Abstract
Black men “on the down low” have been considered prime agents of HIV transmission in the Black community despite little empirical evidence. We assessed the relationship between down-low identification and sexual risk outcomes among 1151 Black MSM. Down-low Identification was not associated with unprotected anal or vaginal sex with male or female partners. Future HIV prevention programs and research should target sexual risk behaviors of Black men, irrespective of identity, and not focus on the “down low.”
The term “on the down low” has been used to describe Black men who identify as heterosexual yet put their female partners at risk for HIV infection by secretly having homosexual sex.1–7 Black men on the down low have been implicated in the popular press as prime agents of HIV transmission in the Black community.1,8–10 However, the extent to which the down low is associated with HIV risk behavior has never been quantitatively examined among a large sample of Black men who have sex with men (MSM). We sought to assess whether or not down low identity is associated with greater sexual risk behavior with male or female partners of Black MSM.
METHODS
Data were collected as part of a study funded by the Centers for Disease Control and Prevention. The Brothers y Hermanos study recruited Black and Latino MSM to examine factors associated with HIV risk behavior and HIV infection. Men were enrolled from May 2005 to April 2006 in Philadelphia, Los Angeles, and New York City. Candidates had to be male (and identify as such); be 18 years or older; self-identify as Black, African American, or Latino; and report sexual intercourse (oral, anal sex, or mutual masturbation) with a man in the past 12 months. Participation was open to men who were HIV positive, HIV negative, or of unknown serostatus. Respondent-driven sampling11,12 was used to recruit participants. Participants completed an audio computer-assisted self-interview followed by HIV testing. All participants, except those who disclosed during screening that they had previously been diagnosed as HIV positive, received pretest counseling and were tested for HIV antibodies using a rapid, oral fluid HIV antibody test. Participants who preliminarily tested positive on the rapid test and those who disclosed during screening that they were HIV positive provided a blood specimen for confirmatory testing through Western blot assay. Our analysis was restricted to data collected from 1151 Black MSM in New York City and Philadelphia.
Identification with “down low” was assessed by the question “Do you identify with any of the following terms? (check all that apply): queer; same-gender loving; in the life; on the down low; none.” Men who checked “on the down low” were categorized as “identify with the down low”; all other men were categorized as “do not identify with the down low.” The meaning of down low was also asked of respondents and worded as follows: “Recently people have been talking more about the down low or DL, but this may mean different things to different people. We would like to know what DL means to you. Which of the following do you feel best describes men who are DL or on the down low? (check all that apply): extremely masculine; always tops (men who penetrate during anal or oral sex); less likely to have HIV; have fewer male sex partners than gay identified men; DL only refers to Black men; have wives or girlfriends; only have male sex partners; I don't agree with any of these; I never heard of the term down low or DL.”
Risk behavior outcomes (yes or no) included insertive unprotected anal intercourse with a male in the past 3 months, receptive unprotected anal intercourse with a male in the past 3 months, or unprotected anal or vaginal intercourse with a female in the past 3 months.
Descriptive analyses and the χ2 test were used to compare demographic and sexual risks of the full sample of down-low MSM and nondown-low MSM. For all analyses, unadjusted bivariate relationships were examined first to test for differences between down-low–identified and nondown-low–identified MSM. Variables included in multivariate models were those found to be statistically significant in bivariate analyses (P ≤ .10) or relevant based on a priori knowledge. Multivariate logistic regression assessed the contribution of down low identity to each of the sexual risk behavior outcomes among MSM reporting sex with male or female partners in the past 3 months, while adjusting for age, sexual orientation, HIV serostatus, study site, sex trade, income, and type of sexual partners.
