RESEARCH AND PRACTICE

“I AlwaysFelt I HadtoProveMyManhood”:Homosexuality, Masculinity, Gender Role Strain, and HIV Risk Among Young Black Men Who Have Sex With Men Errol Lamont Fields, MD, PhD, MPH, Laura M. Bogart, PhD, Katherine C. Smith, PhD, David J. Malebranche, MD, MPH, Jonathan Ellen, MD, and Mark A. Schuster, MD, PhD

Black men who have sex with men (MSM) aged 13 to 24 years have a higher HIV incidence rate than other racial subgroups, a rate that increased by 49% between 2007 and 2010.1,2 Research indicates that this disparity is not explained by differences in rates of sexual risk behaviors between MSM subgroups.3 However, the cultural context of sexual behavior has been identified as an important predictor of risk.4,5 Understanding the culturally relevant contextual factors influencing sexual behavior among Black MSM may help identify processes that increase their HIV risk and disparities. Conceptions of gender and masculinity are examples of cultural factors found to be associated with sexual behavior among heterosexual men6,7 and MSM.4,5,8 Many overlapping conceptions and definitions of masculinity exist.9 We focused on the conception of masculinity described as a social construct involving the negotiation of power and authority, in which socially dominant men who adhere to gender role norms subordinate other men, women, and femininity.9 Masculinities of male subgroups who are not members of the socially dominant group, such as Black men and gay men, have often been described as compensatory masculinities,9---14 developed in reaction to blocked access to the power and authority of the dominant group. Stereotypical Black male gender roles of hypermasculinity (i.e., exaggeration of traditional masculine roles through behaviors such as sexual prowess, physical dominance, aggression, and antifemininity) have been described as a way for men disempowered by racial oppression to demonstrate power and authority.10---15 Similarly, some have argued that hypermasculinity has become the valued and preferred gender culture among gay men in response to subordination by a dominant heterosexual male culture.16---18 Several studies of gay men have identified

Objectives. We explored gender role strain (GRS) arising from conflict between homosexuality and cultural conceptions of masculinity among young Black men who have sex with men (MSM). Methods. We conducted a categorical analysis (a qualitative, 3-stage, iterative analysis) of data from studies conducted in 2001 to 2006, which interviewed 35 men aged 18 to 24 years in 3 New York cities and Atlanta, Georgia. Results. Participants described rigid, often antihomosexual expectations of masculinity from their families, peers, and communities. Consistent with GRS, this conflict and pressure to conform to these expectations despite their homosexuality led to psychological distress, efforts to camouflage their homosexuality, and strategies to prove their masculinity. Participants believed this conflict and the associated experience of GRS might increase HIV risk through social isolation, poor self-esteem, reduced access to HIV prevention messages, and limited parental–family involvement in sexuality development and early sexual decision-making. Conclusions. Antihomosexual expectations of masculinity isolate young Black MSM during a developmental stage when interpersonal attachments are critical. GRS may influence sexual risk behavior and HIV risk and be an important target for HIV prevention. (Am J Public Health. 2015;105:122–131. doi:10.2105/ AJPH.2013.301866)

definitions of masculinity derived from exaggerated traditional masculine roles and stereotypical behaviors.19---21 Expressions of hypermasculinity and antifemininity among young Black men and gay men have been associated with increased confidence and esteem, social acceptance, and reduced anxiety about manhood.15,18,22,23 However, holding traditional masculine gender role beliefs is associated with psychological distress, sexual risk, and other health risk behaviors among both MSM24,25 and Black heterosexual men.26---30 Other negative effects associated with masculine expression are known collectively as gender role strain (GRS). GRS encompasses psychological distress associated with failing to meet masculine ideals (discrepancy strain), difficulty enacting and maintaining normative masculine expression (dysfunction strain), and negative experience with the

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masculine socialization process (trauma strain; box on the next page).31 GRS has been associated with negative health outcomes, including sexual risk behavior and depression.32---34 Limited research addresses GRS among young Black MSM,10---14 for whom GRS may be especially formidable because of their position as both sexual and racial minorities. Further, young Black MSM, as emerging adults, face additional challenges in identity development and may feel more compelled than older counterparts to meet gender expectations as they seek affirmation from important social reference groups.35---38 GRS for young Black MSM may have important implications for sexual risk and other health-related behaviors. Qualitative inquiry allows for in-depth examination of previously unexplored, complex psychosocial factors,39 which is particularly useful in

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RESEARCH AND PRACTICE

Components of Gender Role Strain Discrepancy strain

Psychological strain that results when one fails to meet external or internalized masculine expectations or manhood ideals.

Dysfunction strain

Psychological strain or other negative consequences that result from maintaining normative masculine expectations. Although

Trauma strain

Psychological strain resulting from experiencing the masculine socialization process, particularly during childhood, adolescence, and early adulthood.

these expectations or male characteristics may be viewed as desirable, they can have negative side effects on the men themselves and those close to them.

characterizing GRS in young Black MSM, who are positioned at the confluence of gender, race, sexuality, and adolescent development. Therefore, we qualitatively explored (1) family, peer, community, and racial expectations of masculinity perceived by young Black MSM; (2) GRS associated with these expectations; and (3) influences on HIV risk behavior.

METHODS We performed a secondary analysis of semistructured interviews conducted by Black MSM interviewers with Black MSM aged 18 to 24 years from previous studies in Buffalo and Rochester, New York, and New York City in 2001 (n = 17) and in Atlanta, Georgia, in 2003 (n = 8) and 2006 (n = 10; Table 1). Interviews were audiorecorded and transcribed. Participants provided informed consent and received $25 and transportation reimbursement. Additional design details appear elsewhere.40 Interview protocols were informed by previous research.9,13---15,22,41 Although they differed across studies, all covered masculinity, sexual identity, homosexuality, sexual risk, masculine socialization, the social context of sexual risk, family, race, and religion (Table 2). We used Atlas.ti version 5.2, qualitative analytic software for categorical analysis, which involves fracturing transcripts into discrete segments and sorting the segments into categories.42 This approach allowed comparisons across participants. We used a 3-stage analytic strategy with open and axial coding, followed by selective coding.43---45 In our initial analysis, we employed codes related to contextual factors identified through open coding and data immersion. Through axial coding, we developed a 3-tiered coding hierarchy to reflect relationships between codes. We created a final

codebook with codes organized according to the hierarchy developed through axial coding. During final coding, a second rater doublecoded 20% of the transcripts, and we achieved excellent consistency between coders, as illustrated by our j scores for masculinity (0.86), homosexual conflict (1.00), identity (0.83), social norms and expectations (0.75), and HIV risk (0.86).46,47 For selective coding, we used storytelling memos to develop a theoretical framework.44 We constructed the memos as part of the 2 previous coding stages; they contained emerging research questions, speculations about variations in responses to or in expression of phenomena, comparisons to theory, recurring themes, and possible relationships among major categories.

