Abstract
Sexual minority men (SMM) face persistent stigma in Zambia. From a holistic perspective, we aim to explore its impacts within and between multiple socioecological levels, demonstrating how their interactions create a vicious cycle of barriers to the well-being of SMM. In-depth interviews were conducted with 20 purposively recruited SMM from Lusaka, Zambia. All interviews were audio-recorded, after written consent, transcribed verbatim, and iteratively coded employing inductive (i.e., data-driven) approaches for thematic analysis using NVivo. Results suggest three key themes: (1) interpersonal socially perpetuated sexual minority stigma (SMS); (2) multidirectional interactions between psychosocial well-being and risk-taking behaviors; and (3) institutionally perpetuated SMS as a barrier to seeking and receiving health care. SMS permeates across all levels of the socioecological model to negatively impact the psychosocial well-being of SMM while acting also as a barrier to accessing HIV prevention and care. Our study necessitates structural public health intervention to decrease stigma and discrimination against SMM in Zambia, in efforts to increase their psychosocial well-being as well as their access to and utilization of HIV care by breaking the vicious cycle of SMS that pervades through the intrapersonal, interpersonal, and institutional levels of the socioecological model.
Introduction
Zambia, a country in the southern, sub-Saharan region of Africa, is burdened by a high prevalence of human immunodeficiency virus (HIV). Sexual minority men (SMM) comprise many of those living with HIV. In 2014, 33% of Zambia’s HIV burden was borne by SMM who, alongside other key populations, are estimated to account for 10% of new HIV infections (Smith et al., 2009; “ZMB Narrative,” n.d.). Zambia’s National AIDS Strategic Framework (NASF of 2017–2021) includes SMM as a priority population in their strategy to address the HIV epidemic (“National AIDS Strategic Framework (NASF) 2017-2021—National HIV/AIDS/STI/TB Council—Zambia,” n.d.).
SMM in Zambia face numerous barriers accessing HIV prevention and treatment services that subsequently pose risks to their physical and mental health. One prominent barrier is minority stress, which is characterized by homophobic stigma and discrimination enacted against SMM (Meyer, 1995, 2003). The political, social, and religious environment of Zambia contribute to minority stress and ostracization experienced by SMM in the country. Dating back to Zambia’s colonial period, same-sex intercourse has long been criminalized and, since 2010, has been punishable by up to 14 years of imprisonment (Penal Code Act, 2005). Anti-homosexuality laws not only directly threaten SMM but also endorse homophobic norms and actions as socially acceptable (Ghoshal, 2016; Yelverton et al., 2021). Social norms that consider same-sex intercourse to be taboo have been evidenced through a survey of public opinion reporting high intolerance for homosexuality (The Pew Research Center, 2010). As Zambia is a predominantly Christian nation, there exist negative historic views of homosexuality due to its denotation as sin (Demographic and Health Surveys [DHS], 2002; Subhi & Geelan, 2012). Moreover, there is an influence of religion on healthcare as a majority of health service delivery is conducted through faith-based organizations that comprise 40% of the healthcare available nationally and more than 50% available in rural areas (Mhlanga, 2021). A lack of separation between religion and healthcare as well as political and social perpetuations of homophobia increase sexual minority stigma (SMS) against SMM.
SMS is, therefore, a prominent barrier to accessing healthcare and achieving desired health outcomes among SMM in Zambia. In response to the experienced homophobic prejudice and discrimination against SMM in Zambia, many conceal their identities and health challenges, or delay seeking care, to avoid exposure to SMS (Ghoshal, 2016). Identity concealment is common due to fears of being reported to law enforcement, upon which harassment, violence, and legal repercussions are plausible (Ghoshal, 2016). SMS in healthcare settings has been found to discourage care-seeking behaviors, complicate medication adherence, and contribute to concealment or selective disclosure of sexual identity due to their associations with increased mental health challenges and legal repercussions (Biemba et al., 2020; Kennedy et al., 2013).
