‘It’s my inner strength’: Spirituality, religion and HIV in the lives of young African American men who have sex with men

Abstract

Young black men who have sex with men (YBMSM) account for 48% of 13–29 year old HIV-positive men who have sex with men (MSM) in the USA. It is important to develop an effective HIV prevention approach that is grounded in the context of young men’s lives. Towards this goal, we conducted 31 interviews with 18–30 year old YBMSM in the San Francisco-Oakland Bay Area. This paper examines the roles of religion and spirituality in YBMSM’s lives, which is central in the lives of many African Americans. Six prominent themes emerged: (1) childhood participation in formal religious institutions; (2) the continued importance of spirituality among YBMSM; (3) homophobia and stigmatisation in traditional black churches; (4) tension between being an MSM and Christian; (5) religion and spirituality’s impact on men’s sense of personal empowerment and coping abilities; and (6) treatment of others and building compassion. Findings suggest that integrating spiritual practice into HIV prevention may help programmes be more culturally grounded, thereby attracting more men and resonating with their experiences and values. In addition, faith-based HIV/AIDS ministries that support HIV-positive YBMSM may be particularly helpful. Finally, targeting pastors and other church leaders through anti-stigma curricula is crucial.

HIV/AIDS has reached epidemic proportions among United States (U.S.) non-Hispanic blacks, who constitute 41% of all men living with HIV/AIDS in the USA, with the most common route of transmission being unprotected sexual intercourse with a man who is HIV-positive (Prejean et al. 2008). The situation is particularly severe among young African American (black) men who have sex with men (YBMSM). People between 13 and 29 years of age comprise 34% of new HIV infections in the USA, with MSM making up 38% of the new infections, and black youth constituting 48% of all new HIV infections among MSM in this age cohort (Hall et al. 2008). A recent study estimated that if patterns remain unchanged, 60% of YBMSM who are twenty years old now will be HIV-positive by the time they reach forty (Stall et al. 2009). Substantial work still remains to help YBMSM avoid HIV transmission.

To be most effective, it is important to develop HIV prevention approaches for YBMSM that resonate with their cultural practices and context of their lives, and that build on existing community strengths and institutions. Thus gaining a better understanding of the contextual issues that affect the lives of YBMSM is important to develop a culturally competent intervention. In reviewing national and international polls on the importance of religion, Gallup and Castelli (1989, p.122) wrote that ‘American blacks, by some measures, are the most religious people in the world’. Since African American churches are ubiquitous in most black communities, this study explores the roles of religion and spirituality in the lives of YBMSM to consider if they can be harnessed as a part of HIV prevention approaches.

Role of religion and spirituality in black communities

Black churches are central institutions in U.S. black communities. Financially, black churches are the primary U.S. institutions that are controlled by the black community (Lincoln and Mamiya 1990; Miller 2005). Historically, black churches have functioned as the hub of black politics, spanning from the civil rights era (King et al. 2006) into the present day. Socially, black churches are often the center of activity in black communities, bringing together diverse members of the community (Baumeister and Leary 1995; Stack 1997). These churches have been central in setting norms and defining values for community members (Smith, Simmons, and Mayer 2005). Churches often provide a network of friends for emotional and physical well-being (Caldwell, Green, and Billingsley 1992; Taylor and Chatters 1988). By providing a refuge from discrimination and marginalisation, black churches may offer a safe place for emotional rejuvenation and spiritual catharsis (Lincoln and Mamiya 1990). Thus, black churches provide social and spiritual resources to cope with stressful situations and life-threatening events (Culliford 2002; Miller 2005). For all of these reasons, it is not surprising that religion and spirituality play a central role in the lives of many African Americans.

Several studies suggest that religious involvement is protective against morbidity and mortality (Koenig 1998; Oxman, Freeman, and Manheimer 1995; Pardini et al. 2000). In addition, spirituality has been shown to be an important factor for maintaining psychological well-being among black Americans who have HIV (Boyle et al. 1997; Hudson and Morris 1994). Coleman and Holzemer (1999) found existential well-being (a spiritual indicator of meaning and purpose) to be more important for psychological health than religiosity.

