Abstracts

Introduction

Men who have sex with men (MSM) suffer discrimination due to their sexual orientation (DDSO), defined as the manifestation of heteronormativity and homophobia against MSM ¹1. Frye V, Nandi V, Egan J, Cerda M, Greene E, Tieu HV, et al. Sexual orientation- and race-based discrimination and sexual HIV risk behavior among urban MSM. AIDS Behav 2015; 19:257-69.. DDSO plays an important role in maintaining a high prevalence of HIV infection among MSM in several countries ¹1. Frye V, Nandi V, Egan J, Cerda M, Greene E, Tieu HV, et al. Sexual orientation- and race-based discrimination and sexual HIV risk behavior among urban MSM. AIDS Behav 2015; 19:257-69.^,22. The Lancet. HIV: science and stigma. Lancet 2014; 384:207.^,33. Altman D, Aggleton P, Williams M, Kong T, Reddy V, Harrad D, et al. Men who have sex with men: stigma and discrimination. Lancet 2012; 380:439-45.. Studies conducted among MSM also show a greater likelihood of illnesses and risk behaviors among those who suffer DDSO, such as anal sex without a condom ⁴4. Rogers AH, Jardin C, Mayorga NA, Bakhshaie J, Leonard A, Lemaire C, et al. The relationship of discrimination related to sexual orientation and HIV-relevant risk behaviors among men who have sex with men. Psychiatry Res 2018; 267:102-7., experiences of violence ⁵5. Aho J, Hakim A, Vuylsteke B, Semde G, Gbais HG, Diarrassouba M, et al. Exploring risk behaviors and vulnerability for HIV among men who have sex with men in Abidjan, Cote d'Ivoire: poor knowledge, homophobia and sexual violence. PLoS One 2014; 9:e99591.^,66. Sabidó M, Kerr LRFS, Mota RS, Benzaken AS, Pinho AA, Guimaraes MDC, et al. Sexual violence against men who have sex with men in Brazil: a respondent-driven sampling survey. AIDS Behav 2015; 19:1630-41., mental distress ⁴4. Rogers AH, Jardin C, Mayorga NA, Bakhshaie J, Leonard A, Lemaire C, et al. The relationship of discrimination related to sexual orientation and HIV-relevant risk behaviors among men who have sex with men. Psychiatry Res 2018; 267:102-7.^,77. Ruutel K, Valk A, Lohmus L. Suicidality and associated factors among men who have sex with men in Estonia. J Homosex 2016; 64:770-85.^,88. Vu NTT, Holt M, Phan HTT, La LT, Tran GM, Doan TT, et al. Amphetamine-type-stimulants (ATS) use and homosexuality-related enacted stigma are associated with depression among men who have sex with men (MSM) in two major cities in Vietnam in 2014. Subst Use Misuse 2017; 52:1411-9.^,99. Hylton E, Wirtz AL, Zelaya CE, Latkin C, Peryshkina A, Mogilnyi V, et al. Sexual identity, stigma, and depression: the role of the "anti-gay propaganda law" in mental health among men who have sex with men in Moscow, Russia. J Urban Health 2017; 94:319-29.^,1010. Liu Y, Jiang C, Li S, Gu Y, Zhou Y, An X, et al. Association of recent gay-related stressful events with depressive symptoms in Chinese men who have sex with men. BMC Psychiatry 2018; 18:217., and abusive use of alcohol and other drugs ⁴4. Rogers AH, Jardin C, Mayorga NA, Bakhshaie J, Leonard A, Lemaire C, et al. The relationship of discrimination related to sexual orientation and HIV-relevant risk behaviors among men who have sex with men. Psychiatry Res 2018; 267:102-7.^,88. Vu NTT, Holt M, Phan HTT, La LT, Tran GM, Doan TT, et al. Amphetamine-type-stimulants (ATS) use and homosexuality-related enacted stigma are associated with depression among men who have sex with men (MSM) in two major cities in Vietnam in 2014. Subst Use Misuse 2017; 52:1411-9.^,1111. De Boni RB, Machado IK, Vasconcellos MTL, Hoagland B, Kallas EG, Madruga JV, et al. Syndemics among individuals enrolled in the PrEP Brasil Study. Drug Alcohol Depend 2018; 185:168-72.^,1212. Folch C, Esteve A, Zaragoza K, Muñoz R, Casabona J. Correlates of intensive alcohol and drug use in men who have sex with men in Catalonia, Spain. Eur J Public Health 2010; 20:139-45.. Furthermore, discrimination is one of the main barriers MSM face when seeking health services ¹³13. Cerqueira-Santos E, Calvetti PU, Rocha KB, Moura A, Barbosa LH, Hermel J. Percepção de usuários gays, lésbicas, bissexuais e transgêneros, transexuais e travestis do Sistema Único de Saúde. Interam J Psychol 2010; 44:235-45.^,1414. Araújo MAL, Montagner MA, da Silva RM, Lopes FL, de Freitas MM. Symbolic violence experienced by men who have sex with men in the primary health service in Fortaleza, Ceará, Brazil: negotiating identity under stigma. AIDS Patient Care STDS 2009; 23:663-8.^,1515. Risher K, Adams D, Sithole B, Ketende S, Kennedy C, Mnisi Z, et al. Sexual stigma and discrimination as barriers to seeking appropriate healthcare among men who have sex with men in Swaziland. J Int AIDS Soc 2013; 16(3 Suppl 2):18715.^,1616. Ayala G, Santos G. Will the global HIV response fail gay and bisexual men and other men who have sex with men ? J Int AIDS Soc 2016; 19:21098.^,1717. Logie CH, Lacombe-Duncan A, Brien N, Jones N, Lee-Foon N, Levermore K, et al. Barriers and facilitators to HIV testing among young men who have sex with men and transgender women in Kingston, Jamaica: a qualitative study. J Int AIDS Soc 2017; 20:21385.^,1818. Stojisavljevic S, Djikanovic B, Matejic B. 'The devil has entered you': a qualitative study of men who have sex with men (MSM) and the stigma and discrimination they experience from healthcare professionals and the general community in Bosnia and Herzegovina. PLoS One 2017; 12:e0179101..

