Psychometric Properties of a Scale on Judgmental Communication with Peers About Sex Among YMSM and Their Close Friends in Lebanon

Abstract

We are not aware of any validated sexual health communication scales for use with young men who have sex with men (YMSM). We used data from an HIV prevention study in Lebanon with 226 YMSM aged 18–29 to assess the psychometric characteristics of our scale, Judgmental Communication with Peers about Sex (JCPS). The construct validity of the JCPS scale was supported by it being negatively correlated with general social support, percentage of alters perceived to be supportive, and the percentage of peers who are perceived to use condoms. The scale was positively correlated with gay-related discrimination, feeling part of the gay community, and gay social integration. These findings reflect a reliable, valid measure to assess judgmental sexual health communication between YMSM.

Introduction

Communication about sexual health topics with peers may be particularly important for young men who have sex with men (YMSM) between the ages of 18 and 29 because many of them cannot discuss sexual health issues with their parents or teachers [1, 2]. Positive associations between communication with sexual partners and safer sex among YMSM have been documented [3, 4], but there remains a dearth of information about sexual health communication between young gay men and their peers. However, studies of young adults in general find that sexual communication that is rated by peers as high quality and comfortable is associated with more condom use [5, 6]. Given that sexual health communication plays an important role in sexual health for YMSM, it is important to examine their sexual health communication with their peers, yet we are not aware of any measures that have been validated specifically for use with this population.

As an important feature of social influence, we have found that communication between peers about sexual health topics may lead to social support, thereby altering norms about safer sex [7, 8]. Despite the clear importance of peer influence and norms on sexual behaviors among young adults, very little is known about factors that facilitate or obstruct the flow of influence between young gay men and their friends. In fact, surprisingly few studies have explored the interpersonal processes through which peer influence unfolds in any population [9]. It is critical to better understand sexual communication between YMSM and their peers because peer norms are associated with sexual risk and protective behaviors among YMSM [10-12]. Perceptions of being judged by close friends during communication about sexual health topics may impede conversations about these topics [7, 8]. Judgmental communication may therefore shutdown an important source of support for young gay men. Some of the most effective intervention strategies to date for young gay men have focused on changing peer norms by embedding health education in social activities and communication with friends [13, 14]. Although a measure of communication about safer sex topics has been utilized in such research with gay men [14], past research has not attempted to measure judgmentalism in these conversations.

Qualitative research also found that YMSM in Beirut described gossip and judgmental communication as barriers to support within the community and potentially harmful to an individual’s reputation among peers [15]. As a possible vehicle of internalized HIV/STI and sex-related stigma, judgmental peer communication about sex seemed to reduce individuals’ willingness to disclose their risk behavior to friends. Having multiple sex partners was perceived by some as shameful and stereotypically associated with having STIs; therefore, judgmental communication about this behavior could contribute to negative health outcomes [15]. As Sheff argues, even the slightest indication of shame can break the social bond between self and others, leading to related feelings such as embarrassment, guilt, and even humiliation [16]. Young sexual and gender minorities may need to engage in shame-avoidance behaviors individually without the expectation of societal support within persistently heterosexist and homophobic cultural contexts [17]. Indeed, Javaid argues that gay single Muslims run the risk of experiencing shame in virtually any context in which conversations pertaining to heterosexual norms arise [18]. Furthermore, Georgis finds that gay men in Lebanon experience shame related to their sexual identities in uniquely “Arab” modalities [19]. Rather than countering shame with westernized notions of pride, gay men in Lebanon may need to feel the suffering effects of shame and may emerge with a sense of hope rather than pride. It is imperative to better understand how shame may be induced within conversations with friends as this may be precisely the point of intervening with a small step toward some hope.