and 2). Participants’ definitions also included descriptions of hypermasculine behaviors and attitudes, such as challenging authority, heterosexual hypersexuality, and toughness (Quote 3). Participants perceived that family, peers, community members, and the larger Black social and cultural community expected them to be hypermasculine and to avoid effeminate behavior. For instance, many participants consistently heard that being a man meant pursuing women sexually and being physically strong and aggressive (Quotes 4---6). As Adam related, prescriptive messages about being tough were coupled with proscriptive messages about avoiding effeminate behavior (Quote 7). Perceived effeminacy was met with ridicule. Michael described repeated verbal attacks from his father and peers because of his effeminate behavior (Quote 8).

RESULTS Discrepancy Strain The primary emergent theme was conflict between participants’ homosexuality and their perceptions of family, peer, and community--societal gender role expectations that contributed to GRS. We classified participants’ descriptions of psychological distress and negative consequences of this conflict by type of strain (trauma, discrepancy, dysfunction). We used participants’ descriptions of their own behaviors or perceived behaviors of others to assess the influence of GRS on HIV risk. Direct quotations are shown in the box on page 126; we used pseudonyms for participants.

Trauma Strain Trauma GRS refers to the psychological distress associated with masculine socialization. Participants described growing up with antihomosexual masculine norms and being ridiculed when they did not conform to these norms. When asked what it means to be masculine, the response was often “not feminine” (Quotes 1

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Discrepancy GRS refers to the psychological distress one experiences when unable to meet internalized or external gender role expectations. Among our interviewees, the conflict between homosexuality and expectations of masculinity contributed to this distress. This conflict was illustrated by Eric’s description of the perceived discordance between homosexuality and the rigidly prescribed male role in the Caribbean community (Quote 9). Jordan echoed these comments (Quote 10). For both, masculinity represented an ideal embodiment of strength they were expected to achieve. They felt that important people in their lives saw homosexuality as a threat to masculinity and the Black male gender role because it was associated with being weak and effeminate. As described by Jonathan, these characteristics not only conflicted with gender role expectations, but defiled one’s manhood such that a homosexual was “not even considered a man” and was “lower than the females” (Quote 11).

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TABLE 1—Demographic Characteristics of Participants in Study of Gender Role Strain Among Young Black Men Who Have Sex With Men: New York and Georgia, 2001–2006 Characteristic

No. (%)

City of interview/current residence New York Citya Rochester, NY

8 (23) 4 (11)

Buffalo, NY

5 (14)

Atlanta, GA

18 (51)

Race/ethnicityb Black American

16 (84)

Caribbean

1 (5)

African

1 (5)

Sexual identityc Gay/homosexual Bisexual

Dysfunction Strain 17 (49) 16 (46)

Heterosexual/straight

1 (3)

Other

5 (14)

HIV serostatus Positive

2 (6)

Negative

30 (86)

Unknown Income, $ < 15 000

3 (9) 15 (43)

> 15 000–20 000

5 (14)

> 20 000–30 000

3 (9)

> 30 000–45 000

2 (6)

> 45 000–60 000

0 (0)

> 60 000

1 (3)

No answer Education

9 (30)

Some high school

The discrepancy strain from this conflict emerged because losing one’s standing as a man also threatened social positions and relationships within families, peer groups, and communities. Eric’s beliefs about how his church community would react to him if he disclosed his sexuality illustrated this point (Quote 12). Participants also described psychosocial distress from the internalization of antihomosexual constructs of masculinity. For these young men, discrepancy strain was related to a failure both to conform to external norms of masculinity and to meet internal expectations of masculinity. As Christopher said, “I still don’t like the man that I am. . . . I want to make the masculine part of me more masculine.”

4 (11)

High school diploma/GED

13 (37)

Some college

13 (37)

College degree

3 (9)

Graduate degree

1 (3)

No answer

1 (3)

Employment status Employed

18 (51)

Unemployed

17 (49)

Note. GED = general equivalency diploma. Sample size was n = 35. a Studies conducted in Manhattan and Brooklyn. b Race and ethnicity data were not collected in the Atlanta studies. c Percentages do not add to 100% because some participants used more than 1 term to describe their sexual orientation in the New York study. Homosexual and gay were listed separately on the questionnaire because of stigma associated with gay identity.

Dysfunction strain refers to the negative effects associated with conforming to masculine expectations. It often refers to consequences of hypermasculine behavior but can also refer to psychological strain from the vigilance required to conform to masculine norms. Many participants felt compelled to conform to the antihomosexual constructs of masculinity by camouflaging their homosexuality or engaging in behaviors they believed would prove their masculinity. This was an important way of fitting in and was accomplished through avoiding femininity or presenting a hypermasculine public image. Dysfunction strain was apparent in participants’ descriptions of behaviors that were meant to prove their masculinity but that also put them at risk for harm (e.g., violence, substance use). For example, Anthony felt he needed to prove his masculinity to people who knew he was gay by putting “all that gay shit aside” and proving his masculinity through fighting (Quote 13). Similarly, Shawn as a boy had thought of himself as a “sissy,” but was now assured of his masculinity after becoming sexually experienced with girls and gaining the ability to fight back so that “nobody don’t mess with me.” Shawn and others similarly described maintaining the “mentality of being a man” by engaging in other delinquent behaviors like “chillin’ with your boys, smoking weed, and drinking.” Others described persistent efforts to camouflage their homosexuality by choosing sexual identity labels that belied or minimized samesex behavior (Quote 14), restricting same-sex

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behavior to “masculine” behaviors (Quotes 15---16), avoiding association with effeminate men (Quotes 17---18), and avoiding femininity in dress, speech, and demeanor (Quote 19). Dysfunction strain was also apparent in descriptions of the vigilance and stress many endured in efforts to maintain masculine camouflage. Although participants described many efforts as successful, they were associated with a constant threat of being “clocked” (i.e., having their homosexuality discovered). This threat was significant and salient for these young men because their social connections and interpersonal relationships with family members and peers were at stake. Many narratives referred to the importance of maintaining a public image of masculinity, to avoid social isolation and alienation. For instance, Michael described a need to use masculinity as “camouflage” (Quote 20). He believed he had become more masculine “through effort” but commented that he continued to “be more careful with the way I talk and things that I do.” Stacey, referring to fear of family rejection, described the need to “act straight” (Quote 21). Similarly, Eric feared that being open about his sexuality would make his family, friends, and church community “want to step back and keep [me] at an arm’s distance” (Quote 22). Shawn felt that “if you really don’t have your manhood, then you’re lost”; he described the ridicule and possible insults to self-esteem a person might suffer if he didn’t present a masculine image (Quote 23).

