Drugs, Sex, and Condoms: Identification and Interpretation of Race-Specific Cultural Messages Influencing Black Gay and Bisexual Young Men Living with HIV

Abstract

Black gay and bisexual young men carry a disproportionate burden of HIV in the United States. This study explored Black gay and bisexual young men living with HIV’s identification and interpretation of race-specific cultural messages regarding substance use, sexual activity, and condom use. A total of 36 Black gay and bisexual young men living with HIV (ages 16-24, mean=20.6 years) from four geographically diverse regions of the US participated in qualitative in-depth interviews. Results from this study elucidate the ways in which these young men interpret various forms of race-specific cultural messages and experiences regarding substance use, sexual activity, and condom use. Participants discussed cultural messages and experiences promoting and discouraging condoms and substance use. Regarding sexual activity, only messages and experiences promoting sex were reported. Across all three categories, messages and experiences promoting risk were predominant. Data further revealed that socially transmitted cultural messages received by young men emanated from multiple sources, such as family, peers, sexual partners, community/neighborhood, and the broader society. Race-specific cultural messages and experiences should be addressed in interventions for this population, and programs should assist young men in developing a critical consciousness regarding these messages and experiences in order to promote health and well-being.

Introduction

Black gay and bisexual young men and other men who have sex with men between the ages of 13-24 carry a disproportionately high burden of HIV in the United States, with more than twice as many new HIV diagnoses as their White or Latino counterparts (Centers for Disease Control and Prevention [CDC], 2015). Rates of HIV have been increasing for this sociodemographic group as well, with HIV diagnoses among Black gay and bisexual young men increasing by 87% between 2005 and 2014 (CDC, 2016). Engaging in receptive anal intercourse without the use of condoms continues to be associated with new HIV diagnoses among Black gay and bisexual young men (Crepaz, Marks, Liau, et al., 2009; Mayer, Wang, Koblin et al., 2014). Additionally, the use of alcohol and illegal drugs is further linked to participation in sexual risk behaviors associated with the transmission of HIV and other sexually transmitted infections (STIs) (Bruce, Kahana, Harper, Fernandez, & ATN, 2013; Kelly, St. Lawrence, Tarima, DiFranceisco, & Amirkhanian, 2016). Although participation in these risk behaviors is necessary for HIV transmission to occur, it should be noted that Black gay and bisexual young men do not necessarily engage in higher rates of sexual risk behavior than youth of other races and ethnicities; thus these disproportionate HIV rates are likely driven by factors such as higher prevalence of HIV among sexual partners, undiagnosed HIV/STIs, and lack of adequate healthcare which are exacerbated by social determinants of health such as unemployment, incarceration, and lower educational attainment (Kann, Olsen, Kinchen, Morris & Wolitski, 2016; Millett, Peterson, Flores et al., 2012; Sullivan, Rosenberg, Sanchez, et al., 2015).

Given the high rates of HIV infection among Black gay and bisexual young men, effective primary and secondary prevention interventions are needed. Among youth who are not living with HIV, primary prevention interventions can serve to decrease the incidence of new infections. Secondary interventions are essential to ensure that young men living with HIV are protected against acquiring new STIs, against alcohol and drug use behavior that can mitigate the effects of treatment and cause further damage to their immune system, and to aid in preventing secondary transmission to others. Given the disproportionately high rates of HIV among Black gay and bisexual young men, more interventions are needed to promote the health and well-being of this population.

Cultural Context and Cultural Messages

It has been established that health promotion interventions which take into account the cultural context within which individuals live are more effective than those that do not (Kreuter, Lukwago, Bucholtz, Clark, & Sanders-Thompson, 2002; Lauricella, Valdez, Okamoto, Helm, & Zaremba, 2016). Such interventions have been referred to as being culturally tailored, culturally adapted, culturally appropriate, or culturally grounded. With regard to HIV prevention, it is generally accepted that culture is a significant contextual factor that influences sexual activity and substance use, as well as the response and reception to HIV prevention interventions (Aronson, Rullison, Graham, Pulliam, et al., 2013; Miller, Forney, Hubbard, & Camacho, 2012; Wilson and Miller, 2003). In the broadest sense, culture can be described as “the beliefs, system of knowledge, and patterns of behaviors shared by a group of people” (Thompson-Robinson, Weaver, Shegog, Richter, Usdan, & Saunders, 2007). HIV risk and protective behaviors may be influenced by multiple cultures based on an individual’s social identities, including those related to their race/ethnicity, sexual orientation, gender, and/or religion. These beliefs, ways of knowing, and patterns of behavior can be said to be “socially transmitted,” meaning they are learned from others, co-created, and are transmitted either directly (through instruction) or indirectly (through observational learning) to individuals within a community. These social transmissions can take place through multiple sources such as individuals, peers, families, communities, or the media.

The social transmission of expected cultural behaviors and outcomes can occur from within a culture or from messages received from outside of a culture about a specific cultural group. Since these messages can be communicated explicitly or implicitly, experiences and observations where learning takes place about expected cultural behaviors and outcomes also serve as messages. These culturally specific messages can influence schemas about what it means to be a member of a cultural group (Denham, 2010). Therefore, identifying what cultural messages exist, as well as how those messages are interpreted, are both important in understanding the ways in which such messages can influence behaviors. This information can then be used in the development of community-based HIV prevention programs that support health-promoting cultural messages, and critically analyze and deconstruct health-damaging cultural messages (Harper, 2007; Ortiz-Torres, Serrano-Garcia, & Torres-Burgos, 2000).

