Health Psychology 2014, Vol. 33, No. 12, 1568 –1578

© 2013 American Psychological Association 0278-6133/14/$12.00 http://dx.doi.org/10.1037/hea0000031

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Social Oppression, Psychological Vulnerability, and Unprotected Intercourse Among Young Black Men Who Have Sex With Men David M. Huebner

Susan M. Kegeles and Gregory M. Rebchook

University of Utah

University of California, San Francisco

John L. Peterson

Torsten B. Neilands

Georgia State University

University of California, San Francisco

Wayne D. Johnson and Agatha N. Eke Centers for Disease Control and Prevention, Atlanta, Georgia Objective: Young Black men who have sex with men (YBMSM) are at extraordinarily high risk for HIV infection. Given their dual minority identity, they experience multiple forms of social oppression— racism, homophobia, and poverty. This study tested a model for how these forces contribute to their sexual risk behavior. Method: YBMSM (n ⫽ 1,289) from 2 Texas cities completed a 1-time assessment of sexual behaviors and psychosocial variables. Structural equation modeling was used to characterize relationships among variables. Results: Experiences of racism, homophobia, and socioeconomic distress were all associated with unprotected anal intercourse (UAI) either directly or indirectly in a manner largely consistent with Díaz’s (1997, 1998) model of the effects of social oppression. Racism, homophobia, and socioeconomic distress were each associated with specific psychological vulnerabilities, which were in turn associated with participation in difficult sexual situations (e.g., in a public setting), and then UAI. The effects of racism were largely mediated by depressive symptoms and participation in difficult sexual situations. Homophobia was mediated by depressive symptoms, social support, and internalized homophobia. The effects of socioeconomic distress were partially mediated by decreased social support and greater participation in difficult sexual situations. Socioeconomic distress also had a significant direct effect on UAI not explained by the proposed mediators. Conclusions: Social oppression contributes to YBMSM’s psychological vulnerabilities, participation in difficult sexual situations, and their UAI. Interventions to reduce sexual risk in YBMSM should address socioeconomic disadvantage, homophobia, and racism, as well as the psychological challenges that social oppression creates for them. Keywords: social oppression, sexual risk behavior, perceived discrimination, socioeconomic status, HIV prevention

The Centers for Disease Control and Prevention (CDC) estimated that 47,500 people in the United States were newly infected with human immune deficiency virus (HIV) in 2010 (CDC, 2012a). Men who have sex with men (MSM) represented 61% of these new infections, and are the only group for which the number of new infections continues to increase (CDC, 2012b). Among MSM, Black MSM are especially impacted, comprising only about 14% of the population, but 37% of new HIV infections among MSM (CDC, 2012b). The situation is particularly grave for young Black MSM (YBMSM), where HIV prevalence has reached levels unparalleled in developed countries. One study in 21 U.S. cities found that 21% of YBMSM aged 18 –29 were HIV positive in comparison with 9% of Latino and 7% of White MSM (Smith et al., 2010). In another recent longitudinal study of Black MSM, annual HIV incidence was 1.4% among men age 30 and older, and 5.9% among men under age 30 (Koblin et al., 2013). Although researchers have documented a variety of reasons for these disparities that are unrelated to higher levels of sexual risk behavior among YBMSM (Clerkin, Newcomb, & Mustanski, 2011; Millett, Flores, Peterson, & Bakeman, 2007; Millett, Peter-

This article was published Online First November 25, 2013. David M. Huebner, Department of Psychology, University of Utah; Susan M. Kegeles and Gregory M. Rebchook, Center for AIDS Prevention Studies, University of California, San Francisco; John L. Peterson, Department of Psychology, Georgia State University; Torsten B. Neilands, Center for AIDS Prevention Studies, University of California, San Francisco; Wayne D. Johnson and Agatha N. Eke, Centers for Disease Control and Prevention, Atlanta, Georgia. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention. This work was supported by cooperative agreement UR6PS000334 from the Centers for Disease Control and Prevention. The authors are grateful for the assistance of Anne Freeman, Douglas Sheehan, and Stephen Brown from the University of Texas Southwestern, and Jan Risser and Paige Padgett from the University of Texas, Houston. Correspondence concerning this article should be addressed to David M. Huebner, Department of Psychology, University of Utah, 380 S. 1530 E., Room 502, Salt Lake City, UT 84112. E-mail: [email protected] 1568

