Latino Men Who Have Sex with Men (LMSM), Psychotherapy, and HIV PreventionJonathan Mathias Lassiter I LGBTQ Rights I Research & Policy I May 8th, 2013
Health disparities are prevalent within many marginalized communities, and the Latino community is no exception. HIV/AIDS has had a devastating impact on this population, especially its men, as it represents the sixth leading cause of death among all Latino men.  Furthermore, Latino men who have sex with men (LMSM) are significantly more affected by this epidemic than other members of their ethnic community.  Many factors contribute to the widespread and disproportionate HIV infections among LMSM. These factors include behavioral risks, social oppression, negative familial and community relations, and psychological distress.  Several HIV prevention methods have been developed to decrease infection rates; however, until recently, the majority of these prevention methods have not been tailored to LMSM, therefore failing to address the complex identities and experiences of these men that possess elevated risks of HIV infection. New culturally sensitive methods of prevention enacted in multiple settings need to be implemented to combat HIV in LMSM.
Issues of mental health should be considered when planning prevention interventions with this population. Mental health professionals can facilitate prevention in this community by educating themselves about HIV prevention and sharing prevention knowledge with their clients. It is important that psychotherapists address HIV prevention with their clients in the therapeutic session and work to rectify psychological barriers that put LMSM at risk for HIV infection. This paper aims to present essential background information about LMSM and their views of the HIV epidemic; provide an epidemiological picture of HIV among LMSM; address risk factors pertinent to LMSM; describe the current and future directions of HIV prevention; and discuss the implications HIV has on the psychotherapeutic relationship for therapists working with LMSM.
Description of Latino Men Who Have Sex with Men
LMSM are a diverse group. There are several terms that describe these men. In "Gender Roles among Latino Gay and Bisexual Men," E.S. Morales identifies six types of LMSM: straight-identified, bisexual-identified, gay-identified, drag queens, poncas, and joseador. Straight-identified men possess heterosexual identities and exclusively act as the penetrator in sexual encounters with men. Bisexual-identified men engage in sexual behaviors with men and women. Gay-identified men are mostly attracted to and participate in sexual behaviors with men. Both bisexual and gay-identified men can be penetrators or receivers. Drag queens live as women, possess feminine values, and identify as women. Poncas are men that dress like men but act like women; joseadors are masculine men who have flexible sexual roles and sometimes exchange sex for money.
In "Family and Community Influences on the Social and Sexual Lives of Latino Gay Men," P.A. Guarnero provides definitions to slang terms for LMSM: "Afeminado" describes a man with effeminate characteristics; "joto" is faggot, and "parjaro" is bird; "Manita caida" means limp wrist, which is interpreted as a derogatory term for men who have sex with men; "Mariposa" means flighty queen; "marícon" is a commonly used term which means queer; and the term "vestida" is typically used to describe a transvestite.  These terms are commonly heard throughout the Latino community, and all have negative connotations and contribute to the stigma of LMSM.
LMSM view themselves in a variety of ways. Some identify with the terms above and some do not identify with any labels.  Many LMSM feel as if they have to compartmentalize their sexual and family lives, keeping one private (sexual) and allowing the other to be public (family).  The negative messages about same-sex attraction and behaviors they receive from their families and communities reinforce this belief. There is a lack of positive role models for LMSM to look to for healthy, adjusted examples of same-sex attracted Latino men.  Their understanding of the possibilities they have to create alternative identities and experiences outside of the prescribe norms and labels imposed on them is limited.
Some LMSM internalize the rigid and negative messages about same-sex attracted men. The predominate view that masculinity is a major commodity has its effects on the attitudes of LMSM including their sexual relationships. Even among LMSM, penetrating partners are viewed as powerful and more masculine and receiving partners as weak and more feminine.  HIV-phobia has also been internalized by some LMSM. In a poll conducted for the notable journal, Culture, Health & Sexuality, R.M. Diaz and G. Ayala found that 49% of the LMSM in their study blamed HIV-positive people for spreading HIV/AIDS.  These internalized beliefs are not only self-damaging but fuel intragroup prejudice against anally penetrated, HIV-positive, and other men deemed undesirable. Men targeted by this intragroup bias are subjected to further disenfranchisement and psychological oppression.
