The “Forgotten”

Lisa Bowleg, PhD
Department of Community Health and Prevention, School of Public Health, Drexel University

Heterosexual men? Men who have sex with women? Heterosexually active men? Heterosexually identified men? Men’s heterosexual risk behaviors? Heterosexual men’s behaviors? A dizzying number of terms to be sure, but whatever the label, heterosexually active men have been and remain virtually invisible in most of U.S. HIV/AIDS prevention theory, research, and interventions. They are the “forgotten group” (Exner, Gardos, Seal, & Ehrhardt, 1999, p. 347). More than 10 years after Exner et al. evoked the “forgotten” adjective to describe HIV interventions for heterosexually active men, not much has changed.

There are strong arguments for focusing on heterosexually active men, both those who are exclusively heterosexual and those who may also engage in sex with men. First, there is a startlingly high incidence and prevalence of heterosexually transmitted HIV among women in general, and among women of color in particular. Heterosexual transmission is the leading cause of HIV exposure among women, accounting for 85% of newly diagnosed infections in 2009 (Centers for Disease Control and Prevention [CDC], 2010a). High-risk heterosexual contact, which the CDC (2010a) defines as “heterosexual contact with a person known to have, or to be at high risk for, HIV infection,” accounts for 68 percent, 15 percent and 13 percent of the HIV/AIDS cases among women who are Black, non-Latina White and Latina, respectively. This is the case even though Black, White and Latina women account for 14 percent, 70 percent and 11 percent of the female population in the United States, respectively (CDC, 2010d). Second, HIV is “more efficiently” transmitted from men to women. Third, issues of gender and power make it very difficult for women to negotiate condom use easily with heterosexual partners (e.g., Amaro, 1995; Bowleg, Lucas, & Tschann, 2004; Pulerwitz, Amaro, DeJong, Gortmaker, & Rudd, 2002; Wingood, Hunter-Gamble, & DiClemente, 1993). Does it not make sense from a public health perspective to focus on those who most efficiently transmit the virus to women and wear the condoms?

Men and heterosexual HIV/AIDS exposure

High-risk heterosexual contact accounted for just 14 percent of new HIV cases among all men in the United States in 2009 (CDC, 2010a). Black men accounted for 9 percent of HIV cases reported in 2009 due to high-risk heterosexual contact. Black heterosexual men also play a key role in the heterosexual transmission of HIV to Black women, who accounted for 68 percent of heterosexually acquired HIV reported among women in 2009 (CDC, 2010a). Heterosexual Latino men are also disproportionately affected. Heterosexual transmission accounted for 17 percent of the new HIV cases reported in 2009 among Latino men. By comparison, heterosexual transmission accounted for just 11 percent of the cumulative HIV and AIDS cases among White men. The virus also has a disparate impact on ethnic minority men: In the 37 states reporting HIV statistics, Black, Latino and White men accounted for 14 percent, 14 percent and 69 percent of the male population, respectively (CDC, 2010c).

Invisible men

A quick glance at the HIV/AIDS section on the CDC website aptly shows the invisibility of heterosexually active men in the HIV/AIDS epidemic. Inspection of the page reveals links to key groups such as African Americans, men who have sex with men (MSM) and women, but you will not find any specific link to heterosexually active men. Alas, this is also the case at most U.S. HIV/AIDS conferences.

In the HIV/AIDS prevention literature, men show up as drug users, MSM, people seeking treatment for sexually transmitted infections or HIV tests, sexual partners of women, but rarely as gendered beings in their own right. Although the concepts of gender and power have emerged as important theoretical frameworks for understanding women’s HIV risk (Amaro, 1995), this has happened to a far lesser extent for men. This may be because gender is often obscured for men, for whom risks are deemed not only to be natural but inherent to manhood as well (Courtenay, 2000). It is interesting to note that while same-sex behavior is salient for men in the HIV/AIDS epidemic, a similar focus on men’s heterosexual behaviors is pretty much nonexistent. In the context of the HIV/AIDS epidemic, maleness and heterosexuality, two otherwise powerful statuses, intersect to confer the dubious privilege of invisibility.

Heterosexuality, masculinity, and HIV risk

Ronald Levant, PhD, former president of the American Psychological Association (APA) and one of the pioneers of the study of men and masculinity, has extensively studied various dimensions of masculinity. His research validates that avoidance of femininity, homophobia, achievement/status, attitudes toward sex, restrictive emotionality, self-reliance and aggression are all dimensions of masculinity (Levant & Majors, 1997). Although there is not a monolithic masculinity applicable to all men, findings from qualitative research with low-income Black men suggests that young Black men who fail to meet some of the economic, sociopolitical and sexual requirements for ideal masculinity may develop an incomplete gender identity (Whitehead, 1997). This “fragmented masculinity” in turn may increase risk as men of lower socioeconomic status engage in behaviors such as sex with multiple partners to affirm their masculinity.

