WHAT PUT GAY MEN OF COLOR AT RISK FOR HIV? IS IT ETHNIC IDENTITY? GAY IDENTITY? OR SEXUAL SENSATION SEEKING?

by

Chwee Lye Chng, Ph.D. (University of North Texas)

Jesus Geliga Vargas, M. S. (Resource Center of Dallas)

INTRODUCTION

At the 2001 Retrovirus Conference in Chicago, CDC researchers reported disturbing results from their multi-year Young Men's Survey. They reported Dallas (Baltimore, Los Angeles, New York, Miami, Seattle being the others) with the highest rate of HIV infection among men ages 23-29, of all six cities studied. Asian/Pacific Islander gay men had 50% the rate of whites (considering the smaller number of Asians in the population, this rate is disturbing), while Latinos reported 200% and African Americans reported over 400% the rate of whites. Obviously, ethnic gay men in the US are having problems with maintenance of safer sex behaviors. In light of these latest findings from CDC, we present our study on sexual risk taking among gay men of color conducted in Dallas in 1998-1999 with the hope that itmight provide valuable insights.

One of the factors we included in the study design is Ethnic Identity. It refers to an individual’s identity as a member of an ethnic group, and is measured by acculturation level, degree of participation in ethnic traditions and celebrations, and association with other members of the same ethnic group. Ethnic identity has been found to influence a person’s attitudes and beliefs about health-related behaviors and personal norms regarding safer sex. Researchers have found that being a member of an ethnic group and sharing its cultural norms can increase your risk for HIV infection.

Because men having sex with other men do not necessarily affiliate with the visible gay community, nor always identify themselves as gay, we thought it wise to measure the variable of Gay Identity. Those with a defined gay identity may have more gay friends who may be more educated about HIV, and more likely to encourage them to practice safer sex.

Prevention messages routinely emphasize the importance of a known HIV status, making HIV testing and consistent safer sex practices as important self-protective behaviors. We therefore identified HIV Serostatus (whether you are HIV positive or HIV negative) as a variable for study.

We included Relationship Status as an important factor since researchers have found sexual behavior to be more risky among primary sexual relationships than in casual relationships. Gay men in "sexually exclusive" relationships may not perceive themselves at risk for HIV since trust and comfort are factors commonly associated with such unions. Moreover, the termination of condom use may be perceived as an important step in expressing trust between partners.

Because many ethnic gay men are recent immigrants from Asia and Latin America, we decided to measure Length of Residence in the US. Obviously, as these men live in the US longer, potentially they could be exposed to more HIV prevention messages, which can reduce their risky behaviors. This is a particularly important factor with the Asian/Pacific Islander population with large numbers of immigrants.

METHOD

Using Spanish and English versions of a questionnaire to evaluate levels of ethnic identity, gay identity, and sexual sensation seeking in a sample of gay men of color, we tested the three independent variables: Ethnic Identity, Gay Identity, and Sexual Sensation Seeking. In addition, we collected demographic information on age, HIV status, relationship status, length of residency in the United States, education level and ethnicity. The dependent variable is HIV risk-taking behavior, which is the measure against which we tested the three independent variables listed above.

A total of 332 questionnaires were distributed and 302 completed questionnaires were returned, producing a 91% return rate. The convenience sample (N=302) consisted of multiethnic men meeting the inclusion criteria of reporting sexual contact with other men, and who are able to read either in English or Spanish.

RESULTS

As seen in Table 1, the sample (N=302) consisted of 24% African American, 28% Latino, 25% Asians/Pacific Islander, 19% Caucasian, 1% American Indian, and 3% other ethnicity. Although the study targeted men of color, 55 Caucasian men (19%) completed the questionnaire, and their data were included for multiethnic comparisons. Participants were recruited from four sources frequented by gay men of color: i) gay-oriented community events/programs (35%) such as Renaissance III (African Americans HIV-related service agency), Dragonflies (Asians/Pacific Islanders support group) and Dallas Independent Volleyball Association tournaments (with ethnically diverse membership), ii) bathhouses (10%), iii) gay bars (21%), and iv) the National Minority AIDS Conference (34%) held in Dallas on November, 1998 and attended by gay men of color fromthroughout the U.S. Those included in the sample were highly educated (87% with more than high school education), and non-sexually exclusive (77%). Although the majority reported being HIV negative (69%), 22% reported being HIV positive and 9% did not know their HIV status. Although all men resided in the U.S., 29% were born overseas, with Asian/Pacific Islanders being the majority of foreign-born respondents. Despite efforts to recruit nongay-identified participants, the majority (77%) sampled self-identified as gay.

Not surprisingly, Caucasian subjects reported the lowest ethnic identity scores (M = 2.97) while African Americans the highest (M = 3.53). Asians/Pacific Islanders reported the highest sexual sensation seeking scores (M = 2.85) while African Americans scored the lowest (M = 2.42). Overall, the sample was highly ethnic identified with moderate sensation seeking scores. Despite concerted efforts to recruit nongay-identified men, only 23% of the sample reported an undefined gay identity (32% of African Americans, 31% of Asians/Pacific Islanders, 20% of Latinos and 7% of Caucasians).

