Masculinity

Normative and dominant masculinity in American culture has been described as antifeminine, homophobic, heterosexist, and misogynistic. Some have suggested that stereotypical male gender roles of hypermasculinity (ie, exaggeration of traditional masculine roles through behaviors such as sexual prowess, physical dominance, aggression, competition, and antifemininity) seen in some black men may be a way for black men disempowered by a social context of limited access to socioeconomic power, racism, and discrimination by a predominantly white male society to demonstrate power and authority and to approximate the American masculine ideal.

This compensatory expression of hypermasculinity has been suggested as an important coping strategy for racism, oppression, and marginalization, particularly in young black men. Majors’ and Billson’s conceptual framework “Cool Pose,” describes a hypermasculine strategy embraced by black males to cope with and survive in the face of social oppression and racism. Lacking the resources to obtain the traditional American societal prescription for masculinity, “Cool Pose” fosters the development of compulsive masculinity as an alternative to traditional definitions of manhood that “compensates for feelings of shame, powerlessness and frustration” by typifying toughness, sexual promiscuity, and violence to resolve personal conflicts.

The expression of hypermasculinity among black men has also been associated with community and peer acceptance as well as fortification of self-image and self-esteem. In contrast with the expression of hypermasculinity, disclosure of homosexuality has been associated with depressive distress, alienation, and social isolation within black communities. These social sanctions are due, in part, to perceived direct contradictions between “hypermasculine” gender role expectations for black men and association of homosexuality with exaggerated stereotypes of being weak and effeminate. YBGBM may alter their presentation or expression of masculinity as a strategy to either avoid ridicule or to fit in and maintain social ties with important others.

Although maximizing social reward and avoiding social sanctions are strong motivators, achieving or striving for these homonegative masculine expectations carries significant risk for YBMSM. Fields and colleagues (2015) applied gender role strain theory to a sample of YBMSM who felt pressured to conform to homonegative expectations of masculinity from important others—for example, family, peers, and community. In this analysis, they found examples of psychosocial distress, efforts to camouflage or hide same-sex behavior and identity, strategies to prove one’s masculinity, and the potential for increased HIV risk through social isolation, poor self-esteem, reduced access to HIV prevention messages, and limited parental involvement in the development and exploration of sexuality. Moreover, the norm of nondisclosure of same-sex behavior in black communities where homosexuality is viewed as incompatible with masculine expectations can create opportunities for HIV risk for YBGBM, including exploration of sexuality in hidden, high-risk, often age-discordant, settings such as from the Internet and telephone-based venues.

Religion

Religiosity and religious affiliation have generally been associated with positive mental and physical health outcomes in both cross-sectional and prospective studies. However, among sexual minorities, the beneficial impact of religion is less clear. Religious affiliation, although protective in some ways, has also been associated with mental health pathology in YBGBM including psychological distress, depression, poor self-esteem, and internalized homophobia. This relationship between religious affiliation and internalized homophobia has been described by minority stress theory, which posits that health disparities affecting sexual minorities are the result of differential exposure to stigma, homophobia, and rejection (see Mark L. Hatzenbuehler and John E. Pachankis’ article, “ Stigma and Minority Stress as Social Determinants of Health Among LGBT Youth: Research Evidence and Clinical Implications ,” in this issue). As a result of this process, some LGBT youth may disassociate more from institutional religion as a coping strategy to avoid the stressors associated with homonegative and potentially stigmatizing social environments.

The salience of religiosity in black communities may limit the value and relevance of disassociation as a coping strategy for YBGBM. The Black Church, a term that refers to the 7 historically black protestant denominations founded after the Free African Society of 1787 and representing more than 80% of black Christians in the United States, is a central religious, social, and cultural institution in black American society. It is uniformly recognized as the most influential institution in black American society and has been at the center of social and political activity throughout history, leading the Civil Rights movement, and other social justice issues related to racial oppression and discrimination. The Black Church has also been a refuge from discrimination and marginalization for black communities. Upwards of 80% report religion as an important part of their lives, and for many of these individuals religion and affiliation with the Black Church as a religious and sociocultural institution are salient to both their self-concept and their black identity.