Although there are well established measures on general social support [20], communication about safer sex with YMSM [14], and sexual communication in general [6]; these measures do not capture the key construct of judgmental peer communication about sex. To fill this gap, we developed a measure for judgmental peer communication about sex [7, 8] consisting of original items used to assess judgmental communication about sex between young gay men and their friends. Mutchler and McDavitt developed the scale out of earlier studies with young gay men and their friends. In one such study with a sample of 24 dyads consisting of young gay men and their close friends (N = 48) recruited primarily in Los Angeles, California, Mutchler and McDavitt noted particular discourses around safer sex [7] and implications for sexual communication and sexual health. In this work, we identified a theme, “Watch out for Whores and Sluts” within their sexual communication scripts. Building on this work, the study team expanded on existing sexual communication scales [6] from the literature to capture some of the emerging themes around sexual communication, judgmentalism and sexual health [8]. This work culminated in a paper addressing how young gay men sometimes “slut-shame” each other and this can be a barrier to productive conversations about sex and safer sex. We further refined and expanded the scale with items to measure sexual communication, slut-shaming and judgmentalism in exploratory research with 48 dyads (young gay men and their friends) recruited in Los Angeles, California and Birmingham, Alabama (N = 96). The scale was adapted for use with young gay men in Lebanon through a rigorous process of formative work with the population [15] and items about shaming were added in both directions (“I call my friend a slut” and “My friend calls me a slut”). Working with a Beirut study team, we included this measure in survey instruments used with 226 YMSM in Beirut, Lebanon. Yet, there is a need to validate this scale.

Beirut is considered to be a relatively progressive city in the Middle East and Northern Africa region (MENA), enabling the gay community to develop some safe spaces for gay men to gather [15]. Beirut is located on the fringe of both Europe and the Middle East, and this is reflected in a culture that has both progressive and conservative influences. Community-based organizations have arisen in Beirut to fight for greater societal awareness and tolerance of homosexuality and improved gay community organization and advocacy. The Lebanese Psychiatric Society recently declared homosexuality is not a disease. Gay life in Beirut thrives in discreet enclaves such as university social clubs, gay bars and dance clubs, and gay-friendly cafes. However, these developments are counter balanced by a sustained high level of societal stigma and discrimination towards homosexuality [21]. Homosexuality remains illegal, resulting in an omnipresent risk for arrests and police harassment. Thus, young gay men in Beirut must navigate a complicated social terrain regarding their sexual identity development and expression. Many of them fear what will happen if their families find out about their sexuality [22], and therefore, their peers and friendship networks may be their primary source for seeking social support.

Previous research suggests that greater integration into the gay community may increase opportunities to meet close friends and to discuss sexual health issues, but may also provide more opportunities for young gay men to meet sexual partners, which may lead to unprotected sexual encounters [3]. In a prior analysis of data from the study data used for our scale, judgmental peer communication about sex was positively correlated with condomless anal sex and integration into the gay community [23]. Greater integration into gay communities often results in more social relations with others in the community, which can result in increased peer support for sexual health and also in greater exposure to judgmentalism within sexual communication [15].

With both our qualitative and quantitative research suggesting the detrimental influence of judgmental peer communication on the sexual health of MSM, this paper reports the results of the psychometric evaluation of our novel measure of judgmentalism in peer communication about sex, including data related to its factor structure, internal reliability and construct validity.

Methods

Study Design and Participant Recruitment

The analysis for this paper used baseline survey data from an open trial of a community-based HIV prevention, sexual health promotion intervention that uses a sample of participants to examine the intervention effects on the larger young gay male community in Beirut. Recruitment took place between July 2016 and March 2017 using long chain peer referral methods primarily (73% of the sample), though other methods such as recruitment flyers, postings on social media and word of mouth were added near the end of recruitment in order to enable the study to reach its target sample. Eligibility criteria consisted of being biologically male and/or male-identified, age 18 to 29 years, fluent in English or Arabic, residing in greater Beirut, and having had oral or anal sex with a man in the past 12 months.

For the long chain peer referral methods, recruitment began with a small number of eligible persons designated as “seeds” who were identified through recommendations from community organizations working with gay men and our community advisory board and were purposively selected to be well-connected to other gay men and to represent the diversity in the community. All participants, including seeds and those recruited through flyers, postings and word of mouth, received 3 recruitment coupons to recruit members of their social network, resulting in multiple waves of participants. Participants were instructed to give a coupon to eligible peers who were interested in participating and to inform the recruit to call the study coordinator for coupon verification, eligibility screening, verbal consent procedures, and scheduling of an interview. The survey interview was administered at the project office, by either a young gay man or a queer woman interviewer, depending on the preference of the participant. Participants were compensated $40 for completing the interview, as well as for each recruit ($10) (up to 3) who enrolled in the study. Participants received cash incentives at the time of the interview. The referring person was contacted when one of their recruits was enrolled so they could come in and receive their incentive. Participants gave out coupons that had a code on the coupon, so when a new recruit came in with the coupon, we could link back to the referring person.

