Does Gender Role Conflict Moderate the Relationship Between Lifetime Adversity and HIV Stigma in a Community Sample of HIV-Seropositive Black Men?

Abstract

Previous research highlights the need to better understand the complex relationships between factors marginalizing Black men who have sex with men and women (MSMW) living with HIV, including HIV stigma, trauma, and hegemonic masculinity. We examined associations between gender role conflict (GRC), trauma, and HIV stigma in Black MSMW living with HIV. 117 participants completed the UCLA Life Adversities Screener (LADS), measures of GRC, and HIV stigma. A multivariate model with age, gender role, and the LADS as predictors of stigma was statistically significant F (4, 110) = 12.81, p < .0001. The LADS was significantly associated with stigma (b = 11.06, t = 4.17, p < .0001) and moderated by GRC (b = 12.19, t = 2.25, p < .05); stigma increased significantly at high, but not low GRC. High GRC heightens the relationship between trauma and HIV stigma in Black MSMW. Future research must investigate associations among trauma burden, stigma, and GRC among vulnerable populations.

Keywords

Black MSMW Trauma and adversity HIV stigma Gender role conflict

HIV continues to disproportionately impact Black men, who have the highest lifetime risk of HIV diagnosis in the United States (Centers for Disease Control Prevention 2018). Black men who have sex with men (MSM), and those who have sex with both men and women (MSMW), have heightened risk for HIV infection (Friedman et al. 2014; Harawa et al. 2014; Williams et al. 2008). And a meta-analysis by Millett et al. (2012) suggests that HIV disparities among Black MSM are not attributable to a higher frequency of risky sexual behavior, as might be assumed. Nonetheless, the high prevalence of HIV in Black communities points to the need to curb incident HIV infections, as well as identify ways to reduce the impact of the disease on people living with HIV, such as reducing HIV-related stigma, which decreases the quality of life of people living with HIV (Galvan et al. 2008; NIMH Multisite HIV/STD Prevention Trial for African American Couples Group 2008). Stigma associated with HIV status can result in fears of rejection in important life domains (i.e., interpersonal and occupational), avoidance of treatment, and reduced adherence.

There are numerous factors that serve to stigmatize Black MSMW. These include experiences of trauma and adversity and heightened pressure to conform to homophobic expectations of masculinity, which may increase psychological distress and engagement in HIV-risk behaviors (Fields et al. 2015; Kisler and Williams 2012; Williams et al. 2009). A rigid adherence to culturally sanctioned notions about what it means to be masculine may particularly exacerbate links between histories of trauma and adversity and HIV stigma, yet research has yet to examine this question among Black MSMW.

High levels of HIV stigma persist in the general U.S. population despite the fact that HIV is now considered a manageable chronic disease. HIV stigma—an actual or perceived fear or concern that negative attitudes or unfair treatment would occur if one’s HIV status were known—has been associated with numerous negative mental and physical health outcomes among people living with HIV, particularly among racial and ethnic minority groups (Chenard 2007; Reece 2003; Stangl et al. 2013; Sweeney and Vanable 2016). Negative outcomes include non-disclosure of seropositive status to partners, less consistent engagement in HIV-related care, medical mistrust, and medication adherence difficulties (Simbayi et al. 2006; Vanable et al. 2006).

Often individuals living with HIV experience life adversities that serve as barriers to engaging in HIV-related care (Brezing, Ferrara, and Freudenreich 2015). However, a better understanding of the mediating factors between these life adversities and HIV-related health outcomes (e.g., HIV stigma, medication adherence, mental illness) is still largely needed, in addition to targeted interventions for individuals disproportionately impacted by HIV (LeGrand et al. 2015; Sales, Swartzendruber, and Phillips 2016). Identifying predictors of HIV stigma among vulnerable populations is critical for designing effective interventions (Whetten et al. 2008). High levels of stigma may reduce willingness to engage in HIV interventions and compromise seeking care. Although some predictors of HIV stigma, like high levels of internalized homophobia and lack of perceived social support, have been identified as targets for intervention (Garcia et al. 2016), research has generally not focused on culturally congruent, potentially modifiable targets relevant to individuals with multiple marginalized identities who often experience intersecting stigmas (Arnold, Rebchook, and Kegeles 2014; Logie et al. 2011; Stangl et al. 2013).