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SOCIAL OPPRESSION

son, Wolitski, & Stall, 2006), reducing sexual risk remains a central component of primary prevention. Moreover, within the population of Black MSM, disparities between younger and older men might, in fact, be driven by higher levels of risk behavior observed among younger men (Koblin et al., 2013). In the early phases of the epidemic, these risk behaviors were typically conceptualized as individual-level phenomena, driven primarily by a person’s access to information, motivation to avoid HIV, and behavioral skills required to reduce sexual risk (Fisher & Fisher, 1992). More recently, calls have been made for adopting holistic approaches to HIV prevention that look beyond social– cognitive models of individual sexual risk behavior and that attempt to appreciate the larger contexts which gay and bisexual men navigate socially and sexually, as well as the co-occurring “syndemics” of psychosocial challenges in this community (Halkitis, 2010; Halkitis, Wolitski, & Millett, 2013; Mustanski, Newcomb, DuBois, Garcia, & Grov, 2011; Stall et al., 2003). In particular, scholars seeking to understand communities of color and other socially marginalized groups have suggesting that structural factors associated with their marginalized position in the larger society might equally influence risk behavior (Aggleton, 2004; Díaz & Ayala, 2001; Parker, 2001). Consistent with these ideas, studies have documented that factors such as socioeconomic status (SES), and experiences of racism and homophobia are all associated with sexual risk behavior in a variety of populations (Browning, Burrington, Leventhal, & Brooks-Gunn, 2008; Chae & Yoshikawa, 2008; Díaz, Ayala, & Bein, 2004; Jarama, Kennamer, Poppen, Bradford, & Hendricks, 2005; Rodgers & McGuire, 2009). The multiple minority identities of Black MSM place them at the center of several structural risk factors—poverty, racism, and homophobia. Despite the increased appreciation of associations between social marginalization and sexual risk, relatively little research on this topic has been conducted among Black MSM. Moreover, we currently have a poor understanding of the mechanisms whereby these structural forces might come to influence an individual’s sexual behavior. One potentially useful model for understanding how social oppression might eventually lead to sexual risk behavior builds on the work of Díaz (1997, 1998). In his work with Latino MSM, Díaz (1997, 1998) has hypothesized that racism, homophobia, and poverty all lead men to have sex in what he dubs “difficult sexual situations” (e.g., with a more powerful partner, in a public setting, or under the influence of alcohol or drugs). These situations are characterized as “difficult” because once an individual is in such a situation, his ability to use a condom is limited by the confines of that situation, resulting in less condom use than might otherwise be predicted from his individual knowledge, attitudes, or intentions. In an empirical test of this model in a large sample of U.S. Latino MSM, Díaz and colleagues demonstrated that experiences of racism and homophobia, but not poverty, predicted having sex in difficult situations, which in turn, predicted unprotected anal intercourse (Díaz et al., 2004). Certainly, the experiences of Latino and Black MSM differ in a number of critical ways, and the historical circumstances that are the foundation for their oppression are distinct. Recognizing this reality, the forms of oppression that Díaz has focused on in his work—poverty, racism, and homophobia—are indeed common to both groups, though they might be experienced differently. Consistent with the notion that Díaz’s model might have applicability for Black MSM, findings from a recent study of Black and Latino

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MSM closely mirrored Díaz’s original work—in both groups, racism and homophobia were each related to having sex in difficult situations (Ayala, Bingham, Kim, Wheeler, & Millett, 2012). Although Díaz found no association between poverty and difficult sexual situations in his original study of Latino MSM (Díaz et al., 2004), results from the African American men revealed that a single item broadly assessing financial hardship was associated with engaging in sex in these difficult situations (Ayala et al., 2012). Although this emerging work suggests that having sex in difficult situations provides part of the link between social oppression and sexual risk behavior, how social oppression facilitates entry into those challenging sexual situations is unknown. In his theoretical work, Díaz (1997, 1998) has posited that oppression creates psychological distress, internalized homophobia, and decreases social support, and that these factors make men vulnerable to having sex in difficult situations, such as using sex to escape negative affect, having anonymous sex, or using substances during sex. Consistent with the first half of this model, a large body of work documents that experiences of racist or homophobic discrimination (Pascoe & Smart Richman, 2009), as well as socioeconomic disadvantage (Elovainio et al., 2012), can all lead to mental health challenges. However, we have little empirical support for the full model which integrates all of these components—social oppression (i.e., racism, homophobia, and socioeconomic distress), psychological vulnerability, sex in difficult sexual situations, and sexual risk behavior. In one study of Latino MSM, childhood experiences of sexual abuse and homophobia were both related to adult psychological distress, which provided a potential link to participating in difficult sexual situations (Arreola, Neilands, & Díaz, 2009). However, no formal mediation analysis was conducted, and other parts of the model (i.e., racism, poverty, internalized homophobia, and social support) were unexplored. Another possibility is that social oppression leads directly to entry into difficult sexual situations, without mediation by the psychological variables as Díaz proposed. For instance, an individual with limited financial resources might feel reliant on his partner to meet basic needs, and as a result could yield control of sexual decisions about condom use for fear of losing the partner. In more extreme instances, men might rely on sex as a means for obtaining concrete resources they need for survival, and thus be less likely to use condoms because of the transactional nature of the activity. Consistent with recent calls for a more holistic understanding of how gay and bisexual men’s HIV risk relates to their larger life experiences (Halkitis, 2010; Halkitis et al., 2013; Mustanski et al., 2011), the goal of the present study was to test an integrative model of how social oppression, psychological challenges, and difficult sexual situations relate to sexual risk behavior among YBMSM. To this end, we drew heavily from Díaz’s work on Latino MSM, and aimed to provide the most complete test of his model that we have identified to date. Specifically, we hypothesized that social oppression (racism, homophobia, and socioeconomic distress) would be associated with psychological vulnerability (depressive symptoms, internalized homophobia, and low social support). Those psychological variables would be related to difficult sexual situations, which in turn, would predict sexual risk (see Figure 1). Moreover, we aimed to test each of the specific mediated effects suggested by the model (e.g., that the relation

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Figure 1.

