January 26, 2004

Social barriers hinder health care for black men

By Tia Webster

Black men who have sex with men (BMSM) often share common experiences of racism, sexual prejudice, judgment and displacement from their families, churches and communities. Their everyday stressors can be further complicated by negative encounters within medical institutions, according to an Emory-led study published in the January/February issue of the Journal of the National Medical Association.

Prior studies have shown that one of every 50 African American males is infected with HIV. The U.S. BMSM population is disproportionately affected by HIV and in some cities suffers from rates of HIV infection that rival those in sub-Saharan Africa. The most prevalent estimates for HIV infection in the BMSM population is at 33 percent for 15-29-year-olds in some major metropolitan areas. Astoundingly, up to 93 percent of these men are unaware of their HIV status, according to a 2002 Morbidity and Mortality Weekly Report from the CDC.

"It's important to study how the health care experiences of BMSM play a role in the HIV epidemic because medical facilities are the place where most of this population have access to HIV testing," said lead researcher David Malebranche, an instructor of medicine in the School of Medicine. "Often, BMSM who don't identify as 'gay' will not access community-based organizations that traditionally offer HIV testing services because they fear negative stigmatization by association. But medical providers and other staff play a key role in how comfortable BMSM feel in coming to health care facilities and being honest regarding their sexual behavioral risk for HIV."

Malebranche and fellow researchers at the New York City Department of Health and the Mailman School of Public Health at Columbia University formed eight focus groups of BMSM living in New York and Atlanta in early 2001. Eighty-one men were recruited through community-based organizations and health service providers. Led by a facilitator, the men discussed the external and internal barriers that contributed to their health care experience.

The researchers found that the social context of racial and sexual displacement the men felt in their daily lives was carried into their experiences in the health care system.

"Black men who sleep with men have to cope with the social stigma of being both black and homosexual," Malebranche said. "Not only do they feel disconnected from mainstream white culture, but there is also a social isolation from the black community. It leaves them with a disjointed sense of self."

Malebranche noted that medical providers can be a safe haven for these men and can help them empower themselves to cope and turn health care into a positive experience.

"A positive medical experience can help black homosexual men communicate more truthfully and realistically with each other, and can also help them better evaluate their own HIV risk factors," he said. "Other studies have shown that knowledge of HIV-positive status is an important predictor of improved condom use, which will ultimately slow down the epidemic."

The study also discusses external barriers to medical care such as money, lack of insurance, perceived lack of confidentiality and an impersonal medical system. Not to be overlooked, however, are internalized barriers to health care that surfaced in the focus groups. Issues such as distrust, racial and sexual stigma, and fear of medical services were identified as barriers.

Although important, Malebranche said, increasing HIV education outreach efforts, establishing more local clinics and providing universal health insurance will not sufficiently address these barriers. The researchers suggest three areas that must be addressed: enhancing the cultural competency curriculum for all medical personnel, recognizing the important role of minority health care providers, and expanding future research efforts to target the factors influencing health outcomes in the BMSM population.

"Many medical schools and residency programs have cultural competency programs that, hopefully, cement the message to medical trainees that the key to good patient care is to meet the patient where they are," Male-branche said. "This is somewhat of a cliché, but we as medical providers need to make a concerted effort to ascertain how our patients understand their disease and illness process, and make them active participants in the assessment and care, as they should be."

Malebranche couched the study's conclusions in terms of its limitations, including a reliance on a small sample and the fact that participants were recruited through black community-based organizations that participate in HIV prevention work. The recruitment method possibly resulted in an oversampling of BMSM who were comfortable enough with their homosexuality to access the organizations' services and participate in the study. Also, the researchers couldn't adequately explore the differences between HIV-positive and HIV-negative BMSM since not all men openly discussed their HIV status.

Despite these limitations, Malebranche believes the findings effectively describe the nature of health care experiences for BMSM and are useful for future interventions and the identification of additional barriers to health care.