SMS has been found to contribute to the diminished psychosocial well-being of SMM as, according to the Minority Stress Model, the consequential chronic stress experienced due to homophobic stigma and discrimination, at various levels of the socioecological model, predisposes SMM to mental health challenges (e.g., depression, suicidal ideation, substance misuse; Chen et al., 2015; Díaz et al., 2004; Hatzenbuehler & Pachankis, 2016; Lea et al., 2014; Meyer, 2003; Meyer & Frost, 2013). Both quantitative and qualitative work in Nigeria (Oginni et al., 2018; Ogunbajo et al., 2021), South Africa (Sandfort et al., 2016, 2018), Kenya (Harper et al., 2021; Secor et al., 2015), and Zambia (Armstrong et al., 2021) suggest high levels of psychological distress, post-traumatic stress disorder, depression, substance misuse, and suicidal ideation among SMM.
Despite an increase in empirical studies exploring the impact of SMS on the physical and psychosocial well-being of SMM, much of the existing research has been conducted as a subaim or latter established aim of HIV-related projects (Graham & Harper, 2017). For example, studies in Nigeria have investigated how SMS influences HIV testing uptake and engagement in unprotected sex through psychological pathways such as anxiety, depression, and suicidal ideation (Rodriguez-Hart et al., 2017, 2018). However, the dynamics and mechanisms through which SMS affects the psychological well-being of SMM are multidimensional and necessitate an examination of the perpetuation and impacts of stigma at multiple socioecological levels (i.e., intrapersonal, interpersonal, and institutional; Sallis et al., 2015). Assessing SMS through the lens of the socioecological model allows for an assessment of multidirectional influences of stigma and discrimination between SMM and their broader contexts (Bronfenbrenner, 1977, 1986).
There exists limited empirical evidence of the perceptions, experiences, and impacts of SMS from the perspective of SMM. Of the extant literature, to the authors’ knowledge, there lacks a comprehensive review of the experiences and impacts of stigma on SMM in Zambia, across various socioecological levels. Furthermore, it remains unclear how stigma and discrimination may interact within and between each socioecological level. The present study aims to address these gaps in the empirical evidence, to better understand the psychosocial well-being of SMM in Zambia through their lived experiences, assets, and needs.
Methods
Study Participants, Sampling, and Recruitment
The study was conducted among SMM in Zambia’s capital, Lusaka. Individuals who met the following inclusion criteria were eligible to participate in the study: (1) men aged 18 to 35 years old; (2) living in Lusaka, Zambia; (3) able to read and speak English; (4) who had a sexual encounter with at least one man in the past month and/or inconsistently used a barrier method (e.g., condoms); and (5) were willing to participate in the interview. Individuals who did not meet the above criteria were excluded from the study.
Potential participants were purposely recruited with the assistance of two local partners, Dignitate Zambia Limited (DZL) and the Centre for Infectious Disease Research in Zambia (CIDRZ). Both organizations maintain strong and established collaborations with local SMM communities. Potential participants who were interested in the study contacted the DZL or CIDRZ staff for further eligibility screening and interview scheduling. All participants provided their written informed consent prior to the interviews.
Study Design and Data Collection
The in-depth interviews were conducted in February 2021 by four experienced social science research assistants trained in qualitative data collection methods. In considering the needs of preventing COVID-19 infection, eligible participants were provided either a virtual or an in-person interview option, but all preferred to participate in-person. All interviews were conducted in a private room at the DZL office following all COVID-19 prevention strategies required by the Zambian government.
All interviews were conducted in English, but participants were encouraged to use local verbiage to express their sentiments, as needed. All interviews were audio recorded upon receiving written informed consent. The interviews spanned in length from 30 to 80 minutes, during which, experiences of stigma in clinical settings and their impacts on psychosocial well-being were explored. For example, participants were asked to describe facilitators and barriers, including personal fears and expectations, of accessing STI and HIV services in clinical settings. At the time of the interview participants were asked to complete a basic demographic questionnaire. The audio files were transcribed, verbatim, into text and at de-identified in the interest of protecting participants’ privacy and confidentiality. All participants were compensated for their time and efforts participating in the interview (i.e., USD $10). Upon completion of each interview a reflective summary was written and discussed by research personnel in debriefing meetings with team members from both Zambia and the United States. All data were stored and managed in a web-based shared drive with limited, password-protected access. Quality of the data was ensured by the senior scientists (S.Q., O.A., and A.S.) on the team. All data were reviewed and compared to the recordings to ensure that no data were lost in the transcription process and that all content was accurately presented.
