- What is the impact of victimization on sexual risk behaviour, overall health and antiretroviral medication adherence among men who have sex with men?
- What are effective interventions to address victimization?
Key take-home messages
- Men who have sex with men who have been victimized report high rates of unprotected anal sex (1-3) and other HIV risk behaviours (3).
- Sexual minority adults who have experienced victimization report higher rates of self-harm, suicidal ideation and suicide attempts (4, 5). Among older HIV-positive men, victimization has also been linked to lower mental and physical health-related quality of life (6).
- While victimization does not seem to affect adherence to antiretroviral therapy, it has been shown to affect the decision to initiate treatment. Men with HIV who had been victimized and who had not yet initiated treatment had more concerns about treatment (7).
The issue and why it’s important
Sexual minority adults experience high degrees of victimization in general, as well of high degrees of victimization based on their sexual orientation (8-10). According to a U.S. Federal Bureau of Investigation analysis of 2008 hate crime statistics, 18% of all hate crimes were based on sexual orientation (9).
In a 2012 meta-analysis of 386 studies published between 1992 and 2009, 55% of lesbian, gay and bisexual (LGB) individuals had experienced some form of victimization (though not necessarily related to sexual orientation)(11).
LGB individuals are twice as likely as heterosexual individuals to be victims of sexual assault (9). LGB individuals who are victims of sexual assault are at higher risk of depression, anxiety, posttraumatic stress disorder (PTSD) and fear of future harm than their nonvictimized peers (9). Sexual assault myths (e.g. sexual assault “causes” homosexuality) may cause LGB individuals to associate the assault with their own attractions, and in this way aggravate the severity of PTSD symptoms (12).
Men who have sex with men may be at greatest risk of negative outcomes associated with victimization because — among sexual minority adults – gay men are the most likely to be victimized (9, 10). The high risk for gay men may be because: (a) men are more likely to be victims of violent crime in general, (b) most crimes are perpetrated by heterosexual men, who tend to hold more hostile attitudes toward gay men and (c) gay men may be more visible targets than other sexual minorities, since they are more likely to attend gay-oriented venues (7, 10).
What we found
Effects of victimization on sexual risk behaviour
A U.S. study of 545 men who have sex with men aged 18 to 29 looked at the relationship between bias-motivated bullying before, during and after high school and HIV risk behaviours. Bullying during high school predicted unprotected receptive anal intercourse and bullying after high school was associated with sexual intercourse while under the influence of drugs or alcohol. The researchers concluded that HIV risk behaviours are among the long-term behavioural health consequences of bias-motivated bullying of young men who have sex with men (1).
A study of 297 gay and bisexual men examined associations among stressful life events (including violence, threats and discrimination), avoidance coping and unprotected anal sex over the past six months. The study found no relationship between victimization and HIV status but it did find an association with unprotected anal sex. Men who reported unprotected anal sex with non-primary partners scored highest on victimization, and victimization doubled the odds of having unprotected anal sex regardless of partner type (2).
In a study of 71 gay, bisexual, two-spirit and heterosexual Indigenous men in New York City, researchers found that 45% of two-spirit Indigenous men reported physical or sexual abuse by someone other than a spouse, compared with 2 to 6% of heterosexual Indigenous men. Two-spirit Indigenous men also reported greater exposure than their heterosexual peers to lifetime HIV risk behaviours, including anal sex without a condom, sex with a stranger and condomless sex while drunk or high. However, there were no differences between the two-spirit and heterosexual men in terms of substance use, HIV knowledge or rates of HIV (3).
Effects of victimization on overall health
Suicidality and self-harm
In a study of 1,457 LGBT patients at an urban community health centre, those who had experienced LGBT-based victimization (i.e. verbal or physical attacks) reported higher odds of a lifetime substance use problem, suicidal ideation and suicide attempts (4).
When 1,126 sexual minority individuals were surveyed about traumatic life events (including childhood sexual and physical abuse, adult sexual and physical abuse, discrimination and verbal harassment), as well as suicide attempts and self-injury, 21% reported self-harm behaviours and 24% reported having attempted suicide. Participants who had experienced higher levels of trauma and discrimination had the highest rates of self-injury, and both factors significantly increased the odds of a suicide attempt (5).
A 2010 study of 34,653 U.S. adults – 2% of whom identified as lesbian, gay or bisexual — assessed the relationship between victimization (including physical and sexual trauma in childhood and/or adulthood) and substance use disorders in the past year. Researchers found that gay men were twice as likely as heterosexual men to meet the criteria for substance use disorder. However, most victimization experiences (with the exception of neglect in childhood) did not translate into a greater risk of substance use disorders. The authors concluded that more research is needed to understand the complex relationships among sexual orientation, victimization and substance use (13).
Quality of life
A 2013 study with 226 gay or bisexual men living with HIV who were 50 or older looked at risk and protective factors associated with physical and mental health related quality of life. To measure victimization, researchers asked how many times the men had been verbally or physically assaulted, sexually attacked or threatened due to perceived sexual orientation. They found that men with higher measures of victimization reported lower physical and mental health related quality of life, and that victimization could undermine quality of life among older gay and bisexual men living with HIV (6).
