Laying the Groundwork for an HIV Prevention Intervention: A Descriptive Profile of the Los Angeles House and Ball Communities

Abstract

African American young men who have sex with men (AAYMSM) represent the largest proportion of new HIV infections among MSM. While evidence-based interventions are lacking, all too often HIV interventions are implemented in a community without thoroughly understanding its needs, risks and assets. AAYMSM are not homogenous; subgroups exist that may require different approaches to be effective. The House and Ball communities represent one such subgroup. A community-engaged, mixed-methods approach was used. Participant observations, qualitative interviews (N=26), and a survey at House/Ball events (N=252) were completed. Survey data broadly describe the community. For example: 69% of survey respondents identify as gay; 25% as bisexual; 13% reported recent use of ecstasy and 11% recently participated in sex exchange. The depth of qualitative data is key for intervention development. For example, while the survey provides broad descriptions of respondents’ involvement in the House and Ball communities, leaders provided in-depth descriptions of the structure of the House and Ball scene –something vital to the development of HIV prevention programs within these communities. This kind of rigorous study is recommended prior to implementing an intervention. Findings are discussed in relation to leveraging the communities’ supportive aspects to design culturally relevant HIV prevention programs.

INTRODUCTION

HIV rates among African American men who have sex with men (AAMSM) continue to be among the highest. According to 2009 data from the Centers for Disease Control and Prevention (CDC), AAMSM represent 63% of new infections among all African American men, and 35% among all men who have sex with men (MSM). The situation for African American youth, and young men who have sex with men (AAYMSM) in particular, is especially grave. Within the young African American population, African American youth account for 70% of all HIV/AIDS diagnoses although only representing 17% of the population (1). In a 2008 HIV/AIDS trend analysis, AAYMSM displayed the greatest increase in the number of HIV/AIDS diagnoses from 2001–2006 when compared with the general population of MSM (2).

In spite of the prevalence of HIV/AIDS within the African American communities, there is limited research to better understand HIV risk and protective behaviors among populations of AAMSM and AAYMSM. The challenge in this is that effective HIV prevention interventions require a thorough understanding of a population’s assets and deficits in order to build on supportive mechanisms and address those that may increase risk. Research efforts should also note that AAYMSM are not a homogenous group; subgroups exist that may require different methods and/or theoretical approaches to be effective.

Sexual Risk and Substance Use among AAYMSM

There is a small but growing body of research examining the possible causes of the higher rates of HIV among AAMSM. A recent literature review confirms that this disparity is likely not related to higher rates of substance use, sexual risk behavior, testing history, sex exchange, non-gay identity or nondisclosure of sexual orientation (3). The limited research does identify two possible correlates of AAMSM’s higher rates of HIV: 1) higher rates of sexually transmitted infections (STIs); and 2) higher rates of unrecognized HIV infection among AAMSM.

Use of stimulants, particularly methamphetamine or crystal, is one factor that is contributing to the most recent wave of HIV and other STIs among young men who have sex with men (YMSM) (4, 5). Although AAMSM are less likely to use crystal and more likely to use cocaine or crack than are White MSM,(6, 7)both crack/cocaine and crystal have been associated with heightened sexual risk behavior among MSM and other risk groups (8, 9). Our own research conducted with YMSM suggests that while AAYMSM are less likely to report substance use than Caucasian or Latino YMSM, they are significantly more likely to report experiences of racial discrimination and homophobia, and these experiences are significant predictors of illicit drug use and sexual risk behaviors among AAYMSM (10).

House and Ball Communities

A group that has not been thoroughly examined in the HIV literature are the House and Ball communities, which have been identified as potential high-risk populations (11). The roots of the House and Ball communities originate from 1920s Harlem. Annual Harlem Balls of the 1920s involved working-class, mostly African American men under the age of 30 performing in elaborate and ostentatious female attire as a popular form of entertainment (12). In addition to offering entertainment for spectators, young men dressed in women’s attire, or “in drag”, to compete in costume competitions for cash prizes. Although Balls originated as a safe space for “female impersonators” to compete amongst one another in New York, this phenomenon has become more inclusive of AAYMSM of different sexual and gender identities as well as Latino and Asian YMSM. Although Balls have occurred in other parts of the United States since the 1920s, it was not until 1998 that the first Ball occurred in Los Angeles. House and Ball communities are currently present in cities such as Los Angeles, Oakland, Atlanta, Chicago, Philadelphia, Detroit, Baltimore, and Washington, DC (13).

The limited research with these communities suggests that HIV is a major public health concern. From 1998 to 2000, research on an outbreak of tuberculosis among House members in Baltimore and the New York City area found that 16 of the 26 (62%) House and Ball participants were living with HIV (14). This study highlighted the importance of HIV research within these communities as well as the closely connected nature of its members and associated epidemiologic implications for the spread and transmission of disease. A more recent study (N=504) on the New York City House and Ball scene found a seroprevalence rate of 20%, with 73% of those testing positive for HIV unaware of their HIV status (11).

One qualitative study describes the House and Ball communities in the San Francisco and Detroit areas as communities that are accepting of AAYMSM, as well as African Americans of other gender and sexual identities (13). Houses are identified as having a sense of family, friendship, and support. Sanchez et al. also suggest that support is an integral component of the House and Ball communities that assuages the negative effects of stigma and life stress on risk-taking behaviors (15). Additional research suggests that the Ballroom scene offers a safe space for AAYMSM to express themselves and be recognized for their creativity. This is often an alternative to the discrimination and potential social marginalization that AAYMSM face in other venues (16).

This study provides a description of the Los Angeles House and Ball communities based on a mixed-method, community-engaged study, with the ultimate goal of developing an HIV prevention intervention designed for and by the communities. This type of study is intended to identify the assets and risks in these communities. This is a necessary step in laying the foundation to better understand this at-risk population and designing community-driven, effective HIV prevention interventions.