The survey was administered in English or Arabic, depending on the preference of the participant, with computer-assisted interview software. The survey was developed in English and translated into Arabic using standard translation and back translation methods. Participants were given the option of completing the survey on their own or having the interviewer administer the survey; however, only 7% of participants chose to self-administer the survey.

Item Development

Our prior research showed that many young gay men and their friends want to help each other stay safe from HIV [7]. Young gay men may feel comfortable discussing certain sexual topics with friends, but uncomfortable with other topics. Barriers to sexual health dialogue may undermine or completely obstruct friends’ efforts to support safer sex behaviors. By contrast, other factors, such as humor or expressions of support, may ease the flow of communication and thus also facilitate the transfer of social norms. Barriers and facilitators determine the richness and extent of communication and may therefore form an important link in the chain of influences on sexual risk behavior. One important barrier may be judgmentalism, a construct that emerged in the course of Mutchler and McDavitt’s earlier studies [7, 8]. We define judgmentalism as an attitude involving moralistic devaluation of others based on a perceived behavior. In judgmentalism, much line in shaming, a behavior seen as “immoral” is taken as the defining characteristic of a whole person, who is then discredited. Thus, we conceptualize judgmentalism as a specific form of stigma that occurs in interpersonal contexts. Judgmentalism could become a barrier to dialogue if individuals who feel judged break off communication as a result. Although no research that we are aware of has measured judgmentalism per se within sexual communication, studies have explored how individuals respond to being devalued based on perceived behaviors or identities, sometimes finding that this can lead to breaking off relationships or communication. One strategy sometimes utilized by gay and bisexual young men to protect themselves from heterosexist attitudes consists of avoiding contact with prejudiced individuals or groups [17, 24].

In our previous work [7, 8], we also found that young gay men and their friends often spoke about the importance of reinforcing health-oriented peer norms, such as reminding each other to use condoms. However, their tone was often judgmental, particularly within sexual communication that focused on risky behavior, implying that people who engaged in those behaviors (not using condoms or having many sexual partners) were shameful, reckless, “stupid,” or “gross.” They sometimes used terms like “slut” or “whore” for a young gay man who had engaged in risky sex or had multiple sex partners. We found that judgmental communication with peers about sex frequently impinged on communication about sex, sometimes shutting down conversations completely when one person felt judged by the other.

Because of the salience of judgmental peer communication in our studies with young gay men in the United States [7, 8], we developed items to measure this critical construct (see Appendix) and to capture the nuances of judgmental peer communication. The judgmental communication with peers about sex (JCPS) scale measures the extent to which young gay men perceive themselves or their peers to be judgmental in communication about sexual topics such as condom use and multiple sexual partners. The measure also includes an item that captures whether participants feel that judgmental communication is conveyed even in a joking manner. Following standard procedures for scale development [25], the development of the JCPS scale was informed by our preliminary studies, the literature, and similar constructs used in other contexts.

We drafted original items to reflect the construct of judgmental peer communication about sex that emerged in our previous studies [7, 8]. Using cognitive interviews [26], we validated the scale for face validity with young gay men and their peers in our pilot study (N = 10) of a larger study of young Black gay men and their friends in Birmingham, Alabama (N = 48) and in Los Angeles, California (N = 48). Two senior scientists [Mutchler and McDavitt] developed and refined the scale items. The measure was then used in this study with our sample of YMSM in Beirut, Lebanon in order to explore the psychometric properties of the scale as presented in this paper.

Measures

Socio-demographic Characteristics

The measures for socio-demographic characteristics consisted of age, education level, employment, monthly income, religious affiliation, country of birth, legal status as a resident of Lebanon, sexual orientation, and relationship status. For analysis, response categories were combined to create binary indicators for measures of education (at least some university education), monthly income (< $1000 USD; note that U.S. dollars is a regular currency in Lebanon), and sexual orientation (self-identify as gay).

