The self-esteem of gay men with HIV/AIDS in social adaptation

Abstract

Objective

The stigma and discrimination experienced by gay men with HIV/AIDS may lead to various psychosocial problems, one of which is low self-esteem. This condition might affect their attempts to adapt to the social environment. The objective of this study was to investigate self-esteem among gay men with HIV/AIDS in social adaptation.

Method

This study had a descriptive qualitative design and employed snowball sampling to recruit nine participants. The data were analyzed using thematic analysis.

Results

We identified three themes in this study: (1) self-esteem of gay men with HIV/AIDS, (2) the influence of self-esteem on social adaptation, and (3) coping mechanisms for social adaptation.

Conclusion

In the social domain, stigma and negative perceptions within the society affect the participants’ self-esteem. This paper provides suggestions for non-governmental organizations and health services to assist gay men with HIV/AIDS in overcoming low self-esteem.

Introduction

Sexual orientation is defined as a long-lasting emotional, romantic, and sexual attraction to men, women, or both.¹ Sexual orientation refers to the physical attraction, emotional desire, romantic attraction, and sexual passion an individual feels toward others.² It is generally represented as heterosexual, homosexual, or bisexual.³

Many societies associate homosexuality as an aberration, hence the societal rejection. Homosexuals are either gay men, who are sexually attracted to men and desire to form relationships with men, or lesbians, i.e. women who experience sexual and romantic attraction to women.⁴ Changing sex partners and engaging in anal intercourse that are common among homosexuals are risk factors of HIV transmission and other sexually transmitted infection (STI).

While there is no official data reporting the gay male population in the world, it is estimated that 1–3% of adult males aged 15–59 years are having same-sex relationships.⁵ Throughout the world, sexual intercourse between men is regarded as a contributing factor to HIV transmission.⁶ Based on the data from the Ministry of Health of the Republic of Indonesia (2012), there are about 1,095,970 gay men in Indonesia and 66,180 of them are infected with HIV. Moreover, according to the AIDS Commission, approximately 20,000 people in West Java are infected with HIV/AIDS, 20% of whom are gay men. Reportedly, at the end of 2015, there were 1693 gay men in Ciamis, a popular city among tourists in West Java. In Ciamis, there are 17 documented cases of gay men with HIV/AIDS (Non-Governmental Organization Wisma Ciamis, 2016).

In Indonesia, people began asserting gay and lesbian identities in the late 1970s and early 1980s, in contrast to transsexuals and transgender people, who were known to come out earlier.⁷ However, most Indonesian people still consider homosexuality to be a taboo and reject the homosexuals. Discriminatory behaviors, such as harassment and coercion are often experienced by the homosexuals in Indonesia.⁸ Such behaviors are often exhibited by the society members who wield power or within the families of the gay people.⁸

Behavior directed at gay men with HIV/AIDS, such as rejection, may lead to psychological problems. Furthermore, such behavior, which is caused by stigma and discrimination from family, friends, and society, can lead to low self-esteem, lack of openness, and lack of social support, which could contribute to an increased risk of HIV/AIDS transmission.⁹ Gay men facing discrimination, verbal and physical violence, isolation, and negative perceptions may experience a change in self-esteem, depression, anxiety, and self-injury.

In addition to psychological changes, social changes also occur. These are indicated by the stigma and discrimination that hinder people with HIV/AIDS from receiving social support, which negatively affects their self-care behavior and increases the risk of disease transmission.⁹ The discrimination and negative perceptions within the society could lead to discomfort in healthcare settings or in social relations for HIV-positive gay men. This is alarming because in health services and social relations, it is inconvenient to discuss issues related to same-sex relationships.¹⁰

To date, few studies have been conducted on the relationship between the self-esteem of gay men with HIV/AIDS and their social adaptation. A quantitative study on self-esteem in HIV-positive and HIV-negative gay and bisexual men was conducted in the United States.¹¹ However, it did not explore deeply the self-esteem of gay men with and without HIV/AIDS. A prior qualitative study was conducted in the Indonesian context to investigate the self-esteem of people with HIV/AIDS in Yogyakarta¹²; however, it did not explore gay men with HIV/AIDS in depth. This study sought to understand the self-esteem of the Indonesian gay men with HIV/AIDS in social adaptation.