Data Analysis
The transcripts were coded using NVivo software and subsequently analyzed thematically. Transcripts were coded iteratively, utilizing an emergent, thematic analysis approach to identify the subjective views of the participants (Fereday & Muir-Cochrane, 2006). The analysis implemented an inductive (i.e., data-driven) approach for thematic analysis, following previously established steps, to identify emergent patterns and themes (Braun & Clarke, 2006; Fereday & Muir-Cochrane, 2006). Data analysis was guided by the socioecological model, which focuses on understanding how multilevel factors (i.e., intrapersonal, interpersonal, community, and societal factors) interact with each other to shape the health-seeking behaviors and everyday activities of individuals (Golden & Earp, 2012; Sallis et al., 2015). In efforts to ensure inter-rater reliability and data quality, the coding was crosschecked for consistency across coders before it was analyzed. All themes represented in the manuscript were agreed upon by the research team.
Ethical Considerations
This study was approved by the University of Zambia’s Biomedical Research Ethics Committee (Ref: 1017-2020), the National Health Research Authority (Ref: NHRA 00002/2/8/09/2020), and the University of South Carolina Institutional Review Board (Ref: Pro00088260). The data were collected with the written informed consent of participants prior to their participation in the study.
Results
The mean age of the 20 participating SMM was 25 (SD = 4.0) years, with ages ranging from 20 to 34 years. Most participants were single (95.0%, n = 19), currently not working but seeking work (50.0%, n = 10), and rely on family to pay their medical bills for them when they are unwell (55%, n = 11). In the 6 months prior to the study, most participants had made less than three visits to a healthcare provider (70.0%, n = 14), did not need emergency care (75%, n = 15), and had not been hospitalized (80%, n = 16) (Table 1).
Demographic Characteristics of Participating Sexual Minority Men (n = 20)
SMS Impacts at the Interpersonal Level: Family, Friends, and Community Members
Study participants detailed their lived experiences of SMS ranging from name-calling and stigmatizing language to experiences of discrimination. One participant described how SMS is internalized when they shared, “I felt bad. It was demeaning. You know? They make you feel so small. Like you don’t know anything. You, you not smart. You’re careless and what not. Like you don’t care about your life. So, I felt so small.” (26-year-old, unemployed)
SMS experienced within familial relationships was a common theme among participants. One participant shared that the harmful, stereotypical assumptions placed on them by their mother implied that their lifestyle, as part of the SMM community, indicated a commodification of sexual activities (20-year-old, self-employed). The participant then referred to this situation, saying, “So that contributed [to] my breakdown. Sometimes I really get hurt because I wasn’t okay. I didn’t choose to be like this. I just find myself in this situation” (20-year-old, self-employed).
Other participants shared the impacts of remaining closeted (i.e., concealed sexual orientation/sexual minority status) on their interpersonal relationships. One participant illustrated this experience when they said, “The challenges are many … you can’t really open up to someone on everything that goes around. Especially in our community. Some of our family members don’t really know about us so we are, like, in the closet. I do not really open [up] to my friends, especially the people that are within my community … It really gets bad, so it affects me.” (27-year-old, employed full-time)
In considering the impact of tolerance and acceptance within interpersonal relationships, one participant shared the potential benefits when they said, “. . . if our families understood that this is normal, it would help elevate how we feel about ourselves mentally and physically” (27-year-old, unemployed). A participant summarized the overall feeling of SMS when they shared, “. . . when we are being stigmatized . . . that doesn’t make me feel good at all” (23-year-old, unemployed).