In the last decade, studies indicate a high proportion of DDSO among MSM in different countries ¹⁹19. Mendos LR. State-sponsored homophobia 2019. https://ilga.org/state-sponsored-homophobia-report (accessed on 23/Mar/2022).
https://ilga.org/state-sponsored-homopho... , including Brazil ²⁰20. Magno L, Dourado I, Silva LAV, Brignol S, Brito AM, Guimarães MDC, et al. Factors associated with self-reported discrimination against men who have sex with men in Brazil. Rev Saúde Pública 2017; 51:102.^,2121. Magno L, Silva LAV, Guimarães MDC, Veras MASM, Deus LFA, Leal AF, et al. Discrimination based on sexual orientation against MSM in Brazil: a latent class analysis. Rev Bras Epidemiol 2019; 22 Suppl 1:e190003.. Sexual and affective practices among MSM remain illegal in many countries and are punishable by death in some ¹⁹19. Mendos LR. State-sponsored homophobia 2019. https://ilga.org/state-sponsored-homophobia-report (accessed on 23/Mar/2022).
https://ilga.org/state-sponsored-homopho... . Although homosexuality is legal in Latin America, the patriarchal, religious, and sexist context of countries in the region adds to the impact of DDSO on the physical, mental, social, and cultural well-being of MSM ²²22. De Boni R, Veloso VG, Grinsztejn B. Epidemiology of HIV in Latin America and the Caribbean. Curr Opin HIV AIDS 2014; 9:192-8.^,2323. Malta M, Beyrer C. The HIV epidemic and human rights violations in Brazil. J Int AIDS Soc 2013; 16:10-2.^,2424. Parker RG. Behaviour in Latin American men: implications for HIV/AIDS interventions. Int J STD AIDS 1996; 7 Suppl 2:62-5..

The Brazilian judicial system has protective human right measures for MSM, including recognizing same sex marriage (since 2011) ²⁵25. Faria F. Casamento gay não é lei, mas é direito garantido pela Justiça; entenda. Folha de S.Paulo 2018; 5 nov. https://www1.folha.uol.com.br/cotidiano/2018/11/casamento-gay-nao-e-lei-mas-e-direito-garantido-pela-justica-entenda.shtml.
https://www1.folha.uol.com.br/cotidiano/... , and making discrimination against LGBTQI+ liable to legal prosecution, although specific legislation related to this issue is still pending in the Brazilian National Congress ²⁶26. Della Coletta R. O STF conclui julgamento e enquadra homofobia na lei dos crimes de racismo. Folha de S.Paulo 2019; 13 jun. https://www1.folha.uol.com.br/cotidiano/2019/06/stf-conclui-julgamento-e-enquadra-homofobia-na-lei-dos-crimes-de-racismo.shtml.
https://www1.folha.uol.com.br/cotidiano/... . Nevertheless, in 2018, 420 LGBT individuals were targeted for their identities and murdered in Brazil, out of which 191 (45%) were MSM ²⁷27. Grupo Gay da Bahia. Mortes violentas de LGBT+ no Brasil: relatório 2018. https://grupogaydabahia.files.wordpress.com/2019/01/relatório-de-crimes-contra-lgbt-brasil-2018-grupo-gay-da-bahia.pdf (accessed on 23/Mar/2022).
https://grupogaydabahia.files.wordpress.... . An alarming increase in the prevalence of self-reported DDSO among MSM has been observed in two behavioral and biological surveillance surveys using respondent-driven sampling (RDS), from 27.7% in 2009 to 65% in 2016 ²⁰20. Magno L, Dourado I, Silva LAV, Brignol S, Brito AM, Guimarães MDC, et al. Factors associated with self-reported discrimination against men who have sex with men in Brazil. Rev Saúde Pública 2017; 51:102.^,2121. Magno L, Silva LAV, Guimarães MDC, Veras MASM, Deus LFA, Leal AF, et al. Discrimination based on sexual orientation against MSM in Brazil: a latent class analysis. Rev Bras Epidemiol 2019; 22 Suppl 1:e190003.. We were able to explore the 2016 data in a previous study using latent class analysis (LCA) ²¹21. Magno L, Silva LAV, Guimarães MDC, Veras MASM, Deus LFA, Leal AF, et al. Discrimination based on sexual orientation against MSM in Brazil: a latent class analysis. Rev Bras Epidemiol 2019; 22 Suppl 1:e190003.. In that analysis, 13 variables (e.g., perception of discrimination by institutions, family, and services, among others) were used to construct a DDSO variable which indicated very high, high, average or low discrimination levels (2.2%, 16.4%, 35.1%, and 46.2%, respectively). In this study, we aim to assess factors associated with the identified levels of this latent DDSO construct among MSM in Brazil.