Race Although most participants described expectations from interpersonal interactions with peers and family as the source of their gender role strain, many also described cultural expectations specific to them as Black men as an additional source of strain. Two themes emerged that characterized participants’ perception of these race-specific expectations. Participants described a specific disdain for homosexuality among Blacks arising from perceptions that homosexuality conflicted with Black cultural expectations of masculinity (Quotes 10, 24, and 25). This disdain was a source of strain for many because it threatened their group membership (Quote 26) in a manner that participants felt White gay men were less likely to experience (Quote 27).

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growing up?

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How has being a Black man influenced your sexual identity?

Are you a part of the Black community?

What does risky sex mean to you?

with multiple partners?

unprotected sex (especially anal sex) or have unprotected sex

without a condom.

Tell me about a situation when you had anal sex with another man

What’s more important to you—your race or sexuality? Why?

What issues arise from being both Black and attracted to men?

What are the reasons that you or people you know have

What does it mean to you to be a Black man?

Are Black MSM different from other MSM?

Note. MSM = men who have sex with men. a Study conducted in Buffalo, Rochester, and New York City.

Sexual risk behavior

Race

What are your religious/spiritual influences?

Do the views of the church affect how you see yourself?

more or less at risk for HIV?

What qualities of a potential sexual partner make you feel they are

past 6 mo?

know about “risky” sex, what has your risk for HIV been in the

What is your definition of “risky” sexual behavior? With what you

men of other races/cultures? Are there different communities/ lifestyles?

What makes being Black and attracted to other men different from

What is the Black community to you?

in America, what would you tell him?

If you had to explain to your son what it meant to be a Black man

growing up?

your relationship with your family like? What is spirituality (or being spiritual) to you? Religious influences

family’s expectations of you? Tell me what it was like growing up as a young Black man.

Where does the Black church fit in?

Religion

Where did you grow up? What was your childhood like? What is

are you?

What is the “gay” community to you? “Gay” lifestyle? How involved

What does it mean to you to “come out”? Your experience?

What word(s) do you use to describe your sexual identity?

What family and community messages about homosexuality did you receive growing up?

sexual partners?

How big a role does masculinity play with potential romantic and

Do you consider yourself masculine? Why or why not?

What does it mean to be masculine? What life experiences told you this?

What do you think it means to be a man?

2006 Atlanta, GA, Study

What’s your relationship with father? Mother? What are your

Where do you find strength or support? Family? Friends?

Family

How did your upbringing influence your sexual identity?

How involved are you with the “gay” community?

How open are you and people you know about their attraction

to men?

How would you describe your sexual identity to a stranger?

How do you identify yourself sexually?

Sexual identity

Tell me what it was like growing up as a young Black man. Discussions on sex/sexuality in general? Homosexuality?

partners?

self-esteem? Effect on sexual behavior? Effect on choice of

Do you consider yourself masculine? Why or why not? Effect on

What are your attitudes about sex between men? Your family’s attitude? Attitudes of the Black community?

behavior (partner selection? sex roles?)?

How do definitions/expectations of masculinity affect sexual

different for White men?

How does the Black community define masculinity? Is masculinity

Tell me what it was like growing up as a young black man. What are your family’s definitions of masculinity? Familial expectations of you? Importance of your masculinity/sexuality

What are your family’s expectations of masculinity for you?

2003 Atlanta, GA, Study

What does masculinity mean to you?

2001 New York Statea Study

Homosexuality

Masculinity

Concept

TABLE 2—Sample Interview Questions in Study of Gender Role Strain Among Young Black Men Who Have Sex With Men: New York and Georgia, 2001–2006

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(12)

(11)

(10)

and Male Gender Role Expectations (9)

Discrepancy GRS: Conflict Between Homosexuality

(8)

(7)

(6)

(4) (5)

would think I would be unfit to take on positive responsibilities. Little things are important to me. In fact that’s what I am. Continued

would have a major impact on me. . . . I sing at church, I dance at church, I instruct at church, I work with kids at church and all that would be taken away for the fact that they

Eric: I like what I do in church. I like my position and I like my responsibilities and everything and to get kicked out, that means that I won’t be able to do that stuff anymore. That

considered a faggot. Lower than the females. A female can beat a faggot’s ass.

Jonathan: With the guys—it’s so I’m tough, I’m this, I’m that, I’m not a faggot, I’m not this, I’m not that. That’s a real disrespect to be called a faggot or something ‘cause a gay guy/ faggot is not considered tough or can stand his own ground. He considered more of a girly girl, less of a man almost to the point where he’s not even considered a man—just

thinks you can’t do all those things that they need you to do being a Black man if your gay. Um, I don’t think that’s true. But I think that’s kind of their belief.

Jordan: The Black man has a lot of responsibility, and a lot is placed on him being strong, and supporting his family and doing this and doing that, and I believe the Black community

things like dancing and stuff like that; they are like finicky about it.

Eric: You are the man, you are the provider, you are the one to, you know, get married, have kids, work and take care of them. You can’t engage in any feminine things. You know even

Researcher: What is it that they stand for?

could possibly ever do because you have just like defied everything, everything that we stand for.

Eric: You are supposed to be a man. You are supposed to be the one that can’t do this and you can’t do that and so I guess that this is like oh my God, this is the biggest sin that you

Michael: It took effort. It took effort.

Researcher: Did you make an effort to become more masculine or did it just happen?

bad. As I got older it got better; I became more masculine as I got older.

Michael: I was called faggot. I was just attacked occasionally. Verbally more than physically. At school, too, for a long time. Even up in high school, but I mean it wasn’t, it wasn’t as

Researcher: Umm, did your father ever take issue with your being feminine when you were younger?