Theoretical model of effects of social oppression on unprotected sexual intercourse.

between homophobia and sexual risk is mediated by depressive symptoms and entry into difficult sexual situations).

Method Procedure Data analyzed in this study were collected as the baseline in a trial of the efficacy of a community-level HIV prevention intervention for YBMSM conducted in Dallas, TX, with Houston, TX as the control community. The study recruited two serial crosssectional samples of YBMSM in each community, separated by 1 year (2009 and 2010), to establish a baseline prior to implementation of the intervention. Participants in this analysis were those who participated in either of the two baseline assessments prior to intervention implementation. To be eligible for the study, men had to be between the ages of 18 –29, report their race as Black or African American, live in either the Dallas or Houston metropolitan areas, be alert and able to complete the survey in English, report sex with another man in the past 12 months, and not have already completed the same survey during the data collection period. Participants were recruited using a modified time-locationsampling protocol that was modeled after that used for the National HIV Behavioral Surveillance Survey (Oster et al., 2011), and adapted based on pilot work that established the feasibility for use in recruiting YBMSM in these specific communities. Venues eligible for consideration included bars, dance clubs, retail businesses, cafes and restaurants, social and religious organizations, adult bookstores and bathhouses, high-traffic street locations, and parks. Venues that provided health or social services, or HIV/STD testing or prevention services, were excluded. Additionally, some venues were excluded because of low YBMSM attendance, safety, or disapproval by owners. To help ensure the representativeness of eligible venues, attention was paid to venues that attracted YBMSM under the age of 21. Two major modifications from the NHBS protocol were made: 1) because of cost considerations, at least eight YBMSM had to enter a venue during a 2-hr time point for the venue to be utilized as a sampling location, and 2) venues and associated day/time periods were then purposively selected to maximize representation and productivity, which was composed of time periods that attract sufficient numbers of men to create schedules of 4-hr sampling events. Once study interviewers were stationed at the sampling venue, young Black men who entered a

defined intercept area and appeared age eligible were consecutively approached and screened for eligibility. Ninety-two percent of men who were approached agreed to screening, and 94% of those men who were screened eligible completed the assessment. Participants were compensated $30 for completing any portion of the assessment. All study procedures were approved by the institutional review boards at the investigators’ home institutions, and the CDC.

Assessment Procedure and Measures Participants completed study measures in the locations in which they were recruited (e.g., at the cafe where they were approached) using hand-held personal digital assistants (PDAs) that presented written questions sequentially and allowed participants to respond directly on the device. The privacy afforded by such methods has been shown to increase reporting of socially undesirable behaviors (e.g., sexual behavior and substance use; Gorbach et al., 2013; Newman et al., 2002). Surveys were completed anonymously; however, each participant provided several pieces of information (e.g., first two letters of mother’s first name) that allowed us to create a unique identifier for tracking repeat responders within and across waves. Surveys took 20 –30 minutes to complete. A description of the specific measures follows; Cronbach’s alpha is provided for scale measures as calculated from these data. Experiences of racism (␣ ⴝ .82). We used seven items adapted from Díaz et al.’s longer scale to assess men’s experiences of racism in the past year (Díaz et al., 2004). Sample items assessed how often “your civil rights been violated (i.e., job or housing discrimination due to racism, racial discrimination, or racial prejudice),” how often “you witnessed prejudice or discrimination directed at someone else because of their race/ethnic group,” and how often “you were treated as if you were ‘stupid’ or ‘talked down to’ because of your race/ethnic group?” Five Likertscale responses ranged from never to very often. Experiences of homophobia (␣ ⴝ .75). We used seven items adapted from Díaz et al.’s longer scale to assess men’s experiences of homophobia in the past year (Díaz et al., 2004). Sample items assessed how often men were made fun of or hit or beaten up “for being effeminate (girly) or for being attracted to other men (or gay or bisexual),” assessed how often men heard “that gay people will be alone when they grow old,” or “that homosexuals are sinners,” asked how often did they “feel that your attraction to other men (or

