# Presentation: 287389

## The ‘Down Low’: More Questions than Answers

- Greg Millett, MPH
- Epidemiology Branch
- Division of HIV/AIDS Prevention
- National Center of HIV/STD/TB Prevention

**Notes:**
Good afternoon, the title of my talk is “The ‘Down Low’: More Questions than Answers”. Throughout this presentation I will be using ‘MSM’ (men who have sex with men) as a catch-all descriptor for homosexually active men.

## Overview

- Introduction to the ‘Down Low’
- Epidemiology of HIV/AIDS
- Black MSM
- Black Women
- Relevant Studies
- Gaps and Recommendations

## I. Introduction to the ‘Down Low’

## What is the ‘Down Low’?

- Black men
- Heterosexually identified
- Have sex with men
- Don’t tell female partners

**Notes:**
The ‘down low’ (aka ‘on the low,’ ‘low low,’ or ‘DL’) is a culturally-specific term in the black community that describes heterosexually identified Black men who have sex with men without the knowledge of their primary female partners.  

Since DL men are heterosexually-identified, they do not frequent gay-identified venues nor is their primary network of male friends comprised of gay men.

DO NOT READ:
Analagous term: homo thug: masculine blk male who dresses and acts like someone from the urban ghetto scene.  No one suspects that they have sex with men. (Used to be known as B-boys or banjee boys in the late 80s and through 90s)

Talk about analagous terms and homothugs

## Assumptions about Men on the DL

- Identities
- Black
- Male
- Heterosexual (gay’ or ‘bisexual’ do not apply)
- Masculine
- Shun mainstream gay subculture
- Transitional rather than permanent status
- Partners/ Practices
- Casual male partners
- Steady female partner
- Nondisclosure of MSM activities
- Unprotected sex with both female and male partners

**Notes:**
There are popular assumptions about men on the DL that include some aspects of the definition that I used in the previous slide, plus other characteristics that I intentionally had not mentioned.  These popular assumptions can be divided into three categories: Identities, partners/practices, and HIV status.
In terms of identities, DL men are Black heterosexually-identified masculine men who do not subscribe to any component of the gay subculture (e.g. attending bars or clubs).  It is also popularly assumed that the down low is a a transitional phase that men occupy between being ‘closeted’ about their sexuality and ‘coming out.’ 
The partners and practices of DL men are characterized by casual male partners and steady female partners, and nondisclosure of homosexual activities to female partners, family members or heterosexual friends.  Most of the discourse on DL men also assumes that these men are having unprotected intercourse with both female and male sexual partners.
In terms of HIV status, it is assumed that men on the down low are either unaware of their HIV status; or if they know their status and are HIV+, fail to disclose their HIV diagnosis to sexual partners.
I will return to some of these assumptions later in the presentation when I examine HIV risk assumptions of DL men. 

## Assumptions about Men on the DL

- Identities
- Black
- Male
- Heterosexual (gay’ or ‘bisexual’ do not apply)
- Masculine
- Shun mainstream gay subculture
- Transitional rather than permanent status
- Partners/ Practices
- Casual male partners
- Steady female partner
- Nondisclosure of MSM activities
- Unprotected sex with both female and male partners

**Notes:**
There are popular assumptions about men on the DL that include some aspects of the definition that I used in the previous slide, plus other characteristics that I intentionally had not mentioned.  These popular assumptions can be divided into three categories: Identities, partners/practices, and HIV status.
In terms of identities, DL men are Black heterosexually-identified masculine men who do not subscribe to any component of the gay subculture (e.g. attending bars or clubs).  It is also popularly assumed that the down low is a a transitional phase that men occupy between being ‘closeted’ about their sexuality and ‘coming out.’ 
The partners and practices of DL men are characterized by casual male partners and steady female partners, and nondisclosure of homosexual activities to female partners, family members or heterosexual friends.  Most of the discourse on DL men also assumes that these men are having unprotected intercourse with both female and male sexual partners.
In terms of HIV status, it is assumed that men on the down low are either unaware of their HIV status; or if they know their status and are HIV+, fail to disclose their HIV diagnosis to sexual partners.
I will return to some of these assumptions later in the presentation when I examine HIV risk assumptions of DL men. 

## Assumptions about Men on the DL

- Identities
- Black
- Male
- Heterosexual (gay’ or ‘bisexual’ do not apply)
- Masculine
- Shun mainstream gay subculture
- Transitional rather than permanent status
- Partners/ Practices
- Casual male partners
- Steady female partner
- Nondisclosure of MSM activities
- Unprotected sex with both female and male partners

- HIV Status
- Unaware of HIV status
- Nondisclosure of HIV+ status to sexual partners.