Michael: When I was younger, he [his father] was never really . . . he used to hang out a lot, so I was with my mother and my aunt and their friends, so I picked up things from them—mannerisms, the way they talk, so when I was younger I was real feminine.

the street. He wanted me to be something that he could be proud of.

were a lot of things my dad didn’t want to see me do. He wanted to see me more playing football, doing boxing, playing basketball. He wanted to see me go beat up some kids on

Adam: My father, he had always tried to give me basic prime examples, strict prime examples. You never . . . you couldn’t play double dutch with the girls you couldn’t do this, there

people to leave you alone.

Clayton: The way I was brought up is like if somebody step to me then you know I take care of my business . . . it’s like you . . . in some neighborhoods, you’ve got to fight in order for

over there and get her number and this and that and talk to her and all that and stuff.

Victor: The views that have been taught to me by my parents are a man is this big buff bravado-filled thing that’s pure muscle mass and home protector. Stacey: Pressure of . . . well, yeah, I remember like my dad and uncles and cousins of my age and stuff like that, you know, they always was, oh yeah, look at her and this and that; go

listening to any other authority figures, like challenging authority. You know, standing your ground; don’t let nobody disrespect you in any way and don’t let them get away with it.

Jonathan: From my experience, manhood is just about, you know, getting all the girls, having kids, you know, doing what you want whether it’s dropping out of high school or not

to be . . . just be a man.

Morgan: To be masculine—I guess you can say is not to have any feminine ways. I guess that’s what it is. Not to have any feminine ways; to be very strong and a dominant person and

(2)

(3)

Jordan: Masculine to me is aggressive. Everything that’s not feminine, not kind of shy and soft spoken.

(1)

Trauma GRS: Male Gender Role Expectations

Themes and Quotes From Participant Interviews

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Michael: A lot of people don’t wanna be put in a gay, a homo category, a faggot category and . . . I’m the same way. I mean, I’m not even gonna lie—I don’t—because society is harsh

(20)

(27)

(26)

(24) (25)

GRS and Race

(23)

(22)

(21)

You know what I’m saying, my mom, she’d be like, yeah, you fucking with him. Deven: I’m never going to be feminine acting like, I never wanted it to be a thing where someone just looks at me and would be like okay, he’s gay.

(19)

Continued

young White men who’re coming out, you know, who are gay or whatever and stuff, it just seems as though that their families, you know, still just are with them with open arms.

Stacey: Young Black men or young African American men that is living the life, most of their . . . most families is not too supportive as opposed to, you know, young Caucasian men or

your self-esteem lowered any more than what it might already be, you just try to go with the flow and you act in the same nature as the typical straight Black male would act.

is to them, to a lot of straight Black people is not sociably correct or correct period, so to fit in, that’s a big thing about fitting in, to fit in or to not be talked about or to not have

Stacey: Black people, living in a Black community, being around more Black people, going to school with Black people, going to work with Black people, you know, it’s something that

what manhood’s about.

Michael: Not feminine [ones] because straight Black men don’t like that at all. They have no tolerance for that. They just don’t. I mean it’s just as simple as that. Because that’s not

Joseph: I think in Black men we have stressed this whole thing about masculinity, being a man. And that goes everything they taught us . . . to be gay. Researcher: Do Black gay men feel a part of the Black community?

world . . . they’ll be calling you all types of names—pussy, punk, bitch—all that.

For me, that’s what I’m saying, you have to have your manhood . . . um if you don’t have that, people’ll think you’re a sissy, you don’t know how to take care of yourself out in the

Shawn: Manhood has to be important for you to survive -for you to survive as a person instead of like being. . . I mean, ‘cause if you really don’t have your manhood, then you’re lost.

just get rid of everybody . . . whoever knows me, whoever are my family, my friends and everything, where does that leave me? Utterly alone.

I’m not saying that I’m dependent on what they think, like you know I’ll drastically change my whole life . . . but I will modify just to keep what I have ‘cause, you know, if I was to like

kinda go with the flow, ship up, and act straight. Eric: These are the people that know me and watch me and, to some intent, care for me, so I would say. . . they are important to me and what they think of me is important as well.

you gon’ do? Is you gon’ leave home and try to make it out here on your own and stuff like that, if you’re just coming out because your family is not accepting you? So you have to

and probably White men, too—but more percentage of Black men, some are thrown out of their homes because of it, you know; some are ostracized because of it, and it’s like what

Stacey: Young Black men or young African American men that is living the life [engaging in same sex behavior]; most of their . . . most families is not too supportive. Some Black men—

kinda’ like they camouflage themselves or something.

against gay people . . . so people are . . . a lot of guys are tryna’ you know, straighten up in a way, you know; meaning act more masculine to fit into mainstream society and it’s

Stephen: I prefer masculine dudes . . . ‘cause I want to take, be able to take ‘em around my mom, mom not know. You know, as far as me taking me, you know, an effeminate person.

(18)

the street with somebody that’s just out like that because they’re gonna out me.

Michael: I have feminine friends—I mean not friends that I hang out with exclusively but friends of friends. . . . It depends on how feminine . . . I don’t know. I can’t really walk down

feminine penetrates you, um, I guess penetration as being a, you know, a manly type of thing, that’s what the man is supposed to do as the man.

Stephen: I’m not so eager for a more feminine man to penetrate me than I would be for a guy who is masculine. . . . It just doesn’t seem right to me . . . when, you know, a guy who’s

(17)

Shawn: Masculinity means that you’re a man; you’re a top [insertive partner in anal intercourse].

(16)

Anthony: Yeah, it is because just the whole gay realm, you know what I mean? Just the word gay and what’s associated with it, you know what I mean, and the stereotypes. I don’t know, maybe . . . it’s sad that words do, but it do. ‘Cause honestly I know that I’m gay, you know what I mean; I know I’m gay, but I just say I’m bisexual ‘cause it just feels better.

Researcher: Is it easier for you to say bisexual than for you to say gay?

You know what I mean.

I that I had to prove my manhood. . . . It seems like you always have to because you know what I mean your manhood is always at stake and just because you say you’re gay.

I mean. Not sugar-coated either—it’s gonna be just me, and they found out the hard way, you know what I mean. I hate to be that way but it was hard, it was hard. . . . I always felt

Anthony: I’ve gotten into 2 fights in high school to try to prove who I am, you know what I mean. Like, okay, I put all that gay shit aside; now you ‘bout to see me, you know what

(15)

(14)

(13)

Constructs of Masculinity

Dysfunction GRS: Conforming to Antihomosexual

Continued

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(36)

(35)

(33)

(32)

(31)

GRS and HIV Risk

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(29)

(28)

Continued

it so that was it. I didn’t tell anybody. I had low self-esteem about it because I felt that I was the only one in the world that was going through a problem like that and I had nobody to talk to and I felt weird and out of place.