Materials and methods

Study design and location

This study uses data from the behavioral and biological surveillance survey entitled The 12 City HIV Surveillance Survey among MSM in Brazil 2016 Using Respondent-Driven Sampling: A Description of Methods and RDS Diagnostics²⁸28. Kendall C, Kerr L, Mota RS, Guimarães MDC, Leal AF, Merchan-Hamann E, et al. The 12 city HIV surveillance survey among MSM in Brazil 2016 using respondent-driven sampling: a description of methods and RDS diagnostics. Rev Bras Epidemiol 2019; 22:e190004., conducted in 2016 in 12 Brazilian capitals from states of all five regions in Brazil: Manaus (Amazonas) and Belém (Pará) in the North; Fortaleza (Ceará), Recife (Pernambuco), and Salvador (Bahia) in the Northeast; Brasília (Federal District) and Campo Grande (Mato Grosso do Sul) in the Central-West; Belo Horizonte (Minas Gerais), Rio de Janeiro and São Paulo in the Southeast; and Curitiba (Paraná) and Porto Alegre (Rio Grande do Sul) in the South. Cities were defined, a priori, by the Department of Chronic Conditions and Sexually Transmitted Infections of the Brazilian Ministry of Health.

Participants and recruitment

The survey sample consisted of 4,176 MSM who reported at least one sexual experience in the 12 months prior to the study; aged 18 years or older; did not identify as transsexual or as transgender women; resided, studied or worked in the selected cities; and signed an informed consent form. To recruit participants, RDS was used as recommended for hard-to-reach populations ²⁹29. Heckathorn D. Respondent-driven sampling: a new approach to the study of hidden populations. Soc Probl 1997; 44:174-99.. Formative research using semi-structured interviews and focus groups was conducted in each city to prepare for the main study. Five to seven MSM were purposefully selected to serve as “seeds” throughout the formative research. They were independently selected in each city. These were individuals of different ages and socioeconomic status who had relatively large social contact networks. Each seed was asked to recruit three other MSM from their social network by offering a voucher to each possible recruit. These vouchers provided information about the site and contained a number linking the recruiter and the recruit. This procedure was repeated with each eligible participant until reaching the desired sample size. Participants received a primary and secondary incentive of BRL 25.00 (USD 7.40) for each recruited participant to reimburse expenses such as transport and food.

Data collection

Data were collected by computer-assisted personal interviews (CAPI) in study offices in each city, in which blood samples were drawn for HIV and syphilis testing. Upon completion of the interviews, data were immediately sent via internet to a central server. The research project was approved by the Research Ethics Committee of the Federal University of Ceará (n. 1,024,053 - June 23, 2015). Further details about the methodology can be found in Kendall et al. ²⁸28. Kendall C, Kerr L, Mota RS, Guimarães MDC, Leal AF, Merchan-Hamann E, et al. The 12 city HIV surveillance survey among MSM in Brazil 2016 using respondent-driven sampling: a description of methods and RDS diagnostics. Rev Bras Epidemiol 2019; 22:e190004..

Study variables

The outcome variable, DDSO, was defined by LCA, as previously described ²¹21. Magno L, Silva LAV, Guimarães MDC, Veras MASM, Deus LFA, Leal AF, et al. Discrimination based on sexual orientation against MSM in Brazil: a latent class analysis. Rev Bras Epidemiol 2019; 22 Suppl 1:e190003., and based on 13 questions divided in four DDSO dimensions: (i) discrimination in the work sphere (i.e., not selected for a job or fired from a job); (ii) educational sphere (i.e., mistreated or marginalized by teachers and classmates at school/college); (iii) private sphere (i.e., excluded or marginalized from groups of friends, neighbors, family or religious environment); and (iv) the public sphere (i.e., blackmailed or had money extorted, poorly cared for in health services, prevented from donating blood, mistreated in public services, mistreated by police officers, and prevented from entering markets). LCA is a useful method for identifying underlying groups of individuals with similar profiles ³⁰30. Collins LM, Lanza ST. Latent class and latent transition analysis: with applications in the social, behavioral, and health sciences. Hoboken: Wiley; 2013. (Wiley Series in Probability and Statistics)..

