The Social Environmental Context of Resilience among Substance-Using African American/Black Men Who Have Sex with Men

Abstract

Resilience theory has been suggested as a framework for research on HIV prevention among men who have sex with men. Among this population, literature indicates that African American/Black men who have sex with men experience additional health disparities including elevated HIV incidence rates, victimization, and poor physical health. Conceptualizing resilience as a part of one’s social environment, this qualitative study investigates resilience processes and HIV transmission risk among a sample of 21 substance-using African American/Black men who have sex with men. Data from in-depth interviews describe the social environmental context in which resilience is exhibited and document the influence of homophobia, expressions of agency, and access to social, economic, and cultural capital on resilience processes. Central to this are expressions of hidden resilience, in which African American/Black men who have sex with men mitigate risk and experience their lives as subjectively successful, whether or not outsiders see it as such.

Introduction

Over the last 40 years, the field of psychology has theorized the concept of resilience (see Kolar 2011 for a review) in which consensus has built around that idea that resilience is a dynamic process wherein individuals are capable of positive adaptation or resistance, recovery, coping, and success within the context of adversity (Masten 2001; Luthar et al. 2000). The process of positive adaptation occurs through protective factors, or assets and resources that facilitate a positive outcome for individuals exposed to risk (Wright and Masten 2006). Thus, for individuals to be resilient, they must have experienced some form of adversity and utilized protective factors, or assets and resources, such as personality characteristics and skills, social support, or community supports (Kolar 2011). While risk exists for everyone, and risk factors need to be assessed, the emphasis of resilience research is on protective or enabling factors (Obrist et al. 2010).

Using a framework more closely aligned with anthropology, recent literature advances the idea that resilience is also a quality of an individual’s social environment and conceptualized as the capacity of individuals to navigate to resources (psychological, social, cultural, and physical) that sustain their well-being, and their capacity to negotiate for resources to be provided and experienced in culturally meaningful ways (Liebenberg and Ungar 2009). Thus, resilience is a form of agency, and its expression is dependent on the culture in which the individual is situated and the capacities of that culture, and its associated structures, to make resources available and accessible in ways that are meaningful to the individual.

Examinations of resilience that incorporate both agency and structure are the most appropriate for studying the concept, and they also sharpen the analytical focus (Obrist et al. 2010). Recent literature suggests that human capacity to act is constrained by structures that are shaped by economic, political, and social forces, and that agency is determined by material and non-material resources composed of social, economic, and cultural capital. Thus, resilience is built in the social environment when individuals are able to access different forms of capital. Those unable to access necessary capital will be less likely to express resilience (Obrist et al. 2010).

One of the key contributions of the social environmental approach to resilience is that it avoids subjective assumptions about what is and is not a positive outcome (Obrist et al. 2010; Liebenberg and Ungar 2009). The criteria that constitute resilience are often constructed by researchers at a macro level and therefore positive adaptation is frequently constructed from White, middle-class, Western values (Glantz and Sloboda 1999; Liebenberg and Ungar 2009). Three points from the literature address this criticism. First, the notion of hidden resilience is used to describe patterns of coping or creative solutions that mitigate risk and allow individuals to experience their lives as subjectively successful, whether or not outsiders see them as such (Ungar 2010). Second, it is important for researchers to assess whether individuals recognize a risk, believe it can be overcome, and highly prioritize the risk (Liebenberg and Ungar 2009). Lastly, researchers must broaden the study of resilience to include diverse populations, including adults and minorities outside of the mainstream (Liebenberg and Ungar 2009).

Recently, one population receiving much attention regarding resilience and HIV prevention is men who have sex with men (Buttram 2015; Herrick et al. 2014; Kurtz et al. 2012; Kubicek et al. 2013; McNair et al. 2018; Woodward et al. 2017). As a result, researchers have of late proposed an initial theory of resilience which includes many individual, social, and community factors thought to be important in developing resilience among men who have sex with men, with respect to HIV prevention (Herrick et al. 2014). While several components are similar to those developed in the field of psychology, such as altruism and optimism, many are specific to men who have sex with men, such as sexual and gender identity, level of ‘outness,’ integration with gay life, connection to queer history, and queer family bonding.