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SOCIAL OPPRESSION

being gay or bisexual) hurt and embarrassed your family?” Responses ranged from never to very often. Socioeconomic distress. SES is typically assessed using some combination of indicators of education, income, and occupational status (Adler & Stewart, 2010; Adler et al., 1994; Gallo & Matthews, 2003), although there is no widely accepted or standardized measure. In our case where we were interested in being able to make distinctions within a population where general “low SES” is common, we opted to utilize a measure comprising both common indicators (e.g., education, income), as well as those that would be sensitive to variability at the lower end of the spectrum. Thus, seven dichotomous indicators of low SES were utilized to create a composite (sum) score of socioeconomic distress. These included: not having a high school degree or GED, not currently being employed full time, having a personal annual income of less than $20,000, running out of money at least once in the past year, having to borrow money to meet basic needs during the past year, ever being incarcerated, and ever being homeless. Men in our sample endorsed an average of 2.80 indicators (SD ⫽ 1.83, Range 0 – 8). Depressive symptoms (␣ ⴝ .90). We used seven items from the CES-D Scale (Radloff, 1977) to assess depressive symptoms. In previous research with MSM, these seven items were shown to have good internal consistency and predictive validity with sexual risk behavior (Catania et al., 2008; Pollack, Osmond, Paul, & Catania, 2005). These assessed how often respondents felt or behaved in certain ways during the past week. Sample items included: “I felt depressed,” “I felt fearful,” and “I felt lonely.” Responses ranged from rarely or none of the time (Less than 1 day) to Most or all of the time (5–7 days). Internalized homophobia (␣ ⴝ .84). We used five items from our previous research (Kegeles, Hays, & Coates, 1996), originally adapted from Nungesser’s work (1983) to assess this construct. Sample items included “Does having sex with other men make you dislike yourself,” “Do you ever wish that you were only attracted to women,” and “How happy are you being gay or bisexual?” Responses ranged from not at all to a great deal or extremely along a 5-point continuum. Social support (␣ ⴝ .86). We assessed how much social support respondents received from their African American gay/ bisexual male friends using five items adapted from our previous research (Kegeles et al., 1996) that were originally adapted from Procidano and Heller (1983). The decision to assess support from other gay and bisexual friends was based on previous research suggesting that support from these peers is uniquely important for MSM and YBMSM when they are facing HIV-related concerns or challenges (Brady, Dolcini, Harper, & Pollack, 2009; Hays, Catania, McKusick, & Coates, 1990; Peterson et al., 1995). Sample items included “I rely on my African American gay/bi male friends for emotional support or comfort for my personal problems,” “Being with my African American gay/bi male friends helps me feel good about myself,” and “African American gay/bi male friends provide me with helpful information or advice.” Responses ranged from disagree strongly to agree strongly along a 6-point scale. Difficult sexual situations (␣ ⴝ .90). The survey included 10 items that measured how often in the last 12 months respondents had sex in difficult situations such as having sex: “in order to feel good” when “lonely and depressed,” when “you or your sex

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partner was high on drugs,” and with someone that “you were afraid of losing.” These items were adapted from Díaz’s original work with the construct (Díaz et al., 2004). Responses ranged from never to very often along a 5-point scale. Sexual risk behavior. Participants separately reported the frequency with which they had engaged in insertive or receptive anal intercourse both with a condom and without a condom with partners who were casual and “boyfriends or lovers.” Sexual risk behavior was then operationalized as any (yes/no) unprotected insertive or receptive anal intercourse (UAI) in the previous 2 months with any kind of sexual partner.

Data Analysis Overview. Structural equation modeling (SEM) was used to characterize the relationships among the variables in this study. We first assessed components of the measurement model composed of correlated latent factors and their observed indicators, then made minor model modifications to the measurement model, followed by a structural equation model that specified the hypothesized relationships among the latent variables (Anderson & Gerbing, 1988). Both models were estimated using Mplus version 6.1 (Muthén & Muthén, 2006). Given the large number of participants, power to reject an ill-fitting model approached 1.0 (MacCallum, Browne, Sugawara, 1996). Full-information maximum likelihood estimation was used for the measurement models, in which all latent and observed variables were treated as continuous. For structural models featuring the dichotomous UAI outcome variable, the default weighted least-squares estimator (Mplus estimator WLSMV) was used. This estimator is robust to departures from normality among continuous variables, and is appropriate for use with missing data that are covariate-dependent (Flora & Curan, 2004; Rhemtulla, Brosseau-Liard, & Savalei, 2012). To ensure that our assumption of covariate-dependent missingness was appropriate, we conducted a sensitivity analysis by estimating models after using multiple imputation to manage missing data. Results did not differ substantively from that using WLSMV. After models were fit, we conducted diagnostic analyses to identify potential outliers and cases with disproportionate influence. No problematic cases were found. Global model fit. To evaluate global model fit, we report the chi-square test of exact model fit, Comparative Fit Index (CFI; Bentler, 1990; Bentler & Bonnett, 1980), Root Mean Square Error of Approximation (RMSEA; Browne & Cudek, 1993), and the Standardized Root Mean Square Residual (SRMR). Satisfactory global model fit is attained when two of the following three conditions are met: CFI ⱖ .95, RMSEA ⱕ .06, and SRMR ⱕ .08 (Hu and Bentler, 1999). For models with one or more categorical mediators or outcomes, the weighted root mean square residual (WRMR) is substituted for the SRMR; WRMR ⱕ1.00 signify satisfactory model-data fit (Yu, 2002). For each estimated parameter, we report its unstandardized estimate (B), its standard error (SE), the estimate divided by its standard error (Z), the p value for Z, and the standardized parameter estimate, ␤. Assessment of mediation. In the SEM framework, evidence for mediation is provided by the presence of one or more indirect effects between an independent oppression variable (e.g., racism, homophobia, socioeconomic distress) and unprotected anal intercourse (UAI) through one or more intermediary variables (e.g.,