The explanatory variables included in this analysis were: (a) sociodemographic: age (< 25 and ≥ 25 years old), self-reported race/skin color (white, black, or mixed-race - pardo), educational attainment (primary or incomplete secondary, post-secondary education), religious affiliation (yes, no), and marital status (single, divorced, widowed, and married or living together); (b) economic: three economic categories were created: A-B, high income; C, average income; and D-E, low income, based on the Brazilian Economic Classification Criteria ³¹31. Associação Brasileira de Empresas de Pesquisa. Critério Brasil 2015 e atualização da distribuição de classes para 2016. https://www.abep.org/criterio-brasil (accessed on 23/Mar/2022).
https://www.abep.org/criterio-brasil... ; (c) self-reported sexual identity (heterosexual or gay); (d) experienced violence due to sexual orientation (lifetime): physical violence (yes, no) or sexual violence (yes, no); (e) fear of visiting public places (at some point in life or never); (f) family approval of sexual orientation (approves; disapproves or indifferent; or family does not know); (g) disclosure of sexual orientation: told friends (yes, no), told mother (yes, no), told father (yes, no); (h) participation in LGBTQI+ nongovernamental organizations (NGOs) (yes, no); (i) previous HIV testing (lifetime) (yes, no); (j) suicidal ideation in the previous two weeks (yes, no); (k) alcohol use, classified by the Alcohol Use Disorders Identification Test (AUDIT) score (low risk and abstemious; risky and high risk; or dependent); and use of illicit drug in the previous six months (yes, no).

Data analysis

Gile’s successive sampling estimator ³²32. Gile KJ, Handcock MS. Respondent-driven sampling: an assessment of current methodology. Sociol Methodol 2010; 40:285-327. was used to estimate the weighted ratio estimators via RDS Analyst (http://hpmrg.org). Data from the 12 cities were merged into a single database in which each city was treated as its own stratum. The previously defined latent variable DDSO ²¹21. Magno L, Silva LAV, Guimarães MDC, Veras MASM, Deus LFA, Leal AF, et al. Discrimination based on sexual orientation against MSM in Brazil: a latent class analysis. Rev Bras Epidemiol 2019; 22 Suppl 1:e190003. and RDS weights were transferred to the current database for descriptive, bivariate, and multivariate analyses. Stata 15.0 (https://www.stata.com) was used with complex survey data analysis tools.

Multivariate analysis included ordinal logistic regression modelling as the outcome variable was ordinal. Estimators were adjusted with the simultaneous generation of a constant association measure across the categories of the outcome variable ³³33. Abreu MNS, Siqueira AL, Caiaffa WT. Ordinal logistic regression in epidemiological studies. Rev Saúde Pública 2009; 43:183-94..

The construction of weighted odds ratio (OR) in the logistic model began with a bivariate analysis to assess the factors associated with the outcome variable. Variables associated with DDSO in the bivariate analysis at a p-value of 0.20 were included in the multivariate analysis. Only those with p-value < 0.05 remained in the final model. The selection of these factors was based on the previous literature about DDSO. Weighted OR with 95% confidence intervals (95%CI) were used as measures of association between explanatory factors and DDSO.

Results

We recruited 4,176 MSM in 12 Brazilian cities. Overall, 56.1% of MSM were aged under 25 years; 86.3% were single; 53.1% claimed a religious affiliation; 70.3% reported primary or incomplete secondary education level; 41.8% were mixed-race (pardo), 31.5%, white, and 22.7%, black; 42.4% percent of MSM reported high income levels (A-B). The overwhelming majority of participants (92.4%) reported a gay sexual orientation (Table 1).

More than half of the participants reported fear of visiting public spaces (60.3%), whereas about a quarter of them had experienced physical (23.5%) or sexual (21%) violence. Regarding disclosure of sexual orientation, most participants disclosed to their friends (90.1%) and their mothers (62.8%), whereas fewer disclosed it to their fathers (43%). In total, 45.4% of respondents reported family approval of their sexual orientation; 33.4%, family disapproval or indifference to their sexual orientation, and 21.3%, their families’ unawareness of their sexual orientation. A small percentage (17.9%) reported participating in LGBTQI+ NGOs. A third (33.8%) had never taken an HIV test and almost a fifth (18%) experienced suicidal ideation in the two weeks before our survey. Regarding alcohol use, 35.7% were classified as risky or in high risk, and 9.7% as dependent; and almost half participants reported using illicit drugs in the six months before the survey (48.4%) (Table 1).

Among those who reported any DDSO (65%), a high proportion of MSM (73.1%) did not share this with anyone. Among those who did, 19.7% shared with their family, 6.1%, with their partners/spouses, 0.9%, with friends, 0.1%, with health professionals and another 0.1%, with the police (Table 2).