**Notes:**
There are popular assumptions about men on the DL that include some aspects of the definition that I used in the previous slide, plus other characteristics that I intentionally had not mentioned.  These popular assumptions can be divided into three categories: Identities, partners/practices, and HIV status.
In terms of identities, DL men are Black heterosexually-identified masculine men who do not subscribe to any component of the gay subculture (e.g. attending bars or clubs).  It is also popularly assumed that the down low is a a transitional phase that men occupy between being ‘closeted’ about their sexuality and ‘coming out.’ 
The partners and practices of DL men are characterized by casual male partners and steady female partners, and nondisclosure of homosexual activities to female partners, family members or heterosexual friends.  Most of the discourse on DL men also assumes that these men are having unprotected intercourse with both female and male sexual partners.
In terms of HIV status, it is assumed that men on the down low are either unaware of their HIV status; or if they know their status and are HIV+, fail to disclose their HIV diagnosis to sexual partners.
I will return to some of these assumptions later in the presentation when I examine HIV risk assumptions of DL men. 

## Assumptions about Men on the DL, contd

- Culturally- and race-specific term
- Assumed Black men are on the down low
- Other racial/ethnic groups engage in identical behaviors
- Reasons it is a culture-specific phenomenon
- Term arose from Black MSM community
- General Black community identifies the DL as a problem
- Press about the DL has focused entirely on Black men
- Black men on the DL identify with term

**Notes:**
Note that Black is part of the DL assumption. Other racial and ethnic groups also have men who are bisexually active and unwilling to disclose their sexual behavior to female partners, but they are not on the DL because it is culturally specific term that arose in the Black community.  Unlike other communities. the DL has become a vociferous debate in the Black community, all of the press regarding the DL has featured Black men, and it is a cultural term that Black men on the DL themselves use to describe their bisexual behavior-- whereas similar men from other communities might use other terms to describe the same behavior. 

5) HIV/AIDS rates are higher in Black communities, making the issue more urgent.

## Assumptions about Men on the DL, contd

*"I sleep with men, but I am not bisexual, and I am certainly not gay. I am not going to your clinics, I am not going to read your brochures, I am not going to get tested. I assure you that none of the brothers on the down low like me are paying the least bit of attention to anything you have to say."  **-JL King*

**Notes:**
A few years ago author and public health educator JL King ‘came out’ as a man who was formerly on the DL, and shocked the public health establishment by announcing at a conference that... “

It was the first time that the public health community heard of the ‘down low.’ But the term has been bandied about in the Black community a long time beforehand.

## Evolution of a Concept

- 1998

- 1999

- 2000

- 2001

- 2002

- 1991

- 1994

- 1995

- 1996

- 1997

- 2003

- 2004

**Notes:**
Men sleeping with men and not telling female partners have been happening since time immemorial.  But the origins of the ‘down low’ begins in the late 80s and early 90s.  

THE DL FIRST EMERGES AS A CONCEPT WITHIN THE BLK MSM COMMUNITY:
Black gay writers E. Lynn Harris and James Early Hardy published books in the early 90s that describe black men who have sex with men who are ‘unclockable’ – or men who are able to pass as straight. 
Both authors have since published several more books along the same theme, but while Mr Hardy’s books are popular with Black gay men, Mr. Harris’ books have become popular with heterosexual Black women.  

.

## Evolution of a Concept, contd

- 1998

- 1999

- 2000

- 2001

- 2002

- 1991

- 1994

- 1995

- 1996

- 1997

- 2003

- 2004

- “...And keep it on the ***down low***** **Nobody has to knowWe can keep it on the ***down low***Nobody has to know

- “...So I creep yeahJust keep it on the ***down low***Said nobody is supposed to knowSo I creep yeah'Cause he doesn't knowWhat I do and no attentionGoes to show...”

**Notes:**
The term ‘down low’ gained widespread exposure in the general Black community when two popular R & B acts, TLC and R Kelly, released #1 R&B singles in the mid-90s that mention the ‘down low’ in the lyrics.
Each song describes a woman who is messing around with other men despite having a boyfriend. 
Note that the DL at this point is not specific to MSM activity or gender-specific in the wider Black community. It just means something that is secretive. 

## Evolution of a Concept, contd

- 1998

- 1999

- 2000

- 2001

- 2002

- 1991

- 1994

- 1995

- 1996

- 1997

- 2003

- 2004

**Notes:**
Six years afterward the POPULAR MEDIA CATCHES ON and the down low is once again associated with covert homosexual activity.
There were a flurry of articles in February 2001 after the release of data from CDC showing elevated HIV infection rates among young Black MSM. It marks the beginning of escalating scrutiny paid to DL men :
The USA Today and the LA Times were among the first to describe DL behavior and link it to unsafe sex 
The  NYTimes also prints an article about Black DL men, and it is the first time that the ‘down low’ is mentioned in the mainstream press.  

ER:
The following year, one of televisions top-rated television shows, concretizes the connection between HIV risk and the DL.  In an episode entitled ‘A River in Egypt’, NBC’s ER airs a storyline of a heterosexually-identified Black rap artist who tests HIV-positive and is reluctant to tell his girlfriend.  The rapper contracted HIV from sleeping with a close male associate, whom his girlfriend also knows, but does not suspect is his male lover. 

