Inicial

Goffman (1963) defined stigma as “an attribute that links a person to an undesirable stereotype, leading other people to reduce the bearer from a whole and usual person to a tainted, discounted one” (p. 11). Individuals that are stigmatized have a “spoiled identity” that results in social sanctions against them which may include: experiences of discrimination and unfair treatment, violence, and exposure to negative attitudes (Stuber, Meyer, & Link, 2008). YBGBM experience multiple forms of stigma and discrimination, including racial/ethnic, sexual minority, and HIV-related stigma that make them vulnerable for mistreatment by and within societal institutions (Van Sluytman et al., 2015). These layering experiences of stigma and discrimination are an example of how intersectionality functions. Intersectionality is a concept that Kimberly Crenshaw, along with other Black women in the United States, developed to explain “how structures make certain identities the consequence of and vehicle for vulnerability” (Women of the World Festival, 2016). Intersectionality posits that social positions like race, gender, sexuality, and class are experienced simultaneously, and should not be analyzed independently (Collins, 1990; Crenshaw, 1991; Davis, 1981; Viruell-Fuentes, Miranda, & Abdulrahim, 2012).

A growing body of public health research literature uses the term ‘intersectional stigma’ to characterize the overlap of multiple stigmatized identities within an individual or group, and to address their effects (Barry et al., 2018; Logie, James, Tharao, & Loutfy, 2011; Turan et al.,

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2019). Of interest to researchers is the effects of intersectional stigma on the behaviors, and individual and population health outcomes of groups with intersecting stigmatized identities. YBGBM experience stigma related to their race/ethnicity, sexuality, and presumed HIV status. Intersectional stigma functions as a deterrent to their access to and utilization of HIV prevention and care services by YBGBM (Arnold et al., 2014). The following subsections detail how stigma and discrimination perpetuated by medical and religious institutions negatively affect

engagement along the HIV prevention and care continua among YBGBM. 2.2.2.1.2.1 Intersectional Stigma in Healthcare Settings

YBGBM report more experiences of stigma and discrimination in clinical settings, including hospitals, health care clinics, community health centers, and HIV testing clinics, than young gay and bisexual men of other ethnicities (Bernstein et al., 2008). Negative encounters within clinical settings are often internalized, and impact their utilization of healthcare services in the future (Malebranche et al., 2004). YBGBM are less likely than their White and Latino counterparts to disclose their sexual identity and sexual behaviors to healthcare providers, due to anticipated stigma and mistreatment they may encounter (Bernstein et al., 2008; Magnus et al., 2010; Petroll & Mosack, 2011). YBGBM in several studies reported that experiences of racial discrimination impacted their level of openness with healthcare providers about their sexuality and same sexual behaviors due to fear of additional discrimination based on their sexual orientation (Irvin et al., 2014; Malebranche et al., 2004). Failing to disclose same sex sexual behaviors and sexual identity to a healthcare provider diminishes the likelihood that YBGBM will receive appropriate HIV risk assessments and recommendations for risk reduction tools such as PrEP (Cahill et al., 2017; Garcia et al., 2016). This points to the importance of considering

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how the multiple stigmatized identities of YBGBM may impact their engagement and outcomes along the HIV prevention and care continua.

Gender expression among YBGBM has also been found to affect their perception of experiences of stigma and discrimination in healthcare settings. In a study conducted by Hussen et al. 2013, YBGBM that were perceived to be masculine, reported no homophobia or sexual minority discrimination, but high racial discrimination; while YBGBM with feminine gender expression reported both homophobic and racial stigmatization (Hussen et al., 2013). Perceptions of stigma rooted in homophobia and racism vary among YBGBM. Greater perceived racism is associated with risky sexual behaviors such as unprotected anal intercourse among YBGBM; furthermore, HIV-positive YBGBM are more likely to be infected, yet unaware in comparison to white HIV-positive gay and bisexual men due partly to the avoidance of HIV screening because of the perceived and anticipated racial stigma prevalent in healthcare settings (Peterson et al., 2014). Among HIV-positive YBGBM, greater perceived racial and HIV-related discrimination was associated with being less likely to have an undetectable viral load, less likely to have a high CD4 count, and more likely to visit the emergency department to access HIV treatment services (Peterson et al., 2014).

2.2.2.1.2.2 Stigma in Religious Institutions

Religious institutions are some of the most influential entities within the Black

community. Traditional Black churches share and promote messages that have a substantial role in setting community norms, attitudes, and positions related to various issues (Lassiter, 2015; Ward, 2005). Traditionally, homophobia has been perpetuated and reinforced by Black religious institutions through homophobic messages shared verbally by clergy leadership and mirrored among church members and parishioners, and through the silencing of homosexuality –

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homosexuality is not discussed. YBGBM in several studies reported encountering homophobia within predominately Black religious institutions (Balaji et al., 2012; Lassiter, 2015; Quinn et al., 2015). YBGBM who report involvement and engagement with religious institutions may

internalize these homophobic ideals and behaviors, avoid engaging in stigmatized health

behaviors such as being screened for HIV, and conceal their sexual identity and same sex sexual behaviors from their community members and healthcare providers (Glick & Golden, 2010; Parent et al., 2012).