David Malebranche, MPH, MD
Assistant Professor, Division of General Medicine, Emory University

Black men who have sex with men (MSM) suffer from disproportionately higher rates of HIV infection than do MSM of other ethnicities (Centers for Disease Control and Prevention [CDC], 2005, 2010). In 2006, Black men accounted for two thirds of new infections (65 percent) among all Blacks. The rate of new HIV infection for Black men was six times as high as that of White men, nearly three times that of Hispanic/Latino men, and twice that of Black women. In 2006, Black MSM represented 63 percent of new infections among all Black men and 35 percent among all MSM. HIV infection rates are higher among Black MSM than among other MSM. More new HIV infections occurred among young Black MSM (ages 13–29) than among any other age and racial group of MSM (CDC, 2010).

Researchers have postulated that the reasons behind this racial disparity are multifocal and may include late HIV diagnosis or testing practices, high co-prevalence of sexually transmitted infections, genetic predisposition in HIV susceptibility, and higher likelihood of being uncircumcised (Auvert et al., 2005; Millett, Peterson, Wolitski & Stall, 2006; Williamson et al., 2000). Factors such as poverty, lack of insurance and access, mistrust of the medical profession, and other broad social variables are other reasons for this disparity and likely are relevant to the overall racial health disparities among Black men in the United States.

The variable receiving the most attention in the discussion in public health journals and the media of HIV among Black MSM is the role of sexual identification. Specifically, coverage of so-called “down low” Black men, or men who have girlfriends or wives but secretly have sex with other men, seems to dominate sensationalistic reports about HIV in the Black community, despite that this is not a new dynamic in sexual networks.

Because of an equally disturbing high HIV/AIDS prevalence among Black women, many have suggested that a “bisexual bridge” of transmission (comprising down-low Black men) is bringing HIV from the Black MSM community to Black heterosexual women. Since some bisexual men do not disclose their same-sex behavior to their female sexual partners, they must be HIV-positive and not be using condoms, right?

Although this theory may be appealing in its portrayal of dishonesty (equating to irresponsibility with condoms), it is not necessarily rooted in truth. We know that compared with Black MSM who do disclose their same-sex behavior, those who don’t are less likely to (a) be HIV positive, (b) have multiple male sexual partners, and (c) have engaged in unprotected anal intercourse in the past 6 months with male sexual partners (CDC, 2003). Additionally, a Chicago-based study found that Black MSM with higher levels of “gay” identity engaged in riskier sexual behavior than those who did not (Crawford, Allison, Zamboni, & Soto, 2002).

The truth is, what influences sexual identification among Black MSM may be a complex mix of racial and racist life experiences, gender norms, religious beliefs, and masculine socialization. And it is not certain that how a man sexually identifies or decides to disclose publicly his same-sex behavior ultimately determines whether he will use condoms or not. Expectations of manhood for Black men often focus on physical attributes, heterosexual prowess, athletics, and entertainment. Expectations of homosexuality, on the other hand, are often associated with “gay” identification and political alignment, effeminate behavior, assimilation with the White community and HIV. Whether these sets of expectations of racial, gender, masculine, and sexual norms are founded in reality or are merely stereotypes is not the point here. Black MSM are presented with two very different sets of expectations regarding their racial and sexual identities, and when society asks them to prioritize one over the other, a problem arises.

As the Black gay activist Essex Hemphill once stated, asking a Black gay man to choose between being Black and being gay is like asking him to “choose between his right nut and his left.” The down-low Black man emerges from this context opting not to choose between these identities but rather to have his cake and eat it too. He represents a version of masculinity that is faithful to traditional Black male expectations while also representing an alternative version of homosexuality — clandestine and without any “gay” or other sexually identified political aspirations or affiliations.

In many ways, Black MSM who choose not to disclose their same-sex behavior or “come out of the closet” may actually be using a specific stress-coping mechanism. In the face of persistent racism and other forms of social oppression, Black MSM who view being gay as a lifestyle associated with effeminate behavior, displacement from the Black community, and HIV may consciously choose not to identify as such. This may not necessarily represent “self-hatred” or “internalized homophobia” but rather another form of social survival, a hustling technique intent on avoiding additional social discrimination and prejudice. In other ways, it may simply be an attempt to preserve traditional notions of Black masculinity in the face of the negative and emasculated perception society has of homosexual behavior. Either way, how Black MSM sexually identify may begin and end with the social context of what it means to be a Black man in the United States and the impact this has on their individual and collective mental health.

