The findings from this study suggest that the internalization of oppressive social conditions can influence the healthcare experiences of BMSM. Despite recent debate over its role as an independent scientific health predictor, race and experiences of racism cannot be ignored when discussing sexuality in the medical setting. Experiences with societal and institutional racism, and the subsequent expectation of medical racism, impacts how open BMSM are with providers about their sexuality due to fear of additional discrimination. Additionally, feelings of detachment from white society (including “gay” culture) as black men and from the black community for being homosexual may foster a sense of psychological displacement that influences their expectations of, and interactions with, medical personnel. This internalized displacement makes healthcare access difficult because BMSM do not feel comfortable within medical facilities themselves, not simply because of geographical, transportation, financial or insurance barriers.

Expectations of medical providers were based on a complex mix of past experiences, community opinions, and idealized notions. Providers were seen as educated potential friends or extended family members, or relegated to mere personnel in an impersonal healthcare system, like a mechanic in an auto shop. While the former expectation is consistent with research findings that African Americans emphasize issues of support and comfort in doctor-patient relationships, the latter expectation emphasizes potential reactions to personal displacement among BMSM because of their dual marginal status as both black and homosexual. If interactions with medical personnel were simply a mirror of prejudicial social experiences, behaviors, such as not utilizing services, overemphasizing ER facilities, or not telling the truth about risky sexual practices, could be seen as reactions to unmet or confirmed expectations. While these dynamics do not directly influence the sexual behaviors of BMSM, they limit the extent to which medical facilities can effectively address HIV in this population, HIV testing practices, and also may help explain why 93% of HIV-infected BMSM in select cities do not know their HIV status. online canadian pharmacy

Barriers to healthcare utilization for BMSM in this study included external problems of insurance; questionable confidentiality; multiple personnel; a rushed impersonal atmosphere and noncommu-nicative staff; as well as internalized barriers of medical distrust and fear of both sickness and discrimination based on being a member of a risk group for HIV Increasing HIV education outreach efforts, establishing more local clinics, and providing universal health insurance will not sufficiently address these barriers. Improving the healthcare utilization and adherence patterns of BMSM must occur in three areas: 1) enhancing existing cultural competency curricula; 2) recognizing the important role of minority providers; and 3) increasing research efforts on BMSM.

Current cultural competency curricula in medical education programs must be expanded to include all medical personnel, as brief interactions with staff other than medical providers can impact the overall healthcare experience of the patient. Additionally, these programs should equally stress training foreign health professionals about considering the diverse racial and cultural backgrounds of American patients, just as we train American doctors to consider the cultural backgrounds of our varied foreign-born patients. While participants’ responses on negative experiences with culturally “foreign” doctors may be viewed as isolated events, they nonetheless emphasize that the fact that medical cultural competency is a two-way street and can have a significant impact on healthcare utilization and communication practices. prescription drugs online pharmacy

Improved medical training in sexuality and sexual history-taking is needed, which acknowledges the varied cultural expressions of sexuality among different populations. Teaching healthcare-professional students to screen for HIV risk by targeting risk groups like “BMSM, straight, or gay, in essence, tells a patient they are at risk for HIV because of who they are and may make them fearful to engage medical facilities for fear of diagnosis just based on their personal demographic profile. This, may, in turn, perpetuate fear-based miscommunication of risky sexual behaviors, avoidance of testing services, and access to prevention materials among the very population it is designed to target. Instead, providers-in-training should be instructed to screen patients according to HIV risk behaviors (unprotected anal sex, vaginal sex, oral sex), which will avoid stigmatizing individuals based on risk groups, while enhancing HIV screening of those who are behaviorally putting themselves at risk despite not belonging to traditional risk groups.

While discussing potential solutions to the external barriers to healthcare may be beyond the scope of this article, addressing the problem of internalized barriers to care among BMSM must start with acknowledging the need for more minority providers in minority communities. Finding a cultural connection with a provider is an important component of the doctor-patient relationship, and the need for black and/or homosexual patients to see physicians with whom they feel a cultural connection was emphasized by findings in this study. Continued active recruitment of minority applicants to medical schools and encouraging future service in minority communities among current minority medical students and residents can make a huge difference in our patients’ healthcare experiences. The larger issues of racial and sexual prejudice that BMSM face outside and within the black community are key here: If BMSM are feeling displaced from the mainstream white, gay white, and general black communities, black medical providers can play a pivotal role in not only combating this sense of displacement during the outpatient encounter but also by individually empowering BMSM to become more invested in their own healthcare, particularly with regards to HIV Additionally, black medical providers can become more involved in research, policy, and collaborative efforts with black community and faith-based organizations that can begin to discuss and address the roots of the social isolation felt by many BMSM in their everyday lives.
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Finally, more research is needed to examine the factors influencing health outcomes in this population. Specifically, minority researchers who are familiar with the cultural issues impacting the black community and willing to ask the difficult questions and explore the complex social dynamics that shape the healthcare experiences for diverse sexual people of African descent are needed. Despite the alarming HIV prevalence among BMSM, few studies have explored the complex role that medical culture plays in this epidemic. Additional qualitative studies are warranted based on this study’s findings, and pursuing quantitative research with representative sampling can further assess the relationship between personal variables (age, geography, HIV status, sexual identity, provider characteristics) and the healthcare utilization, communication and adherence practices of BMSM.

There are several limitations to this study. We described the nature of the healthcare experiences and utilization practices of BMSM but cannot determine causal relationships that influence healthcare utilization, adherence, and HIV testing. Moreover, reliance on a small convenience sample and lack of an experimental design limits the internal and external validity of the data. Specifically, all participants were recruited through black CBOs who did HIV prevention work, resulting in an over-sampling of BMSM who were comfortable enough with their homosexuality to access these services and participate in this study. Likewise, geographical and individual (HIV status, age, SES) sub-analyses were difficult to perform, as subject diversity within the focus groups made it difficult to make generalized group conclusions based on individual comments that could not be traced back to certain demographic characteristics. Specifically, we could not adequately explore differences between HIV-positive and HIV-negative BMSM in these groups, as not all men openly discussed their HIV status within the group, and the focus groups had individuals of mixed serostatus. One-on-one interviews or recruitment of seroconcordant focus groups would be more suitable methodologies for efficient exploration of these differences. Additionally, the presence of a medical doctor as one of the facilitators is also a potential bias.
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Ultimately, qualitative research discusses the meaning behind relevant themes emerging from research questions. We did not include quantitative assessments of how many participants expressed a certain theme—as a theme mentioned—even once, is a relevant finding. The themes included in this manuscript, however, reflect the most common that emerged during our discussions across all the geographical regions and are evidenced by the diversity in sources of quotes in the Results section. Despite these limitations, our findings effectively describe the nature of healthcare experiences for BMSM and are useful for future pilot interventions and the identification of additional barriers to healthcare for subsequent quantitative studies.

The results from this qualitative study have important implications for public health and medical responses to the HIV epidemic among BMSM. While BMSM may lack knowledge of their serostatus and underestimate their HIV risk, institutional and internalized barriers experienced by these men may negatively impact healthcare utilization behaviors, communication, and adherence that could influence this ignorance and underestimation of risk. As underutilization of outpatient HIV services leads to poorer health outcomes among African Americans in general, it is apparent that specific HIV prevention and treatment initiatives for BMSM must focus on improving the quality of outpatient medical experiences that are currently available for these men. suhagra