Among men who have sex with men, such an approach would likely counter common experiences of minority stress, which include stigma, prejudice, and discrimination, and microagressions which consist of brief and commonplace verbal, behavioral, or environmental abuses (Meyer 2003; Nadal et al. 2011). Such experiences may be linked to specific places or to religious dogma (Barton 2010; Lewis 2009). As a response to minority stress men who have sex with men often conceal their sexual orientation, which results in mental health problems such as depression or anxiety (Meyer 2003). Thus, connectedness to the gay community and engagement with other men who have sex with men may ameliorate minority stress and mental distress symptoms (Frost and Meyer 2012). Gay community engagement and connectedness represents a positive coping resource (Zablotska et al. 2011; Frost and Meyer 2012), although it may also have some negative effects as well (Buttram & Kurtz 2014; Kurtz 2009). Thus, a valuable contribution to this literature would include an in-depth understanding of variables that both support and hinder resilient actions among men who have sex with men (Herrick et al. 2014), including the social environmental context.

To fully understand agentic practices of resilience among this population, as it relates to HIV transmission risk, an in-depth examination of social environmental and cultural context is necessary (Obrist et al. 2010; Liebenberg and Ungar 2009). Literature indicates that African American/Black men who have sex with men (BMSM) experience greater rates of HIV incidence, and a host of related health disparities, including substance use, victimization and gang involvement, incarceration, and poor physical health, compared to other men who have sex with men (Friedman, et al. 2018; Garofalo et al. 2010; Harawa et al. 2008; Hatfield et al. 2009; Mays et al. 2004; Prejean et al. 2011; Tobin et al. 2011).

Homophobia is well documented within African American communities (Díaz et al. 2008) and it has been suggested that health inequalities among BMSM, such as HIV infection and victimization, may be attributed to homophobia and stigma within African American communities (Harawa et al. 2008; Mays et al. 2004). As a result, BMSM are less likely to disclose sexual orientation and are more likely to be exposed to heterosexist community, family, and religious norms (Balaji et al. 2012; Garcia et al. 2016; Maulsby et al. 2014; Millett et al. 2006; Storholm et al. 2017). Furthermore, BMSM are less likely to have access to adequate social support (Mays et al. 2004), which may in part be due to messages against homosexuality and stigma disseminated by many African American churches and religious African American families (Fullilove and Fullilove 1999; Peterson and Jones 2009). The absence of social support is also associated with many other adversities, including financial hardship (Ayala et al. 2012).

Conceptualizing resilience as a part of one’s social environment, this exploratory qualitative study investigates resilience and HIV transmission risk among a sample of 21 substance-using BMSM.

Methods

Qualitative interviews were conducted with BMSM recruited from among participants in a two-armed randomized intervention trial, Project ROOM, testing the efficacy of an empowerment theory-based small group intervention compared to a single session counseling condition. See Kurtz et al. (2013) for a full description of the study procedures, assessments, interventions, and outcomes. Men eligible for Project ROOM were 18–55; reported condomless anal intercourse with a non-monogamous partner(s) during the past 90 days; and met one or more of three substance use inclusion criteria during the past 30 days: binge drinking (5 or more drinks) at least three times, using marijuana on 20 or more days, or using any other drug (including prescription drug misuse) at least three times. In total, 108 BMSM participated in the larger Project ROOM study and all were invited via e-mail and telephone to participate in the present qualitative study. A total of 21 men completed the in-depth interviews, which were conducted between May and August 2013. Interviews took place in a private room of the research field office and lasted approximately 90 minutes. Respondents provided written informed consent and were compensated $50 for their time and travel. Research protocols were approved by the Institutional Review Boards at Nova Southeastern University and Florida International University.

The interview guide was developed with a focus on the social environment to gain a deeper insight into the expression of resilience and HIV transmission risk and related health disparities. The interview was comprised of several key sections which inquired about background and environment, current challenges and adversities, and resilience – including actions men undertook and access to resources. Questions were open-ended to allow for multiple themes to emerge from the discussion. The digitally audio-recorded interviews were transcribed by an independent transcriptionist and reviewed for accuracy by the author. Transcribed interviews were entered in ATLAS.ti version 7 software for data management, coding, and analysis.

Interviews were coded using descriptive (words or short phrases to summarize passages of data) and in vivo (actual language from participants to name concepts and themes) coding schemes (Saldaña, 2013). Memos were written after each participant was interviewed and after each interview was coded to reflect code choices, and emergent themes and patterns (Saldaña, 2013). Two independent researchers participated in the coding process, which included establishing codes and meanings and cross-checking code choices. Regular discussions were held between the coders that yielded insights to refine the coding scheme and facilitate agreement on code choices (Barbour, 2001). Finally, the final set of codes and their meanings were transformed into longer and more descriptive themes to organize recurrent meanings and patterns. Themes and definitions of themes were constantly compared across interviews to ensure consistency and reliability.