But where does this leave us with regard to sexual risk and HIV transmission in the Black community? My experience as a clinician working with HIV-positive Black men tells me that the context of past and current sexual risk behavior involves a complex mix of poverty, poor mental health, miseducation, substance abuse, and low life expectations, regardless of sexual identification. Working as a medical provider in an HIV clinic in Atlanta over the past 5 years, I have come across Black men who identify as heterosexual, gay, and everything in-between. Some use condoms all the time, others never, and others describe how it depends on the situation, the status of their partners, and how close their level of intimacy is with their significant others. The one consistent theme running through all their stories is the myriad social issues influencing their sexual behavior decision-making. More important, these are men who don’t believe they have the tools, resources, role models, self-esteem, or internal fortitude to address these issues in a positive and constructive manner. HIV is not the problem but rather one of the symptoms of a much larger illness currently ravaging Black men.

In my experience as a behavioral researcher, I have found that among Black MSM, what sexual identification term one uses in public or if one discloses his same-sex behavior does not determine HIV sexual risk behavior. In a small qualitative sample of Black MSM interviewed in Atlanta 2 years ago, participants described major influences on unprotected sex, including trust in sexual partners, perceptions of one’s personal and sexual partner being at “low risk,” low self-esteem and “heat of the moment” sex. The majority of the men we interviewed expressed these common themes, regardless of what term they used to describe their homosexual identities.

Given the severity of the current HIV epidemic among Black MSM, it would be fruitful to move our discussions beyond conversations of “down low” and sexual identification. Disclosing one’s same-sex behavior in public or to other sexual partners does not equate to safer sex practices. Black MSM are subject to issues and pressures concerning race, masculinity, religion, and economics similar to those that other Black men experience, and these very factors influence much more than simply how one sexually identifies. We should be focusing our future health interventions on the collective mental health of all Black men, but particularly Black MSM. Mental health, whether good or not, is the primary mediator of behaviors such as substance abuse, condom use and HIV-testing practices that are at the center of this epidemic. If we can effectively address the fundamental social causes influencing the mental health of Black MSM and create interventions focusing on redefining masculine expectations and stress-coping mechanisms, we can make inroads in the prevention and treatment of HIV in this population.

References

Auvert, B., Puren, A., Taljaard, D., Lagarde, E., Sitta, R., & Tambekou, J. (2005, July). Impact of male circumcision on the female-to-male transmission of HIV (Abstract TuOa0402). In D. Serwada & N. Padian (Chairs), Sexual transmission. Oral abstract session conducted at the Third IAS Conference on HIV Pathogenesis and Treatment, Rio de Janeiro, Brazil.

Crawford, I., Allison, K. W., Zamboni, B. D., & Soto, T. (2002). The influence of dual-identity development on the psychosocial functioning of African-American gay and bisexual men. Journal of Sex Research, 39, 179–189. doi:10.1080/00224490209552140

Centers for Disease Control and Prevention. (2003). HIV/STD risks in young men who have sex with men who do not disclose their sexual orientation—Six U.S. cities, 1994–2000 (PDF, 203 KB). MMWR, 52(5), 81–85.

Centers for Disease Control and Prevention. (2005). HIV prevalence, unrecognized infection, and HIV testing among men who have sex with men—Five U.S. cities, June 2004–April 2005. MMWR, 54(24), 597–601.

Centers for Disease Control and Prevention. (2010). HIV/AIDS among African Americans [Fact sheet].

Millett, G. A., Peterson, J. L., Wolitski, R. J., & Stall, R. (2006). Greater risk for HIVinfection of Black men who have sex with men: A critical literature review. American Journal of Public Health, 96, 1007–1019. doi:10.2105/AJPH.2005.066720

Williamson, C., Loubser, S. A., Brice, B., Joubert, G., Smit, T., Thomas, R., …van der Ryst E. (2000). Allelic frequencies of host genetic variants influencing susceptibility to HIV-1 infection and disease in South African populations. AIDS, 14, 449–451.