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JANUARY 2007
Main Article:
The Mythology of the Down Low: A critical exploration of Black men who have sex with men and HIV transmission
Lisa Hightow-Weidman, MD, MPH Clinical Assistant Professor of Medicine Division of Infectious Diseases School of Medicine The University of North Carolina - Chapel Hill Speakers Bureau: Gilead, Tibotec, Abbott Justin Smith, BA Project Coordinator Division of Infectious Diseases School of Medicine University of North Carolina at Chapel Hill Disclosures: Nothing to disclose Defining the "Down Low" Dialogue focused on the "down low" (DL) has been a dominant feature of conversations about black men and HIV/AIDS in both HIV prevention circles and the popular press. The term down low is used most often to refer to black men who are involved in relationships with women but who also have sex with other men, and do not inform their female partners about their same sex encounters. Certainly, male bisexual behavior is not new, but the ways in which it has been discussed has led many to believe that it constitutes a public health emergency due to the belief that DL black men serve as the primary HIV transmission "bridge" to black women. DL men are perceived within some communities as the sole reason for the high rates of HIV among black women. Although a primary thesis of the bestselling book that launched discussion of the DL into to the mainstream media,1 the evidence culled from the public health literature does not bear this out. There is limited research that focuses exclusively on the experiences of black men who have sex with men (MSM) relating to HIV prevention generally, and even fewer that critically examine the DL. The research literature presents a more nuanced view of the dynamics of black MSM behavior than the popular media, but HIV prevention for black MSM requires a more detailed investigation. In media depictions, DL men have been described as secretive and, because they do not perceive themselves to be at risk for HIV infection, not amenable to standard HIV prevention messages.2-5 Further, discussions about the DL generally rest upon four major myths: all DL men are HIV positive; all black MSM are on the DL; the DL can only be applied to black men; and lastly, that DL men are entirely responsible for the rising rates of HIV among black women. Our discussion will center on exploring each of these problematic assumptions. Given the disproportionate rates of both HIV and incarceration among black men, awareness of this issue and the perceptions surrounding the DL are of importance to correctional staff engaged in health care, HIV prevention and community reintegration. Myth #1: All down low men are HIV-positive Despite decreased rates of new cases of HIV among MSM following the 1980s, there is evidence for increasing unsafe behavior and HIV transmission among MSM, especially young MSM.6-8 MSM continue to constitute the largest number of HIV/AIDS patients in the United States, and black MSM are disproportionately affected by this epidemic nationwide.9 Studies that report the HIV disparity among black MSM, however, are not studies of DL men and should not be confused as such. Much of the discussion about the DL is fueled by a belief that DL men place their female sex partners at high risk for HIV infection. However, this would only be true if most or all DL men were infected with HIV. While a recent study estimates HIV prevalence rates as high as 46% for black MSM,10 this study did not specifically examine whether these men reported unprotected sex with females. The Young Men's Study - a cross-sectional survey conducted during 1994-2000 of men aged 15-29 years who attended MSM-identified venues in six U.S. metropolitan areas (Baltimore, Maryland; Dallas, Texas; Los Angeles, California; Miami, Florida; New York; and Seattle, Washington) - found that compared with black MSM who disclosed their homosexuality, those who didn't were actually less likely to be HIV-positive, less likely to have multiple male sexual partners and less likely to report unprotected anal intercourse (see IDCR-o-Gram).7 Further, although often portrayed as promiscuous, bisexual men compared with homosexual men have been found to report fewer male sexual partners and are less likely