Black churches and associated cultural practices are also related to activism among African Americans. Pattillo-McCoy (1998) studied “church culture” and found that black church rituals are powerful cultural tools for facilitating local organising and activism among African Americans. She asserts that these tools, which she identifies as primarily prayer, call-and-response interaction and Christian imagery, ‘invoke the collective orientation of black Christianity and draw strength from the belief in a direct, beneficial relationship to God’ (Pattillo-McCoy 1998, 768). Black churches typically have a collective orientation that seeks to stimulate activism towards common goals. Activist culture within the black community frequently corresponds to church culture. Perhaps black church-related activism approaches could be used to support HIV prevention efforts for YBMSM. Before pursuing this possibility, however, it is necessary to understand YBMSM’s experiences with and attitudes towards black churches.

Stigma and homophobia in traditional black churches and black communities

Despite the health-supportive impact of religious involvement for many black heterosexuals, traditional black churches often stigmatise sexual minorities (Haile, Padilla, and Parker 2011; Jeffries, Dodge, and Sandfort 2008; Fullilove and Fullilove 1999; Han et al. 2010; Ward 2005; Woodyard, Peterson, and Stokes 2000). For example, interviews with clergy revealed that the non-responsiveness of black churches to the AIDS pandemic was due to the stigmatisation of gay men; this presented the most insurmountable obstacle to action, compared to stigmatisation of injection drug users (Fullilove and Fullilove 1999). Homosexuality has traditionally been denounced as a sin in black churches. Harsh criticism and denunciation of homosexuality from the pulpit have been acceptable practices in many black churches. Indeed, many have avoided HIV prevention efforts as part of their ministries due to the association of HIV/AIDS with homosexuality, and due to a general discomfort with discussing sexuality and condom use (Adler et al. 2007; Smith, Simmons, and Mayer 2005; Ward 2005).

The current study was part of a larger effort to understand issues facing YBMSM as they relate to HIV prevention, with the goal of developing HIV prevention interventions for this population. To explore these issues, we conducted in-depth interviews about a number of different issues with YBMSM in the San Francisco-Oakland Bay Area in 2002–2003. The aim of this paper is to explore the place of religion and spirituality in YBMSM’s lives, to consider how these might relate to the development of HIV prevention efforts. Thus young men were asked about their experiences with churches, their feelings about spirituality, and how they reconcile possible tensions between the sense of support and community they may derive from these institutions and the attitudes expressed towards them by church leaders and other congregants.

Methods

Sample and recruitment

Data were collected using a stratified sampling approach to recruit approximately equal numbers of HIV-negative (or unknown status) and HIV-positive 18–30 year old African American men who reported sexual contact with a man in the past six months and resided in the Oakland-San Francisco Bay Area. For this exploratory study, a diverse sample of YBMSM was desired. Interviews were conducted with 31 YBMSM, of whom 23 identified as gay/homosexual, 2 as same gender loving (SGL), 5 as bisexual and 1 as heterosexual/straight. Fifteen men reported being HIV-positive and 16 reported being HIV-negative or did not know their HIV status. They ranged from 18 – 30 years of age, with a mean of 23.5 years. Three percent had not completed secondary school (high school); 42% had completed secondary school and had no additional education; 42% had some college or a college degree, and 13% had completed some graduate school or an advanced degree. Twenty-three percent were currently in school, and 42% were currently employed. Twenty-six percent of the men had lived in the San Francisco-Oakland Bay Area all their lives, and men who had moved to the area had lived there an average of 5.6 years.

The men were recruited into this study through the posting of flyers that advertised the project at community-based organisations targeting YBMSM and through street outreach. Men interested in participating called a study telephone number. Of 60 phone calls received, 20 individuals were ineligible due to age restrictions, and 13 were unreachable when we attempted to call them back. Six additional participants were recruited directly through street intercepts. Two interviews were excluded, one because of the age restrictions and the other because he appeared to be under the influence of a substance, yielding 31 interviews for this study. Respondents were compensated with US$35 for participation. Interviews were conducted during 2002–2003. The UCSF Committee on Human Research approved all protocols and procedures.

