Hindering HIV Care: Concealing Sexual Identity May Have Impeded Access for Some Men, Study Suggests

Openly gay, bisexual and other sexual minority men were more likely than those who conceal their sexual orientation to seek care for mpox last year during a global outbreak of the disease that disproportionately affected their community, researchers from Cornell and the University of Toronto found.

But it wasn’t necessarily concern over being “outed” that kept some sexual minority men from seeking care for the disease, formerly known as monkeypox. According to the researchers, it was an information gap, partially attributable to separation from community due to identity concealment.

“The resource knowledge and community-connected piece seems to be implicated in that process, not outing concerns, and that was a surprise to me,” said Joel Le Forestier, a postdoctoral researcher in the Department of Communication, in the College of Agriculture and Life Sciences.

Le Forestier is first author of “Identity Concealment May Discourage Health-Seeking Behaviors: Evidence from Sexual Minority Men During the 2022 Global Mpox Outbreak,” which published Jan. 12 in Psychological Science.

Co-authors were professors Elizabeth Page-Gould and Alison Chasteen, Le Forestier’s doctoral advisers at Toronto.

For their study, Le Forestier and the team recruited hundreds of sexual minority men from Australia, Canada, the U.K. and the U.S. at two points in the mpox outbreak: during its peak, in August of 2022 (864 participants) and as the outbreak waned, approximately two months later (685).

Participants filled out an online questionnaire testing the researchers’ hypothesis that sexual orientation concealment would be associated with reduced mpox-related health behavior. Agree-or-disagree statements for participants in the first time period included: “I alter my appearance, mannerisms, or activities in an attempt to ‘pass’ as straight” and “I plan to receive a vaccine to protect against monkeypox soon, as soon as one becomes available where I live, or as soon as I become eligible to receive one where I live.”

For the second time period, statements included: “I have received a vaccine to protect against monkeypox”; “Between May 2022 and now, I have been tested for monkeypox”; and “Between May 2022 and now, I have had monkeypox.”

Most of their findings, but not all, were as expected, Le Forestier said.

“People who conceal their sexual orientations reported what we thought they would: concerns that if they sought out mpox resources, that would ‘out’ them and that would be bad,” he said. “But we also predicted that having those concerns would be related to a lower likelihood of them accessing those resources – they’d be concerned about that and they wouldn’t go to the clinic – but that’s not what we found.”

Some participants’ responses indicated that the dangers of mpox trumped concerns over identity revelations. “What that suggests,” Le Forestier said, “is that people who are in the closet and afraid of being outed are nonetheless saying, ‘This is important enough to me that I’m going to do it anyway.’”

Le Forestier said a friend’s perspective on the awareness factor sparked the research. During his doctoral work, Le Forestier was living in Toronto next to a facility that had been repurposed into a COVID-19 vaccination clinic. Then during the mpox outbreak, the clinic began offering mpox vaccinations, as well. There were usually two lines, stretching out onto the sidewalk, of people waiting for their shots.

Le Forestier noticed that the mpox line overwhelmingly featured men who presented as sexual minority. “I’m thinking, if you’re in this long line of identifiably sexual minority men, and your friend walks by, you’ve just been outed to your friend.”

But then in talking to his friend, Le Forestier’s perspective shifted. “He said, ‘It might not just be that they would be too afraid to get in that line because they worry about being outed; it might be that they don’t know that line even exists,’” Le Forestier said. “The only places that my friend had seen ads for mpox vaccine clinics were in gay bars, and in the local gay village community center. So if you’re not engaging in the community in these sort of public ways, then these resources just aren’t getting to you.”

So how does the public health community make sure people from marginalized groups get the kind of health-related information they need? It’s the “million-dollar question,” Le Forestier said. Questions like that are what motivated Le Forestier to come to Cornell for his postdoctoral work; health communication researchers here study those very questions.

“[Public health departments] can’t market every possible health resource to every possible person; and the public just wouldn’t be able to absorb all that information,” he said. “So how do you continue to message efficiently, while also making sure that these key people aren’t getting missed? While there’s good work and good research being done on that topic, I think our findings speak to the fact that we have not cracked the code yet.”

“I think the lesson here is that there are things to be gained by enmeshing yourself in your community, if you can,” he said. “Affiliating with that community and becoming a part of that community can confer some real benefits to you. Knowing about public health resources is not the only thing but it’s definitely one of them.”

This work was supported in part by a Social Sciences and Humanities Research Council of Canada Doctoral Fellowship.