Michael: I had to keep everything inside. I didn’t have anybody to talk to about it so I just dealt with it. I didn’t want to tell anybody anyway because of the way people thought about

whatever.

not until like 2 weeks ago did I go to the like gay and lesbian community center. Before I was like I would never set foot into there because I don’t know who’s around there or

Deven: If they’re openly gay, then they’ll go to the community centers but there’s a lot of paranoia of who knows what about you and what you want them to know. Like even with me,

they think they’re the only one they’re sleeping with because they are feeling this way.

of unprotected sex goes on as well because you know the young kids be thinking oh, they love me so much I don’t think they would do anything to hurt me or cheat on me and so

Ricky: That [ridicule] keeps them out into the world and that leaves them to be like, you know, the Church don’t love me, they feel like their parents or their family don’t love ‘em, so they go to somebody else who they think will give them that love so they’re like well I don’t have to protect myself because I love you and you love me and you know, that’s how a lot

a relationship with another man . . . they’ll do whatever with anybody else.

own complex, your own issues that you’re dealing with. That’s another reason actually that people might, you know, just go do risky things. If they can’t see themselves in

Eric: I’ll tell you that much . . . cause you know, you’re in a relationship and you say you know. What I can’t do this no more. . .the person is left high and dry just ‘cause you have your

because I’m thinking okay, you know, I’m gonna go to Hell anyway, so what’s the point?

gonna do this, I’m gonna go to Hell anyway, so why should I put on a condom again, you know? It would just, you know, it would not inspire me to at least try to have safe sex

Christopher: I felt really bad, I felt really bad about myself. I did not like myself at all, you know, and me not respecting myself, me not liking myself, had me thinking that, okay, I’m

and everything and having them have orgasms and things, so it’s like there’s a pressure among us to go and take women in the romantic sense like you see on TV.

Rory: Yeah ‘cause we’re supposed to be Mandingos . . . we’re supposed to have such big penises and everything that we’re supposed to be going out and having our way with women

Researcher: Do you think that’s a big pressure among Black men . . . to pretend to be straight?

because of that.

everybody’s fighting to prove that they have money, that they’re more, they’re better so Black men are gonna be a little bit more aggressive than any other man in the world just

Michael: I think Black Men are more aggressive than White men because of the situation they’re put in. African Americans, we’ve been put in these low-budget communities so

educated. Black men have been taught, hey, hustle, make it any way you can. I mean that’s the perception we’ve been taught.

Darius: We have been, both Black and White, have been taught different versions of masculinity. White men are taught to be the provider, just (inaudible) to get a good job, get

RESEARCH AND PRACTICE

The second theme described distinctions in masculine expectations and expression between White and Black men. Participants perceived masculine expectations for White men as less proscriptive, with greater emphasis on education, employment, and socioeconomic status (Quote 28) and less emphasis on sexual prowess, physical dominance, and gamesmanship, which were thought to be more important for Black men. Participants described these latter expectations as specific to Black men because of relative social positioning (Quotes 23 and 29) and societal and stereotypical perceptions of Black men (Quote 30).

HIV Risk

Many participants perceived trauma, discrepancy, and dysfunction GRS and the attendant psychological distress, social isolation, and diminished self-esteem as factors that might influence HIV risk. This perception stemmed from respondents’ own risk behaviors and observations of peers. Trauma strain. Christopher described HIV risk behavior that he believed resulted from poor self-esteem emerging from the ridicule and shame he experienced growing up hearing antihomosexual messages about masculinity. At one point, he “felt like hating [him]self” and “felt really bad about [him]self.” This lack of self-respect led him to ask, “why should I put on a condom again?” (Quote 31). Eric similarly expressed how ongoing conflicts with homosexuality, religion, and his masculinity prevented him from developing a monogamous same-sex relationship, and that may be a reason “that people might, you know, just go do risky things. If they can’t see themselves in a relationship with another man . . . they’ll do whatever with anybody else” (Quote 32). Discrepancy strain. Many participants felt that failure to achieve masculine expectations threatened important social ties. Observations of others caused many participants to conclude that this particular strain may influence HIV risk. Ricky, for example, believed that young men rejected by important referent groups were more vulnerable and at greater risk for HIV transmission because they sought acceptance and affirmation through sexual intercourse (Quote 33) and reasoned that they did not need to use condoms with a partner who provided love and support: “[T]hey love me so

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much I don’t think they would do anything to hurt me or cheat on me.” Dysfunction strain. For some participants, the vigilance involved in maintaining a hypermasculine “nonclockable” image extended to avoiding HIV education outreach and materials because they perceived an association with homosexuality and to avoiding gayspecific community organizations (Quote 34). Although this vigilance helped these young men maintain their masculine image and camouflage their homosexuality, it also contributed to dysfunction strain by limiting access to HIV prevention information. Furthermore, although these young men maintained important social ties by camouflaging their homosexuality, hiding their sexuality left them with limited social support in their efforts to come to terms with it (Quotes 35 and 36).

DISCUSSION We explored family, peer, community, and racial expectations of masculinity described by young Black MSM, the GRS associated with these expectations, and how this strain may contribute to HIV risk. Participants’ descriptions of personal experiences or peer observations suggested that trauma, discrepancy, and dysfunction GRS may influence individuallevel HIV risk behavior. Participants perceived rigid manhood expectations from important others, demanding that they avoid femininity and maintain an appearance of hypermasculinity. Although gender and sexual orientation are distinct social constructs, our results suggest that participants’ important others often conflated the 2 constructs, equating homosexuality with femininity, such that the masculine expectations experienced by participants were both antihomosexual and antifeminine. Participants described being ridiculed and reprimanded as children by important others if they fell short of these expectations. Thus, many experienced trauma GRS as part of their childhood masculine socialization. This type of strain is thought to be particularly prominent for gay men because masculine socialization, a process whereby sexual orientation and gender are frequently conflated, is often antihomosexual.31,48 Our findings were consistent with this supposition.