Cultural Messages and Risk Behaviors among Black Young Men

Among Black men, including adolescents and young adults, heterosexuality and sexual activity are central to notions of masculinity (Bowleg, 2004; Horner, Romer, Vanable, et al., 2008; Wilson, Harper, Hidalgo, Jamil, Torres, Fernandez, & ATN, 2010). There are social sanctions and decreased status for Black young men who abstain from sex, and perceptions of manliness are often associated with the frequency of sexual behavior (Horner et al., 2008). Cultural messages about sex are often contradictory, with the aforementioned messages juxtaposed to messages that Black men may receive from faith-based institutions and maternal figures encouraging abstinence from sex until a significant love relationship or marriage is established (Harper, Timmons, Motley, Tyler, Catania, Boyer, & Dolcini, 2012; Horner et al., 2008; Thompson-Robinson et al., 2007).

Culturally specific messages about condoms further influence sexual behavior. Messages that condoms reduce sexual pleasure and that they are only used to prevent pregnancy may diminish the frequency with which some Black men use condoms (Horner et al., 2008). In a similar manner, cultural messages about substance use may also influence behaviors. The overrepresentation of Black men using drugs and alcohol in popular media images may subsequently increase participation in substance use behaviors among young Black men (Anderson, de Bruijn, Angus, Gordon & Hastings, 2009; Miller, Lykens, & Quinn, 2007).

While cultural messages appear to impact participation in risk behaviors among young Black heterosexual men, there is a paucity of research on their Black gay and bisexual counterparts (Wade & Harper, 2015). Frequently, Black gay and bisexual young men must not only contend with the negative societal reactions to their sexual orientation, but also may experience racial prejudice, limited economic opportunities and resources, and limited acceptance within their own families and cultural communities (Harper & Wilson, 2016; Quinn, Dickson-Gomez, & Kelly, 2016; Thoma & Huebner, 2013). These young men may further experience racial prejudice and marginalization within the larger predominately White mainstream gay community, and may be sexually objectified and eroticized (Graham, 2012). This objectification and eroticization circumscribes Black gay and bisexual men as hypersexual, well endowed, and sexually dominant (McKeown, Nelson, Anderson, Low, & Elford, 2010; Husbands, Makoroka, Walcott, Adam, George, Remis, & Rourke, 2012)

For Black gay and bisexual young men, these varied messages regarding their race and sexual orientation may lead to confusion, frustration and potentially increased rates of participation in HIV-related risk behaviors. Reed & Miller (2016) recently explored differences between young Black gay and bisexual men who demonstrated resilience associated with the avoidance of psychosocial health conditions that increase vulnerability to HIV (i.e., no syndemic conditions) to those who did not demonstrate such resilience (i.e., syndemic conditions). With regard to race-related cultural messaging, they found that those men who reported syndemic conditions described being gay as not acceptable within the Black community, and some participants wished they could change their race due to a perception that being White and gay would afford them more freedom and acceptance. Participants also discussed feeling limited with regard to their freedom of expression as a gay or bisexual young men, for fear that they would “violate” masculinity norms for behavior in the Black community (Reed & Miller, 2016).

Identification and Interpretation of Race-Specific Cultural Messages

As previously stated, it is important to identify both what cultural messages exist and how these cultural messages are interpreted by young Black gay and bisexual men in order to develop culturally appropriate HIV prevention interventions. Qualitative research methods provide an opportunity to gain a nuanced and rich understanding of the identification and interpretation of cultural messages as voiced by members of this community. Despite its multiple benefits as a method of inquiry, there has been a noteworthy deficit of qualitative studies conducted with Black gay and bisexual young men (Wade & Harper, 2015).

Qualitative research involves an interpretive naturalistic approach to understanding phenomena in terms of the meanings that people bring to them, thus providing a rich understanding of a specific subject matter and gaining insight into the shared social constructions that exist within a particular culture-sharing group (Creswell, 2012; Denzin & Lincoln, 2011). Such an approach is important in conducting research with oppressed and marginalized groups such as Black gay and bisexual young men living with HIV because it allows for the phenomena of interest to be explored using the unique conceptualizations and words typically used by the population as opposed to those imposed by the researcher. Qualitative methodologies have been shown to be particularly useful in developing interventions that are culturally meaningful and effective in applied settings because they help researchers and interventionists to understand the ways in which members of a particular group conceptualize their lives and interact within their cultural and environmental contexts (Brodsky, Buckingham, Scheibler, & Mannarini, 2016; Harper, Lardon, Rappaport, Bangi, Contreras, & Pedraza, 2003).

Given the disproportionately high rates of HIV among Black gay and bisexual young men in comparison to gay and bisexual young men from other ethnic/racial groups, it is critical to explore race-specific cultural messages regarding sexual activity, condom use, and substance use. Although we do adhere to an intersectional framework which posits that all people possess multiple interdependent social identities that intersect at the individual level of experience (Harper & Wilson, 2016), the primary focus in this analysis is on the identification and interpretation of race-specific cultural messages among Black gay and bisexual young men living with HIV.

Methods

Participants

Data for this study are from a sub-sample of young men who participated in the qualitative phase of a mixed-methods study investigating stressors and coping mechanisms that impact healthy identity development among gay/bisexual young men living with HIV. Participants were recruited from four geographically diverse adolescent medicine clinics that provide a range of services to youth living with HIV and are part of the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) (Baltimore [n=12], Chicago [n=6], Memphis [n=13], San Francisco [n=5]). The inclusion criteria for the study included: (1) biologically male at birth and currently identified as male; (2) HIV-infected as documented by medical record review or verbal verification with referring professional; (3) HIV infection occurred through sexual or substance use behavior of the participant; (4) between the ages of 16 and 24 years; (5) able to understand both written and spoken English; and (6) history of at least one sexual encounter involving either anal or oral penetration with a male partner during the past 12 months.