Results

Project ROOM assessments included measures of age, education, HIV-status, past 90-day measures of substance use behavior (i.e., frequencies of days in which the participant got high on alcohol or drugs and drugs and sex used in combination), sexual behavior (i.e., number of sexual partners and frequency of condomless sex) and the number of people available for social support and satisfaction with available support. Men included in the present study were not significantly different from the other BMSM Project ROOM participants who did not participate regarding demographics, substance use, sexual behavior, mental distress, victimization history, past year homelessness, self-identification as gay, HIV status, and social support (Buttram 2014).

Respondents ranged in age from 20 to 52 (mean 40.8). Of the 21 respondents, 20 completed 12 or more years of education, 5 were employed full-time, and 8 experienced homelessness during the past year. Eleven men were HIV-positive. All respondents were born in the United States. One man was of Haitian descent and none were Hispanic.

Two primary themes emerged from the data: 1) the social environment of homophobia, religion, and family, and 2) experiences with substance use and sexual risk behavior. While there were many similarities among men in the sample, including levels of education and income, substance use and sexual behaviors, 16 men had more experiences of homophobia and a lack of family support, which led to concerns over disclosing sexual orientation or same-sex behaviors. A smaller group of 5 men also described experiences of homophobia, yet these experiences were offset by having a supportive family and connections with gay men and the gay community. The unique social environments of each group influenced their expressions of resilience.

Social Environment of Homophobia, Religion, and Family

One of the most important influences on the lives of men in this sample was homophobia. Indeed, in discussions of men’s lives, homophobia seemed to be ever-present and intertwined with African American communities, religion, and social relationships. This in turn affected the men’s relationships, decision-making, and daily existence.

In total, 16 men described their sexual orientation or sexual behavior as being ‘taboo’ within African American communities. Illustrative of this are sentiments from three respondents. The first, a young Miami man stated, ‘Well, mostly in the Black culture, being gay is a taboo, and, you know, it’s not really accepted among the Black community, especially here in Florida.’ Another older respondent said, ‘Homosexuality was a big taboo, which was one of the reasons I, you know, I decided to leave and go off to college.’ He went on to add, ‘In my religious circle, it was very, very taboo.’ Others had similar experiences, with one man describing African American communities as being ‘hardcore’ regarding negative attitudes toward men who have sex with men.

A majority of these same men had religious families and were raised in African American churches. Thus, their view of African American communities were heavily influenced by their religious affiliation. Men described the religious message of, ‘homosexuality is damnation,’ and the fear associated with it. This had a profound impact on some respondents, summed up by one older respondent, ‘They would talk like you were going straight to hell. So, I think that was more of a problem for me than, you know, the community stigma. The knowledge or the idea that I was going to hell, I think that was my biggest fear.’

For this group of 16 men, homophobia found in the wider community and religious institutions was often present in family relationships as well. For most men, families were reluctant to be accepting of the men’s sexual orientation or same-sex behavior. One older man living in Miami described his family this way,

I was saying to my mother, I said, “I’ve got all of these strikes against me.” I said, “I’m a black man in America,” I said, “I’m HIV positive,” I said, “and I’m gay,” and she said, “You’re gay?” And she kept saying, “You’re gay?” And I’m thinking to myself, “Now, she didn’t say nothing about me being HIV positive, but she is stressing all of this about me being gay,” you know, but I have this illness that we have no cure for, that we know - this was back in the ‘90’s - that we know almost nothing about, and she’s focusing on the fact that I’m gay.

The fact that this respondent’s mother’s homophobia was stronger than her concern for his HIV infection, considered fatal at that time, was quite surprising to him. However, the strength of such homophobic attitudes among men’s families was not uncommon.

This group of 16 men largely did not disclose sexual orientation or same-sex behaviors to anyone. Those who did often engaged in avoidance of discussing or mentioning it around family members. Experiences similar to that of this man from Miami were common, ‘I’m cordial with my family. I speak to them, but I don’t have a relationship with them. I don’t have a personal relationship where they know what’s going on in my life or what I don’t do and do.’

