Nina T. Harawa , M.P.H, Ph.D Hema C. Ramamurthi , M.B.B.S, M.S.

1. Power and Prejudice: Perceptions of people who provide services to Non-Gay Identifying African American men who have sex with men Nina T. Harawa, M.P.H, Ph.D Hema C. Ramamurthi, M.B.B.S, M.S. Charles Drew University of Medicine and Science John K. Williams, M.D University of California, Los Angeles Linda Muticelli, M.A University of Southern California, Los Angeles August 4, 2008 Supported by California HIV/AIDS Research Program

2. Academic -Community Collaborative Academic Institutions Charles Drew University of Medicine and Science & University of Los Angeles, California Community Partners AmaSSI Culture and Wellness Center JWCH Institute & Palms Residential Care Facility

3. Discrimination and HIV • HIV predominantly affects groups that are stigmatized in the absence of infection (gay men, injection drug users) (Mays, Cochran, 2001; Burke, White, 2001) • In the US, HIV disproportionately affects African Americans who experience racial and ethnic discrimination

4. Discrimination and NGI MSM • Men who have Sex with Men (MSM) are more likely to report discrimination than injection drug users (Schuster et al, 2005) • Non gay identifying (NGI) MSM are associated with the following characteristics: • Incarceration (Doll et al.,1997) • Engaging in survival sex • Being closeted to maintain socially acceptable lifestyles (Stokes & Peterson, 1998)

5. NGI Black MSM • HIV- positive and HIV- negative Black MSM experience: • Institutional discrimination • Sociopolitical challenges from within the community and from outside groups. • Triple minority status • Black • MSM • Perceived HIV positive

6. Why is it important to understand the role of prejudice among service providers? • Prejudice among service providers may negatively affect a relationship that involves inherent “power differentials”. • Studies in the US have demonstrated that African American patients express less satisfaction with their healthcare providers compared to their White counterpart.

7. Aim of this presentation • To describe findings from the qualitative phase of the Men of African American Legacy Empowering Self (MAALES) Project • Questions that are addressed in this presentation: • What are the prejudices that service providers have regarding non-gay identified Black MSM? • How do these prejudices affect provider-client power dynamics?

8. Methods • In person qualitative interviews with Los Angeles-based service providers • Conducted in 2007-2008 • Participants included:2 nurses, a corrections officer, a housing manager, 2 case managers, 2 spiritual leaders, a HIV testing counselor/group facilitator and a hairdresser • Participant characteristics (3 women & 7 men; 8 African American, 1 White, 1 Latino) • Interviews were recorded and transcribed • Analyzed using constant-comparison method • analysis still in process

9. RESULTSMajor Themes and Definitions • Prejudice Refers to positive or negative prejudgments or broad generalizations by the providers’ of their NGI African American MSM clients. • Power Differential Refers to the imbalance in the relative power in a provider- client relationship.

10. Expressions of Prejudice and Implications for Power Differentials

11. Preference of labels by NGI AA MSM • By using terms other than “gay”, NGIs are considered as being indecisive and playing games. “I think they are confused, I think they are really confused and I think nowadays a lot of people just try it. They try it and they like it and they still consider themselves straight.”

12. Preference of labels by NGI AA MSM • Another example: “The gay one is going to be very upset with the one that’s really bisexual and that’s just the way it is because they (gay men) feel like the person (the bisexual) is playing games...”

13. Preference of labels by NGI AA MSM Contd. • In some cases, not using the term gay may create admiration. “I had an actual client tell me that he just does not like that label. He likes who he likes and when he likes them. It’s a preference…” “This generation does not want to be labeled, because then you are putting them in a box. And I want to stretch, I don’t wanna be in your boxes.”

14. Use of labels by NGI AA MSM: Implications for Power Differential Force clients to choose an identity or provider forces identity for them (i.e., “they are just gay”) Or Respect clients’ identities

15. Non-Disclosure of Sexual Preferences • Frowned upon and leads to assumptions “He (the client) walks through my door and he hasn’t told her (client’s partner) . She doesn’t know. She doesn’t know…He is not using protection. I think she is going to get it (HIV)”

16. Non-Disclosure of Sexual Preferences • Accepted when provider understands the risks (stigma from community, and church and loss of social support) “You know, in church, any of that, don’t feel comfortable with that. And there are many people who are in those kind of environments. Today you’re in that kind of black male macho environment. In that environment, to talk about sleeping with another guy is just taboo among brothers.”

17. Non-Disclosure of Sexual Identity: Implications for Power Differential Withholding services or revealing “non-disclosing clients’ sexual preferences” Or Being respectful and offering more support to the client

18. Non-Disclosure of HIV Status • Viewed as being selfish and without conscience. “For example here is a person who, is positive and I’m asking, “Have you disclosed ?”, (to one of his ex-partners) he’s like, “No.” I said, “Well, are you using condoms?” And he’s like, “No.” I was like, “How does that make you feel, knowing you knew all along?”

19. Non-Disclosure of HIV Status • Viewed sympathetically in certain instances. “…it’s the sense of wanting to be wanted, I guess their fear, probably, of, if I tell my partner, I’ll be alone, they’ll just leave me. And that could contribute to them not disclosing.”

20. Non-Disclosure of HIV Status: Implications for Power Differential Provider can be upset about the client and seek silent retribution Or Provide skills to overcome fear and loneliness and communication about HIV status to partner

21. RELATION BETWEEN PREJUDICE AND POWER DIFFERENTIAL PREJUDICE DYNAMIC PROCESS + + + + - - - - Higher Power DifferentialLower Power Differential Less Support More support Less access to resources More access to resources Less respect and boundaries Maintain boundaries and respect Risk of affecting confidentiality Higher chance of maintaining confidentiality

22. REVISITING “Why is it important to understand the role of prejudice among service providers? • More HIV + cases  Increased need for providers • “Triple Minority” population + Economic Vulnerabilities  Unique needs

23. IMPLICATIONS FOR PRACTICE- MAALES PROJECT Facilitator • Sensitization training (sexual identity, HIV status) • Training in boundary issues and confidentiality MAALES Curriculum - Intervention for NGI AA MSM • Communication skills-building • Explore expectations regarding Black masculinity • Acceptance of self and sexual identity • Critical Thinking skills to negotiate prejudices from the community, providers and society

24. Acknowledgements • Participants of the interviews • Interviewers • Marvin Jones (JWCH Institute) • Tyrone Clarke (AmASSI Health and Wellness Center) • Tony Wafford (Palms Residential Care Facility) • Nina Harawa (Charles Drew University)