LMSM have a range of views about their relationship to HIV. Some believe it will not affect them or it can be prevented. Others think HIV infection is not under their control but God's  and some believe it is inevitable.  Some LMSM view condoms as barriers to intimacy and objects of external oppression ; unsafe sex is perceived as a liberating act. The research presents complex and conflicting information about LMSM's perception of HIV and their relationship to it. These issues must be considered when working with this community towards HIV prevention. It would be useful to use a combination of approaches that affirm these men's external locus of control but simultaneously promote self-efficacy.
HIV Rates Among Latino Men Who Have Sex With Men
In the Latino community, LMSM are hit the hardest by HIV infection.  In 2006, it was estimated they comprised 5,360 of all new HIV infections in the US.  LMSM also tend to be infected earlier than their white peers. Forty-three percent of HIV infections among LMSM are in LMSM age 13-29.  LMSM seem to be particularly vulnerable to this disease, even more so than other members of their community.
HIV Risk Factors for Latino Men Who Have Sex with Men
There are some unique risk factors that make LMSM more at risk for HIV infection. High-risk behaviors, social discrimination, traumatic familial and community interactions, and psychological factors all contribute to the vulnerability of LMSM to HIV infection. High-risk behaviors are any behaviors that significantly increase the likelihood of being infected by HIV. Unprotected receptive anal sex is one high-risk behavior that some LMSM engage in. Unprotected receptive anal sex is ten times more risky than unprotected receptive vaginal sex.  Drug and alcohol abuse can also lead to riskier sex practices that increase one's vulnerability to HIV.  These unhealthy behaviors are actions performed on the personal level that compromise LMSM's health.
Social oppression in the form of racism and poverty has an adverse affect on the health of LMSM.  Diaz and Ayala (2001) found that LMSM who experienced rude mistreatment and police harassment due to their race and/or ethnicity in their childhood and adulthood were significantly more likely to have recently engaged in unprotected anal sex with a non-monogamous partner. LMSM who reported having trouble meeting their basic financial needs also reported more recent unprotected anal sex. These are alarming findings considering these systemic problems in the Latino community are much harder to rectify and thus makes HIV prevention a more formidable task.
Family and community-based homophobia, rejection, and ridicule regarding same-sex attractions and behaviors undermine LMSM's sense of self and disconnect them from their support systems, thus rendering them more susceptible to HIV infection. Diaz and Ayala (2001) found LMSM who reported verbal and physical abuse as children from their families endorsed having more recent unprotected anal sex. Rejection from their communities and families also contribute to psychological distress that compounds their HIV risk. For example, researchers  reported effeminate LMSM who displayed more feminine behaviors tended to report higher levels of physical and verbal abuse; this abuse was associated with higher depressive symptoms and mental distress. LMSM who were taunted and rejected as children grew up to internalize shame and internal conflict, and experienced identity crises. All of these familial, community, and psychological experiences are part of the risk factors that LMSM encounter, which increase their susceptibility to HIV and thus endanger their lives.
HIV Prevention with Latino Men Who Have Sex with Men
There are many HIV prevention methods currently being used to decrease HIV infection in LMSM. These include routine HIV testing, partner services, prevention programs for people living with AIDS, prevention programs for groups at risk, antiretroviral therapy, substance abuse treatment, condom access and clean syringes programs, screening and treatment for other STIs.  Pre-exposure prophylaxis and early HIV treatment are new biomedical methods being used to combat HIV. 
LMSM are encouraged to regularly monitor their HIV status by obtaining a HIV test on a regular basis. The rationale is that if one is aware of his status he is able to seek treatment earlier and stop transmission. Prevention programs focused on people already infected by HIV have been shown to decrease transmission of the virus. Partner services discretely identifies and notifies partners of people that test positive for HIV in an attempt to encourage the partners to get tested and hopefully prevent transmission of the virus. Treating other sexually transmitted diseases has also been proven to decrease the risk of LMSM from contracting HIV and spreading it. These are just a few methods that are currently used to prevent the dispersion of HIV and have been empirically proven to be effective.
