Perspectives on substance use and disclosure among behaviorally bisexual Black men with female primary partners

Abstract

Black men who have sex with men and women (MSMW) are believed to be a bridge to HIV infection among heterosexual Black women, and substance use can increase the risk of infection among men. However, empirical evidence on the social context of MSMW’s sexual behavior and substance use is needed. This study examines the perspectives of Black MSMW with female primary partners on the role of substance use in their sexual encounters with men and their reasons for disclosing or not disclosing this behavior to their female partners. Findings can inform culturally relevant HIV prevention interventions for this population.

Significant racial and ethnic disparities in HIV persist in the United States, with the rate of infection among Blacks and African Americans more than nine times as high as in the white population and nearly three times as high as in the Hispanic/Latino population. Black Americans represent approximately 13 percent of the total U.S. population, but 52 percent of all HIV diagnoses in 2008 (CDC, 2010; Census, 2010). The primary HIV/AIDS transmission category for Black men is sexual contact with other men (MSM), followed by high-risk heterosexual contact (with a person known to have, or to be at high risk for, HIV infection) and injection drug use. For Black women, the primary categories are high-risk heterosexual contact and “other,” which includes unreported and unidentified risk factors (CDC, 2010, 2011). It is likely that some of the “other” unidentified risk factors for infection among Black women include having sexual relationships with men who do not disclose their same sex sexual activity to their female partners. Substance use can increase risk for Black men, by decreasing condom use or increasing the number of partners (Harawa, Williams, Ramamurthi, Manago, Avina, & Jones, 2008; McKirnan, Vanable, Ostrow, & Hope, 2001)

Black MSM who also have sex with women (MSMW) are believed to be a bridge to infection among heterosexual Black women (Bing, Bingham, & Millett, 2008; Dodge, Jeffries IV, & Sandfort, 2008; Malebranche, Arriola, Jenkins, Dauria, & Patel, 2010). However, empirical research to support the claim has been flawed by methodological problems such as: too few Black men in bisexual samples, bisexual men in homosexual samples, inconsistent or absent definitions of “down low” when researching behaviorally bisexual Black men, and conflating sexual behavior with sexual identity (Malebranche, 2008; Malebranche et al., 2010). Qualitative research can help to remedy some methodological problems, by clarifying definitions and illuminating distinctions between behavior and identity, for example.

One small quantitative study (Siegel, Scrimshaw, Lekas, & Parsons, 2008) of ethnically diverse MSMW who did not disclose their same sex sexual behavior to their female partners provided support for the “bridge” theory, reporting that concurrent sexual relationships with male and female partners were common, and unprotected sex was more likely to occur within the bounds of an ongoing or committed sexual relationship. However, being in a committed relationship was not associated with a reduced number of male or female partners, and the majority of men reported unprotected sexual encounters with both male and female partners (Siegel et al., 2008). Alternatively, some recent qualitative work has found that many Black MSMW take strategic action to reduce the risk of HIV transmission with their partners, although condom use is often inconsistent (Dodge et al., 2008; Malebranche et al., 2010). These studies indicate a need to explore how contextual factors such as substance use, reasons for disclosure or non-disclosure of sexual behavior, and the social meaning of sexual identity and same sex behavior impact HIV risk behaviors among Black MSMW.

Substance use and HIV risk among MSMW

Some research suggests higher levels of drug use among Black MSM who are non-gay-identified and/or bisexual than among those who identify as gay (e.g., Williams, Mackesy-Amiti, McKirnan, & Ouellet, 2009), and substance use appears to be associated with sexual risk behaviors for Black MSMW. A recent study by Operario and colleagues (Operario, Smith, Arnold, & Kegeles, 2011) reported high rates of unprotected sex among African American MSMW with male (51.5% reported unprotected insertive anal sex, 33.8% reported unprotected receptive anal sex), female (70.6% reported unprotected vaginal sex) and transgender female (25% insertive anal sex, 10.3% receptive anal sex) partners as well as high rates of alcohol and drug use before sex; unprotected sex with male and transgender partners was associated with being under the influence of drugs. These findings echo a report by Williams et al. (2009) that found high rates of crack use among an ethnically diverse sample of 343 low income MSMW as well as high rates of unprotected sex with both male and female partners. Based on these findings, Williams and colleagues (2009) suggest that discordance in drug use between MSMW and their sex partners (e.g., non-using female partners) warrants concern as a “bridging” factor that is independent of the more widely recognized factor of same-sex activity. Sex with male partners may also serve an instrumental function as a means to obtain drugs among non-gay identified men (Harawa et al., 2008; Washington & Brocato, 2011). One study has found that bisexual men are more likely than heterosexual men to use crack, to have a sex partner who injects drugs and to share injection equipment (Logan & Leukefeld, 2000).

Use of drugs and/or alcohol can impair judgment and decision-making, leading to high-risk sexual encounters. One study of drug-involved gay and bisexual men (McKirnan et al., 2001) found that HIV risk was most pronounced among men who reported strong expectations for cognitive escape via substances, particularly escape from anxiety and “burnout” associated with maintaining safe-sex practices. Harawa and colleagues (2008) identified four ways in which drugs influence same-sex behavior among African American MSM and MSMW in Los Angeles: they serve as motivators for men who report having sex with other men solely or primarily because of their drug use or dependence (including transactional sex); they allow men to satisfy a desire for sex with another man despite a personal intention to avoid the behavior; they enable men to rationalize same-sex behavior in a way that avoids social stigma; and they facilitate same-sex activity by lowering inhibitions. Harawa and her colleagues observe that the allower and rationalizer roles may be strategies for coping with racism and homophobia, and thus are consistent with the escape model described by McKirnan (2001).