Data collection

The interviews were conducted in San Francisco at a location that was easily accessed by mass transportation. The interviewer was trained to develop rapport with the study participants. Semi-structured in-depth interviews lasted approximately ninety minutes and followed an interview guide. The guide contained general questions, which were followed by short probes to elicit additional information and increase the richness of the informant narratives. Topics included family, work/school, religion/spirituality, peers, sexual identity, HIV disclosure, and community involvement. The data for this analysis came from the following interview guide questions: Did religion play a role in your life growing up? Growing up, what did you hear about HIV/AIDS in church? Does religion or spirituality play a role in your life today and if so, in what way? What have you heard from your family, friends, or church about HIV/AIDS?

Interviews were recorded and transcribed verbatim; identifying information was removed from the transcripts.

Data Analysis

Transcripts were entered into Atlas*TI and then broadly coded for content by using a codebook based on the interview schedule, the primary questions of the research, and emergent themes in the data. The emerging themes were identified through discussions involving the first author, the principal investigator, and the second author, each of whom conducted independent analysis of the transcripts and then met to discuss the emergent themes. Using a thematic analysis approach (Rubin and Allen 2004), interviews were examined for major themes related to religion and spirituality. Because the research was formative in nature we did not apply existing theoretical frameworks which might not be relevant for the target population. Instead, following the tenets of thematic analysis, we allowed the themes and theory to emerge from the data. As such, a line-by-line analysis was conducted on relevant portions of interview transcripts to generate additional themes from these data if they provided explanatory value across cases. Codes representing the themes were developed and applied to narratives. Illustrative quotations were selected to represent themes in the narratives and were used to explore each theme independently.

Results

Issues regarding spirituality, religion, motivations for participation in formal religious institutions, homophobia expressed by the church, and the desire to detach oneself from formal religion emerged as prominent themes during analysis. The following specific themes emerged through the young men’s narratives regarding church and spirituality, including: (1) childhood participation in formal religious institutions; (2) the continued importance of spirituality among YBMSM; (3) homophobia and stigmatisation at traditional black churches; (4) tension between being an MSM and Christian; (5) religion and spirituality’s impact on men’s sense of personal empowerment and coping abilities; and (6) treatment of others and building compassion. Each theme is discussed below.

Childhood participation in formal religious institutions

All of the young men were raised in Christian churches or were reared in a way that emphasised spirituality. Thirty of the 31 YBMSM reported attending church throughout their childhood, typically every Sunday, from their youth through adolescence. One man stated, ‘I was forced to go to church. At first I was forced to go to Sunday school every week….the bus would come and pick us up.’ (James). Many went to church with their grandmothers or mothers regularly as this young man described:

‘It was like Saturday night you were in bed and you had to get up for Sunday school that morning. So religion was like some—I wouldn’t say it was forced upon me but it was something that was always like a requirement for my grandmother. And once I got like 13, 14, 15, I enjoyed it for myself.’

(Maurice)

The participants were raised in Baptist, African Methodist Episcopal, Methodist, Catholic, and Lutheran churches. Even the young man who did not attend church as a child said that he was raised in a ‘spiritual environment.’

The continued importance of spirituality among YBMSM

Spirituality, and for many of the men, religion, remained important to many men as adults. Nearly all of the YBMSM (30 out of 31) expressed that they remained spiritual. One young man who identified himself as spiritual stated,

‘It’s my inner strength, as far as how I deal with things, how I deal with people when I’m down, what picks me back up, or if I need to really get things accomplished what’s really going to get me through it…’

(Henry)

This young man leaned heavily on his personal sense of spirituality—on his faith— to sustain him during difficult times. He relied heavily on his spirituality to strengthen and reinvigorate himself in order to confront life’s challenges—HIV/AIDS, perhaps being one of the challenges to which he referred. Many of the men mentioned spiritual practices they continued to do, such as saying grace before meals, praying nightly before going to sleep, and consistently acknowledging God’s presence in their lives.

The importance of spirituality was independent of church attendance. Of the 16 men who discontinued worshipping at a religious institution, 15 described themselves as spiritual nonetheless. Stated one young man, ‘I’m big on spirituality. I consider myself a spiritual being, and I’m not at all religious….I like to consider myself to be connected to the universe.’ (James) Another individual stated that, ‘I have no religion because I love God personally, but organised religion—I’m going to have to say that that’s not my thing….I’ve been on my own spirit quest…’ (Marquis) Several other men described themselves as being ‘God-loving’ or ‘God-fearing’ despite their lack of connection with formalised religion and discussed the importance of personal prayer, fellowship with other spiritual beings and the significance of turning to God for guidance and strength during challenging times.