Method

A descriptive qualitative method was employed in this study, which focused on fact-finding regarding a social phenomenon, to understand human behavior based on the participants’ perspectives. A qualitative research design using a descriptive approach should yield findings that adequately reflect the research data.¹³ Snowball sampling was used to select the participants, where the next participant was selected according to information provided by the previous participant.¹⁴ Based on this consideration, the inclusion criteria for this study were gay men with HIV/AIDS.

We did individual interviews and reached a data saturation with nine participants. After each interviews, the first author transcribed and processed the data.

We applied ethical principles in our study process. The principles were:

Autonomy: When the participant agreed to participate, the main researcher then provided him with the informed consent form.

Beneficence: The main researcher gave the participants time to share their experience of adapting to their environment.

Non-maleficence: During the interview, the main researcher observed the participant's expression. When there was any emotional change, the interview would be stopped and resumed after the participant was ready to do so.

Justice: The main researcher gave equal treatment and rights to all participants and maintained their confidentiality, including information relating to the participants’ lives and their identities, by assigning codes to the participants or using their initials instead of their names.

Participant recruitment process

The main researcher obtained information about potential participants via the gatekeepers from Non-Governmental Organizations Wisma Ciamis and Mata Hati Banjar. The gatekeeper explained the study to the participant candidates before they had any contact with the main researcher. Then the main researcher, accompanied by the gatekeeper, met the participant candidates to explain the study in more detail. The main researcher offered the participant candidates 24 h to determine their willingness to participate. They then signed the informed consent form to express their agreement to participate in the study.

Data analysis

Thematic analysis method was employed with the following six stages: understanding the data, creating the codes, considering the themes, reviewing the themes, determining the themes, naming the themes, and preparing reports.¹⁵

In this study, validity was achieved through four principles¹⁶:

Credibility: The main researcher transcribed the interviews, drew conclusions, and submitted this information to the participants to check the accuracy of the data obtained from the interviews.

Transferability: If the reader of the research report obtained a clear description and believed the same procedure could be applied elsewhere, the report was considered to be in accordance with the transferability standard.¹⁷

Dependability: The main researcher's supervisors audited the activities undertaken during the research process.

Confirmability: The main researcher used field notes in addition to the data obtained from the interviews in order to confirm what the participants said during the interviews and how they said it, which was then further discussed with the supervisors to determine the themes of the findings.

Results

Table 1 presents the characteristics of the participants in the study.

Table 1.

Characteristics of the participants.

Participant code	Age	Occupation	Education	Diagnosed HIV
01	28 years old	Private employee	Junion High School	2013
02	37 years old	Private employee	Diploma	2014
03	39 years old	Entrepreneur	Junion High School	2012
04	29 years old	Private employee	Junion High School	2013
05	26 years old	Private employee	Senior High School	2013
06	28 years old	Student	Senior High School	2015
07	23 years old	Private employee	Junion High School	2015
08	31 years old	Private employee	Bachelor	2015
09	28 years old	Does not work	Bachelor	2014

All nine participants were HIV-positive gay men living in Ciamis or its neighboring city, Banjar; seven of them were affiliated with NGO Mata Hati Banjar and the other two were affiliated with NGO Wisma Ciamis. The participants varied in the duration of their affirmation of a gay identity, ranging from elementary school age, to adolescence, to college age.

Based on the thematic analysis,¹⁵ the identified themes were self-esteem of gay men with HIV/AIDS, the influence of self-esteem on social adaptation, and coping mechanism for social adaptation.