RESULTS
One third of participants (31%) identified with the term “on the down low.” Down-low MSM were more likely than were nondown-low MSM to report their sexual identity as bisexual and to report that it was “very important” to keep their same-sex behaviors secret (Table 1). One fourth of down-low MSM also reported a gay sexual identity, and 11.1% reported being straight or heterosexual. Regarding the meaning of “down low,” comparable proportions of down-low MSM and nondown-low MSM selected similar characteristics that “best describe” men who are down low. Half of the men (irrespective of down-low identity) did not characterize the down low as having a wife or a girlfriend.
TABLE 1.
Demographic, HIV Status, and Risk Behavior Comparison of Black MSM Who Do and Do Not Identify With the Term “Down Low”: Philadelphia and New York City, 2005–2006 (N = 1151)
| Do Not Identify With Down Low, No. (%) (n = 790) | Identify With Down Low, No. (%) (n = 361) | P | |
| Age | .353 | ||
| 18–29 | 111 (14.1) | 47 (13.1) | |
| 30–39 | 174 (22.1) | 65 (18.1) | |
| 40–49 | 364 (46.1) | 175 (48.6) | |
| ≥ 50 | 140 (17.7) | 73 (20.3) | |
| Gross annual income | .680 | ||
| < $5,000 | 264 (34.4) | 131 (36.8) | |
| $5,000–$9,999 | 183 (23.8) | 85 (23.9) | |
| $10,000–$19,999 | 163 (21.2) | 66 (18.5) | |
| $20,000–$29,999 | 72 (9.4) | 39 (11.0) | |
| ≥ $30,000 | 86 (11.2) | 35 (9.8) | |
| Sexual identity | <.001 | ||
| Homosexual or gay | 443 (56.2) | 101 (28.1) | |
| Bisexual | 225 (28.6) | 200 (55.6) | |
| Heterosexual or straight | 83 (10.5) | 40 (11.1) | |
| Other | 37 (4.7) | 19 (5.3) | |
| What best describes men on the down lowa | |||
| Have wives or girlfriends | 400 (51.0) | 176 (48.8) | .489 |
| Extremely masculine | 142 (18.1) | 87 (24.1) | .018 |
| Always the top partner | 131 (16.7) | 82 (22.7) | .015 |
| Have fewer male partners than gay men | 152 (19.4) | 82 (22.7) | .191 |
| Don't agree with any of above statements | 119 (15.2) | 48 (13.3) | .406 |
| Never heard of the “DL”b | 25 (3.2) | … | … |
| Ever tested for HIV | 726 (92.0) | 324 (89.8) | .206 |
| HIV status | <.001 | ||
| Negative | 343 (43.8) | 202 (56.3) | |
| Positive (infected, aware)c | 362 (46.2) | 124 (34.5) | |
| Positive (infected, unaware)c | 79 (10.1) | 33 (9.2) | |
| Type of sexual intercourse, past 3 months | |||
| Traded sex with a male | 160 (20.3) | 106 (29.4) | .001 |
| Any anal intercourse with male | 555 (70.3) | 265 (73.4) | .273 |
| Insertive UAI with male (n = 820)d | 263 (47.4) | 138 (52.1) | .209 |
| Receptive UAI with male (n = 820)d | 205 (36.9) | 74 (27.9) | .011 |
| Any vaginal/anal intercourse with female | 182 (23.0) | 167 (46.3) | <.001 |
| Unprotected vaginal or anal intercourse with female (n = 349)e | 108 (59.3) | 98 (58.7) | .901 |
| Importance of keeping sex with men secret | .001 | ||
| Not at all important | 273 (34.7) | 50 (13.9) | |
| Somewhat/little important | 328 (41.3) | 145 (40.2) | |
| Very important | 188 (23.9) | 166 (46.0) |
Note. MSM = men who have sex with men; DL = down low; UAI = unprotected anal intercourse. Numbers may not add to totals due to missing data.
These statements were checked by participants as best describing men who are down low. Other statements not shown were checked by less than 15% of participants in the DL or non-DL samples.
Zero participants who identified with the term “down low” reported that they had “never heard of the DL.”