## Evolution of a Concept, contd

- 1998

- 1999

- 2000

- 2001

- 2002

- 1991

- 1994

- 1995

- 1996

- 1997

- 2003

- 2004

**Notes:**
By 2003, an explosion of articles have already been written about the DL in the mainstream, Black and gay press.  The public health community also weighs in on the issue:

In February 2003, CDC releases a report from the Young Men’s Survey that finds that:
Black MSM are less likely to disclose their sexual behavior to others
less likely to perceive themselves at risk for HIV infection and 
Among nondisclosing men, more likely to be HIV-positive.

Later that same year both the NY Times and the Washington Post publish articles about the DL.  The NY Times magazine article focuses on the demimonde inhabited by DL men, while the Post’s piece highlights Black women who were  infected by bisexually active men. 

Both articles spark acrimonious debate within the black and black gay communities.  I will use quotes of reader responses to the NY Times magazine article as a backdrop for other points in the presentation.

## What is the uproar about?

*"We will continue to lose sisters because men will not come out.”  -JL King*
*	**Down-Low' Activity Threatens Black Women’ by R Dotinga for Gay.com/PlanetOut.com Network 4/30/02*

**Notes:**
So what is the media and community uproar about?

Black women– or the belief that DL men are transmitting HIV to heterosexual Black women.

JL king comments that “...”

## What is the uproar about?, contd

*“**Too often the DL brother is constructed as the vessel of contagion... behind this ...[is a ] heterosexist assumption that AIDS is born and bred in gay communities then venomously spread to pure, sterile black communities... [the fact is] that many ...straight black people are HIV-positive and spreading the disease among themselves without any help from ‘evil’ black gay men.” **Posted by Blackbrit 8/1/03 NY Times Magazine Web Forum** *

**Notes:**
A response to the NY Times magazine article captures the counterargument put forward by some Black MSM “...”

## II. Epidemiology of HIV/AIDS: Black MSM and Women

**Notes:**
Much of the discord has been fueled by epidemiological data of HIV/AIDS among Black MSM and Black women.

## Black Men: AIDS Cases By Exposure 

- 2002 AIDS cases among Black men:
- 	32% 	Men who have sex with men
- 	19% 	Injection drug use
- 	14% 	Men who have sex with women
- 	4%	Sex with men/ Injection drug use

- N= 14,334

**Notes:**
We know that among Black men, gay and bisexual men represented the largest proportion of AIDS cases reported in 2002.

## Black MSM: HIV Data

- Initial dx of HIV among MSM ages 13-24
- Black  16% ; Latino 13%; White  9% (MMWR, 1/14/00)** **
- Among MSM ages 23-29
- HIV Prevalence: Black 32% , Latino 13%, White 7% (MMWR, 6/1/01)
- HIV Incidence: Black  14.7%, Latino 3.5%, White 2.5%. (MMWR, 6/1/01)

**Notes:**
Surveillance data from 25 states between reported in a recent MMWR also shows that proportionally more young Black MSM between the ages of 13 and 24 become infected with HIV than White or Latino MSM. (MMWR, 1/14/00).

Likewise, data from a cross-sectional, multisite, venue-based survey of MSM sampled across 6 cities found a significantly higher HIV prevalence and incidence among young Black MSM compared to other racial/ ethnic groups of MSM.  However, These data must be interpreted with caution since the men were sampled at primarily gay-identified venues. 

[More info if needed:
higher HIV prevalence among Black MSM compared to white MSM (N=2492)
higher HIV incidence rates among Black MSM  compared to white MSM. (N= 290 STAHRS tested; 373 positives)
A three-stage sampling plan was used to randomly select venues from the sampling frame of venues and then to randomly select times. Sampled venues and times were then scheduled for the third stage of sampling in which young men were sampled at 194 venues in Baltimore, Maryland; Dallas, Texas; Los Angeles, California; Miami, Florida; New York, New York; San Francisco, California; and Seattle, Washington.]
During 1998--2000, YMS Phase II was conducted to sample MSM aged 23--29 years in six of the seven cities (excluding San Francisco). Data are preliminary. Of the 2942 young MSM, 1409 (48%) were white, 651 (22%) were Hispanic, and 497 (17%) were black. Of these, 373 (13%) were HIV-positive; HIV prevalence was 7% among whites, 14% among Hispanics, and 32% among blacks.
The findings in this report are subject to at least three limitations. First, although enrollment rates were high, sampling was conducted through outreach at venues, and it is not known whether young men with recent high-risk behaviors were more likely to enroll. Second, young men were sampled only at randomly selected venues, and incidence may have been lower if young MSM who did not go to venues or did not live in cities had been sampled. Third, data for YMS Phase II are preliminary, particularly because not all specimens were STARHS-tested and the final results may change slightly. 