SMS Impacts at the Individual Level: Psychosocial Well-Being and Risk-Taking Behaviors
The deleterious impacts of SMS on SMM in Zambia were illustrated when one participant shared that “It goes back to that mental health. Like you talked about. Depressed—if it’s killing myself, I will kill myself, if I’m not that strong, enough to handle that situation” (21-year-old, unemployed). The effect of SMS, as perpetuated through interpersonal relationships, on SMM’s psychosocial well-being was illustrated when one participant stated, “. . . like young people would be going somewhere. They would, like dress what they feel like they wanna dress and then people in public would be like, no. Screaming names. That’ll affect their mental disturbance and whereby a lot of people like me, they’re chased [out of] their houses. They are outside there. They are suffering. So, it takes that mental … now we have a bigger number of those that are people that commit suicide.” (21-year-old, unemployed)
Most participants described the interactions between psychosocial well-being and substance use patterns within SMM communities in Zambia. One participant described the social norms of substance use as a method through which to cope with SMS when they said, “Most of the times, I mean, we like drink alcohol in order to run away from our problems. Our mental, you know, our mental, let me call them demons. And then we indend to, like, run. Most of the times that we want to, we don’t want to just feel, like, let me zone out. So, hence, let me just indulge in this thing.” (21-year-old, employed part-time)
Another participant describes SMM’s motivations for engaging in frequent substance use when they shared, “[I] think in our community, people drink a lot. And, I think it’s because some mentality. They feel, I don’t know [laughs], with not accepting oneself about the community. So, they feel like they take drugs [to] kind of make them forget that there are such issues, and they find comfort. So taking alcohol and drugs is very high in the community.” (25-year-old, unemployed)
Additional participants affirmed patterns of frequent use when they shared, “… nowadays, young men, they take alcohol like everyday. Yes, it’s like, it’s like abusing themselves. They are using drugs everyday. Alcohol everyday” (23-year-old, unemployed). Similarly, another participant described, “I think for now, the average number of young people drinking beer and stuff out there is above the older people. I think I’ve noticed young people drinking beer not because they want to [get] noticed, [but] because of what they are going through.” (21-year-old, unemployed)
Furthermore, a participant shared the cyclical impact of SMS-motivated substance use on interpersonal relationships when they said, “Yes, it [substance use] does [have a negative effect], because you won’t be able to provide for family like you’re supposed to. And, maybe you won’t have time to communicate or socialize with your family members because most of the time you will be drank, sleeping, or maybe drinking at a bar. So, there won’t be that time where you have, like, social time with your family.” (27-year-old, unemployed)
The interactions between SMM’s substance use patterns and sexual risk-taking behaviors are demonstrated as one participant describes, “If someone blacked out, [you] don’t know whether you used the condom or not. Usually, it makes them have unprotected sex and STIs” (25-year-old, unemployed). Furthermore, “… by having unprotected sex, like, I mentioned before, like, if you drink, you don’t think like correctly. You just end up getting anyone without knowing where they come from, or maybe their sexual status. So, you just sleep with them. And then if they are sick, in return you can also end up getting sick.” (27-year-old, unemployed)
Similarly, another participant noted that, “Alcohol makes you, yeah, I, I mentioned the whole euphoria thing, so it’ll make you make bad choices, like literally sleep with whoever you want in that moment, and not really worried about putting on a condom or their HIV status or anything. So that can affect your sexual health in that you will get sick at the end of the day.” (26-year-old, unemployed)
Coinciding with sexual risk-taking behaviors, a participant illustrated the impact of substance use on medication adherence when they shared, “Usually people end up fighting if they’ve taken too much alcohol and get too drunk. And sometimes you don’t take precautions—you forget to bring a condom, but you can bet, like me, maybe forget take your drugs. If you’re too drunk [you] might not mind what will happen because you just get carried away with whatever is happening.” (25-year-old, unemployed)
In addition to the potential infection risks to physical health when engaging in sexual risk-taking behaviors, while under the influence of substances, one participant describes its compounding impact on overall psychosocial well-being when they share that “Because you wake up. You find out that you had sex. That you had unprotected sex with someone that you don’t know. So, it affects your mind, mentally and emotionally at the same time” (27-year-old, employed full-time).