People living with HIV experience higher rates of traumatic and adverse events, including childhood and adult sexual trauma, revictimization, interpersonal violence, discrimination, community violence, and exposure to more than one type of trauma than the general population (Brezing, Ferrara, and Freudenreich 2015; Liu et al. 2015; Whetten et al. 2008; Wyatt et al. 2002). Subgroups of men, particularly Black MSMW, experience even higher rates of trauma (Allen, Myers, and Williams 2014). For Black MSMW who are LWH, multiple stigmatizing characteristics—particularly experiences of discrimination related to race/ethnicity, sexual orientation, and HIV status—may increase experiences of minority stress which has been associated with unfavorable mental and physical health inequities (Allen, Myers, and Williams 2014; Arnold, Rebchook, and Kegeles 2014; Bogart et al. 2011).

Stress specifically related to one’s race or ethnicity has been found to be adversely related to health, and also plays a role in explaining any racial/ethnic differences in health outcomes (Khaylis, Waelde, and Bruce 2007; Paradies et al. 2015; Williams et al. 1997). It is critical to analyze other social determinants of health for individuals disproportionately impacted by life adversities, and better understand how these multiple factors interact with one another. Histories of trauma and adversity have been associated with decreased HIV-related health care utilization, inconsistent HIV treatment adherence, and increased engagement in HIV-risk behaviors (Kisler and Williams 2012; Meade et al. 2009; Zeglin 2015). Additionally, there is some evidence that supports that previous trauma exposure is associated with higher levels of perceived HIV stigma which is a known contributor to poor HIV health outcomes (Soto et al. 2013; Sweeney and Vanable 2016). These factors may contribute to the morbidity, mortality, and ultimately forward transmission of the disease, rendering an understanding of the relationship between trauma and HIV of paramount importance for new HIV treatment and prevention modalities (LeGrand et al. 2015). HIV care settings do not routinely screen for experiences of trauma that may serve as significant barriers to care, and experiences with trauma are rarely addressed in HIV interventions generally (LeGrand et al. 2015; Leserman 2008; Sales, Swartzendruber, and Phillips 2016).

Modifying conformity to hegemonic masculine norms is an emerging and promising target for reducing HIV stigma and improving HIV-related health outcomes (Dworkin, Treves-Kagan, and Lippman 2013). For example, an intervention in South Africa designed for men to challenge masculine norms and promote gender equality found that men participating in the intervention had an increased capability to overcome masculine-related barriers to HIV testing, care, and treatment, and also increased their ability to be vulnerable and disclose their HIV status with others (Fleming et al. 2016). While cultural mandates to adhere to hegemonic masculine norms apply to men regardless of ethnic background, there is variability in conformity to these norms, both across individuals and various subpopulations of men (O’Neil 2008). This manuscript’s focus is on how expectations to reproduce societal norms around masculinity may be at odds with HIV-positive Black MSMW’s identities, and how this influences stigma associated with HIV status. For example, Bowleg et al. (2011) show that an implicit masculine ideology that Black men should not be gay or bisexual leads some Black men to conceal their gay or bisexual identity and same-sex partners for fear of stigmatization. Greater conflict with hegemonic masculine norms may also arise for men LWH with more severe histories of trauma (Easton 2014; Sikweyiya, Jewkes, and Dunkle 2014). Additional research has shown that pressure to conform to masculine norms can increase the spread of HIV by influencing an individual’s number of sexual partners, attitudes toward condom use, substance use, sexual positioning, condom decision-making, attitudes toward HIV testing, and HIV treatment adherence (Zeglin 2015).

