Ricky and Lucy: Gender Stereotyping among Young Black Men Who Have Sex with Men in the US Deep South and the Implications for HIV Risk in a Severely Affected Population

Abstract

HIV disproportionately affects young Black men who have sex with men in the USA, with especially high rates in the Deep South. In this Alabama study, we interviewed 24 pairs of young Black men who have sex with men aged 19-24 and their close friends (N=48) about sexual scripts, dating men, and condom use. Three main themes emerged from the study: the power dynamics of ‘top’ and ‘bottom’ sexual positions for condom use; gender stereotyping in the iconic style of the ‘I Love Lucy’ show of the 1950s; and the sexual dominance of ‘trade’ men. Gender stereotyping was attributed to the cultural mores of Black families in the South, the preferences of ‘trade’ men who exerted sexual and financial control, and internalised stigma relating to being Black, gay, and marginalised. The findings suggest that HIV prevention education for young Black men who have sex with men is misguided if gendered power dynamics are ignored, and that funded access to self-protective strategies such as PrEP and PEP could reduce HIV risk for this severely affected population.

Introduction

Black men who have sex with men are at high risk for HIV in the USA (Centers for Disease Control and Prevention [CDC] 2016a). HIV is often acquired at a young age, with Black men aged between 13 and 34 years accounting for 75 percent of new diagnoses in this group (CDC 2016b). The overall HIV risk for Black men who have sex with men is particularly alarming: half of these men are projected to be diagnosed at some point during their lifetime, and most diagnoses occur in southern states in which most African Americans live (CDC 2016a). A variety of factors make young Black men who have sex with men disproportionately vulnerable to HIV infection, including a significant tendency to have older, same-race partners (who have higher cumulative rates of HIV) (Berry, Raymond and McFarland 2007), negative cultural and religious attitudes toward homosexuality (Quinn et al. 2015), peer attitudes against condom use (Kelly et al. 2016), reluctance to test for HIV (St. Lawrence et al. 2015), and conflict with rigid gender role norms (Fields et al. 2015).

This study addresses gender stereotyping and HIV risk among young Black men who have sex with men and who live in Alabama, where socially conservative views toward same-sex activity and HIV coincide with traditional gender ideals for men and women (Lichtenstein 2012). In particular, we describe how these ideals influence men who invoke the 1950's ‘I Love Lucy’ archetype in which sexual partners adopt defined gender roles. While previous studies have recognised unique risk factors among young Black men who have sex with men, including gender role conflict with heterosexual norms for Black masculinity (e.g., Fields et al. 2015), few have noted the parallels with women's experience of gender roles in the Black community. Because Black men and women typically have similar sexual networks and socioeconomic and cultural backgrounds, it follows that their structural-level risk factors are similar as well. Comparable risks include racial discrimination (Bogart et al. 2016), housing instability (Hicks 2016), and limited access to resources and healthcare services (Elopre et al. 2017).

Similarities in risk between the genders also exist at the individual level, including in how power differentials between sexual partners interfere with condom negotiation (Lichtenstein 2005; VanderDrift et al. 2013). In an examination of heterosexual male/female couple dyads, VanderDrift et al. (2013) determined that the most salient predictor of condom use involves the intentions and desires of the partner with higher relational power. The authors found this predictive power to be present at all stages of the decision-making process—that is, even if both partners had discussed their intention to use condoms prior to sex, the partner with higher relationship power was likely to dictate actual condom use behaviour. For this study, we examined the role of gendered power dynamics in relation to HIV risk among young Black men who have sex with men in a southern region with the highest rates of diagnosed HIV among men who have sex with men in the USA (Rosenberg et al. 2016). We sought to identify and explain the association between gender norms, relational power, and sexual risk-taking among young Black men who have sex with men, or those who have sex with both men and women. This group is of increasing concern to public health authorities because, despite having the highest lifetime HIV risk in the nation, they are underserved on every dimension of HIV control, including knowledge about risks that could inform targeted prevention programmes (Nedelman 2016).