Significantly at least one instance of unprotected anal sex was reported by 51% of the sample (n = 154). Of all ethnic groups Asians/Pacific Islanders reported the highest frequency of unprotected anal sex (66%), followed by Caucasians (48%), African Americans (47%), and Latinos, (45%). Statistical analysis confirmed that although there were differences among ethnic groups regarding unprotected sex, gay men of color with higher ethnic identity scores did not report significantly more HIV risk-taking behaviors. Apparently, a man's ethnic identity does not have a direct effect on his risk taking behaviors.

Sexual sensation seeking was identified as a predictor of unprotected anal sex,

supporting the hypothesis that gay men of color who sought higher sexual sensation would report significantly more risk-taking behaviors. For instance, moving upwards one unit along the sexual sensation-seeking scale can increase a subject's risk in unprotected sex by 4.2 times. Not surprisingly, Asian/Pacific Islander men (with the highest sensation seeking scores among all groups) also reported the highest rate of risky behaviors, among all ethnic groups measured.

Not having a defined gay identity was a significant predictor of unprotected anal sex, where gay men of color with higher gay identity scores also reported significantly less risk-taking behaviors. At least one incident of unprotected anal sex in the previous month was reported by 69% of subjects with an undefined gay identity, compared to only 45% of men with a defined gay identity. In other words, men with an undefined gay identified are 3.6 times more likely to engage in unprotected anal sex than their peers.

Reported HIV status is a significant predictor of unprotected anal sex among the sample. Not surprisingly, HIV-negative men (46%) reported the lowest rate of unprotected anal sex, whereas men with unknown HIV status reported the highest frequency (77%), followed by HIV positive men (57%). We found that HIV negative men are 75% less likely to engage in unprotected anal intercourse than HIV positive men or those with unknown serostatus.

In addition, a sexually exclusive relationship status predicted unprotected anal sex. In other words, those men who reported being in a sexually exclusive relationship are almost 3 times more likely to engage in unprotected anal sex than those in nonsexually-exclusive unions.

Our analysis on the sample of gay men who were born overseas (N = 89) suggested a negative correlation between unprotected anal sex and length of residence (years) in the United States. In other words, the shorter their length of stay in the U.S. the more likely these men will engage in unprotected anal intercourse.

DISCUSSION

Ethnic Identity: Ethnic identity scores were not significant predictors of unprotected anal intercourse among the sample. Perhaps, in an attempt to apply the same ethnic identity measurement across all ethnic groups, we might have ignored ethnic-specific attitudes associated with HIV risk taking, such as machismo, family preeminence, patriarchy, homophobia, and religious beliefs.

Gay Identity: An undefined gay identity was a significant predictor of unprotected anal intercourse. Men with an undefined gay identity are 3.6 times more likely to engage in unprotected anal intercourse than those with a defined gay identity. The findings here suggest that, for many nongay-identified men, sexual interactions occur in casual and anonymous sex where a code of silence is enforced, with limited opportunities to negotiate for safer sex practices. For those whose identity is primarily a sexual one and for those who do not have access to a gay community, anal sex can be perceived as central to the need to affirm their identity regardless of HIV risk. Those lacking social support for their sexuality may find comfort and security in anal intercourse as a means of making contact with others like them. Accepting semen for these men may be associated with commitment, devotion, and affiliation. In this cultural context, what has been called "unsafe sex" has become an expression of affirmation and validation. Sex is a culturally rewarded act deeply embedded in and influenced by the social context in which it occurs. Interventions targeting sexual behaviors of nongay-identified men that ignore the cultural context in which these men interact are doomed to fail.

Having a more defined gay identity and being affiliated with the gay community can provide access to a "safe sex culture" for men seeking sex with other men. The threat of HIV/AIDS is made more vivid by community publications presenting accurate HIV information, when support from social networks mitigate against the lack of self esteem which may lead to unsafe practices, and when there is first hand experience of the epidemic. It has been argued that contact with the gay community probably plays a different role for different men. For those who already have a strong orientation towards safe sex, links with the gay community help to strengthen that resolve. By contrast, for those with great difficulty in maintaining safe sex, the opposite holds. It may be, for these men, contact with the community simply serves to present more temptations to engage in risky behaviors. Significant correlation has been found between unsafe sex with the proportion of a man's closest friends being gay, the frequency with which he reads the gay press, and the number of men he knew who are living with HIV. Obviously, contact with the gay community serves as a multiplier; it enhances tendencies that already exist. Care should be exercised about indiscriminately linking non-gay identified men with the community.