Pathways linking hegemonic masculinity and HIV-risk behaviors may be intensified for men with histories of childhood trauma, specifically childhood sexual abuse (CSA). One study looking at HIV risk among Black men and women with histories of CSA found a strong relationship between CSA history and a positive HIV status, as well as increased psychological vulnerability as adults (NIMH Multisite HIV/STD Prevention Trial for African American Couples Group 2010). Multiple studies have reported that men with histories of CSA are more likely than those without such histories to report condomless sex with multiple partners, hypersexual behaviors, and depression (Lloyd and Operario 2012; Paul et al. 2001; Williams et al. 2008). One theoretical explanation for these outcomes among male survivors of CSA suggests that the parents of children with known histories of CSA perceive their child’s masculinity and sometimes racialized identity, as being “threatened” by these experiences (McGuffey 2008). The child’s parents in turn experience pressure to reaffirm their child’s sexual identity through hegemonic masculine norms (e.g., emotional detachment, objectification of women, homophobia, etc.), which may then be internalized by the child (McGuffey 2008).

Societal mandates regarding the importance of male invulnerability pose significant barriers to HIV risk reduction messages, promoting the denial of risk, and the need for sexual protection (Dworkin, Treves-Kagan, and Lippman 2013; Fields et al. 2015). Further structural, economic, and historical barriers that prevent men from developing self-awareness of these gender role expectations may result in an overemphasis on these high-risk sexual behaviors (Kisler and Williams 2012; O’Neil 1990; Pitt 2009; Reese 2004). Findings from Project Eban, a randomized clinical trial and focus groups with HIV serodiscordant couples, suggest that societal pressure toward overconformity to masculine norms is especially important to address among Black men. Experiencing marginalized status poses significant barriers to achieving societal expectations concerning masculinity (NIMH Multisite HIV/STD Prevention Trial for African American Couples Group 2008). Research has called for HIV/AIDS treatment and prevention efforts to examine how gender-transformative interventions may increase intervention efficacy (Dworkin, Treves-Kagan, and Lippman 2013; Fleming et al. 2016; Underwood et al. 2014); measuring gender role conflict (GRC) among men disproportionately impacted by HIV might be one key component for effectively designing these interventions.

GRC refers to an individual’s internal conflict with hegemonic masculine norms and the perceived need to participate in or reject these gendered expectations (Bingham, Harawa, and Williams 2013; O’Neil and Denke 2016). Moreover, GRC as captured by the GRC scale is theoretically defined as “a psychological state in which socialized gender roles have negative consequences for the person or others” (O’Neil 2008). Similar measures assessing attitudes toward gender norms such as the gender-equitable men (GEM) scale have been developed and effectively used in HIV and violence research (Pulerwitz et al. 2010). However, these two measures are conceptually different. The GEM scale mainly assesses for support of equitable or inequitable gender norms within several situational contexts. The GRC scale captures different GRC complexities with four psychological domains (cognitive, affective, unconscious, and behavioral), three personal experiences of GRC (devaluations, restrictions, and violations), and several situational contexts (O’Neil 2008; Pulerwitz and Barker 2008).

GRC, in particular, has been associated with increased psychological distress and sexual risk behaviors (i.e., less HIV knowledge, lower risk reduction skills, more condomless sex) among Black MSMW, with different predictive patterns of condomless sex observed for male and female partners (Bingham, Harawa, and Williams 2013; Malebranche et al. 2012). Additional GRC research with Black men has also found a significant relationship between GRC and low self-esteem, higher anxiety and depression, negative attitudes toward help-seeking, marital dissatisfaction, and hopelessness (O’Neil 2008; O’Neil and Denke 2016). Recent evidence relates GRC not only to psychological and emotional problems, but also discrimination and internalized oppression (Robinson and Brewster 2014; Szymanski and Ikizler 2013). Men who are marginalized with respect to their HIV-positive status, ethnic background, and sexual identity may experience even greater conflict with societal expectations of masculinity (Fields et al. 2015; O’Neil 2008; Zeglin 2015). This in turn may exacerbate the extent to which these men feel impacted by HIV stigma, and strengthen the relationship between histories of trauma and adversity with HIV stigma. Despite evidence of its influence on important correlates of HIV (Bingham, Harawa, and Williams 2013), research has yet to examine GRC as a potential moderator of the relationship between histories of trauma and adversity and HIV stigma.

The purpose of this study is to examine the relationship between histories of trauma and adversity, assessed by the UCLA Life Adversities Screener (LADS), and severity of HIV stigma in a community sample of Black MSMW. We will also examine whether GRC moderates any potential relationship between the LADS and severity of HIV stigma in this sample. We hypothesize that greater endorsement of trauma and adversity on the LADS will be associated with greater HIV stigma and that GRC will moderate this relationship.