## Black Women: Heterosexual Contact AIDS Cases

- In 2002
- Black women 65% of heterosexual transmission AIDS cases among all women
- 42% of AIDS cases among Black women was transmitted sexually
*It is unknown what proportion of these heterosexually transmitted HIV cases are attributable to DL men in comparison to non-DL men*

**Notes:**
In 2002, Black women comprised the largest proportion of AIDS cases (65%) due to heterosexual sex  among all women. 

Heterosexual transmission is also the largest risk category among Black women:
42% of AIDS cases diagnosed in Black women in 2002 were due to heterosexual sex

It is unknown what proportion of these heterosexually transmitted HIV cases among Black women are attributable to DL men in comparison to non-DL men (e.g. heterosexual, bisexual, homosexual identified men)?

DO NOT READ: 
2002 AIDS cases among Black women (N=7553):
	42% 	Heterosexual contact
	19% 	Injection drug use
	38% 	Risk not identified

## Black MSM: Prevalence of Sex with Women

| Study  | N  | Population | Sex with women*
(%)  |
| --- | --- | --- | --- |
| Binson (1995)  | 11 | Bisexually active Black men  | 57%+  |
| Doll (1992)  | 72 | HIV+ Black MSM  | 48%  |
| McKirnan (1995)  | 279 | Bisexually active Black men  | 40%  |
| Montgomery (2003)  | 1582  | HIV + Black MSM  | 34%  |
| Wohl (2002)  | 90 cases;
272 controls  | Heterosexually-ID Black MSM  | 31% cases;
16% controls  |

- * Different timeframes (‘ever’, 6 months, year, past 5 years)
- + Sex with ‘men and women’. No estimate of sex with ‘women only’ provided.

**Notes:**
There are research studies that have estimated the level of bisexual activity among Black MSM. The estimates, however, are problematic because they are based upon convenience samples and not generalizable to the Black MSM population.  The estimates of bisexual activity also include Black MSM of various sexual identities, not just heterosexually-identified men.

The only relevant estimate here is the last: a study of heterosexually-identified, bisexually active men that found that 31% of HIV+ men and 16% of HIV-negative men reported sex with women.  However the estimates for this study, like the other studies, are based upon convenience samples and not generalizable to the Black MSM population.

## III. Relevant Studies

## 
“... I think a lot of these young men only have wives or girlfriends to cover up their homosexuality.  In the meantime, they are denying who they are...” 
	Posted by Brandip  8/3/03 NY Times Magazine Web Forum 

*“... **I think a lot of these young men only have wives or girlfriends to cover up their homosexuality.  In the meantime, they are denying who they are...” *
*	**Posted by Brandip  8/3/03 NY Times Magazine Web Forum** *

- _Sexual orientation_: to whom you are attracted (men, women, both)
- _Sexual identity_: how you describe yourself (to yourself and others)
- _Sexual behavior_: with whom you have sex
- 							(Purcell et al., 1996)

- Sexual Identity and Behavior

**Notes:**
The DL debate is replete with references to men who deny their ‘true’ sexual desire and in the process endanger the lives of Black women.
But sexuality is not that simple.
Let’s review 3 key concepts....

(after reading concepts and defn)

In the least complicated of all worlds a man attracted only to men would have a homosexual orientation, a gay identity, and sleep only with men.
But we don’t live in that world and there are innumerable incongruent combinations including men who’s sexual orientation is homosexual, identify as straight, and sleep with women and men.

## Sexual Behavior and Identity

- Sexual Behavior and Identity

- Black MSM studies mostly gay- ID men rather than bisexual men

- MSM Behavior Studies

- Gay ID
- Sample

**Notes:**
Most studies of Black MSM primarily include men who ID as gay rather than bisexual

The few studies of Black behaviorally bisexual men largely include men who identify as bisexual rather than heterosexual

Most studies of Black heterosexual men primarily include men who only engage in sex with women

Only 1 study examines Black heterosexual men who engage in sex with both men and women

Among Black MSM, most data are men who ID as gay and less for men who are bisexual

Have data on Black men who are gay and bisexual, but need to know the difference in Black MSM and identity

## Sexual Behavior and Identity

- Sexual Behavior and Identity

- Black MSM studies mostly gay- ID men rather than bisexual men
- Studies of bisexually active men primarily bisexual-ID, not heterosexual

- MSM Behavior Studies

- Gay ID
- Sample

- Bisexually
-      ID
-  Sample

**Notes:**
Most studies of Black MSM primarily include men who ID as gay rather than bisexual

The few studies of Black behaviorally bisexual men largely include men who identify as bisexual rather than heterosexual

Most studies of Black heterosexual men primarily include men who only engage in sex with women

Only 1 study examines Black heterosexual men who engage in sex with both men and women

Among Black MSM, most data are men who ID as gay and less for men who are bisexual

Have data on Black men who are gay and bisexual, but need to know the difference in Black MSM and identity

## Sexual Behavior and Identity

- Sexual Behavior and Identity

- Black MSM studies mostly gay- ID men rather than bisexual men
- Studies of bisexually active men primarily bisexual-ID, not heterosexual
- Studies of heterosexual-ID men primarily men who only have sex with women

- MSM Behavior Studies

- Gay-ID
- Sample

- Bisexually          -ID
-  Sample

- Heterosexually-ID Sample

- DL men

**Notes:**
Unfortunately...

Most studies of Black MSM primarily include men who ID as gay rather than bisexual

The few studies of Black behaviorally bisexual men largely include men who identify as bisexual rather than heterosexual

Most studies of Black heterosexual men primarily include men who only engage in sex with women, not heterosexually-identified men who are bisexually active like men on the down low.