Effect of victimization on antiretroviral therapy
In a 2013 study that documented rates of trauma exposure (including physical or sexual assault) among 303 HIV-positive men who have sex with men, researchers also assessed antiretroviral medication adherence or uptake over the past 30 days. Results showed that almost two-thirds of participants reported at least one crime-related event, while one-third reported physical or sexual trauma. Among men on antiretroviral medication, there was no link between adherence and trauma. However, men who were not on antiretroviral medication had higher rates of trauma and had more concerns about initiating treatment (7).
In 2014, researchers tested a communicationbased intervention with 46 LGBQ individuals, aged 18 to 53, who were victimized based on their sexual orientation. Participants wrote about forgiving the perpetrator, the trauma itself or a neutral subject. Those who wrote about forgiveness or the assault reported lower stress levels after the exercise (14).
Researchers have also recommended the following interventions to reduce the impact of victimization among sexual minorities:
- Develop substance abuse and suicide prevention programs tailored specifically to the needs of LGBT individuals (4, 5).
- Screen for discrimination in addition to trauma when assessing the risk of suicidality and self-harm (5).
- Include questions about victimization when assessing the health of gay and bisexual men (2).
- Help gay and bisexual men develop proactive coping strategies (15).
What we did
We searched Medline and PsycInfo using a combination of text terms (gay or men who have sex or homosexual* or bisexual* or MSM or queer) and [text terms (victim* or hate or Physical* Abuse*) or MeSH terms (Crime Victims or Physical Abuse or Hate or Victimization or Bullying or Crime Victims)]. All searches were conducted on July 12, 2016 and results limited to English articles published from 2006 to present in high income countries. The search yielded 1,114 references, from which 15 studies were included. Sample sizes of primary studies ranged from 1,551 to 46.
Factors that may impact local applicability
One study included in this review was conducted in the U.K. All other studies were conducted in the U.S. The papers included in this search addressed discrimination, hate crimes, physical assault and sexual assault among sexual minority adults. We did not include papers specifically addressing childhood sexual abuse, intimate partner violence, or bullying directed at sexual minorities during childhood or adolescence. Childhood sexual abuse and intimate partner violence have been discussed in separate rapid responses; schoolage bullying would need to be assessed separately as well.
- Li MJ, Distefano A, Mouttapa M, Gill JK. Bias-motivated bullying and psychosocial problems: Implications for HIV risk behaviors among young men who have sex with men. AIDS Care. 2014;26(2):246-56.
- Martin JI, Alessi EJ. Stressful events, avoidance coping, and unprotected anal sex among gay and bisexual men. Am J Orthopsychiatry. 2010;80(3):293-301.
- Simoni JM, Walters KL, Balsam KF, Meyers SB. Victimization, substance use, and HIV risk behaviors among gay/ bisexual/two-spirit and heterosexual American Indian Men in New York City. Am J Public Health. 2006;96(12):2240-5.
- Mereish EH, O’Cleirigh C, Bradford JB. Interrelationships between LGBT-based victimization, suicide, and substance use problems in a diverse sample of sexual and gender minorities. Psychol Health Med. 2014;19(1):1-13.
- House AS, Van Horn E, Coppeans C, Stepleman LM. Interpersonal trauma and discriminatory events as predictors of suicidal and nonsuicidal self-injury in gay, lesbian, bisexual, and transgender persons. Traumatology. 2011;17(2):75- 85.
- Emlet CA, Fredriksen-Goldsen KI, Kim HJ. Risk and protective factors associated with health-related quality of life among older gay and bisexual men living with HIV disease. Gerontologist. 2013;53(6):963-72.
- Soto T, Komaie G, Neilands TB, Johnson MO. Exposure to crime and trauma among HIV-infected men who have sex with men: Associations with HIV stigma and treatment engagement. J Assoc Nurses AIDS Care. 2013;24(4):299-307.
- Mahoney B, Davies M, ScurlockEvans L. Victimization among female and male sexual minority status groups: Evidence from the British Crime Survey 2007-2010. J Homosex. 2014;61(10):1435-61.
- Cramer RJ, McNiel DE, Holley SR, Shumway M, Boccellari A. Mental health in violent crime victims: Does sexual orientation matter? Law Hum Behav. 2012;36(2):87-95.
- Herek GM. Hate crimes and stigma-related experiences among sexual minority adults in the United States: Prevalence estimates from a national probability sample. J Interpers Violence. 2009;24(1):54-74.
- Katz-Wise SL, Hyde JS. Victimization experiences of lesbian, gay, and bisexual individuals: A meta-analysis. J Sex Res. 2012;49(2-3):142-67.
- Gold SD, Marx BP, Lexington JM. Gay male sexual assault survivors: The relations among internalized homophobia, experiential avoidance, and psychological symptom severity. Behav Res Ther. 2007;45(3):549-62.
Rapid Response Service. Impact of victimization on the health of men who have sex with men. Toronto, ON: Ontario HIV Treatment Network; April 2017.
Emily White and Jason Globerman