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A Qualitative Study of Medical Mistrust, Perceived Discrimination, and Risk Behavior Disclosure to Clinicians by U.S. Male Sex Workers and Other Men Who Have Sex with Men: Implications for Biomedical HIV Prevention

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Abstract

Access to biomedical HIV prevention technologies such as pre-exposure prophylaxis (PrEP) requires individuals to disclose risk behavior to clinicians, but experiences of discrimination and medical mistrust may limit disclosure among male sex workers and other MSM. We explored experiences of perceived discrimination, medical mistrust, and behavior disclosure among male sex workers compared to other men who have sex with men (MSM). We conducted 56 interviews with MSM and compared findings about medical mistrust, discrimination, and disclosure for 31 men who engaged in sex work vs. 25 men who did not. MSM who engaged in sex work reported more medical mistrust and healthcare discrimination due to issues beyond MSM behavior/identity (e.g., homelessness, substance use, poverty). MSM who did not report sex work described disclosing sex with men to clinicians more often. Both subgroups reported low PrEP awareness, but willingness to disclose behavior to obtain PrEP. Medical mistrust and perceived discrimination create barriers for sexual behavior disclosure to clinicians, potentially impeding access to PrEP and other forms of biomedical HIV prevention. These barriers may be higher among male sex workers compared to other MSM, given overlapping stigmas including sex work, substance use, homelessness, and poverty. An intersectionality framework for understanding multiple stigmas can help to identify how these dynamics may limit access to biomedical HIV prevention among male sex workers, as well as suggesting strategies for addressing stigmas to improve the delivery of PrEP and other HIV prevention approaches in this population.

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Acknowledgments

We are grateful to the study participants, Project Weber, Miriam Community Access, the Yale Center for Interdisciplinary Research on AIDS, the Lifespan/Tufts/Brown Center for AIDS Research, Melissa Guillen, Genevieve Ilg, Bobby Ducharme, and Dr. Caroline Kuo for help during the implementation of this study. We are also grateful to Dr. Douglas Krakower for advance review and commentary on this manuscript.

Research Support

This work was supported by NIH grants 5K01MH093273 and U24AA022000.

KHM has received unrestricted research and educational grants from Gilead (Foster City, CA, USA). All other authors have nothing to declare.

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Authors and Affiliations

  1. Yale Center for Interdisciplinary Research on AIDS/Yale Law School, Yale University, P.O. Box 208215, New Haven, CT, 06520, USA

    Kristen Underhill

  2. Centers for Behavioral & Preventive Medicine, The Miriam Hospital, Providence, RI, USA

    Kathleen M. Morrow & Christopher Colleran

  3. Project Weber, Providence, RI, USA

    Richard Holcomb

  4. Yale School of Public Health, Yale University, New Haven, CT, USA

    Sarah K. Calabrese

  5. Program in Public Health, Brown University, Providence, RI, USA

    Don Operario

  6. Department of Health Services, Policy and Practice, Brown University, Providence, RI, USA

    Omar Galárraga

  7. The Fenway Institute, Fenway Health, Boston, MA, USA

    Kenneth H. Mayer

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  1. Kristen Underhill
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Correspondence to Kristen Underhill.

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Underhill, K., Morrow, K.M., Colleran, C. et al. A Qualitative Study of Medical Mistrust, Perceived Discrimination, and Risk Behavior Disclosure to Clinicians by U.S. Male Sex Workers and Other Men Who Have Sex with Men: Implications for Biomedical HIV Prevention. J Urban Health 92, 667–686 (2015). https://doi.org/10.1007/s11524-015-9961-4

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