Judgmental Communication with Peers About Sex

With the JCPS scale developed as described above, respondents were asked about their experiences and communications that they have with their friends and others regarding sexual health behaviors. They were asked to rate how often (Never, rarely, often, always) they have expressed or felt judgmental attitudes with/by their peers when communicating about sexual behavior [e.g. “I have called a friend ‘stupid’ or ‘dumb’ for having sex without a condom (even as a joke)”; “If I had sex without a condom, a friend would judge me fore it”]. The mean item score was calculated; higher scores represent greater judgmentalism (please see Appendix A for all 11 items).

Sexuality-Based Discrimination

Discrimination was measured with the subscale of the Multiple Discriminations Scale [27] that asks the respondent to indicate whether or not they experienced any of five types of discriminatory events (e.g., insulted or made fun of; denied or lost a job; physically assaulted) in the past year as a result of others thinking the respondent was gay or bisexual; the sum of types of discrimination experienced was used in analyses.

General Social Support

Three items from the Social Relationship Scale [20] were used to measure general social support; respondents were asked about access to someone for emotional (to talk to about personal problems), caregiver (when sick or unable to care for self), and tangible (e.g., money, transport) support. Response options range from 1 ‘definitely not’ to 5 ‘definitely yes’, with a mean item calculated and higher scores representing greater support.

Gay Community Integration

This construct was measured with 4 items developed by our study team that assessed the proportion of social time spent with YMSM (from 0 ‘none at all’ to 4 ‘all of the time’), degree of being open about one’s sexuality in one’s personal life and at work or school (from 0 ‘not at all’ to 4 ‘completely’, in separate items), and frequency of spending time at predominantly gay venues such as bars and coffee houses (from 0 ‘never’ to 4 ‘several times a week’); the mean item score was calculated and used in analyses.

Feeling Part of a Gay Community

Respondents were asked to rate the degree to which they “feel part of the gay community,” using a response scale of 0 ‘not at all’ to 4 ‘A lot’.

Social Network Characteristics

Participants were asked to list 20 individuals (or “alters”) who are also YMSM and with whom they have often been in communication in the past 6 months (by phone, email, in person, etc.), starting with those most important to them. These individuals could include kin (immediate and extended family), friends, people they work with, neighbors, or others in the community. The respondent was asked to describe several characteristics of each alter, including whether the alter “can be counted on for providing support when needed” and is perceived to “use condoms mostly or always during sex”. For this analysis, we included the percentage of alters whom the respondent feels are supportive, and who use condoms mostly or always.

Peer Communication Regarding HIV Prevention

Using an 8-item scale developed by Kegeles et al. [14], respondents were asked to report how many times in the last 60 days that they and their MSM friends had talked about or encouraged each other to engage in HIV protective behaviors (e.g., how to negotiate condom use, shared experiences of having used condoms, HIV testing) or given each other condoms to use or safe sex literature. The mean item score was calculated.

Peer Sexual Health Norms

This was measured using items adapted from a scale on peer sexual norms [28]. Nine questions assessed the respondent’s perception of their MSM friends’ sexual health behaviors (e.g., use of condoms during anal sex with new and regular partners, getting HIV-tested, discussing STIs with new and regular partners); for each item the respondent rated their level of agreement with the statement on a scale of 1 ‘strongly agree’ to 5 ‘strongly disagree’, mean item score was calculated (after reverse coding some items), and higher scores represent a perception of healthier sex behavior being more normative among MSM peers.

Data Analysis

For cross-validation purposes, the dataset (N = 226) was randomly split into a training set (N = 116) and test set (N = 110). Items were allowed to load freely on factors, and several exploratory factor analysis (EFA) models were fit to the training data. Models were compared using proportion of variance accounted for, individual residual correlations and their root mean square, loading patters (after Promax rotation), and communalities. The test set was used for the confirmatory factor analysis. For all the remaining analyses, the full sample (N = 226) was used. All of the analyses were conducted on Stata 13.

Results

Sample Characteristics

A sample of 226 YMSM enrolled in the study. Table 1 lists the socio-demographic and background characteristics of the sample, as well as characteristics related to judgmentalism, and constructs examined in relationship to judgmental peer communication in our analysis. Two-thirds (60.2%) were under age 25, nearly a half (45.6%) were attending university, and a quarter (24.6%) were in a committed relationship; 74.8% were born in Lebanon and held Lebanese citizenship.