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depression, internalized homophobia, social support, difficult sexual situations). Indirect effects are computed as the product of their constituent paths (MacKinnon, 2008; MacKinnon, Lockwood, & Williams, 2004), which should each be statistically significant (Valeri & VanderWeele, 2013). If the product of the constituent paths is significantly different from zero, mediation is said to be present (MacKinnon, 2008). For linear models, this product is mathematically equivalent to the difference between the effect of the predictor on an outcome with and without control for the mediator(s), consistent with Baron and Kenny’s seminal definition of mediation (1986). Because distributions of indirect effects are not symmetric, inference should be based on a method that generates asymmetric confidence intervals. One such approach is the bias-corrected bootstrap; here we report 95% confidence intervals based on 5,000 bootstrap samples (MacKinnon, 2008; MacKinnon et al., 2004). If the 95% confidence interval of the effect does not include zero, it is statistically significantly different from zero at p ⬍ .05.

Results

sessment were not used). Demographic characteristics of the sample are summarized in Table 1.

Preliminary Analyses and Measurement Model The complete correlation matrix is available from the first author. Generally, items showed significant correlations with other items from the same scale. We then constructed a measurement model consisting of latent factors for experiences of homophobia, experiences of racism, depressive symptoms, internalized homophobia, social support, and sex in difficult situations. Because socioeconomic distress was calculated to be the sum of several potentially independent dichotomous indicators, it was not modeled as a latent construct, but rather included in subsequent models as a measured variable. The fit of the modified measurement model to the data met the criteria for good global model fit: ␹2(725) ⫽ 2608.28, p ⬍ .001; CFI ⫽ 0.96, RMSEA ⫽ 0.05, and WRMR ⫽ 1.54. Factor loadings are available from the first author. Intercorrelations among latent factors, socioeconomic distress, and UAI are presented in Table 2.

Participants Structural Equation Model Participants in the present analysis included 1,289 men who participated in either of these two baseline assessments in either Dallas or Houston (40 men who participated in both of the assessments were only included once, i.e., data from their second as-

Table 1 Characteristics of Study Sample (N ⫽ 1,289) Research to Evaluate an Effective Community-Level Intervention Adapted for Young Black Men Who Have Sex With Men, Dallas and Houston, Texas, 2009 and 2010 Variable Age 18–20 21–25 26–29 Education Less than HS degree HS graduate or equivalent Some college College graduate Annual Income Less than $10,000 $10,000⫺$19,999 $20,000⫺$39,999 $40,000 or more Employment Unemployed Part-time Full-time Ran out of money in past year Ever incarcerated Ever homeless HIV Status Untested or unknown Negative Positive UAI in past 2 months

n

Percent

325 675 289

25.2% 52.4% 22.4%

351 495 291 142

27.4% 38.7% 22.8% 11.1%

414 268 372 217

32.6% 21.1% 29.3% 17.1%

377 252 647 702 388 189

29.5% 19.7% 50.7% 55.2% 30.5% 14.7%

108 1,056 118 460

8.4% 82.4% 9.2% 36.6%

Following satisfactory fitting of the measurement model, we specified the paths suggested by our hypotheses (see Figure 2). We also included direct paths from the social oppression factors (homophobia, racism, and low SES) to difficult sexual situations and to unprotected sex, given the analytical objective to determine the degree to which the effects of these forces are mediated by both psychological vulnerabilities and difficult sexual situations. Factor loadings and path coefficients from this model appear in Table 3. The overall fit of this model was good: ␹2 (796) ⫽ 2700.24, p ⬍ .001; CFI ⫽ 0.96, RMSEA ⫽ 0.04, WRMR ⫽ 1.50. Kline (2011) has suggested that observing a large number of residual correlations with an absolute value greater than 0.10 is another indication of poor model fit. Inspection of these residual correlations revealed that fewer than 2% of the correlations had an absolute value greater than 0.10. Several mediated effects were relevant to our scientific questions. First, we sought to understand whether each of the social oppressive forces (homophobia, racism, and socioeconomic distress) was associated with UAI through a mediated chain from psychological vulnerabilities to difficult sexual situations to UAI. These results are presented in Table 4. Experiences of homophobia were associated with UAI through depressive symptoms, social support, and internalized homophobia, and then through difficult sexual situations. Experiences of racism were associated with UAI through depressive symptoms and then difficult sexual situations, but not through internalized homophobia or social support. Finally, socioeconomic distress was associated with UAI through social support, but not through depressive symptoms or internalized homophobia. The second mediated effects of interest were those linking social oppression to UAI directly through difficult situations. Each of the social oppressive forces had a remaining significant mediated effect on UAI through difficult situations that was not explained by psychological vulnerabilities.