than homosexual men to have engaged in anal intercourse.11-14 Moreover, having a non-gay identity has not been found to increase HIV-risk taking behavior with male sexual partners among black MSM.15 In summary, the evidence suggests that non-gay identified men (DL men) may, in fact, be less likely to be HIV-positive than gay-identified black MSM, and in turn, less likely to transmit HIV to their female sex partners. Myth #2: All black men who have sex with men are on the down low Another assumption underpinning DL dialogue is that all black MSM are on the DL. Evidence does show that black MSM are less likely to disclose their sexual orientation or behaviors,16-18 and are less likely to identify as homosexual,16,19,20 and a larger proportion self-identify as bisexual as compared with white MSM.11,21,22 Further, among HIV-infected MSM, higher proportions of black MSM report also having sex with women compared with white MSM.21, 23 Higher proportions of bisexuality among black men may be due to the fact that same-sex relationships are often stigmatized in the black community, and black MSM face more disapproval from their families and friends than similar whites.24, 25 Other factors that may contribute to gender-role expectations and social pressures for black MSM to maintain a masculine identity and conform to sexual norms include: racism, segregation, and the powerful influence of the church within the black community.17, 26, 27 However, it is important that these data are evaluated within the context of the relatively low prevalence of bisexuality among black men; approximately 2% overall.28, 29 Moreover, while DL men are behaviorally bisexual, not all men who have sex with both men and women are on the DL. By definition, men on the down low are leading a sexually duplicitous lifestyle, knowingly lying to their female sex partners about their same sex activities. While some black MSM do not disclose their sexual practices for the aforementioned reasons, there are many who have found ways to integrate their sexuality and their racial identities. Myth #3: The down low can only be applied to black men As the high profile "outings" of former New Jersey Governor James McGreevey, and Evangelical leader Ted Haggard illustrate, being on the down low about one's same-sex desire is not the exclusive purview of black men. However, nowhere in the public discussion of these men's sex lives was there a discussion about the risk of these men transmitting HIV to their wives. While data show that black MSM are less likely than other MSM to identify as gay or to disclose their sexual identity or behavior to others, significant numbers of non-black MSM also choose not disclose to others. 11,17 In a Centers for Disease Control and Prevention (CDC) analysis of data from the Young Men's Survey, 8% of white MSM did not disclose their sexual behavior to others, compared to 14% and 18% for Hispanic and black MSM, respectively (see IDCR-o-Gram).18 Additional, research has found that substantial and similar proportions of heterosexually identified black, white and Latino men report having sex with men.11, 21, 22, 30 Myth #4: DL men are entirely responsible for the rising rates of HIV among black women Much of the rhetoric surrounding this myth stems from the assumption that HIV is a "gay disease" which spreads outwards from gay communities to infect those in the straight world. This belief demonizes and places the blame for HIV transmission on black men while also removing responsibility for HIV prevention from black women. Further, it obscures some of the other structural factors that influence black women's risk for HIV, including high rates of poverty and concurrent sexual partnerships as well as the higher rates of incarceration among black men which may contribute to the disparity in HIV rates between black women and women of other races (see Spotlight).31 While evidence suggests that black men who have sex with both men and women play important roles in connecting sexual networks of MSM and heterosexual women, the extent to which this contributes to HIV transmission to black women is unknown.32 In 2005, there were 6,978 black female AIDS cases reported in the United States. Out of that number, only 115 (2%) reported "sex with a bisexual male" as the method of exposure. This compares to 1,794 AIDS cases among white women of which 60 (3%) reported "sex with a bisexual male" as the method of exposure. 