Table 1.

Demographic and key characteristics of the sample (N = 226)

	Mean (SD)/%
Socio-demographics
Age between 18 and 24 years	60.2%
Education
Did not complete high school	4.9%
Completed high school	9.7%
Attended some university	50.0%
University degree	35.4%
Currently attending university	45.6%
Religious affiliation
Christian	24.0%
Muslim	38.0%
Other	28.1%
Atheist	10.0%
Monthly income < $1000 USD	70.3%
In a committed relationship	24.6%
Legal residency status in Lebanon	86.3%
Self-identify as gay	81.9%
Judgmental peer communication about sex
Never = 1, Rarely = 2, Often = 3, Always = 4	1.98 (.605)
Constructs tested for validity
Gay related discrimination	1.70 (1.65)
General social support	4.34 (.96)
Gay social integration	2.30 (.84)
Feeling part of a gay community	1.91 (.96)
Alters who are supportive	.35 (.23)
Alters who mostly/always use condoms	.37 (.39)

Factor Structure

The iterative factor analysis process yielded a one-factor model with acceptable fit to the training data, which was then fit to the test data for cross-validation. The final loadings (≥ 0.30) and scale compositions of the one-factor model are presented in Table 2. Goodness-of-fit indices were used to determine model fit [29]. The comparative fit index (CFI) can range from 0.0 to 1.0, with values closer to 1.0 indicating a better model fit, while values less than 0.08 for the standardized root mean square residual (SRMD) and the root mean square residual (RMSEA) indicate a good model fit. These indicators supported the one-factor model as the best fit to the data (chi square = 50.12, df = 39, p = 0.109; CFI = 0.956, TLI = 0.938, SRMD = 0.064, and RMSEA = 0.052). The one-factor model revealed a single large primary factor, with an eigenvalue equal to 2.44; this factor explained 77% of the common variance. The mean (standard deviation) score for the final measure is 1.978 (0.061).

Table 2.

Factor loadings and final scale for 11 items measuring judgmental peer communication (N = 116)

	Items	Factor loadings
1	I have called a friend “stupid” or “dumb” for having sex without a condom (even as a joke)	0.494
2	I sometimes leave out details of my sexual experiences when talking with a friend because they might judge me	0.408
3	A friend has called me “slut” or “whore” for having sex without a condom (even as a joke)	0.357
4	If I had sex without a condom a friend would judge me for it	0.493
5	A friend has called me “stupid” or “dumb” for having sex without a condom (even as a joke)	0.385
6	Some friends leave out some details of their sexual experiences because they think I might judge them	0.361
7	I have called a friend “slut” or “whore” for having sex without a condom (even as a joke)	0.484
8	If a friend had sex without a condom, I would judge him/her for it (even as a joke)	0.675
9	If I tested positive for HIV, some friends would gossip about me	0.489
10	I have felt judged by my friends for the number of sexual partners that I have	0.554
11	I have judged my friends for the number of sexual partners they have	0.388
	Coefficient alpha	0.762

^*Questions explored experiences and communications participants had with their friends and others regarding sexual health behaviors. The choices were “Never”, “Rarely”, “Often”, and “Always”

Internal Reliability

Cronbach’s alpha for the 11-item measure was 0.76, which reflects high internal consistency [30].

Construct Validity

We tested the judgmental communication with peers about sex (JCPS) scale for divergent and convergent validity with related constructs measured in the survey. To provide evidence of divergent construct validity, we examined the correlation between judgmentalism and measures of social support, specifically general social support and percentage of MSM peers who are perceived to be supportive. With judgmentalism in peer communication about sex viewed as a form of shaming or not being supportive, we expected that judgmentalism would be negatively correlated with these measures of social support. As expected, the social relationship scale measuring general social support was negatively correlated with our JCPS scale (r = − 0.14, p = 0.038), as was the percentage of alters perceived to be supportive (r = − 0.174; p = 0.022). With many of the JCPS items relating to how judgment is conveyed in the context of engagement in risky sexual behavior (on the part of the either the respondent or their friends), we also expected that judgmentalism would be negatively correlated with the percentage of MSM peers who are perceived to mostly/always use condoms during sex, and in fact, this was borne out in our data (r = − 0.180, p = 0.018).