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Table 2 Intercorrelations Among Latent Variables, Socioeconomic Distress, and UAI (N ⫽ 1,289) Research to Evaluate an Effective Community-Level Intervention Adapted for Young Black Men Who Have Sex With Men, Dallas and Houston, Texas, 2009 and 2010

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1. 2. 3. 4. 5. 6. 7. 8.

Racism Homophobia Socioeconomic distress Depressive symptoms Internalized homophobia Social support Difficult sexual situations UAI

1

2

3

4

5

6

7

8

— 0.57ⴱⴱⴱ 0.18ⴱⴱⴱ 0.35ⴱⴱⴱ 0.47ⴱⴱⴱ ⫺0.16ⴱⴱⴱ 0.47ⴱⴱⴱ 0.12ⴱⴱⴱ

0.50 — 0.32ⴱⴱⴱ 0.35ⴱⴱⴱ 0.64ⴱⴱⴱ ⫺0.22ⴱⴱⴱ 0.70ⴱⴱⴱ 0.18ⴱⴱⴱ

0.18 0.30 — 0.19ⴱⴱⴱ 0.25ⴱⴱⴱ ⫺0.31ⴱⴱⴱ 0.35ⴱⴱⴱ 0.16ⴱⴱⴱ

0.31 0.30 0.18 — 0.33ⴱⴱⴱ ⫺0.01 0.34ⴱⴱⴱ 0.11ⴱⴱⴱ

0.41 0.54 0.23 0.28 — ⫺0.24ⴱⴱⴱ 0.49ⴱⴱⴱ 0.10ⴱⴱⴱ

⫺0.14 ⫺0.19 ⫺0.29 0.01 ⫺0.20 — ⫺0.24ⴱⴱⴱ ⫺0.10ⴱⴱⴱ

0.44 0.65 0.35 0.30 0.44 ⫺0.23 — 0.25ⴱⴱⴱ

0.14 0.20 0.22 0.10 0.23 ⫺0.10 0.30 —

Note. Bivariate correlations among latent variables (shown above the diagonal) represent those calculated using the same WLSMV estimator in MPlus that was used for the full analysis. Because standard errors cannot be computed on bivariate correlations using the WLSMV estimator, significance values are not available for those correlations. To provide estimates that have calculable significance levels, we also estimated bivariate correlations by constructing a measurement model using the Bayesian estimation procedure in Mplus, and then computed factor scores and correlated them. ⴱⴱⴱ p ⬍ .001.

Discussion Experiences of racism, homophobia, and socioeconomic distress were all associated with UAI in our sample of YBMSM either directly or through their associations with having sex in difficult situations. These findings are largely consistent with two previous studies, one of Latino MSM and one of both African American and Latino MSM (Ayala et al., 2012; Díaz, 2004). Moreover, our study expands this research by identifying specific psychological vulnerabilities that might provide the links between social oppression

Figure 2. on UAI.

and sex in difficult situations, and in doing so, provides one of the most comprehensive tests to date of Díaz’s theory for how social oppression contributes to sexual risk among minority MSM. Experiencing homophobic discrimination was indirectly associated with UAI through all three of the proposed psychological vulnerabilities— depressive symptoms, internalized homophobia, and low social support—and then through difficult situations. Racist discrimination was indirectly associated with UAI through depressive symptoms and then difficult sexual situations. In addi-

Standardized path coefficients for structural equation model examining effects of social oppression

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Table 3 SEM Illustrating Associations Between Social Oppression, Psychological Vulnerability, Difficult Sexual Situations, and UAI (n ⫽ 1,289), Research to Evaluate an Effective Community-Level Intervention Adapted for Young Black Men Who Have Sex With Men, Dallas and Houston, Texas, 2009 and 2010

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Variable Directional structural effects Racism ¡ Depressive symptoms Racism ¡ Internalized homophobia Racism ¡ Social support Racism ¡ Difficult sexual situations Racism ¡ UAI Homophobia ¡ Depressive symptoms Homophobia ¡ Internalized homophobia Homophobia ¡ Social support Homophobia ¡ Difficult sexual situations Homophobia ¡ UAI Socioeconomic distress ¡ Depressive symptoms Socioeconomic distress ¡ Internalized homophobia Socioeconomic distress ¡ Social support Socioeconomic distress ¡ Difficult sexual situations Socioeconomic distress ¡ UAI Depressive symptoms ¡ Difficult sexual situations Internalized homophobia ¡ Difficult situations Social Support ¡ Difficult sexual situations Difficult sexual situations ¡ UAI Latent variable correlations Racism ⬍⬎ Homophobia Racism ⬍⬎ Socioeconomic distress Homophobia ⬍⬎ Socioeconomic distress Depressive symptoms ⬍⬎ Internalized homophobia Depressive symptoms ⬍⬎ Social support Internalized homophobia ⬍⬎ Social support

Estimate

SE

Z

0.18 0.21 ⫺0.06 0.11 0.01 0.16 0.57 ⫺0.11 0.53 ⫺0.03 0.03 0.03 ⫺0.13 0.05 0.07 0.09 0.05 ⫺0.06 0.38