Participants for the current study were selected from the 54 young men included in the qualitative sample of the parent study, and were chosen based on their race and sexual orientation identification. Specifically, young men were included in the sample if they identified as Black, African American, or Mixed race including Black/African American, and also identified as gay, bisexual or some other non-heterosexual sexual orientation. The final sample included 36 young men with a mean age of 20.6 years who self-identified as gay (n=23), bisexual (n=5), queer (n=1), or homosexual (n=7).

Design and Procedures

The study was approved by the institutional review boards at all participating sites, as well as the home institutions of all primary investigators. Since the population of interest for this study was gay and bisexual young men, the institutional review boards granted a waiver of parental permission for youth under the age of 18. This was done to avoid selection biases present in recruiting only youth whose parents are aware of their sexual orientation.

Young men living with HIV between the ages of 16-24, who were receiving care within clinic settings at one of the four participating sites, were approached by study coordinators to assess eligibility. Study coordinators conducted a brief screening interview in a private room in order to determine eligibility and then obtained signed consent/assent from participants. Upon receiving informed consent or assent from participants, interviews were conducted by one of four trained qualitative interviewers in private rooms at the participating facilities. The interviewers were diverse with regard to gender, race/ethnicity, and sexual orientation, and included two doctoral-level investigators and two masters-level graduate students. All transcribed interview files were validated by members of the interview team who listened to the digital recordings and confirmed accurate transcription of the interviews. Original recordings and transcribed interviews were stored on a secure server with access restricted to key research staff.

Interview Guide

A semi-structured qualitative interview guide was created with open-ended questions to elicit specific and contextual data regarding participants’ experiences, beliefs, interpretations, and behaviors. Since the larger study from which these data were derived was focused on both stressors and coping for gay and bisexual young men living with HIV, the Disability-Stress-Coping Model (Wallander & Varni, 1992) was used as an initial framework in order to develop domains and questions that would assess a range of stressors and coping mechanisms related to participants’ HIV status and identity development.

This model applies stress and coping theory to children and adolescents living with a chronic illness, and proposes that both stressors and coping mechanisms interact to impact an adolescent’s adaptation to his/her chronic illness and/or disability. In this model, stressors include a) disease/disability parameters, b) functional independence, and c) psychosocial stress. Coping mechanisms fall into three categories: a) intra-personal (e.g., competence), b) socioecological (e.g., peers, family, and health care providers), and c) stress-processing (e.g., coping strategies). This model purports that as modifiable stress and coping factors are identified in empirical research studies, they then provide heuristic guidance for new treatment interventions for adolescents living with chronic illnesses and disability (Wallander & Varni, 1992). Specific questions were developed to assess stressors and coping mechanisms within the six areas posited by the Disability-Stress-Coping Model as they related to the various identity development areas assessed (i.e., ethnic/racial identity, sexual identity, identity as a person living with HIV, and identity integration). This included questions such as “What are some of the ways that you deal with stress that you think is associated with being a(n) [participant’s stated ethnic/racial identity] young man?” and “How has being a(n) [participant’s stated ethnic/racial identity] young man presented difficulties for you in terms of your interactions with other people?”

The interview guide was also grounded in phenomenological and constructivist frameworks. Phenomenology is specifically focused on inductively describing what a given group of participants have in common as they experience a particular phenomenon (Creswell, 2012; Moustakas, 1994). The phenomenological approach to data collection and analysis is focused on identifying elements of a particular phenomenon by describing both what the phenomenon is and how it is experienced by a particular group of people (Creswell, 2012). More than other types of qualitative inquiry, phenomenology is concerned with the subjective experience of phenomena, positing that phenomena cannot be separated from perception. This guided the types of questions and probes in the interview guide. For example, in the section of the interview regarding challenges related to participant’s sexual identity, youth were asked about challenges, followed by questions asking how these challenges affected their feelings and emotions.

The constructivist approach to data collection and analysis further influenced the development of the interview guide by assuring that the questions allowed participants to define and fully describe constructs within their own unique cultural context. Thus participants were first asked to define their various identities (e.g., living with HIV, sexual orientation, racial/ethnic) using their own words and conceptualizations, and then were guided through an in-depth exploration of stressors and coping mechanisms related to each specific identity.

Data Analysis

Data analysis was conducted using a phenomenological framework (Creswell, 2012; Moustakas, 1994). Data coding and analysis were iterative and interactive processes conducted by a team of four analysts who met weekly. The first step involved each analyst reading all interview transcripts to increase familiarity with the data. Content codes were then created collaboratively by the data analysis team to capture the experiences described by participants, and a codebook was created which included operational definitions of all codes. Transcripts were then re-read by all analysts and pattern codes were created in a similar collaborative manner to connect subsequent concepts under larger headings within each individual transcript. Following this, consistent patterns in meaning, concepts, and themes across all interviews were identified, and data matrices were created as visual representations of the thematic findings. These matrices consolidated a large amount of data across all participants into visual displays that assisted with further describing and interpreting the data, as well as uncovering potential new relationships. All themes and sub-themes, regardless of their frequency of occurrence, were considered meaningful elements of how each phenomenon was experienced by participants and thus included in the analysis (Creswell, 2012; Moustakas, 1994).