Table 3 shows the association between explanatory variables and the DDSO categories. Bivariate analysis indicated increased odds of DDSO among MSM aged under 25 years (OR = 2.13; 95%CI: 1.60-2.83) who were white (OR = 1.58; 95%CI: 1.13-2.21) and had post-secondary education (OR = 2.00; 95%CI: 1.42-2.83) and higher socio-economic status: A-B (OR = 2.35; 95%CI: 1.52-3.63) and C (OR = 1.67; 95%CI: 1.06-2.63), when compared with those in D-E socioeconomic status. Moreover, gay sexual identity (OR = 5.15; 95%CI: 2.30-11.50), physical (OR = 4.26; 95%CI: 3.00-6.06) and sexual violence (OR = 3.37; 95%CI: 2.29-4.95), family disapproval or indifference (OR = 1.37; 95%CI: 1.01-1.85), having told mother (OR = 2.04; 95%CI: 1.52-2.74) and father about sexual orientation (OR = 2.05; 95%CI: 1.54-2.72), and participating in an LGBTQI+ NGO (OR = 1.94; 95%CI: 1.33-2.83) were also associated with this outcome. Finally, ever taking an HIV test (OR = 1.67; 95%CI: 1.22-2.29), suicidal ideation (OR = 2.45; 95%CI: 1.70-3.52), risky or high risk of alcohol use (OR = 1.36; 95%CI: 1.02-1.82), and illicit drug use in the previous six months (OR = 1.54; 95%CI: 1.17-2.04) showed increased DDSO odds.

In the final multivariate analysis, the following variables were independently associated with DDSO: age under 25 years (OR = 1.66; 95%CI: 1.21-2.27), white skin color (OR = 1.43; 95%CI: 1.02-2.01), experience of sexual (OR = 2.33; 95%CI: 1.58-3.43) and physical violence (OR = 3.08; 95%CI: 2.11-4.49), shared sexual orientation with their fathers (OR = 2.00; 95%CI: 1.47-2.72), experienced suicidal ideation in the previous two weeks (OR = 2.09; 95%CI: 1.46-2.98), and used illicit drugs in the previous six months (OR = 1.61; 95%CI: 1.19-2.18) (Table 4).

Discussion

In this analysis, we were able to confirm the relevance of contextual factors which potentially increase the likelihood of DDSO among MSM in Brazil. The combination of a latent indicator of discrimination previously described and an ordinal logistic regression approach used for analysis may more comprehensively capture the effects of potential exposures on different levels of DDSO.

Between our two MSM surveys in 2009 and 2016, the prevalence of self-reported DDSO increased from 27.7% to 65% ²⁰20. Magno L, Dourado I, Silva LAV, Brignol S, Brito AM, Guimarães MDC, et al. Factors associated with self-reported discrimination against men who have sex with men in Brazil. Rev Saúde Pública 2017; 51:102.^,2121. Magno L, Silva LAV, Guimarães MDC, Veras MASM, Deus LFA, Leal AF, et al. Discrimination based on sexual orientation against MSM in Brazil: a latent class analysis. Rev Bras Epidemiol 2019; 22 Suppl 1:e190003. in Brazil. Since the end of the first decade of the 21st century, the Brazilian government, though in favor of the social and preventive agendas claimed by MSM, decided to negotiate with the extreme right-wing caucus to approve its other social and economic, and start to give up progressive agendas. The most affected by this decision were younger men, who were found more likely to report DDSO than older men, a trend already observed in 2009 ²⁰20. Magno L, Dourado I, Silva LAV, Brignol S, Brito AM, Guimarães MDC, et al. Factors associated with self-reported discrimination against men who have sex with men in Brazil. Rev Saúde Pública 2017; 51:102. in Brazil, as well as in other countries ³⁴34. Santos GM, Beck J, Wilson PA, Hebert P, Makofane K, Pyun T, et al. Homophobia as a barrier to HIV prevention service access for young men who have sex with men. J Acquir Immune Defic Syndr 2013; 63:e167-70.^,3535. Huebner DM, Rebchook GM, Kegeles SM. Experiences of harassment, discrimination, and physical violence among young gay and bisexual men. Am J Public Health 2004; 94:1200-3.. Moreover, another explanation may be that older MSM could be desensitized from repeated exposure to abuse, creating cognitive mechanisms that may partially neutralize the identification and effects of discrimination ³⁶36. Nuttbrock L, Hwahng S, Bockting W, Rosenblum A, Mason M, Macri M, et al. Psychiatric impact of gender-related abuse across the life course of male-to-female transgender persons. J Sex Res 2010; 47:12-23..