Infected-aware men self-reported that they were HIV-positive at the time of study enrollment, and their positive status was confirmed through study testing. At enrollment, infected-unaware men self-reported they were HIV-negative, did not know their status, did not return for result of their last HIV test, or last test result was indeterminant. These men subsequently tested HIV-positive through study testing.
Includes only participants who had a male sex partner in the past 3 months (n = 820; 265 DL men; 555 non-DL men).
Includes only participants who had a female sex partner in the past 3 months (n = 349; 167 DL men; 182 non-DL men).
A majority of participants had previously been tested for HIV and there were no significant differences between down-low MSM and nondown-low MSM in HIV testing history. Similar proportions of down-low MSM and non down-low MSM tested HIV positive and were unaware of their infection, but down-low MSM were significantly less likely to be HIV positive overall.
Similar proportions of down low and nondown-low men had recent sexual intercourse with a male partner. Among these participants, comparable proportions of down-low and nondown-low MSM reported insertive unprotected anal intercourse, whereas down-low MSM were significantly less likely than were nondown-low MSM to report receptive unprotected anal intercourse. Down-low MSM were more likely to report sex trade activities with men and more likely than were nondown-low MSM to have sexual intercourse with women. However, one fourth of nondown-low men also reported recent sex with a woman, and down-low MSM and nondown-low MSM reported comparable rates of unprotected sex with women.
Table 2 shows the results of 3 multivariate logistic regression models for each risk behavior outcome. Controlling for other covariates, down-low identity was not significantly associated with any sexual risk outcome. In additional analyses we conducted (not shown) in which we restricted the sample to HIV-positive men, we found no significant differences in the proportions of down-low identified and nondown-low identified men reporting unprotected sex with female partners who were HIV negative or whose HIV status was unknown (N= 72; χ2 = .937; P = .333) or male partners (N= 365; χ2 = .016; P = .898).
TABLE 2.
Multivariate Logistic Regression Models of the Association Between Down Low Identity and Unprotected Intercourse with Male and Female Partners, Among Black MSM Recruited in New York City and Philadelphia, 2005-2006
| Unprotected Insertive Anal Intercourse With a Male in the Past 3 Monthsac (n = 801) |
Unprotected Receptive Anal Intercourse With a Male in the Past 3 Monthsac (n = 801) |
Unprotected Vaginal or Anal Intercourse With a Female in the Past 3 Monthsbc (n = 342) |
||||
| AOR (95% CI) | P | AOR (95% CI) | P | AOR (95% CI) | P | |
| Identify as “down low” | 1.12 (0.80, 1.55) | .511 | 0.87 (0.60, 1.27) | .474 | 0.84 (0.53, 1.34) | .471 |
| Age, y | 0.99 (0.98, 1.01) | .517 | 0.99 (0.97, 1.00) | .090 | 1.00 (0.97, 1.02) | .843 |
| Sexual identity | ||||||
| Heterosexual or straight | Ref | Ref | Ref | |||
| Homosexual or gay | 0.97 (0.50, 1.90) | .938 | 7.36 (2.68, 20.22) | <.001 | 1.07 (0.40, 2.88) | .894 |
| Bisexual | 1.03 (0.54, 1.99) | .921 | 2.27 (0.83, 6.22) | .112 | 0.94 (0.53, 1.67) | .826 |
| Other | 0.59 (0.22, 1.54) | .279 | 2.27 (0.62, 8.37) | .218 | 0.85 (0.29, 2.47) | .763 |
| HIV status, self-reported | ||||||
| Negative | Ref | Ref | Ref | |||
| Positive | 0.97 (0.69, 1.37) | .870 | 1.42 (0.97, 2.07) | .074 | 0.57 (0.31, 1.05) | .073 |
| Unknown | 1.09 (0.69, 1.70) | .719 | 1.61 (0.98, 2.64) | .058 | 0.94 (0.48, 1.83) | .853 |
| Traded sex with a male past 3 months | 1.95 (1.36, 2.78) | <.001 | 2.11 (1.43, 3.13) | <.001 | 1.17 (0.69, 1.99) | .552 |
| Type of sex partner(s) in past 3 monthsd | ||||||
| Main partner only | Ref | Ref | Ref | |||
| Casual partner only | 0.96 (0.65, 1.41) | .836 | 0.64 (0.41, 0.99) | .043 | 1.07 (0.65, 1.78) | .780 |
| Both main partner and casual partner | 2.16 (1.40, 3.31) | <.001 | 1.65 (1.05, 2.60) | .030 | 3.93 (1.97, 7.85) | <.001 |
| Study site | ||||||
| Philadelphia, PA | Ref | Ref | Ref | |||
| New York City, NY | 1.29 (0.94, 1.76) | .114 | 1.08 (0.77, 1.53) | .648 | 0.65 (0.39, 1.09) | .104 |
Note. MSM = men having sex with men; AOR = adjusted odds ratio; CI = confidence interval.