Results

The results elucidate the ways in which Black gay and bisexual young men living with HIV experience and interpret various forms of race-specific socially transmitted cultural messages. These messages concern three types of behaviors: (1) substance use, (2) sexual activity, and (3) condom use. In keeping within the phenomenological frame of describing what the phenomenon is and how it is experienced, the results present the general message youth receive regarding these behaviors while describing participants’ interpretation or perception of these messages.

Youth received messages that promoted and discouraged substance use and condom use, but they only received messages that promoted sexual activity. Across all three behaviors, messages promoting risk were predominant. Themes are presented in conjunction with illustrative quotes to exemplify and elaborate on the theme presented. Following each quote is a citation containing the participant’s location/city, self-reported ethnic identification, self-reported sexual identification, and age at the time of the interview. A comparative analysis revealed that the presence and patterns of themes did not differ by region of participant; therefore, regions are included in illustrative quotes for informational purposes only. For each behavior examined, messages and interpretations promoting the behavior followed by messages and interpretations discouraging the behavior are presented.

Substance Use: Promotion

Participants reported socially transmitted messages occurring at the community-level and emanating from the media. Messages that promoted substance use centered around three areas: (a) observation of substance use in their community; (b) ease of accessibility to substances in their community; and (c) media images promoting use.

Black gay and bisexual young men cited the regularity of seeing other Black people in their community using drugs and alcohol as a message promoting substance use. They interpreted this message to mean that substance use was acceptable and would lead to substance use behavior among those observing the phenomenon:

It’s all about stereotypes and perception. If you see people hang out on the stoop and drinking from a 40, you yourself may end up hanging out on the stoop and drinking from a 40… These are visuals, these are things that you hear. It’s what you hear, what you see, what you experience [in the Black Community]. (Chicago, Black, Gay, 23)

In addition to the perceived stereotypes regarding substance use in their community, some participants also believed that the availability and promotion of drugs/alcohol in the Black community served as a message that they were supposed to use substances. This availability was interpreted to connote that it was easier for African Americans to use substances than others:

It’s easy for me to do drugs because I’m Black. It’s easy for me to do drugs. I can walk in a Black neighborhood and they can come up to me, “Got the weed, got the drink, got the White girl” and that’s just terms of cocaine…“White girls” or “Christina” or “Brittany” or anything… I don’t use them. I drink socially. (Baltimore, Black, Homosexual, 21)

Messages conveyed by the media regarding young Black men and substance use were salient to many of the participants. Regarding messages promoting substance use, one young man from Baltimore said:

Like more or less on TV, you hear more about a drug dealer that’s Black than drug dealer that’s White…or if you look at movies, you’ll see more – if you look are more movies and it goes and it involves drugs and stuff like that, then you’ll see it more along the lines of the Black person in the Black neighborhood than a White person in a White neighborhood. (Baltimore, African American, Bisexual, 21)

Another young man from Chicago commented that:

I think that it’s a part of the culture but I think the media has really made it so glamorous and so sought after that it’s now kind of a part of the culture. I definitely think the media plays a big part in that because if you look like at times like – you know – the civil rights movements and times in past history before there were music videos and stuff, I don’t think there were the same societal pressures to be this ghetto boy who drinks 40s and wears his pants down to his ass. (Chicago, African American, Gay, 24)

Both of these young men acknowledged what they perceived to be as the overrepresentation and glamorization of drug and alcohol use by African Americans in the media.

Substance Use: Discouragement

In contrast to the variety of messages that were interpreted as promoting substance use, participants cited few culturally specific messages that they interpreted as discouraging substance use. Those that were described were all related to the theme of family history of substance use.

Well, I really don’t have much to say on that besides, I don’t drink, I don’t smoke… I got enough health problems myself so I really can’t. I watched my mom drink herself to crazy, I’d see a different person she became. So I really stepped up off her. (Memphis, Black, Homosexual, 19)

You know growing up as an African American you see so many things, family members, I have family members that are on drugs, had everything, just lost it over maybe a year two and just start using drugs. So I definitely look at that and I say oh I don’t want to be like that. (Baltimore, African American, Gay, 20)

Unlike observing media images of African Americans utilizing substances, or observing community members utilizing substances, when observation of substance use took place within the family, participants’ subjective experience changed. Seeing the negative consequences of substance use among those whom participants had close personal ties resulted in a perception of a message of discouragement, as opposed to promotion. These participants appeared to causally associate substance use with poor health outcomes, negative life circumstances, disrupted familial relationships, and mental health challenges, which deterred them from substance use.

Sexual Activity: Promotion

As mentioned previously, all cultural messages that participants reported receiving with regard to sexual activity promoted sexual activity among Black gay and bisexual young men. These messages fell into eight categories: (a) an expectation for Black men to be dominant; (b) sexual inactivity equaling weakness; (c) an expectation of promiscuity; (d) stereotypes of insatiability; (e) media images promoting the sexuality of Black men; (f) sexual objectification by partners; (g) stereotypes that Black men are “the best at sex.” There were no messages discouraging sexual activity among Black gay and bisexual young men identified by participants.