We theorized that experiencing gay-related discrimination may increase shame and perceptions of stigma about being gay and therefore increase perceptions of judgmentalism in communication. In support of this hypothesis, we found that the gay-related discrimination scale was positively correlated with our scale (r = 0.253, p = 0.000). Since becoming more integrated into the gay community may increase opportunities for communication with peers and conversations with peers about HIV prevention, we expected that the JCPS scale would be positively correlated with this construct. In support of this hypothesis, the judgmentalism scale was positively correlated with the respondent feeling part of the gay community (r = 0.211, p = 0.002) and gay social integration (r = 0.18, p = 0.007). We expected the judgmentalism scale to be negatively correlated with peer support for sexual health, social norms about sexual health practices, and peer communication about HIV prevention; it was marginally related to peer communication about HIV prevention (r = 0.133, p = 0.057), but unrelated to peer support for sexual health and social norms about sexual health practices.

Discussion

This article describes our analysis of the psychometric properties of the Judgmental Communication with Peers about Sex (JCPS) scale, consisting of original items developed to assess judgmental communication about sex between young gay men and their friends in a variety of contexts (Birmingham, Alabama and Los Angeles, CA, U.S.; and Beirut, Lebanon). Our findings suggest that the scale is unidimensional in its assessment of judgmentalism in peer communication about sex, and that the scale has high internal consistency. We also found evidence to support the construct validity of the measure. As expected, the measure was negatively correlated with social support measures, and positively correlated with measures of gay-related discrimination and integration into the gay community.

The factor structure of the JCPS scale revealed that all items were correlated and loaded on a single factor, even though some items focused on judgmental comments from friends, while others inquired about judgmental comments by the respondent. One possible reason for these not being differentiated is related to the concept of stigma sensitivity [31]. Individuals with strong internalized stigma may assume that friends are motivated by judgmentalism when their friends’ comments are in fact neutral—a projection of internalized stigma. The single factor structure of the scale implies that the scale represents a single construct, and that a single index (i.e., mean item score) can be used in analysis to examine levels of judgmentalism and the relationship of judgmentalism to other constructs.

The JCPS scale correlated negatively with both social support in general and the percentage of alters who were supportive. This was consistent with our expectation that friends’ supportiveness would be undermined by judgmental attitudes toward each other. Similarly, the percentage of alters who are viewed as supportive was expected to be lower among those who adopt a judgmental attitude and perceive their friends as judgmental. The JCPS scale also correlated negatively with the percentage of alters who were perceived to engage in safer sex. This fit our expectation that respondents who adopt a judgmental attitude toward friends would be likelier to assume their friends are not having safer sex.

Although we expected the JCPS scale to be negatively correlated with peer communication about HIV prevention, we found that it was marginally positively correlated with this scale. Those MSM who are judgmental of their peers for their risky sexual behavior may also be particularly concerned/vigilant about preventing HIV to safeguard against additional judgmentalism (internalize and externally experienced). This may be because some young gay men who communicate about or advocate for safer sex do so in judgmental ways. Although we anticipated that the JCPS scale would be negatively correlated with the peer sexual health norms scale, it was not. This may be because the JCPS scale measures a type of communication, which may be independent from the actual content (social norms) conveyed in sexual health communication.

The JCPS scale was positively correlated with measures of how much young gay men felt part of a community, integration into the gay community specifically, and gay-related discrimination. As described below, this finding is consistent with the literature insofar as greater integration into the gay community may provide greater opportunities for sex, condomless sex, and communication about sex including judgmental communication about sex [3, 8]. Since judgmental communication may be a vehicle for stigma, internalized stigma, and discrimination, we were not surprised to find that our scale was also positively correlated with our measure of gay-related discrimination.

