Role Flexing: How Community, Religion, and Family Shape the Experiences of Young Black Men Who Have Sex with Men

Abstract

While the disproportionate impact of HIV on young black men who have sex with men (MSM) is well documented, the reasons for this disparity remain less clear. Through in-depth interviews, we explored the role of familial, religious, and community influence on the experiences of young black MSM and identified strategies that these young men use to negotiate and manage their sexual minority status. Between February and April 2008, 16 interviews were conducted among HIV-infected and HIV-uninfected young (19- to 24-year-old) black MSM in the Jackson, Mississippi, area. Results suggest that overall, homosexuality remains highly stigmatized by the men’s families, religious community, and the African American community. To manage this stigma, many of the participants engaged in a process of “role flexing,” in which individuals modified their behavior in order to adapt to a particular situation. The data also provided evidence of internalized homophobia among a number of the participants. The impact of stigma on risk behavior should be more fully explored, and future intervention efforts need to explicitly address and challenge stigma, both among young men themselves and the communities in which they reside. Attention should also be paid to the role masculinity may play as a driver of the HIV epidemic among young black MSM and how this knowledge can be used to inform prevention efforts.

Introduction

Young black men who have sex with men (MSM) are disproportionately affected by HIV. In 2009, there were more new HIV infections among black MSM aged 13–29 years than among any other racial or ethnic age group of MSM. Moreover, it has been estimated that, between 2006 and 2009, young black MSM were the only subgroup with increasing HIV incidence in the United States.¹

While the disproportionate impact of HIV on young black MSM is well documented, the reasons for this disparity remain less clear. Past research has shown the higher rates of HIV among young black MSM cannot be explained by differences in risk behavior.^2–4 The lack of racial differences in HIV-related risk behavior has directed attention to other, more contextual factors and the roles they may play in creating and maintaining observed disparities in HIV infection. Societal institutions such as the family, religion, and the larger community shape the experience of being a young, black MSM and so may, in turn, influence HIV risk.^5–7 Stigma and homophobia have been identified as driving forces in this process and can lead to emotional distress, impact the willingness of young men to access HIV prevention and care, isolate them from family and community support, and influence their ability to make healthy choices, including decisions around sexual behavior and substance use.^6,8–13

Given its strong presence in the African American community, religion has played a substantial role in shaping attitudes toward same-sex behavior. In this capacity, religion has often been identified as a source of homophobia. While rooted in biblical teachings, these negative attitudes toward same-sex behavior are often perpetuated in African American churches and religious institutions.^9,14,15 This stigma is frequently replicated and supported in other domains of these young men’s lives, including their relationships with family, friends, and the larger African American community. Studies have found that blacks consistently express more negative attitudes toward homosexuality and black men engaging in same-sex behavior are more likely to experience disapproval from their families and friends than are their white counterparts.^16,17 In addition, negative attitudes toward homosexuality and a rejection of effeminate behavior are defining components of traditional ideologies of masculinity in the black community.¹⁸

In November 2007, officials at the Mississippi State Department of Health (MSDH) observed an increase in HIV diagnoses among young black MSM at a sexually transmitted disease (STD) clinic in Jackson, Mississippi. Analysis of HIV case surveillance data demonstrated a 45% increase in newly diagnosed HIV infections among black MSM aged 17–25 years from 2004–2005 to 2006–2007.²⁴ MSDH invited the Centers for Disease Control and Prevention (CDC) to collaborate in an investigation to understand risks for HIV infection among young black MSM in Mississippi.

The investigation began with a rapid assessment to gain a better understanding of the behaviors and experiences of young black MSM in the Jackson area and inform the investigation. For the rapid assessment, interviews were conducted individually and in groups with approximately 25 community leaders, staff from HIV-related organizations and universities, disease intervention specialists, young black MSM, and other key informants. One recurrent theme across these interviews was the prevalence and deleterious effects of homophobia in the African American community in general and in small, southern African American communities in particular. Participants indicated that homophobia led to feelings of depression, rejection, and isolation and, consequently, resulted in a lack of disclosure of sexual identity to family and peers. Participants also indicated that they believed that southern African American culture and religion were forces that hampered openness about sexual identity and behavior.