0.03 0.04 0.04 0.03 0.06 0.04 0.07 0.06 0.04 0.10 0.01 0.02 0.01 0.01 0.02 0.03 0.03 0.02 0.08

5.66 4.94 ⫺1.43 3.81 0.05 4.21 8.44 ⫺1.99 12.03 ⫺0.317 3.12 2.03 ⫺8.74 5.08 2.98 2.77 1.76 ⫺2.62 4.74

0.25 0.25 0.34 0.04 0.05 ⫺0.06

0.02 0.04 0.04 0.02 0.02 0.02

14.43 6.01 8.85 2.56 3.35 ⫺2.57

P ⴱⴱⴱ ⴱⴱⴱ

ns

ⴱⴱⴱ

ns

ⴱⴱⴱ ⴱⴱⴱ ⴱ ⴱⴱⴱ

ns ⴱⴱ ⴱ ⴱⴱⴱ ⴱⴱⴱ ⴱⴱ ⴱⴱ † ⴱⴱ ⴱⴱⴱ ⴱⴱⴱ ⴱⴱⴱ ⴱⴱⴱ ⴱ ⴱⴱ ⴱ

␤ 0.21 0.19 ⫺0.05 0.12 0.01 0.17 0.42 ⫺0.08 0.48 ⫺0.02 0.09 0.07 ⫺0.26 0.13 0.13 0.08 0.06 ⫺0.07 0.27 0.50 0.18 0.30 0.10 0.11 ⫺0.10

Note. N ⫽ 1,289; ⬍⬎ denotes covariances; ¡ denotes directional effects; B ⫽ Unstandardized regression weight; SE ⫽ standard error of B; Z ⫽ Z-test of B ⫽ 0; p ⫽ p-value for Z-test; ␤ ⫽ standardized regression coefficient. ns ⫽ nonsignificant. † p ⬍ .10. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.

tion to the mediated paths through psychological vulnerabilities, both homophobia and racism were also directly associated with having sex in difficult situations, suggesting additional mechanisms linking discrimination to participation in challenging sexual situations. For instance, it is possible that individuals who experience racism or homophobia have less of a sense of self-efficacy or fewer skills for navigating relationships, and thereby end up in challenging situations. Alternately, experiences of racism or homophobia may leave men lacking financial or other material resources, and these needs might land them directly in challenging sexual circumstances. For example, men who have experienced racist or homophobic discrimination in housing might need to live with a romantic partner and could then find it difficult to negotiate condom use with this person whom they rely on for housing stability. Because these explanations are only speculative at this point, future research should explore these possibilities. It is notable that neither experiences of racism nor homophobia had any direct relation to UAI other than through difficult sexual situations, suggesting that these situations are central to understanding how discrimination can facilitate sexual risk behavior. Socioeconomic distress appeared to function somewhat differently from discrimination. Socioeconomic distress was associated with having less social support, greater depressive symptoms, and more internalized homophobia. However, the only significant mediated paths from SES to UAI ran through social support to

difficult sexual situations, and directly through difficult sexual situations. Many previous studies have found that low SES is associated with decreased social support and that this phenomenon might account for some of the larger associations between SES and health (Beatty, Kamarck, Matthews, & Shiffman, 2011; Gorman & Sivaganesan, 2007; Mickelson & Kubzansky, 2003; Turner & Marino, 1994). With respect to our findings specifically, understanding what aspects of social support might inhibit participation in difficult sexual situations will be essential to informing interventions. For example, it is possible that friends offer direct guidance to their peers in a manner that discourages participation in challenging sexual situations. Alternately, men who feel more supported might have less need to seek sexual reassurance from more powerful partners. Future research should explore these possibilities. Socioeconomic distress also had a significant direct effect on UAI, even after controlling for the other variables in our model. Thus, although it is clear that SES is important to YBMSM’s mental health and to their risk for HIV, our findings suggest that we have much more to learn about the specific mechanisms that might link SES to sexual risk. Social support and difficult situations appear to be important, but other factors such as increased hopelessness (Bolland, 2003), different family socialization and values (Brook, Morojele, Zhang, & Brook, 2006; Rodgers & McGuire, 2009), and decreased collective efficacy (Browning et

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Table 4 Mediated Effects of Social Oppression on Unprotected Anal Intercourse (N ⫽ 1,289), Research to Evaluate an Effective CommunityLevel Intervention Adapted for Young Black Men Who Have Sex With Men, Dallas and Houston, Texas, 2009 and 2010

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Unstandardized estimates Experiences of racism Effect on UAI mediated directly through difficult sexual situations Effect on UAI mediated effect through: Depression ¡ Difficult sexual situations Internalized homophobia ¡ Difficult sexual situations Social support ¡ Difficult sexual situations Remaining direct effect on UAI1 Experiences of homophobia Effect on UAI mediated directly through difficult sexual situations Effect on UAI mediated effect through: Depression ¡ Difficult sexual situations Internalized homophobia ¡ Difficult sexual situations Social support ¡ Difficult sexual situations Remaining direct effect on UAI1 Socioeconomic distress Effect on UAI mediated effect directly through difficult sexual situations Effect on UAI mediated through: Depression ¡ Difficult sexual situations Internalized homophobia ¡ Difficult sexual situations Social support ¡ Difficult sexual situations Remaining direct effect on UAI1