Sexual Sensation Seeking: As hypothesized, sexual sensation seeking was a strong predictor of unprotected anal intercourse among the sample. High-sexual-sensation-seeking gay men are much more likely (12.7 times) to engage in unprotected anal intercourse than their peers who have less need for new and exciting experiences. However, many traditional HIV prevention messages that stress the dangers of HIV infection do not get through to these people because high-sexual-sensation seekers have different perceptions of risk. Messages using fear tactics may inadvertently enhance the attractiveness of unsafe sex for high-sensation seekers. Offering activities that could substitute for the unsafe sexual experience is key with high-sensation seekers. Traditionally, HIV prevention programs do not offer an alternative to unsafe sex that is going to provide this group of individuals with the novelty they really want. To identify effective ways to reach this population and to produce effective messages, developers of prevention messages should assemble focus groups of high-sexual sensation seekers among gay men of color and ask them what they really like.

HIV status: More than 22% of the gay men of color in this study reported being HIV positive and 51% of the study sample reported at least one instance of unprotected anal intercourse during the past month. This data suggests that in this sample of gay men of color, HIV is a reality and that unprotected anal intercourse is a common behavior. However, men with unknown HIV status reported the highest frequency of unprotected anal sex (77%), whereas those reporting being HIV negative were 73% less likely to engage in unprotected anal sex than those with an HIV positive or unknown serostatus. Apparently, for gay men there is value in knowing one's HIV serostatus. Not only does it initiate an early entry into treatment of HIV disease if one is infected, but simply knowing one's serostatus appears to protect the man from becoming infected. Men who tested and learn that they are not HIV infected may initiate changes in their behaviors that could protect them from subsequently becoming infected. Prevention messages routinely emphasize the importance of a known HIV status, making HIV testing and consistent safer sex practices as important self-protective behaviors. In our sample 57% of HIV seropositive men continue to engage in unprotected anal sex in the previous month, a rate even higher than that reported in the Multicenter AIDS Cohort Study, where only 35% of HIV seropositive men had engaged in insertive anal intercourse in the previous 6 months. Obviously, as the number of men who become infected with HIV grows and as they continue to survive longer (as evidenced by the many positive reports at the 2001 Retrovirus Conference), there is an increasing need to develop effective interventions supporting the long-term behavioral changes required of HIV seropositive gay men.

Judgments about the HIV status of gay men and that of their sexual partners appear central to understanding risk taking. Men could be challenged on the basis on which these judgements are based. Rather than telling them to ignore HIV but to always use condoms when they have anal sex, it may be prudent to encourage them to think carefully about the HIV status of their partner before they engage in unprotected anal sex.

Relationship Status: The relationship context in which sexual behaviors occur is an important aspect of understanding sexual behavior of gay men of color. Sexual behaviors connote disparate meanings in different types of relationships. Twenty eight percent of the sample reported being in a sexually exclusive relationship, making them 2.9 times more likely to engage in unprotected anal sex than men in non-sexually exclusive unions. Several studies suggest that risky sexual behavior is more frequent in primary sexual relationships than in casual relationships. Gay men in sexually exclusive relationships may not perceive themselves at risk for HIV since trust and comfort are factors commonly associated with such unions. Moreover, the termination of condom use may be perceived as an important step in achieving trust between partners. However, there is evidence to suggest that many individuals in a "sexually exclusive relationship" often have sex outside their primary union, and these relationships are often not longstanding. Therefore, there is an increased potential risk in engaging in unprotected anal intercourse within the context of a sexually exclusive relationship. In addition, HIV

infected men may also negotiate safety in their relationship by selecting seroconcordant (both partners in a couple having the same HIV serostatus) relationship partners regardless of whether they practice safe sex. Within AIDS prevention circles, this is generally referred to as "negotiated safety" and not bareback sex (intentionally seeking out anal sex without a condom). Couples whose relationships follow "negotiated safety" rules may have sex with other persons, but maintain safer sex guidelines (using condoms) with outside partners.

Length of Residence: Results suggest a negative correlation between unprotected anal intercourse and length of residence (years) in the U.S., for those born overseas. In other words, the shorter the length of stay in the United States the more likely men are to engage in unprotected anal intercourse. Implications for HIV prevention and intervention are obvious: provide effective culturally appropriate HIV prevention programs for immigrants as soon as they arrive on our shores or their risk for HIV infection will increase significantly with each passing month and year.

CONCLUSION

Unfortunately, until very recently, socio-cultural pressures for gay men and the barriers they create, as well as gay cultural contexts that promote risk for men of color, have been ignored by HIV prevention, research and service programs. This neglect continues to hinder prevention efforts in gay ethnic communities. What's more, because socioeconomic factors may preclude treatment, gay men of color are likely to receive fewer of the benefits of the newer emerging therapies. *

* The study reported here was published in its entirety, with statistical details, in AIDS Education and Prevention, 2000, Volume 19, Number 4. We acknowledge the editorial assistance of John Pasco.

Table 1

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