METHODS

The study utilized both quantitative and qualitative methods including a survey administered at House and Ball events and semi-structured qualitative interviews with House leaders. The study was a collaborative effort between research staff and members of the House and Ball communities. As such, the House and Ball community members were involved in the study design and methods through participation in a community advisory board. The communities chose a name for the study, the Positive Partnership for Prevention (P3) and provided input on different aspects of the study (e.g., recruitment, survey items). All methods were presented to local House leaders in order to ensure that the methods were not intrusive to the community’s activities and that the methods were appropriate for the target population.

Quantitative Data Collection and Measures

We conducted a confidential survey to better understand the HIV risk and protective behaviors among persons involved in the Los Angeles House and Ball communities. Individuals were recruited regardless of gender, sexual identity or behavior.

Between February 2009 and January 2010, 263 unduplicated surveys were completed at 12 survey events. House and Ball community members were eligible to participate if they attended an event during the study time period and had not previously participated in the research survey. Balls often attract individuals from Houses in other cities. However, eligibility was not based on city of residence so that we could better assess all of those who participated in the Los Angeles House and Ball communities during the study period. Observations at Balls and survey data confirm that the majority (67%) of participants have been House members (see Table 2); a large Ball in Los Angeles will have about 250 people and House rosters collected during the data collection period estimate about 175 Los Angeles House members at the time of data collection.

Table 2.

House and Ball Participation

		Total Sample (n = 263)	Males (n = 233)
		Mean (SD)	Mean (SD)
Age - first attended Balls	Range: [10, 49]	19.61 (5.01)	19.31 (4.65)
Age - first joined House	Range: [14, 35]	19.45 (3.26)	19.40 (3.20)
		N (%)	N (%)
Attended Ball in LA past 3 mo.	Yes	239 (91)	211 (91)
Walked in a Ball in LA past 3 mo.	Yes	92 (35)	85 (36)
Attended Balls in other cities	Any	99 (38)	91 (39)
	- Atlanta, GA	59 (22)	55 (24)
	- Detroit, MI	10 (4)	9 (4)
	- Chicago, IL	33 (13)	31 (13)
	- New York, NY	50 (19)	46 (20)
	- Oakland, CA	36 (14)	32 (14)
	- Philadelphia, PA	7 (3)	5 (2)
	- Washington, DC/Virginia	16 (6)	15 (6)
	- Miami, FL	7 (3)	7 (3)
	- Baltimore, MD	6 (2)	6 (3)
	- Charlotte, NC	12 (5)	11 (5)
	-Other	23 (9)	22 (9)
Reason for attending Balls	To feel supported	138 (53)	123 (53)
	To feel accepted	115 (44)	100 (43)
	To feel like part of a group	144 (55)	126 (54)
	To find friends	139 (53)	124 (53)
	To get access to drugs	12 (5)	11 (5)
	To meet sexual partners	46 (18)	42 (18)
	To feel validated	62 (24)	54 (23)
	For entertainment	259 (99)	229 (98)
	To walk in categories	172 (66)	156 (67)
House member (ever)	Yes	177 (67)	161 (69)
House member (currently)a	Yes	136 (52)	121 (52)
Changed/left House in past yearb	Yes	44 (25)	42 (26)
How long in current House**	6 Months or less	40 (29)	35 (29)
	Between 6 mo. and 1 year	26 (19)	25 (21)
	Between 1 and 5 years	58 (43)	50 (41)
	Longer than 5 years	12 (9)	11 (9)
Reason for joining a Houseb	To feel supported	101 (74)	88 (73)
	To feel accepted	80 (59)	70 (58)
	To feel like part of a group	101 (74)	89 (74)
	To find friends	85 (63)	76 (63)
	To get access to drugs	2 (2)	2 (2)
	To meet sexual partners	14 (10)	12 (10)
	To feel validated	39 (29)	31 (26)
	For entertainment	122 (90)	111 (92)
	To walk in categories	114 (84)	100 (83)
	To be part of a family	122 (90)	109 (90)

^aPercent total sample

^bIncludes only those currently reporting to be a House member

Sampling procedures were modeled after the Young Men’s Study, with venue selection and participant recruitment adapted for the target community (17). Recruitment venues were categorized into three types: Balls, House meetings, and community events. Events and venues included in the sampling frame had at least a 2-hour time period with an expected yield of at least 4 House and Ball community members. Private survey areas were created at Balls and other events through the use of portable “voting booths” designed for the project. Sampling periods typically occurred during late-night or early-morning hours.

Study staff approached persons who entered the designated venue to assess eligibility. Screening questions were administered to assess eligibility of each person. A total of 296 people were found eligible to take the survey; 287 (97%) completed the survey and a total of 263 (89%) unduplicated surveys were completed (n=24 surveys were deemed duplicates through reviewing demographic and other survey data). Eligible persons were escorted to the private survey booths to complete the data collection activity.

Respondents completed a 30–45 minute audio, computer-assisted self-interview (ACASI) survey on site. All respondents provided written informed consent. For persons younger than 18, a waiver of parental permission was obtained. Participants received a $40 incentive for completing this survey.

The survey included questions on social and demographic characteristics, sexual identity and attraction, experiences of racism and homophobia, participation in the House and Ball communities, past 3-month sexual behavior, lifetime and past 3-month substance use, HIV and STI testing behaviors, HIV status, and mental health.

Demographic variables

Participants were asked to report their: gender; age; race/ethnicity; residence; employment status; sexual identity; and sexual attraction.

Motivations for Participating in the House and Ball Communities

Using a scale developed in partnership with House leaders, questions were developed to assess motivations for joining Houses and attending Balls. Participants were asked how much of a reason various motivations (e.g., feel supported, feel accepted, feel like part of a group, find friends, access drugs, meet sexual partners, feel validated, entertainment, walk in) are for their participation. Items were scored on a five-point scale (1 = Not a reason, 2 = A little bit of a reason, 3 = Somewhat of a reason, 4 = A lot of the reason, 5 = One of the main reasons).