There are limited data, but there is a study which I pointed out earlier, that examines Black heterosexual men who engage in sex with both men and women

## Heterosexually-Identified Black MSM: Sexual Risk-Taking

|  | HIV+
(N= 90) | HIV-
(N=272) |
| --- | --- | --- |
| Anal sex w/ man | 32% | 16% |
| Inconsistent condom use w/ male partners | 100% | 68% |
| Anal sex w/ women | 46% | 37% |
| Inconsistent condom use w/ female partners | 95% | 95% |

- (Wohl  et al., 2002)

**Notes:**
The authors of that study found that:

Nearly a third of HIV+ and 16% of HIV- heterosexually ID black men reported anal sex w/ a man (HIV+: 28/90; HIV-: 43/272) 
Of men reporting anal sex with a man, 100% of cases and 68% of controls reported ‘never’ or ‘sometimes’ using condoms (HIV+: 28/28; HIV-: 29/43) 
Nearly half of cases (46%) and over a third of controls reported anal sex with a woman (HIV+: 41/90; HIV-: 101/272) 
Of men reporting anal sex with female partners, nearly all cases and controls reported ‘never’ or ‘sometimes’ using condoms. (HIV+: 39/41; HIV-: 96/101) 

DO NOT READ TO AUDIENCE: The authors also found that most of the HIV-positive heterosexually-identified men disclosed their HIV status to their female partners. However
21% ‘sometimes’ told female partners that they were HIV+ 
18% ‘never’ told female partners that they were HIV+
The disclosure data must be interpreted with caution since it is inclusive of all HIV+ men in the sample.  The authors do not stratify the sample of nondisclosing HIV+ men by sexual behavior.  We do not know the proportions of nondisclosing HIV+ men who are bisexually active vs. heterosexually active only. Also does not reflect recent sex since men were asked ANY unprotected sex since 1978 to date of first HIV+ test for cases and the date of cases first HIV+ test for each matched control. 

## Popular Theories of HIV Risk among DL Men

- Homophobia in Black community
- Dual minority status (fragmented identities)
- Nondisclosure of sexuality
- Incarceration
- Drug use

**Notes:**
In the absence of data on DL men, there are many popular theories of factors that contribute to HIV risk in the population.  I will just mention a few of the theories with solid public health rationale:
The first is a perception that there is greater homophobia in the Black community which contributes to men being reluctant to come out. Men who are not out, will not be targeted for appropriate HIV prevention messages and engage in higher HIV risk behaviors. 
Homophobia in the Black community forces Black men to compartmentalize their racial and sexual identities, which leads to higher risk-taking behavior
Men who are less open about their sexuality are less likely to perceive themselves at high risk for HIV infection (b/c they do not ID as gay) and engage in higher risk behavior with both men and women
Incarceration: Blk men have a 1 in 4 likelihood of going to prison in their lifetime compared to 1 in 23 among white men. Black men represented 45% of all incarcerated males in Federal and State prisons and local jails in 2001.  It is theorized that higher incarceration results in greater prevalence of same sex behavior (‘situational homosexuality’), leading to greater risk of HIV infection
Crack/ cocaine use is elevated among African Americans compared to other populations. There is an assumption that drug addiction makes straight-identified men prone to engaging in trading sex for drugs or money, resulting in a > likelihood of sexual behavior with men.

We will examine the available data on each of these assumptions over the next few slides ...

## Popular Theories of HIV Risk among DL Men

- Homophobia in Black community
- Dual minority status (fragmented identities)
- Nondisclosure of sexuality
- Incarceration
- Drug use

**Notes:**
In the absence of data on DL men, there are many popular theories of factors that contribute to HIV risk in the population.  I will just mention a few of the theories with solid public health rationale:
The first is a perception that there is greater homophobia in the Black community which contributes to men being reluctant to come out. Men who are not out, will not be targeted for appropriate HIV prevention messages and engage in higher HIV risk behaviors. 
Homophobia in the Black community forces Black men to compartmentalize their racial and sexual identities, which leads to higher risk-taking behavior
Men who are less open about their sexuality are less likely to perceive themselves at high risk for HIV infection (b/c they do not ID as gay) and engage in higher risk behavior with both men and women
Incarceration: Blk men have a 1 in 4 likelihood of going to prison in their lifetime compared to 1 in 23 among white men. Black men represented 45% of all incarcerated males in Federal and State prisons and local jails in 2001.  It is theorized that higher incarceration results in greater prevalence of same sex behavior (‘situational homosexuality’), leading to greater risk of HIV infection
Crack/ cocaine use is elevated among African Americans compared to other populations. There is an assumption that drug addiction makes straight-identified men prone to engaging in trading sex for drugs or money, resulting in a > likelihood of sexual behavior with men.