Sexual script theory has also been explored as a useful framework for understanding attributions for sexual behavior (Gagnon & Simon, 2005; Simon & Gagnon, 2003). Parsons and colleagues identified three types of sexual scripts involving alcohol that contributed to risk of unsafe sex among a diverse sample of HIV+ MSM in New York City (Parsons, Vicioso, Punzalan, Halkitis, Kutnick, & Velasquez, 2004). In routine scripts, alcohol was consciously used to facilitate social interactions (the social lubricant concept) and to diminish sexual inhibitions. In spontaneous sexual scripts, alcohol also facilitated sexual interaction but not in a planned way; rather, men reported that after drinking they became less selective about partners or more adventurous and engaged in behavior they otherwise would have avoided. In taboo scripts, men reported that alcohol enabled them to overcome guilt and fear regarding behaviors they felt were immoral or stigmatized, such as cheating on a partner or engaging in anal receptive sex.

Stigma and Non-Disclosure among Black MSMW

For substance-using Black MSMW, perceived homophobia in the Black community may lead some men to conceal their same-sex behavior from their female partners and others (Bing, Bingham, & Millett, 2008; CDC, 2003; Kennamer, Honnold, Bradford & Hendricks, 2000; Lemelle & Battle, 2004; Operario, Smith, & Kegeles, 2008; Stokes & Peterson, 1998). As previous research on the role of substance use as a coping strategy utilized by MSMW to manage conflicting emotions or thoughts regarding the meaning of their same sex sexual encounters has identified, stigma associated with being perceived or labeled as non-heterosexual may play a role in non-gay identified (NGI) men’s use of substances during sexual encounters with other men. For men with female main partners, stigma may influence how these men negotiate issues of disclosure and sexual identity.

A small but growing body of recent qualitative research has explored MSMW’s attributions for disclosure or non-disclosure of their same sex sexual behavior to their female partners. Malebranche and colleagues (Malebranche et al., 2010) identified a variety of disclosure practices among their sample of Black MSMW; while some men reported valuing honesty and full disclosure with their intimate partners of either gender, the stigma attached to being perceived as homosexual by female partners, family and community members was the primary barrier to disclosure. A qualitative study conducted by Dodge and colleagues (Dodge et al., 2008) with Black MSMW found that men were more comfortable telling their male partners about their bisexual behavior than their female partners, as men were viewed as less judgmental. The men sampled by Dodge and colleagues (2008) described women as being threatened by male bisexuality, although bisexual women were viewed as being less likely to react negatively when learning of their male partner’s bisexuality. The need for Black MSMW to maintain boundaries between their public presentation of heterosexuality and relationships with women and their hidden sexual encounters with men may also influence venue choice for connecting with male partners (Schrimshaw, in press); this may also impact their likelihood of being reached by HIV prevention outreach campaigns.

For non-gay identified Black MSMW, the role of drug and alcohol use in sexual risk-taking is complicated by men’s perceptions of Black masculine identity, community stigma toward MSM, and feelings of guilt and shame connected to concealing risk behavior from their female partners and others. While previous research has explored substance use and sexual risk behavior among non-gay identified men who have sex with men and women (Harawa et al., 2008; Operario et al., 2011), this body of research is still small, and few studies have connected substance using MSMW’s perspectives on the role substance use plays in their sexual encounters with other men and their decisions to disclose or conceal their same sex sexual behavior from female primary partners. Therefore, the purpose of this study is to explore the perspectives of non-gay-identified (NGI) Black MSMW with female primary partners regarding the role of substance use in their sexual behavior with other men, as well as men’s reasons for disclosing or not disclosing these behaviors to their female partners. One purpose of this analysis is to corroborate or challenge findings from the limited research done to date with behaviorally bisexual men on disclosure (e.g., Dodge et al., 2008; Malebranche et al. 2010) and on substance use in sexual encounters with other men (Harawa et al., 2008; Operario et al., 2011; Parsons et al., 2004).

Method

The narrative data analyzed in this paper come from qualitative interviews with 33 mostly low-income Black MSMW in New York City. Each man completed one interview as part of a NIDA-funded study to explore the feasibility of recruiting for research substance using NGI MSMW with female primary partners. This study was approved by the institutional review board of the authors’ home institution. Eligibility criteria included: Black or African American male age 18 or over; reports past-year use of illicit drugs or alcohol or both; does not identify as gay or homosexual; main current sexual partner is female; has engaged in sexual activity with men at least once in the past 12 months.

Recruitment and Procedure

Men were recruited by staff ethnographers through four outreach methods: existing social networks (based on previous studies in which the ethnographers and the lead author were involved), known MSM venues in New York City, community organizations and Internet websites. After providing informed consent, participants chose code names and completed a semi-structured, audio-recorded qualitative interview with an ethnographer. The interviews were designed to explore men’s perspectives on how substance use influenced their same-sex behavior and their reasons for concealing or disclosing that behavior from their female partners. Basic demographic information was also collected during the interview. Audio files were transcribed, removing any potential identifiers, and demographic information was tabulated following the interviews. Demographic data and narrative responses were entered into FileMaker Pro, a relational data base management program that the research team has used for a number of years to manage qualitative data. FileMaker Pro facilitates analyses across and within cases and allows for the application of thematic coding.