Substance use

Respondents were asked about their lifetime and past 3-month use of alcohol and illicit drugs including cocaine, crystal/methamphetamine, ecstasy, other club drugs (e.g., poppers, GHB, Ketamine, other forms of speed), hallucinogens (e.g., LSD, PCP, mushrooms) heroin, and prescription drugs without a physician’s order (e.g., anti-anxiety, depressants, anti-depressant/sedatives, opiate/narcotics, and attention deficit disorder medications). Respondents were also asked how often in the past three months they and their sexual partners had used alcohol and drugs prior to or during sex. Respondents assessed this use on a 4-point scale: (1 = None of the time, 2 = Some of the time, 3 = Most of the time, 4 = All of the time).

Sexual behavior

Respondents were asked about their sexual activity during the past three months, including number of sexual partners, gender of sexual partners, if they had engaged in anal and/or vaginal insertive and/or receptive sex, and if they had used a condom. Responses were combined to form a four-category index of past three months’ sexual risk: no partners; consistent protected anal intercourse (AI) regardless of the number of partners; UAI with a single seroconcordant partner; or “high-risk” UAI with a single partner whose HIV status was reported to be serodiscordant or unknown to the respondent or with multiple partners regardless of seroconcordance. Respondents were also asked if within the past 3 months, they had participated in sexual activity for payment such as money, a place to stay, a ride, clothes, jewelry or other thing of value.

History of STIs and HIV was assessed by asking respondents if they had ever been told by a doctor or health care provider that they had an STI, and if so, how many times per STI. Respondents were also asked if they had ever been tested for HIV.

Depressive Symptoms

Respondents completed the Centers for Epidemiologic Studies Depression Scale (CES-D) short form as an indicator of their psychological distress (18). Participants reported how often they had experienced each of four depressive symptoms within the past week (i.e., feeling depressed, lonely, sad, and having crying spells; α =0.84). A total score was calculated by summing the items.

Qualitative Data Collection and Measures

Between July 2008 and December 2009, 26 House leader and/or parent respondents were identified and recruited to participate in semi-structured qualitative interviews. Through our community engagement activities and participant observations, we identified and approached each of the local leaders to participate in this portion of the data collection. Participants included at least one House leader from each of the Los Angeles Houses. The interview discussion guide was designed to gather in-depth information on the structural, social and cultural characteristics of the Houses; challenges members experience in the House and Ball scene; perceived benefits of participation; House rules, activities, and communication; relationships within and outside the House; values, norms and expectations related to HIV/STI risk behaviors; and receptiveness to interventions. Each interview lasted 1.5 to 2.5 hours and was digitally recorded and professionally transcribed. All interviews were conducted in the P3 project offices or at a location convenient to the respondents (e.g., coffee house). Respondents were provided a $45 incentive for completing the interview.

Analysis

The qualitative analysis for this manuscript utilized a “constant comparative” approach, an aspect of grounded theory that entails the simultaneous process of data collection, analysis and description (19). In this process, data are analyzed for patterns and themes to discover the categories that are most salient, as well as any theoretical implications that may emerge. As the data are collected, they are immediately analyzed for patterns and themes, with the primary objective of discovering theory implicit in the data. Interview transcripts and observation notes were included in the analysis. Atlas.ti was used for coding and analysis of relationships between and within text segments.

Members of the research team reviewed an initial sample of interviews to identify key themes, which formed the basis of the project codebook. Codes focusing on a range of topics were identified and defined based on the key constructs included in the discussion guide. The codebook was modified as needed, and once finalized, three members of the research team were responsible for coding the interviews. To establish the coding system, 15% of the transcripts were double-coded. Differences in coding were discussed and resolved by the team; every 4^th transcript was double coded and then reviewed by the Ethnographer for quality checks. The open coding process included refining codes based on the data. Codes related to House activities, leadership, structure, and rules were included in the current analysis. This process led to the structure of the present study which describes: 1) the demographic composition of the Los Angeles House and Ball communities; 2) the House and Ball structure and participation; and 3) HIV risk behaviors.

RESULTS

Demographics

As summarized in Table 1, a total of 263 participants were enrolled in the study, including 7 (3%) American Indian/Native American, 3 (1%) Asian/Asian American/Pacific Islander, 218 (83%) Black/African American, 17 (7%) Latino/Hispanic, 2 (1%) White/Caucasian, and 16 (6%) identifying as some other ethnicity; nearly one-third of the sample identified with more than one ethnicity. The average age was 23.74 years, with 50% of the sample being 21–25 years of age. A majority of the respondents reported living either in their own place/ apartment (49%) or with family (37%). While 35% reported being employed and 25% reported both attending school and being employed, nearly a quarter of participants (21%) also reported being neither in school nor employed.

Table 1.

Demographics

		Total Sample (n = 263)	Males (n = 233)
		Mean (SD)	Mean (SD)
Age	Range [17, 53]	23.74 (6.16)	23.56 (6.03)
		N (%)	N (%)
Age category	17–20 years	78 (30)	70 (30)
	21–25 years	131 (50)	119 (51)
	26+ years	54 (21)	44 (19)
Gender	Male	233 (89)	233 (100)
	Female	17 (7)	--
	Transgender MtF/Femme Queen	10 (4)	--
	Transgender FtM	1 (0)	--
	Other	2 (1)	--
Primary ethnicity	American Indian/Native American	7 (3)	5 (2)
	Asian/Asian American/Pacific Islander	3 (1)	3 (1)
	Black/African American	218 (83)	194 (83)
	Latino/Hispanic	17 (7)	15 (6)
	White/Caucasian	2 (1)	0 (0)
	Other	16 (6)	16 (7)
Multiethnic	Identifies with >1 ethnicity	85 (32)	72 (31)
Residential status	Family	98 (37)	92 (40)
	Own place/apartment	128 (49)	109 (47)
	Friends/partner/House/Ball members	32 (12)	28 (12)
	No regular place/other	5 (2)	4 (2)
School/work combined	In school	51 (19)	47 (20)
	In school, employed	65 (25)	58 (25)
	Employed	91 (35)	83 (36)
	Not in school, not employed	56 (21)	45 (19)
Sexual identity	Gay/other same sex	173 (66)	166 (71)
	Straight	25 (10)	7 (3)
	Bisexual	64 (24)	59 (25)
	Don’t know	1 (0)	1 (0)
Attraction	Men only	137 (52)	117 (50)
	Men and women	111 (42)	103 (44)
	Women only	9 (3)	7 (3)
	Neither/don’t know	5 (2)	5 (2)

