Conceptualizations of intersectional stigma in HIV prevention research are limited and almost exclusively individualistic.1,2 Even when stigma is conceptualized as a social process, individuals are typically the focus, as is the case with internalized, anticipated, and enacted stigma. Because constructs are often inseparably tied to their level of measurement, studies of stigma as both individual and social phenomena reify stigma as a behavioral phenomenon and obfuscate the origin of stigma in oppressive systems and structures.
We advocate an expansion of intersectional stigma to include place as a level of measurement in HIV prevention research for sexual minority men (SMM) at marginalized intersectional positions, such as racial or ethnic minority status, socioeconomic position, and gender expression. Understanding the spatial manifestations of intersectional stigma in social–structural contexts has the potential to expand behavioral understandings of stigma and highlight new avenues for intervention to mitigate the perpetuation of stigma in and through social structures, systems, and institutions.3,4 We posit that place is important and understudied as an analytical unit in HIV prevention research on intersectional stigma. Our stance is informed by burgeoning public health literature on spatial stigma and place as a social determinant of health and our research on intersectional stigma and HIV prevention among SMM.3,5,6
Place is often conceptualized as a geographic area (e.g., neighborhoods) that both shapes and is constructed by the lived experiences, interactions, practices, and identities of those who inhabit and navigate in a space.7 Social–structural factors in health-restrictive environments (places) heighten the risk associated with HIV-related behaviors and obstruct engagement in HIV prevention and care. Places characterized by violence, poverty, unemployment, social disorder, and lower social capital and social cohesion are associated with heightened HIV vulnerability among SMM at marginalized intersectional positions.8 Although the study of place has had a resurgence in public health (e.g., place-based interventions to create health-promoting environments), its inclusion in the axes of intersectional stigma remains limited.
Spatial stigma posits that negative representations of marginalized communities can be deleterious to the health of their residents and widen health inequities. Spatial stigma may affect health by limiting access to employment and educational opportunities, restricting available coping resources, limiting access to and engagement with health care, and constricting identity formation and management.4 Multidisciplinary research has used the concept of spatial stigma to examine links between geographic boundaries, social institutions and practices, and policy and legal aspects of place and health inequities. Through this lens, intersectional stigma connects to and is reproduced by characteristics of a place—both as an internal process by which social–structural factors perpetuate stigma and from a top-down or external process involving laws, policies, and practices that reinforce oppressive systems.
Structural racism is one of the mechanisms that produces health-restrictive environments and links place to health inequities.8 Structural racism is often expressed in the form of stigmatizing laws and criminal justice–related factors and is compounded by unequal enforcement of laws, which has implications for intersectional stigma and HIV prevention among SMM.5 Laws that criminalize HIV exposure are also structurally racist insofar as they are more likely to be enforced against Black SMM than SMM of other races, do not reflect advances in HIV prevention and treatment, and stigmatize people with HIV. Structural racism is also linked to practices that promote the overpolicing of places frequented by Black and Latino SMM as well as the increased surveillance of individuals and institutions (e.g., medical and educational systems), which further restricts social and structural resources from these groups.9
Overpolicing operates in tandem with gentrification to displace individuals and disrupt community support systems that protect against acquiring HIV.9,10 Gentrification-related displacement and replacement also affects access to HIV prevention and care through NIMBY (not in my back yard)–based opposition to establishing and expanding place-based services for marginalized populations.10 The availability of affordable and safe housing is yet another example of intersectional stigma operating through place. Although the Fair Housing Act (1968; Pub L No. 90-284) protects against discrimination based on single axes of identity (e.g., race/ethnicity, disability), it has limited impacts on transforming institutional practices that reduce access to affordable and safe housing for SMM.
The level of inclusivity and safety of a place further limits the ability of SMM at marginalized intersectional positions to navigate or travel in a place without experiencing stigma.11 Moreover, not having to self-monitor to avoid stigma or consider whether one belongs or is safe in a place is a form of social privilege that becomes increasingly less common among SMM. Place-based stigma may also cause SMM to internalize negative stereotypes about a place. For example, from our work with Black and Latino SMM living in low-income urban neighborhoods, we observed that SMM internalized spatial stigma, which further constrained access to HIV prevention services in other settings.
Understanding manifestations of intersectional stigma in place has the potential to contextualize behavioral understandings of stigma and shift focus to the structures and systems of its origin; redirect intervention efforts from individuals to modifiable social–structural factors that systematically reinforce power imbalances and constrain opportunities; illuminate critical information on how spatial, institutional practices, and policies disproportionately heighten vulnerability to acquiring HIV; and provide guidance on the embodiment of spatial stigma to affect health even when an individual is removed from the devalued environment.6,12 We caution that the omission of place from intersectional stigma and HIV prevention research will hinder efforts to abolish spaces that systematically oppress and contribute to persistent HIV inequities. Omission of spaces and places as axes of intersectional stigma also perpetuates a hyperfocus on individual behaviors and prevention techniques, with insufficient attention to the social–structural forces that constrain the availability and effectiveness of HIV prevention.
To fully assess the role of intersectional stigma as a driver of health inequities among SMM, future research and interventions must attend to the social–structural processes in, and external to, places that drive these inequities. Inherent to intersectionality is the goal of deconstructing and uprooting systems of power and privilege.12 We believe the following objectives must be actualized to achieve this goal:
| 1. | Conceptualize space as a modifiable driver of intersectional stigma and partner with communities to develop multilevel solutions to increase access to and engagement with HIV prevention, including maintaining existing safe and trusted places for HIV prevention that use identity-affirming practices and prioritize holistic wellness, investigating the social and health-related impacts of affirming places in communities, and prioritizing community resilience and community-driven development as key programmatic elements in HIV prevention. | ||||
| 2. | Use place-based methodological approaches that provide information on the interlocking systems and structures that require intervention. Integrating qualitative methods with spatial analyses to capture how SMM define place and broader social–structural boundaries (e.g., community-led approaches like participatory photomapping) may better inform the use of administratively defined (e.g., census tracts and zip codes) place-based data in future intersectional stigma research. | ||||
| 3. | Invest in collaborative, place-based and systems-focused approaches to address HIV inequities. Interdisciplinary approaches are needed to conceptualize and intervene in the social–structural factors, policies, and institutions that drive place and spatial stigma, including geographers, transportation experts, policymakers, and public health practitioners to abolish stigmatizing spatial structures. | ||||
Attending to place and space as axes of intersectional stigma in HIV prevention research is critical to addressing the social–structural factors that drive HIV inequities and achieving the goals of Ending the HIV Epidemic.
ACKNOWLEDGMENTS
We thank the US National Institutes of Health Office of AIDS Research, National Institute of Mental Health, and the guest editors of the special issue on HIV-related intersectional stigma.
CONFLICTS OF INTEREST
The authors have no potential conflicts of interest to declare.