A common sub-theme related to homophobia was the lack of or avoidance of disclosure of sexual orientation or same-sex behaviors, which was a direct response to homophobia and stigma that affected the men’s larger social environment. One older respondent said, ‘Like my mother once told me, ‘You can be gay. Just don’t be gay around me.’ I never really understood what that meant, but in a way, I did, you know? And I think to this day I’m still gay, but I’m not gay around certain people, if you get my meaning.’ One young man from Miami had a similar experience and described his family’s attitude as, ‘I still love you but that doesn’t mean that I have to accept what you do.’ He went on to say, ‘That’s no problem, I understand. Just because [I] want to live a certain way doesn’t mean that everybody has to accept that, and I got that in my head.’

Attitudes such as these heavily influenced men’s behavior and decision making. As a response to societal, religious, or familial homophobia, it was common for this group of 16 men to describe the notion of ‘D.L.’ or ‘down low,’ in which men actively conceal their sexual behaviors. One Ft. Lauderdale respondent who said, ‘I played the game. I had a girlfriend, which I think a lot of men do.’ He went on to say that, ‘Everyone’s doing it.’ These 16 respondents stated that down low behavior is prevalent in African American and Black communities in an effort to ‘satisfy the masses; to satisfy the people around them.’ Another respondent from Ft. Lauderdale said that it is not uncommon to see guys, ‘looking like gangsters… and they’ll play that role out in public, but privately you know, they’re still hooking up with other guys.’

From these examples, it is evident that limited disclosure was accepted by these 16 men as an appropriate and necessary response to societal, religious, and family stigma. Thus, the decision to not disclose had positive consequences for men’s lives. Men mentioned the avoidance of abuse and violence as a benefit of not disclosing sexual orientation or same-sex behavior. The 16 respondents in this group described pervasive verbal abuse directed toward young men who were open about their sexual orientation. One young man from north-central Miami said, ‘Well, the ones that were, you know, decided to come out were teased.’ He went on to say that, ‘Teasing always, in one way or another, leads to that inevitable fight.’ Others described openly gay men from their neighborhoods or schools getting beat up or, ‘having the gayness beat out of you.’

Another sub-theme related to homophobia was the maintenance of developed social, economic, or cultural capital because of non-disclosure. Social capital, in the form of family and social relationships, and the potential loss of that capital, was a big motivator for men to not disclose sexual orientation or same-sex behaviors. Men described the pain of not being accepted by their parents or by African American communities. As mentioned above, family relationships often suffered because of disclosure with men feeling forced to limit social relationships with unaccepting family members. For men who had not disclosed, they had heard stories. As one respondent stated,

I heard stories from, you know, my friends when I was in the army how some of them would get beat up by family members, and how different people they knew, their own mothers put them out. And some of these people were actually thrust away from their family at 15 or 16 years old, you know? And I was like, ‘Whoa…’ And, I don’t know, because I was very close to my mother, and I was always close to family like my grandmother, so if they had turned their back on me at that age, I don’t know what would have happened to me.

Another, younger, man described the need to maintain familial relationships in this way, ‘Oh yeah, affection, and, uh, I mean affection and the loss of your family, I mean that’s crazy. The loss of…when your family turns their back on you…your family is all you really have in this lifetime. And that loss could be, yeah, incredible.’ Six men mentioned loneliness as a result of what limited disclosure they had undertaken. Moreover, two additional respondents also mentioned that in addition to the loss of family, it was also important to maintain social capital in other relationships, including with friends and neighbors. Disclosure would mean that a man, ‘wouldn’t be able to hang out with the same crowd,’ or maintain, ‘contacts within the community.’

Related to the desire to maintain social relationships is the need to use those relationships to foster individual economic well-being. Thus, economic capital was another motivator in avoiding disclosure of sexual orientation or same-sex behaviors. Men who had jobs and economic opportunities did not want to lose them due to homophobia. By not disclosing, one respondent said, ‘You’re able to live in the – probably stay in the church. Then, possibly, there could be business contacts that you may be able to, you know, elevate your income or your living situation.’ As seen above, men learned not to ‘be gay’ around family members and they carried these attitudes into their jobs, workplaces, and employment opportunities. One respondent from Ft. Lauderdale stated, ‘Like, when it comes to work, I’m very focused at work. I don’t mix my personal life with work and so forth,’ while another acknowledged that in an effort to avoid disclosure he intentionally sets a tone of not asking anything personal about coworkers so that they will not ask anything personal about him.