Eighty-nine percent identified their gender as male. Two-thirds (66%) identified as gay or some other same-sex sexual identity. Interestingly, although only 24% identified as bisexual, nearly double (42%) reported an attraction to both men and women. This is a proportion nearly similar to those reporting an attraction to men exclusively (52%).

House and Ball Structure and Participation

Typically, participation in the House and Ball community is catered towards AAYMSM, with the majority joining the scene as early as their mid-to-late teenage years. Although not all people involved in the Ballroom scene are associated with a House, during qualitative interviews, some parents (e.g., House leaders) estimated as many as 95% of Ball participants as being members of a House.

As presented in Table 2, the average age respondents first attended Balls or joined a House was 19.61 and 19.45 years, respectively. While a majority (91%) of participants reported having attended a Ball in Los Angeles in the past 3 months, only 35% had actually “walked” or competed in a Ball during the past three months¹. Thirty-eight percent of respondents also reported attending Balls in other cities, with the most common being Atlanta, Chicago, New York, and Oakland. When respondents were asked for their reasons for attending Balls, common responses included for entertainment (99%), to walk in categories (66%), to feel like part of a group (55%), to find friends (53%), and to feel supported (53%). Among the least common responses were to meet sexual partners (18%) and to get access to drugs (5%).

Two-thirds (67%) of respondents reported ever being a House member and over half (52%) identified themselves as being a current House member in one of the 24 different Houses represented within our sample. Although 25% reported changing or leaving a House in the past year, 43% reported being a member in their current House anywhere between 1 and 5 years. When respondents were asked for their reasons for joining a House, common responses included to be part of a family (90%), for entertainment (90%), to walk in categories (84%), to feel supported (74%), and to feel like part of a group (74%). Among the least common responses were to meet sexual partners (10%) and to get access to drugs (2%).

House Structure and Leadership

Qualitative data provided additional detail on the structure and activities related to House and Ball participation. While each House differs in terms of demographics, excelling in particular categories, and status (legendary vs. icon), most Houses are similar in terms of their structure and leadership. Nationally, each House is typically a part of a larger network with a formal Board and hierarchical structure. Most Houses are run in a democratic fashion and are led by one or two parents at the local level. Responsibilities of the parents include creating rules (which are then passed down and voted on by other House members) and discussing important House topics, such as major Balls to attend and assigning status or awarding “of the year” to certain members.

House parents serve a role akin to that of a traditional mother and father and generally remain involved in the House and Ball community past young adulthood. Furthermore, each House may be led by the founding parent(s), grandparent(s), overall parent(s) throughout each chapter, and/or the Godparent(s), whose legendary status is important in lending credibility to a House. Additional individuals who also help run a House include a governess; ambassador; goddess, who acts as another head figure and is similar to an “aunt”; duke/duchess; emperor/empress; and officers, such as a sergeant-at-arms and secretary. It is also common for House parents to train a prince or princess to assume the House leader position in the future. Typically, seniority dictates those who help run a House, as these members are likely to be established, walk Balls, “get their tens,” (e.g., meet the minimum criteria for a category) win trophies, travel consistently to other states, and have been involved in the scene the longest.

Expectations and Characteristics of House Parents/Leaders

Given that parents are the most experienced members of the House, they are typically viewed as the leader and are often turned to as a major source of support and guidance. As such, respondents felt it was important that they embody certain characteristics that allow them to run the House successfully while also maintaining a personal connection with their members. House parents described the importance of being approachable and demonstrating genuine love and concern:

I try to come up with a plan so it’s not you just talked to me today and then you never talked to me again. So I try to see it through and that also kind of gives them the impression, “Okay, then she really is concerned. Then she is really willing to help me through this.” So that usually works for me.

By engaging in open and honest communication, mutual trust and understanding between the parent and their “child” can be developed. This serves to increase their comfort level in approaching them in the future. As the leader of the House, many parents appreciate the need to approach their position with a positive attitude, which includes avoiding drama and Ballroom politics, showing their pride in being a House parent, demonstrating a balance between self-confidence and humility, avoiding displays of favoritism towards members, and recognizing members for good House behavior, such as working/going to school, and/or helping during Balls.

Furthermore, guiding members through personal problems is a responsibility that many House parents face. Often this entails lending a listening ear, working together towards a solution, instilling a sense of belief that a solution can be reached, and mediating fights between House members. As a result, House parents may develop a relationship with their members that find them prioritizing their role as a parent first and a House leader second. Although Ball participation is a major aspect of involvement in the scene, parents emphasized the importance of prioritizing members’ personal lives over Ball participation:

I believe that the importance of a House mother is, like I said, someone that is nurturing, someone that is caring, someone that has the best interest of everyone, not just herself or her status in the Ballroom scene or in the world. To me, that’s just the most important thing, someone that is going to, like I said, not just focus on the Ballroom scene and winning grand prizes but someone that is going to focus on what are you doing outside of the Ballroom scene. How are you dealing with your family? How is everything happening with you? Are you okay?