SMS Impacts at the Institutional Level: Barriers to Seeking and Utilizing Healthcare Services
Participants repeatedly expressed the negative impacts of SMS experienced at the hand of healthcare providers and the institutional environment where SMM are made to feel uncomfortable and despised. One participant shared such an experience when they said, “Healthcare providers, they discriminate in the form of discriminating [that] you feel uncomfortable sometimes when you go there because you expect some bad influence from them” (23-year-old, unemployed). Participants described that the hostile, stigmatized environment within healthcare institutions contributes to the concealment of their sexual orientation and their avoidance seeking healthcare all together. Another participant illustrated an example of SMS experienced within healthcare institutions, when they said, “… we have diseases that people don’t have. I will give an example; if I had a wart on my anal area and I go to a public hospital, they will definitely ask how they got there [and] instead discriminate [against] me. No one wants to be shouted at while you are sick.” (25-year-old, unemployed)
Multiple other participants recount similar experiences, such as, “I started developing some pimple like, yeah, to my private part. So, I explained my situation and the doctor was like looking at me with that face. It’s very uncomfortable. And then that stare gave me a sense of restraining from giving out what I was experiencing.” (21-year-old, employed part-time)
In addition to inciting hesitation among SMM, SMS within health care institutions was described as a barrier to care and treatment. This was illustrated by an additional participant who detailed that, “A gay friend was accessing services in a mini health facility for issues with his anal region and the healthcare provider passed a comment that; ‘these are the people that practice anal sex.’ The client left without getting treatment and has refused to visit any health facility for the illness till date.” (21-year-old, employed part-time)
In a separate instance, another participant illustrated the impact of institutionally perpetuated SMS in the health care setting when they described a situation where “Once they go to like the health facility, they are treated badly. And then, if not so, they are insulted, if not so exposed. They give me a reason to say ‘I can’t go there because you guys [healthcare providers] embarrass me. You finish my business. In doing so, it’s better I die with them. It’s better I rot with [them] . . .’” (21-year-old, employed part-time)
Furthermore, a participant shared, “[I] was experiencing a burning sensation whenever I went to the loo. A friend of mine told me to go to the clinic. After I went to the clinic, they referred me to the hospital and then the nurse told me, ‘you look like one of those guys who sleep with fellow guys.’ It made me uncomfortable. When I got this medication, I just left. I feel she’s going to call other people. She was rude. She [made me] feel unwanted. I felt like I was not even worthy to be there, so I left.” (25-year-old, unemployed)
Additional participants share experiences of SMS affecting the healthcare they receive, including interrogating questions that are deemed unnecessary and uncomfortable, testing conducted without receiving proper consent, passing patients between providers, name-calling, incorporating religious aims into care, confidentiality breaches, and allowing personal biases to impact the care provided. One participant illustrated such experiences as follows: “When I was being treated, when I was getting the test that has been done, [the] clinical officer was obviously a bit disrespectful. He’ll kind of look down on me for not really taking care of yourself properly. And, you know, people who were supposed to give me medication, but didn’t. Nurses will pass [me] around and, also gonna be a bit, uhh, bad to you, towards, towards me. So, it was all kind of bad.” (26-year-old, unemployed)
Another participant described experiencing SMS as a result of the incorporation of religious aims into care when they described, “They went to [a] hospital to access these services, and [when] they got there, this nurse left him in the office. She called her fellow workmates to come and see what type of a client she’s having. And it, kind of, made jokes and asked him to change. That God loves him. Such an episode made him feel uncomfortable and he decided never to go there again to access such services.” (25-year-old, unemployed)
One participant illustrated an experience of SMS, from their health care institution, through name-calling when they shared, “These nurses and these doctors, they have a say[ing]. It’s not everyone, but they have, like, this perception of when they see somebody, a guy, you know, behaving so gay, they have this mindset of ‘it is a demon.’ You get? Yeah, you’re talking about these ‘Jezebels.’ You know? They’ve even given them names. ‘Oh, you are talking about this cursed generation? If it was my child, I’d, kill such a one.’ And then imagine you’re in a line, and you’re in a line, you want to access some services and then you hear somebody saying that. Can you be able to even stay a longer period of time? No, you can’t.” (21-year-old, employed part-time)
Concerns of confidentiality and privacy were common among participants, such as one who shared, “These are the people that do not think. Like, even counselors are the one[s] who mostly, those are the people who are employed, and then those again are the people who are close to our community. Again, those are the people we know, and they are the same people who brings out more information about this person’s privacy, which is not very good.” (21-year-old, unemployed)