33 Further research is needed to understand more fully the roles of these sexual networks and other structural factors in facilitating HIV transmission in the black community. Issues for Corrections At year end 2004 the rate of confirmed AIDS cases in state and federal prisons was more than three times higher than in the total U.S. population.34 The racial disparity of HIV rates in the general community is also present in correctional facilities. A Georgia-based study showed that 86% of male state inmates identified as HIV-positive upon entry were black.35 As of December 31, 2005, 8.1% of black males age 25 to 29 years were in state or federal prison, compared to 2.6% of Hispanic males and 1.1% of white males in the same age group.34 Some have speculated that the increased incarceration rates among black men contribute to HIV transmission by facilitating homosexual encounters with other men during periods of imprisonment. The contribution of situational bisexuality (engaging in same sex behavior due to the unavailability of and prolonged isolation from female partners) on HIV rates has not been adequately explored. One study of black men with a history of incarceration found these men reported a higher frequency of anal intercourse with men in the community rather than during periods of confinement (45% vs. 16%, respectively). In this study, only 13% of those men who reported anal sex while incarcerated had done so for the first time during imprisonment.36 Conclusions Some bisexual men may be in transition to a homosexual identity while others will never identify as gay and will not even identify as bisexual. These non-gay identified black MSM may have risk reduction needs that are different from other MSM. To be most successful, it is critical that HIV interventions take into account that the sexual behaviors of group members may be discordant with their sexual identities.37 Further, current dialogue centered on the DL must address the veracity of each of the aforementioned assumptions. Therefore, more focused and open discussions with regard to HIV prevention in the black community are needed. Until the myths surrounding the DL phenomenon are appropriately explored, continued placement of blame of the HIV epidemic on black men does not empower black women (or men) to protect themselves and fails to foster strategies to quell the epidemic in the black community. References: 1 King J, Hunter K. On the Down Low: A Journey into the Lives of 'Straight' Black Men Who Sleep with Men: Harlem Moon; 2004. 2 Vargas J. HIV-positive without a clue: black men's hidden sex lives imperiling female partners. The Washington Post;Sect. B01. 3 Steinhauer J. Secrecy and stigma keep AIDS risk high for gay black men. The New York Times February 11, 2001;Sect. 37. 4 Harris E, Roberts T. Passing for straight. Essence 2004:156-61,210. 5 Denizet-Lewis B. Double lives on the down-low. New York Times Magazine;Sect. 28-33,48,52-3. 6 CDC. Fact Sheet- HIV/AIDS among men who have sex with men. 2005:Also available at: http://www.cdc.gov/hiv/pubs/facts/msm.htm. Accessed November 2, 2005. 7 Valleroy LA, MacKellar DA, Karon JM, et al. HIV prevalence and associated risks in young men who have sex with men. Young Men's Survey Study Group. Jama 2000;284(2):198-204. 8 Wolitski RJ, Valdiserri RO, Denning PH, Levine WC. Are we headed for a resurgence of the HIV epidemic among men who have sex with men? Am J Public Health 2001;91(6):883-8. 9 CDC. HIV/AIDS Surveillance Report, 2003. 2004(November 2, 2005):Also available at: http://www.cdc.gov/hiv/stats/2003surveillancereport.pdf. Accessed November 2, 5. 10 CDC. HIV Prevalence, Unrecognized Infection, and HIV Testing Among Men Who Have Sex with Men --- Five U.S. Cities, June 2004--April 2005. MMWR June 24, 2005 54(24):597-601. 11 Doll LS, Petersen MD, White CR, Johnson ES, Ward JW. Homosexually and Nonhomosexually Identified Men Who Have Sex With Men: A Behavioral Comparison. Journal of Sex Research 1992;29(1):1-14. 12 Diaz T, Chu SY, Frederick M, et al. Sociodemographics and HIV risk behaviors of bisexual men with AIDS: results from a multistate interview project. Aids 1993;7(9):1227-32. 