Most of the above methods of HIV prevention are enacted on an individual level and do not address the more systemic contributors of HIV infection. There is a need for more community focused prevention interventions that work to change the social climate that creates circumstances that put LMSM at risk for HIV infection. In a 2005 report submitted to AIDS Patient Care and STDs, Brooks, Etzel, Hinojos, Henry, and Perez  suggest sponsoring prevention activities and events in the community that address sexual diversity, sexual identity, and HIV. Such events for intervention can be community forums, health fairs, and establishing a gay/straight alliance with community members. These types of events will expose the larger Latino community to HIV related issues, HIV-positive people, and same-sex attracted people. Thereby, hopefully, decreasing negative stereotypes and biases held by the larger community. It is important to develop culturally appropriate prevention methods, include HIV prevention within a broader context of healthy living, and target more than just traditionally high-risk segments of the community. It is important to disperse HIV prevention interventions in myriad settings including churches, beauty salons, schools, jails, barbershops, non-gay settings, and non-HIV community events.  This type of broad based intervention will ensure that HIV prevention is culturally sensitive, appropriate, and relevant. It is also likely to facilitate the erosion of stigma and homophobia that is associated with elevated risky sex behaviors in LMSM. Community based interventions have the potential to affect many different people in many different settings in a way that is salient to them.
Powerful venues for HIV prevention at the community level are Ballroom houses. Ballroom houses developed out of Ballroom culture, which began during the Harlem Renaissance in the 1920s in New York City.  Since that time, they have expanded to other major cities. Houses are largely comprised of Latino/a and African American LGBTQ individuals. They are structured like a literal household with housemothers, fathers, and "children." Housemothers and fathers are responsible for providing nurturance and guidance to their children. Children are the house members that are under the care and tutelage of the houses' mothers and fathers. The Ballroom community provides a sociological family for youths whose biological families have yet to fully accept their variant sexual orientations and expressions.
Within the Ballroom houses, HIV prevention is approached with several techniques. House mothers often teach their children about low risk sexual behaviors and prophylactic measures; house fathers focus on structural factors that increase their children's vulnerability to HIV and other sexually transmitted infections (e.g. socioeconomic status and personal development).  Some houses are "prevention houses" which receive funding from and work in conjunction with community-based organizations  to promote HIV prevention. Some house hosts HIV prevention themed balls.  HIV prevention interventions enacted by Ballroom houses are effective because they employ cultural insiders (older house members) to educate the younger members about safer sexual practices. The theme within the community is "for us, by us." This peer intervention decreases stigma and makes prevention messages more salient.
New biomedical HIV prevention techniques are being developed and tested. Pre-exposure prophylaxes are oral medications HIV-negative people can take to prevent HIV infection. Early HIV treatment with antiretroviral medication in HIV-positive people is being tested to determine whether this line of therapy will prevent new HIV infections.  These new interventions offer hope and promise effective prevention at the molecular level.
HIV Prevention in the Therapeutic Relationship
Culturally competent psychotherapists should be sure to educate themselves about HIV/AIDS and how this disease can impact their clients' lives. This is especially the case when working with marginalized populations such as communities of color or clients whom engage in same-sex behaviors. When working with a population, like LMSM, who belong to both marginalized groups, it is important to be sensitive to their concerns and requests given their high vulnerability to several forms of injustice, one of them being elevated HIV risk.
It is important to remember concepts such as simpatia and personalismo when counseling LMSM. As evidenced by research described above, some of these men have had very traumatic and negative experiences in their lives. It is important to establish trust and an affirming environment where the clients can discuss their concerns freely. In addition to these things, Carballo-Dieguez (1998) recommends that when working with LMSM, therapists are sure to communicate in a language that the client is comfortable with and understand.  The therapist should also consider the client's immigration status, social structures within the clients family, religious/spiritual issues, and socioeconomic status.
Psychological barriers around HIV prevention might arise in therapy. These include fatalism around contracting HIV, feelings of worthlessness, depression, and self-esteem issues. Some clients might be paranoid about being infected with HIV and experience severe anxiety. LMSM might also present their interpersonal conflicts with their family and community members. It is important that the therapist be able to talk openly about these things and address these issues is a competent manner.
HIV is a significant threat to the well being of LMSM. LMSM are a diverse group of men with diverse identities and experiences. However, it is important to remember the current research often overlooks LMSM's heterogeneity and lumps all groups of LMSM together; the differences of HIV risk and prevention between LMSM from disparate countries of origin are not known. Yet despite their differences, all LMSM face several risk factors that affect their lives on individual, familial, community, and societal levels. These men approach HIV prevention in many different ways; some resign to it and some rebel. Therapist must be capable of addressing HIV-related issues and HIV prevention methods when working with this population. Mental health professionals can prove to be a salubrious resource in the lives of these men whose livelihoods are threatened by mental illness, physical maladies, and oppression.
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