One participant reflected on the expectation for young Black men to be dominant during sexual intercourse. He described this as being compared to King Kong:

For me personally it – I guess people that like expect you [a Black man] to be like – I don’t know just like this big old like King Kong you know very dominant like when it comes to like having sex. (Chicago, Black, Gay, 24)

For this participant sexual dominance is equated with being animal like and exhibiting brute strength. Participants felt pressure to meet these sexual role expectations. Additionally, there was a feeling that if Black gay men did not have sex, they were viewed as weak:

Sex to them is power… Like they have sex for a totally different reason than in the straight community and it’s just like being as a Black man it’s just like if you don’t have sex it looks just like you’re weak or something to that effect and it’s just like – like the word “virgin” to them like it’s just unspoken. (Baltimore, Black, Queer, 18)

In both examples, sexuality is associated with power and strength. While this participant discusses lack of sex being seen as a sign of weakness, the former example illustrates that once Black gay men do have sex, they are expected to express power by being sexually dominant.

Abstinence from sex was perceived to reflect shortcomings or an inability to acquire partners. Young men also reported that not only were they expected to be sexually active, but they were expected to be promiscuous. For participants this promiscuity equaled irresponsibility and disrespect. For example, one participant stated:

I think that they [Black men] get this message of promiscuity; not really respecting others that they’re having sex with, not taking the responsibility that comes along with having sex. (Chicago, Black, Gay, 18)

Extending from expectations regarding dominance and promiscuity, some participants also thought that others stereotyped them as sexually insatiable. One participant stated that potential partners perceive him as being insatiable based on his race, and that such perceptions were shaped by the media:

Like I don’t know if it’s because I’m a Black young male or because I’m a gay boy… Yeah, it makes me really sought after and so I have a lot of opportunities to have a lot of sex with pretty much who I’m going to have it with…. I think that it’s because of the stereotypes associated with being Black, whether they be true or not… I’m going to have to say again that mostly like the media because it’ the way that Black men are portrayed as not really beings but kind of just sexual beings who like to fuck all the time, and so I think that’s where a lot of it comes. (Chicago, African American, Gay, 24)

In addition, the media was perceived by some participants as transmitting the message that Black men are hypersexual, having a direct influence on Black men’s own sexual behavior:

It’s the role models ain’t right, like they got the rappers on TV with the naked girls and they pounding on each other and all this and then you got the young thing, naked over here, shaking it and there’s just too much sex. There’s just too much sex sailing around. And then everybody seeing the sex. (Memphis, Black, Gay, 20)

Messages regarding enhanced sexual activity were reinforced by sexual partners who viewed participants as racialized sexual objects. These notions were perceived as problematic:

I have to try and be careful of people who will objectify me about me being a young Black man because there are these people who are called chocolate chasers. They basically treat you like a sex object because you’re Black or they’ll – that’s basically it. That’s a big problem. You have to be wary of people who’ll objectify you, who’ll stereotype you and expect you to act a certain way. (Chicago, Black, Gay, 23)

In addition to the numerous expectations regarding sexual dominance, promiscuity, and insatiability, as well as objectification, several participants received the message that Black men were sexually superior. This message was experienced as an intense pressure to be good at sex; to perform sexually at a higher level because they are Black:

Sort of like a standard you got to live up to. Everybody say, well not everybody, it’s just like stereotypes that um, Black people have bigger dicks or whatever like that. And like if you don’t then you’re going to get talked about. Or it’s just you got to know how, you got to know how, you got to know what you’re doing if you’re Black. But yeah, I feel like it’s, you have to, it’s something that you have to live up to no matter who you have sex with. They expect things from you and you are supposed to be the best at it. (San Francisco, Black, Gay, 19)

Finally, one young man from Memphis reported his understanding of the role of sexual activity in the lives of Black gay and bisexual young men in terms of what he perceives in White gay male relationships contrasted to what he sees in Black gay male relationships. Because of this, he models his own relationship on what he views as the White gay standard:

I noticed a lot of Black homosexuals, they like to have open relationships, where they like to invite people into their bedrooms and do all that – I don’t like that… That’s why I say White homosexual couples, they got more put together. And I like that. Not being racist or anything, but I kind of base our relationship more on a White homosexual couple than I do a Black homosexual couple. (Memphis, African American, Gay, 22)

Condom Use: Promotion

Messages perceived by participants as promoting condom use related to the following: (a) seeing Black gay men use condoms in pornography; (b) publicity regarding the high rates of HIV among Black gay men; (c) condom-related television messages targeting the Black community.

One young man commented on condom use among Black gay men, and believed that they use condoms more than White gay men based on what he had seen in pornography:

And I would say that African Americans are more safer. And the reason why I say they’re more safer is because from the clips of porn that I’ve seen, African Americans have on condoms and most of the Caucasian clips that I’ve seen, they’re bare backing and bare backing means, raw, no condom. And that’s all I know to say. (Memphis, African American, Homosexual, 19)

Several participants alluded to messages that Black gay and bisexual young men have high rates of HIV infection. Participants interpreted this message to mean that they should be using condoms during sexual encounters. One young man from Baltimore noted:

I think it has a big role because it makes me want to strap up. Of course, now I’m strapping him all the time but when you’re doing it since the statistics show that African American males is higher than any other you know you got that in the back of your mind. So yeah, you’re going to, yeah, it’s the first thing you’re going to think about. (Baltimore, African American, Bisexual, 22)

Referring again to the media, several participants mentioned messages targeted to the Black community promoting condom use that were transmitted through outlets such as Black Entertainment Television (BET). For example, one participant stated:

With the Black community you have like protection and safe sex is everywhere, like BET, that’s a Black Internet [sic] like channel. And all they talk about is safe sex” (San Francisco, Black, Bisexual, 17).

Condom Use: Discouragement

Messages discouraging condom use among young Black men identified by participants included: (a) pleasure is decreased with use of a condom; (b) a perceived norm that consequences are dealt with at a later time; (c) Black men’s penises were too big for condoms; and (d) condoms were only for pregnancy prevention.