Background

Sexual Script Theory and HIV risk

Perceptions of HIV risk are guided by discourses that are produced and reinforced through sexual communication in interpersonal and subcultural contexts. Therefore, we draw primarily on recent developments in sexual scripts theory (Plante 2006), a conceptual framework that helps to explain how sexuality is constructed in the context of social and cultural norms and values that shape people's lives (Simon and Gagnon 1986). For example, a common set of sexual scripts involves ‘procreative scripts’, in which a morally sound person has sex only for procreative purposes within specific contexts. This set contrasts with recreational scripts that allow for sex with casual partners – scripts in which gender often plays a prominent role (Gagnon 1990). Recent advances in sexual script theory account for individual agency in the process and show how cultural scripts may be adopted or changed through interpersonal negotiation or self-reflection at the intra-psychic level. Because they contain implications about what kind of person does what kinds of things, and under what circumstances, sexual scripts are theorised to influence sexual behaviour. Sexual health communication is one mode through which scripts can be exchanged and negotiated for HIV prevention. This study examines sexual communication between young Black men who have sex with men and their close friends in order to obtain sociological insights into their exceptional vulnerability to HIV infection.

Gender and Relationship Dynamics in HIV risk

The literature on relationship dynamics indicates that power differentials are the key to understanding the risk of HIV infection among both women and gay men in sexual relationships. In addressing women's risk, researchers have suggested that the ‘gendered power’ dynamic in heteronormative relationships is a significant cornerstone of condom use behaviour and, as such, relates closely to the risk of HIV infection among women who lack decisional power (Rosenthal, Levy and Earnshaw 2012). The authors defined gendered power as the relational influence that men often wield in family life (especially in low-income or resource-limited settings) and consensual ideologies, which are the norms and stereotypes that prevail in society and culture outside of the norms of the household.

This definition has relevance for sexual power dynamics among men who have sex with men, including in non-regular relationships such as hook-ups and transactional sex. In one such study of Latino and Asian/Pacific Island men, Tan et al. (2014) described relationship power between men as a kind of trade, in which the less advantaged partner may trade sex for material goods, a place to live, or even access to a particular social community. In another qualitative examination of relationships among young men who have sex with men that has particular relevance to our study, Kubicek, McNeeley and Collins (2015) found that the men used highly gendered, heteronormative language to discuss relationship issues, and that power differentials were clearly stratified along dominant ‘male’ and submissive ‘female’ lines. The authors suggested that the struggle among young men who have sex with men for self-assertion and control in their intimate relationships is the consequence of a lack of awareness and homophobia in the wider community. In our study, we use the terms ‘tops’ and ‘bottoms’ in reference to gendered power dynamics among Black men who have sex with men. This terminology, and the power differentials implied in such framing, has defined gender roles among such men on an historical basis because ‘We have been conditioned to think that tops and bottoms fit into opposing roles: controlling versus controlled, active versus passive, pursuer versus pursued, older versus younger, masculine versus feminine, rich versus poor…’ (Underwood 2003, 13). In the present case, we discovered that the top/bottom terminology was constructed through sexual scripts among young Black men who have sex with men who, while chafing at sexual reductionism, nevertheless conformed to gender roles for young Black men in their southern US gay community.

Data and Methods

We received IRB approvals from The University of Alabama and the University of California at Dominguez Hills for all aspects of the parent study. Our methods involved semi-structured interviews of 24 pairs (dyads) of young Black men who have sex with men and their close friends in Birmingham, Alabama and 24 pairs in Los Angeles, California for a total of 48 dyads and 96 participants. We found that particular themes emerged within the Birmingham site, and thus focused our attention on this study site for this analysis. In addition to adding trustworthiness to the study (Eisikovits and Koren 2010), the dyadic method elicits spontaneous interactions between friends and proved conceptually useful for interviewing young Black men who have sex with men on perceptions of PrEP (pre-exposure prophylaxis) use in California (Mutchler et al. 2015). For this study, we wanted to identify how young Black men who have sex with men communicate with each other about sexual topics (i.e., we sought mutual understandings about word use, sexual language, and perceptions of risk). The Alabama dyads consisted of a ‘priority’ participant between the ages of 19 and 24 who identified as a young Black man who has sex with men, and a close friend (sexual partners were ineligible) between the ages of 19-29. In this study, a close friend was defined as someone with whom the priority participant shared information about sexual health topics such as meeting men, gender and sexual norms among young Black men who have sex with men, social networks, and condom use. Most friends (N=18) were also young Black men who have sex with men, although five were women and one was transgender. The priority participants were all young Black men who lived in Birmingham, which has the state's largest population and highest rate of HIV infection (Elopre et al 2017). Young Black men who have sex with men represent 53% of new diagnoses in Alabama, with 66% of this cohort being Black youth between 15-29 years old (Alabama Department of Public Health 2014). Each interview was preceded by a brief questionnaire for basic demographic and health information, including participants' drug use and HIV status. The dyads were interviewed together for approximately two hours, followed by a 15-minute follow-up with the priority participant to check if the friend's presence had been an inhibiting factor.