We will examine the available data on each of these assumptions over the next few slides ...

## Popular Theories of HIV Risk among DL Men

- Homophobia in Black community
- Dual minority status (fragmented identities)
- Nondisclosure of sexuality
- Incarceration
- Drug use

**Notes:**
In the absence of data on DL men, there are many popular theories of factors that contribute to HIV risk in the population.  I will just mention a few of the theories with solid public health rationale:
The first is a perception that there is greater homophobia in the Black community which contributes to men being reluctant to come out. Men who are not out, will not be targeted for appropriate HIV prevention messages and engage in higher HIV risk behaviors. 
Homophobia in the Black community forces Black men to compartmentalize their racial and sexual identities, which leads to higher risk-taking behavior
Men who are less open about their sexuality are less likely to perceive themselves at high risk for HIV infection (b/c they do not ID as gay) and engage in higher risk behavior with both men and women
Incarceration: Blk men have a 1 in 4 likelihood of going to prison in their lifetime compared to 1 in 23 among white men. Black men represented 45% of all incarcerated males in Federal and State prisons and local jails in 2001.  It is theorized that higher incarceration results in greater prevalence of same sex behavior (‘situational homosexuality’), leading to greater risk of HIV infection
Crack/ cocaine use is elevated among African Americans compared to other populations. There is an assumption that drug addiction makes straight-identified men prone to engaging in trading sex for drugs or money, resulting in a > likelihood of sexual behavior with men.

We will examine the available data on each of these assumptions over the next few slides ...

## Popular Theories of HIV Risk among DL Men

- Homophobia in Black community
- Dual minority status (fragmented identities)
- Nondisclosure of sexuality
- Incarceration
- Drug use

**Notes:**
In the absence of data on DL men, there are many popular theories of factors that contribute to HIV risk in the population.  I will just mention a few of the theories with solid public health rationale:
The first is a perception that there is greater homophobia in the Black community which contributes to men being reluctant to come out. Men who are not out, will not be targeted for appropriate HIV prevention messages and engage in higher HIV risk behaviors. 
Homophobia in the Black community forces Black men to compartmentalize their racial and sexual identities, which leads to higher risk-taking behavior
Men who are less open about their sexuality are less likely to perceive themselves at high risk for HIV infection (b/c they do not ID as gay) and engage in higher risk behavior with both men and women
Incarceration: Blk men have a 1 in 4 likelihood of going to prison in their lifetime compared to 1 in 23 among white men. Black men represented 45% of all incarcerated males in Federal and State prisons and local jails in 2001.  It is theorized that higher incarceration results in greater prevalence of same sex behavior (‘situational homosexuality’), leading to greater risk of HIV infection
Crack/ cocaine use is elevated among African Americans compared to other populations. There is an assumption that drug addiction makes straight-identified men prone to engaging in trading sex for drugs or money, resulting in a > likelihood of sexual behavior with men.

We will examine the available data on each of these assumptions over the next few slides ...

## Popular Theories of HIV Risk among DL Men

- Homophobia in Black community
- Dual minority status (fragmented identities)
- Nondisclosure of sexuality
- Incarceration
- Drug use

**Notes:**
In the absence of data on DL men, there are many popular theories of factors that contribute to HIV risk in the population. The first is a perception that there is greater homophobia in the Black community which contributes to men being reluctant to come out. Men who are not out, will not be targeted for appropriate HIV prevention messages and engage in higher HIV risk behaviors. 
Homophobia in the Black community forces Black men to compartmentalize their racial and sexual identities, which leads to higher risk-taking behavior
Men who are less open about their sexuality are less likely to perceive themselves at high risk for HIV infection (b/c they do not ID as gay) and engage in higher risk behavior with both men and women
Incarceration: Blk men have a 1 in 4 likelihood of going to prison in their lifetime compared to 1 in 23 among white men. Black men represented 45% of all incarcerated males in Federal and State prisons and local jails in 2001.  It is theorized that higher incarceration results in greater prevalence of same sex behavior (‘situational homosexuality’), leading to greater risk of HIV infection
Crack/ cocaine use is elevated among African Americans compared to other populations. There is an assumption that drug addiction makes straight-identified men prone to engaging in trading sex for drugs or money, resulting in a > likelihood of sexual behavior with men.
We will examine available data on each of these assumptions over the next few slides ...