Many House parents also spoke of approaching their role by leading through example as they believe that their House “children” are likely to follow their lead, both good and bad. With this in mind, many House parents reported choosing to avoid negative influences, such as substance use, promiscuity, and engaging in trivial fights at Balls. Instead, they opted to set good examples including getting tested for HIV, maintaining jobs as opposed to engaging in sex work, following the House rules and guidelines, and working towards educational and career goals. In addition, House parents felt a strong sense of dedication to their own House:

I am a parent now. It’s not like I can just out of nowhere just say I am done because there are people that are with me. So I will let them down and just as well they will let me down if they decided to leave.

Traditionally, parents are in charge of coordinating House meetings in the weeks leading up to a major Ball in order to coordinate certain details, such as deciding which members will walk specific categories and making sure those who are walking are equipped with their full outfit and props. House parents also utilize this time to advise and critique Ball participants to assure they are prepared to represent their House on the Ballroom floor. One parent spoke of the importance of staying up to date with the Ball scene to be able to coach other House members on what the latest trends in the scene are:

So, whether you vogue, whether you runway, whether you are realness, -- I have to be able to answer your questions. Who you look like, how did you look, was it right, I have to be able to critique all those so which means I have to have the knowledge of everything that’s going on, not only in the House, in the scene period. I have to see what’s the new thing. I have to go out there-- I go by myself to a lot of different Balls just so I can see what’s new. Oh, that’s the new dip -- because everything is constantly evolving so I think that’s one of my responsibilities to keep up and make sure that they are keeping up. I think from them they expect support and that’s it.

Finally, House parents described being a source of financial and basic needs support, particularly for clothing, food, housing, transportation, and unpaid House dues. As many Houses require their members to either attend school or maintain a job, many parents also serve as a mentor by tutoring those in school, financing their education, or teaching those who are searching for jobs how to build their resumes.

Recruitment and Selection of New Members

When Houses are recruiting new members, certain physical and personal characteristics are often sought. Depending on the current needs of the House, leaders and members look for those with the potential to strengthen their status in the Ballroom scene, such as filling a void in a category for which the House does not have a strong walker. The ability to compete and represent the House well in multiple categories is also favored as this allows the House to maintain a smaller number of members. According to some House parents, quality over quantity of House members was valued, as many preferred to maintain Houses with a smaller number of members:

It’s a smaller number of people and the reason being because we are able to focus more attention on everyone individually and to me that’s so important as the mother, to really be able to reach out to them. I know that when you have a bigger House, it becomes more so about the Ballroom scene as opposed to their personal lives because you are not able to reach out to everyone equally as you would like to.

Other Houses found having a large number of members to be more optimal, allowing for a larger presence in the scene.

House parents also noted particular attitude and personality traits that are important for potential members to have, such as being personable, conducting oneself in a “classy” and respectable manner, and being productive members of society outside of the House and Ball scene by going to school or maintaining a job. In addition, the ability to fit in well with current members is not only important but necessary as a majority of House members must vote in favor of accepting a new member into the House. Thus, many spoke of particular types of people to avoid, including “messy” people who “keep a lot of stuff going, just talk too much…always got to get into it with somebody” and those with a history of switching from one House to another.

In order to demonstrate their value to the House, potential members are also asked to complete specific tasks that showcase their teamwork and commitment to the House. These tasks are purposely designed to be demanding to create a team atmosphere and also make it more difficult for them to feel comfortable with leaving the House for something trivial:

When you are able to have that memory like, “God, we went through this and that and this to get into this House.” It’s like—it’s a little harder for them to just get up and leave for one thing because they went through all of this bull to get in…So they immediately build a rapport with that. They immediately build that camaraderie […]

Prior to granting official membership, some Houses set a probationary period during which new members must fulfill additional requirements, such as walking a certain number of Balls and either winning or “getting their tens.”

Switching and Leaving Houses

Occasionally, a member may be “dismissed” from a House if the leaders feel he or she is not living up to the standards of that House. Those who begin to show a lack of interest and dedication to their responsibilities as a House member are initially given a warning and placed on probation. Should the issue or behavior continue, the member is dismissed and asked to leave the House. According to House leaders, reasons for dismissal include failure to show up for House activities and meetings, not participating in Balls, walking a category “sloppy” due to lack of practice, or being disruptive during House meetings. In addition, members may also switch Houses if other Houses are seen as a better fit, they do not feel they are receiving enough attention, or they are simply looking for something different. Members are expected to switch Houses the “right way” and inform the parents prior to leaving as opposed to “just [coming] out as a new House, under a new name.”

House Activities

A major aspect of involvement in the House and Ball scene includes participation in House activities. While doing so is generally expected and required to remain in good standing, these activities are also valuable in allowing House members to demonstrate their dedication and commitment to the House as well as bond as a family. Generally, these include an array of activities such as family outings, House meetings, and preparing for Balls.

Generally held on a weekly or monthly basis, House meetings are an opportunity for House members to stay in constant communication with one another and discuss important House business, such as recruiting new members and planning upcoming events and Balls. Membership dues, ranging from $10 to $20 per month, are usually collected to cover travel arrangements and accommodations when attending out-of-town Balls. House parents will also utilize this time to reiterate certain House rules or guidelines to serve as a reminder to members or offer suggestions on ways to collectively improve as a House.

In the weeks leading up to a major Ball, Houses will conduct meetings at clubs or dance studios in order to find out who is interested in competing, discuss their overall strategies and dress code, and rehearse categories. This time is often used for House parents and members to help “walkers” in preparing for their categories, such as assisting with hair, makeup, and costume components. One House parent described the intense practices by having members “battle” one another as a way to build competitive spirit prior to a Ball. For national Houses with chapters across the US, national House meetings are organized once or twice a year in major cities such as Atlanta or New York City as a way for Houses to come together on at least a yearly basis.