Lastly, the importance of cultural capital was a sub-theme that emerged among respondents. Men stated that disclosure of sexual orientation or same-sex behaviors could not only lead to losses of social and economic capital, but also the loss of one’s place in their community. For example, one young man from Miami’s Liberty City neighborhood said, ‘You mention the word ‘gay’ and the next thing you know, you’re ousted.’ Additional respondents corroborated this statement by saying that family, friends, church, and the African American community were all they had ever known.

A smaller group of 5 men described some experience of homophobia, yet they did not experience this phenomenon in their family relationships. Two men described their mothers as ‘always being there for them,’ while two other men noted that they had supportive families. Early exposure to other gay people, in addition to supportive families, was influential for two respondents. One older man became more comfortable with this sexual orientation, not just because of his positive family experience, but also because during his adolescence his family moved from a small town to a large city and he began to see other people like himself and realize that he was not alone. A younger respondent had a similar experience during his adolescent years when he was a competitive dancer. In his words, ‘Dance is…it’s interesting. Being young and being around other males who dance who were not heterosexual was influential.’

As a result, this small group of 5 men did not experience the negative family relationships, or the fear of losing social, economic, or cultural capital due to their sexual orientation or same-sex behaviors. Instead, these 5 men found it easier to be more open and to form connections to gay communities. These men found themselves within a social environment that was not only more ‘gay friendly’ but also included other gay men. One man from Ft. Lauderdale described how he made friends and connections with other gay men and as a result, ‘we have this core group of, like, maybe like 12 of us, and we get together for holidays, and if it’s one of our birthdays, we pick a restaurant and go out and we celebrate. We’ll go dancing once in a while. We go to the film festivals.’ Another Ft. Lauderdale respondent described it as, ‘a good place to be at, out of the closet, and a lot of social network going on, and a lot of things to do. You know they weren’t against that, and you know, celebrated the gay lifestyle.’ As evidenced in the quotations, these men did not experience the extent of homophobia and fear that was such a common experience for the majority of men in in the study.

Experiences with Substance Use and Sexual Risk Behavior

All men from this study experienced health disparities when compared to men in the general population. This is certainly due to the eligibility criteria for participating in Project ROOM which included current and heavy substance use and recent condomless anal intercourse. However, the ways in which men described the co-occurrence of substance use and HIV transmission risk in their own lives varied.

A large majority of 16 men described their substance use and sexual behavior as related to coping with mental distress resulting from experienced homophobia and the toll it took on their decision making and behavior. Men stated that substance use was a means of dealing with depression. One young respondent described substance use among African Americans in general saying, ‘Well, as for African Americans, basically, we don’t tend to talk about our problems, and basically, you know, you’re carrying a load, and your main recourse is drugs and alcohol, so to be able to lift the burden off your shoulders…’ He went on to say that among BMSM the situation is even worse and that, ‘Drugs and depression works almost hand in hand. You look for an outlet, and, you know, not having – not having the acceptance within the community, you know, being bullied from within the community.’ An older man from Ft. Lauderdale agreed stating that, ‘I think we tend to numb ourselves or something. I think the pain of the past, the pain of maybe not being accepted by parents, the pain of still not being accepted by society…I think that to fill the void of whatever they feel is missing in their lives, they turn to other things to fill those voids.’

Two men described substance use as intimately connected to sexual behavior, in that BMSM have difficulty being intimate because of homophobic experiences. Another older respondent from Ft. Lauderdale, said of substance use,

That’s your escape of something that you was already willing to do. I was in that. That was me for umpteen years. That’s why I was so deep into the bottle of alcoholism, and smoking my weed, and my crack because that gave me that, like, to put on the g-sign that says ‘Hey, hello, I’m gay,’ so that when something happened I said, ‘Oh my God, I’ve must of been real messed up when we did that.’ No, I knew. But I had an excuse to fall back on.

An older man from Miami’s Overtown neighborhood described his experience this way,

The majority of the sex that I’ve had is gotten through the use of drugs. I think I originally got into it because I had a difficult time getting into the gay scene. I didn’t feel like I fit, or I didn’t really know how to approach other gay men, and that seemed to be the only way I could really get, you know, with someone. You know, I was very shy with very, very low self-esteem.

