The ‘Down Low’: More Questions than Answers

The ‘Down Low’: More Questions than Answers Greg Millett, MPH Epidemiology Branch Division of HIV/AIDS Prevention National Center of HIV/STD/TB Prevention

Overview • Introduction to the ‘Down Low’ • Epidemiology of HIV/AIDS • Black MSM • Black Women • Relevant Studies • Gaps and Recommendations

I. Introduction to the ‘Down Low’

What is the ‘Down Low’? • Black men • Heterosexually identified • Have sex with men • Don’t tell female partners

Identities Black Male Heterosexual (gay’ or ‘bisexual’ do not apply) Masculine Shun mainstream gay subculture Transitional rather than permanent status Partners/ Practices Casual male partners Steady female partner Nondisclosure of MSM activities Unprotected sex with both female and male partners Assumptions about Men on the DL

Identities Black Male Heterosexual (gay’ or ‘bisexual’ do not apply) Masculine Shun mainstream gay subculture Transitional rather than permanent status Partners/ Practices Casual male partners Steady female partner Nondisclosure of MSM activities Unprotected sex with both female and male partners HIV Status Unaware of HIV status Nondisclosure of HIV+ status to sexual partners. Assumptions about Men on the DL

Assumptions about Men on the DL, contd • Culturally- and race-specific term • Assumed Black men are on the down low • Other racial/ethnic groups engage in identical behaviors • Reasons it is a culture-specific phenomenon • Term arose from Black MSM community • General Black community identifies the DL as a problem • Press about the DL has focused entirely on Black men • Black men on the DL identify with term

Assumptions about Men on the DL, contd • "I sleep with men, but I am not bisexual, and I am certainly not gay. I am not going to your clinics, I am not going to read your brochures, I am not going to get tested. I assure you that none of the brothers on the down low like me are paying the least bit of attention to anything you have to say." -JL King

Evolution of a Concept 1991 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Evolution of a Concept, contd “…So I creep yeahJust keep it on the down lowSaid nobody is supposed to knowSo I creep yeah'Cause he doesn't knowWhat I do and no attentionGoes to show…” “…And keep it on the down lowNobody has to knowWe can keep it on the down lowNobody has to know 1991 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Evolution of a Concept, contd 1991 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

What is the uproar about? • "We will continue to lose sisters because men will not come out.” -JL King Down-Low' Activity Threatens Black Women’ by R Dotinga for Gay.com/PlanetOut.com Network 4/30/02

What is the uproar about?, contd • “Too often the DL brother is constructed as the vessel of contagion… behind this …[is a ] heterosexist assumption that AIDS is born and bred in gay communities then venomously spread to pure, sterile black communities… [the fact is] that many …straight black people are HIV-positive and spreading the disease among themselves without any help from ‘evil’ black gay men.” Posted by Blackbrit 8/1/03 NY Times Magazine Web Forum

II. Epidemiology of HIV/AIDS: Black MSM and Women

Black Men: AIDS Cases By Exposure • 2002 AIDS cases among Black men: 32% Men who have sex with men 19% Injection drug use 14% Men who have sex with women 4% Sex with men/ Injection drug use N= 14,334

Initial dx of HIV among MSM ages 13-24 Black 16% ; Latino 13%; White 9%(MMWR, 1/14/00) Among MSM ages 23-29 HIV Prevalence: Black 32% , Latino 13%, White 7% (MMWR, 6/1/01) HIV Incidence: Black 14.7%, Latino 3.5%, White 2.5%. (MMWR, 6/1/01) Black MSM: HIV Data

Black Women: Heterosexual Contact AIDS Cases • In 2002 • Black women 65% of heterosexual transmission AIDS cases among all women • 42% of AIDS cases among Black women was transmitted sexually • It is unknown what proportion of these heterosexually transmitted HIV cases are attributable to DL men in comparison to non-DL men

Black MSM: Prevalence of Sex with Women * Different timeframes (‘ever’, 6 months, year, past 5 years) + Sex with ‘men and women’. No estimate of sex with ‘women only’ provided.