The permeation of SMS impacting commitments to privacy and confidentiality within health care institutions is exemplified by an additional participant who said, “The example that I can give is that we are not really recognized at the moment. So, for us to go there and be open to tell someone that ‘this is what I do’; I feel like this, it’s really a challenge. Especially in these government hospitals that we have in our country. So, we would rather go to one of our private ones. By this you know your information will be kept a secret or we would rather talk to one of our people from this same organization that we have within our reach.” (27-year-old, employed full-time)
Accordingly, multiple participants noted care differences between public- and private-sector hospitals, such as, “They [i.e., government hospitals] are not caring like they do in private hospitals” (25-year-old, unemployed) and, “There’s one thing I’ve noticed. The private sector is more advanced than the public sector. And mostly it’s not all people that have money. And you may find that a lot of diseases, they get more, more, worse because, due to the fact that other people [don’t] want to go to the public sector.” (23-year-old, unemployed)
Overall, one participant describes their experiences and sentiments about health care institutions when they state, “It really makes me less of a human. And, sometimes, it really takes me like two days back then. Where I used to feel like I’m not worth living and am mistake. . . I will go through with life, but it’s very hard.” (21-year-old, employed part-time)
Discussion
The present study provides unique insight into the lived experiences of SMS amongst SMM, living in Lusaka, Zambia, as related to the Minority Stress Model, within and between the intrapersonal, interpersonal, and institutional levels of the socioecological model (Bronfenbrenner, 1977, 1986; Meyer, 1995, 2003; Meyer & Frost, 2013). The Minority Stress Model conceptualizes the accumulating effects of chronic stress from SMS on SMM (Meyer, 2015). Stress accrued from SMS can then be attributed to various levels of the socioecological model to understand the role of broader contexts and environments on the well-being of SMM (Bronfenbrenner, 1977; Meyer, 2015). The themes extracted from the in-depth interviews reveal cyclical impacts and perpetuations of stigma as negatively impacting the mental health, social support, coping mechanisms, sexual risk-taking behaviors, and HIV prevention and care uptake among SMM.
The cyclical nature of SMS emerged as it was identified that stigma perpetuated within the interpersonal and institutional levels may be internalized to the intrapersonal level where there are subsequent, compounding effects that place additional strains upon interactions with the interpersonal and institutional levels (Figure 1). For example, in response to perpetual SMS, from the interpersonal and institutional levels, maladaptive coping mechanisms (e.g., substance use, high-risk sexual behaviors) may be adopted, which further exacerbate strains on interpersonal relationships and subsequently contribute to an increased reliance on such coping mechanisms.
The Vicious Cycle of Interactions Within and Between Multiple Levels of the Socioecological Model as Impacting Sexual Minority Stigma Against Sexual Minority Men
Within the intrapersonal level, the adverse effects of stigma on psychosocial well-being are repeatedly demonstrated by participants and are affirmed by the extant literature set within southern Africa (McAdams-Mahmoud et al., 2014; Stoloff et al., 2013). Stigma, experienced at all levels, was detailed as a primary cause of negative self-perception and self-image, feelings of shame and guilt, as well as experienced depression and suicidal ideation among SMM in Zambia. The perpetuation of SMS from healthcare institutions (i.e., institutional level) and community members (i.e., interpersonal level) contributed to feelings of guilt, shame, and a loss of dignity that can be understood as internalized stigma (i.e., intrapersonal level) and sustained minority stress (Duby et al., 2018; McAdams-Mahmoud et al., 2014; Meyer, 2015). Chronic exposure to SMS requires relief through the utilization of coping mechanisms.
As described by participants, substance use is a predominant mechanism used to cope with the chronic SMS and associated adverse psychosocial concerns among SMM, as imparted by systemically normed homophobic stigma and discrimination (Armstrong et al., 2021). Concordant with the emerging literature, where substance use burdens have been reported to be the highest among those aged 25 to 39 years and people living with HIV, concerns from the study population of young SMM (i.e., HIV epidemic priority population) regarding the frequency and quantity of peer substance use are validated (Nouaman et al., 2018; Yaya & Bishwajit, 2019). Within the emerging literature, substance use has been associated with increased likelihood of sexual risk-taking behaviors, HIV transmission and acquisition, lower odds of viral suppression, and suboptimal outcomes along the HIV care continuum (Chang et al., 2022; Daniels et al., 2018; Vinikoor et al., 2022). Emergent themes demonstrate the associations between stigma-induced substance use among SMM and high-risk sexual behaviors such as unprotected sex with STI prevalence and HIV infection (Rogers et al., 2019; Stephenson et al., 2021). Assumptions of peer substance use among SMM create a social environment where its use for coping is normalized, despite potential consequences (Rogers et al., 2019). Despite findings that substance use serves to build and sustain interpersonal relationships among SMM, including meeting sexual partners, it has also been found to further strain relationships within the interpersonal level (Daniels et al., 2018).