Methods

Procedure

The study hypotheses were tested using baseline data from the Enhanced Sexual Health Intervention for Men (ES-HIM), a six-session sexual risk and stress reduction intervention for non-gay identified Black MSMW LWH with histories of child sexual abuse (Williams et al. 2013). Participants were compensated up to $220.00 for participation in all study procedures, which were approved by the UCLA Institutional Review Board (Williams et al. 2013). See Glover, Williams, and Kisler (2013) and Williams et al. (2013) for a complete description of the study goals and procedures.

Participants

A community sample of 117 Black men LWH was recruited using fliers, print advertisements, and face-to-face recruitment at community-based organizations that provided health care to HIV-positive Black men. To be eligible, respondents had to be at least 18 years old, English speaking, self-identify as African American/Black, confirmed as HIV-positive through recent HIV, CD4 or viral load tests or medical records, report at least one current (i.e., the past 90 days) unprotected sexual activity with both male and female partners, and have a history of CSA. In addition, participants in the study did not self-identify as gay or bisexual, most likely due to fears of stigmatization and/or discovery of having same-sex sexual partners outside of committed relationships. CSA was defined as having experienced any unwanted or forced sexual contact or sexual experiences with someone at least 5 years older before the age of 18 years (Williams et al. 2013).

Measures

Participants were administered a questionnaire using a laptop computer with Audio Computer Assisted Self Interview (A-CASI) technology. A-CASI was used to increase confidentiality and comfort for participants when disclosing sensitive information, such as sex and substance use behaviors. This questionnaire took approximately 90 minutes and included demographic variables such as age, household income, education, employment status, and relationship status.

Potential Demographic Covariates

Age was assessed via self-report and was included as a demographic covariate in these analyses.

Predictor

Life Adversities Screener

To assess cumulative trauma history, the UCLA LADS was developed to assess five domains of trauma and adversity that are often overlooked in health settings but have been shown to predict psychological distress and severity of somatic symptoms in community samples (Liu et al. 2015; Loeb et al. 2018). The UCLA LADS is a brief, validated, multi-dimensional five-item screening tool used to assess the history of trauma and adversity, and results in a weighted lifetime exposure score (refer to Liu et al. 2015). The five items ask participants whether they perceive that they have been discriminated against due to their race, gender, or other marginalized identity during the past month (item weight = .30), whether they have been exposed to a situation in which they feared impending death or serious bodily harm (item weight = .22), whether a past or current partner has physically hurt them (intimate partner violence (IPV); item weight = .18), whether there has been any hitting or throwing of objects amongst any family members (family violence; item weight = .17), and whether they have ever been penetrated without their consent (sexual abuse; item weight = .13). Responses to these items are summed to create a score between 0 and 1 based on the weights of each item endorsed. An optimal cut-off of .33 has been reported for identification of patients at high risk for mental health problems (Liu et al. 2015). The LADS has demonstrated predictive validity for mental health issues and ease of administration, showing promise as a screener to identify individuals in primary care settings for more extensive evaluation and intervention (refer to Myers et al. 2015 for more information). The UCLA LADS is easy to administer in primary care settings and captures adversity and trauma-related experiences of populations that may not be captured with current screening approaches (Liu et al. 2015). The UCLA LADS was developed primarily with Black and Latino men and women participants who represented demographic populations that were marginal consumers of health and mental health services.

Moderator Variable

Gender Role Conflict Scale

We utilized Bingham, Harawa, and Williams’ (2013) modified version of the 37-item GRCS originally developed by O’Neil (1981) (also refer to O’Neil et al. 1986). The GRCS measures participants’ view of gender role stereotypes across four main dimensions: (1) success, power, and competition; (2) difficulty expressing emotions or having others express them; (3) difficulty showing or observing affection between men; and (4) conflict between work and family relations. The modified version omitted the fourth dimension, as the sample reported high rates of unemployment. Bingham, Harawa, and Williams (2013) developed five new items to measure masculine presentation (e.g., “Men should never show their feminine side” and “I never want to look or seem weak”). They obtained α coefficients between .86 and .87 for O’Neil’s first three subscales and .73 for the newly developed subscale. Internal consistency was .94 for the modified, 35-item GRCS. Respondents rated each item according to a six-point Likert scale (1 = strongly disagree to 6 = strongly agree) for a total score of 35 to 210. Consistent with Bingham, Harawa, and Williams’s (2013) approach, higher total scores indicated greater GRC (Bingham, Harawa, and Williams 2013) and GRCS scores above the median (GRCS of 110 or above) were categorized as high GRC (M = 104.5, SD = 42.5, range = 35–208).