Although black churches are not a monolithic entity and do not uniformly object to homosexuality, many, like other religious institutions, do espouse proscriptive messages against same-sex behavior and identities. The Black Church as an institution has generally been described as homophobic and intolerant of same-sex sexuality and is one of the principal sources of homonegative messages in black communities, influencing churchgoers and nonchurchgoers alike. In some churches, this message is manifested as silence during the AIDS crisis and in others, the message manifests as explicit and consistent condemnation of homosexuality and homosexual persons. This is sometimes replicated in families, among peers, and in the larger community. In addition to the morality of homosexuality, the conflation of gender and sexuality in masculine socialization as described is also entwined in the homonegative messages, which further emasculates such men by making them incapable of meeting expectations for men in the church or in the larger community.

YBGBM are challenged with significant conflict at the intersection of their same-sex behavior and sexual identity, racial identity, and religiosity. For many, the church environment is highly salient to other aspects of their multiple and intersecting identities and central to black American life and black racial identity. In studies of YBGBM experiences with religiosity, many describe managing this conflict by compartmentalizing their sexual identity within religious contexts. Balaji and colleagues (2012) in a qualitative study of 16 YBMSM (19–24 years of age) described study participants engaging in ‘role-flexing,’ a strategy for maintaining masculine expectations and camouflaging or concealing sexual orientation to avoid exposure to direct homonegative prejudice in religious settings. This strategy may place youth, particularly those who have not integrated their sexual identity into their sense of self (ie, identity integration), at risk for internalizing many of the homonegative messages they seek to avoid. Others, often older adults, described managing this conflict by integrating their religiosity and sexuality through attending religious institutions (often nonblack or non-Christian) that affirmed same-sex sexuality, creating new religious communities outside of traditional church environments, abandoning institutional religion in favor of a more personal and individual relationship with a higher power, or remaining in traditional black religious institutions and rejecting homonegative or nonaffirming messages.

Promoting Factors

In the preceding sections, we provided a conceptual approach to understanding how intersecting identities like race, gender, and culture impact one’s risk for adverse health outcomes. Marginalization for YBGBM can be promoted further by factors like poverty and low socioeconomic status, racial segregation, homonegativity, stigma, and limited social connectedness. YBGBM, for example, are often disproportionately burdened by the socioeconomic inequity and poor social and built environment that increases risk for HIV and other poor outcomes relative to their white sexual minority peers. Table 1 reviews these promoting factors further and summarizes how these factors increase risk for HIV and other health and social disparities for YBGBM. Factors such as poverty, social environment (including racial segregation), homonegativity, stigma, and limited social connectedness can further isolate YBGBM predisposing them for risk. Such factors further perpetuate macrolevel factors that impact on the individual level.