III. Relevant Studies

“… I think a lot of these young men only have wives or girlfriends to cover up their homosexuality. In the meantime, they are denying who they are...” Posted by Brandip 8/3/03 NY Times Magazine Web Forum Sexual orientation: to whom you are attracted (men, women, both) Sexual identity: how you describe yourself (to yourself and others) Sexual behavior: with whom you have sex (Purcell et al., 1996) Sexual Identity and Behavior

Sexual Behavior and Identity • Black MSM studies mostly gay- ID men rather than bisexual men MSM Behavior Studies Gay ID Sample

Sexual Behavior and Identity • Black MSM studies mostly gay- ID men rather than bisexual men • Studies of bisexually active men primarily bisexual-ID, not heterosexual MSM Behavior Studies Bisexually ID Sample Gay ID Sample

Sexual Behavior and Identity • Black MSM studies mostly gay- ID men rather than bisexual men • Studies of bisexually active men primarily bisexual-ID, not heterosexual • Studies of heterosexual-ID men primarily men who only have sex with women MSM Behavior Studies Bisexually -ID Sample Gay-ID Sample DL men Heterosexually-ID Sample

Heterosexually-Identified Black MSM: Sexual Risk-Taking (Wohl et al., 2002)

Popular Theories of HIV Risk among DL Men • Homophobia in Black community • Dual minority status (fragmented identities) • Nondisclosure of sexuality • Incarceration • Drug use

Homophobia and AIDS-phobia in Black and White Communities • “The ‘reporter’ or anthropological tour guide provided no basis for his assertion that blacks are generally more homophobic than whites…” Posted by Blublklove 8/4/03 NY Times Magazine Web Forum • Similar attitudes among Blacks and Whites re: • PWAs(Herek & Capitanio, 1993) • Homosexuals(Herek & Capitanio, 1995; Lewis, 2003) • Blacks and Whites have negative associations with gay sex and HIV(Herek & Capitanio, 1999)

Sexual/ Racial Identity Integration and HIV Risk • Influence of racial and sexual identity on psychosocial functioning: • N= 174 Black MSM • Integrated identity associated with self-efficacy to engage in HIV preventive behaviors (Crawford, et al, 2002) Racial ID Hi Low Hi Sexual ID Low

Disclosure and HIV Risk • Compared to Black MSM who disclosed their sexuality, Black MSM nondisclosers: • Peceived HIV risk • Less likely to believe that they could become infected with HIV • HIV test and status • Less likely to report > 3 lifetime HIV tests • Less likely to be HIV-positive • Sexual partners and risk: • More likely to have> 3 lifetime female partners or report unprotected vaginal or anal sex with women • Less likely to > 5 lifetime male partners or report unprotected sex with men (MMWR, 2003)

Prison and HIV Risk • Few studies documenting homosexual activity among incarcerated Black men(Alarid, 2000; Lichtenstein et al., 2000) • Black MSM LA County (N=332)(Wohl et al., 2000) • No association between incarceration and HIV status • Higher rates of anal sex outside of prison • This finding was consistent across sexual orientation

Drug Use and HIV Risk • Heterosexual-ID men (N=90 HIV+; N=272) • Cases more likely to use: • Heroin • Methamphetamine • Nitrites • No difference in trading sex for drugs between cases and controls • Cases less likely to report condom use when trading sex for drugs (Wohl et al., 2000)

Summary • Sexual orientation, identity, and behavior are not always congruent • Most previous research on Black MSM is not applicable to DL men. • Theories of HIV risk among DL men must be tested with DL populations

IV. Gaps and Recommendations

Gaps and Recommendations • Need additional qualitative and quantitative studies • Specify meaning of DL • Integrate probability-based methods into sampling procedures • Determine sexual risk of DL men in relation to other Black men

Gaps and Recommendations • Investigate contextual factors of HIV risk for DL men • Develop effective interventions for Black MSM

CDC Katherine Bina Lisa Fitzpatrick Alan Greenberg Charles Heilig Gary Marks Byron Mason Pilgrim Spikes Georgia State University John Peterson Acknowledgements

The ‘Down Low’: More Questions than Answers