Because of the antihomosexual nature of these expectations, many of these young men felt discrepancy GRS from being deemed or believing they would be deemed “less of a man” or “lower than a female” because of their homosexuality. This discrepancy strain also included psychological distress associated with the threat of losing, or the actual loss of, important social ties and social support systems. Many responded to this strain by constructing a public image that was hypermasculine and void of feminine characteristics, which helped them fit in by camouflaging their homosexuality, which was seen by others as inconsistent with their masculine gender role. Others described engaging in delinquent behavior, consistent with dysfunction GRS, to prove their manhood. Participants described potential for increased HIV risk resulting from the psychosocial effects of each type of strain. Trauma strain was thought to negatively affect self-esteem and self-worth, which have both been associated with increased HIV risk through maladaptive coping and HIV risk behavior.6 Our findings reflected this potential for increased risk. Both personal and anecdotal experience led participants to feel that this diminished self-worth could decrease motivation to engage in protective sexual behaviors. Participants also believed that psychosocial distress from discrepancy strain (from failure to conform to antihomosexual constructs of masculinity) might influence HIV sexual risk behavior through social isolation, which has also been recognized as a risk factor for sexual risk behavior.4 Dysfunction strain resulting from camouflaging homosexuality might increase HIV risk by limiting access to factors identified as protective in previous studies, such as access to (1) HIV prevention and outreach49 and (2) parental involvement, social support, and guidance during sexuality development and early sexual decision-making.50 These risks may be particularly relevant for youths. Adolescents and young adults face the challenge of identity development and exploration, often seeking affirmation from their familial, peer, and other interpersonal interactions.35---38 Black youths often traverse this experience in the context of close ties to family and the immediate and larger Black community.38,51,52 However, young Black MSM may

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experience, or fear experiencing, rejection, ridicule, and isolation from the family, peers, and community who would otherwise be a source of support. These findings highlight an important dilemma for young Black MSM. Camouflaging homosexuality helps preserve important social connections but may also obstruct important protective factors. In studies of non-Black MSM, disclosure of sexual orientation is associated with decreased sexual HIV risk,53,54 ostensibly because disclosure helps to build social support within gay communities. However, among Black MSM, neither gay identity nor disclosure of homosexuality has been shown to be associated with reduced sexual risk.6 Furthermore, our participants saw disclosure of homosexuality as a threat to existing social supports, potentially weakening social ties that might otherwise be protective. Loss of these important social ties may even exacerbate risk for young Black MSM. In another study, family rejection because of sexual orientation was associated with increased sexual risk behavior among young Black, but not White or Hispanic, MSM. In the context of this social isolation, young Black MSM may be willing to take sexual risks (e.g., acquiescing to a partner’s desire not to use condoms) to reestablish social support through sexual relationships.4 GRS, discrepancy strain in particular, may be an important contextual factor influencing this social isolation. Our previous analysis of these data focused on how perceptions of masculinity might lead to increased HIV risk by influencing partner selection, prevention heuristics, and risk assessment of potential partners.40 The analysis reported here described the conflict between homosexuality and masculinity and the resulting GRS that may underlie these perceptions and preferences. Our findings also revealed other risk factors potentially influenced by this conflict that are important to consider in interventions targeted toward young Black MSM. GRS has been associated with increased sexual risk behavior30 and psychological distress55 in other populations; however, it has not been well studied in young Black MSM. Our participants felt that GRS resulted from antihomosexual and hypermasculine expectations. Although these expectations are not unique to young Black MSM, our participants reported aspects of both that they felt were specific to

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their experiences as Black men. They described specific disdain for homosexuality stemming from cultural expectations of masculinity, emphasis on hypermasculinity for individual and community survival resulting from racial and social oppression and disadvantage, and inter- and intraracial stereotypes of Black masculinity. These findings are consistent with previous studies on masculinity in Black men.41,56---58 Our participants’ difficulty in maintaining antihomosexual, hypermasculine expectations as both Black men and MSM suggests a degree of psychological distress that is unique to this population and arguably more severe than for other young MSM. Our study had several limitations. Because we did not use quantitative scales, we could not draw definitive conclusions about the degree of social support or GRS experienced. Samples were also compiled from different primary studies with varying sampling strategies and potentially different selection biases; thus, the samples were not entirely comparable across the different locales. The nature of qualitative inquiry tends to promote transferability and applicability of findings rather than generalizability to all young Black MSM. These data were collected several years ago, and it is possible that the contexts described by participants may have shifted for young Black MSM today. Despite these limitations, several implications for public health can be garnered. Our study provides context for quantitative findings of similar populations of young Black MSM, particularly our findings that suggest that social support may influence HIV risk.3,59 Our analysis may also help to generate additional hypotheses about HIV risk, such as that GRS and sexual risk are directly correlated, which could be tested quantitatively. Young Black MSM experience intersectional identities of race and sexuality, yet many draw support from their racial community,60---64 such that preserving a connection to family, peers, and community is paramount, despite the conflict homosexuality may engender. The importance of this connection is made evident by the efforts described by participants to situate homosexuality within an inherently antihomosexual social construction of masculinity. Therefore, future research and HIV prevention efforts for young Black MSM must take into account the influence of cultural identity and the socialization of Black men in Black communities.

In light of the importance placed on masculinity in the Black community and its potentially wide-reaching implications for HIV risk in young Black MSM, interventions would likely benefit from addressing issues specifically related to Black men’s experiences and conceptions of masculinity. Indeed, the conflict between homosexuality and expectations of masculinity that many participants faced suggests a need for interventions that help young Black MSM redefine their own masculinity rather than be conflicted by externally defined expectations of masculinity that devalue their homosexuality. Research focused on resiliency among young Black MSM who are able to develop integrated sexual, gender, and racial identities despite the antihomosexual social expectations they may face could inform such interventions.65 Research comparing GRS among other young MSM of color could be similarly helpful. Furthermore, communitylevel interventions are needed to effect change in negative group attitudes directed toward homosexuality. Intervention efforts that increase acceptance may quell the anxiety about fitting in expressed by many of the participants and eliminate the oft-expressed need to camouflage their lives. j

About the Authors Errol L. Fields and Jonathan Ellen are with the Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, School of Medicine, and Katherine C. Smith is with the Department of Health Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Laura M. Bogart and Mark A. Schuster are with the Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, and the Department of Pediatrics, Harvard Medical School, Boston, MA. David J. Malebranche is with Student Health Services, University of Pennsylvania, Philadelphia. Correspondence should be sent to Errol L. Fields, MD, PhD, MPH, Division of General Pediatrics and Adolescent Medicine, Johns Hopkins School of Medicine, 200 N Wolfe St, No. 2083, Baltimore, MD 21287 (e-mail: errol.fields@ jhmi.edu). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted December 23, 2013.