White MSM and those with higher education were more likely to report DDSO, although the multivariate analysis excluded the latter. In Brazil, higher schooling educational levels are more prominent among white men than in black men ³⁷37. Instituto Brasileiro de Geografia e Estatísticas. Pretos ou pardos estão mais escolarizados, mas desigualdade em relação aos brancos permanece. Agência IBGE Notícias 2019; 13 nov. https://agenciadenoticias.ibge.gov.br/agencia-sala-de-imprensa/2013-agencia-de-noticias/releases/25989-pretos-ou-pardos-estao-mais-escolarizados-mas-desigualdade-em-relacao-aos-brancos-permanece.
https://agenciadenoticias.ibge.gov.br/ag... . We may hypothesize that white, younger MSM with higher schooling level are potentially more willing to report DDSO ²⁰20. Magno L, Dourado I, Silva LAV, Brignol S, Brito AM, Guimarães MDC, et al. Factors associated with self-reported discrimination against men who have sex with men in Brazil. Rev Saúde Pública 2017; 51:102.. Stigma and discrimination are consequences of social structures and forms of domination used in society to identify and to discriminate against all divergence from heteronormative white male identity. In Brazil, DDSO affects even white and educated men who express or identify their sexual orientation. On the other hand, for black MSM, facing the intersection of sexual, racial, and class discrimination ³⁸38. Reisen CA, Brooks KD, Zea MC, Poppen PJ, Bianchi FT. Can additive measures add to an intersectional understanding? Experiences of gay and ethnic discrimination among HIV-positive Latino gay men. Cultur Divers Ethnic Minor Psychol 2013; 19:208-17.^,3939. Thai M. Sexual racism is associated with lower self-esteem and life satisfaction in men who have sex with men. Arch Sex Behav 2019; 49:347-53.^,4040. Watkins-Hayes C. Intersectionality and the sociology of HIV/AIDS: past, present, and future research directions. Annu Rev Sociol 2014; 40:431-57. may affect both visibility and willingness to report discrimination.

Another concern relates to the fact that only 26.9% of MSM reported DDSO. Moreover, when they did, the vast majority failed to report it to the judicial system, doing so to their friends or relatives. This lack of reporting is problematic in two senses. First, due to underreporting, DDSO is underestimated in the Brazilian society, reducing public administrators, legislators, and the civil society’s visibility of this problem. On the other hand, this may affect MSM’s physical and mental health since not talking about the problem may aggravate internalized homophobia ⁴¹41. Newcomb ME, Mustanski B. Internalized homophobia and internalizing mental health problems: a meta-analytic review. Clin Psychol Rev 2010; 30:1019-29.^,4242. Berghe WV, Dewaele A, Cox N, Vincke J. Minority-specific determinants of mental well-being among lesbian, gay, and bisexual youth. J Appl Soc Psychol 2010; 40:153-66., which can be defined as homophobic attitudes toward oneself which, in turn, can lead to low self-esteem and self-hatred ⁴³43. Meyer IH. Minority stress and mental health in gay men. J Health Soc Behav 1995; 36:38-56.. This difficulty in reporting discrimination may be aggravated if there is a lack of family acceptance. In this study, we showed that one-third of participants reported their families’ disapprove their sexual identity. Moreover, disclosing their sexual identity to their fathers was independently associated with a greater likelihood of experiencing DDSO.

In this study, both physical and sexual violence were strongly associated with DDSO, as in other studies ⁶6. Sabidó M, Kerr LRFS, Mota RS, Benzaken AS, Pinho AA, Guimaraes MDC, et al. Sexual violence against men who have sex with men in Brazil: a respondent-driven sampling survey. AIDS Behav 2015; 19:1630-41.^,2020. Magno L, Dourado I, Silva LAV, Brignol S, Brito AM, Guimarães MDC, et al. Factors associated with self-reported discrimination against men who have sex with men in Brazil. Rev Saúde Pública 2017; 51:102.. Discrimination and violence may influence perception of insecurity among MSM: 60% reported feeling fear of circulating in public places, a much higher percentage than that found in hostile locations for MSM in Abuja, Nigeria (17%) ⁴⁴44. Strömdahl S, Williams AO, Eziefule B, Emmanuel G, Iwuagwu S, Anene O, et al. An assessment of stigma and human right violations among men who have sex with men in Abuja, Nigeria. BMC Int Health Hum Rights 2019; 19:7..