Based on findings from the rapid assessment, CDC and MSDH incorporated an in-depth qualitative interview component into their broader investigation, which also included a case-control study,^20,21 a phylogenetic analysis,²² and a network analysis.²³ In the present study, we analyzed data from the qualitative interviews with HIV-infected and HIV-uninfected young black MSM to explore the role of community, religious, and familial influence on the experiences of young black MSM. In turn, we identify the strategies that these young men use to negotiate and manage their sexual minority status. By drawing on this qualitative data, we were able to develop a more nuanced, contextually grounded understanding of the experience of being a young African American male in Jackson, Mississippi, who has sex with men.

Methods

Design and setting

Between February and April 2008, the CDC and MSDH conducted an investigation¹⁹ that included an in-depth qualitative assessment to explore issues among this population that might have been difficult to fully capture through quantitative methods. This study was conducted in the context of a public health epidemiological investigation, and it was determined by CDC that the study did not require approval from the CDC or local Institutional Review Boards.

Sampling and recruitment

HIV-infected and uninfected black MSM aged 16–25 years who participated in the quantitative component of the investigation²¹ were asked if they were willing and able to complete an in-depth qualitative interview. A stratified purposeful sampling criterion was used based on HIV serostatus. The initial sample size goal was 20 participants; however, recruitment was stopped after 16 completed interviews because saturation was reached. Among the 16 participants, 7 were HIV-infected and 9 were HIV-uninfected; their median age was 22 (range, 19–24) years. Qualitative assessment participants received a non-monetary incentive valued at $25.

Data collection and measures

The areas of inquiry for the qualitative interview were informed by the preliminary discussions with community stakeholders, including health department staff, staff from local HIV/AIDS organizations, and young African American MSM. Specifically, interview participants were asked about (1) general characteristics of young black MSM in the Jackson area and the degree to which they were open about their sexuality; (2) personal networks and community social groups of MSM; (3) relationships and ways to meet other men; (4) individual and community attitudes toward safe sex and HIV/AIDS; (5) community attitudes about homosexuality and personal experiences of, or exposure to, discrimination; (6) access to and utilization of health care; (7) their experience of, and response to being diagnosed with HIV (for participants who were HIV infected); and (8) their recommendations for improving HIV prevention. The data for this analysis came primarily from questions concerning what it is like to be a young black MSM in the Jackson area, openness about sexuality, community perceptions of MSM, and personal experiences with discrimination.

One-on-one, in-person interviews were conducted in a private room at either a local STD clinic or a local university library. Interviews were conducted by a male interviewer, a CDC scientist with expertise in qualitative research methods, and digitally recorded for transcription. Consent was sought from all participants prior to their interviews, each of which lasted approximately 1–1.5 h.

Data management and analysis

For this study, we primarily used an inductive approach, allowing the data to guide the identification and articulation of patterns, themes, and conclusions.^24,25 Digital recordings were transcribed verbatim, and quality assurance techniques were applied to raw text to verify accuracy of the transcripts. Finalized transcripts were then entered into EZ-Text version 3.06c, a qualitative data analysis software developed by the CDC, for thematic analysis. The analytic approach consisted of a standardized iterative process centered on three activities: codebook development, coding, and data interpretation. An initial set of codes was developed based on preliminary review of a subset of transcripts. These codes were then applied to all the transcripts, where they were used to categorize participants’ responses to questions. Codes were added, removed, or modified as needed throughout the coding process through discussions between the data analyst and the interviewer. In the end, 75 codes were developed and applied to the text by a data analyst. The interviewer then reviewed the selected text to verify coding and maximize reliability of coded data.

To assist with data interpretation, coding reports were generated in EZ-Text by areas of inquiry. These coding reports illustrated the set of codes applied to participants’ responses in each of the areas of inquiry. For example, one coding report showed all the codes applied to participants’ responses to questions regarding discrimination. These coding reports were then examined to identify patterns in the participants’ responses and to identify key themes and recurring concepts across responses. Following a review of these reports, coded text was referred to for validation and elaboration of themes and relationships. In a final step, the coded text was organized into four domains representing important social forces in the young men’s lives; the general community, gay community, religion and faith, and family. Findings are presented using this organizational structure.