Contributors E. L. Fields originated and implemented the study and led the writing. L. M. Bogart and M. A. Schuster assisted with writing, revisions, and article conceptualization. K. C. Smith and D. J. Malebranche assisted with study design, data analysis, and writing. D. J. Malebranche was the principal investigator on 2 of the primary studies from which data were garnered. J. Ellen assisted with study conceptualization and writing.

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Acknowledgments This work was supported by the National Institute of Child Health and Human Development National Research Service Award, Johns Hopkins School of Public Health Doctoral Distinguished Research Award, Harvard Medical School Health Disparities Post-graduate Fellowship, Boston Children’s Hospital Division of Adolescent/ Young Adult Medicine (MCH/HRSA LEAH T71 MC00009), Johns Hopkins School of Medicine Division of General Pediatrics and Adolescent Medicine (MCH/ HRSA LEAH T71MC08054), and Johns Hopkins School of Medicine Adolescent Health Promotion Research Training Program (NICHD T32-HD052459). We thank S. Jean Emans for editorial support and Madeline Wachman for technical and research assistance.

Human Participant Protection Institutional review boards at all study institutions approved data collection; analyses were deemed exempt.

References 1. Prejean J, Song R, Hernandez A, et al. Estimated HIV incidence in the United States, 2006---2009. PLoS ONE. 2011;6(8):e17502. 2. Centers for Disease Control and Prevention. Estimated HIV incidence in the United States, 2007---2010. HIV Surveill Rep Suppl Rep. 2012;17(4):1---26. 3. Millett GA, Peterson JL, Wolitski RJ, Stall R. Greater risk for HIV infection of Black men who have sex with men: a critical literature review. Am J Public Health. 2006;96(6):1007---1019. 4. Warren JC, Fernández MI, Harper GW, Hidalgo MA, Jamil OB, Torres RS. Predictors of unprotected sex among young sexually active African American, Hispanic, and White MSM: the importance of ethnicity and culture. AIDS Behav. 2008;12(3):459---468. 5. Poppen PJ, Reisen CA, Zea M, Bianchi FT, Echeverry JJ. Predictors of unprotected anal intercourse among HIV-positive Latino gay and bisexual men. AIDS Behav. 2004;8(4):379---389. 6. Santana MC, Raj A, Decker M, La Marche A, Silverman JG. Masculine gender roles associated with increased sexual risk and intimate partner violence perpetration among young adult men. J Urban Health. 2006;83(4):575---585. 7. O’Sullivan LF, Hoffman S, Harrison A, Dolezal C. Men, multiple sexual partners, and young adults’ sexual relationships: understanding the role of gender in the study of risk. J Urban Health. 2006;83(4):695---708. 8. Malebranche DJ, Gvetadze R, Millett GA, Sutton MY. The relationship between gender role conflict and condom use among Black MSM. AIDS Behav. 2012;16(7): 2051---2061. 9. Connell RW. Masculinities. Berkeley: University of California Press; 1995. 10. Franklin CW. Men’s studies, the men’s movement, and the study of Black masculinities: further demystification of masculinities in America. In: Majors RG, Gordon JU, eds. The American Black Male: His Present Status and His Future. Chicago, IL: Nelson-Hall Publishers; 1994:4-- 19. 11. Bowser BB. Black men and AIDS: prevention and Black sexuality. In: Majors RG, Gordon JU, eds. The American Black Male: His Present Status and His Future. Chicago, IL: Nelson-Hall Publishers; 1994:114---126.

American Journal of Public Health | January 2015, Vol 105, No. 1

RESEARCH AND PRACTICE

12. Franklin CW. Ain’t I a Man? The efficacy of Black masculinities for men’s studies in the 1990s. In: Majors RG, Gordon JU, eds. The American Black Male: His Present Status and His Future. Chicago, IL: Nelson-Hall Publishers; 1994:272---283.

30. Santana MC, Raj A, Decker MR, La Marche A, Silverman JG. Masculine gender roles associated with increased sexual risk and intimate partner violence perpetration among young adult men. J Urban Health. 2006;83(4):575---585.

13. Whitehead TL. Urban low-income African American men, HIV/AIDS, and gender identity. Med Anthropol Q. 1997;11(4):411---447.

31. Levant RF. The new psychology of men. Prof Psychol Res Pr. 1996;27(3):259---265.

14. Whitehead TL, Peterson JL, Kaljee L. The” hustle”: socioeconomic deprivation, urban drug trafficking, and low-income, African-American male gender identity. Pediatrics. 1994;93(6 pt 2):1050---1054.

32. Eisler RM. The relationship between masculine gender role stress and men’s health risk: the validation of a construct. In: Levant RF, Pollack WS, eds. A New Psychology of Men. New York, NY: Basic Books; 1995: 207---228.

15. Majors RG, Billson JM. Cool Pose: The Dilemmas of Black Manhood in America. Lexington, MA: DC Heath and Co; 1992.

33. Fragoso JM, Kashubeck S. Machismo, gender role conflict, and mental health in Mexican American men. Psychol Men Masc. 2000;1(2):87---97.

16. Clarkson J. “Everyday Joe” versus “pissy, bitchy, queens”: gay masculinity on StraightActing.com. J Mens Stud. 2006;14(2):191---207.

34. Eisler RM, Skidmore JR, Ward CH. Masculine gender-role stress: predictor of anger, anxiety, and health-risk behaviors. J Pers Assess. 1988;52(1):133--141.