Approximately half (15) the men reported attending a religious institution—12 worshiped in Christian churches, and 3 worshipped in non-Christian religious institutions (2 in Buddhist institutions and 1 practiced a variety of world religions). For these men, formalised religion has remained an important part of their lives, as indicated, in part, by their continued church attendance as adults. When asked what place religion and spirituality play in one young man’s life, he stated,

Faith, pray, believe, trust. It plays a lot. If you believe in trust and have faith, God will, He will….There is a God and I believe that He has taken care of me and He will [continue to do so].’

(William)

For this young man, the ritual of attending church secures God’s presence in his life. Similar thoughts were expressed by another young man, who stated that,

‘I’m a firm believer of God. I’ve accepted Jesus into my life. I grew up reading the Bible and grew up knowing what to do and what not to do. Religion has played a role in my life growing up and it still does.’

(Robert)

For this young man, the teachings from church, reinforced through prayer and other acts of faith, provide a sense of comfort and security, a roadmap to clarify “what to do and what not to do.”

Homophobia and stigmatisation at traditional black churches

Many young men related stories of anti-gay rhetoric being delivered from the pulpit, and the homophobic attitudes and tremendous stigmatisation within the traditional black churches that they had attended. This was not merely a heterosexist orientation at the faith-based organisations, in which a focus on heterosexuals took predominance over others; over half the men recounted specific experiences in which the ministers preached damnation against homosexuality and homosexuals during church services. For example, speaking about the church’s beliefs about homosexuality, one participant recalled,

‘They said that it [homosexuality] was wrong…Came out flat and said it and a couple of people in the parish said that they were gay and he [the pastor] outed them in the service.’

(Alvin)

Many of the men stated that the anti-gay rhetoric they heard expressed by ministers at the pulpit led to their decision to disconnect from the black church entirely. The following excerpt from the same young man captures this: ‘…I rejected the church … because they were like “I know there are some gay people here.” And I was like fuck that…I’m not going back…We used to go to church every Sunday.’ (Alvin) The overtly expressed homophobia and marginalisation of openly homosexual congregants led to this and other informants’ decisions to leave the traditional black church altogether.

The tension of being an MSM and Christian

The conflict of being an MSM and attending church was a very prominent issue. Many men discussed the challenges they had encountered as a child or younger adolescent as they were recognising their same-sex desires, and nearly all animatedly discussed their current experiences of being gay/bisexual/SGL and being Christian. One young man described his earlier conflicts:

‘I found out real early that I was gay. But I didn’t have any problems until I got to my mid-teens where I thought that I needed a religion and then there was this religion that was telling me that I couldn’t be gay…so I was going through this religious battle.’

(Sheldon)

The emotional pain that some of the men still experienced was palpable, since religion had been extremely important to them, but the treatment they received at the church rendered it impossible for them to continue attending. It seemed that the desire to seek Christian community and solace continued for many men, while they asserted that they could not tolerate being stigmatised at their place of worship. The following young man exemplified this internal struggle:

‘Well, I’m going to get back to going to church. I used to think I was going to hell because of my lifestyle…they was saying that if you gay or whatever you’ll go to hell for eternity. And I was so scared. I even tried to change trying to be somebody that I wasn’t. I had sex with a woman and thought I was going to change. But the truth is I couldn’t do it…so now I’m at a point in my life that I have more of a relationship with my God….When He blot my tears away, He’s there and I can feel He’s present….He loves me gay or if I was straight. He don’t love us no lesser….And I haven’t been to church in a long time ….but I’m going to start back because I don’t deserve that.’

(Leo)

young man decided that he has a right to his relationship with God, and that he believes that God will accept and love him as he is, “gay or straight.” A number of men actively rekindled their connections to the church despite previous experiences with institutional homophobia because they derived affirmation and comfort through religious practice. As this man states, he does not “deserve” to be cut off from that comfort, and this framing of religious practice and comfort as a right allows him to reconnect with the church.

