Gay and bisexual men living in European countries with strong attitudes and policies against homosexuality are far less likely to use HIV-prevention services, test for HIV, and discuss their sexuality with health providers, according to research led by Yale School of Public Health (YSPH).



The study is published online in the journal AIDS.



Attitudes about homosexuality vary greatly across Europe, noted YSPH associate professor and lead author John Pachankis and his colleagues. The research team wanted to investigate the impact of homophobia on gay and bisexual men’s health — specifically their sexual behavior, use of HIV-prevention services, HIV status, and ability to cope with HIV.



To conduct the study, the researchers used data from the European MSM Internet Survey (EMIS), a joint project of academic, governmental, non-governmental, and online media partners from 35 European countries. EMIS is a 25-language study that assessed HIV-related knowledge, behaviors, and health-service use among 174,000 gay and bisexual men. The researchers combined the EMIS data with a measure of country-level laws, policies, and social attitudes toward homosexuality.



The study authors found stark differences in how countries treat and view homosexuality. They also found that men living in countries with higher levels of homophobia knew less about HIV and were less likely to use condoms, leading the researchers to conclude that homophobia reduces the use of health services and compromises health-service quality.



Researchers also noted a heightened risk of disease for gay and bisexual men in homophobic countries, where appropriate prevention services are limited but the opportunity for sexual contact is increasing.



“Our findings suggest that rather than primarily being the result of personal failure, HIV risk is largely determined by national laws, policies, and attitudes toward homosexuality,” said Pachankis. “This study shows that gay and bisexual men in homophobic countries are denied the resources, including psychological resources like open self-expression, that are necessary to stay healthy.”



An additional finding is that gay and bisexual men in countries where homophobia is more pronounced have fewer sex partners and were less likely to have HIV. The researchers concluded that this finding was the result of efforts by gay and bisexual men to conceal their sexual orientation, or stay in “the closet.” While homophobia keeps men in the closet and suppresses their opportunities to meet and have sex, noted the researchers, it also keeps them uneducated about the risks of unprotected sex and unskilled in the use of condoms in their sexual relationships, which can facilitate HIV transmission.



The research raises new concerns about the vulnerability of men in homophobic countries since they are denied the knowledge, skills, and resources needed to avoid or cope with HIV, the study authors noted. At the same time, opportunities for sex are expanding due to increasing mobility and travel, as well as rapid developments in technology, such as hook-up websites and mobile apps.



The publication is a joint effort between Yale, Columbia University, the London School of Hygiene & Tropical Medicine, the Norwegian Knowledge Centre for Health Services, the German Robert Koch Institute, and the Swiss Federal Office of Public Health FOPH.



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