Results

General community

When asked about how people in the larger community of Jackson, Mississippi, felt about black gay men, a majority of the participants indicated that being gay was not accepted, particularly among other African Americans. The participants identified several sources for these attitudes. Many of the men cited faith, religious teachings, and faith leaders as contributing to the lack of tolerance in the African American community (religion and faith are discussed more fully in a later section). Negative stereotypes and misconceptions about gay men being, “flamboyant,” “permissive,” “careless,” “loud,” “messy,” and “having no manners” also emerged as both drivers of, and responses to, broader discriminatory attitudes. Finally, some participants linked the African American community’s negative stance on homosexuality with perceptions of it as being a “white man’s disease,” potentially “catching,” and a source of the HIV epidemic.

All of the participants had experienced, witnessed, or heard about instances of discrimination directed toward African American gay men. While all had encountered prejudice and discrimination, the young men’s reactions to these experiences took on a variety of forms. Some chose to ignore or dismiss the prejudice and discrimination expressed in the wider community:

There has been places I’ve been where they discriminate against gay people. They have a right to do what they want. They got a right to say whatever they want to say. You know it’s just how you react to it. Which of course I never react to anything. You know I let people say whatever they wanna say. ‘Cause I don’t care what you say. You really don’t matter. You know as far as anything I’m gonna be judged by God and not by you. So it really don’t matter to me. (age 19, HIV negative)

By contrast, another respondent considered the stigma attached to black gay men to be particularly distressing given the historical experience of African Americans in the United States:

How can you sit up and be…I mean oppress someone else when you went through years…our race as a whole has went through so many years of oppression. I would think that you would be the first person to allow someone to do what they want to do or see how they feel about somethin’. (age 24, HIV negative)

Many of the men indicated that, depending on the context, they altered their behavior or concealed their sexual orientation as a means of managing and reducing their exposure to overt prejudice and discrimination. The participants described it as “adjusting to your surroundings,” “adapting to the environment,” and putting on a “persona”:

If I want to go out in public [with a male date], I’m not the type of person that’s gonna go out and hold your hand or let me put my hand in your pocket. Let’s cuddle at the movies. No, I’m still…I’m still…I’m socially conscious that no, this is not accepted here so I am not going to show affection in public. (age 24, HIV negative)

I hate goin’ to the mechanic people. I absolutely hate it. ‘Cause I have to put on this whole manly persona. Like a straight man persona. And it’s just…it’s weird. (age 24, HIV negative)

For some, altering their behavior involved engaging in homophobic dialogue as a means of guarding against the possibility that their own sexual preferences would come under suspicion:

I join in and joke with ‘em……and stuff like that. ‘Cause I don’t want to draw any attention to myself. Okay, why is he bein’ defensive or anything like that. See, some people will get offended really easy. But I…you know I prepare myself for that to where like it won’t bother me so much. So…just to keep them from knowin’ I join in with them. (age 22, HIV positive)

In contrast, when these participants found themselves in environments in which their same-sex behavior was accepted (e.g., gay clubs, friends’ homes) or were in some way shielded from exposure to the community (e.g., through the anonymity afforded by distant cities, particularly larger ones with reputations for greater tolerance of sexual minorities, such as Memphis, Atlanta, or New Orleans), they reported being able to relax normative constraints they typically imposed on their behavior; specifically, they could be more open with their sexuality and show affection toward other men. For example, one respondent who made efforts to hide his sexuality on a daily basis stated, “I have been known to act gay when I’m around my friends and we’re out of town.” (age 22, HIV positive)

Gay community

Many of the participants described situations and places that offered a more supportive environment for same-sex behavior and identity than that offered by the larger community. Some of the participants felt most open and comfortable when they were able to hang out privately (e.g., at a friend’s house) while others identified gay clubs as places where they felt accepted and free to express their sexuality. Clubs in particular served as a prime location to meet sex partners and were often described as the only public venues in which a gay man would consider approaching a strange man—largely because the club’s reputation and typical crowd largely serve as a way to identify other gay men.