We will talk about what’s going on and what needs to be changed over here and stuff like that, to make sure that everything is being ran according to [House] guidelines and not just this way and ran here this way, keep everything structured.

As a way to connect socially and on a more personal level beyond House meetings and Balls, House members will often organize family “outings” such as dancing/clubbing, bowling, roller skating, competing in sports tournaments versus other Houses, hanging out at the beach, going to theme parks, shopping, and throwing birthday parties. In addition, going out to eat or hosting dinners, barbeques, or cookouts was noted as an opportunity for members to have deeper and more meaningful conversations with one another. House parents often open the floor for discussion to allow members to voice their opinion on any topics:

We have dinners but we actually have talks. We eat our food. We talk. We always-- I always bring up the topic of is there anything that anyone wants to talk about. Is there any conflict, anything that’s going on? Is there anything that we need to address? So because I stay on top of that I think that really helps.

Balls

With Balls considered to be a major event in the House and Ball scene, many Houses spend a great deal of time planning, particularly the House sponsoring the Ball. Ideally, there should be about a six-month period prior to a major event to provide ample time for planning. Houses utilize this time to organize the logistics necessary to create and execute the overall concept of the event. This entails brainstorming the categories, which provide specific instructions on how to present the category (e.g., “Butch Alexander McQueen in Pumps: No mention of the pumps. Gaga will show you the way. A complete ‘McQueen Effect’ should be the goal if you want to come and play”²), developing promotional flyers, and securing a venue or space. Houses that are competing in Balls generally focus their efforts on preparing to compete in the different categories by scheduling group rehearsals for categories requiring more than one member (e.g. group or House categories) or organizing “glam squads” who are in charge of everyone’s hair and make-up. For Balls that are held out-of-state, House members typically travel together in pairs or small groups since only a small state for Balls.

HIV Risk Behaviors

Alcohol and Drug Use

As shown in Table 3, respondents identified alcohol (81%) and marijuana (67%) as the two most common substances ever used. This trend continued when asked to identify drugs used in the last 3 months, with alcohol (72%) and marijuana (53%) representing the majority. Additionally, 16% of respondents reported having recently used any illicit drug (excluding marijuana), and 15% reported recently using club drugs, (e.g., cocaine, crystal/meth, ecstasy, GHB, poppers, ketamine, other forms of speed). Fifty-one percent of respondents reported light alcohol use within the last 30 days, with 31% reporting non-use. A little less than half (43%) reported drinking alcohol at least one time in the past 3 months prior to or during sex. Similarly, a quarter (25%) reported using an illicit drug in the past 3 months prior to or during sex.

Table 3.

Substance Use

		Total Sample (n = 263)	Males (n = 233)
		N (%)	N (%)
Drug use (ever)	Alcohol	212 (81)	189 (81)
	Marijuana	176 (67)	153 (66)
	Any illicit drug (excl. marijuana)	91 (35)	75 (32)
	-Cocaine	30 (11)	22 (9)
	-Ecstasy/X	76 (29)	64 (28)
	-Club drugs	87 (33)	73 (31)
	-Hallucinogens	3 (1)	3 (1)
	-Inhalants (nitrous)	1 (0)	1 (0)
	-Rx drugs without an Rx	8 (3)	8 (3)
	-Heroin	2 (1)	1 (0)
	-Injected drugs	2 (1)	1 (0)
	None	34 (13)	30 (13)
Drug use last 3 monthsa	Alcohol	189 (72)	169 (73)
	Marijuana	140 (53)	124 (53)
	Any illicit drug (excl. marijuana)	43 (16)	36 (16)
	-Cocaine	10 (4)	7 (3)
	-Ecstasy/X	32 (12)	28 (12)
	-Club drugs	39 (15)	34 (15)
	-Hallucinogens	1 (0)	1 (0)
	-Rx drugs	4 (2)	4 (2)
Alcohol use last 30 days	Non-use	82 (31)	71 (31)
	Light use	134 (51)	120 (52)
	Frequent non-binge	25 (10)	22 (9)
	Infrequent binge	16 (6)	16 (7)
	Frequent binge	6 (2)	4 (2)
Substance use prior to or during sex	Alcohol (at least once in last 3 months)	--	101 (43)
	Drugs (at least once in last 3 months))	--	58 (25)
Partner substance use prior to or during sex	Alcohol (at least once)	--	94 (40)
	Drugs (at least once)	--	56 (24)

^aPercent of total sample

Rules and Expectations for House Members

Generally, each House has a set of rules and expectations that members are expected to abide by upon initiation. The method by which they are distributed to members differs per House, with some choosing to create handbooks or contracts for members to sign and keep or creating a House website. House parents noted several rules including respecting other members, participating in major House events, bringing conflict to the attention of House parents, and keeping in contact and checking in on fellow House members. As Balls are seen as major events, many Houses expect their members to not only compete in a certain number of Balls per year, but also travel to other cities to do so. One House parent also noted that their rules undergo a review once or twice a year during a House retreat as they evaluate themselves based on their measurements of success and identify weak areas to improve upon.

While most parents advised against substance use, the majority of Houses are tolerant as long as members do not allow its use to interfere with their ability to contribute positively to the House or compete on the Ballroom floor. Each member is a representation of the House and its reputation and thus, some parents also expect members to avoid using substances in public. Furthermore, parents were less likely to tolerate “bad drug” use, which was described as any substance with the exception of alcohol or marijuana. Several parents did mention that they feared drug use was increasing in the community. They explained this increase in use as being related to the community’s structure including the use of stimulants such as crystal meth to stay up late for the Balls (which typically start around 2:30 in the morning) and also to assuage performance anxiety when walking at the Balls.