Table 1

Promoting factors affecting adverse health outcomes among YBGBM

Domain	Key Points
SES and the structural, social and built environment	• Racial disparities in health can be explained by differences in SES and low SES has been associated with health-related behaviors and poor health outcomes. Structural, social, and the built environment (where people live) also explains many of these disparities. • HIV and other poor outcomes are often clustered in areas stricken by poverty, crime, high density of alcohol outlets, poorly performing schools, food deserts, vacant houses, and other markers of underinvestment in infrastructure and social services. • These areas are often characterized by socioeconomic inequity, which can lead to negative health outcomes through poor social cohesion, low collective efficacy, and physical and social disorder. • Several studies have demonstrated an association between the social and environmental context of disadvantaged neighborhoods and sexual risk behavior or sexual outcomes among heterosexual adolescents and emerging adults. Far fewer studies of this sort have been done among YBMSM; however, there is evidence of similar associations. In a study of 1289 YBMSM (18–29), socioeconomic distress (as measured by less than a high school degree or GED, less than full-time employment, annual income of less than $20,000, in the past year borrowing money to meet basic needs or running out of money at least once, ever being incarcerated, and ever being homeless) was associated with CAI, a significant risk factor for HIV. A similar study of 328 Detroit YMSM (age 18–29), demonstrated those with income below the poverty line were less likely to have ever been tested for HIV and more likely to report CAI with a serodiscordant partner. In the same study, YMSM living in neighborhoods with greater socioeconomic disadvantage were more likely to have had an HIV test and less likely to report CAI with serodiscordant partners, a finding authors postulate may be due to targeted HIV control efforts to address HIV disparities in underserved areas.
Racial segregation of sexual networks and HIV risk	• New HIV infections among YBMSM (aged 13–24) continue to outpace other racial/ethnic MSM subgroups in the United States, despite equivalent or lower rates of individual HIV risk behavior. • Racial/ethnic segregation—particularly in poor, urban, inner-city environments—has left black and other racial/ethnic minorities disproportionately affected by both low SES and social and built environments that negatively impact health. Public health surveillance data and several studies have demonstrated that black MSM are more likely to live in neighborhoods with lower income and higher HIV prevalence and are more likely to have lower individual SES compared with white MSM. • Evidence suggests that HIV disparities affecting YBMSM are perpetuated by differences in their sexual networks, including greater race concordance and age discordance between sex partners, higher sexual density (ie, extent to which members are having sex with each other), and greater likelihood of residence in neighborhoods with high HIV prevalence in YBMSM sexual networks. • Another notable difference is the racial segregation of sexual networks. Preference for black partners has been described in qualitative studies of young and adult black MSM and likely reflects salience of black identity and desire for shared experiences. However, there is also evidence of marginalization of blacks in sexual minority communities that contributes to the racial homogeneity of the sexual networks of black MSM.
IH	• IH is an unconscious process where negative societal messages about lesbian, gay, bisexual people become internalized by lesbian, gay, and bisexual persons. • The impact of IH on health outcomes has been unclear, but strongest associations have been seen with mental health outcomes, where higher IH predicts greater internalizing mental health problems (eg, depression and anxiety). There have also been positive associations reported between IH and guilt, shame, and low self-esteem and evidence that IH also predicts poor sexual identity development and nondisclosure of sexual identity. • Youth-specific studies have been limited, but existing work has demonstrated links between IH and unsafe sexual behaviors, substance use, and nondisclosure of sexual orientation among sexual minority youth. • Internalized homophobia has also been shown to vary by race and class with greater IH associated with black race, lower education, poverty, homelessness, and history of incarceration. Qualitative studies of YBGBM and adult black MSM have consistently described internalization of homonegative messages among study participants, the negative impact on psychological well-being, and the mechanism by which these ill effects can lead to increased HIV risk.
Stigma	• Black gay and bisexual men experience stigma and discrimination in the form of isolation and detachment from both the black and the gay communities. • The personal experience of stigma, homophobia, and discrimination related to one’s race and sexual orientation has been directly related sexual risk behavior including condom nonuse ; poorer mental health outcomes, including low self-esteem, increased depression, anxiety, suicidal ideation and suicide attempts ; and maladaptive coping strategies, including substance abuse and engaging in fewer health-seeking behaviors. • HIV-related stigma additionally impacts care for HIV-infected and at-risk YBGBM and has been associated with a delay in care seeking after HIV diagnosis and nonadherence to HIV medical appointments and may be a barrier to HIV and other sexual health promotion screening services. • Minority stress theory suggest that it is the additive effect of socially based membership in marginalized groups that further magnifies the type of social stress that is the result of one’s environment.
Limited social connections	• YBGBM are less likely, compared with their white peers, to benefit from connectedness to sexual minority communities. The experience of racism in predominantly white sexual minority communities has been cited as a deterrent to seeking connectedness or support from these communities. • Black gay, bisexual, and other MSM often describe social isolation and lack of social support from black communities and, in qualitative studies, have consistently reported the absence of organized communities and opportunities to connect with and support one another, citing homophobia and secrecy around same-sex behaviors as contributing factors. • Instead, opportunities for interpersonal and peer social interaction, particularly for young men, have been limited to pornography, sexual venues, and social media outlets. This social isolation and lack of social support can have deleterious effects on identity development, self-mastery, and self-esteem, lead to IH and identity concealment and contribute to sexual and other risk behaviors.

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