17. Asencio M. “Locas,” respect, and masculinity: gender conformity in migrant Puerto Rican gay masculinities. Gend Soc. 2011;25(3):335---354. 18. Courtenay WH. Constructions of masculinity and their influence on men’s well-being: a theory of gender and health. Soc Sci Med. 2000;50(10):1385--1401. 19. Halkitis PN. An exploration of perceptions of masculinity among gay men living with HIV. J Men’s Stud. 2001;9(3):413---429. 20. Halkitis PN, Green KA, Wilton L. Masculinity, body image, and sexual behavior in HIV-seropositive gay men: a two-phase formative behavioral investigation using the Internet. Int J Mens Health. 2004;3(1):27---42. 21. Sánchez FJ, Greenberg ST, Liu WM, Vilain E. Reported effects of masculine ideals on gay men. Psychol Men Masc. 2009;10(1):73---87. 22. Harris SM. Black male masculinity and same-sex friendships. West J Black Stud. 1992;16(2):74---81. 23. Majors R, Billson JM. Cool Pose: The Dilemmas of Black Manhood in America. New York, NY: Touchstone; 1993. 24. Parent MC, Torrey C, Michaels MS. “HIV testing is so gay”: the role of masculine gender role conformity in HIV testing among men who have sex with men. J Couns Psychol. 2012;59(3):465---470. 25. Hamilton CJ, Mahalik JR. Minority stress, masculinity, and social norms predicting gay men’s health risk behaviors. J Couns Psychol. 2009;56(1):132---141. 26. Kerrigan D, Andrinopoulos K, Johnson R, Parham P, Thomas T, Ellen JM. Staying strong: gender ideologies among African-American adolescents and the implications for HIV/STI prevention. J Sex Res. 2007;44(2): 172---180. 27. Pleck JH, O’Donnell LN. Gender attitudes and health risk behaviors in urban African American and Latino early adolescents. Matern Child Health J. 2001;5(4):265--272. 28. Pleck JH, Sonenstein FL, Ku LC. Masculinity ideology: its impact on adolescent males’ heterosexual relationships. J Soc Issues. 1993;49(3):11---29. 29. Wolfe WA. Overlooked role of African-American males’ hypermasculinity in the epidemic of unintended pregnancies and HIV/AIDS cases with young AfricanAmerican women. J Natl Med Assoc. 2003;95(9):846--852.

35. Petersen AC. Adolescent development. Annu Rev Psychol. 1988;39(1):583---607. 36. Hoffman MA, Ushpiz V, Levy-Shiff R. Social support and self-esteem in adolescence. J Youth Adolesc. 1988;17 (4):307---316. 37. Benson PL. Adolescent development in social and community context: a program of research. New Dir Youth Dev. 2002;2002(95):123---147. 38. Scales P, Leffert N, Lerner RM. Developmental Assets: A Synthesis of the Scientific Research on Adolescent Development. Minneapolis, MN: Search Institute; 1999. 39. Vogt WP, Gardner DC, Haeffele LM. When to Use What Research Design. New York, NY: Guilford Press; 2012. 40. Fields EL, Bogart LM, Smith KC, Malebranche DJ, Ellen J, Schuster MA. HIV risk and perceptions of masculinity among young Black men who have sex with men. J Adolesc Health. 2012;50(3):296---303. 41. Malebranche DJ, Fields EL, Bryant LO, Harper SR. Masculine socialization and sexual risk behaviors among Black men who have sex with men. Men Masculinities. 2009;12(1):90---112. 42. Muhr T. Atlas.ti Computer Aided Text Interpretation and Theory Building. User’s Manual. Berlin, Germany: Scientific Software Development; 1994. 43. Corbin JM, Strauss AL. Grounded theory research: procedures, canons, and evaluative criteria. Qual Sociol. 1990;13(1):3---21. 44. Strauss AL, Corbin JM. Basics of Qualitative Research. Newbury Park, CA: Sage Publications; 1990. 45. Glaser BG. The constant comparative method of qualitative analysis. Soc Probl. 1965;12(4):436---445. 46. Cohen J. A coefficient of agreement for nominal scales. Educ Psychol Meas. 1960;20(1):37---46. 47. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33 (1):159---174. 48. Wilkinson WW. Authoritarian hegemony, dimensions of masculinity, and male antigay attitudes. Psychol Men Masc. 2004;5(2):121---131.

50. Perrino T, González-Soldevilla A, Pantin H, Szapocznik J. The role of families in adolescent HIV prevention: a review. Clin Child Fam Psychol Rev. 2000; 3(2):81---96. 51. Tatum BD. Why Are All the Black Kids Sitting Together in the Cafeteria? New York, NY: BasicBooks; 1999. 52. Price R, Cioci M, Penner W. Webs of influence: school and community programs that enhance adolescent health and education. Teach Coll Rec. 1993;94(3):487--521. 53. Malebranche DJ. Black men who have sex with men and the HIV epidemic: next steps for public health. Am J Public Health. 2003;93(6):862---865. 54. Vincke J, Bolton R, Mak R, Blank S. Coming out and AIDS-related high-risk sexual behavior. Arch Sex Behav. 1993;22(6):559---586. 55. Good GE. Male gender role conflict: psychometric issues and relations to psychological distress. J Couns Psychol. 1995;42(1):3---10. 56. Wilson PA, Valera P, Ventuneac A, Balan I, Rowe M, Carballo-Diéguez A. Race-based sexual stereotyping and sexual partnering among men who use the internet to identify other men for bareback sex. J Sex Res. 2009; 46(5):399---413. 57. Ward EG. Homophobia, hypermasculinity and the US Black church. Cult Health Sex. 2005;7(5):493---504. 58. Malebranche DJ, Peterson JL, Fullilove RE, Stackhouse RW. Race and sexual identity: perceptions about medical culture and healthcare among Black men who have sex with men. J Natl Med Assoc. 2004;96(1): 97---107. 59. Bingham TA, Harawa NT, Johnson DF, Secura GM, MacKellar DA, Valleroy LA. The effect of partner characteristics on HIV infection among African American men who have sex with men in the Young Men’s Survey, Los Angeles, 1999---2000. AIDS Educ Prev. 2003; 15(1, suppl A):39---52. 60. Martinez DG, Sullivan SC. African American gay men and lesbians: examining the complexity of gay identity development. J Hum Behav Soc Environ. 1998; 1(2---3):243---264. 61. Monteiro KP, Fuqua V. African American gay youth: one form of manhood. High Sch J. 1993;77(1/2):20---36. 62. Wright JW. African-American male sexual behavior and the risk for HIV infection. Hum Organ. 1993; 52(4):421---431. 63. Crawford I, Allison KW, Zamboni BD, Soto T. The influence of dual-identity development on the psychosocial functioning of African-American gay and bisexual men. J Sex Res. 2002;39(3):179---189. 64. Sellers RM, Caldwell CH, Schmeelk-Cone KH, Zimmerman MA. Racial identity, racial discrimination, perceived stress, and psychological distress among African American young adults. J Health Soc Behav. 2003;44(3):302---317. 65. Herrick AL, Lim SH, Wei C, et al. Resilience as an untapped resource in behavioral intervention design for gay men. AIDS Behav. 2011;15(suppl 1):S25---S29.

49. Mustanski BS, Newcomb ME, Du Bois SN, Garcia SC, Grov C. HIV in young men who have sex with men: a review of epidemiology, risk and protective factors, and interventions. J Sex Res. 2011;48(2---3):218---253.

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