Not using a condom was seen to be more satisfying because of the increased sensitivity experienced without a barrier during intercourse. One young man from Chicago expanded on this idea and thought that for young Black men it was not only about the physical pleasure of not using a condom, but the psychological rush that takes place from participating in a risk behavior:

Because I think that the behavior affiliated with not using condoms is in some ways for the young Black man more stimulating and gratifying. Like that high risk behavior, it stimulates them… It wasn’t portrayed as being unsafe, but rather a more gratifying experience, even though there is a risky behavior… Mentally and sexually and for some reason, you know what I’m sayin’, it just triggers the behavior and the mental stimulation of taking a risk. (Chicago, Black, Gay, 24)

Some participants also voiced the perception that from what they observed, in the heat of the moment young Black men are focused on the act of sex and the immediate gratification from that act, while the long term consequences of not using a condom are less salient.

I think we are – African Americans are very ambitious when it comes to havin’ sex. We’re very quick to have sex without thinkin’ about the consequences. I mean, proof is in the pudding with the number of babies that are being raised, you know, you know, come – you know, girls are getting pregnant all the time and, of course HIV is, you know, spreading quicker and quicker. So I think to more African Americans it’s like, however I can get it, however I can get it, I’m gonna not – I think that people think about the consequences later rather than – and just go for what’s there right now. (Memphis, African American, Gay, 21)

The message that Black men’s penises were too large for condoms and as a result a deterrent for use was not pervasive, but did come up when speaking to one Chicago youth:

The message I always get is that – that I mean – I don’t always get it but I’ve had a lot of instances where maybe I’ve been with men of color. It might be more men of color than not. It’s they just don’t want to use condoms. They don’t feel like they’re necessary, they impede on them. My dick is too big, I’m not trying to put this shit on, like some fucking rubber you know I think that it’s like I’m this big, studly man and I don’t need condoms. (Chicago, African American, Gay, 24)

Finally, participants reported being exposed to messages in the Black community that men should use condoms to prevent pregnancy, without a focus on disease prevention aspects of condom use. As a young gay man, this was interpreted as it being less important to use condoms.

A lot of Black people are not educated on sexual- don’t protecting yourself ‘cause I wasn’t. I wasn’t hearing use a – I heard it, but it wasn’t really being stressed to me use a condom; this can happen. The worst thing that I was hearing that could happen to you is you getting’ pregnant. I wasn’t hearing syphilis. I wasn’t hearing HIV. I wasn’t hearing gonorrhea. (Memphis, Black, Bisexual, 20)

Discussion

Black gay and bisexual young men living with HIV experience and interpret various forms of race-specific cultural messages regarding substance use, sexual activity, and condom use. Results indicated that young men perceived an array of health promoting and health threatening messages that were often contradictory, and that interact in complex ways. For example, some youth reported that the media such as news outlets, movies and music videos were plagued with messages that Black men should be promiscuous and use drugs; whereas others recognized commercials on Black-targeted media outlets that discouraged risky behavior and promoted safer sex. Therefore, it may be difficult and confusing for a developing adolescent to reconcile the mixed messages they receive about health-related behaviors.

Data further indicated that cultural messages received by young men emanated from multiple sources, such as family, peers, sexual partners, community/neighborhood, and the broader society (Graham et al., 2009). These varied sources may have a differential impact on youth’s subsequent participation in risky behavior. For example, while family members’ history of drug and alcohol abuse may dissuade youth from substances, peers and sexual partners may encourage their use. Messages further originated from both within and outside of Black communities. Some participants perceived a need to be sexually dominant within Black communities, as such activity was perceived as being equated with strength and masculinity among Black men. However, others feared being stereotyped as promiscuous and sexually insatiable from individuals outside of Black communities, especially White gay men.

While the present study sought to explore the diversity of cultural messages received by Black gay and bisexual young men living with HIV, and how those messages are interpreted, it should be noted that such messages and interpretations were filtered through the lens of the youth. Specifically, several youths reported that these messages did not influence their subsequent behavior. For example, one young man acknowledged the ease with which he could obtain drugs in his neighborhood, but then stated that he does not use drugs and only drinks socially. Given this incongruence, it is important to recognize that the cultural messages and perceptions identified by participants are not meant to be predictive of actual behavior. Rather, they allude to the distinctive themes that youth encounter about how individuals of their race may engage in certain risk behaviors, and sociocultural elements that influence these messages.

Intersectionality

In the current analysis, our goal was to focus on the race-specific cultural messages that Black gay and bisexual young men living with HIV identified regarding substance use, sexual activity and condom use, and how they interpreted these messages. Therefore, messages that were specific to other identity-specific factors (i.e., sexual identity or identity as a person living with HIV) which did not include any mention of race were not included in the analyses. Race was chosen as the central focus for this analysis given the disproportionately high rates of HIV among Black gay and bisexual young men compared to gay and bisexual young men from other ethnic/racial groups. In addition, this primary focus on race provides information that can be used for the development of both primary HIV programs for youth who are not living with HIV as well as secondary prevention programs for those who are living with HIV.