“Gay families”^a were also identified as an important source of acceptance and support, particularly for those young men whose biological families had either disowned them or did not want to be involved in their lives. As one respondent explained, his own family “don’t want to be a part of me. They don’t disown me, but they don’t know anything about it. So it’s kind of good to have that [gay] mother and father there.….in your life. And you can go ahead and talk to [them].” (age 23, HIV positive)

While the gay community could provide a sense of belonging, social support, and acceptance, this did not necessarily preclude the simultaneous tolerance or even endorsement of the prejudices against homosexuality found in the broader community. The internalization of these negative attitudes was also reflected in the qualitative data:

Even though I’m bisexual I do consider myself still bein’ homophobic. Because when it gets to the extreme.….I don’t want to be around it. Because I was raised knowing that, well…well I was raised with the belief that you know homosexuality is wrong, all this stuff. So that is still in the back of my mind. (age 20, HIV negative)

I come from this little small town. And everyone is always usin’ those stereotypes…So it was somethin’ that I saw everyone else you know throwin’ rocks at. So I wanted to throw rocks at it too. So I grew up you know like a homophobe. It was like a disease to me. (age 22, HIV negative)

Among members of the gay community who were the focus of this study, prejudice and stigma were most often reserved for two particular groups: individuals who displayed feminine traits and those who were (or were suspected of being) HIV positive. In terms of a prohibition against expressions of femininity, several of the young men identified incongruence between being a black man and being effeminate, regardless of sexual behavior. As a result, those whose behavior was considered feminine were more stigmatized than those whose behavior was considered more masculine. One man summed up this perspective when he stated:

I don’t understand how some guys they’re walkin’ around and act feminist [sic]. ‘Cause like whatever you do behind closed doors is fine but when you out in public you a man first. (age 22, HIV negative)

Some of the men also emphasized the stigma HIV-infected persons faced in the gay community. These men described how members of the gay community often joke about the disease and speculate about who might have it (whispering “He’s sick, he’s sick” to one another). In addition to mockery, gossip, or outright avoidance in social settings, HIV-infected persons also face sexual ostracism. As one respondent noted:

They turn their nose up at ya. Even more of the guys in…in the quote, unquote gay lifestyle…So it’s hard here. It’s hard as far as dealin’ with it, socially. Here as far as meetin’ new people and developing relationships with them.” (age 24, HIV positive)

Religion and faith

Reflecting the patterns of the larger African American community, the participants in this study indicated that religious faith and involvement in religious institutions was important in their lives. The importance of faith and religion readily emerged during the qualitative interviews. When asked how it felt when he first found out that he was HIV positive, one respondent stated that he “found comfort in God” and God was a part of “my support system” while another said that prayer would help him prepare to tell his family about his HIV status. In addition, a number of the qualitative participants indicated that they attend church regularly, had a positive relationship with a pastor or clergy member, or participated in church activities such as a youth ministry or choir.

Even as they acknowledged the role of religion in their lives, many participants identified biblical teachings, religious leaders, and the faith community as critical sources of homophobia and discrimination toward gay men. When asked if there were any places in the community where they felt particularly unwelcome or discriminated against, one participant stated, “You know most pastors they try to talk about homosexuality. They try to talk about it. Most of the churches I visit here in Jackson, they like make it their main target.” (age 22, HIV positive)

Another respondent described a time when he visited a local church with a [gay] friend who was a member. He recalls enjoying the sermon until the preacher started talking about homosexuality:

So he’s in church preachin’ the…that homosexuality was bad. That you get AIDS. That um, you gonna get full blown AIDS. You get this from the down low. And I’m like people…in positions like that people listen to you. So whatever you saying, these people gonna take outta here and believe this is what it is. ‘Cause you God’s messenger. God told you to tell us this, so that is what’s right. I mean you really have a lotta responsibility. And I’m sittin’ listenin’ to you tell these people. So if they were open to the idea, you just closed their minds off. (age 24, HIV negative)

A number of participants also described how people in their life used biblical teachings to justify homophobia, often referring to homosexuality as a “sin,” an “abomination,” and that those who engaged in same-sex behavior were “going to hell:”