Sampling and Data Collection

Recruitment for the study took place in Birmingham through targeted outreach to lesbian, gay, bisexual and transgender youth organisations and smartphone dating apps such as Tinder, Snapchat, Grindr, and Jack'd. Approximately equal numbers of priority participants were recruited from these venues in order to obtain a diverse group of young Black men who have sex with men for participation in the study. Purposive recruitment of 24 priority participants and 24 friends allowed us to reach thematic saturation for non-probabilistic sampling sizes (Guest, Bunce and Johnson 2006). For eligibility purposes, the priority participants had to 1) self-identify as Black or African American, 2) live in the Birmingham area currently and for a period of at least two years, 3) have a close friendship with someone in the stated age range who was not a family member, boyfriend, or sexual partner, and 4) have discussed with the friend their sexual orientation and topics related to sexual health. Although most friends self-identified as African American, being Black or Biracial was not a criterion for inclusion. The large number of Black friends in the study relates to norms for racial homogeneity in Alabama, including in the gay community. As reported by Card, Mas and Rothstein (2008), the level of inter-racial contact among residents in Birmingham, Alabama is lower than the US average, which helps to explain the participants' intra-group preferences. Demographic information for priority participants and their friends is presented in Table 1.

Table 1. Description of the Study Sample (n=48).

		Priority Participants		Friends		Overall
Variables	Categories	n	Mean/Range/SD	n	Mean/Range/SD	n	Mean/Range/SD
Age		24	21.83/19-24/2.08	24	22.88/19-29/3.54	48	22.35/19-29/2.92
		n	%	n	%	n	%
Gender	Male	24	100	18	75.0	42	87.5
	Female	0	0	5	20.8	5	10.4
	Transgender (M F)	0	0	1	4.2	1	2.1
Race/ethnicitya	Black	24	100	23	95.8	47	97.9
	White	0	0	2	8.3	2	4.2
	Native American	0	0	1	4.2	1	2.1
	Other	0	0	1	4.2	1	2.1
Sexual identityb	Gay	15	62.5	17	70.8	32	66.7
	Bisexual	9	37.5	5	20.8	14	29.2
	Heterosexual	0	0	3	12.5	3	6.3
	Other	0	0	1	4.2	1	2.1
School status	In college	10	41.7	8	33.3	18	37.5
	Not in college	14	58.3	16	66.7	30	62.5
Job status	Full time	9	37.5	6	25.0	15	31.3
	Part time	8	33.3	8	33.3	16	33.3
	Unemployed	6	25.0	10	41.7	16	33.3
	Disability	1	4.2	0	0	1	2.1
Home status	Stable housing	22	91.7	23	95.8	45	93.8
	Other	2	8.3	1	4.2	3	6.3
HIV statusc	HIV positive	4	16.7	4	19.0	8	17.8
	HIV negative	20	83.3	17	81.0	37	82.2
Sexual behaviourd	Protected anal sex/past 30 days	14	73.7	10	71.4	24	72.7
	Unprotected anal sex/ past 30 days	5	26.3	4	28.6	9	27.3

^aTotal percentage sums to more than 100 because participants could have selected multiple ethnicities

^bTotal percentage sums to more than 100 because participants could select multiple sexual identities

^cTotal number is 45 because of 3 missing cases.

^dTotal number is 33 because only biological males were given this item, and 8 biological males did not have anal sex within the past 30 days.

The first author conducted the interviews by using open-ended questions for the main topic areas (e.g., meeting men, gender and sexual norms among young Black men who have sex with men, social networks, and condom use). The interviews began with an icebreaker ‘how did you both meet?’ after which each dyad was probed for meanings, examples, and definitions of words or activities that appeared to be contextual. One such example relates to the participants' use of ‘trade’ for typically masculine-looking men who have sex with both men and women, and whose greater economic power and/or social status are attractive to financially-strapped youth. The dyadic technique of introducing a topic, generating discussion between the priority participant and friend as an interactive process, and probing for clarification or examples when unfamiliar words, practices, perceptions, or topics arose during this dialogue had the advantage of eliciting richer material for analysis than usually obtained in personal interviews (Morgan et al. 2013).

