Although the American Psychiatric Association removed homosexuality from its list of psychiatric disorders in 1973, negative attitudes within the mental health community persist and continue to affect the treatment provided to MSM.¹ Many MSM patients report nondisclo- sure of their sexual orientation to providers despite feeling that disclosure is important for their optimal care. As a result, many MSM individuals do not seek care or fear disclosing their sexual orientation to providers to avoid rejection, discrimination, or poor care. Unfortunately, many studies confirm their fears.¹ Harm from “reparative” or “conversion” interventions (treatments with the goal of changing an individual’s sexual orientation) has been demonstrated, and there is a body of work on homophobia showing that health care providers’ negative attitudes can be hazardous to their patients.² The mental health care clinician should create a safe, affirming, and nonjudgmental environment that encourages patients who are MSM to disclose their sexual identity and sexual orientation and to discuss their sexual behavior with the clinician. The following strategies might be used to create an office environment free of heterosexism (the expectation of heterosexuality) and homophobia, which will encourage open dialog between the clinician and patient and therefore better health outcomes. For example, one should use intake forms that do not assume heterosexuality and offer the option of “significant other, partner, or other,” in addition to “married, single, or divorced.”³ Similar assumptions should be avoided when interviewing patients. In hospitals or clinics, one should display a nondiscrimination statement that includes sexual orientation and any distribution of health education materials should include language referring to and pictures of same-sex couples and transgendered individuals with information about local community resources.³ Assumptions about sexual behavior based on an individual’s sexual orientation, whether heterosexual, homosexual, or bisexual should be avoided. Clinicians should routinely ask whether sexual partners are male, female, or both. Research shows that many self-identified gay men have been sexually active with women. Clinicians who are not comfortable discussing different sexual behaviors with MSM patients and ways to reduce the risk of sexually transmitting HIV should seek training or supervision to enhance their comfort level and their clinical skills.

There are social and cultural disincentives to being attracted to people of the same sex: violence, discrimination, marginalization, illegal status, youth homelessness (runaways/ throw-aways), imprisonment, individual and social abuse, and less than equal status in relation to public services.² Meyer discusses how minority stress—stigma, prejudice, and discrimination—create a hostile and stressful social environment that causes mental health problems, possibly explaining why MSM may have a higher prevalence of mental disorders than heterosexuals.⁴ The experience of prejudice, expectations of rejection, hiding, concealing, and internalized homophobia may worsen coping processes. Internalized homophobia has been found to be a predictor of mental health problems, intimacy problems, and AIDS-related risk-taking behavior and is not uncommon even among self-identified gay and bisexual men who report acceptance of their homosexual orientation.⁴ Rates of domestic violence in same- gender relationships are the same as in heterosexual relationships, and screening should be performed accordingly. However, accessing services tends to be more difficult for MSM victims of domestic violence.

Earlier in the epidemic, the gay community was ravaged by death and a sense of hopelessness; many lost partners and friends to AIDS. This resulted in a chronic state of bereavement, with survivor guilt and/or loss of support system. HIV-negative partners in serodiscordant couples (one HIV-positive and one HIV-negative) desiring sexual intimacy (“normal sex” is unsafe), driven by survivor guilt, wanting to offer support to their infected partner, or not wanting to feel left out, may have chosen not to engage in safer sex and therefore risk becoming HIV-infected. The lack of government responses and the devastating impact of HIV disease among MSM obliged the organized gay community efforts to focus on the needs of their HIV-infected members, leaving the non-HIV infected members to potentially perceive themselves as outsiders within their own gay community. Further, some HIV- negative young MSM (YMSM; aged 15 to 22) felt isolated in their coming out process, because their potential mentors seemed unavailable. Wanting to belong to the community drove some of these YMSM not to take the precautions necessary to avoid infection. For the current generation of YMSM the specter of AIDS has diminished. They did not lose their cohort of gay friends and did not attend multiple memorials—for some of them the first person they had any connection with who died of AIDS was Pedro Zamora from MTV’s “The Real World.” It is important when working with uninfected MSM, particularly YMSM to consistently remind them of the risks of HIV infection and other sexually transmitted infections (STI) and encourage safer behaviors using skills described later on in this chapter.

Until the 1990s, there was a void in the research, professional training, media presence, and recommendations for medical and mental health care of YMSM.¹,⁵ Their invisibility increased their vulnerability. YMSM face the same developmental needs and health and mental health challenges as their heterosexual peers, with the addition of social and health challenges associated with having a stigmatized sexual orientation or identity. Stigma, not deficit, is what separates YMSM from their heterosexual peers, and some gay youth, such as ethnic and racial minorities, are stigmatized even more.¹,⁵ Documented consequences of homophobia include suicide among young homosexual men and women.²

Providers should encourage all adolescents to postpone sexual activity, while respecting them by providing appropriate information and discussing their choices. For youth who are intent on sexual exploration, providers should discuss a range of safer sex options—explaining the continuum of sexual behaviors from “outercourse” (nonpenetrative massage, petting, and mutual masturbation) to the use of barriers (condoms or dental dams) when exchange of fluids is possible. Providers should clearly explain the risks (HIV, sexually transmitted infections [STIs], Hepatitis B and C, pregnancy) of unprotected oral, anal, and vaginal intercourse and should demonstrate the proper use of latex or polyurethane condoms, including female condoms.¹,⁵

Worldwide, AIDS cases among MSM are under-recognized, under-reported, or ignored.⁶ Inadequate surveillance systems and the stigma associated with same-sex behavior contribute to the lack of data; this situation worsens in less developed countries.⁶ The trend of HIV incidence among MSM for much of the world is unknown. Latin America, particularly Brazil, has the largest number of AIDS cases among MSM in emerging nations. An increasing HIV prevalence among MSM in Eastern Europe may point to a rising epidemic. Little can be understood about the trends of HIV incidence among MSM in North Africa; the Middle East; East, Central, and South Asia; and sub-Saharan Africa because of the virtual absence of MSM focus in the surveillance and epidemiologic data.⁶ Currently, in the United States, about 70% of new HIV infections occur among men.⁷ Among the newly infected men, 60% became infected through homosexual sex and 25% through injection drug use (which includes MSM
who use injection drugs).⁷ MSM represent 40% of all new AIDS diagnoses.⁷ However, MSM are less likely than women and heterosexual men to receive prevention counseling and only 10% of the U.S. HIV prevention outcome studies have focused on MSM.⁸