Qualitative Data Analysis

Narrative responses were analyzed using grounded theory methods (Charmaz, 2006). This qualitative analytic process requires reading narrative responses several times, coding initially by key words and phrases drawn verbatim from the transcript. On subsequent passes, initial codes are compared until categories emerge and content saturation is achieved. The analyst rereads transcripts and field notes, develops conceptual models and coding systems, and cycles back and forth between the transcript and conceptual frames in writing an analysis of the social processes discussed in the narratives (Charmaz, 2006). Two members of the research staff completed this process, with minor differences in coding that were discussed and reconciled. Patterns arising across interview narratives will be presented here with quotes from men serving as exemplars of each theme; each quote will be accompanied by the participant’s self-selected code name, age and sexual identity label.

Results

Participant Characteristics

Respondents ranged in age from 21 to 60, with a mean age of 42; the majority (88%) identified as heterosexual or bisexual. Less than one-third (n = 9, 27%) reported employment as their primary source of income; more than half reported that their main source of income was from disability payments or other public benefits. Nearly two-thirds of the sample reported annual income of less than $25,000. Almost three-quarters of the men had been arrested at least once, and half of the total sample had been incarcerated for some period of time. Alcohol was the most commonly reported substance used (66.7%; n = 22), followed by marijuana (48.5%, n = 16), crack (21.2%, n = 7), cocaine (15.5%, n = 5), heroin (6%, n = 2), prescription stimulants (3%, n = 1) and ecstasy (3%, n = 1). More than half the sample (54.5%, n = 18) used more than one substance, and four participants had recently entered substance abuse treatment.

Qualitative Themes

Disclosure of Same Sex Behavior to Female Partners

The men who participated in this study all reported having female main partners, and frequently additional casual female partners as well. Men’s relationships with their female main partners ranged from fairly new (three months or more) to long term and committed; many of the men were married or cohabitating with women they had been with for many years. In response to interview questions regarding disclosure of their same sex sexual encounters, the majority of the men (24 out of 33, 73%) reported that they did not disclose these encounters to their female partners (or, in most cases, anyone else). Reasons for non-disclosure included concern that this information would hurt their partner’s feelings, the potential that their partner might reject them, fear that they would be labeled ‘gay’ by their partner and damage to their social identity as a heterosexual man. Many of these concerns reflect ‘anticipatory stigma’ whereby men anticipate loss of status or labeling as stigmatized should they disclose their same sex sexuality (Quinn & Chaudoir, 2009).

One of the most common themes in men’s narratives regarding disclosure to their female partners regarded their desire to maintain these relationships and fear of the consequences should they reveal their same sex behaviors. Men’s narratives often reflected ambivalence or guilt regarding keeping their sexual encounters with men a secret, as “Barney”, a 42 year old man who identifies as “straight” described:

I think it is important [to disclose] but also I’m not really able to disclose at this point as far as what I really like to do, what is my cup of tea, because everybody is not going to accept what you do in your bed to bring to another person’s bed so I have to be mindful of people’s feelings even though you got to be honest but sometimes honesty can push people away by being too honest… The most important reason for not telling her is that she is kind of against same sex marriages. We talked about that one time and I got her viewpoint so I pretty much know that she is not really into men-men or women-women thing. She is really into a heterosexual thing so I’m afraid that if I disclose that then it would shatter our relationship we have.

Barney’s comments illustrate not only his fear of rejection by his female partner but also the link between his fear of her reaction and the larger social stigma attached to homosexuality. Rather than challenge his partner’s views, Barney strives to maintain this relationship, even as he expresses difficulty resolving his value of honesty in relationships with his fear of losing his partner should he disclose. Similarly, “Red Bull”, a 48 year old straight-identified man, relates:

If I don’t tell, my rationalization is that I’m protecting her from herself, because she cannot handle the truth…I think she would be hurt. I think she would be devastated. I think she would be like ‘Oh! You gotta leave!’ and she won’t be the same.

While Barney and Red Bull describe ambivalence toward their lack of honesty regarding their same sex behaviors as a form of compromise to preserve their relationships, other men expressed a hope that at some point in the future they might open up to their female partners. Sometimes this possibility was connected to a desire to learn more about their female partner’s sexuality as a way of gauging their potential reactions to their own. Boss, a 46 year old man who identifies as heterosexual, relates why he hasn’t yet disclosed his same sex encounters to his female partner of over one year:

Not as yet, until she reveals more of herself to me…If she’s bisexual and I find that out later and it just happens to spring up or come out then I’ll take advantage of that opportunity and then I’ll work from there. [I: what are the reasons for not telling them?] I guess it’s a thing of not wanting to lose them…or not wanting to hurt their feelings because some people come crashing down harder than others.

Boss anticipates that a bisexual woman may be less likely to reject him for his own bisexual behavior, a theme that was reflected by other men who described being more open with bisexual women (to be described later). Other men related a desire to be more open with their partners, but wanted to delay disclosure until they determined how committed the relationship with their female partner would become. One straight-identified man, “B.T.”, age 49, described his desire for openness and fear of rejection when questioned directly by his female partner:

She asked me was I gay and I told her no. And for a moment, I was smoking a cigarette and she said ‘Why did you get quiet?’ I said ‘because I’m watching TV. But honestly, I had went into a thought about should I tell her or should I not. And we left it alone but she got kind of irritable with me because I didn’t get into the details that I think she wanted… I might just tell her. I’m the type of person that you can’t keep biting at my fucking feet and expect me to stay there. Then again I might not. But right now I don’t think I want to let her know that. That is a little bit too much information but if I feel like we decide to get a little bit more in depth I would let her know. [I: But you don’t think she would be able to handle it?] No. I don’t think we can stay together if I tell her.