Analysis

The interviews (dyadic and individual) were audiotaped with the participants' permission and professionally transcribed using their preferred pseudonyms as identifiers. The participants in each dyad were asked to select names beginning with same letter and, because there were 24 dyads, the first letter ranged from A to X. The first two authors reviewed the transcripts independently before discussing preliminary analyses. Next, the transcripts were imported into Dedoose, a qualitative data analysis software programme, for emergent coding. During analysis, we focused on participants' discussion of sexual and social norms among young Black men who have sex with men, which were prompted by the following two questions in the interview protocol:

1. Do you talk about being a ‘top’ or ‘bottom’?

2. What does ‘top’ and ‘bottom’ mean to you in terms of masculine or feminine roles?

We agreed upon three primary nodes relating to these topics, which were highlighted in the interview text. A sample of transcripts was then coded and, once 80 percent inter-rater reliability was reached, all transcripts were coded. Then, we selected a set of themes for their salience and by frequency; for example, each theme was discussed by at least half (N=12) of the dyads. The three recurring and interrelated themes involving gender norms and sexual roles among young Black men who have sex with men were: masculinity and femininity; ‘top’ and ‘bottom’ dynamics, and characterisations of the ‘trade’ man (hereafter; trade man).

The findings were triangulated by presenting our analysis to young Black men who have sex with men, HIV providers, social workers, community outreach coordinators, researchers, and interested community members at an AIDS Service Organisation in Birmingham, Alabama. We asked for feedback on interview quotes relating to each theme and sub-theme, and engaged in interactive discussion with the audience about the main findings of the study. We then incorporated that feedback into our analysis as a validity-enhancing measure.

Results

The themes in this section involve a set of gender scripts that the participants used heuristically to assess social desirability, select partners, and, in some cases, ascribe the risk of HIV infection on the basis of projected masculinity or gay-identified status. In order to contextualise these findings and allow for unedited representation, we include direct quotes, where appropriate. The quotes are followed by the speaker's self-selected pseudonym and role in the dyad (e.g., priority participant or friend)

Masculinity/Femininity in Relationships

The most common sexual script involved typical gender roles associated with top and bottom sexual position labels, which all but one dyad (N=23) agreed were strictly defined. The only dyad to contest this stereotype referred to gender fluidity and changing gender norms within the community, stating that ‘we've become more open to things now’. Nevertheless, even this dyad expressed frustration with the ‘top-as-male’ and ‘bottom-as-female’ dynamic that Black men who have sex with men used for assessment. As Chase (priority participant) lamented, ‘Personally, I think people should break out of the whole masculine/feminine stereotype period, but what can you do?’

As the following exchange demonstrates, some participants felt, in fact, that they were falsely gender-stereotyped because of the way they looked or acted:

Quevin (priority participant): People look at me and they be like, ‘oh, that's a top’.

Queena (female friend): Because of his attitude, people automatically assume he's a top, but really, he's a bottom.

Quevin: Just a very masculine one.

Almost half (N=11) of the priority participants self-described as ‘versatile’ (i.e., they were interchangeably top or bottom). Nevertheless, even the participants who identified with a versatile sexual role stated that being a top or bottom in sexual encounters largely depended on their partner's physical appearance. As explained by Trade (priority participant): ‘It depends on the person that I'm with. If I'm topping someone, they are a lot more feminine than I am’.

Despite the top/bottom dichotomy being strictly reinforced in terms of gender identity, many participants had negative attitudes toward men who were deemed overly effeminate and therefore less desirable as sexual partners. In one interview, Hunter (priority participant) revealed that he had broken up with a man in the past because he was ‘playing with dresses and wigs and everything like that’. Furthermore, although some participants had known masculine bottoms and feminine tops, this orientation was deemed to be the exception to the rule and was sometimes characterised negatively as ‘weird’ or ‘defeating the purpose’ of being gay. The consensus in the interviews was that some gender fluidity in relationships was fine, as long as gender norms were not being altered too drastically. The following exchange between a friend pair illustrates this social pressure more succinctly:

Elon (priority participant): The gay community is very judging, because everyone sticks to stereotypes.