Outcome Variable

HIV Stigma

Twelve items from the HIV stigma scale (α = .92) were used to measure participants’ experiences of HIV-related stigma over the last 30 days (Emlet 2005; Sowell et al. 1997). The scale included such items as; “I feared that I might lose my job if someone found out about my HIV status,” “I avoided getting treatment because someone might find out about my HIV status,” and “I feared my family would reject me if they learned about my HIV status.” The frequency of incidents was assessed using a four-point scale of 1 (Not at All), 2 (Rarely), 3 (Sometimes), and 4 (Often).

Statistical Analyses

We conducted analyses in several phases. First, we obtained Pearson correlation coefficients to determine bivariate associations between HIV stigma, the LADS, GRC, and age. Next, one linear regression model was fit to estimate the relative contribution of the LADS and GRC on HIV stigma, with age included as a covariate. Finally, to formally evaluate whether GRC is a moderator of the association between the LADS and HIV stigma, we examined the interaction of the LADS and GRC in predicting HIV stigma, controlling for age. Analyses were conducted using SAS, version 9.4.

Results

The average age of this male-identified, Black sample was 46 years (range = 24–67, SD = 8.8), with the majority of the sample self-reporting as unemployed (85%), low-income (90% of the sample reported a total monthly income ≤ $1,249), single, and having less than a high school education (29%) (refer to Table 1). Participants scored a mean of 17.93 on the HIV stigma scale, which represents moderate stigma (possible range from 1 to 48). Bivariate analyses showed that the LADS and GRC were significantly related to HIV stigma. Specifically, higher trauma burden (r = .46, p < .0001) and higher GRC (r = .322, p = .0004) were associated with greater fear of stigma. Additionally, the LADS was related to greater GRC (r = .307, p = .0009) (refer to Table 2).

Table 1.

Sociodemographic Characteristics of Study Sample.

Variables	N (%)
Income
≤$1,249/m	102 (90.27)
>$1,249/m	11 (9.73)
Education
Less than high school	34 (29.06)
More than high school	83 (70.94)
Employment
Not working	99 (85.34)
Work full/part time	17 (14.66)
Relationship status
Not married	104 (88.89)
Married/living with partner	13 (11.11)
M (SD)
Age	46 (8.8)
HIV stigma	17.9 (7.8)
UCLA LADS	.37 (.25)
Gender role conflict (GRC)	104.5 (42.5)

Table 2.

Correlations Between Age, LADS, Gender Role Conflict, and HIV Stigma.

Variable		1	2	3	4
1.	Age	1	−.08	−.22*	−.13
2.	GRC^a		1	.31**	.32**
3.	LADS^b			1	.46***
4.	HIV stigma^c				1

*p < .05; **p < .01; ***p < .0001.

^a Gender role conflict.

^b UCLA Life Adversity Screener.

^c HIV stigma.

Next, we conducted a regression with GRC and the LADS as predictors, and age as a control variable. Other demographic variables were not included due to limited variability. The model accounted for 28% of the variance (R² = .286) and was statistically significant, F (3, 114) = 14.84, p < .0001). Both GRC and the LADS were significant predictors of HIV stigma (b = 4.54, t = 3.46, p < .001; b = 11.06, t = 4.17, p < .0001, respectively). To examine the interaction between GRC and the LADS, we conducted the full multivariate model with age as a control variable, GRC and the LADS as predictors of HIV stigma, and GRC by the LADS, the model accounted for 32% of the variance (R² = .318) and was statistically significant, F (4, 110) = 12.81, p < .0001. The relationship between the LADS and stigma was moderated by GRC (b = 12.19, t = 2.25, p < .05), where stigma of having HIV increased significantly at high but not low GRC (refer to Table 3 and Figure 1).