While these men’s narratives illustrate fear of rejection if they were to disclose to their female partners, they also reflect a desire to avoid hurting their partners and protect these relationships.

Some men described concern not only for their female partner’s reaction to their same sex behaviors, but also a desire to avoid being seen by others – or to see themselves – as homosexual. “Close”, a 25 year old straight-identified man, related:

First of all, I mean what she would think. I mean she would fly off the handle saying I’m a faggot or yada, yada yada. And that is not the case. It’s just that I like to get down with dudes sometimes, from time to time.

In narratives like the one above, distancing from stigmatized labels such as “faggot” reflects not only his desire to avoid conflict with his partner, but also his own internal conflict around the meanings of his sexual relationships with other men. “Smooth”, a 49-year-old man who identifies as heterosexual, imagined how he might react should a female partner label him as homosexual:

Because I don’t want no one to say ‘Ooh! That is nasty! You are fucked up! Get away from me! I don’t want to see you no more! You are a homo! No! As soon as that homo word comes out of her mouth I know my anger. I’m going to be like ‘Yo! You got the wrong one!’

These men describe grappling with their worry over female partners’ anticipated reactions as well as the social meaning of being perceived as homosexual in a culture that denigrates same sex behavior among men. At times, men recounted struggling with their feelings regarding their same sex encounters, as “B. Orient”, a 21 year old bisexually identified man, says, “I guess I’m a little scared of the shame and what she might have to say. It is pretty much being ashamed.”

Men made clear connections between the social stigma attached to homosexuality and anticipated loss of relationships and social status should their same sex behaviors be revealed. “Red”, a 53-year-old man who self-identifies as bisexual described his concern over the potential social ramifications of disclosure to his female partner:

Well because you would lose her, you don’t want your name to get out that you are gay and all that kind of stuff. You know how this world feels about it, at least our society here in America, anyway. It’s not accepted.

Similarly, “JuJu”, a 25-year-old bisexual man, states:

I don’t tell them [women] my sexual experiences with men…like we don’t really discuss that. That is not something we talk about. [I: Why not?] Because the way this country is now, it is all about in this society and how people look at you and if you have sex with a man you are automatically called gay. So I don’t want nobody looking at me as gay. I’m just a free-spirited person.

These men’s views reflect both an internal conflict over the meaning of their sexual behavior and awareness of the larger social stigma attached to same sex behavior among men. For these men, disclosure to female partners is a threat to their relationship as well as to their standing in the community, where they strive to project an image of heterosexual masculinity. Some men expressed concerns that their ‘cover’ would be blown by family members, as “Sean”, a 42-year-old bisexually identified man married to his female partner, relates:

She [his wife] is a drama queen! Yes, she is too dramatic, and she is a blabber mouth…it won’t be a down low experience any more. [I: So her reaction would be what?] Too dramatic and overblown. Blown way out of proportion and then it turns into something else. Another assault charge or something. [I: What have you told her?] I haven’t told her anything but actually other people have told her...I have some jealous-ass brothers and sister-in-law and they have told her some things about me…like he sleeps around, he’s bisexual, he’s this and he’s that and he ain’t no damn good! My aunt told her that part but that part I couldn’t attest to.

As the previous narratives illustrate, efforts to keep same sex behaviors secret from female partners reflect not only a desire to preserve their relationships with women, but often as well an internal struggle over the meaning of their same-sex encounters in a culture that devalues homosexuality. However, not all of the participants who participated in this project kept their behavior a secret from their female partners.

Eight of the 33 men who participated in this study (about 24%) reported discussing their sexual behaviors with other men with their female partners. These men, who self-identified as “bisexual” more often than the non-disclosing men quoted above, described a range of disclosure strategies, from partial disclosure (revealing past history of same sex behaviors) to complete disclosure. Reasons for disclosure reflected their value of being honest in the context of an intimate relationship and desire for acceptance of their ‘true’ selves.

Some men reported carefully negotiating discussions of their same sex sexual behaviors with female partners, choosing to disclose some, but not all, of their behavior. These men described opening up about past encounters with male partners while continuing to hide their recent or ongoing sexual relationships with men. For these men, honesty about their sexual history afforded them the opportunity to feel accepted for who they are by their female partners, while avoiding potential conflicts about engaging in concurrent sexual relationships with men. “Henry”, a 42-year-old bisexually identified man, described how he came to open up to his female partner:

It [disclosure] is very important so we can have good communication. [I: Wait! She knows you do this?] Yeah, in a way. [I: Why do you say that?] Because she sees me talking to a lot of gay guys. Most of my friends are gay. [I: Okay. So does she know what you do? Does she know everything you’re doing?] No, not really. [I: What have you told her?] I told her about my past experiences with men. [I: Does she know you’re still doing it?] No. No. No. [I: Okay, how did she react to that?] She was kind of baffled by it; confused, but she accepts me for who I am. [I: So why did you tell her?] I felt that it was very important for her to understand. I didn’t want her finding out through somebody else later on or whatever and come at me with that.