Eryn (lesbian friend): And the first thing when you come out to people is someone always feels the need to inform you of what is expected. Right when you are still confused about what you're trying to be, you're trying to conform me into what you think is right.

Elon: See that's what I'm saying, in a White relationship if you have two versatiles it doesn't matter if they're masculine or feminine, but in a Black relationship if you have two versatiles, it's either or.

Interviewer: So, what happens if you've got two versatiles?

Elon: They can't be together.

This male/female characterisation centred on power differences between the two types, which followed gendered scripts for heterosexuality. Two dyads referred to the traditional male/female roles between tops and bottoms as analogous to the relationship between Lucy and Ricky Ricardo in the US television show of the 1950s, ‘I Love Lucy’, and as depicted artistically in some gay venues in Birmingham:

Like, it's weird, because top and bottom, like, the whole top is the masculine, bottom is the feminine is very— I call it ‘I Love Lucy.’ That's what I call it because of the whole ‘Ricky and Lucy’ kind of ordeal. He's the one that works; does everything; the masculine one. He handles the house, the money…She was at home. You know what I'm saying? She was very sensitive – you know what I'm saying? Very frail, fragile and really didn't step outside the house (Greshawn, friend).

Although only two friend pairs explicitly referred to ‘I Love Lucy’ when discussing gender norms, many participants used 1950s-era language when referring to women and men with feminine qualities. Feminine men, especially ‘fish’ or ‘queens’, were considered to be weak or submissive, and were frequently described in derogatory terms:

I despise a feminine. I want them to look masculine. To the point, he's so over-masculine. I don't go for the feminine type (Untae, friend).

This characterisation had implications for condom use as well, as two participants discussed. Issues with condom negotiation derived from an unequal balance of power, in which tops were more likely to dictate whether or not a condom was used for sex. Hunter (priority participant) asserted that: ‘It is not easy [to insist on condom use], only because basically a bottom is a woman, so you are going to listen to what your husband or man is going to say’. Isaiah (friend) also spoke about this dynamic, stating that ‘the man of the relationship…will have the power to decide whether he is going to wear a condom or not. He would have a problem with wearing condoms, just like a lot of men would have a problem with wearing condoms with women’.

Along with the sexual control found in the ‘I Love Lucy’ relationship dynamic, financial control was a cornerstone of this relationship type. One participant felt that he should be the traditional male provider, while his partner should be the so-called ‘stay-at-home’ woman:

I feel as though my partner shouldn't have to work unless you want to and I should take care, you know, of bills and things of that nature. If you want to work then that's fine, but whatever decision is made, if it's something I don't like we're not gonna do it (Man, friend).

During the presentation of our results, we learned that this dynamic was often mutually desired. As one audience member stated, some young Black men who have sex with men consider the role of ‘house husband’ to be an ideal type for same-sex relationships. Further, several men in the audience explained that many young Black men who have sex with men actively pursue relationships that mirror traditional heterosexual relationships, since they were modelled by their community of origin. These strict gender scripts for relationships are therefore more complex than they appear from comparisons with media icons such as Ricky and Lucy because they often relate to culturally-informed gender roles.

Top and Bottom Sexual Dynamics

A second common sexual script, similar to the first, describes the roles and expectations that accompany being a top or bottom. Seventeen (17) of the friend pairs discussed these roles and how they related to social interactions and status. Participants revealed that they were often asked to define their preferred sexual position regardless of the type of venue (i.e., gay clubs or online), and before they even introduced themselves by name:

Like, ‘omigosh, you're so cute, are you a top or a bottom?’ I'm like, ‘hello, my name is…’ (Greshawn, friend).

Another participant (Irwin, priority participant) added that this type of labelling was especially common in the Black gay community, while ‘in other races and cultures and stuff like that they don't care, it is ‘hi I am [name], I am [name]’ and you know whatever, like.’ Stan (priority participant) also noted that the act of coming out as a young Black man who has sex with men meant having to conform to strict bottom/top dynamics because ‘they [older Black men who have sex with men] try to mould you to what they feel has not been moulded, as opposed to when you see other races and sexuality it's like, you know, “if I like you, I like you”’.

A consensus among the participants was that sexual position designation was significant and that only individuals who identified as versatile could have sex with anyone — tops could only be with bottoms, and vice versa. However, while roles were fixed in the present, they did sometimes change over time. Chase (priority participant) expressed his belief that all men who have sex with men will be versatile at some point in their lives: ‘I think as you mature in the gay lifestyle, I think, everyone at some point is going to want the top and everyone at some point is going to bottom’.