Table 3.

Regression Model Predicting HIV Stigma from Age, Cumulative Trauma, and Adversity (LADS) and Gender Role Conflict (GRC).

	b	SE	t Value
Age	−.01	.07	−.22
GRC (high)	4.54	1.31	3.46**
GRC (low)	0
LADS	11.06	2.65	4.17***
LADS*GRC (high)	12.19	5.41	2.25*
LADS*GRC (low)	0

*p < .05.

**p < .001.

***p < .0001.

Figure 1.

Significant Interaction Plot of Cumulative Trauma and Adversity (LADS) by Gender Role Conflict (GRC).

Discussion

Our study sought to understand the relationship between lifetime adversity and HIV stigma, as moderated by GRC in a community sample of Black MSMW LWH. In this study, we hypothesized that more severe histories of trauma and adversity would be associated with greater HIV stigma. We also hypothesized that GRC would moderate the relationship between the severity of trauma history and HIV stigma. In this community-based sample, we found support for our first hypothesis: bivariate analyses revealed that higher cumulative trauma burden was significantly associated with greater HIV stigma, and it was also significantly related to GRC. We also found support for our second hypothesis: in a regression model controlling for age, cumulative trauma burden significantly predicted HIV stigma, and this relationship was moderated by high levels of GRC. Men with more severe histories of trauma reported more HIV stigma, and higher levels of GRC strengthened this relationship.

While the moderating role of GRC on the relationship between histories of trauma and HIV stigma has not been previously examined, other studies have found a significant relationship between GRC and internalized oppression (Robinson and Brewster 2014; Szymanski and Ikizler 2013). Our results may be partly explained by previous work that has related GRC among sexual minority men with other measures of internalized stigma and oppression (Szymanski and Ikizler 2013). Additionally, it might be the case that men with more severe histories of trauma feel that they have failed to live up to idealized masculine norms (Easton 2014; Szymanski and Ikizler 2013). Research with men LWH in South Africa has also shown that notions of hegemonic masculinity pre-diagnosis negatively impacted men’s adjustment to an HIV positive diagnosis (Sikweyiya, Jewkes, and Dunkle 2014), which may further explain our findings.

These findings highlight the potential benefit of culturally loosening masculine norms in interventions designed to promote health access and utilization among populations with high levels of HIV stigma and histories of trauma. This is consistent with research conducted in sub-Saharan Africa that suggests while hegemonic masculinity is associated with increased HIV stigma and barriers to care, interventions designed to promote more flexible definitions of masculinity have the potential to facilitate acceptability and engagement in HIV care (Sileo et al. 2018, 2019).

To the best of our knowledge, this is the first study to examine these intersecting phenomena utilizing a validated measure (the LADS). The relationships among trauma and adversity, HIV stigma, and GRC among Black men LWH are highly complex and need to be better understood in order to develop interventions to decrease stigma and promote greater health management in this population. Recent research shows that disrupting pathways to HIV stigma—such as violence and victimization—may be key for inclusion in HIV treatment and prevention strategies, but more research on specific trauma/masculinity/HIV stigma pathways is needed (Pantelic et al. 2017). This study included recent experiences of discrimination as one dimension of cumulative trauma burden. As results of this study indicate that histories of cumulative trauma predict HIV stigma among Black MSMW, interventions designed to promote health should take experiences of trauma commonly reported by community samples, including discrimination, into account.

As demonstrated by our analyses, GRC moderated the relationship between trauma and HIV stigma at high levels. Greater conflict in adherence to or deviation from hegemonic masculine norms may have strengthened the trauma–stigma link; the moderating effect of GRC was not found for low levels of GRC. Past research has noted that Black men’s definition of what it means to be a man is constructed along the lines of hegemonic masculinity, with emphasis on ambition, competitiveness, and being a provider (Pierre, Woodland, and Mahalik 2001). However, some research notes that for Black men, this definition may also include non-traditional aspects of manhood, including spirituality, pride, family, self-determinism, and accountability which may counter societal messages that link risky sexual behaviors to manhood (Hunter and Davis 1992; Wade and Rochlen 2013). There is also evidence for Black men that other factors form important aspects of the definition of manhood which need to be promoted in HIV interventions, such as valuing relationships with others, and active family and civic involvement (Hammond and Mattis 2005; Hunter and Davis 1992). These more flexible dimensions of what it means to be a man have emerged from cultural meanings regarding manhood that have been instrumental in the survival of Black families and communities (Hunter and Davis 1994). To be effective, interventions must be developed utilizing culturally relevant and congruent HIV messages and take histories of trauma into account.

