In 2021, the Centers for Disease Control and Prevention (CDC) declared racism as a public health threat and a fundamental driver of racial/ethnic health inequities in the United States (CDC, n.d.; Media Statement from CDC Director Rochelle P. Walensky, MD, MPH, on Racism and Health, 2021; Orr et al., 2021). While racism in public health is not a new concept, it has recently gained traction after events that shed light on existing racial/ethnic inequalities during the COVID-19 pandemic (CDC, n.d.; Media Statement from CDC Director Rochelle P. Walensky, MD, MPH, on Racism and Health, 2021). Racism, defined as interpersonal discrimination against a group based on the color of their skin, race, or ethnicity or structural barriers that impede the equity of racial/ethnic groups (affecting where they live, work, study, worship, gather in community, or receive health care), is a driving force of social determinants of health and adversely affects health (CDC, n.d.; Racism and Health., 2021; Williams et al., 2019). Exposure to racism negatively affects the mental and physical health of populations (CDC, n.d.; Media Statement from CDC Director Rochelle P. Walensky, MD, MPH, on Racism and Health, 2021; CDC, n.d.; Racism and Health., 2021; Williams et al., 2019) and may have life-long and intergenerational consequences on the well-being of marginalized groups (CDC, n.d.; Media Statement from CDC Director Rochelle P. Walensky, MD, MPH, on Racism and Health, 2021; Williams et al., 2019). For these reasons, there is a growing call for racism to be addressed to dismantle existing barriers to health equity in the United States.
Racism is a multidimensional construct and may present in a myriad of forms and operates through multiple pathways to influence population health (Condon et al., 2021; Williams & Chung, 2004; Williams et al., 2019). For instance, institutional racism may present as structural barriers that limit access to goods and services or create social marginalization of environments that result in racial/ethnic health inequalities, whereas interpersonal racism or racial discrimination may present as harmful biases, assumptions, or beliefs reinforcing bigotry and hostility (Condon et al., 2021), triggering negative physiological responses or health behaviors (Williams et al., 2019). Evidence suggests that exposure to interpersonal racial discrimination may also act as a psychosocial stressor disrupting normal biological responses or processes through a stress-mediated pathway (Williams & Chung, 2004; Wright et al., 2020). Similarly, exposure to indirect or vicarious racism (e.g., hearing or observing acts of racism or discrimination; Martz et al., 2019) is associated with elevated levels of inflammation (Condon et al., 2021) and poor socioemotional and mental health outcomes among the children of caregivers who are exposed to racism (Heard-Garris et al., 2018). Although there exist a large body of literature on racism and its manifestations in society, more research is needed to identify the ways in which racism drives health inequalities and poor health outcomes among marginalized populations.
Marginalized groups, such as young men who have sex with men (YMSM), are at increased risk of racial discrimination (Kipke et al., 2020). Previous research found that over 85% of YMSM of color reported experiences of racism in their life (Kipke et al., 2020), which has been associated with greater distrust in the health care system (Hsueh et al., 2021), lower uptake of HIV pre-exposure prophylaxis (PrEP; Quinn et al., 2019), substance use (Wong et al., 2010), and unprotected sex in this population (Huebner et al., 2014). Such adverse behaviors have long-term health implications that may increase risk of poor health outcomes or HIV infection and exacerbate racial health disparities among YMSM (Kipke et al., 2020). According to the CDC in 2015-2019, YMSM (ages 15-24 years) had higher rates of sexually transmitted infection and newly diagnosed HIV compared with other groups ("CDC HIV in the United States. At a Glance"; Herbst et al., 2014). Given the health disparities among YMSM (Beyrer et al., 2013) and the increased awareness that young sexual minorities experience discrimination (Cook et al., 2017), and limited data examining this relationship, more research is needed to understand racial discrimination and its impacts on HIV-related outcomes. Previous work identified that the link between racial discrimination and health was mediated by stress (Paradies, 2006), but further research is needed to investigate the link between racial discrimination and stress among YMSM. Moreover, the nuances of racial discriminatory events experienced by YMSM is unknown. To illuminate these issues, identification of racial discriminatory events and empirical verification of their association with stress in YMSM are essential to better understand the ways in which racism affects health in this population (Williams & Chung, 2004). In addition, most of the studies on racism and health among YMSM are among Black and Hispanic youth, and more data are needed on other YMSM of color such as Native Americans/Alaskan Natives and Asian Pacific Islanders. Such information may be useful in guiding the development of future interventions targeting early life exposure to racial discrimination (Brody et al., 2014; Williams et al., 2019) and ultimately fostering health equity in YMSM.
