Furthermore, only students who attended school participated in the survey, so the study findings may not be generalizable to students not attending school; of note, data regarding the percentage of students in attendance during the period of data collection are not available. There is also a potential for attribution bias as youth were asked about perceived harassment due to various aspects of their identity—race, gender, and sexuality—as well as the potential for reporting and recall bias due to social desirability. Strengths of the study include utilization of a large probability sample that is representative of the California high school student population, which allowed comparisons among peer groups. Moreover, this survey was administered in the school setting, an important environment for youth. School is also a potential setting for culturally informed interventions to support trans BLY and reduce their risk of substance use. The presence of student clubs, such as Gay-Straight Alliances, is associated with reduced risk of substance use and attenuating other health risks among gender-diverse and sexual minority students. The Gay, Lesbian, and Straight Education Network advocates intersectional approaches to foster support for Black and Latinx gender-diverse and sexual minority youth, specifically to reduce school-based victimization and harassment, which our study shows is associated with substance use. Finally, our study demonstrates the relative vulnerability for substance use among trans BLY, reinforcing the need for schools, community-based organizations, cannabis drying system and clinicians to work together to prevent substance use by addressing factors that increase risk of substance use with culturally informed interventions.
The term stress is generally used to refer to heightened psychological distress resulting from physical, verbal, or sexual abuse, in addition to discrimination from family, peers, and adverse experiences with schools, churches, and other institutions . Studies have indicated that sexual minorities, including MSM, consistently report higher rates of psychological stress compared with the general population . According to the minority stress theory, sexual orientation victimization is a result of the transactions between gays, lesbians, bisexuals, and other sexual minorities with hostile social environments, which leads to adverse mental health consequences . Some researchers have examined sexual orientation victimization as a single construct that includes both personal and institutional sexual orientation victimization . However, theory and research has indicated that sexual orientation victimization can be reliably subtyped into three categories: childhood, personal, and institutional sexual orientation victimization . Childhood sexual orientation victimization refers to childhood experiences of physical or emotional abuse based on an individual’s sexual orientation, sexual identity, or gender nonconformity. Much of the literature on stress and HIV sexual risk behavior among MSM has focused on the link between childhood sexual abuse and adult vulnerability . Studies on the effects of childhood sexual-orientation victimization on HIV sexual risk behavior among MSM are rare. Research on childhood sexual-orientation victimization has examined the consequences that childhood gender nonconformity has on the mental health of adolescent and young adult sexual minorities. Results from these studies found that adolescents and young adults who report being bullied or victimized based on their gender nonconformity exhibit elevated risks of depression and suicidal thoughts and behaviors .
Based on a sample of gay and bisexual men in New York City, Pachankis et al. found boyhood gender role nonconformity to be associated with sexual compulsivity among adult MSM. Using the minority stress framework, studies have also found childhood peer-rejection, internalized homophobia, discrimination experiences, and expectations of rejection to be associated with HIV risk behavior among MSM . Personal sexual orientation victimization can result from individual or personal conditions such as losing a job, being beaten, being raped by another male, or being verbally abused . For example, a descriptive study of the effects of rape on men in Britain observed victims experiencing long-term adverse psychological symptoms of anxiety, depression, increased feelings of anger and vulnerability, and loss of self-image .Institutional sexual orientation victimization involves systematic forms of action or inaction based on sexual orientation, sexual identity, or gender nonconformity that contribute to physical mistreatment and emotional stress . This includes discriminatory institutional policies , being denied a job, being fired from a job, and being denied housing based on an individual’s sexual orientation, sexual identity, or gender nonconformity. Studies examining the effects of institutional factors found that gays and lesbians who experience institutional sexual orientation victimization report significantly more mental health disorders than heterosexual respondents. Using data from the National Epidemiologic Survey on Alcohol and Related Conditions , researchers examining states that enacted constitutional amendments against same-sex-marriage found significant increases in mental disorders among lesbian, gay, and bisexual respondents compared to heterosexual respondents in these states .