…in communities where you’re around people in church they always…you know it’s like they’re quotin’ what the Bible says. You know two men should not lie together and all that. (age 23, HIV positive)

One respondent discussed his belief that the unacceptability of homosexuality in religious communities transcended racial barriers in a way that few other issues could:

But if you ever noticed that black people, if nothing else they could [inaudible] white folks all day. But bring a gay person in the room and say somethin’ they gonna band together against this gay person for the common…common uh, bond of religion. They have a common interest there. Religion is the one thing that has been cross-cultured on everything. (age 24, HIV negative)

Among the participants, many criticized church congregations’ and pastors’ intolerance toward gay men and objected to the normative messages and stances toward homosexuality. One respondent, referencing his friends’ and family members’ tendencies to view homosexuality as a sin, noted that:

Straight people do…they do the same thing we do. But it’s not with the same sins. So we all sinner. We…we all…we…everybody sins at least once or twice a day…You know you can’t say what I’m doin’ is wrong. And then by you tellin’ me it’s wrong you’re actually wrong too. Because you’re judgin’ me. You’re judgin’ me what I do, you know. (age 22, HIV positive)

Similarly, other participants questioned the validity of the negative messages about homosexuality commonly espoused in religious teachings, asserting:

I was taught all my life that gay people are automatically goin’ to hell and all that. So how do they know that I’m goin’ to hell? ‘Cause they don’t know my relationship that I have with God. Because he…he been still blessin’ me in so many ways since I’ve been uh…I’ve still been blessed. I still have conversation with him. I still talk to him. I still feel his presence. (age 23, HIV positive)

I think the religious thing is…that’s the biggest thing about homosexuality. It’s against God. It’s against God. We could deal with hate, racism, rape, murder. All that’s fine. But you gay, we all will join together and kill y’all. I think if they would really put everybody together and throw us over there and do some genocide. (age 24, HIV negative)

Instead of the homophobia they currently encounter, some participants wished that pastors and others in their religious community would adopt a more generous or sympathetic approach in their dealings with gay men. As one respondent allowed, “It [homosexuality] might be a sin.” But if that was the case, then:

As a pastor it’s your job then to lead me to the right way. But you’re not doin’ it…you’re not doin’ a good job when you tellin’ it’s a sin, it’s a sin. You know what I’m sayin’? Counsel me. (age 22, HIV positive)

The respondent who described his visit to the church where the sermon contained homophobic messages was compelled to speak with the preacher afterwards:

And after church the only thing I could do was just go to him and say well, I do HIV work. And I would love to come into your church and do a session. Or to sit…I mean educate. They are like “oh, yeah, we really need that in the church. And like why don’t you give me your card or somethin’? You can come in and do this.” It bothers me, I hate to hear people say “Full blown AIDS.” Learn about the disease. If you gonna preach about it, learn about it. At least know the basics. And you are the point where people…people…straight people in your church are gonna get this. So you can teach them and tell ’em how to protect they selves as opposed to tellin’ ‘em if you ain’t gay, you okay. You ain’t gonna get it. Are you…everyone’s…and this is not a certain disease that a certain type of people get. Anybody can get it. (age 24, HIV negative)

Not everyone questioned the prevailing beliefs and messages about homosexuality in the faith community. A few participants either agreed with normative religious values surrounding the sinfulness of homosexual behaviors or they indicated that even if they did not agree with particular Biblical interpretations or the messages of religious leaders, they still respected those alternative views:

You know my religious beliefs tell me okay, it’s an abomination. You know my faith…I believe that. I still chose to um, engage into this lifestyle. But I do believe that. My belief has turned that into truth for me. (age 23, HIV negative)

This quote suggests that in addition to adjusting one’s behavior to accommodate external forces, some of these young men also experience a struggle between their sexual behavior and religious or moral framework, a tension that may result in an internalization of stigma.