Several participants who identified as bottoms provided a financial incentive for their preference, such as receiving gifts for having sex with tops. Quevin (priority participant) explained that he obtained ‘food, clothes, [and] money’ for sex and that ‘[tops with] money is everything, because you probably won't pay for nothing’. As voiced by Wallis (priority participant), ‘the Black gay scene is all about being flashy. You will go to the extreme to get new clothes, cars, money, jewelleries, to look good when you lay on that bed’. The financial basis for being a bottom can be explained, in part, by socioeconomic disadvantage among many participants, and the complex interplay between education, employment, and culture in relation to sexual decision-making. Only one priority participant had a college degree and, as noted in Table 1, only nine were employed on a full-time basis. The financial motive also helps to explain why so many of the participants spoke of the Black gay community in Birmingham as ‘having more bottoms than tops’ (Isaiah, friend).

From the community presentation of our results, we gained further insight into this phenomenon. As several Black men who have sex with men explained, bottoms were more likely to be openly gay and young, whereas tops were more likely to be older, ‘pass for straight’, and keep their sexual orientation private. Therefore, while bottoms often socialised with each other in groups, tops were more likely to socialise with their heterosexual friends and to be isolated from the Black gay community. The power differential between bottoms and tops was presented in terms of the sexual dominance and status of the older partner. However, the age-power dynamic could also operate in reverse. According to audience members, young men who were ‘beautiful’ could use their youthful sexual appeal to ‘play the game’ and extract money and gifts from an older partner in exchange for assuming a stereotypical feminine role. Thus, some young men became ‘house husbands’ in the retro style of Ricky and Lucy. Nevertheless, it was apparent from this group and the study as a whole that many participants had limited respect for bottoms, and the way in which they framed their criticisms was strongly reminiscent of stereotypes about women as dependent, frivolous, and ‘catty’. Clear sub-scripts for social preference and esteem for tops segued into the next theme.

The Trade Man

About half of the dyads (N=13) provided a useful and illuminating depiction of the trade man. At this point, it is important to clarify that, according to the results and the input we received from the community presentation for validity checking ‘trade’ (also ‘deal’ or ‘hook-up’) is the word that Birmingham's young Black men who have sex with men typically use to describe non-gay-identified men as sexual partners. In one dyad, Paul (priority participant) and Patrick (friend), who both maintain online dating profiles in which they present themselves as women, declared that trade men are the ones most likely to show interest in them, as opposed to men who are openly gay. The allure of the trade man was multi-faceted but related to perceived masculinity, the top/bottom dynamic, the clandestine quality of such encounters, and the promise of sexual or material reward as indicated by the terms ‘trade’ and ‘deal’. As Isaiah (friend) stated ‘a lot of people in the gay community see trade as a plus, because most of [us] are feminine looking for a masculine type’. Quevin (priority participant) admitted being attracted to trade men because ‘they're cheaper to be with; they give you stuff like food, clothes, and money’.

Trade men's sexual power and status within the gay Black community were offset by the interviewees' concerns about their putative bridging role in the HIV epidemic. Seven (N=7) friend pairs discussed their view of the health risk that trade men pose to young Black men who have sex with men through a sexual script involving the trade's lack of condom use and testing for HIV infection. Elon (priority participant) complained that ‘a trade would try to do you raw [without a condom] because he doesn't care, he doesn't care – because if he cared, he wouldn't be in a relationship with a female during the day’. In another dyad, Byron (friend) shared the same sentiment because, ‘I feel like a lot of guys these days are bisexual. They think they can just, you know, they don't have to use a condom ‘cause they don't want to be labelled gay’. When asked about how public health programmes could educate young Black men who have sex with men about HIV prevention, Hunter (priority participant) pointed out that trade men's activities should be addressed as a public health priority:

These [prevention programmes] are biased against gay people, because like I said, we are catching these things from trade [men]. But trades are not going to come to no gay centre, so they [programmes] need to go where they are, not just be for gay people.