A key finding of the present study includes the demonstrated impacts of the cyclical, compounding effects of SMS between the intra- and interpersonal levels. Participants illustrated that the complicated interactions, between the intra- and interpersonal levels, are influenced by the necessity to shroud or conceal their sexual minority status from those in their social networks due to the social and political environments of Zambia (Stahlman et al., 2016). SMM considering sharing their identity or status with others described a fear of rejection where, based on previous personal experiences, or those of others, further stigmatization, discrimination, and harassment are anticipated within interpersonal relationships due to their social, political, and religious environment. Participants highlight the impact of community-wide stigma as diminishing social support leading to further dissociation and isolation which, cyclically, furthers mental health concerns and associated adverse effects on substance use and psychosocial well-being.
Due to the prioritization of SMM as a priority population in HIV epidemic mitigation efforts, it is necessary to consider the impact of institutional perpetuations of SMS on impeding or preventing access to consistent, reliable, and quality HIV prevention and care. Repetitive, emergent themes demonstrate that stigma and discrimination enacted against SMM when seeking healthcare decrease service uptake. SMS enacted against SMM, and key populations living with HIV, by healthcare providers of various roles in southern Africa, has been found to threaten service uptake (Krishnaratne et al., 2020; Lane et al., 2008). Of the literature assessing community health workers’ (CHWs) sentiments, it has been reported that there exist stigmatizing beliefs among CHWs where their biases against key populations, such as SMM, go as far as to believe that they should be denied care (Krishnaratne et al., 2020). Compounding the impacts of the biases held by health care providers, at the interpersonal level, are the findings that health care workers providing care to SMM had inadequate knowledge, skills, or training necessary to meet their needs (Duby et al., 2018).
In Zambia, SMS is systemically perpetuated within the institutional level. As SMS has long been codified at the policy level, through the criminalization of homosexuality, a deleterious institutional precedent has been set that privacy and confidentiality within health care institutions need not be upheld for SMM. Furthermore, findings indicate that stigma is normalized through collegial interactions that create and maintain standards of care that then become institutionalized within healthcare institutions. An example of this process is the threat of confidentiality breaches to interpersonal relationships through the involuntary disclosure of identity, sexual orientation, or infection status that further contribute to the stigmatizing social environment. Unpermitted, involuntary disclosure of medical information or SMM status to others heightens population distrust in healthcare institutions and escalates tensions within interpersonal patient–provider relationships.
Institutional SMS that creates a fear of consequences among patients identifying as SMM acts as a significant barrier to the uptake of HIV prevention and care services where patient decision-making is influenced by factors at the interpersonal and institutional levels (Qiao et al., 2018). The present findings are consistent with the extant literature that identifies barriers to healthcare utilization for SMM as including verbal harassment, name-calling, judgmental biases, refusal of care, and confidentiality breaches (Pilgrim et al., 2019; Risher et al., 2013; Stahlman et al., 2016). As a result of interpersonal interactions within healthcare institutions, participants reported associated feelings of embarrassment, exposure, uncomfortability, and belittlement. Avoidance of disclosure aligns with findings from work in Eswatini, located in southeastern Africa, that demonstrate low rates of disclosure of sexual orientation or practices, among SMM, to healthcare providers (Risher et al., 2013). The institutionalization of SMS is demonstrated through the derogatory use of the biblical term Jezebel, by healthcare providers, to imply assumptions that the patient is immoral and of low status. Institutionalized SMS adversely impacts interpersonal patient–provider relations and deters patients from utilizing health and HIV services, thereby necessitating SMM access to inclusive, tolerant, and quality care (Micheni et al., 2017).