Many of the YBMSM who continued to attend church as young adults felt deeply conflicted about living as a sexual minority. For instance, one young man commented that,

‘Basically, I’m a sinner and a hypocrite. I go to [name of church] church sometimes and I go to [name of church] sometimes…But I am not really going to church every Sunday or…three or four times a week. But I just believe in God strongly so that’s my religion as far as I see it.’

(Prince)

Interestingly, this same respondent fluctuated between attending a conservative, traditional black church that was similar to the one in which he was raised and a black church that openly accepted gay members. Despite the homophobia that he encountered at the conservative church, he remained steadfast in his religious convictions and attended church regularly regardless of the unwelcoming treatment of fellow congregants: ‘I still go to [name of conservative church]…You know what I’m saying? Only God can judge me. That’s how I feel about it.’ (Prince)

Some men continued attending more traditional, conservative churches, where they were often subjected to hearing negative statements regarding homosexuality—preached by the minister, as well as espoused by other parishioners. For these men, all of whom were HIV-positive, the more conservative churches resonated with them and reflected family tradition regarding church theology and practice. Hence, six of the seven church-attending HIV-positive men attended traditional churches. While churches that were relatively liberal provided a more accepting social environment, they did not necessarily meet the religious and spiritual needs of HIV-positive men raised attending traditional churches. Some men expressed that they felt family pressures to continue attending their ‘family’s church’ which tended to be conservative, and were aware of their families’ (particularly their grandmothers’ and mothers’) desire that they continue attending the church in which they had been raised.

In contrast, none of the HIV-negative men continued attending traditional churches. Five of the 16 HIV-negative men (and one HIV-positive man) opted to go to non-denominational, gay-friendly churches. The following quote is illustrative:

‘And it’s like now that I’m older I don’t go to Sunday school but now I get up on my own and I go to church. And it’s like I don’t go to the same church that my grandmother goes to no more…Now I go to [name of church].’

(Maurice)

Three other HIV-negative men disavowed their association with Christianity, in large part because of the homophobia they had encountered at traditional churches and instead, explored and joined non-Christian religions. One young man discussed his search:

‘I was exploring every world religion I could get my hands on. I was just very interested in [spirituality] in general and I was interested in finding our places as gay people within those traditions, and we do have them, you know; I found them. That was amazing!’

(Sylvester)

Religion remained important to these young men as they searched for alternatives to Christianity.

Half (16) of the 31 YBMSM interviewed had disconnected entirely from institutionalised religion, and most stated that they did so because they were unwilling to accept the stigmatising, homophobic environments they encountered (8 of 16 HIV-negative and 8 of 15 HIV-positive men). As one man stated,

‘I don’t go to church. I won’t step foot in a church. No.’ When asked why, he burst out laughing and stated, ‘It might burn down! Who knows? You walk in and a big flame just bursts out.’ He went on to say that after leaving the church, he returned once, ‘and the preacher would literally say this over the microphone, “The devil has walked into the building.”’

(Richard).

Importantly, however, nearly all of the men who disconnected from organised religion (15 of the 16) continued to identify as Christian. They reported nurturing their spirituality by forming prayer groups, studying the Bible independently, and/or being ministered to through gospel music. One man, who was HIV-positive, identified as an atheist.

Personal empowerment and coping abilities

Several men reported that their religion helped them feel empowered to confront life’s challenges effectively, increased their ability to establish internal peace, and helped them accept the difficult situations they faced. They stated that church provided a context for them to take stock of their lives and their faith gave them the strength to cope with being HIV-positive. They reported that teachings of traditional black churches helped them interpret their HIV-positive status in an affirming way, as a challenge that God has prepared them to deal with. Stated one young man,

‘Religion does play a role today, definitely. I went through a period that I was very self-destructive and then when I came out of that I re-established a personal relationship with God….I think my faith in God has kept me going through tough times and especially coping with being HIV-positive…I know God would only give me only what I could handle. I have to believe that. I’m still alive and healthy. That’s when I made the choice to have a relationship with God. I have to believe that through the grace of God, I will survive.’