95% CI

.041ⴱ

.019⫺.071

.006ⴱ .004 .001 .012

.002⫺.012 .000⫺.010 .000⫺.005 ⫺.084⫺.103

.201ⴱ

.126⫺.292

ⴱ

.005 .011ⴱ .002ⴱ ⫺.031

.002⫺.012 .001⫺.024 .001⫺.007 ⫺.202⫺.123

.019ⴱ

.011⫺.030

.001 .001 .003ⴱ .073ⴱ

.000⫺.003 .000⫺.002 .001⫺.007 .032⫺.116

Note. 95% Confidence intervals for indirect effects were calculated using the bootstrap method. Intervals that do not include 0 are significant at the p ⬍ .05 level; CI ⫽ Confidence Interval. 1 The remaining direct effect is also known as the “unmediated” effect. When this effect is significant in the presence of one or more mediated effects, partial mediation is present. ⴱ p ⬍ .05.

al., 2008) have all been proposed as mechanisms linking SES to sexual risk in other populations. Future research should explore these possibilities in YBMSM as well.

Limitations These findings must be qualified by a number of limitations. Most importantly, our findings are based on cross-sectional data. Thus, although the patterns of association identified in our structural model are consistent with a theory-based model for how social oppression operates to affect sexual risk behavior, other temporal configurations of these variables are also plausible. This is a limitation that our study shares with the two other primary explorations of the effects of social oppression in minority MSM (Ayala et al., 2012; Díaz, 2004). Future longitudinal research will be required to more firmly establish the temporal and causal associations suggested by this growing body of work. In addition, although we observed moderate associations between variables located proximally to one another in our model (e.g., between difficult sexual situations and UAI), in some cases the more distal effects (e.g., the doubly mediated paths from social oppression to UAI) were small. Although this is not uncommon when modeling complex psychological processes, it suggests that some portions of the model have greater implications for intervention than others. Although this analysis is based on a large and diverse sample, our sample does not necessarily represent the population of YBMSM. Thus, care must be taken in generalizing our findings to YBMSM from other geographic regions, as well as YBMSM who cannot be found in the venues from which we sampled. Finally, the

endpoint of our analysis was UAI, and not actual HIV or sexually transmitted infections (STIs). Accumulating evidence suggests that although risk behavior is required for HIV transmission, disparities in risk behaviors do not explain the excess HIV infection we see among Black MSM compared to other MSM (Millett et al., 2007; Millett et al., 2006). Thus, our analysis cannot explain how social oppression is related to the sociocultural phenomena that contribute to disparities in infection rates (e.g., undiagnosed STIs, more untreated HIV infection).

Conclusions and Implications for Intervention Historically, effective HIV-prevention interventions have primarily focused on reducing specific sexual risk behaviors by attempting to alter the most proximal predictors of those behaviors (e.g., information, motivation, and behavioral skills; Fisher, Fisher, & Harman, 2003; Wingood & DiClemente, 1999). While this approach has certainly shown success for some populations (Lyles et al., 2007; Noar, 2008), its strict emphasis on sexuality and on individual cognitive constructs might be insufficient when intervening with populations whose challenging life circumstances create barriers to sexual safety, independent of their knowledge or motivation. Previous studies indicate that many YBMSM confront racism from other ethnic groups and face homophobia in the African American community and in society at large (Neff, 2006). Moreover, like other African Americans, these men are disproportionately affected by poverty (Finegold & Wherry, 2004). The present findings suggest that these three forms of social oppression are associated with psychological challenges, and are likely to

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operate together to facilitate sexual risk behavior. Thus, when intervening to reduce sexual risks in YBMSM, it is important that interventions consider and evaluate the whole individual, and seek to address multiple aspects of his health and well-being. Looking first at the most distal variables (socioeconomic distress, homophobia, and racism), interventions might attempt to directly address these forms of social oppression by offering guidance in obtaining educational training, finding jobs (e.g., skills for job searching, developing a resume, and interviewing), or providing access to legal guidance for those involved in the criminal justice system. Creating safe places for men to socialize might limit their exposure to racism or homophobia. However, it is clear that no intervention can entirely eliminate social oppression from the lives of YBMSM. Fortunately, our findings do suggest other targets for intervention that might mitigate its influence. Specifically, depressive symptoms and social support were each important in linking oppression to risk. Therefore, interventions should consider providing mental health resources (e.g., psychotherapy or pharmacotherapy) to YBMSM struggling with depression. Interventions might also work to build supportive peer networks which appear to be protective. In addition, participation in difficult sexual situations is central to understanding sexual risk behaviors. Interventions might attempt to raise men’s consciousness about the challenges that these situations pose to their sexual safety, and help them recognize and avoid those situations in which they have less control over their sexual behavior.

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Received May 9, 2013 Revision received September 19, 2013 Accepted September 20, 2013 䡲