Despite the primary focus on race-specific cultural messages, participants’ narratives often demonstrated an underlying intersectional framework whereby participants embodied multiple identities and core social statuses (Harper & Wilson, 2016). A closer look at messages reported by youth demonstrates the dynamic ways in which identities intersect. When exploring the data from an intersectional framework, the most common intersecting identities discussed were about being Black and being a man. This occurred within themes under the major areas of Substance Use Promotion, Sexual Activity Promotion, and Condom Use Discouragement. These areas are associated with the promotion of risk behaviors and the discouragement of protective behaviors. In these narratives youth recalled cultural messages in the form of negative media images of Black men related to both substance use and sexual activity, including a Black man as a “…ghetto boy who drinks 40s and wears his pants down to his ass,” or Black men as “…not really beings but kind of just sexual beings who like to fuck all the time.” In addition, participants described messages regarding Black men that were perpetuated by objectifying sexual partners who have an expectation for Black man to be a “…big old like King Kong you know very dominant like when it comes to like having sex.”

The other intersecting identities discussed were about being Black, being gay, and being a man. This occurred within the segments of text that fell within the major categories of Sexual Activity Promotion and Condom Use Promotion. Some narratives clearly identified that Black men in the gay community received different messages than other gay and bisexual men regarding sexual activity, with sexual inactivity being linked to weakness and powerlessness. Others discussed racialized objectification in the gay community— “I have to try and be careful of people who will objectify me about me being a young Black man.” Yet another participant shared that he was unaware of which of his intersecting identities lead others to view him as a desirable sexual partner— “Like I don’t know if it’s because I’m a Black young male or because I’m a gay boy… Yeah, it makes me really sought after and so I have a lot of opportunities to have a lot of sex with pretty much who I’m going to have it with.” It is important to note that the intersection of identities regarding being a Black gay young man only occurred in Condom Use Promotion and in the context of participants reporting condom use because they realize that their sociodemographic group (Black gay young men) has the highest rates of new HIV diagnoses.

Objectification

The psychological effect of objectification and eroticization may enhance our understanding of behavioral health risk among Black gay and bisexual young men (Burstin, 1999; Diaz, Ayala, Bein, Henne, & Marin, 2001). Our sample only provided limited insight into how these two elements play into sexual risk behavior, though related subtopics—including the expectation of sexual dominance and promiscuity, weakness associated with not engaging in sex, and stereotypes of insatiability and sexual virility—were all recurring themes. Fredrickson and Roberts’ (1997) model of objectification theory may serve as a useful framework for investigating these experiences among this population. Objectification occurs when an individual is treated as a body or a collection of body parts valued primarily for its use to others. Fredrickson and Roberts’ (1997) state that objectification can cause an individual to begin to view themselves as objects to be looked at, evaluated, and used by others. Consequently, this self-objectification leads to negative psychological outcomes. While their model focused expressly on the experiences of women within a cultural context that objectifies the female body, many of the themes that emerged from their article may also be applied to the experiences of Black gay and bisexual young men. Such themes included an array of adverse psychological and behavioral health consequences, such as depression and eating disorder risk, as well as a unique sense of internalized self-objectification. Both related and unique outcomes may exist for ethnic/racial and sexual minority populations that are subject to repeated instances of objectification, such as a decreased or limited sense of self-worth and a subsequent propensity to engage in HIV risk behaviors.

Consistent with the premise of objectification theory, Black gay and bisexual young men must also navigate a social environment where the dominant group imposes restrictive and sexualized expectations. To date, there is limited research on the experiences of objectification and eroticization for Black gay and bisexual young men, though some studies have pointed to the imposition of White cultural constructions of gay and bisexual identities, and the typecasting of sexual performance roles for Black gay and bisexual men as persistent and oppressive experiences among this population (Teunis, 2007; McKeown, Nelson, Anderson, Low, & Elford, 2010; Husbands et al., 2013). Future studies should aim to capture the nuanced and stress-inducing realities of objectification among Black gay and bisexual young men, with a focus on how such experiences may lead to negative identity development and sexual health risk.

Sexually Explicit Media

Sexually explicit media may prove to be another focal point in exploring the dynamics that contribute to sexual risk behavior. While pornography was alluded to in several of our qualitative interviews, there is still a paucity of research demonstrating its broader impact on the psychosexual development of Black gay and bisexual young men. Internet pornography has become easily accessible with the arrival of high-speed online connectivity, and the recent proliferation of information technology has fueled a generational shift toward digital avenues of media consumption and information processing. Moreover, studies suggest that erotic media may serve as an adolescent’s introduction to graphic sexual content, and further indicate that this exposure is formative and commonly experienced across periods of sexual and psychosocial development (Peter & Valkenburg, 2006; Sabina, Wolak, & Finkelhor, 2008; Weber, Quiring, & Daschmann, 2012). Prior studies with gay and bisexual male youth have identified access to internet-based pornography as helpful for youths’ understanding of the mechanics of same-sexual sexuality (Kubicek, Carpineto, McDavitt, Weiss, & Kipke, 2011; Kubicek, Beyer, Weiss, Iverson, & Kipke, 2010). A recent qualitative study with Black gay and bisexual youth found that participants described using sexually explicit media primarily for sexual development, including learning about sexual organs and function, the mechanics of same-gender sex, and to negotiate one’s sexual identity (Arrington-Sanders, Harper, Morgan, Ogunbajo, Trent, & Fortenberry, 2015). They also reported engaging in sexual risk behaviors that were modeled in the media.

Our present study illustrates that Black gay and bisexual young men are already inundated with messages promoting sexual behavior within their own sociocultural milieus, before factoring in the increasingly common access to internet pornography. Combined with the existing complexities of sexual identity formation among gay and bisexual adolescents, the added effect of sexually explicit media on the psychosexual development of Black gay and bisexual young men may be substantial. Future studies should aim to garner an understanding of the pervasiveness of specific media content and its effects on the sexual behaviors of Black gay and bisexual young men.