By disclosing his past history, Henry avoided the danger that his female partner may learn about it from others in the community, and was able to experience acceptance from his partner. Similarly, “Cheetah”, a 45-year-old bisexually identified man, related opening up about his past while remaining circumspect about his present day encounters with men:

I told her about my past, I told her about my past drug history, the past arrests, past sexual encounters with men… and she still wanted me. [I: Since you told her, what are the most important reasons for doing so?] My own conscience, just knowing that I wasn’t lying to her and to be truthful to a point. I mean I don’t tell her every single thing in the world that I think and feel and do and whatever…[I: Sum up real quick what you don’t tell her.] Well I don’t tell her every encounter I ever had. I mean when I don’t see her, I don’t tell her nothing.

These men value honesty about their sexual history with their female partners even while struggling with the choice to keep their current same sex encounters hidden. These men valued feeling accepted for their sexuality as well as other potentially stigmatizing behaviors such as drug use. As “Outstanding”, a 46-year-old bisexually identified man, explains:

It [disclosure] is real important because it’s like I couldn’t be with that person if that wasn’t the case. I want them to be honest and I’ll be honest with them. [I: What have you told her?] I told her about my sexual experiences, about the money, about the drugs, about wanting to and then having to. I pretty much disclosed everything to her concerning the matter… because I want to have honesty there. You gotta have honesty somewhere.

Similarly, “Buddha”, a 45-year-old bisexually identified man, felt more comfortable discussing these sensitive issues after his female partner opened up about her own personal history:

Yeah. It is important to let her know. As long as there is honesty then we can work on it, whatever it is, as long as there is honesty. [I: What have you told her? When was the right time for you to tell her?] When she told me. She started talking about how when she was in jail and shit she had to do until she got on her feet and I told her. That was it.

Some men related coming to value openness about their sexuality after learning from earlier painful experiences. Shy, a 37-year-old bisexually identified man, empathized with women who feel threatened by their male partner’s same sex relationships:

Well, normally in my case, they [female partners] know because I don’t hide it. With undercover and down low guys, they don’t tell and it’s wrong. And I used to date guys that had girlfriends. I stopped doing that…because I feel guilty afterwards. And when I was younger I used to think ‘Yeah! I got this bitch’s boyfriend or this bitch’s man!’ But it is not right. It is really unfair to the women. It is very dangerous. Someone could get hurt. [I: Get hurt how?] Violently. Physically. I had someone come after me about her man…a couple of years ago. She tried to stab me. She hid on my roof with a knife. She tried to run me over with her car.

The narratives offered by the men who disclosed to their female partners – which reflected a value for honesty within the context of intimate partnerships – mirror in many ways those of the men who chose not to disclose to their female partners, even as they expressed regret over their lack of honesty. It is possible that men who participated in this project and related disclosing to their female partners had a greater degree of self-acceptance regarding their same-sex sexual behavior, as reflected in their sexual self-identification as “bisexual” rather than “straight” or “heterosexual.” Yet even some of these men separate their private sexual identity from their public presentation of self: Phillip, for example, said he sees himself as bisexual but would never say so openly. Similarly, Henry identifies as bisexual “in my mind, or depending on the situation … because a lot of people judge.”

While the interviews for this project did not explicitly probe for men’s level of ‘outness’ around their sexuality within their community, some men described greater degrees of openness and public identification as bisexual. A few of these men also reported a preference for similar qualities in their female partners. “Mr. Smith”, a 38-year-old bisexually identified man, described valuing the companionship of bisexual women:

Basically the way I roll is that, number one, my female partner has got to be bi-lesbian. That is number one because I don’t have to worry about all this drama going on. I mean basically my profile says bisexual, think about what you are going to get into. [I: So when you say your profile do you mean that is the profile you put on the internet?] In general, on the internet and in person also. Meaning if you are going to come into my world this is the way I am.

Open discussion of sexual behavior with female partners also led to discussions of safer sex. “Max 40”, a 43 year old bisexually identified man whose primary female partner is bisexual, reports:

Yes I do [disclose]. It is very important. Communication is the key to anything. Back then I didn’t care but now that I’m a little older, more mature, stronger, wiser, it is very important to communicate and talk about it. And if they say no then that will be so. [I: Do you find that to be true of most women?] No. No. Everybody has their likes and dislikes I guess and with her she goes the other route too…her thing is we hit it off and we are the best of friends…[I: what have you told her about your bisexuality?] Well basically I broke it down and told her I was seeing a male. We both had been communicating and I told her I’m dating a male figure so she said she didn’t care as long as I wear a condom.

While these men express awareness of the potential risk of disclosing their same sex behavior to female partners, the potential benefits of honesty include feeling accepted by their female partner, increased emotional intimacy, and having the opportunity to have frank discussions about sexual health. For some men, this level of honesty was more likely to be realized with bisexual female partners.

The diversity and complexity of men’s views regarding disclosure to female partners summarized here reflect the uneasy position of Black and African American behaviorally bisexual men within their communities. While a portion of the sample reported being partly or completely open about their sexuality with female partners, concerns about rejection by these partners and loss of status within the larger community reflect the continuing stigma associated with same sex behavior among men in the Black community (Operario, Smith, & Kegeles, 2008; Ward, 2005). The ambivalence men narrated around their own feelings about their sexual behavior with other men and their conflict over disclosure to female partners is no doubt a source of considerable stress. One way to cope with the stress of concealing a stigmatized behavior such as same sex encounters, or to manage one’s own emotional ambivalence about the meaning of this behavior, is to employ the use of mood-altering substances (Halkitis, Mukherjee, & Palomar, 2009). The next section describes the role of alcohol and drug use in the sexual encounters men had with other men and their perceptions of how these substances facilitated such behavior.