To expand the literature on racial discrimination and stress among YMSM, our study had two objectives. First, to measure various experiences with racism by estimating the prevalence of vicarious racism, general interpersonal racial discrimination, and nine specific racial discriminatory events experienced by YMSM. In the literature, data on racial discriminatory events are often aggregated into broad categories, limiting our ability to fully understand when and where discrimination occurs and how to adequately respond with action or policies (Orr et al., 2021), but our study measured distinct experiences of racism. Second, we assessed the association between racial discrimination and perceived stress in a diverse sample of YMSM and stratified by racial and ethnic groups. Elucidating the link between racial discrimination and stress will increase the body of evidence by demonstrating how racism, as a potential psychosocial stressor, can adversely affect health (CDC, n.d.; Media Statement from CDC Director Rochelle P. Walensky, MD, MPH, on Racism and Health, 2021). An improved understanding of the contributors to high levels of stress in YMSM will allow future public health work to implement interventions that may mitigate the deleterious effects of racism on health (Williams et al., 2019). Furthermore, our stratified analysis by racial and ethnic groups measured varying associations between racial discrimination and stress among different group members, whereas previous studies on this topic limited their statistical adjustments to race or ethnicity, as opposed to stratified analyses (Paradies, 2006), which does not examine the data in small units and may overlook strata-specific associations (Kahlert et al., 2017). However, our study included stratified analyses by race and ethnicity. Finally, given that health disparities among YMSM are often overlooked compared with other adolescents, our research focused exclusively on YMSM aged 13-18 years. Our data also comprise a diverse sample of YMSM of color, including racial groups not commonly studied in the racial discrimination literature (i.e., American Indian or Alaskan Native, Asian, Native Hawaiian or Pacific Islander, Multiracial). We hypothesize that there is a positive linear relationship between racial discrimination and perceived stress, with the strongest relationship occurring among YMSM of color given their increased risk of exposure to racial discrimination. By examining racial discrimination and stress in this population, we hope to describe the complex role that racism plays as a determinant of health among YMSM in efforts to effectively address it (CDC, n.d.; Media Statement from CDC Director Rochelle P. Walensky, MD, MPH, on Racism and Health, 2021; Paradies, 2006).
Methods
Study Population
A secondary analysis was conducted using baseline data from a randomized controlled trial (RCT) conducted from 2018-2020 to test the efficacy of the MyPEEPS Mobile intervention on HIV risk behaviors for YMSM. Eligible participants were YMSM aged 13-18 years, assigned male at birth, self-identified as male or nonbinary, sexually attracted to men, self-reported living without HIV infection, and resident of the United States or territories. Recruitment was completed at study sites in Birmingham, Alabama; New York City, New York; Seattle, Washington; and Chicago, Illinois. While our initial plan was to recruit youth locally for in-person visits, reaching local enrollment targets proved challenging, and, therefore, enrollment procedures were expanded nationally to online platforms. While some recruitment took place at local community-based organizations, most participants were recruited through free and paid online national advertisements promoted on Reddit, Facebook, SnapChat, and Instagram. Study sites were responsible for enrolling participants within their regional area. Once enrolled, study participants completed self-administered surveys online. More details on the RCT are published elsewhere (Kuhns et al., 2020). There were 761 participants enrolled in the RCT at baseline. To examine the overall effect of the MyPEEPS Mobile intervention accounting for 20% attrition, we estimated 97% power to detect a risk ratio (RR) of 0.73 with analytic sample size of 700 participants in the RCT. The RCT was also powered to conduct stratified analysis based on race and ethnicity and determined we would have 92% power to detect a relative risk of 0.37 in each racial/ethnic subgroup (e.g., Black, Non-Hispanic; Asian, Native Hawaiian/Pacific Islander). However, the current analysis used data from all study participants who fully responded to questions regarding demographics, racial discrimination, and perceived stress score (N = 542). Written or electronic informed assent (younger than 18 years) and consent (18-year-olds) was obtained for participants with parental consent waived for minors. All study activities of the MyPEEPS RCT (NCT03167606) were approved by the Columbia University Institutional Review Board (IRB-AAAR1305). However, our secondary data analysis did not require Institutional Review Board approval and was exempt.
