Why criminalising homosexuality is a public health hazard

TheConversation: Homosexuality remains illegal in 38 of 55 African nations. Such a stance against homosexuality is concerning from ethical and human rights perspectives. It also poses serious risks from a public health perspective, not least of all because of the significant rates of HIV across Africa. Men who have sex with men account for a substantial minority of those affected by HIV, with their risk of infection more than double that of the general population. Many African countries also harbour homophobic cultures and attitudes. Together, this creates an environment where homosexuality is highly stigmatised, with homosexual people socially isolated and marginalised.

We know from decades of research across stigmatised and socially excluded groups, such as sex workers, injecting drug users and men who have sex with men, that criminalisation does little to change behaviour, while actively contributing to increased stigma and marginalisation of these groups. This amplifies the health risks by driving stigmatised communities underground, isolating them from health or support initiatives.
What does this mean for homosexual people across Africa?

HIV

One of the greatest health risks created through the criminalisation of homosexuality relates to the treatment and prevention of HIV.
The current situation in Uganda provides a striking case study of how the law can affect responses to HIV. Uganda was once considered a regional leader in HIV prevention. Just over 7% of the Ugandan population are HIV positive. This is significantly lower than the rate of 15%, which was projected two decades ago. Uganda’s success in preventing HIV transmission is often attributed to an early, progressive, and ambitious government response.
However, in recent years the Ugandan government has taken an increasingly conservative approach to HIV-prevention, supporting abstinence-only programs and refusing to promote condom use.
This has been accompanied by a major crack down on homosexuality in the form of the Anti-Homosexuality Bill, signed into law in 2014, although it was later annulled. The Ugandan government plans to introduce further anti-gay legislation, and homosexuality remains illegal. Similar legislation has also been introduced in The Gambia.

Where homosexuality has been criminalised, men are likely to avoid HIV testing. Leonie Pauw/Shutterstock

Criminalisation of same-sex sexual practice cripples any initiatives aimed to prevent HIV transmission among this group or to provide treatment to HIV-positive men. Men are rightly afraid of disclosing their sexuality to service providers – who are required by law to report same-sex sexual practices. Anyone trying to organise a program around HIV prevention for men who have sex with men could be charged with “promoting homosexuality”.
Research has shown that where homosexuality has been criminalised, men are likely to avoid HIV testing or seeking knowledge about safer sex if it risks exposing their sexual activities.
But beyond this, increased levels of stigma – which inevitably results from criminalisation – mean gay and bisexual men are actually more likely to engage in risky sexual behavior.
Criminalisation also decimates gay networks and communities. Gay and bisexual men in Western countries such as Australia and the United States had the social capital needed to mobilise the community to initiate HIV information and prevention programs. Community-led prevention – and government support for community led prevention – has long been acknowledged as the most important element of Australia’s successful efforts to reduce HIV transmission.
Criminalising homosexuality removes the capacity for gay communities to organise and to mobilise around HIV prevention by effectively making such initiatives a criminal offence.

Mental health and well-being

The decimation of homosexual communities and stigmatisation of homosexuality has further implications for health and well-being.
The criminalisation of homosexuality entrenches the stigma associated with it. There is a great deal of evidence that many individuals who experience stigma or marginalisation also experience considerable stress.
Worldwide, lesbian, gay, and bisexual (LGB) men and women experience far higher rates of depression, anxiety, and other stress-related disorders compared to the rest of the population. Such stress may come from discrimination, rejection, and concealment, as well as internalised stigma that leads to feelings of shame and low self-worth. In countries where homosexuality is a criminal offence, a fear of persecution and living in secrecy only adds further stress.

Criminalising homosexuality removes the capacity for gay communities to organise and to mobilise around HIV prevention. oceanfishing/Shutterstock

According to Minority Stress Theory, living with stigma-related stress has direct repercussions on health. Not only does it place individuals at greater risk of mental health problems, but chronic stress is also linked with physical health outcomes, such as heart disease.
Self-medication through substance abuse is also a risk, with LGB populations also tending to have higher rates of alcohol consumption and drug dependence.
Conversely, LGB people with strong social networks and support tend to have better mental and physical health outcomes.

The law as harm

Criminalisation forces LGB men and women to live in stressful circumstances, and amplifies the stigma and marginalisation these groups experience. It renders LGB people invisible and creates significant barriers to openly accessing relevant health services and treatment.
In a continent that withstands the worst of the global HIV epidemic, the criminal regulation of homosexuality can only be viewed as an affront to the health of homosexual communities.