(Lamont)

Six of the men, all of whom were HIV-positive, continued their family’s tradition by attending a traditional, conservative church, from which they derived strength to cope with HIV.

The following statement from a young man who grew up Baptist conveys a similar sentiment: ‘What keeps me going is, they have a saying that “God will never give us no more than what we can bear” …I’m not going to have too much on my shoulders, or the things that I went through can’t compare to the things that Jesus Christ went through.’ (Mark) Many of the young men seemed to feel that church involvement gave them the inner resources to continue with life and to continually search for ways to cope with their illness.

Treatment of others and building compassion

Several YBMSM expressed that teachings from church have a positive influence on their interactions with others. They had learned to treat others with caring and compassion. Having internalised many of the positive aspects of Christian values and the beliefs of those around him at church, one young man elaborated on how religious activity had helped him to treat others with respect and to remain humble. He remarked,

‘It [church] keeps me…on the right path—my path of treating people like I’d want to be treated and to not think that I’m better than anybody else. To be safe and care about people; [to] care about myself.’

(Jamal)

Some young men discussed that that their Christian upbringing and current Christian beliefs spurred them to work on issues related to social justice.

Discussion

Religion and spirituality clearly play important roles in the lives of this group of YBMSM. Nearly all of the men were raised attending a black Christian church and went to services weekly throughout their youth. Spirituality continued to be extremely important, with most men identifying spirituality as a guiding force in their lives. Nearly all men identified ways to maintain a spiritual connection to a higher power. The importance of spirituality in YBMSM’s lives and the finding that half continue to attend a religious institution in the “liberal” San Francisco-Oakland Bay Area was unexpected by the authors, as it was assumed that religion and spirituality would not receive much emphasis in this locale. However, these results that show the prominent role of spirituality in men’s lives, and that half the men continue attending religious institutions, thus suggesting that a culturally grounded HIV prevention approach for this group address these issues.

While nearly all the men considered themselves to be spiritual, half of them, regardless of HIV status, disengaged from formal religion altogether. Instead, many young men developed a personal relationship with a higher power that did not include a religious institution. However, a number of young men remained connected with a church, although many worshipped in gay accepting churches. Alternatively, others decided to cease worshipping in Christian religious settings altogether and instead participated in non-Christian religious institutions that were more welcoming to openly gay and bisexual men. In addition to showing that YBMSM nurture their religious and spiritual needs through various pathways, this study has elucidated a number of issues that have practical implications regarding HIV prevention and optimising outcomes for those with HIV disease.

Resiliency and incorporating spirituality into HIV/AIDS programming

YBMSM cope with homophobia in the black churches in various ways. Men in the current study who continued attending church implemented various coping strategies to deal with the homophobia they encountered at black churches. These men acknowledged their experiences with homophobia, but strived to look beyond them in order to have the kind of relationship with a higher power and the theology and religious practices that they found both familiar from childhood and fulfilling. Other men turned away from these environments and sought religious communion in more affirming and welcoming churches. Yet others fostered a personal relationship with a higher power in a non-institutionalised, informal manner. They relied on personal prayer, listening to gospel music and/or worshipping with other persons. Many of the men were deeply spiritual, but found it difficult to meet their spiritual needs through the churches of their youth, and despite family pressures to do so, sought other outlets to express their spirituality, including prayer, music and fellowship.

Given the central importance of spirituality in men’s lives, these findings suggest that it may be beneficial to explore ways that HIV/AIDS programmes can tap into the reservoirs of strength that YBMSM draw from spiritual practice. HIV prevention strategies might be strengthened by incorporating aspects of spirituality into existing approaches to decrease sexual risk behaviour among both HIV-negative and HIV-positive men and to increase regular HIV testing. Similarly, spirituality could be incorporated into strategies to help HIV-positive YBMSM to take their medications regularly, thus optimising treatment outcomes. Thus men’s resiliency regarding quenching their spiritual thirst is potentially a resource to be channelled towards health promotion.

Addressing spirituality and HIV in religious and nonreligious settings

Religion and spirituality varied widely among the YBMSM in this study in terms of their level of involvement, denominational preference, and the influence of their HIV status on their religious practices. With these factors in mind, we suggest two strategies for addressing the HIV prevention and spiritual needs of YBMSM, depending on whether or not they are still attending church.

