Intersectional Discrimination and Sexual Health among Young Black Sexual Minoritized People Assigned Male at Birth in the United States

Abstract

Sexual health inequities remain pervasive across the United States (US), with Black sexual minoritized people assigned male at birth (AMAB) experiencing a disproportionate share of incident HIV cases during young adulthood. With HIV-related inequities unexplained by individual risk behaviors, such as condomless anal sex, and the ongoing, intersecting sources of oppression experienced by this population, it is critical to examine structural drivers that inhibit sexual health, such as discrimination. Drawing from intersectionality and the Modified Social Ecological Model, the purpose of this dissertation is to understand the varying manifestations and impact of intersectional discrimination on sexual health, with a focus on HIV prevention engagement, for young Black sexual minoritized people AMAB in the US. A community-engaged, explanatory sequential mixed methods study was first informed by a systematic review focused on the impacts of racism and homophobia on sexual health and HIV prevention among young cisgender Black gay, bisexual, and other men who have sex with men (YBMSM) in the US (Chapter 2). Findings revealed a need to focus on intersectional discrimination, reaching beyond oppression related to race and sexual identity, and the impacts on sexual health and well-being for YBMSM across individual, interpersonal, institutional, and systemic levels. Quantitative analysis of data from a nationwide randomized controlled trial subsequently examined the heterogeneity of the trajectories of discrimination experiences among YBMSM (n = 266) using latent class growth analysis and evaluated the impact of emerged discrimination trajectory subgroups on HIV prevention, specific PrEP use over time, using linear mixed-effects modeling (Chapter 3). This quantitative analysis informed the collection of qualitative data through semi-structured interviews with a subsample (n = 24) of Chapter 3 participants, purposively sampled based on discrimination trajectory subgroups to explore lived experiences pertaining to everyday discrimination and sexual health across and within different discrimination trajectories (Chapter 4). Mixed methods integration across Chapters 3 and 4 uncovered how varying levels of discrimination and sexual health care engagement emerged in the everyday lives of Black sexual minoritized people AMAB.Discrimination and sexual health vary across ecological levels within a population over time, emphasizing the importance of young adulthood for Black sexual minoritized people AMAB to develop promotive sexual behaviors and patterns of care engagement. Barriers, such as low provider knowledge of PrEP and limited provider-patient discussions, pose a great risk to the perpetuation of HIV inequities, particularly for this population. Seroconversions of participants in the span of data collected across chapters underscore the urgency of which multilevel interventions are needed, specifically those that drive institutional and systemic reform, such as mandated provider training and provider advocacy for policies to minimize resource-related barriers to care. Amidst historical and ongoing policies that threaten the health and well-being of all Americans, with those at multiple marginalized intersection left to feel the greatest impact, it is more crucial than ever for providers and researchers to recognize and mitigate these structural drivers of sexual health inequity in the US.