Explicit and Implicit Messages

Another area that may warrant further examination includes the impact, frequency, and consistency of explicit versus implicit messages about sexual risk behaviors. One participant in our sample identified explicit messages from Black Entertainment Television promoting condom use, and another identified implicit messages promoting the use of condoms in pornography, noting that Black male performers were more likely to use condoms than White male performers. This again highlights the importance of exploring the content of erotic media and its auxiliary effects, but also points to a key distinction between messages that are spoken and those that are demonstrated. While the above examples occur in the context of media, explicit and implicit messages may occur in many different contexts—such as oral instruction on how to seek out healthy intimate relationships, or behavior modeling that occurs within family dyads and community networks. Future research should consider the distinctions that may exist between explicit and implicit messages relating to sexual behavior, as well as employ comparative analyses across a range of mediums through which these messages are communicated.

Implications for Intervention Development

Our findings demonstrate the wide range of cultural messages related to substance use, sexual activity and condom use that may influence Black gay and bisexual young men living with HIV. It is important to recognize that the negative cultural messages and experiences encountered by Black gay and bisexual young men living with HIV can be understood as oppression by dominant groups to maintain power and privilege (Parker & Aggleton, 2003). Oppressive cultural messages should be addressed and challenged in both primary and secondary prevention programs for Black gay and bisexual young men. Such programs could be implemented at multiple levels—individual, group, community—and delivered within various settings (e.g., homes, schools, clinics, community-based organizations) using an array of modalities including social media and mass media. In addition, secondary prevention programs for young people living with HIV from various oppressed identity groups should assist youth in developing a critical consciousness regarding these messages to promote health enhancing behaviors.

Watts & Serrano-Garcia (2003) stress that resistance to oppression does not occur without some type of action or intervention, and that the process is often challenging. The difficulty in this process may be related to the need to deconstruct the cultural and ideological foundations of oppression (Watts & Serrano-Garcia, 2003), which requires a critical analysis of dominant ideologies and cultural messages that are pervasive and endemic. Critical consciousness requires an active and intentional process of challenging these ideologies and messages, and exploring avenues for resisting oppression.

Unfortunately, pervasive and long-standing oppressive and dominant ideologies can lead to an internalization of a stigmatized and subordinate status (Parker & Aggleton, 2003), thus decreasing the likelihood of spontaneous resistance to oppression. As critical consciousness is enhanced and developed, individuals and groups become more aware of the power differentials and multiple points of asymmetry that exist in society (Watts, Griffith, & Abdul-Adil, 1999) and move toward acts of resistance and liberation. Watts and his colleagues have detailed successful youth-focused interventions aimed at using critical consciousness methods to promote and enhance critical consciousness and increase awareness of social injustices among heterosexual Black adolescents living in urban low-income environments (Watts & Abdul-Adil, 1998; Watts, Abdul-Adil, & Pratt, 2002; Watts, et al., 1999).

Such critical consciousness strategies can be adapted for use with Black gay and bisexual young men—both those living with HIV and those at risk for HIV—and can be delivered using modalities that provide privacy and safety such as smartphone apps. In addition, mass media and community-level interventions could also utilize elements of critical consciousness approaches and strive to increase awareness of and promote resistance to negative cultural messages and social injustices that threaten the health and well-being of Black gay and bisexual young men. Policymakers could also be targeted with interpersonal and mass communication efforts that alert them to the oppressive forces that are likely contributing to increased rates of HIV among Black gay and bisexual young men. Community-level and policy-level interventions also need to focus on decreasing stigma encountered by gay and bisexual young people as well as people living with HIV, and work toward creating access to health care environments that do not perpetuate negative cultural messages related to race, gender, sexual orientation and HIV.

Strengths, Limitations, and Future Research

A major strength of this study lies in the focus on the health and well-being of Black gay and bisexual young men living with HIV, a population of young people that is increasing. In addition, the study’s exploration of both the identification and interpretation of race-specific cultural messages related to three health risk/protective behaviors—substance use, sexual activity, and condom use—is unique and critical to the development of interventions focused on promoting the health of this population. The sample was sizable for a qualitative study of a highly stigmatized population, and the geographic diversity of the sample was impressive. The qualitative methodology used allowed for a deeper understanding of the lived experiences of Black gay and bisexual young men living with HIV. Furthermore, this study highlights the critical need for culturally-specific primary and secondary HIV prevention interventions.

One major limitation of this study is the cross-sectional design. By interviewing youth at one-time point, researchers were unable to confirm the themes with study participants or explore themes in greater detail with the youth. The self-report nature of the study further warrants concern as participants were asked to recall past experiences that may have been difficult to discuss with the interviewers. Finally, the current study sample only included Black gay and bisexual young men living with HIV, and thus this may not reflect the lived experiences of Black gay and bisexual youth who are not living with HIV.

Intervention development and evaluation studies are greatly needed to assess the effectiveness of prevention interventions for Black gay and bisexual young men living with HIV. Such programs should be culturally specific and allow youth to develop a critical consciousness regarding cultural messages that may influence their risk behavior. Studies should seek to recruit larger samples across varied ethnic groups and examine data within and between ethnicities. Studies comparing the experiences of young gay and bisexual men who are and are not living with HIV should be conducted to parse out the role of HIV serostatus in the interpretation of cultural experiences. Moreover, it would be especially beneficial to longitudinally study young people living with HIV as more youth currently are living with HIV than ever before.