In spite of this general sense of tolerance, most of the parents had very strong opinions about drug use within the scene, relating how drug use had torn apart one of the original Los Angeles Houses and created a huge riff in the community. One parent related a story about this House and how crystal methamphetamine use had destroyed many of its members, “These people were-- they were exceptional and it’s like a lot of people just deteriorated, like some of the best or the most gorgeous Face kids, all that. When you look now, you are only seeing remainders of them.”

Sexual Behavior

Table 4 presents data related to sexual behaviors among the males in the survey sample. In general, respondents reported an average of 1.7 male partners in the last 3 months. The majority (70%) reported at least one male partner in the last 30 days. About a quarter (27%) reported inconsistent condom use (either anal or vaginal sex) in the last three months. In addition, 10% of the male respondents reported engaging in sex exchange (e.g., engaging in sex for money, rides, clothing, jewelry, a place to stay, drugs, etc.) in the last three months. In order to better understand some of the sexual risk behaviors, a sexual risk index was constructed which indicates that about a quarter (27%) of the male respondents had not had any sexual partners in the last 3 months; half (50%) had consistently engaged in protected anal intercourse in the past 3 months; only 1% had engaged in unprotected anal intercourse (UAI) with a seroconcordant partner; and about a quarter (22%) engaged in UAI with either multiple partners or at least one serodiscordant partner.

Table 4.

Sexual Risk among Male Respondents

		Males (n = 233)
		Mean (SD)
Total # male partners in last 3 months	Range: [0, 25]	1.73 (2.97)
Total # female partners in last 3 months	Range: [0, 8]	0.27 (0.95)
Total # transgender partners in last 3 months	Range: [0, 6]	0.03 (0.41)
Total # sex partners in last 3 months	Range: [0, 25]	2.04 (3.28)
		N (%)
Gender of sex partners last 3 months	At least one male partner	164 (70)
	At least one female partner	28 (12)
	At least one transgender partner	2 (1)
Inconsistent condom use last 3 months	Anal (insertive or receptive)	60 (26)
	Vaginal	11 (5)
	Any	62 (27)
HIV status of primary/main partner	Positive	7 (3)
	Negative	99 (43)
	Don’t know/refused	9 (4)
	Do not have primary partner	118 (51)
Sexual risk index	No partners	61 (27)
	Protected anal intercourse	114 (50)
	Single seroconcordant/UAIa	3 (1)
	Single serodiscordant/multiple partners UAI	49 (22)
Sex exchange last 3 months	Yes	23 (10)
STI test (ever)	Yes	207 (89)
STI diagnosis (ever)	Any	62 (27)
	- Gonorrhea	29 (12)
	- Syphilis	17 (7)
	- Chlamydia	27 (12)
	- Genital herpes	10 (4)
	- HPV/Genital warts	16 (7)
	- Hepatitis C	9 (4)
	- Scabies/crabs	12 (5)
	- Other	7 (3)
Last HIV test	Within past 6 months	188 (81)
	Tested 6 to 12 months ago	20 (9)
	Tested > 1 year	13 (6)
	Never tested	5 (2)
	Don’t know/refuse	7 (3)
HIV Status	Positive	13 (6)
	Don’t Know	3 (1)
	Refused	7 (3)

^aUAI – unprotected anal intercourse

Most respondents (89%) have been tested for STIs at some point in their lifetime and a little over a quarter (27%) reported having at least one STI diagnosis in their lifetime. Among those with a STI diagnosis, the most common were gonorrhea and chlamydia at 12% each. Most of the respondents (81%) reported having an HIV test in the last 6 months, with an additional 9% reporting an HIV test in the past year. Among the male respondents, 6% reported being HIV positive.

Different Houses also have various rules regarding intimate relationships and sexual hookups between members of the same House. Some House parents described a “don’t ask, don’t tell” policy where dating and hookups are allowed as long as it does not interfere with their ability to be a good House member, with particular leniency shown towards those who are in serious relationships. Most parents mentioned the potential challenges that can result with inter-House dating including fighting and arguing between members when relationships “go bad”. Thus some Houses have adopted a no tolerance policy regarding within House dating that can result in dismissal from the House. When asked about the types of things that cause conflict in a House, the most common response was relationship issues:

…say within the House they are allowed to have sex with one person or people in the House. So this person has sex with one person, they enjoy each other but then this person is like, “Okay, well I want to move onto the next.” This person becomes jealous. It becomes a beef with this person and those two. So, it brings a segregation in the House then it only keeps adding… So, I think that that brings a problem because jealously for one. Secondly, you can’t control emotions sometimes or your heart sometimes. So it’s like it brings all the different things that you shouldn’t have to focus on within your House. So, as opposed to having House meetings that are productive or about the Ball, you are having problems like, “Okay, why are you guys arguing now. Why don’t you get along, blah, blah.” It becomes that as opposed to becoming what the purpose of the House is.

In addition to addressing dating and “hooking up” with fellow House members, parents also indicated that they address HIV and other risk behaviors within the House and the Balls themselves. For example, Ball categories often carry a prevention theme – asking participants to include HIV prevention messages within their costume. An annual Ball in Los Angeles, sponsored by a local HIV prevention agency, has HIV prevention as its primary theme and requires participants to integrate condoms or other safe sex messaging within their “illusions”. Some parents also spoke about their responsibility for educating House members about HIV in both formal and informal settings. For example, one House Father described starting conversations about HIV prevention in the House meetings by putting HIV on the meeting agenda. Another emphasized the effectiveness of casual conversations about HIV with House members communicated by House parents rather than prevention agencies – indicating a need to know how to address the House member respectfully and honestly.

DISCUSSION

We are well into the third decade of the HIV/AIDS epidemic; however, public health researchers and service providers are still trying to understand the disparities in HIV incidence among African American MSM and young MSM. This study served to provide a general overview of the House and Ball communities in Los Angeles, communities important to a segment of the AAYMSM population. Research with communities such as these is important as they often represent populations that may not be reached through more traditional research methods. However, in order to better address the HIV epidemic across all affected populations, it is necessary to fully understand those populations. Thus, more community-engaged efforts to work with these high risk populations is necessary to ensure we understand the risk and protective factors in populations such as these.

