On World AIDS Day 2018, “Know Your Status” Really Is a Matter of Status

December 18, 2018 @ 10:11 pm

By Elwin Wu

Do you remember the first time you saw a man and a woman kiss? Most young adults do when I ask them. Usually they were quite young, under 10. Maybe they saw their parents kiss or a couple kissing on a television show. Then I ask: what about two men kissing? Err. Pause. Most reply: much later, maybe at 14, 18, or even as an official adult at 21.

What about showing tenderness to a partner, or providing loving care? In my experience, many men in same-sex relationship had not seen examples of these basic foundations of a relationship. How, then, did they learn
how to show tenderness and care to a partner of the same sex?

That’s where I begin in one of my studies of black men who have sex with men. How does heteronormativity impact their relationships? I also looked at the prevalence of child sexual abuse in this population and whether it contributes to the likelihood of acquiring HIV or dying.

What I found was incredibly stark, and highlights the need for our continued observance of this day of remembrance, World AIDS Day. This year’s theme, “know your status,” resonates beyond the virus that causes HIV. And it really is about status.

Since the onset of the HIV/AIDS epidemic in the United States, men who have sex with men have almost a four-fold lifetime risk of becoming infected by HIV compared to the next highest risk group, women who inject drugs. Among black men who have sex with men, the figures are even bleaker. Since 2008, the number of annual HIV diagnoses among these men has exceeded those among white men who have sex with men, despite the white non-Hispanic population being six times larger than the black population in the United States. In fact, black men who have sex with men have a one-in-two lifetime risk of becoming infected by HIV—50%.

These outcomes are exacerbated by lack of status in society, and the ever-present stigma, often leading to intimate partner violence and complicated by substance use. What other condition has a higher than 50% morbidity rate?

Only death.

We are seeing you

We are seeing you: “You” in this case are the 1,002 black men who have sex with men who participated in the study I conducted in New York City at the Social Intervention Group (SIG) here at Columbia University School of Social Work. The study, “Connect and Unite,” is abbreviated as CNU—which we pronounce as “seeing you”: we are seeing you, the invisible black men.

In the CNU study, we applied knowledge from SIG’s early couples-based therapy research spearheaded in the 1990s by SIG’s Director Dr. Nabila El-Bassel, to the population of black men who have sex with men. We wanted to assess three things about these men’s lives:

  • Did they experience childhood sexual abuse?
  • Have they experienced intimate partner violence, and were they using illicit substances?
  • Then: how does this impact HIV risk and transmission?

Assessing intimate partner violence included customized questions about whether a partner had “threatened to out” a respondent’s sexuality or “threatened to disclose” them as HIV-positive (regardless of actual status). The men and their partners conjointly worked with a facilitator to address HIV, substance misuse, and other threats to the well-being and physical/sexual health of black men in same-sex relationships.

How stigma impacts status

As mentioned, most kids might have seen Mommy, not Daddy, kissing Santa Claus. What we see and experience impacts our perception of what is normal. Childhood sexual abuse goes unreported among black men who have sex with men because they are already marginalized—both as black men and as gay men. The lack of status these men hold in society, and the stigma—defined by sociologist Erving Goffman as the social devaluation and discrediting associated with certain characteristics, behaviors, illnesses, and social statuses—increases the likelihood that they will be a target for abuse. The ideal victim remains silent, and the perpetrator knows this.

Coping with the trauma of this abuse often involves self-medicating—getting high—which can exacerbate the incidents of intimate partner violence and in turn cycle back to more substance use. Further, men often report fear of sharing their history of childhood abuse due to their terror of being outed as gay, since the perpetrators of this abuse are most often men. Sexual minorities are targets for abuse due to the very nature of their social isolation.

In addition to suffering from the effects of childhood sexual abuse, the men are reluctant to get tested for HIV. Many reported, “As a black man, I’m sick of HIV being my life, and getting treated as a potential vessel of HIV.”

Childhood sexual abuse is not only a developmentally early stressor. Much research has documented the link to subsequent problems like HIV, substance misuse, mental health problems, and intimate partner violence among many populations. It is also a precursor to increased HIV risk.

I have often posited that if you remove the stigma and barriers to seeking treatment for ill health, you remove the behaviors and social structures that lead to that ill health in the first place.

Implications for World AIDS Day and beyond

The only time many men in the CNU study saw men together like them was through porn. The debate on the harm of pornography is for another article, but most would agree that porn typically depicts a problematic notion of sex, one that is quite silent on how individuals should behave in relationships outside of a literal sex act.

It is not surprising that gay men, given they lack the broader context to deepen their understanding of how to relate beyond sex, feel compelled to have sex—mostly surreptitiously, due to the stigma involved and their status in society. In contrast, the heterosexual version of relationships is not just sex.

We have a long way to go before same-sex relationships or gender non-conforming relationships are seen as part of the broader gradient of healthy relationship possibilities, but seeing this—and depicting gay couples in meaningful relationships—is one of the keys to ending HIV transmission and substance use, as well as curbing childhood sexual abuse. By moving away from identities to interactions, and not just viewing gay man as vessels for disease, we end the fear associated with knowing your status.

Elwin Wu is a professor at the Columbia School of Social Work, an associate director of CSSW’s Social Intervention Group, co-director of the HIV Intervention Science Training Program (HISTP), and a faculty affiliate of the Columbia University Global Health Research Center of Central Asia. Dr. Wu conducts prevention and intervention research that focuses on those who reside at the nexus of drug abuse, partner violence, and HIV. He has served as PI for studies concerning marginalized populations such as criminal justice-involved individuals, men who have sex with men, and racial/ethnic minorities and people of color in the USA. In his role as co-director of HISTP, Dr. Wu has also been funded to train promising new investigators from social work, psychology, and other behavioral health sciences who are interested in bringing innovative programs of HIV research to larger scale.

Related Links:

  • Childhood sexual abuse among Black men who have sex with men: A cornerstone of a syndemic?, by Elwin Wu, PLOS|ONE, 1 November 2018.
  • Social Work LIVE: Elwin Wu and Intersectionality in Social Work