 40.
    Spanier GB. Measuring dyadic adjustment: new scales for assessing the quality of marriage and similar dyads. J Marriage Fam. 1976;38(1):15–28.CrossRefGoogle Scholar
  41. 41.
    Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption-II. Addiction. 1993;88(6):791–804.CrossRefPubMedGoogle Scholar
  42. 42.
    Sanchez FJ, Westefeld JS, Liu WM, Vilain E. Masculine gender role conflict and negative feelings about being gay. Prof Psychol Res Pr. 2010;41(2):104–11.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Courtenay WH. Constructions of masculinity and their influence on men’s well-being: a theory of gender and health. Soc Sci Med. 2000;50(10):1385–401.CrossRefPubMedGoogle Scholar
  44. 44.
    Rudman LA. Sources of implicit attitudes. Curr Dir Psychol Sci. 2004;13(2):80–3.CrossRefGoogle Scholar
  45. 45.
    Meyer IH. Minority stress and mental health in gay men. J Health Soc Behav. 1995;36(1):38–56.CrossRefPubMedGoogle Scholar
  46. 46.
    Pachankis JE, Hatzenbuehler ML, Rendina HJ, Safren SA, Parsons JT. LGB-affirmative cognitive-behavioral therapy for young adult gay and bisexual men: a randomized controlled trial of a transdiagnostic minority stress approach. J Consult Clin Psychol. 2015;83(5):875–89.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Whitton SW, Weitbrecht EM, Kuryluk AD, Hutsell DW. A randomized waitlist-controlled trial of culturally sensitive relationship education for male same-sex couples. J Fam Psychol. 2016;30(6):763–8.CrossRefPubMedGoogle Scholar
  48. 48.
    Cao H, Zhou N, Fine M, Liang Y, Li J, Mills-Koonce WR. Sexual minority stress and same-sex relationship well-being: a meta-analysis of research prior to the U.S. nationwide legalization of same-sex marriage. J Marriage Fam. 2017;79(5):1258–77.CrossRefPubMedGoogle Scholar
  49. 49.
    Nosek BA, Hawkins CB, Frazier RS. Implicit social cognition: from measures to mechanisms. Trends Cogn Sci. 2011;15(4):152–9.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Greenwald AG, Poehlman TA, Uhlmann EL, Banaji MR. Understanding and using the implicit association test: III. Meta-analysis of predictive validity. J Pers Soc Psychol. 2009;97(1):17–41.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Institute for Sexual and Gender Minority Health and WellbeingNorthwestern UniversityChicagoUSA
  2. 2.Department of Medical Social SciencesNorthwestern University Feinberg School of MedicineChicagoUSA
  3. 3.Department of PsychologyUniversity of CincinnatiCincinnatiUSA

Personalised recommendations