## Homophobia and AIDS-phobia in Black and White Communities

*“**The ‘reporter’ or anthropological tour guide provided no basis for his assertion that blacks are generally more homophobic than whites...” *
*	**Posted by Blublklove 8/4/03 NY Times Magazine Web Forum*

- Similar attitudes among Blacks and Whites re:
- PWAs(Herek & Capitanio, 1993)
- Homosexuals (Herek & Capitanio, 1995; Lewis, 2003)
- Blacks and Whites have negative associations with gay sex and HIV (Herek & Capitanio, 1999)

**Notes:**
With regards to a homophobic Black community giving rise to the DL, one reader balks at the suggestion and writes.. “...”

Studies by Greg Herek and others  affirm the reader’s point: 

The studies (including one meta-analysis) found no differences in attitudes between white and black populations toward People living with HIV/AIDS or homosexuals.

The studies also found that both communities most negatively stigmatize people who contract HIV through homosexual sex compared to any other means.

DO NOT READ:
No difference in homophobic attitudes:
 Sex between two men is just plain wrong.  Blk 74%; Wht 69% 
 I think male homosexuals are disgusting.  Blk 57%; Wht 58%
 Male homosexuality is a natural expression of sexuality in men. Blk 21%; Wht 23%

## Sexual/ Racial Identity Integration and HIV Risk

- Influence of racial and sexual identity on psychosocial functioning:
- N= 174 Black MSM
- Integrated identity associated with self-efficacy to engage in HIV preventive behaviors (Crawford, et al, 2002)

| 
Integration | 
Separation |
| --- | --- |
| 
Assimilation | 
Marginaliza-
tion |

- Hi

- Low

- Hi

- Low

- Sexual ID

- Racial ID

**Notes:**
In terms of dual minority status and compartmentalizing identities, one study studied the influence of racial and sexual identity on psychosocial functioning.  
A sample of 174 Black MSM were divided into 4 categories that reflected various combinations of low or hi racial and sexual ID based upon psychometric measures.  The authors reported that an ‘integrated identity’ (hi racial and hi ethnic identity) was associated high self-efficacy (belief that one could successfully perform a given task) to engage in HIV preventive behaviors  

DO NOT READ:
Men in integration experienced higher self-esteem, HIV prevention self efficacy, stronger social supports, greater life satisfaction, lower psych distress

(problem: Sample is 71% gay; 23.5% bisexual , only 2.9% heterosexual)
Describe the self-efficacy scale: # of items, etc.  LOOK UP IN GOOGLE!

## Disclosure and HIV Risk

- Compared to Black MSM who disclosed their sexuality, Black MSM nondisclosers:
- Peceived HIV risk
- Less likely to believe that they could become infected with HIV
- HIV test and status
- Less likely to report _>_ 3 lifetime HIV tests
- Less likely to be HIV-positive
- Sexual partners and risk:
- More likely to have _>_ 3 lifetime female partners or report unprotected vaginal or anal sex with women
- Less likely to _>_ 5 lifetime male partners or report unprotected sex with men  (MMWR, 2003)

**Notes:**
In terms of disclosure of sexuality and higher HIV risk: One study found that compared to Black men who disclosed their sexuality, Black MSM nondisclosers were:  (N= 910 & 920)

Less likely to believe that they could become infected with HIV
Less likely to report > 3 lifetime HIV tests
Less likely to be HIV-positive
More likely to have > 3 lifetime female partners and have unprotected vaginal or anal sex with women
Less likely to > 5 lifetime male partners or have unprotected sex with men  (MMWR, 2003)

DO NOT READ: Personal notes:
YMS:
Knowledge of serostatus: 
N= 920; 2/3 Black MSM tested for HIV; median # of tests: 1
Previous negatives (N=536): 16% HIV+ 
No previous test (N=148):  7% HIV+   

## Prison and HIV Risk

- Few studies documenting homosexual activity among incarcerated Black men (Alarid, 2000; Lichtenstein et al., 2000)
- Black MSM LA County  (N=332) (Wohl et al., 2000)
- No association between incarceration and HIV status
- Higher rates of anal sex outside of prison
- This finding was consistent across sexual orientation

**Notes:**
As far as homosexual activity in prison or jails leading to greater HIV risk, few studies have documented homosexual activity among incarcerated Black men.

One study conducted in LA County matched 305 HIV+ Black male cases w/ 305 Black male neighborhood controls and found that among men who reported a history of incarceration (332 total), there 
Was no association between incarceration and HIV status
And that higher rates of anal sex with other men took place outside of institutional settings (undercuts situational homosexuality argument).  This finding was consistent across sexual orientation.  In other words, gay, bisexual, and heterosexually-identified men all reported higher rates of anal sex with other men outside of rather than inside penal institutions. This data undercut the argument that detainment among straight-identified men leads to a greater probability of engaging in situational homosexuality.

DON’TREAD: 69% of cases self-ID as gay or bi, compared to 11% of controls.