Family

When asked about disclosure of their sexuality, most participants either specifically noted or implied that they were out to their immediate families. Those who had come out to their families described a variety of reactions, from initial abandonment to support. However, in every case their families eventually reached some sort of accommodation with participants. These accommodations often seemed to involve avoidance of the issue (“don’t ask, don’t tell” or it’s the “elephant in the room”) or “love in spite of” the respondent’s sexuality. Full tolerance or even acceptance on the part of family members was rarely mentioned, either as an experienced reality or hopeful possibility:

When I finally came out to my parents and told ‘em that I was gay you know, they went really into it and was really upset about it. Especially my mother. But you know they got over it. You know they came…got used to it. Because I…I’ve talked to them and talked them down sayin’ you know, there’s nothin’ they can do about it you know. This is how I feel. That’s how I feel. There’s nothin’ yellin’ me can you know…they is not gonna do nothin’. But you know my mother just came to realize it don’t matter. You’ll still be my son gay or not. You know I still support you, anything you do. So we came there to an agreement…(age 19, HIV negative)

While most of the participants reported being open about their sexuality to some degree with select family members, a few did report that they had not disclosed their sexuality to anyone in their family. The reasons given for concealing one’s sexuality included fear of family rejection, stigma, and isolation. Not infrequently, these fears were rooted in the observed experiences of other family members and friends. Regardless of their own level of disclosure, all the participants knew at least some young, black gay men who were unable to discuss their sexuality with their family:

But most of the people I know they don’t tell their family. No, they’re more open with like their friend group and stuff. But like with their family it’s like they have to kind of switch you know when they get around their family. (age 24, HIV negative)

As one respondent described it, he chose not to disclose his sexuality after he saw how his family treated a cousin who was gay:

If I was to come out and just tell everybody then it…it would be a different perspective about me. Because I have a cousin you know. We…all my life the only person that I knew of him was…is the gay cousin. You know I don’t even know who he is. And I feel like I’ve missed out on a relationship with him also. Because that’s how I was taught. That’s the way I was brought up you know with him. Oh, he’s gay. That’s the gay cousin. That had prevented me from getting too close to him. And it also prevented me from venturing out in my own thoughts, my own actions you know. (age 23, HIV negative)

While it is not unusual for young gay men to report difficulty with disclosing their sexuality to family members, it may be particularly challenging for African American gay men to do so. As one respondent noted:

You know I guess with black families you know there’s already…already so much pressure…with everything then you come here and drop the big bomb, hey, I’m gay. You know that kind of…just kind of makes you the black sheep of the family. So I guess that…that probably contribute to that a little bit, why people don’t tell ‘em. (age 24, HIV negative)

Discussion

Although the young men in this study reported that some in their lives offered acceptance and even support for their same-sex behavior, overall, homosexuality remained highly stigmatized by the men’s families, religious community, and the African American community. To manage this stigma, many of the participants engaged in what has been described as “role flexing”⁸ in the literature. This is a process in which individuals modify their behavior in order to adapt to a particular situation. In the context of the present study, when these young men found themselves in situations that were identified as non-gay friendly (including many public spaces in the community) they adapted their behavior to conform to normative expectations of masculinity, avoiding public displays of intimacy with other men and other verbal or behavioral cues that might betray their sexual orientation. By contrast, when these participants found themselves in environments where same-sex behavior was perceived as being more accepted or were able to cloak themselves in the anonymity of a larger urban center (e.g., Memphis, Atlanta, or New Orleans), they were able to relax the norms surrounding masculinity, be more open with their sexuality, and show affection toward other men.

While role flexing provided a mechanism through which young men were able to respond to homophobic external forces, it afforded less protection against the internalized homophobia expressed by a number of participants. As members of communities in which prejudice and discrimination toward homosexuality are common, it not surprising that these young men were complicit in, and in some cases agents of, the homophobia expressed in the larger community. However, past research suggests that such internalized homophobia can have an impact on HIV risk. Using data from the General Social Survey, a repeated cross-sectional survey of US households that includes a variety of attitudinal questions, Glick and Golden¹⁶ found that MSM with unfavorable attitudes toward homosexuality were less likely to have ever had an HIV test. Other researchers have documented associations between internalized homophobia and negative mental health outcomes, such as lower self-esteem and psychological distress,^5,26–28 that may contribute to sexual behaviors that put individuals at risk for HIV.^5,28