Measures
Our exposure variables of interest were interpersonal racial discrimination (general and specific events) and vicarious racism. At baseline, participants responded to questions regarding their experience with general interpersonal racial discrimination, specific events of interpersonal racial discrimination, and vicarious racism (experiences of racism witnessed by participants who were directed at their parents or other family members). General interpersonal racial discrimination was self-reported and assessed by, "Have you ever felt discriminated against because of your color, language, accent, or because of your culture or country of origin?" Participants who endorsed experiences of interpersonal racism were asked to respond to nine items focused on the types of racial discriminatory events that occurred in their lifetime. These nine items were previously developed and validated among a diverse sample of children and youth (aged 8-18 years) from various racial/ethnic backgrounds using the instrument Perceptions of Racism in Children and Youth (Cronbach's alpha of 0.78; Pachter et al., 2010). This included questions such as how often in their life participants were victims of name calling, insulting remarks, rude behavior, unfair treatment by police, being watched or followed closely by store clerks, false accusations at school, unfair treatment by a teacher, being feared by others, and being assumed unintelligent because of their color, language or accent, or culture/country of origin. The YMSM participants were asked about their experience with vicarious racism. Vicarious racism was reported as "how often (0 = never, 1 = once, 2 = twice, 3 = three times or more) have you witnessed your parents or other family members being treated unfairly or badly because of the color of their skin, language, accent, or because they come from a different country or culture." For the analysis, all items that measured the frequency of events were dichotomized as never or ever experienced (Table, Supplemental Digital Content 1, http://links.lww.com/JNC/A33).
The outcome variable of interest was perceived stress score. Participants' level of stress was measured at baseline using the well-established shortened version of the Perceived Stress Scale (Cronbach [alpha] = 0.84; Taylor, 2015). This scale consisted of 10 items that asked how often in the last month participants experienced symptoms of stress (0 = never to 4 = very often), including feeling upset, nervous or stressed, unable to cope, unable to control important things, angry, or having difficulties piling up (Cohen et al., 1983). Positive responses, such as feeling in control of irritation, on top of things, that things are going their way, or confident, were reverse coded. For the analysis, we summed the responses across all 10 items for each participant, where higher scores indicated higher stress levels (mean = 20.2; median = 20.0; SD = 6.6; range = 34). The Kolmogorov-Smirnov test and Shapiro-Wilk tests (p-values >.05) were used to validate the normal distribution of the perceived stress summed score; no outliers were detected (kurtosis = -0.46; skewness = -0.02), and the mean score was used as our unit of analysis.
Covariates
Covariates were selected a priori using directed acyclic graph, informed by literature review (Tennant et al., 2020). Covariates included age, education level, mother's education level, father's education level, food insecurity, race, and ethnicity. Participant's age was treated as a continuous variable in the analysis. All other variables were categorized as follows: participant's education level (less than high school or some high school or more), mother's and father's education level (advanced graduate degree, graduated 4-year college, some college/technical training, high school graduate/General Educational Development (GED), or did not finish high school), food insecurity in the past 12 months (have to skip or cut the size of meals: yes or no), race (American Indian/Alaskan Native, Asian American, Black/African American, Native Hawaiian/Asian Pacific Islander, White/Caucasian, Multiracial, or unknown/not reported), and ethnicity (Hispanic or non-Hispanic).
Statistical Analysis
Univariate analyses were conducted to estimate the prevalence of general interpersonal racial discrimination and nine specific interpersonal racial discriminatory events experienced by YMSM and general racial discrimination experienced by parent or other family members (vicarious racism). Overall frequency and percentage of participant's characteristics were also calculated by interpersonal racial discrimination and vicarious racism. Perceived stress score and the residual term were normally distributed (Bender, 2009). Therefore, we used linear regression models to assess the association between racial discrimination (separate models conducted for interpersonal racial discrimination, vicarious racism, and nine type of racial discriminatory events) and perceived stress score. Multivariable linear models were adjusted a priori for all covariates. For the multivariable regression models, there were 128 participants with missing data on covariates dropped from the models with interpersonal racial discrimination and vicarious racism, and 73 participants dropped from the models with the nine specific interpersonal racial discriminatory events. Stratification by racial/ethnicity groups was also conducted for bivariate and multivariable models. Owing to sample size and power concerns, we did not examine the nine items focused on the specific types of racial discriminatory events in the stratification analysis. Regression coefficients ([beta]), 95% confidence intervals (CIs), and p-values were calculated. All analyses were performed using SAS 9.4 software (SAS Institute, Cary, NC).