Participants reporting no sex in the past 3 months with a male partner are excluded from this analysis.
Participants reporting no sex in the past 3 months with a female partner are excluded from this analysis.
Models adjusted for income level of participants.
Type of partner refers to male partners in models predicting insertive and receptive unprotected anal intercourse, and female partners in model predicting unprotected vaginal and anal intercourse. Main partner was defined as a “committed relationship.”
DISCUSSION
Our study suggests several important findings. First, contrary to what has been reported in the popular press, down-low identity was not associated with engaging in greater sexual risk behavior with female or male partners. Black MSM who identified with the down low (irrespective of their HIV serostatus) engaged in similar sexual risks with male and female partners as nondown-low–identified MSM. Although down-low MSM were more likely than were nondown-low MSM to report a female sex partner, both groups of men engaged in comparable sexual risks with female partners. Second, identifying with the down low did not always imply having female sex partners. Half of the down-low men in our study reported no recent sex with a woman, whereas 23% of nondown-low men reported a recent female sex partner. Third, our study challenges prevailing assumptions that men on the down low primarily identify as heterosexual. Down-low MSM were much more likely to identify as bisexual or homosexual than heterosexual, and nondown-low MSM were just as likely as down-low MSM to report being heterosexual. Last, compared with nondown-low MSM, down-low–identified MSM reported fewer instances of receptive unprotected anal intercourse with male partners and were less likely to test HIV positive.
Our study has its limitations. First, the survey did not differentiate primary identification as down low from other identities that down-low men may have chosen. Second, the men in our sample were predominantly low income and were recruited in metropolitan areas in the Northeast; they may not be representative of Black MSM overall. Third, we relied on self-reports to assess sexual risk behaviors, although use of audio computer-assisted self-interviews likely reduced underreporting because of social desirability.
Findings from our study underscore the limitations of using identity rather than sexual behavior to predict sexual risk.13–17 Interventions that focus on men who identify as down low will fail to reach significant numbers of nondown-low–identified men who are sexually involved with women. The scientific community should address more salient, and scientifically valid, contributors to sexual risk among Black MSM than identifying as “down low.”
Acknowledgments
The Brothers y Hermanos study was funded through a cooperative agreement from the US Centers for Disease Control and Prevention.
The authors would like to thank the entire Brothers y Hermanos study team, community-based partners in Philadelphia and New York City for their collaboration on the study, and volunteer members of local community advisory boards who guided the design and implementation of the study.
Human Participant Protection
This study was approved by the institutional review boards of the Public Health Management Corporation, the New York City Department of Health and Mental Hygiene, Hunter College, and the Centers for Disease Control and Prevention. All HIV testing information was collected with signed informed consent.
