# Presentation: 136477

## The Social Context of HIV Risk among Black MSM: A Qualitative Exploration

- David J. Malebranche, MD, MPH
- Emory University Division of Medicine
- PACHA 31st Meeting
- October 17, 2006

## Funding and Support 

- The Collaborative HIV-Prevention Research in Minority Communities Program
_**Director**_: Barbara Marin, PhD
_**Faculty**_: Hector Carillo, DrPH; Tor Neilands, PhD; Margaret M. Dolcini, PhD;  Olga Grinstead, PhD, and Jeanne Tschann, PhD

## Bisexual behavior, “gay” identity and Black MSM

- Black MSM more likely to identify as heterosexual or bisexual than white MSM (Montgomery 2003;Heckman, 1999)
- Black MSM are less likely to identify as “gay” than MSM of other ethnicities (Young Men’s Survey, 2001)
- Black MSM are more likely to report bisexual behavior than white MSM (Stokes, 1996;Torian 1999; Kramer 1980)
- Sexual identification & Disclosure not predictive of high sexual risk behavior (Millett et al., 2006)

## Masculinity and HIV risk

- Most black masculinity research and focus has been regarding heterosexual men
- Black heterosexual men rely on female conquests, number of female partners, fathering children, and having sex without a condom as sexual indicators of masculinity (Harris 1992; Franklin 1994; Whitehead 1997; Jackson 1997; Nowatzki 1999; Blazina 2001).
- Connections between masculinity, self-esteem and HIV risk among Latino MSM has been documented (Diaz, 1998)

## Methods

- 29 one-on-one interviews with black MSM in Atlanta, GA
- Recruited via internet and at local park
- June – August 2003
- 5 – 10 minute quantitative survey
- 90 minute interviews
- $25 participant reimbursement

## Objectives

- 1) Describe the subjective life experiences of BMSM
- 2) Explore the social context in which BMSM developed perceived masculine norms
- 3) Describe the influence of masculine socialization on sexual identity of BMSM
- 4) Explore how masculine socialization influences the sexual identities, networks and behavior of black MSM

## Survey Findings

| Mean Age | 28.8 |
| --- | --- |
| Sexual Identification | 69% non ”gay” - identified |
| Bisexual History | 35% (10/29) any
14% (4/29) current |
| Childhood Sexual Abuse | 28% (9/29) |
| Masculine Priorities | 66% ranked spirituality as most important |

## THEMES

## Familial Upbringing Dynamics

- Young age of parents
- Paternal disconnect/Maternal closeness
- Geographical instability
- Few positive black male role models
- Strong spirituality/religious influence

## Familial Upbringing Influence

- “I think it was my upbringing, the way I was raised. My parents always told me be the best at what you do. I’m not gonna go out there and put myself out there and make myself seem like all I’m about is partying. I’m all about trying to better myself, better the person I’m with, we can grow emotionally strong without sex, sex is something we can look forward to and not have.” (23)

## Childhood Sexual Abuse

- “I was 7 or 8. He [male cousin] molested me all the way up until I was like 17 or somethin’.” (28)
- “I guard sexuality. In it’s complete form. I don’t feel comfortable hugging people.” (24)
- “I did him [male cousin], and after that it was like nothing but suicidal thoughts. I wanted to kill myself.” (31)
- “I thought it [CSA] was natural. All my cousins were doing it.” (22)
- “It [CSA] came back to haunt me years later. I began to fear being around other guys.” (39)

## Dynamics of CSA

- Insidious nature of CSA
- Manipulation with curiosity, fear, intimidation
- Age-related dynamics (older male relatives)
- Depression, PTSD, suicidal thoughts
- Lack of verbal communication
- Homosexual “blame” on CSA
- Association of same-sex desire with CSA
- Unprotected sex

## Masculine Socialization

- Masculine ≠ “gay”
- Influence on same-sex attraction/partners
- Associated with responsibility & providing
- Awareness/denial of black masculine stereotypes
- Defined by mannerisms

## Masculine Socialization

- “At the time it meant John Shaft. You remember the movie Shaft, he had his theme music and everything, the way that he walked, everything about him was perfect. The way his hair was combed to the way he expressed himself, he had his clothing, the women loved him, the men wanted to be him, that was masculinity, and nothing less would do.”  (39)
- “It’s more about to me being able to uphold or live up to your responsibilities. Accountability, you know, having a goal, a career, something in mind, something long term and not so much living for now but living for the future and for now. That’s what I see masculinity as. (24)
-  “Just don’t get anybody pregnant.”  (18)

## Upbringing and Black Masculinity

- “We got a lot of issues as African-Americans and that’s partly, I think, because of the absence of real male role models who could clearly define what it means to be masculine and what it means to be a man. So, you know, we’ve come up with these false definitions of manhood and masculinity that are really, to me, just ludicrous.” (33)

## Dimensions of “Gay”

- “The white and black gay lifestyles are the same – it’s about partying, f*****’ who you can, drugs, whatever the case may be – just really, really fast paced life.” (22)
- “Labels put limits on what you think you can do, and I don’t want to do that to myself. I mean if you want to call me gay, I don’t care. I’ll say I’m gay, I’ll say I’m homosexual, I’ll say I’m bisexual, whatever. I’m a lot of things, but am I willing to label myself?  No.”  (22)

## Bisexuality, “Cheating” and HIV Risk

- “Yeah, I haven’t slept with a dude in about 2 weeks, but as long as I don’t cheat on her [my girlfriend] with another female, then that’s cool. But I’ll still mess with males. Cause, I don’t know, there’s sometimes when I want to mess with a female and sometimes I want to mess with a male.” (18)
- “A girl I might have had sex [unprotected] with her just twice, but I’ve had sex with men without a condom more than twice so I guess that’s, you know, I felt like I couldn’t get them pregnant.  Disease was like, after pregnancy in my head.” (18)

## Sexual Networking & Behaviors

- Influence of age, race & perceived masculinity of partner
- Perception of trust
- Relationship & sexual modeling
- Mental health fluidity
- Surface perceptions of partner risk
- Early sexual experiences

## Universality of sexual risk among men

- “I was just having a discussion with J about that the other day about gay men being more promiscuous than heterosexual men. And I told him I couldn’t really see it because when I was just datin’ females, we used to have sex like I’m doin’ now. We was just havin’ sex with girls all the time, so it was like. And my boys, I still, they married and everything but they have their little things on the side, and they still be doin’ it.” (33)

## Personal reasons for not using condoms

- Heat of the moment sex
- Poor risk assessment
- No Fear
- Trust/Intimacy
- Low self-love

## Conclusions

- Familial dynamics crucial
- Sexuality - fluid and unique
- Bisexuality a part for 1/3 of participants
- Sexual identity labels problematic
- Masculine socialization influences:
-  sexual networks
-  sexual roles and identities
* **not condom use*

## Future Directions

- Research exploring the factors influencing sexual networks and behavior
- Consider familial-based HIV prevention programs
- Male mentorship as an HIV intervention
- Beyond testing & treatment

## Works in Progress

- Brothers United Study – CDC
- Qualitative analysis – influences on sexual behavior, network and HIV testing
-  Quantitative analysis – 480 surveys with Black MSM in Atlanta, GA
- The Gatekeepers Study – Qualitative Bisexual risk and disclosure

## Curbing risky sexual behavior –A Difficult Dilemma...

- “Duh, because it feels good...”