Results
Most participants in the study were aged 16 years or older (69%), had some high school education or more (89%), did not experience food insecurity in the past 12 months (87%), identified as a racial minority (68%), and were non-Hispanic (54%). Approximately 60% of mothers and 50% of fathers received some college or more. Mother's education level was associated with vicarious racism (p-value: .0149), whereas education level of participant (p-value: .0246), food insecurity (p-value: .0202), and race (p-value: .0009) were associated with interpersonal racial discrimination. Hispanics reported vicarious racism (p-value: .0002) and interpersonal racial discrimination (p-value: .0140) more often than other non-Hispanic ethnic groups. Age of participant, ethnicity, and father's education level were associated with both vicarious racism and interpersonal racial discrimination, Table 1.
Over 50% of participants (N = 542) experienced vicarious racism (56%) or interpersonal racial discrimination (53%) in their lifetime. Of the total sample, 288 participants endorsed experiences of interpersonal racism and were asked to respond to nine items focused on the types of racial discriminatory events that occurred in their lifetime. Name calling, insulting remarks, and being treated rudely because of their race, ethnicity, or cultural background were reported by approximately 90% of participants, respectively. The event reported less frequently was unfair treatment by a policeman (31%), Table 2.
The mean perceived stress score was 20.4 and 20.5 for those who experienced interpersonal racial discrimination and vicarious racism, respectively, compared with 19.9 and 19.8 who did not experience these events (Figure, Supplemental Digital Content 2, http://links.lww.com/JNC/A34). The unadjusted model found no significant association between vicarious racism and perceived stress score nor general interpersonal racial discrimination and perceived stress score among YMSM. However, the multivariable models (N = 414) found that perceived stress score was associated with vicarious racism ([beta] = 1.77, 95% CI: 0.46-3.08, p-value: .0082) and interpersonal racial discrimination ([beta] = 1.43, 95% CI: 0.08-2.78, p-value: .0382), after adjusting for covariates (age, education level, food insecurity, mother's educational level, father's education level, race, and ethnicity).
Supplemental Digital Content 3, http://links.lww.com/JNC/A35, displays the mean perceived stress score for those who experienced any of the nine specific interpersonal racial discrimination events compared with those who did not. Three interpersonal racial discrimination events were significantly associated with perceived stress score in the unadjusted models: watched by a security guard or store clerk ([beta] = 1.83, 95% CI: 0.24-3.42, p-value: .0245), treated unfairly by a teacher ([beta] = 1.89, 95% CI: 0.27-3.52, p-value: .0225), and name calling ([beta] = 3.82, 95% CI: 0.83-6.81, p-value: .0124) because of their race, ethnicity, or cultural background. These findings were consistent in the multivariable models adjusting for covariates (N = 215): watched by a security guard or store clerk ([beta] = 2.31, 95% CI: 0.44-4.18, p-value: .0155), treated unfairly by a teacher ([beta] = 2.55, 95% CI: 0.66-4.44, p-value: .0083), and name calling ([beta] = 4.89, 95% CI: 1.59-8.18, p-value: .0037) because of their race, ethnicity, or cultural background. Although not statistically significant in the unadjusted model, one additional racial discriminatory event was associated with perceived stress score in the multivariate model: being wrongfully accused in school ([beta] = 2.09, 95% CI: 0.16-4.02, p-value: .0336) because of their race, ethnicity, or cultural background, Table 3.
Stratified Analysis
Models stratified by racial/ethnicity groups found that both interpersonal racial discrimination ([beta] = 5.84; 95% CI: 1.90-9.79) and vicarious racism ([beta] = 5.24, 95% CI: 1.41-9.07) were significantly associated with higher perceived stress scores among Asian YMSM, after adjusting for covariates. In addition, vicarious racism was associated with elevated perceived stress score among multiracial ([beta] = 5.00, 95% CI: 1.58-8.42) and non-Hispanic ([beta] = 2.18, 95% CI: 0.56-3.79) YMSM in the adjusted stratified models, Table 4. Analysis of the nine specific racial discriminatory events was not conducted in the stratified analysis because of small sample sizes.