The Role of Substance Use in Sexual Encounters with Men

Qualitative analyses of men’s narratives of their perceptions of the connection between their use of substances and sexual encounters with other men yielded four categories of effects – facilitating, enhancing, risk-inducing and transactional – regarding the role of alcohol and other drugs. In the following sections we describe these categories and discuss ways in which they corroborate or challenge the frameworks developed in previous qualitative studies (Harawa et al., 2008; Parsons et al., 2004).

Facilitating role: lowering inhibitions

Men described two general ways in which drugs and alcohol helped to facilitate sexual encounters: lowering inhibitions and “creating” desire. Most of the men who described substances as facilitators discussed a variety of ways in which they lower inhibitions, enabling them to engage in sex with other men - something they want to do but would avoid doing while sober. Several respondents voiced the notion that drugs and alcohol are liberating, that they free men to do things they may want to do but resist for one reason or another when they are sober. One respondent, “J. Love,” a 44-year-old, bisexually identified man, provided a detailed example:

You and this person have been chatting for a long time and you know that this person may have feelings for you and you for them, but you both have girlfriends or whatever so one wants to be a little bit more macho than the other one. So you don’t want to come across like a bitch so you try to play it off, but at the same time you may be somewhere and you have to undress to change or something and you, out of the corner of your eyes, checking each other out. You are checking each other out. I’ve seen this. But you are doing it in a very slick way where one can’t … you know … Now, drinking – when you drink it does edge things on a little bit more because you got that liquor in your system and you feel like I can conquer the world and you just go for it. You just say what you gotta say.

Similarly, 37-year-old bisexually identified “Shy”, said simply, “I’m more able to approach someone if I’m under the influence.”

J-Love and Shy describe substances as sources of courage. Closely related is the idea of drugs or alcohol as social lubricants, as expressed by Mr. Smith (age 38, bisexually identified):

When it comes to seducing, that would be the key remedy for anyone, not only me. You know. But to express your own feelings, that would come in handy, especially alcohol because that is like a truth serum. … Yeah. Alcohol is a truth serum, you know, and what goes down, goes down and you don’t know nothing about it and you keep it moving.

Mr. Smith’s statement also hints at the secretive character of some same-sex encounters among non-disclosing MSMW. In a similar vein, JuJu, a 25-year-old bisexually-identified man, explained that drugs and alcohol can override the best intentions:

That is a big part … being under the influence of alcohol and you really don’t care about what goes on. You just carefree at that point in time and whoever is around you might just do something you don’t want to do. That’s why a lot of people like have problems, because they cheat on their lovers because they be high and under the influence of alcohol and drugs.

For men who end up doing what they “don’t want to do,” drugs and alcohol can serve as a backup excuse to attribute a same-sex encounter should it be revealed. Outstanding, age 46 and self-identified as bisexual, explains:

Oh, definitely! … [P]eople’s inhibitions are down and it is easier to do what you want to do. … [I]f a guy wants to have sex with other men it is much easier and they can blame it on the situation at hand – the drugs, the environment … yeah. It’s like any excuse for me …

In other words, drugs and alcohol offer plausible deniability as protection against social stigma and homophobia, whether internalized or expressed by members of a man’s community or social networks.

By lowering social and sexual inhibitions, drugs and alcohol can remove impediments to acting on same-sex desires by relieving shyness and reducing stress related to fear of rejection. Thus they allow men to engage in behavior they ordinarily resist, and they facilitate access to partners (Harawa et al. 2008). The liberating effects can be spontaneous (as in JuJu’s example) or they can be routine if men anticipate them and deliberately use substances as a source of social courage (Parsons et al. 2004). Substances can also liberate men temporarily from feelings of shame or moral conflict that accompany their desire for male partners, and provide them with a ready excuse if their secret actions were to become known. In the terminology of Harawa et al. (2008), substances thus allow men to cope with homophobia and to rationalize engagement in socially stigmatized behavior. These functions are also consistent with what Parsons et al. (2004) identified as a taboo script.

Facilitating role: Creating desire

Although most men discussed drugs and alcohol as facilitating encounters they secretly wanted to have, a few men reported that they were not aware of any interest in having sex with other men while sober. In these cases, getting high generated a desire that they otherwise did not perceive as present. For example, Joel, a 39-year-old respondent who sexually identifies as “deviant” states:

Yes, because if I’m sober I don’t even think about it. Is that funny?… To have sex with males!? I mean it doesn’t even come to mind unless I’m getting high!

When asked how he identifies himself sexually, Joel rejected bisexual, heterosexual and other standard labels, insisting on describing himself as “deviant.” When the interviewer followed up by asking if he considered himself “down low,” Joel replied, “Of course. Nobody knows…and I will kill anybody that opens their mouth.”

For Smooth, a 49-year-old who self-identifies as heterosexual, getting high on crack and alcohol will lead him to sex with another man only if a female partner is not available:

If I can’t find a female to be with, you know, and a male walks up on me then, yeah, I’m down … It [being high] builds my sex drive up. … I mean, I get paranoid, but after that I got to go get me something. And if I don’t see a female I want to be with, I’ll tap a man.