While he initially would only purchase drugs for his partner, in time, he began using too. He says that eventually he came to recognize that, ‘I was trading drugs for sex. My self-esteem was so low to where I was unable to get anyone without the use of drugs, and that’s pretty much it.’ Still another respondent engaged in substance use and sex trading as a coping mechanism. He says, ‘That was my way of healing from life’s disappointments or limitations; to have some fun as a result of feeling pain inwardly.’

A small number of 5 men described their attachments to the gay community, and this influenced their experience with substance use and sexual risk behavior. One Ft. Lauderdale man describes the gay community as being ‘open’ in which he found himself, ‘to be more around gay friends and building up my own self-confidence versus being an outsider and being the minority in the straight world.’ He went on to say that, ‘I find myself moving away from a lot of straight venues and straight people. Being in [the gay neighborhood of] Wilton Manors and being in this area, it kind of just reinforces who I am and what I’m about.’ This respondent describes the bars and bathhouses in his neighborhood as ‘incredible,’ though he acknowledges that some men are ‘reckless’ when it comes to substance use and sex. For him, however, he says, ‘I have a certain level of discipline.’ Thus, while he enjoys the openness and active night life and social scene of the gay community, he actively reinforces a balance in his life so that he is still able to go to work the next day.

When asked about substance use and sex, one Ft. Lauderdale man stated that it is more prevalent in the gay community. This man added that for him, ‘When I wasn’t busy at work and, you know, being productive, [the gay community] increased my appetite to start doing drugs and having unprotected sex.’ Another Ft. Lauderdale respondent had similar feelings, and stated, ‘I still have my, you know, I have my sexual preferences and I like bareback [condomless] sex,’ and he also added, ‘I do like poppers [amyl nitrites]. I guess that’s a substance and that hasn’t changed.’

Discussion

Though there were some differences, men from this sample experienced similar social environments, composed of inequality and societal homophobia. However, the largest group of men was less able to disclose sexual orientation or same-sex behaviors. A smaller number of men had supportive families in which homophobia was less of a problem, and they had social relationships with other gay men and the connections with the gay community that resulted in them not having fewer issues with disclosure.

The majority of men found themselves within a structure that was bound in large part by African American societal norms prohibiting the expression of homosexuality or same-sex behaviors, a strong religious influence from African American churches that promoted homophobia in its messages, and family structures that, perhaps influenced by societal norms and churches, were also unable to accept homosexuality or same-sex behaviors. Thus, for these men, a key component of their agentic expression of resilience was limited disclosure.

While some HIV prevention researchers interested in resilience have proposed that sexual identity, ‘outness,’ integration with gay life, connection to queer history, and queer family bonding are keys to being resilient among men who have sex with men (Herrick et al. 2014), the majority of men from this study suggest otherwise. In fact, such obvious connections to homosexuality would have a negative impact on their ability to be resilient because of the social structure in which they are situated. Consistent with recent resilience literature (Obrist et al. 2010), it appears that men’s limited disclosure to maintain social, economic, and cultural capital, is an agentic expression of resilience in which men are navigating to available and meaningful resources. Similar to the concept of hidden resilience (Ungar 2010), it is in this way that men are defining for themselves what it means to be resilient and expressing agency within their social structure. These men did experience health disparities (e.g. substance use, HIV transmission risk, mental distress) which they connect to experiences of homophobia and their inability to disclose their sexual orientation or same-sex behavior. Such experiences cohere with the theory of minority stress, which suggests that concealing sexual orientation is associated with increased mental distress among men who have sex with men (Meyer 2003). At the same time, it is from the perspective of these men that their livelihoods are made possible by navigating toward access to and utilization of social, economic, and cultural capital. Thus, men in this study understand building and maintaining capital as a resilient process, even if it entails limited disclosure and continued exposure to health disparities.

The social environment described by a smaller number of men was somewhat different. Though these men still experienced African American societal norms against homophobia, familial support lessened the strain of this burden. Agency was expressed by the formation of connections to the gay community which further lessened the burden of homophobia in the African American community. Thus, not only did they navigate toward assets and resources provided by the gay community, their connection to the larger gay community allowed them to join in the process of negotiating for assets and resources to be provided in culturally meaningful ways. Even though homophobia was still present in their lives, these men were able to experience acceptance of sexual orientation and same-sex behavior that a majority of men in this sample were not.