Discussion
Vicarious racism and interpersonal racial discrimination were commonly reported among YMSM in this study. The most frequently reported events of interpersonal racial discrimination were name calling, receiving insulting remarks, and being treated rudely because of their race, ethnicity, or cultural background. We found that among YMSM, exposure to vicarious racism and some specific interpersonal racial discriminatory events were associated with elevated perceived stress levels, after controlling for race/ethnicity and other confounding factors. In stratified models by race and ethnic groups, the association between vicarious racism and perceived stress was significant among Asian, multiracial, and non-Hispanic YMSM, while interpersonal racism was significant only among Asian YMSM. These findings suggest that these groups may be particularly susceptible to the effects of vicarious and interpersonal racism on stress, respectively.
There is evidence to suggest that children as young as age 3 years recognize racial groups and may display differential treatment of one another based on race (Feagin & Van Ausdale, 2001; Gee et al., 2012). Moreover, because the lives and development of children and adolescents are closely intertwined with the experiences of their family or caregivers (Heard-Garris et al., 2018), they are particularly vulnerable to vicarious racism (indirect or second-hand exposure to racism) and its effects on health (Condon et al., 2021; Heard-Garris et al., 2018). Our study found that over 50% of YMSM experienced vicarious racism in their lifetime, and such exposure was associated with increased levels of perceived stress, after controlling for race/ethnicity and other confounding factors. Our results substantiate previous findings stating that exposure to racial discrimination can vicariously affect others, giving rise to adverse health consequences that extend beyond the immediate victim (Heard-Garris et al., 2018; Martz et al., 2019). For example, prior research found that the children of caregivers exposed to racism have elevated levels of inflammation (Condon et al., 2021) and poor socioemotional and mental health outcomes compared with children not exposed to vicarious racism (Heard-Garris et al., 2018). Exposure to vicarious racism may also threaten a child or adolescent's sense of safety and fairness in society and bring about unintended consequences to their mental and physical health (Brody et al., 2006; Dominguez et al., 2008; Heard-Garris et al., 2018). Together these data demonstrate that vicarious racism may influence child health and development and underscore the value of continued research of vicarious racism and health in children and adolescents in the future.
Given that exposure to racial discrimination may occur in multiple social settings or contexts, identifying where or how YMSM encounter racial discrimination is necessary for the development of future interventions and/or policy change. Currently, there has been insufficient attention given to document racial discriminatory events that occur among YMSM (Williams & Chung, 2004), and most of the studies to date have been conducted in adults (Paradies, 2006). However, one study of African American adolescents reported that online and offline racial teasing and vicarious racial experiences were their most pervasive exposures to racial discrimination (English et al., 2020). In our study of YMSM, we found that name calling, receiving insulting remarks, and being treated rudely were the most reported racial discriminatory events. In addition, events such as being watched or followed by a store clerk, falsely accused at school, unfair treatment by a teacher, and name calling were associated with higher levels of perceived stress. We contend that more research is needed to comprehensively characterize discrimination in the specific contexts or domains in which racism occurs in the lives of YMSM (Pachter et al., 2010; Williams & Chung, 2004). Such efforts may help to achieve health equity by naming and identifying racism where it occurs and challenging the social structures and policies that perpetuate inequities in YMSM (Orr et al., 2021).