Responses such as these correspond to the motivator theme identified by Harawa et al (2008), because they indicate that men had sex with other men either solely or primarily because of their drug use; however, many of the men described sexual encounters wherein the motivation was to obtain drugs, although sex could also be seen as an added bonus.

Transactional

Several men (n = 6) who participated in this study reported exchanging sex for drugs or the money to buy drugs, a situation in which sex is currency. Shy, a 37-year-old bisexual man explained: “I have traded, you know … We were using together and having sex or they gave me money for sex or vice versa.” Another man, Robert, a 53-year-old who self-identified as heterosexual, says he is a daily crack user and has had sex with men in order to obtain drugs or the money to buy them. He explains, “Sometimes men have drugs and the other men don’t have drugs and when you are in the grip of using drugs you are bound to do anything.” However, his narrative resists reduction to sex-for-drugs as a simple transaction: “At that moment I prefer men to women … when I’m high.” Thus sex may be used as a way to obtain drugs and also as a facilitator for sexual encounters with other men while under the influence. John, a 57-year-old man who calls himself a “switch-hitter”, reported enjoying insertive anal sex and stated that drugs are always part of the interaction for him, but not always in the same way: “Always. Either I need to get some or I got some and I see somebody that I want to bust their butt.” John said that he exchanges sex for money and drugs on a fairly routine basis, but does not identify himself as a sex worker. He also said that when he is seeking a sex partner, he frequently offers drugs because he has found that giving money to drug users for sex is a poor deal:

I only collect money. I never give anybody cash. It’s an old habit. I’m an old-timer at this and plus, they let you hump them more when you give them drugs as opposed to money. When you give them money they try to suck you off so fast or they just give you the “jerk-off, suck-off” so they can run and cop. Yeah. When you pay them in drugs you come off better.

John’s experience is corroborated by other participants who said they prefer to trade sex for drugs rather than for money. However, a few men identified sex for money encounters as purely transactional, a way to obtain drugs when they didn’t have the funds to buy them. These men did not describe such encounters as inherently pleasurable. As Jay, a 28-year-old bisexually identified man who used crack explained:

I get with guys so I can get money so I can get drugs … I don’t crave sex when I’m high. My motivation is to get money and then when I get money then I go off and get high by myself … If somebody has some crack I’ll trade sex for crack.

Jay’s quote reflects an instrumental approach to sex with men, wherein obtaining substances is the desired goal, and sex with men is a way to achieve this goal. His narrative serves as a reminder that sexual behavior can serve many purposes, including functional ones. For some men who trade sex for drugs, the sex may simply be a means to an end.

Enhancing

Regardless of whether they would have sex with men when sober, several men said that using drugs and alcohol enhances the quality of the experience. Henry, age 44, identifies himself as bisexual and says he was driven by curiosity to have sex with men after being incarcerated. He said that he does not need drugs to have a sexual encounter with a man, but that being high enhances the experience: “Yes! Definitely…that plays a big part because it enhances the euphoria and feelings to the highest degree; I love that.”

Similarly, Boss, a 47-year-old who describes himself as heterosexual, said:

I think basically it [drug and alcohol use] does not play really a big part but it enhances my sexuality … and you enjoy it more. Plus, I guess, basically you have a little better erection.

Some men found that drugs and/or alcohol served to enhance feelings of attraction as well as the physical experience. Max 40, a 43 year old bisexually identified man, described the benefits of using Ecstasy during sexual encounters:

Well, Ecstasy, in general … Ecstasy is like a drug that enhances emotions, so of course when you are at the club you are dancing, you drink maybe one or two drinks and take the Ecstasy pill and then you take it and then you over fantasize … It can be an asset.

And with marijuana: “It is an enhancement, so when I smoke and they smoke we reach a whole new level. So it can play a big part in sexual attraction.” Situations like those described by Henry, Boss and Max 40 evoke the routine script identified by Parsons et al. (2004), because the men have learned to attribute positive sexual experiences in part to the intoxicants. They may or may not find that substances also motivate or facilitate their sexual encounters with other men.

Risk-inducing

Many of the men interviewed said that they did not always use condoms for anal sex and attributed some of this risk behavior to being under the influence of drugs and alcohol. Failure to use condoms is sometimes a consequence of the enhanced quality of the sexual experience produced by using substances. As Phillip, a 40-year-old bisexually identified man, said:

Well …I guess like marijuana …well, for me it boosts up my sexual desire and I become relaxed and to me the sex is a little better. … It is like you are more passionate and so a lot of times in the heat of the moment you ain’t trying to stop and go get a condom.

At other times, drug use simply diminishes competence. From Charlie, age 53, who self-identified as heterosexual:

You know, sometimes you don’t want to put on a condom and sometimes you might be too high to put on a condom and sometimes you put on [the] condom wrong. Sometimes it breaks. Sometimes it breaks because you are not putting it on right.

All of the respondents said they make an effort to use condoms routinely, and some said they felt they were more consistent in using condoms with male partners than with female partners. However, the semi-structured qualitative interviews conducted for this study did not systematically measure condom use, so it is difficult to assess the level of risk associated with the sexual practices of men in this sample.