Our findings suggest that for HIV-negative men, spirituality-based HIV prevention programmes might be implemented in different settings, including in both gay affirming religious, as well as non-religious settings. Since none of the HIV-negative YBMSM in our sample attended religious services at traditional black churches, church-based programmes in such settings would be unlikely to reach them. It may be that community-based HIV prevention programmes could reach more men, or be more culturally grounded, by incorporating a spiritual component into their existing programmes. Some men who might have little or no interest in a traditional HIV prevention programme might attend a programme with a spiritual focus. It is important to note, however, that this sample was recruited in the San Francisco-Oakland Bay Area, an area noted for its sociopolitical liberalness; it is quite likely that HIV-negative men who live in other regions of the USA continue attending traditional churches.

In contrast, most of the HIV-positive men who continued their connection with formal religion attended traditional black churches. This suggests that secondary prevention efforts, such as Prevention with Positives (PwP) programmes, might be most needed in this context. However, it is likely to be unacceptable to discuss sexuality and sexual safety, particularly for MSM, in traditional black churches. Therefore, it is crucial that this topic be addressed sensitively and incrementally. More specifically, the initial step might be to address overt stigmatisation by drawing from biblical teachings that emphasise that all human beings are worthy of a loving relationship with God. Then it may be effective to discuss caring of oneself and others through medical adherence since increasing research shows that being on antiretroviral medications reduces infectiousness (Attia et al. 2009). And finally, it may be appropriate to address HIV prevention through behaviour change, overall, and then for MSM specifically.

Spirituality, HIV, and wellness

Although slightly over half of the men disengaged from religious institutions altogether, nearly all reported that spirituality remained important. Hence efforts must target both religious and non-religious YBMSM alike through spirituality-based approaches. One culturally appropriate strategy may be to connect HIV prevention to spirituality and well-being for oneself and one’s sexual partner(s), thus broadening the approach to issues of community wellness. For example, discussions about safer sex, as a primary prevention strategy, could be infused with spirituality and community wellness by re-framing condom use, for example, as treating others well and/or as treating others as you wish to be treated.

Furthermore, spirituality and community wellness might also be reframed as a secondary prevention approach. These findings suggest the possible role for HIV/AIDS ministries to address the psychosocial and emotional needs of HIV-positive worshippers—including MSM. HIV ministries could focus on the blessings of treatment and support that are now available for HIV-positive people. This could also address community wellness and mutual responsibility by underscoring the importance of protecting one’s sexual partner(s) from contracting HIV.

Compassion towards others as an element in community mobilisation

The findings that spirituality and religion affect men’s treatment of and compassion for others could have an important place in HIV prevention efforts. Being raised with homophobic attitudes and HIV stigma may reduce men’s motivation to reduce their sexual risk behaviour when having sex with other black men. It may be helpful to emphasise the spiritual aspects of caring for one’s brothers in HIV prevention efforts, both by reducing risky activities with other men, and by encouraging other black men to reduce their risk behaviour and get HIV testing regularly. Hence promoting compassion and caring for one’s brothers could be a key part of community mobilisation for HIV prevention efforts.

Anti-stigma efforts for church leaders

Another important finding of the current study is the homophobia and HIV-related stigma in many black churches. Many of the men suffered from the homophobic remarks by their clergy by having low self-esteem, questioning their self-worth, and losing a community that supports and cares for them. Research from international settings indicate that it is possible to address stigma with community and faith leaders by increasing awareness of stigma or prejudice, accepting difference, and reflecting on the lives of others, and then using this awareness and acceptance to act in more mindful, more compassionate ways (Rutledge and Abell 2005; Wu et al. 2008). Furthermore, this research suggests that couching sensitive topics such as same-sex relations among MSM in the broader context of HIV testing and access to care makes them more palatable for a religious audience (Andrinopoulos et al. 2011). Research conducted with religious leaders from black and Hispanic communities in the USA has shown that clergy are open to addressing HIV prevention and care with their congregants, as long as approaches respect the values and practices of their particular religions (Adler et al. 2007). Curricula could be developed for church settings to reduce institutional homophobia and HIV-related stigma, perhaps making YBMSM feel more welcome in these spaces.