Self-esteem of gay men with HIV/AIDS

We identified three points of view for describing the self-esteem of gay men with HIV/AIDS: (1) the affective point of view was derived from feelings that arose during social adaptation; (2) the cognitive point of view was derived from participants’ perceptions of problems and their ability to solve them, especially those related to socializing; and (3) the behavior point of view, which was associated with participants’ behaviors during the social adaptation process. Participant 1 conveyed the affective point of view as follows:

I still sometimes feel inferior, also inferior in my social status. Now, I just believe more in God… because no matter how hard the problem we face… people can only help little… hmm… the key is in ourselves… (Participant 1)

The in-depth interview with this participant revealed his feeling of inferiority during the process of socializing. This feeling was related to his status as an HIV-positive gay men. Meanwhile, another participant experienced embarrassment due to his behavior as a gay men, which led him to become infected with HIV. Consequently, he became introverted, which was shown by his avoidance of social relations and tendency to seek solitude.

Influence of self-esteem on social adaptation

Some influences were identified in this research—namely, influences on oneself, family, and society. The negative perception of gay life and HIV in the society caused a fear of one's identity being known by other people. This was reflected in the statement of Participant 4:

I do not want to reveal my status as a gay to my family… because …because… I know no one or family in this world would accept a child like me [an HIV-positive gay men]…I understand how much pain they would feel if they knew one of their family members suffers like this…so, in my family, I tried my best to cover up this issue, even though they have been so inquisitive recently…(Participant 4)

As gay men with HIV positive, the participant felt afraid of negative judgment from the people around him. Homosexuality and HIV/AIDS are taboo subjects in Indonesian society, and this creates stigma which leads to discrimination. Therefore, the participants feared negative views from the society and worried that such views could have a negative impact on their families. For this reason, most participants chose not to disclose their identity as gay men with HIV/AIDS.

Coping mechanisms for social adaptation

The data revealed some coping mechanisms relating to social adaptation, such as reducing social interactions and engaging in social interactions with the gay community. Participant 8 referred to reducing social interactions as a coping mechanism as follows:

First, I would try to get close… maybe in our community, I’d be open…but among other people… such as in the work environment… I will not reveal who I am…that's maybe the difficulty I’ve encountered so far… Also, if I meet someone who doesn’t understand me… it is difficult to be honest. I am afraid to reveal that… I am HIV-positive, while they aren’t…I try to cover up my identity… That's it. (Participant 8)

The participant's coping mechanism was to reduce social interactions by concealing his identity, especially his sexual orientation and HIV status. The participant would be open only with his friends in the gay and HIV/AIDS community and introverted with those who do not know about his life as a gay men with HIV. This has caused the participant to be less sociable, and thus, he is perceived as a quiet person.

Discussion

Self-esteem in gay men with HIV/AIDS

The embarrassment felt by participants was related to their status as HIV-positive gay men, which was associated with stigma and negative perceptions within the society. This condition is supported by a study in which people with HIV/AIDS expressed feelings of shame and low self-esteem.¹⁸ In addition, another study also revealed that a person with HIV/AIDS admittedly felt guilty and ashamed of his status and had difficulty telling others about his condition.¹⁹ The embarrassment was caused by negative views within the society either relating to homosexuality or HIV/AIDS. This feeling of embarrassment had made participants in this study introverted and caused behavioral changes, such as becoming aloof and avoiding social relations.