In sum, a sexual script in which trade men were viewed as risky centred on their power to exert control over sexual decision-making while avoiding condom use, a problem that prevention programmes could address. More surprising was the belief about trade men being risky precisely because they had sex with women, a perception aligned to young Black men who have sex with men's certainty that closeted men have women partners. In this case, although trade men were believed to avoid safer sex, HIV transmission was attributed to women as third parties because, ‘you never know what your partner is doing … I didn't know that my ex was still having sex with females’ (Walter, friend). In the same vein, bottoms or ‘fems’ were considered ‘AIDS carriers’ regardless of being at greater risk of exposure to HIV in the top/bottom dynamic because, ‘in gay relationships, if the top has multiple guys he's a player and if the bottom has multiple guys you're a whore’ (Elon, priority participant). These attributions were likened to the gendered power dynamics of heterosexual relationships. According to Eryn (lesbian friend) ‘the fem is always blamed, she is nasty … and it carries over, it's the same stigma being taught’. Projections of blame for lack of condom use were therefore deeply gendered and were attributed to denigrated femininity in heterosexual or gay relationships, further stigmatising the bottoms.

Discussion

The power relations that were identified in this study help to explain the dynamics of HIV risk among young Black men who have sex with men in the Deep South. The three themes drew upon the men's perceptions and attitudes toward sexual partners and highlight what McDavitt and Mutchler (2014, 488) described as sexual scripts that ‘operate within a system of power influenced by stigma and heterosexism’. In the first theme, ‘masculinity and femininity in relationships’, we found significant parallels in the relationship power dynamics between young Black men who have sex with men and heterosexual men and women. In the second theme, ‘top and bottom dynamics’, stereotypical Ricky and Lucy gender roles represented a dialectic for role-taking and condom use. This dialectic had two purposes: dispensing with social niceties in order to get to the business of hooking up, and reinforcing a social order in which tops dictated the terms because of their superordinate status. In the third theme, ‘trade’ man, these power dynamics were further delineated by a sexual script in which bisexually-behaving men exerted dominance over openly gay partners and who, as asserted by the participants, did not use condoms or engage in HIV testing. The lack of self-empowerment among young Black men who have sex with men in relation to condom use with trade men, who were considered to be desirable, elusive, and a source of financial support, helps to explain the alarmingly high HIV rates among such men in the USA (Rosenberg et al. 2016). Being a bottom in such encounters raises the risk of HIV by a factor of 13 compared to someone who engages in penetrative sex without a condom (CDC 2015a).

Sexual mores among young Black men who have sex with men were shaped and influenced by the African American community at large. First, the participants spoke about how their families of origin embraced Bible Belt injunctions for heteronormativity which, in some cases, led to their being alienated from families and/or straddling both worlds through bisexuality. Homophobia is especially pronounced in the US Deep South, where Black church leaders strongly oppose homosexuality on biblical grounds (Cleek 2014), and where the participants self-identified as bisexual for privacy's sake. The second point relates to living in the racially divided South. Here, the participants identified strict gender norms as defined by top/bottom introductions in person or online, which were deemed to be less common in the White gay community. One explanation for this division is that the scripts are a natural extension of fixed gender norms in the Black community more broadly, which Fields et al. (2015, 129) defined in terms of misogynistic denigrations about Black men who have sex with men being ‘lower than a female’. Other differences include less tolerance for inter-racial contact than the US average (Card, Mas and Rothstein 2008), as well as frank racism as expressed in the ‘no fems, no fats, no blacks’ provisions of some dating apps (Allen 2015). Social class differences added another layer of difference for young Black men of limited means who actively seek trade men as a source of financial support.

The paradox of the non-gay-identified trade man is that his exalted role among the participants was offset by fears of acquiring HIV from them. This perception deserves clarification in terms of actual risk factors among behaviourally bisexual Black men. As Ford et al. (2007) noted, the ‘down-low’ mystique is more of a social construction than an actual risk category, and, to date, there is little evidence to suggest that such men are responsible for the higher rates of HIV infection among African Americans. In fact, some authors have suggested that the literature's appropriation of the term has served further to pathologies Black men's sexuality as overly aggressive or extreme (Saleh and Operario 2009). This topic deserves further investigation for its relevance to risk perceptions and activities among young Black men who have sex with men, particularly in the Deep South where there is a clear financial aspect to partnering with down-low ‘trade’ men.