The JCPS scale measures a critical communication pattern—one that could be addressed in interventions to reduce judgmental communication. This is important because we know that perceived judgmental communication can disrupt or completely obstruct conversations about sex that may not be happening anywhere else. Importantly, such disruption could occur even if a friend is not even intending to be judgmental and believes they are being fully supportive. They may be unaware of the judgmental implications of their communication, or they may be perceived as judgmental if their friend is prone to view the other as motivated by judgmentalism, regardless of whether that is actually the case. Therefore, interventions to address judgmental communication may need to have a dyadic structure, addressing both the perceived judgmental party and the perceived judged party.

Breakdowns of dialogue could occur even when an individual intended to reinforce safer sex norms. In cases such as these, obstructing communication appeared to be a self-protective strategy for the friend who felt judged, consistent with findings that sexual minority adolescents may avoid situations in which they are likely to be stigmatized based on their sexuality [17]. Notably, friends’ judgmental attitudes may not result in the complete severing of their relationships. Instead, participants in a recent study of young gay men and friendship communication reported that they tended to simply avoid those topics of conversation that might expose them to judgmental communication responses [8]. However, judgmental communication about sexual risk may lead to avoiding the topic of sexual risk, which can in turn reduce opportunities for friends to explore the reasons why unprotected sex occurs and obstruct sharing of valuable information about and support for sexual health.

Limitations

There are limitations to this study. First, this analysis was conducted within a specific cultural context (i.e., Beirut, Lebanon). Although the measure was developed in another context (two regions within the United States of America), it will be useful to replicate our findings regarding the scale’s psychometric properties in other cultural contexts. Also, the psychometric analysis was limited by the use of particular scales in the larger study. Therefore, expanding the analyses to include other relevant scales such as comfort with sexual communication, measures of judgmental attitudes or social anxiety, may be useful. Another limitation of our data is the representativeness of our sample. While long-chain peer referral recruitment is designed to penetrate all segments of a population, our sample lacked in representation of men who were less educated and not self-identified as gay; however, our sample had good diversity in terms of being well balanced on religious affiliation, and the inclusion of refugees as well as Lebanese citizens.

In our prior research we found that judgmental communication can also subvert stigma, paradoxically, by being playful and campy [8]. Judgmentalism was often mixed with humor, as friends gently teased each other about sexual behavior or risk. In addition, words like “slut” could be used in campy ways to foster sexual freedom and transgression of conventional gender roles. The JCPS scale fuses two aspects of communication: judgmental criticism together with playfulness, by allowing for judgmental communication that is playful to be endorsed in the same items. It seems likely that it would be rare for communication that is judgmental to be done in an explicitly hostile or contemptuous manner between friends. More frequently, it is likely to be a combination of judgmental implications together with a playful tone. Therefore, it may be challenging to disentangle these two elements of communication that are likely to occur simultaneously in most cases. It may be useful to elaborate on the JCPS in order to capture these nuances of communication (the mixing of playful versus judgmental communication about sex) in future research.

Conclusion

In conclusion, we found that the JCPS has high internal consistency and evidence for construct validity in our study with young gay men in Lebanon. The findings reflect a reliable, valid measure of a construct that can be used to assess sexual health communication between peers and used in both observational and intervention research. The JCPS may also be adapted for use with other populations who may be engaging in sexual communication. Additionally, the JCPS may be a useful tool in studies seeking to capture how social influence between peers (in the form of communication) may be affected by judgmentalism. Finally, the JCPS may be used to help gather data that can be used to address shame and judgementalism in programs seeking to foster sexual communication skills and sexual health.

Appendix A

Judgmental peer communication about sex scale items (response scale: never, rarely, often, always, refused to answer):

	Items
1	I have called a friend “stupid” or “dumb” for having sex without a condom (even as a joke)
2	I sometimes leave out details of my sexual experiences when talking with a friend because they might judge me
3	A friend has called me “slut” or “whore” for having sex without a condom (even as a joke)
4	If I had sex without a condom a friend would judge me for it
5	A friend has called me “stupid” or “dumb” for having sex without a condom (even as a joke)
6	Some friends leave out some details of their sexual experiences because they think I might judge them
7	I have called a friend “slut” or “whore” for having sex without a condom (even as a joke)
8	If a friend had sex without a condom, I would judge him/her for it (even as a joke)
9	If I tested positive for HIV, some friends would gossip about me
10	I have felt judged by my friends for the number of sexual partners that I have
11	I have judged my friends for the number of sexual partners they have