## Drug Use and HIV Risk

- Heterosexual-ID men (N=90 HIV+; N=272)
- Cases more likely to use:
- Heroin
- Methamphetamine
- Nitrites
- No difference in trading sex for drugs between cases and controls
- Cases less likely to report condom use when trading sex for drugs (Wohl et al., 2000)

**Notes:**
A case-control study of heterosexually-identified Black men found that
HIV+ cases were more likely to use:
Heroin
Methamphetamines
Nitrites

But there was no difference in trading sex for drugs between cases and controls

However, cases were less likely to report condom use when trading sex for drugs

(The study is not specific on whether sex trade included male or female partners.)

## Summary

- Sexual orientation, identity, and behavior are not always congruent
- Most previous research on Black MSM is not applicable to DL men.
- Theories of HIV risk among DL men must be tested with DL populations

**Notes:**
In summary,
Men who live their lives on the down low demonstrate that sexual orientation, identity, and behavior are not always congruent.  

Most of  the previous research on Black MSM is not applicable to DL men because they include primarily gay- or bisexually-identified samples.

And although there are data that demonstrate the merit of the theories of HIV risk among DL men, those data are also from studies that recruited primarily gay- or bisexually-identified Black MSM.  Similar studies need to be undertaken with heterosexually-identified, bisexually active Black men.

## IV. Gaps and Recommendations

**Notes:**
There are several research gaps of men on the down low. DO NOT READ: Summation of previous 5 slides?
Blk comm not as homophobic
Integrated ID may help in HIV self-efficacy
Nondisclosers less likely to get tested, but more likely to be HIV-negative, have fewer male sexual partners, and engage in protected sex with male partners
Trading sex for drugs not associated with HIV infection in one study of Het-ID Black men
Incarceration not associated with HIV infection and does not > frequency of unprotected sex among Black men.   

## Gaps and Recommendations

- Need additional qualitative and quantitative studies
- Specify meaning of DL
- Integrate probability-based methods into sampling procedures
- Determine sexual risk of DL men in relation to other Black men

**Notes:**
The biggest gap is that there is limited information about the HIV risk behaviors of men on the DL.  We need additional qualitative and quantitative studies of HIV risk behaviors of Black MSM, and specifically Black MSM on the DL. There are  studies underway at CDC that might be able to offer pieces to the puzzle, but none of these studies primary focus is to examine the HIV risk behaviors of DL men. We need studies that investigate the lay theories of HIV risk among DL men, not bisexually- or gay-identified men
As researchers, we need to specify what we mean by the DL:
1. Just because a man is NGI does not mean he is on the DL [There are Black men who for all intents and purposes are gay (in terms of being homosexually active only, having mostly male friends, attend gay-ID events) who do not identify as gay but ‘SGL’, ‘In the Life’, ‘One of the kids’, etc]
2. Also, Although all DL men are bisexual, not all bisexual men are on the DL. Bisexual men who are open about their sexuality or attend gay-ID venues are not on the down low.
3. Last: Because of its aura of masculinity, there are gay men who identify as being on DL. 
We have to be careful and define the DL as only heterosexually_ID, bisexually active men who do not disclose their MSM activity to female partners, or we risk recruiting study participants who do not reflect the target population. 

## Gaps and Recommendations

- Need additional qualitative and quantitative studies
- Specify meaning of DL
- Integrate probability-based methods into sampling procedures
- Determine sexual risk of DL men in relation to other Black men

**Notes:**
We cannot generalize from the existing data. Most of the studies on Black MSM are based upon convenience samples and caution needs to be exercised in generalizing to the population of Black MSM. Utilizing time-space sampling methods, like those used in Young Men’s Survey or other probability-based (random) methods will yield better estimates of bisexually active MSM.
We must determine the sexual risks of men on the DL, and compare them to other populations of Black men. Unfortunately, most of the data we have of Black MSM communities include bi- or gay-identified men. Few studies recruit sizable numbers of heterosexually-identified Black men.

## Gaps and Recommendations

- Investigate contextual factors of HIV risk for DL men
- Develop effective interventions for Black MSM

**Notes:**
Studies are needed of the contextual influences of HIV risk among Black DL men, such as the effect of the Internet on HIV risks and the role of sexual networks on HIV risks. The Internet is one of the few places where DL men openly congregate and identify as ‘DL’ in chat rooms and web boards.  However, the few studies of HIV risk associated with men who use the Internet to find sexual partners do not include large samples of Black men. Likewise, the sexual networks of MSM, and specifically Black MSM, remains understudied. We need to understand the social and sexual networks of Black MSM and  DL men, and whether these networks promote or lessen HIV risk. 
There are a dearth of interventions targeting Black MSM.  More effective HIV prevention interventions (that promote HIV testing) must be implemented for Black men generally, irrespective of sexual identity. 

## Acknowledgements

- _CDC_
- Katherine Bina
- Lisa Fitzpatrick
- Alan Greenberg
- Charles Heilig
- Gary Marks
- Byron Mason
- Pilgrim Spikes

- _Georgia State University_
- John Peterson

**Notes:**
I would like to thank several people who helped me conceptualize this talk.  I would especially like to thank Drs. Alan Greenberg, Gary Marks, Charles Heilig and John Peterson for their input.