Feelings of disempowerment, sexual receptivity, and dependence upon trade men for financial support were described in terms of ‘perks’, ‘treats’, ‘money to spend’ or, more tellingly, ‘a place to stay’ in relation to housing insecurity. Rather than these drivers being viewed as risky because of the element of sexual exchange, we found that young Black men who have sex with men ascribed their vulnerability to dominant partners who called the shots and whose everyday lives were less knowable or controlled by gay sexual norms, scripts, or reputation. For this reason, the participants believed that it would be productive to engage behaviourally bisexual men for HIV prevention efforts. However, in our follow-up discussion, Black men who have sex with men who worked in community outreach reported that their younger counterparts were among the least likely to be tested during community HIV testing events and seemed to think it was a ‘joke’. These community workers suggested that there was an attitude of, ‘I figure I will get HIV anyway’ which made the youth appear to be fatalistic about their future or indifferent to HIV prevention efforts on their behalf. This fatalism may result from the homophobia and social exclusion reported here, as well as structural barriers such as unemployment and unstable housing that prevent young Black men who have sex with men from becoming financially independent (Hicks 2016).

In terms of the parallels between Black men who have sex with men and Black women's experience of HIV risk as proposed at the beginning of this article (see Underwood's [2003] history of such parallels), we found that culturally-informed sexual scripts define both genders, although being the receptive partner is clearly riskier for Black men. However, the fundamental issue for HIV risk is sexual disempowerment rather than gender itself, although contextual factors such as location (US South), culture (being Black), and income levels define how this risk plays out in terms of bottom/top dynamics. For instance, the financial arrangements that we have identified among young Black men who have sex with men mirror Black women's exposure to HIV risk in low-income settings. In both cases, male partners are often older, wealthier, and exercise gendered power, not only through unilateral decisions about condom use and concurrency but also through expectations of gift giving, child support, and other incentives (Lichtenstein 2005). Interestingly, Masvawure et al. (2015) found that wealthy, feminine-identifying men in South Africa also had little control in same-sex relationships and were resigned to playing the provider role in order to secure access to masculine-identifying men. Even in this transactional context, the men's identity was constructed through a femme-phobic lens. With reference to the USA, Fields et al. (2015) argued that cultural framing of young Black men who have sex with men as a subclass of women is a primary factor in theirsocial isolation, reluctance to use condoms, and affirmation-seeking through frequent sexual intercourse.

Limitations

There are some limitations that are noteworthy. First, the data were based on self-report and therefore, bias is possible—although having two parties in dyadic interviews could act as a validity check. Second, while young Black men who have sex with men's use of ‘trade’ referred to men who had sex with both men and women, further study is needed in order to determine if situational factors, such as closeted bisexuality, or actions such as gift-giving and financial support, give the term its definitive meaning. Further research is also needed to explore the cultural meanings of the term ‘trade’ in the context of the Deep South.

Conclusion

This article has identified gender norms, behavioural risks, and cultural scripts for sex that fuel the HIV epidemic among young Black men who have sex with men in a US Deep South locale. Role bifurcations such as dominant/submissive, masculine/feminine, and breadwinner/housewife all exacerbate relationship inequality and reduce the probability that sex is fully consensual. The financial and status elements of these arrangements are a barrier to traditional prevention methods such as condoms, and call for adjunctive prophylaxis such as PrEP or PEP that have been likened to birth control options for women because they do not require negotiation with a partner (Mutchler et al. 2015). In parallel to self-empowerment strategies for women, these methods offer a path to independent decision-making without a dominant partner's knowledge or permission. However, the US South is notable for the lack of access to biomedical methods for HIV prevention compared to other regions (Rosenberg et al 2016). Elopre et al.'s (2017) report on PrEP uptake in Birmingham, Alabama laments the abysmally low response rates among Black men who have sex with men, which the authors attribute to severe socio-cultural and economic disadvantages that interfere with health seeking. These deficits must be addressed if young Black men who have sex with men are to escape the ‘1 in 2’ statistic that potentially awaits them. The findings of this article identify the urgent need for alternatives to condom use in order to stem the hyperendemicity of HIV infection in this vulnerable population, including new scripts and strategies for risk reduction that would bring the Deep South into line with the life-saving interventions that are available in many areas of the United States and the globe. Our finding that young Black men who have sex with men feel vulnerable in transactional relationships could be used to promote such methods, thus providing a person-based incentive for PrEP uptake. In all cases, such scripts must be sensitive enough to ‘speak’ to such youth self-care strategies such as PrEP and will require targeted resources and outreach in order to effect meaningful change.