Research has called for approaches that encourage critical self-reflection on gender and equitable attitudes and behaviors, including those that are trauma-informed, in research and interventions to promote the health of men/boys (e.g., Brush and Miller 2019; Ruane-Mcateer et al. 2019). Reviews of gender-transformative interventions are promising, suggesting that questioning and/or disputing hegemonic masculine norms and expectations may influence the acceptability of help-seeking and engagement in health-protective behaviors (Casey et al. 2018; Dworkin, Treves-Kagan, and Lippman 2013; Ruane-Mcateer et al. 2019). Existing interventions could be adapted to be more culturally congruent, targeting diverse populations of men, including sexual and racial/ethnic minority groups with histories of trauma exposure by focusing on the effects of trauma on emotional regulation and sexual health. Should future research confirm the associations noted here between trauma, GRC, and HIV-related stigma, these and other HIV patient-level factors could be used to adapt gender-transformative interventions for this vulnerable population.

Limitations of this study include its cross-sectional design and use of self-report measures. We cannot confirm whether GRC prospectively moderates the association between trauma and HIV stigma severity given that all measures were assessed simultaneously. Similarly, we could not address the persistence of adversity, GRC, or HIV stigma over time (Loeb et al. 2018). Our measure of discrimination did not allow us to identify the particular marginalized identity targeted by discrimination and responses were restricted to the past month, while other items assessed lifetime prevalence of adverse and traumatic experiences. We also did not control for the impact of unemployment due to disability or limited job opportunities, incarceration, and other potentially important social and structural factors on GRC. Finally, ours is a convenience sample of MSMW, which limits the generalizability of the findings. Despite these limitations, our study has notable strengths, including robust measurement of lifetime adversity, GRC, and HIV stigma.

Conclusions

It is important to address high GRC and stigma, given growing evidence for the potential impact of this confluence of factors on physical and mental help-seeking and HIV care (Wahto and Swift 2016). Given our findings, high GRC may further exacerbate avoidance of health care utilization and thereby negatively impact health outcomes among MSMW LWH and histories of trauma. Male gender role norms vary according to age, social class, ethnicity, and sexuality, and HIV interventions should focus on the development of culturally relevant, individual, and community level modifications of these societal mandates to promote risk and stigma reduction (Bingham, Harawa, and Williams 2013; Underwood et al. 2014). These interventions should incorporate culturally congruent messages about what it means to be a Black man, emphasizing individual, family, and community wellbeing, and acknowledgment of the challenges of being a Black male LWH and experiences of trauma, including discrimination, in American society. Further studies need to continue this line of research to identify ways to decrease HIV stigma and facilitate health promotion among HIV-seropositive Black men with histories of trauma and adversity. This research should investigate not only the relationship between GRC and health, but particularly the complex associations among lifetime adversity, stigma, and high GRC in relation to health care utilization among marginalized and vulnerable populations.

Footnotes

Acknowledgments

We would like to thank John K. Williams of the Center for HIV Identification, Prevention, and Treatment Services, for his previous work with the dataset and measures used in this study. Thanks to Kavvya Gupta, Amber Smith, Alex Kim, and Danielle Campbell for assistance in preparing this manuscript.

Declaration of Conflicting Interests

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the National Heart, Lung, and Blood Institute (U01HL142109), NIMH Grant T32 MH171140, and the Southern California HIV/AIDS Policy Research Center, through a generous grant from the University of California HIV/AIDS Research Program (Grant Number RP15-LA-007). Additional support was provided by the UCLA Center for HIV, Identification, Prevention, and Treatment Services funded by the National Institute of Mental Health (Grant Number P30MH058107).

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Tamra Burns Loeb

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