The growing literature on racism and adolescent health has predominantly focused on African Americans, with a paucity of information on other minority groups (Pachter & Coll, 2009). This is concerning given that experiences of racial discrimination may differ by racial/ethnic groups based on varying characteristics such as skin color, cultural practices, country of origin, language, or accent (Pachter & Coll, 2009). Therefore, the inclusion of diverse racial and ethnic groups in research studies is necessary. To fill this gap in the literature, our study analysis was stratified by multiple racial/ethnic groups to measure the associations between racism and stress within each group. Elevated levels of perceived stress were found among Asian, multiracial, and non-Hispanic YMSM. While previous studies have demonstrated high levels of stress hormones among African Americans (Brody et al., 2014) and dysregulation of cortisol levels among Native Hawaiians (Kaholokula et al., 2012) when exposed to discrimination, our study did not corroborate these findings. Furthermore, our study found that among participants who identified as White and reported vicarious racism or interpersonal racism, the majority also identified as Hispanic (28% [50/176]; 21% [37/176]) compared with non-Hispanics (12.5% [22/176]; 8.5% [15/176]). Therefore, the unexpectedly high percentage of White participants reporting vicarious and interpersonal racism was inflated by those who specifically identified as Hispanic White rather than non-Hispanic White. However, given that some non-Hispanic White participants reported experiencing some form of racism suggests that further investigation is warranted to explore whether these events are related to discrimination because of their color, language, accent, or because of their culture or country of origin or the dubious notion of "reverse racism" in the United States (Norton MI et al., 2011). We also believe that because the work of racial discrimination and health in YMSM is in its infancy, further research is urgently needed to unravel existing discrepancies in the literature and identify determinants of health inequalities that currently exist in this population.
Currently in the United States, YMSM have the greatest burden of newly diagnosed HIV infection (CDC HIV in the United States. At a Glance; Herbst et al., 2014), exacerbating health disparities in this population (Kipke et al., 2020). Investigators have previously reported that exposure to racism has been linked to greater distrust in the health care system (Hsueh et al., 2021), lower uptake of HIV (PrEP; Quinn et al., 2019), and unprotected sex in this population (Huebner et al., 2014). This is of concern, given the high prevalence of racism found in our study population. Moreover, racial discrimination is associated with greater perceived stress among YMSM, who are at high risk for HIV, and a better understanding is needed on how internalized racial discrimination and stress develop and interact with intrapersonal factors and adverse behaviors with long-term health implications. This may help to identify key strategies and interventions to reduce the negative effects of internalized racial discrimination and stress on overall health and behaviors. Finally, integration and discussion of such social determinants of health during health care visits may help improve the uptake of preventive care and adoption of prevention health behaviors (Andermann A. 2018), such as PrEP and sex with condom, among YMSM.
To advance the field of racism and health, researchers call for careful attention to specific mechanisms by which racial discrimination adversely affect health (Williams & Chung, 2004). There are multiple pathways by which racism can affect health over the life course (Williams & Chung, 2004). One frequently cited hypothesis is that health effects of racism are mediated through the stress-mediated pathway (Williams & Chung, 2004; Wright et al., 2020), resulting in adverse behavior and mental health (Pachter & Coll, 2009). A recent review of 121 studies found consistent associations between racial discrimination and poor mental health or high-risk health behaviors among children and adolescents (Priest et al., 2013; Williams et al., 2019), but very few studies have addressed the effects of racism on stress in marginalized youth (Pachter & Coll, 2009). Although our study did not directly examine the stress-mediating pathway, we found positive associations between racial discrimination and stress levels, which provide preliminary evidence to suggest that stress may play a role in the relationship between racism and health in YMSM. Our findings were consistent with 13 studies included in a systematic review which previously reported significant positive associations between self-reported racism and stress (Paradies, 2006). However, it is important to note that six other studies found no association (Paradies, 2006). More research on racism as an agent of stress is warranted to elucidate possible biological mechanisms linking it to health (Pachter & Coll, 2009). Furthermore, it is essential for future research in this field to identify long-term health effects of racism on stress to understand its contribution to health inequalities that persist in adulthood.
There were several limitations in this study. First, this study assessed self-reported racial discrimination, which is subject to recall bias. Moreover, the instrument we used to measure racial discrimination was based on one's subjective perception of racism, which may vary by individual. However, according to Clark and et al., individuals respond differently to events and one's appraisal of an event will determine whether it is perceived as racist and how it effects one's stress level (Clark et al., 1999; Pachter & Coll, 2009; Pachter et al., 2010). For this reason, we view racism as a phenomenological (i.e., subjective) experience (Pachter & Coll, 2009) and contend that self-reported racial discrimination was an appropriate measure to achieve our study objectives, albeit a limitation. Second, stress level was also measured as self-reported perception, and future studies should include biological indicators of stress (e.g., cortisol or inflammation levels) to provide further insight into the stress-mediated pathways or physiological mechanisms through which racism adversely affects health (Pachter & Coll, 2009). Third, our study is cross-sectional in design. Therefore, we were unable to determine causality or life course effects of racial discrimination on stress; for this, longitudinal studies are needed. Fourth, the subsample for the stratified analysis was particularly small for all groups except Black, non-Hispanic White, and Hispanic individuals, and thus, the results should be interpreted with caution. Finally, our study population was restricted to YMSM, and study results may not be generalizable to adolescents who do not identity as men who have sex with men (MSM).