A handful of studies have demonstrated links between “traditional” male gender role norms and HIV risk behavior. For example, traditional male gender roles are associated with more sexual partners, less consistent condom use and less belief in male responsibility for contraception (Pleck, Sonenstein, & Ku, 1993). Such gender roles are also associated with more negative attitudes toward condoms (Noar & Morokoff, 2002; Pleck et al., 1993), less unprotected sex and more intimate partner violence (Santana, Raj, Decker, La Marche, & Silverman, 2006). Furthermore, preliminary evidence from a qualitative study suggests that nontraditional male gender role norms such as being at least as emotionally invested in relationships as their female partners — if not more so — may be associated with more protective behaviors (Bowleg, 2004). Conversely, findings from other qualitative research demonstrates that masculinity ideologies — such as that men should have sex with multiple women, often concurrently (Bowleg et al., in press; Carey, Senn, Seward, & Vanable, 2008); men should not be gay or bisexual; men should not decline sex, even risky sex; and women should be primarily responsible for condom use — may increase risk for Black heterosexual men (Bowleg et al., in press). These studies, combined with others showing that men typically control condom use (e.g., Bowleg et al., 2004) and women most commonly bear the burden of negotiating condom use (e.g., Wingood & DiClemente, 1998; Wingood et al., 1993), demonstrate the need for more theory, research and interventions focused on the issues of gender and HIV risk.

Whither MSM in the heterosexually active male and HIV prevention equation?

According to the CDC (2010a), the category called “other/risk factor not reported or identified” accounts for 29 percent of incident HIV cases in 2009. For Black men, this category is higher than it is for men from any other ethnic category, accounting for 57 percent of new HIV cases in 2009. This finding prompted the CDC to posit that most of the unspecified risk exposures among Black men are due to unprotected sex with men. Empirical research bolsters the CDC’s hypothesis. A study with heterosexually identified Black men found that 47 percent reported anal sex with men (Wohl et al., 2002), suggesting that a focus on MSM is critical in HIV prevention initiatives. Still, what about the 53 percent of men who did not report anal sex with men? More than two decades into the epidemic, there is still so much we do not know about men who are sexually active with women, regardless of whether or not they have sex with men. For example, to what extent, if any, do they overlap with MSM? To what extent do they perceive themselves as being at risk for HIV? What are their risk and protective behaviors? What male-focused interventions would be most effective in reducing the heterosexual transmission of HIV?

Larry Gant, PhD, professor of social work at the University of Michigan and principal investigator of a National Institute on Drug Abuse–funded intervention for predominantly heterosexual Black men in residential substance abuse programs in Detroit, stresses that men desperately need affirming spaces in which to discuss sexuality and HIV prevention (Gant, 2008). As evidence for his assertion, Gant notes that 40–50 Black men who were participants in his study have continued to meet on a regular basis to discuss sexual issues even though the study ended long ago. Gant’s experience certainly dispels the common notion that men will not talk openly about sex.

The sociocultural context of risk for heterosexually active men of color

Several years ago, public health officials in the District of Columbia postulated the theoretical link between sociocultural context and HIV risk for heterosexual Black men by noting that poverty and high unemployment rates create “a high-risk situation [because] the low morale/esteem that [this economically disenfranchised] status breeds can lead to drug use and high risk behaviors” (District of Columbia Department of Health, n.d.). Among Blacks, those who live in urban poverty — approximately 46 percent — are at highest risk for HIV (Denning & DiNenno, 2010). Furthermore, Black men are disproportionately represented in U.S. prisons and jails, where the overall rate of confirmed AIDS cases in 2007–2008 was two times that of the general population (Maruschak & Beavers, 2009). Thus, not only are incarcerated men themselves at risk but their sexual and drug-sharing partners are also a hidden at-risk population (e.g., Comfort, Grinstead, Faigeles, & Zack, 2000).

Structural factors broadly defined as the “physical, social, cultural, organizational, community, economic, legal or policy aspects” that either hinder or help an individual’s ability to prevent HIV infection (Sumartojo, Doll, Holtgrave, Gayle, & Merson, 2000) are associated with increased rates of HIV/AIDS (CDC, 2010b). HIV prevention researchers have highlighted several structural factors that are associated with HIV risk, including poverty (Denning & DiNenno, 2010; Sumartojo, 2000), housing (Aidala, Cross, Stall, Harre, & Sumartojo, 2005), incarceration (Comfort, 2008), and impoverished neighborhoods (Cubbin, Santelli, Brindis, & Braveman, 2005; Denning & DiNenno, 2010). Understanding how structural factors may be related to sexual HIV risk is a critical prerequisite to developing effective interventions for heterosexually active men.

In reflecting on the success of his intervention, called JEMADARI, for Black men in Detroit, Gant asked, “What does it say about the need and importance for a program [like JEMADARI] when so many Black men continue to meet week after week for 2-hour sessions, without a break, for up to 9 years?” (L. Gant, personal communication, February 17, 2008). He believes that the answers to that question are to be found in the contextual benefits that JEMADARI confers its participants. In Gant’s words,

JEMADARI was and is about relationships, about communication, about shared respect, and about the unequivocal reality that these Black men matter to each other, to their families, and to their communities. These men — some slowly, and others somewhat more quickly — come to realize the daily battles and struggles to maintain their truth in the face of largely indifferent, often hostile larger society views of Black men. If they get this larger vision and reality and support for themselves nowhere else in society, they get it in the [JEMADARI] groups.

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