Previous research with House and Ball communities has been limited. The existing research does indicate that this is potentially a high-risk population, with HIV rates of 17% among House and Ball members in New York City as reported in the only prior epidemiological study among House and Ball communities (11). This study also identified that among those testing positive, 73% were unaware of their HIV status. The New York study found that 60% of the respondents reported HIV testing in the last year. While the current study did not include HIV testing, we did identify that Los Angeles House and Ball community members are testing at high rates, with 90% of male respondents reporting an HIV test in the last year. This may be due in part to incentives provided by some local HIV prevention agencies that offer free admission to some Balls for those who go for an HIV test.

Data from this study indicate that patterns of substance use among the House and Ball participants are somewhat different from that of other YMSM populations (20). For example, data from our own prior research with a general sample of YMSM found that recent use of ecstasy is higher among Los Angeles House and Ball members (12% in the last 3 months) compared to 7% of AAYMSM (p <0.001) in a venue-based sample (21). Similar patterns were seen with marijuana use, with 53% of House and Ball respondents reporting marijuana use in the past 3 months compared to 46% of the venue-based AAYMSM sample (p <0.001). Data from the qualitative House leader interviews also indicate that rules and methods to address this issue vary across Houses. This is typically due to the House structure (e.g., size of membership, communication of rules) and leadership styles. It may be of interest to conduct additional research to understand to what extent these rules and leadership styles may affect members’ substance use.

This study indicates that rates of unprotected sex among House and Ball affiliated youth are similar to those of other AAYMSM populations (22) and lower than those of more general YMSM populations (21). Among other sexual risk behaviors, this population had relatively high rates of sex exchanges (10%) in the past three months, particularly when compared to a venue-based sample of YMSM where 6% reported sex exchange in the last 6 months (21).

Thus, what these data do seem to indicate is that this population of House and Ball AAYMSM is not considerably different from other YMSM populations. What is unique about this population is that the communities in which they live and play are well defined and have built-in mechanisms that can support HIV prevention interventions. Research continues to show that YMSM are a vulnerable population that require culturally and developmentally relevant HIV prevention interventions. Thus, leveraging the supportive mechanisms within the House and Ball communities may be key to designing effective HIV prevention programs.

For example, research with the general YMSM populations has found that many young men lack social support from family and friends (23–25). The data from this study indicate that social support and connectedness to a community are clearly important for House and Ball participants, as indicated by survey data on reasons for participating in the House and Ball communities. Research among the general African American population has found that seeking such informal support from sources such as friends and family is common to reduce negative consequences of stress (26).

Qualitative data also indicate that House leaders and parents generally take their responsibilities as parent figures very seriously, offering as much emotional, social and material support as necessary. They often spoke about how their members lack general support from biological and other family, and felt that they were well positioned to serve as a familial substitute, similar to “fictive kin” identified through ethnographic work with different African American communities (27–29). Parents reported feeling as though they needed to lead by example and provided advice to their “kids” as needed. Prior qualitative work in other House and Ball communities has identified similar roles for House leaders, with House mothers typically filling in the role of nurturing parents (e.g., confidantes, sexual advice, providing referrals for health services).(13)

Building on these types of supportive behaviors can be one avenue for HIV prevention development within these communities. More recent research among AAYMSM found that peer norms can positively influence engaging in risky sexual behavior (22). As parents and other members “lead by example” and provide support and assistance to their fellow members, this may be one way to support community-led interventions that can promote healthful behaviors. Identifying aspects such as this, which may be unique and strong support mechanisms, can be used to tailor HIV prevention intervention models for these communities and others across the country.

This study lays the groundwork for additional analyses with the data collected from this study. While we can currently identify that the House and Ball communities offer a supportive environment for its members, this is only the beginning of understanding how these Houses and larger social networks may influence other behaviors, including HIV risk and protective behaviors. Future research will further explore these relationships to identify how the more supportive aspects of these communities can be leveraged.

There are a number of limitations to this study that should be acknowledged. First, the findings rely on respondents’ self-reported behaviors, which cannot be independently verified. Self-report data regarding respondents’ involvement in risky behaviors may have underestimated the true prevalence given that many of these behaviors, such as drug use, are illegal and socially undesirable. We expect that the use of ACASI surveys may have minimized the underreporting of these behaviors. A second limitation is that this study did not collect biological samples to verify HIV status and relied on self-reported HIV status. Recent studies that did collect biological samples found high rates of unrecognized HIV infection among AAYMSM.(11) Also, the data reported here are cross-sectional and therefore do not contain information about the temporal relationships between demographics and risk behavior. Finally, these analyses are based on perceptions from one Ballroom community and may not be generalizable to Ballroom communities in other cities. For HIV prevention efforts, future studies should include comparisons to other cities, particularly those with a longer history of the Ballroom scene, to identify other mechanisms of support or risk within the scene.

Despite these limitations, it is clear that this is an important community in which we should engage in further research to identify and develop appropriate intervention strategies. The data presented here provide ideas for providers on leveraging the support systems available in the House and Ball scene so they can develop and/or advocate for new programs designed for House and Ballroom communities. Little is known about these communities, and this study provides an important foundation for understanding the social and structural characteristics of a Ballroom community. While there are a number of risks associated with this community, including issues around substance use and sexual risk, the House and Ball scene offers many healthful aspects that can be leveraged as part of an intervention effort. In particular, the scene offers a unique, supportive environment for its members to freely express themselves. Prevention programs designed for this community should consider building on these strengths. For example, programs can train the current leaders in HIV prevention so that information is disseminated through the House networks. As we learn more about how these networks are constructed and utilized, ideas to leverage the more supportive aspects may emerge that can be integrated into an HIV prevention intervention.