Conclusion
The present study demonstrates the pervasive presence and adverse effects of SMS across various socioecological levels, including the intrapersonal, interpersonal, and institutional levels. Findings demonstrate a vicious cycle that compounds the effects of SMS, with severe impacts on SMM, as related to psychosocial well-being, substance use, sexual risk-taking behaviors, as well as social support in Lusaka, Zambia. Origins of the SMS experienced lie within the interpersonal and institutional levels (e.g., othering, discrimination and harassment from health care workers, confidentiality breaches) and may be subsequently internalized. This vicious cycle presents a unique challenge to mitigating and eliminating SMS against SMM in Zambia as situated within its distinctive social, political, and religious contexts. Findings of the present study affirm the necessity to measure, address, mitigate, and eliminate stigma across the various levels of the socioecological model due to the driving force of stigma (i.e., SMS) as a determinant of health inequity and disparity among SMM (Hatzenbuehler et al., 2013). This work is notably situated to demonstrate the presence and impacts of SMS on SMM living in sub-Saharan, southern, Africa as conducive to efforts to mitigate the HIV epidemic among priority populations.
Strengths of the present study are related to the prioritization of assessing stigma and minority stress from the perspectives and lived experiences of SMM as situated within and between various socioecological levels. This perspective was necessary to maintain throughout the analysis but remains imperative to future public health research and intervention due to the intersectional nature of stigma (e.g., gender identity, gender presentation, sexual orientation, sexual partners, etc.). A limitation of the present study includes a lack of information about participants’ HIV status. Although HIV status itself was not used as an inclusion criterion in recruitment, this information would have been helpful in exploring the intersection of HIV-related stigma and SMS. Representativeness of the sample was likely affected by the inclusion criteria as it required English speaking and reading abilities. In addition, there is a limited generalizability of the findings outside of the study population (i.e., young, self-identifying SMM, in urban Lusaka, Zambia). Due to the limited basis of literature within the Zambian context, with similar implications for generalizability, the authors relied on complementary literature situated within southern, eastern, and western Africa.
Future directions should devote special attention to the impacts of SMS from an intersectional perspective emphasizing the whole person (e.g., gender identity, HIV status, religion). Intersectionality must serve as a core tenant of public health interventions and research in Zambia, due to the social, economic, and political environment that ostracizes SMM. The voices, needs, and experiences of SMM should be prioritized in facilitating anti-stigmatization research and programming. SMM should be engaged as stakeholders to avoid a further perpetuation of SMM as solely objectives of HIV epidemic surveillance and monitoring. Integrative efforts are, therefore, needed to address the psychosocial well-being of marginalized populations. Future work should prioritize implementing an integrative, multilevel approach that addresses the vicious cycle of stigma across multiple levels of the socioecological model. Failing to implement an integrative, multilevel approach risks being insufficient while also risking further perpetuating stigma. For example, an intervention approach with an emphasis only on the inner resilience of SMM risks exacerbating SMS, as it indirectly places a form of blame while failing to hold accountable the interpersonal and institutional perpetrators (Meyer, 2015).
Footnotes
Acknowledgements
We acknowledge all the support from the research staff from the University of Zambia, Dignitate Zambia Limited (DZL), and the Centre for Infectious Disease Research in Zambia (CIDRZ) who provided support in recruiting participants and arranging interviews. We greatly appreciate all those who participated in the in-depth interviews in Zambia. We also thank, very much, all the members on the Community Advisory Board in Zambia for their insightful suggestions and feedback on the study protocol.
Author Contributions
G.W.H., S.Q., and A.M. concepted the research topics and research questions. N.M., A.S., C.L., and A.M. organized data collection. L.N. and M.K. conducted the interviews. S.Q., O.A., D.M., and P.A. conducted the data analysis. S.Q. drafted the first version of introduction, methodology, and discussion. P.A. drafted the result. C.G. significantly modified and edited the whole manuscript. S.W., X.L., and G.W.H. reviewed and edited the manuscript further. All the authors reviewed and agreed on the current manuscript version. The grant was secured by S.Q. and G.W.H.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Fogarty International Center/National Institutes of Health, Grant No. R21TW011064.
Ethical Approval
This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the University of Zambia Biomedical Research Ethics Committee (Ref: 1017-2020), the National Health Research Authority (Ref: NHRA 00002/2/8/09/2020), and the University of South Carolina Institutional Review Board (Ref: Pro00088260).
Informed Consent
Informed consent was obtained from all individual participants included in the study.