Discussion

The purpose of this study was to qualitatively explore the perspectives of Black MSMWs with primary female partners on their sexual encounters with men, their views on disclosure of their same-sex behavior to their female partners, and their thoughts on the roles that alcohol and drugs play in their same-sex encounters. The majority of men who participated in this study reported keeping their same-sex behaviors with other men secret from their female partners, primarily out of fear that disclosure would lead to rejection, hurting their partner’s feelings, and potentially losing status within their community after being labeled as “homosexual” by others. Many men described feelings of ambivalence as they were torn between their value of being honest within intimate partnerships and their fear of the negative repercussions of disclosure. Many men also reported feelings of shame regarding their same-sex behaviors and conflict regarding the meaning of these behaviors for their sexual identity.

The qualitative themes around disclosure to female partners are similar to those identified by Malebranche and colleagues (Malebranche et al., 2010). Disclosure to female partners occurs along a continuum, from full secrecy to partial or complete disclosure, in a social context in which same-sex behavior among men is not viewed as acceptable within the Black community. The men in this sample who did choose to disclose their same sex behaviors to female partners were more likely to self-identify as bisexual than the men who did not disclose at all, hinting at degrees of self-acceptance regarding identity and sexual behavior with other men. Men who disclosed their same-sex encounters to female partners also reported feeling more comfortable doing so if their female partner identified as bisexual, or if they were in an intimate and committed relationship with this partner (although narratives from men who were in such relationships were divided between disclosure and non-disclosure in this sample). Some of these themes corroborate earlier findings from a small qualitative study of Black MSMW in New York (Dodge et al., 2008).

It is clear that substance use may encourage same sex encounters, either by helping men overcome shyness, insecurity and social taboos or by “creating” desires that men don’t perceive when they are sober. They can enhance the quality of sexual encounters with other men, yet may also increase the risk involved. Sex with another man is also sometimes used instrumentally as a way to obtain desired substances. The men in our study are conscious of all of these roles and were able to discuss them thoughtfully in the interview.

Our results add to and corroborate findings from earlier work on alcohol-using Black MSM (Parsons et al., 2004) and substance-using Black MSMW (Harawa et al., 2008). Men reported decreased social and sexual inhibitions and increased impulsive sexual behavior when under the influence of substances. We also saw evidence that men sometimes use substances deliberately to reduce inhibitions, and may engage in unplanned behavior after getting high, consistent with Parsons et al.’s findings regarding routine and spontaneous sexual scripts (Parsons et al., 2004). However, we did not explicitly ask men to recall their intentions for using substances, so our findings in that area are not systematic. In the present study, these issues are explored with alcohol and drug using MSMW who have female primary partners, expanding on previous qualitative research while corroborating themes identified in prior samples.

There are several limitations to the findings reported here. Like previous research on samples of Black MSMW, our project relied on the willingness of non-gay identified substance using MSMW to discuss their perspectives with the research team. NGI Black MSMW are a hard-to-reach population and our sample is biased by including men who were comfortable discussing these sensitive topics with our research team; thus it is difficult to gauge how generalizable these findings are to the larger population of non-gay identified Black MSMW. Because our study employed open-ended qualitative interviews, we did not collect systematic data on men’s level of outness, internalized homonegativity (IH), or safer sex practices, nor did we assess the frequency of their substance use or levels of dependence. Thus, although our qualitative data have implications for risk reduction interventions for substance using Black MSMW, our findings cannot specify levels of substance dependence or HIV risk behavior in our present sample. Our sample was comprised of Black MSMW residing in the New York metropolitan area, and thus may not be generalizable to Black MSMW in non-urban areas.

Despite limitations, all of these findings are encouraging for identifying ways to engage non-disclosing, NGI Black MSMW in prevention and treatment efforts. The qualitative themes reported in this paper reflected men’s struggles with their own same-sex behaviors, their sexual identity, and their place in the Black community, where most men strove to present themselves as heterosexual to others. While the present study did not assess internalized homonegativity (IH), men’s narratives reflected ambivalence and even shame regarding their sexual behavior with other men.

Previous research on IH among samples of low-income, urban MSM and MSMW has found that Black MSMW who reported recent use of cocaine were more likely to score high on levels of IH (Shoptaw, et al., 2009). IH has also been found to be highest among HIV+ Black MSM who do not identify as gay, in a recent study reporting findings from a six-city sample of MSM (Ross & Rosser, 2008). In that same study, IH was also associated with lower condom self-efficacy and lack of disclosure of HIV status to casual partners. These studies indicate future directions for research on substance-using Black MSMWs; mixed methodologies assessing levels of IH and qualitative interviews exploring men’s sexual identity development, comfort with their sexuality, and level of outness would lay the foundation for culturally relevant, tailored intervention approaches.

Further in-depth qualitative research is also warranted to develop greater understanding of the social context of substance use and risk behavior among MSMWs. Understanding these contextual factors is critical to the development of effective, integrated prevention and treatment strategies for Black MSMW, something that currently is not widely available for non-injection drug users (SAMHSA 2010). It is known that messages aimed at the gay community are not likely to reach NGI men, and especially not Black NGI men who may perceive the gay community as largely white and somewhat closed (Ward, 2005). Furthermore, interventions designed to persuade men to reveal their same-sex risk behavior to their female partners may be counterproductive, given the fears of repercussion that men have expressed in this and other studies (Dodge et al., 2008; Malebranche et al., 2010; Operario et al., 2008; Stokes et al., 1996). However, some of this same research also suggests that men may be willing to talk openly with service providers if they feel they are in a safe, nonjudgmental situation where their anonymity will be protected and their sexual identity will not be questioned (Operario et al., 2008). In order to facilitate this, it is imperative to develop risk interventions and substance use and HIV prevention strategies that do not focus on group membership and identity.