References
- 1.Denizet-Lewis B. Double lives on the down low. New York Times Magazine. August 3, 2003. Available at http://query.nytimes.com/gst/fullpage.html?sec=health&res=9F0CE0D61E3FF930A3575BC0A9659C8B63. Accessed July 1, 2007
- 2.Harris EL. Passing for straight: talking to brothers on the down low. Essence. June 8, 2004. Available at http://www.essence.com/essence/bodyandsoul/relationships/0,16109,648878,00.html. Accessed July 1, 2007
- 3.King JL. On the Down Low: A Journey Into the Lives of “Straight” Black Men Who Sleep with Men. New York, NY: Broadway Books; 2004 [Google Scholar]
- 4.Williams S. My downlow husband. Black Star News. March 11, 2005. Available at: http://www.blackstarnews.com/?c=135&a=1394. Accessed July 1, 2007
- 5.A secret sex world: living on the “down low” [television broadcast]. Oprah Winfrey Show. CBS television. April 16, 2004 [Google Scholar]
- 6.Johnson JB. Secret gay encounters of Black men could be raising women's infection rate. San Francisco Chronicle. May 1, 2005. Available at: http://sfgate.com/cgi-bin/article.cgi?file=/c/a/2005/05/01/DOWNLOW.TMP&type=health. Accessed July 1, 2007
- 7.National Association of State and Territorial AIDS Directors Black Men Who Have Sex with Men. Issue Brief No. 1; February 2006. Available at: http://www.nastad.org/Docs/Public/Publication/2006221_BlackMSM_IssueBrief_FINAL.pdf (PDF). Accessed July 1, 2007
- 8.Wright K. The great down-low debate. A new Black sexual identity may be an incubator for AIDS. The Village Voice. June 6–12, 2001. Available at: http://www.villagevoice.com/news/0123,wright, 25340,5.html. Accessed July 1, 2007 [Google Scholar]
- 9.Sternberg S. The danger of living ‘down low’; Black men who hide their bisexuality can put women at risk. USA Today. March 15, 2001:1D [Google Scholar]
- 10.Vargas JA. HIV-positive, without a clue: Black men's hidden sex lives imperiling female partners. The Washington Post. August 4, 2003. Available at: http://www.washingtonpost.com/wp-dyn/content/article/2006/11/27/AR2006112700669.html. Accessed July 1, 2007 [Google Scholar]
- 11.Heckathorn DD. Respondent-driven sampling: a new approach to the study of hidden populations. Soc Probl. 1997;44:174–199 [Google Scholar]
- 12.Heckathorn DD, Semaan S, Broadhead RS, Hughes JJ. Extensions of respondent-driven sampling: a new approach to the study of injection drug users aged 18–25. AIDS Behav. 2002;6:55–67 [Google Scholar]
- 13.Ford CL, Whetten KD, Hall SA, Kaufman JS, Thrasher AD. Black sexuality, social construction, and research targeting “the down low” (“the DL”). Ann Epidemiology. 2007;17:209–216 [DOI] [PubMed] [Google Scholar]
- 14.Millett GA, Malebranche D, Mason B, Spikes P. Focusing “down low”: bisexual Black men, HIV risk and heterosexual transmission. J Nat Med Assoc. 2005;97:52S–59S [PMC free article] [PubMed] [Google Scholar]
- 15.Pathela P, Hajat A, Schillinger J, Blank S, Sell R, Mostashari F. Discordance between sexual behavior and self-reported sexual identity: a population-based survey of New York City men. Ann Intern Med. 2006:145;416–425 [DOI] [PubMed] [Google Scholar]
- 16.Wheeler DP. Exploring HIV prevention needs of nongay-identified Black and African American men who have sex with men: a qualitative exploration. Sex Transm Dis. 2006;33(suppl 7):S11–S16 [DOI] [PubMed] [Google Scholar]
- 17.Wolitski RJ, Jones KT, Wasserman JL, Smith JC. Self-identification as “down low” among men who have sex with men (MSM) from 12 US cities. AIDS Behav. 2006;10:519–529 [DOI] [PubMed] [Google Scholar]