Bringing Church culture into HIV prevention efforts

In considering the development of HIV prevention messages for YBMSM, it is not only important to consider the content of those messages but also how culture can influence how messages are expressed most effectively. As noted earlier, Pattillo-McCoy (1998) found that black Church culture has been used to provide powerful cultural tools for facilitating local organising and activism in other areas, particularly prayer, call-and-response interaction, and Christian imagery. Non-denominational prayer and call-and-response interactions might be used to help spread and reinforce messages about reducing sexual risk behavior, obtaining frequent HIV testing, and adhering to treatment regimens in ways that feel culturally relevant to YBMSM. For example, some HIV prevention intervention approaches bring together groups of black MSM for various reasons. It may be helpful in such a setting to lead prayer with the group regarding some aspect of HIV prevention, or to have the group facilitator set up a call-and-response type interaction that focuses on an HIV prevention message. Incorporating these approaches into communication might resonate culturally with the young men, resulting in culturally compelling messages.

Study limitations

There are limitations to this study, the most salient of which is that the study was conducted in the San Francisco-Oakland Bay Area, a place known for its liberal environment. However, it is important to note that despite there being a very active mainstream, gay community in San Francisco, the black communities in San Francisco and Oakland, where many of the participants lived, are more traditional than might be assumed. Regardless, the generalisability of these findings to YBMSM in conservative parts of the USA may be limited. Research has shown that there are large regional differences within the U.S. regarding blacks’ religious involvement, and it may be that fewer YBMSM elsewhere, particularly in the U.S. South, stop attending church (Chatters, Taylor and Lincoln 1999). The distinction that the men in this sample make between religion and spirituality may be less relevant in other parts of the USA, particularly in the South where church is a more central aspect of black communities, and institutionalised religion may play a stronger role in young men’s lives. Additionally, the religious options that exist in the San Francisco-Oakland Bay Area may not be as plentiful elsewhere, particularly gay-friendly or accepting churches, as well as non-Christian religious alternatives.

Another issue to consider concerns the different findings regarding HIV-positive and HIV-negative men who attended a religious institution. About half of each group separated from attending religious institutions. We have assumed that the HIV-positive men chose to attend traditional churches because they desired greater connection to a traditional religious environment, and that HIV-negative men did not feel compelled to have traditional religion in their lives. However, we do not know if the HIV-positive men had ever stopped attending their churches at one time and returned once they knew they were infected with HIV as a way to obtain support. Additionally, it is possible that the men who attend traditional churches are different than men who decide to leave these institutions (e.g., type of religious training received as children, extent of internalised homophobia). Since we did not ask questions that would elucidate such differences, we cannot say with certainty the extent to which these differences may be related to seeking support from traditional religion when the young men learned that they were HIV-positive.

Another limitation concerns the reasons why half the men chose to stop attending church. While we have suggested that the decision to separate from formal religion stems from homophobic experiences they experienced in such environments and the tension of being Christian and MSM, we did not determine at what point in the men’s lives they stopped attending church, or if this coincided with awareness of their same sex desires. In addition, we were unable to locate comparable statistics on the proportion of young heterosexual African American males who stop attending black churches. Hence, we acknowledge that YBMSM’s separation from formal religious organisations may mirror heterosexual young black men’s departures from the black church, and that this is may be part of a pattern that exists in the black male community in general. Nevertheless, our participants strongly stated to us that homophobia and marginalisation was a major factor in their decisions to leave the church.

Conclusions

Religion and spirituality play prominent roles in the lives of YBMSM, regardless of their level of church involvement, religious preference and HIV status. Spirituality remains important for nearly all of the men. Given the alarming statistics on HIV incidence and prevalence among YBMSM, it may be helpful to address the epidemic by engaging all institutions that may be able to reach this population. Both religious and spirituality-based approach may be vital resources in the battle against HIV/AIDS among YBMSM, many of whom are active churchgoers and/or hold strong beliefs about the importance of spiritual guidance. However, given the apparent prevalence of homophobia in these institutions, an important step would be to develop anti-stigma curricula for black church leaders.