Our study also showed an association with suicidal ideation in the previous two weeks and illicit drug use in the previous six months before the survey, respectively. However, we should note the cross-sectional nature of the data and time-frame differences among these variables. Despite this, other studies have shown an association between DDSO, mental health distress ³⁵35. Huebner DM, Rebchook GM, Kegeles SM. Experiences of harassment, discrimination, and physical violence among young gay and bisexual men. Am J Public Health 2004; 94:1200-3.^,4545. Hatzenbuehler ML, Nolen-Hoeksema S, Erickson SJ. Minority stress predictors of HIV risk behavior, substance use, and depressive symptoms: results from a prospective study of bereaved gay men. Health Psychol 2008; 27:455-62.^,4646. Anderson AM, Ross MW, Nyoni JE, McCurdy SA. High prevalence of stigma-related abuse among a sample of men who have sex with men in Tanzania: implications for HIV prevention. AIDS Care 2015; 27:63-70., and the use of psychoactive substances among MSM ⁴4. Rogers AH, Jardin C, Mayorga NA, Bakhshaie J, Leonard A, Lemaire C, et al. The relationship of discrimination related to sexual orientation and HIV-relevant risk behaviors among men who have sex with men. Psychiatry Res 2018; 267:102-7.^,88. Vu NTT, Holt M, Phan HTT, La LT, Tran GM, Doan TT, et al. Amphetamine-type-stimulants (ATS) use and homosexuality-related enacted stigma are associated with depression among men who have sex with men (MSM) in two major cities in Vietnam in 2014. Subst Use Misuse 2017; 52:1411-9.^,1111. De Boni RB, Machado IK, Vasconcellos MTL, Hoagland B, Kallas EG, Madruga JV, et al. Syndemics among individuals enrolled in the PrEP Brasil Study. Drug Alcohol Depend 2018; 185:168-72.^,1212. Folch C, Esteve A, Zaragoza K, Muñoz R, Casabona J. Correlates of intensive alcohol and drug use in men who have sex with men in Catalonia, Spain. Eur J Public Health 2010; 20:139-45..

At the highest government levels, between 2002 and 2014, policies and health interventions were developed in Brazil which positively addressed MSM’s discrimination and vulnerabilities. For example, the Committee for LGBTQI+ Health in the Brazilian Ministry of Health, the reassertion of LGBTQI+ rights to health care in the Brazilian Unified National Health System (SUS), and the Brazilian National Policy for LGBTQI+ Health ⁴⁷47. Departamento de Apoio à Gestão Participativa, Secretaria de Gestão Estratégica e Participativa, Ministério da Saúde. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília: Ministério da Saúde; 2013.^,4848. Ministério da Saúde. Carta dos direitos dos usuários da saúde: ilustrada. 2ª Ed. Brasília: Ministério da Saúde; 2007. (Série F. Comunicação e Educação em Saúde). were developed. However, Brazil has experienced setbacks in LGBTQI+ health policies over the last five years due to the advance of reactionary conservative religious groups and social movements in Brazilian society, reflected in the National Congress and the Presidency ⁴⁹49. Brandão ER, Cabral S. Sexual and reproductive rights under attack: the advance of political and moral conservatism in Brazil. Sex Reprod Health Matters 2019; 27:1669338.^,5050. Montenegro L, Velasque L, LeGrand S, Whetten K, Rafael RMR, Malta M. Public health, HIV care and prevention, human rights and democracy at a crossroad in Brazil. AIDS Behav 2020; 24:1-4.. More recently, the current national government, as of 2019, has further exacerbated this situation ⁵⁰50. Montenegro L, Velasque L, LeGrand S, Whetten K, Rafael RMR, Malta M. Public health, HIV care and prevention, human rights and democracy at a crossroad in Brazil. AIDS Behav 2020; 24:1-4.. The new president and his old party - who elected the largest number of members in the National Congress - were voted in on a platform which contained explicit rejection of LGBTQI+ individuals and identities and published a program vowing to exclude LGBTQI+ communities from human rights protections and social policies ⁴⁹49. Brandão ER, Cabral S. Sexual and reproductive rights under attack: the advance of political and moral conservatism in Brazil. Sex Reprod Health Matters 2019; 27:1669338.. Moreover, the Department of Continuing Education, Literacy, Diversity and Inclusion, responsible for promoting policies to secure sexual, gender, and ethnic diversity in Brazilian public schools, was terminated. HIV prevention guidelines for transgender populations were also removed under the argument that this document contained “content offensive to families” ⁴⁹49. Brandão ER, Cabral S. Sexual and reproductive rights under attack: the advance of political and moral conservatism in Brazil. Sex Reprod Health Matters 2019; 27:1669338..

Brazil faces a political context of increased stigma directed toward LGBTQI+ communities that most likely will increase DDSO. From 2009 to 2016, the persistence and increase in DDSO may constitute a significant barrier for access to health services, including the commitment to universal access to antiretroviral therapies to treat and to prevent HIV (such as pre-and post-exposure prophylaxes) ⁵¹51. Khan S. Examining HIV/AIDS-related stigma at play: power, structure, and implications for HIV interventions. Health Commun 2019; 35:1509-19.^,5252. Ferraz D, Couto MT, Zucchi EM, Calazans GJ, Santos LA, Mathias A, et al. AIDS- and sexuality-related stigmas underlying the use of post-exposure prophylaxis for HIV in Brazil: findings from a multicentric study. Sex Reprod Health Matters 2019; 27:1650587.^,5353. Magno L, Dourado I, Coats CS, Wilhite D, Silva LAV, Oni-Orisan O, et al. Knowledge and willingness to use pre-exposure prophylaxis among men who have sex with men in Northeastern Brazil. Glob Public Health 2019; 14:1098-111..