13 Hernandez M, Uribe P, Gortmaker S, et al. Sexual behavior and status for human immunodeficiency virus type 1 among homosexual and bisexual males in Mexico City. Am J Epidemiol 1992;135(8):883-94. 14 Lewis DK, Watters JK. Sexual behavior and sexual identity in male injection drug users. J Acquir Immune Defic Syndr 1994;7(2):190-8. 15 Millett GA, Peterson JL, Wolitski RJ, Stall R. Greater Risk for HIV Infection of Black Men Who Have Sex With Men: A Critical Literature Review. Am J Public Health 2006;96(6):1007-19. 16 Ostrow DG, Whitaker RE, Frasier K, et al. Racial differences in social support and mental health in men with HIV infection: a pilot study. AIDS Care 1991;3(1):55-62. 17 Kennamer JD, Honnold J, Bradford J, Hendricks M. Differences in disclosure of sexuality among African American and White gay/bisexual men: implications for HIV/AIDS prevention. AIDS Educ Prev 2000;12(6):519-31. 18 CDC. HIV/STD risk in young men who have sex with men who do not disclose their sexual orientation-six U.S. cities, 1994-2000. MMWR 2003;52:81-5. 19 McKirnan D, Stokes JP, Doll L, Burzette R. Bisexually active men: social characteristics and sexual behavior. J Sex Res 1995;32:65-76. 20 Heckman TG, Kelly JA, Bogart LM, Kalichman SC, Rompa DJ. HIV risk differences between African-American and white men who have sex with men. J Natl Med Assoc 1999;91(2):92-100. 21 Montgomery JP, Mokotoff ED, Gentry AC, Blair JM. The extent of bisexual behaviour in HIV-infected men and implications for transmission to their female sex partners. AIDS Care 2003;15(6):829-37. 22 Goldbaum G, Perdue T, Wolitski RJ, et al. Differences in Risk Behavior and Sources of AIDS Information Among Gay, Bisexual, and Straight-Identified Men Who Have Sex with Men. AIDS and Behavior 1998;2(1):13-21. 23 Chu SY, Peterman TA, Doll LS, Buehler JW, Curran JW. AIDS in bisexual men in the United States: epidemiology and transmission to women. Am J Public Health 1992;82(2):220-4. 24 Lewis LJ, Kertzner RM. Toward improved interpretation and theory building of African American male sexualities. J Sex Res 2003;40(4):383-95. 25 Stokes JP, Peterson JL. Homophobia, self-esteem, and risk for HIV among African American men who have sex with men. AIDS Educ Prev 1998;10(3):278-92. 26 Miller M, Serner M, Wagner M. Sexual Diversity Among Black Men Who Have Sex with Men in an Inner-City Community. Journal of Urban Health 2005;82(1):i26-i34. 27 Wolfe W. Overlooked role of African-American males' hypermasculinity in the epidemic of unintended pregnancies and HIV/AIDS cases with young African-American women. J Natl Med Assoc 2003;95:846-52. 28 Mercer CH, Fenton KA, Copas AJ, et al. Increasing prevalence of male homosexual partnerships and practices in Britain 1990-2000: evidence from national probability surveys. Aids 2004;18(10):1453-8. 29 Binson D, michaels S, Stall R. Prevalence and social distribution of men who have sex with men: United States and its urban centers. J Sex Res 1995;32:245-54. 30 Millett G, Malebranche D, Mason B, Spikes P. Focusing "down low": bisexual black men, HIV risk and heterosexual transmission. J Natl Med Assoc 2005;97(7 Suppl):52S-9S. 31 Adimora AA, Schoenbach VJ, Doherty IA. HIV and African Americans in the southern United States: sexual networks and social context. Sex Transm Dis 2006;33(7 Suppl):S39-45. 32 Hightow LB, Leone PA, Macdonald PD, McCoy SI, Sampson LA, Kaplan AH. Men who have sex with men and women: a unique risk group for HIV transmission on North Carolina College campuses. Sex Transm Dis 2006;33(10):585-93. 33 CDC. Cases of HIV infection and AIDS in the United States and Dependent Areas, 2005. HIV Surveillance Report 2005;17. 34 Bureau. of Justice Statistics, HIV in Prisons, 2004. November 2006;NCJ 213897. 35 CDC. HIV Transmission Among Male Inmates in a State Prison System --- Georgia, 1992--2005. MMWR;55(15):421-26. 36 Wohl AR, Johnson D, Jordan W, et al. High-risk behaviors during incarceration in African-American men treated for HIV at three Los Angeles public medical centers. J Acquir Immune Defic Syndr 2000;24(4):386-92. 37 Ross MW, Essien EJ, Williams ML, Fernandez-Esquer ME. Concordance between sexual behavior and sexual identity in street outreach samples of four racial/ethnic groups. Sex Transm Dis 2003;30(2):110-3. |
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