While stigma toward same-sex behavior itself was reflected in the interviews, an even more consistent pejorative response was reserved for men who were effeminate in their behavior, speech, or dress. Brown,³⁰ reflecting on a similar finding in his study of African American MSM, describes this phenomenon in the following way: “if one expresses masculinity, he is not hated as vociferously for his homosexuality as his effeminate counterpart.” Some researchers theorize that the exhibition of effeminate traits is denounced because it challenges masculine gender-role expectations, which value physical strength and aggression and sexual prowess with women and hold particular expectations of dress, speech, and behavior.^30,31 How the valuation of masculinity and the degradation of femininity influence HIV risk among young black MSM has yet to be fully characterized. However, recent research on young, black MSM found that perceptions of a partner’s masculinity influenced HIV risk assessment and condom use; masculine men were perceived as safer partners and controlled condom decision-making.³¹

Although conducted in a small southern community, the dominant themes noted in this study do not appear to be unique to this environment. Participants in an investigation of increasing HIV diagnoses among MSM aged 13–29 years in Milwaukee County, Wisconsin, reported similar experiences of internalized homophobia, HIV stigma, religious condemnation of homosexuality as well as the use of religious beliefs by family members to justify prejudice. (W.Lt. Jeffries et al., unpublished observations). In addition, recent published work has explored the role of church ideologies around sexuality and health in the response to HIV/AIDS among black MSM in New York City³² and masculinity and sexual risk behaviors among black MSM in Atlanta, Georgia.⁷

One theme that was notably absent from our interviews was experience with racial stigma and discrimination. Young black MSM in several other studies have discussed issues such as racism from the white, gay community and the intersection of stigma and discrimination due to sexual orientation and race.^6,8,33 Although the absence of these themes in our study may be partly due to the nature of the investigation and the questions asked during the qualitative interview, it is also possibly related to the setting of the study. A majority of residents of Jackson, Mississippi, are African American; it is home to several historically black colleges and universities, and has relatively high levels of neighborhood segregation.^34,35 Therefore, contact with a white gay community and experiences of racism from the greater white community may not be as salient to the everyday lives of these young African American MSM.

This study has limitations that should be noted. Due to the size of the sample, the convenience methods used for recruitment, and the analytic approach, the findings from this study may not be generalizable to young African American MSM in Jackson, Mississippi, or other communities. While the sample is small, the findings from this study are reflected in the broader literature.^6,8,11,29,36 As the interview guide did not include specific questions or probes related to the link between stigma and homophobia and HIV risk behavior, we were not able to explore this association.

At present, there remain significant gaps in the research on HIV risk among young, African American MSM and, consequently, there is a dearth of validated prevention interventions targeted toward this population.¹¹ The findings from this study highlight several areas that warrant further investigation. First, the impact of stigma on risk behavior should be more fully explored and future intervention efforts need to explicitly address and challenge stigma both among young men themselves and the communities in which they reside. Research suggests that increasing acceptance by families and communities as well as self-acceptance would have beneficial health effects for young black MSM.^12,37,38 Second, greater attention should be paid to the role that ideals of masculinity may play as a driver of the HIV epidemic among young, black MSM and how this knowledge can be used to inform prevention efforts.^30,31 Finally, family and religion clearly offer potential sources of support and routes through which to deliver HIV prevention interventions: the fact that a majority of the young men had disclosed their sexuality to at least some family members suggests that, in some situations, family-based HIV prevention programs may present a promising avenue for supporting risk reduction among young gay men. However, the data presented here also indicate that faith and family can also be sources of intolerance, condemnation, and rejection. Given the prominent role of religion in shaping opinions and influencing attitudes, public health programs should partner with religious officials to improve tolerance and acceptance of young black MSM and promote prevention of HIV and other conditions that disproportionately affect MSM. Finally, future research should explore the familial dynamics which shape the experience of young black MSM.³⁹

Stigma and homophobia are a powerful social determinants of health that can have profound negative consequences. To achieve the goals of the National HIV/AIDS Strategy,⁴⁰ which include making new HIV infections a rarity and providing all persons who are HIV positive with high-quality and life-extending care, it is critical to address stigma and homophobia as well as other social determinants that contribute to ongoing disparities in HIV infection.