Despite these limitations, there were several strengths to our study. First, our study included a racially and ethnically diverse sample of YMSM who were geographically dispersed throughout the United States. Our findings contributed to the current literature by providing data on racism that were exclusive to the experiences of YMSM. Second, we used the Perceptions of Racism in Children and Youth instrument to measure racial discrimination, which is a valid and reliable instrument that measures the perception of racism among children and adolescents (ages 8-18 years; Pachter et al., 2010). This instrument was the first to develop and test on an ethnically diverse group of minority children and youth (Pachter et al., 2010) and was applicable for our study population. Third, this study investigated various events of racial discrimination reported by YMSM, which to our knowledge have not been previously described (Williams & Chung, 2004).
Implications
Racial inequalities in health persist in the United States, especially among YMSM, and accumulating evidence suggest that racism is a contributor (Pachter et al., 2010). Given that exposure to racism may occur at any point in life (Gee et al., 2012), exposure during key developmental stages in adolescence may bring about lifelong health inequalities that carry on to adulthood (Kipke et al., 2020). Because a complex interaction of adolescent experiences of racial discrimination and adult health may exist (Vines et al., 2017), efforts to effectively tackle health inequalities may require a life course approach. Without a life course approach, the adverse health effects of racism that occur in adolescence may extend to early adulthood and exacerbate health inequalities later in life (Gee et al., 2012). A life course approach would involve a comprehensive examination of the effects of racism at different developmental stages of adolescence and provide measures of its cumulative effects on stress over time (Vines et al., 2017). We believe that this method would provide data that adequately inform policies and evidence-based interventions in efforts to reduce and prevent racism, as well as promote future health equity for YMSM (Orr et al., 2021; Wright et al., 2020).
Disclosures
The authors report no real or perceived vested interest related to this article that could be construed as a conflict of interest.
Author Contributions
All authors on this article meet the four criteria for authorship as identified by the International Committee of Medical Journal Editors (ICMJE); all authors have contributed to the conception and design of the study, drafted or have been involved in revising this manuscript, reviewed the final version of this manuscript before submission, and agreed to be accountable for all aspects of the work. The specific contribution of each author is as follows: Conceptualization and Methodology: Evette Cordoba; Formal Analysis: Evette Cordoba; Funding Acquisition: Rebecca Schnall; Investigation: Robert Garofalo, Lisa M. Kuhns, D. Scott Batey, Cynthia R. Pearson, Rebecca Schnall; Project Administration: Robert Garofalo, Lisa M. Kuhns, D. Scott Batey, Cynthia R. Pearson, Rebecca Schnall; Supervision: Robert Garofalo, Rebecca Schnall; Validation: Evette Cordoba; Writing-original draft: Evette Cordoba; Writing/Revision: Evette Cordoba, Robert Garofalo, Lisa M. Kuhns, Cynthia R. Pearson, Josh Bruce, D. Scott Batey, Asa Radix, Uri Belkind, Marco A. Hidalgo, Sabina Hirshfield, Rebecca Schnall.
Key Considerations
Racial discrimination is associated with greater perceived stress among young men who have sex with men, who are at high risk for HIV.
Health care providers should consider the intersectionality of racial discrimination with other social identities such as gender or sexual orientation, particularly among young men who have sex with men at risk of HIV.
Understanding how internalized racial discrimination and stress develop and interact with intrapersonal factors and health behaviors should be assessed by health care providers at each visit.
Discussion concerning the relationship between racial discrimination and stress among young men who have sex with men at risk of HIV and its impact on their overall health should occur.
Offering key strategies to reduce the health effects of internalized racial discrimination and stress should be considered as usual care for young men who have sex with men at risk of HIV.
Acknowledgments
This research uses data from MyPEEPS, a randomized control trial supported by the National Institute of Minority and Health Disparities of the National Institutes of Health (NIH) under award number [U01MD11279]. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Clinical Trial Registration Number: NCT03167606, registered May 30, 2017.
References