Seven participants in the present study exhibited low self-esteem. Someone who has low self-esteem exhibits some affective characteristics, such feeling ashamed, inadequacy, despair, a sense of uselessness, and other negative feelings about oneself.²⁰ Only two participants showed evidence of high self-esteem, as they were proud to reveal their homosexuality and HIV status to members of their society, despite the negative views in the society. Individually, these participants considered revealing their status to the society as appropriate in their lives, but this sentiment is not in accordance with the cultural values in Indonesia, where most Indonesians only recognize heterosexuality and consider homosexuality as taboo. Dede mentioned that gay people in Indonesia today, who are becoming braver about affirming their identity, experience rejection from the society.⁸

Influence of self-esteem on social adaptation

This study shed light on the influence of self-esteem on oneself, family, and society. The influence on oneself was shown to be associated with fear. This echoes a study result revealing that the fear experienced by gay men with HIV/AIDS of the unpleasant attitudes they might encounter caused them not to disclose their status to individuals or openly to the society. Many gay men expressed a feeling of isolation caused by their sexual orientation, particularly during adolescence and adulthood.²¹ They were afraid of being rejected if they revealed their identity to others.

The gay men in the present study stated that they had various sources of stress that could affect their lives. The stress concerning sexual orientation was related to the “coming out” process of gaining recognition, acceptance, and openness about their sexual orientation with other people, family, conflict during interactions, as well as negative views from the society.²² They reported experiencing stress as gay people throughout their lives, but the worst stress arose after they were diagnosed with HIV. Some participants revealed that the stress was caused by people's attitudes toward them and the conflicts they faced owing to their sexual orientation.²³ Since the society denies the existence of gay people, they had an exclusive place to meet with friends in their community.²⁴

Coping mechanisms for social adaptation

Gay men who are diagnosed with HIV/AIDS and experience various pressures in the society need unique coping mechanisms to face these pressures and overcome other psychosocial problems.²⁵ Difficulties in socializing were caused by having an introverted nature; yet gay men had no difficulty socializing with friends in their own community, as they gained emotional support and acceptance from their fellow community members.²⁶

A prior study examined the correlation between stigma and the psychological condition of people with HIV/AIDS.²⁷ Their research showed that individuals with HIV/AIDS had different abilities for dealing with stress and problems associated with stigma, and these abilities influenced their psychological wellbeing. It can be assumed that the psychological condition of the participants in the present study affected their means of coping. Social adaptation occurs when an individual adjusts to the lifestyle and values of a particular community but maintains his or her own lifestyle and values within the society.²⁸ In this study, some participants stated that they remained sociable within their society without revealing their sexual orientation or HIV status.

Research limitation

The research was limited owing to the lack of emphasis on the length of the HIV/AIDS diagnosis in the inclusion criteria. This factor might have affected participants’ coping mechanisms and their answers to the interview questions. Based on the research findings, participants who had been diagnosed with HIV for more than three years had better coping mechanisms than those who had been diagnosed with HIV for less than two years.

Conclusion

This study on the self-esteem and social adaptation of gay men with HIV/AIDS, involving nine participants, resulted in three themes: self-esteem of gay men with HIV/AIDS, the influence of self-esteem on social adaptation, and coping mechanisms used by HIV-positive gay men for social adaptation.

The participants’ self-esteem was regarded from affective, cognitive, and behavioral points of view. Affectively, participants expressed embarrassment relating to their status as gay men with HIV/AIDS, which made them fearful and lacking in confidence for socialization. Further, most of the participants cognitively showed introverted attributes, as they refused to allow others to know their status. However, this was different among the participants with open personalities, who were ready to be known as HIV-positive gay men.

The influences of self-esteem on social adaptation were directed at the self, as indicated by the fear of dealing with negative views; at the family, as indicated by the family's ignorance of the negative views from the society; and at the society, as indicated by the insults and scorns with regard to one's status as a gay men with HIV/AIDS as well as being effeminate.

One coping mechanism for social adaptation was reducing social interactions and becoming introverted, less sociable, and quiet. Another coping mechanism was participating in social interactions within the non-gay community without revealing one's status as a gay man with HIV/AIDS. Another coping mechanism was improving social relations by making new friends within the gay and HIV/AIDS community.

Conflict of interests

The authors declare no conflict of interest.

Acknowledgments

This work is supported by Hibah PITTA 2017 funded by DRPM Universitas Indonesia No. 378/UN2.R3.1/HKP.05.00/2017.