At the same time, this small number of men also experienced health disparities of substance use and HIV transmission risk, perhaps due to increased gay community affiliation. Data presented here suggest that their connection with the gay community led to an understanding of substance use and sexual risk as normalized behaviors. This coheres with existing literature on urban gay community life (Kurtz 2009_). Thus, it seems that among men with connections to the gay community, recognition of HIV transmission as a risk, and prioritizing it as such, is lacking. This preliminary step is necessary in achieving a resilient outcome (Obrist et al. 2010). It is also conceivable that this small group of men do not define being resilient as abstaining from all condomless anal intercourse. Thus, resilience may be minimizing the risks associated with engaging in condomless anal intercourse, rather than abstaining from it.

This study makes several contributions to the study of resilience, the first of which is the inclusion of the constructs of agency and structure. Though some work has incorporated theories of agency and structure into conceptualizations of resilience (Obrist et al. 2010; Ungar 2010), it is not common. Thinking of resilience as intimately connected to the social environment broadens the definition of resilience and moves it beyond the investigation of single outcome variables.

Another strength of this study is that it addresses recent criticism that definitions of what is or is not resilience are frequently constructed from White, middle-class, Western values (Glantz and Sloboda 1999; Liebenberg and Ungar 2009). The hidden resilience expressed in the limited disclosure of sexual orientation or same-sex behavior by some men in the sample exemplifies this. It is crucial that future studies examining resilience investigate such hidden resilience among populations, especially as it relates to HIV transmission risk.

Moreover, this study adds minority voices to both the resilience and men who have sex with men health literatures and contributes valuable insights into how BMSM express resilience. Using a social environmental approach to resilience, this is one of the first studies to undertake qualitative research to identify key variables related to resilience among BMSM. Thus, the target population and the approach of the present study are important because they expand thinking beyond current boundaries and encourage researchers to conceptualize resilience more widely and with more diversity in mind.

The findings and contributions of this study have several implications for future research investigating resilience among men who have sex with men. First, research should incorporate a socio-cultural perspective to understanding health and well-being. Future research should utilize qualitative methods to more fully understand health disparities and expressions of resilience more fully, as both are intimately connected to and informed by the social environmental context.

Such a perspective would be especially useful in understanding why men who have sex with men make decisions regarding HIV transmission risk, how they prioritize (or not) this risk in their lives, and the means by which they mitigate this risk. With the promotion of biomedical HIV prevention initiatives such as Pre-Exposure Prophylaxis (PrEP) becoming of increasing interest among scientists, future research must address the social environmental context in which men who have sex with men choose PrEP or other biomedical interventions as HIV prevention tools (Kippax and Stephenson 2012). As was demonstrated in this study, social, economic, and cultural capital contribute to resilience processes among men who have sex with men. Thus, it is likely that various forms of capital will be instrumental in informing the choices men who have sex with men make regarding PrEP or other HIV prevention technologies. Furthermore, research must examine decisions as they are made within social, political, and economic structures. Research that does not include a socio-cultural perspective will miss these important data.

This study has some limitations which must be noted. First, data presented are based on self-report and recall bias, interviewer effects, and social desirability bias are potential limitations. However, the use of a theoretically informed interview guide and strong rapport between respondent and interviewer likely mitigated these effects. Second, many men from Project ROOM were unable to be contacted for the final qualitative interview which took place more than a year following study completion. Thus, only men who had working phone numbers or e-mail addresses were able to participate in the qualitative portion of the study presented here. Additionally, comparisons are made between 16 men who described greater experiences of homophobia, limited family support, and concerns related to disclosure of same-sex behaviors and five men who described having a supportive family and connections with the larger gay community. Given the number of participants on which to base this comparison, these results should be viewed as preliminary. Finally, the Project ROOM eligibility criteria, small sample size, and unique South Florida context limit the generalizability of these findings. Future research examining resilience among this populations will likely contribute to and expand upon the present findings.

This study illustrates that African American men who have sex with men are resilient. Resilience factors are influenced by and in some cases developed through men’s social environment and the availability of social, economic, and cultural capital within it. Resilience is a process wherein individual agency and structure interact. Therefore, studying only individual action and ignoring the social environmental context presents an incomplete picture of expressions of resilience. Stories from the men interviewed explain the ways in which they have expressed resilience throughout their lives, including the expression of hidden resilience. With data presented here, it is hoped that the words and experiences of these men will positively influence the continued development of resilience theory in general, but also expand conceptualizations of resilience among populations of men who have sex with men.