Concealment of homosexual identity, social support and CD4 cell count among HIV-seropositive gay men

Abstract

Objective: Previous research has indicated that the concealment of homosexuality is related to poorer health among gay men with HIV. This study explored mechanisms by which concealment of homosexuality may be related to HIV disease status by examining associations between concealment of homosexuality, social support, social constraints, depressive symptoms and CD4 count among HIV-seropositive gay men. Method: Questionnaires assessing concealment of homosexuality, social support, depressive symptoms and social constraints were administered to 73 HIV-seropositive gay men. Medical charts were accessed to gather HIV disease information including CD4 counts. Regression analyses were conducted to examine associations between psychosocial variables and CD4 counts. Results: Concealment of homosexuality was associated with lower CD4 count, greater social constraints, greater depressive symptoms and less social support. The association between concealment of homosexuality and CD4 count varied according to level of social support. Among participants with higher levels of social support, those with greater concealment had lower CD4 counts than those with lower concealment. Concealment of homosexuality was not related to CD4 count among participants reporting low social support. Conclusion: Concealment of homosexuality among HIV-seropositive gay men is associated with lower CD4 counts, depressive symptoms and strained social relationships. In addition, the benefits of being open about homosexuality may be most evident under conditions of greater social support.

Introduction

Gay and bisexual men account for more cases of HIV infection in the United States than any other transmission category [1]. As a consequence, many persons with HIV are coping with multiple stressors including those related to HIV infection and those associated with gay lifestyle, such as the disclosure or concealment of homosexual identity. The disclosure of homosexual identity, or “coming out,” is considered an important step towards developing a positive identity as a gay man [2], [3], [4], [5]. However, those who do “come out” may face social stigma, prejudice and upheaval in their current relationships [6], [7], [8]. In order to avoid these stressors, some gay men choose to conceal their homosexual identity [8], [9].

Concealing homosexual identity may have a negative impact on the mental and physical health of gay men. For example, in cross-sectional research, the concealment of homosexual identity has been related to poorer mental health among gay men [4], [10], [11]. In addition, two prospective studies have demonstrated that HIV-seropositive gay men who conceal their homosexual identity experience more rapid disease progression and increased risk of cancer and infectious disease is compared to HIV-seropositive gay men who do not conceal their homosexual identity [12], [13].

The concealment of homosexual identity may be able to impact HIV disease status through processes associated with the inhibition of expressions of thoughts and feelings. When persons are secretive about aspects of their self-image or important life events, they may suppress rather than express thoughts and emotions. For example, there is some evidence that women who have had an abortion and kept it hidden from others report more thought suppression and greater psychological distress [14]. Similarly, it may be that gay men with HIV who conceal their homosexual identity tend to engage in efforts to inhibit their thoughts and emotions about stressors related to their sexuality. Numerous studies have suggested that expressing rather than inhibiting thoughts and feelings related to stressors is associated with better physical health and immune system functioning (e.g., [15], [16], [17]). It may be that the expression of thoughts and feelings related to one's homosexuality can lead to improved HIV disease status.

Concealing homosexual identity may be associated with socially constrained relationships [18], [19]. Social constraints are features of social relationships that cause an individual to be unwilling to discuss personal stressors. Social constraints regarding talking about HIV-related stressors can be due to perceptions that others hold negative attitudes towards particular issues or groups (e.g., gay lifestyle) and negative or insensitive reactions to discussions of distressing topics [20]. Studies suggest that the association between stress and depression may be strongest in socially constrained relationships [20], [21], [22], [23]. This study sought to extend these findings by examining whether social constraints regarding talking about HIV would account for the hypothesized association between the concealment of homosexual identity and an index of HIV disease status (CD4 cell count).

Although a gay man may conceal his homosexuality from some persons in his life, this does not preclude the formation of close relationships. For example, a gay man may hold close relationships in the gay community but conceal his homosexual identity from his family. Substantial research supports the possibility that social support may influence the physical health of gay men with HIV [24], [25]. It may be that social support and concealment of homosexuality both contribute to physical health among gay men with HIV. This study examined the associations between concealment of homosexual identity, satisfaction with social support, social constraints regarding talking about HIV and CD4 cell count in gay men with HIV infection. CD4 cell counts serve as a useful indicator of HIV disease status because the HIV virus infects and destroys cells expressing the CD4 surface protein [26]. Lower CD4 cell counts indicate more advanced HIV disease.

It was predicted that greater concealment of homosexual identity would be related to increased social constraints and decreased CD4 cell count. Social constraints regarding talking about HIV, satisfaction with social support and depressive symptoms were tested as potential mediators of the hypothesized association between concealment of homosexual identity and CD4 cell count. As there is evidence that social support may moderate the effects of stressors on mental health among persons with HIV [27], the present study also sought to determine whether the association between concealment of homosexual identity and CD4 cell counts would vary according to level of satisfaction with social support.