Another study found that sexual minority youth who were in non-supportive or discriminatory social environments toward sexual minority youth were at a significantly higher risk of suicide compared to heterosexual youth .Alcohol is the most commonly abused substance, followed by marijuana , in South Africa . Approximately 46% of South Africans over age 18 report problem or binge drinking in comparison to the global average of 11.5% . A population-based study conducted in South Africa in 2012 revealed that among households reporting consumers of alcohol, 31% were male and 10% were female . Studies have shown that sexual minorities are more vulnerable to alcohol and substance abuse than the general population . A study by Irwin, Morgenstern, Parsons, Wainberg, and Labouvie showed a positive correlation between drinking alcohol and HIV risk behavior among HIV-negative MSM. Studies have also evidenced a positive relation between marijuana use and HIV risk behavior among MSM . Lane et al. observed in a sample of MSM in South Africa that men who reported smoking marijuana in the past 6 months were more likely to report being infected with HIV. The impact that problem drinking and marijuana use have in mediating the effects that sexual orientation victimization has on HIV sexual risk behavior is unknown. Plausibly alcohol abuse and marijuana use may function as buffers in reducing the stress from sexual victimization, thus lessening the probability for engaging in condomless sex. Alternately, sexual orientation victimization may foster alcohol abuse and substance use, which could lead to condomless sex among MSM. This is an area requiring investigation. The primary aim of this study is to advance understanding of the psychosocial correlates of the three sexual orientation victimizations and HIV sexual risk behavior among Black South African MSM, taking into consideration relevant factors including social support, outness,gender identity, and perceived masculinity. Secondarily, this study examines whether marijuana use and problem drinking mediate the relationship between the three types of sexual orientation victimization and HIV risk behavior among this high-risk population.The institutional review board at Temple University reviewed and approved this study. Study participants comprised 125 Black men residing in Port Elizabeth and the adjoining townships of Kwazakhele and New Brighton who self-reported having sex with men. Participants were recruited using snowball sampling by two Black South African recruiters who were members of the target population and who lived in the targeted communities. Eligible participants had to be 18 years or older, reported having had sex with another man within the past year, and could speak and read English. Participants received R20 and light refreshments for completing a 90-minute survey. Surveys were administered in small groups and were read aloud in English and IsiXhosa by two research assistants who were Black MSM fluent in IsiXhosa and English. Each participant completed a written survey administered in small groups.Descriptive staThistics, including percentages, means, and standard deviations, were used to describe the sociodemographic characteristics of the sample. Three multiple regressions were conducted to analyze psychosocial correlates of the three types of victimization: childhood, personal, and institutional. Each regression model included age, education, social support, outness, gender identification, drying rack for weed and other’s perception on masculinity. Mean differences and corresponding 95% confidence intervals are reported for the regression analyses. The p = 0.05, two-tailed staThistical significance criterion was employed. Multiple regressions were conducted to analyze the relations between the three types of sexual orientation victimization and having condomless anal sex with casual partners. Mediation path analyses with multiple parallel mediators were conducted to test direct effects of sexual orientation victimizations on condomless anal sex, and potential mediators including problem drinking and marijuana use that mediated the relations between sexual orientation victimizations and having condomless anal sex with casual partners. We analyzed three mediation models for the three different victimizations.
We used PROCESS, a computational tool for path analysis-based mediation analysis, to conduct the analyses. This method generates direct and indirect effects in mediation models with multiple mediators functioning in parallel. It constructs heteroscedasticity-consistent standard errors and percentile-based bootstrap confidence intervals and is recommended as superior to a normal theory approach. All analyses were conducted using SPSS with the PROCESS macro for Windows. The significance criterion was p < .05 two-tailed, and the number of bootstrap samples for bias-corrected bootstrap confidence interval was set at 5000.This study addresses the question of what are the relationships between the three forms of sexual orientation victimization stressors and HIV sexual risk behavior among South African MSM. Second, this study tests whether problem drinking and marijuana use mediate the relationships between the three forms of victimization and HIV sexual risk behavior. The finding that personal and institutional sexual orientation victimizations were directly associated with condomless anal sex is consistent with studies exploring the relationships between adverse health behavior and experiences of personal victimization among sexual minorities . The finding that others’ perceptions of participants’ masculinity was associated with personal sexual orientation victimization is notable. This finding may reflect the concerns that these men have about negative cultural and societal attitudes on gender nonconformity. As posited by the minority stress theory , personal victimization may heighten the concern that these men have of being perceived by others as deviant if they do not comply with cultural masculine gender norms. The finding that older participants tended to report experiencing institutional sexual orientation victimization stress more than younger participants may reflect a heightened sensibility and awareness of systemic discrimination among older men. Surprising and not consistent with other studies with MSM is the finding that neither problem drinking or marijuana use was associated with condomless anal sex. However, caution is suggested in making inferences from this finding. Alcohol abuse is a major health problem in South Africa. Problem drinking was measured using the CAGE questionnaire, which focuses on attitudes. Plausibly, social and cultural attitudes on drinking alcohol may be less inhibitory in South Africa. Therefore, measures on the frequency and amount of consumption may be more culturally appropriate. The finding that childhood sexual orientation victimization was positively associated with problem drinking is consistent with other studies exploring the relationship between childhood sexual abuse and the health and mental health of MSM . Strengths of this study include examining the effects of three types of sexual orientation victimization on HIV sexual risk behavior among Black South African MSM in a middle income country with a high HIV prevalence. Early studies examined the effects of sexual orientation victimization as a construct that combined personal and institutional stressors . More recent studies have either examined the consequences of one type of sexual orientation victimization, e.g., personal victimization , or institutional sexual orientation victimization on the health and mental health of MSM. To our knowledge the current study is the first to concurrently examine the consequences of both types of sexual orientation victimization. The emphasis on exploring experiences of childhood sexual orientation victimization among adult MSM is also notable. This is one of the few studies to examine the effects of childhood sexual orientation victimization on health behavior among MSM. Although childhood sexual orientation victimization was not associated with HIV risk behavior, the association with problem drinking is important, indicating the need for further research in this area. The reliance on self-reports of behavior is a limitation. Additionally, while the nature of the sample afforded a unique opportunity to learn about the effects of problem drinking and marijuana use among South African MSM with histories of experiences of sexual-based stressors in the Eastern Cape, it may limit the generalizability of the study. Globally, MSM are disproportionately infected with HIV.