An unfavorable and stressful environment is increasingly associated with physiological effects that make MSM more vulnerable to several diseases ⁵⁴54. Li MJ, Takada S, Okafor CN, Gorbach PM, Shoptaw SJ, Cole SW. Experienced homophobia and gene expression alterations in black and Latino men who have sex with men in Los Angeles County. Brain Behav Immun 2019; 83:120-5.. In line with minority stress theory ⁴³43. Meyer IH. Minority stress and mental health in gay men. J Health Soc Behav 1995; 36:38-56.^,5555. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull 2003; 129:674-97., stressors are portrayed as events and conditions requiring constant change, causing exposed individuals to make intense efforts to adapt to new circumstances. Therefore, individuals subjected to stressors suffer from constant psychological and physical tension which erodes their capacity to adapt, inducing mental and somatic disorders ⁵⁵55. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull 2003; 129:674-97.. As Goffman ⁵⁶56. Goffman E. Estigma: notas sobre a manipulação da identidade manipulada. 4ª Ed. Rio de Janeiro: LTC; 2013. indicated, the response to “deviance”, embedded in stigma and discrimination, can lead to the problematization of previously uncontested terrains: challenges to masculinity and heteronormativity can be seen as a response to serious problems of gender violence and intimate partner violence, both widespread in Brazil and elsewhere. As with in-group stigma, occupying a stigmatized role can offer opportunities for leadership, not just oppression. In the light of this, in relation to strategies that diminish DDSO among MSM, there are several initiatives in Latin America, including interventions sensitive to gender and culture, which focus on creating new values that enable an expansion of different forms of masculinity ⁵⁷57. Martinez O, Wu E, Levine EC, Muñoz-Laboy M, Fernandez MI, Bass SB, et al. Integration of social, cultural, and biomedical strategies into an existing couple-based behavioral HIV/STI prevention intervention: voices of Latino male couples. PLoS One 2016; 11:e0152361..

Although this study shows robust results, it also has some limitations. The original questionnaire was not designed to evaluate DDSO. Moreover, we do not have information about exposure timing or duration, the context in which episodes occur, and DDSO intensity and frequency. Furthermore, RDS studies show limitations regarding sample representativeness, potential biases in estimating and sampling social networks and indicator data, and potential violation of several theoretical assumptions of RDS in implementation.

Conclusion

This study reports a high level of DDSO among MSM in Brazil, which shows a concerning increase from 2009 to 2016. We emphasize the high levels of reported DDSO among younger, white, and better-educated MSM. However, the potential “iceberg” nature of DDSO may indicate that the documented discrimination might be significantly smaller than the actual one. We should also highlight other contextual factors associated with DDSO in our analysis, namely, sexual and physical violence and use of illicit drugs, which may synergistically increase the chances of DDSO among MSM. This study was conducted in 2016, a time of relatively progressive political and social movement in Brazil. The current government in Brazil has worsened the rising homophobia it engendered since it has implicitly and explicitly granted permission for homophobia. There is certainly a need for vigilance and documentation of discrimination and violence acts, as well as more in-depth studies on the association between DDSO and racial discrimination in an intersectional perspective, and the social and political context in which they occur. The rise and patterns of distribution of DDSO show how contingent stigma and discrimination depend on political and moral leadership or lack thereof. Therefore, monitoring DDSO throws into sharp relief our broad social and political failings, affecting all Brazilians.

Acknowledgments

We wish to thank the Department of Chronic Conditions and Sexually Transmitted Infections/Brazilian Ministry of Health, the gay and other MSM who were interviewed, and the Brazilian HIV/MSM Surveillance Group: Alexandre Kerr Pontes (Federal University of Rio de Janeiro/Rio de Janeiro); Ana Cláudia Camillo (Alfredo da Mata Foundation/Manaus); Ana Maria de Brito (Oswaldo Cruz Foundation/Recife); Ana Rita Coimbra Motta-Castro (Oswaldo Cruz Foundation and Federal University of Mato Grosso do Sul/Campo Grande); Daniela Riva Knauth and Andréa Fachel Leal (Federal University of Rio Grande do Sul/Porto Alegre); Edgar Merchan-Hamann e Ximena Pamela Díaz Bermúdez (University of Brasília/Brasília); Luana N. C. Lima (Evandro Chagas Institute/Belém); Maria Amélia Veras (Santa Casa de São Paulo School of Medical Sciences/São Paulo); Inês Dourado (Federal University of Bahia/Salvador); Lígia Regina Sansigolo Kerr, Raimunda Hermelinda Maia Macena, and Rosa Salani Mota (Federal University of Ceará/Fortaleza); Lisangela Cristina de Oliveira (Autonomous University Center of Brazil/Curitiba); Mark Drew Crosland Guimarães (Federal University of Minas Gerais/Belo Horizonte); Maria do Socorro Cavalcante (Ceará State Health Secretariat/Fortaleza); Carl Kendall (Tulane University/New Orleans and Federal Univeristy of Ceará/Fortaleza); and George Rutherford and Willi McFarland (University of California San Francisco/San Francisco).

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