RELATIONAL RESILIENCE, SENSE OF COMMUNITY, AND SYNDEMICS AMONG
YOUNG BLACK GAY AND BISEXUAL MEN
By
Sarah J. Reed

A DISSERTATION
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
Psychology – Doctor of Philosophy
2014

ABSTRACT
A CONTEXTUAL ANALYSIS OF SYNDEMIC RESILIENCE AMONG YOUNG BLACK
GAY AND BISEXUAL MALES
By
Sarah J. Reed
Syndemics theory suggests that there are overlapping, synergistic epidemics that
contribute to HIV risk in culturally and socioeconomically marginalized communities. As a
conceptual framework, syndemics postulates that HIV is only one of many social problems that
infringes upon the health of affected communities. The seminal syndemics literature urges
researchers and scholars to identify the socio-cultural antecedents of syndemic production and
the conditions facilitative of health and well-being; however, much of the syndemics literature
has prioritized the identification of syndemics, rather than the causes of syndemics or the factors
that preclude syndemic production.
The conceptual syndemics literature is evolving to include attention to protective factors
that inhibit or mitigate health problems or risk behavior. In this dissertation, I examined
relational factors associated with the avoidance of syndemic production among a group
disproportionately likely to be affected by HIV: young Black gay and bisexual men. Using
analytic induction, I analyzed the relational lives of 23 young Black gay and bisexual who have
avoided syndemic production (i.e., the expression of psychosocial health issues associated with
heightened risk for HIV) to examine how relationships and relational factors promote young
men’s healthy development and sexual health. Using theoretical sampling, I also examined the
narratives of 23 young men who evinced syndemic production associated with heighted HIV risk
as a means of exploring how they differ in their relational characteristics from men who have
avoided syndemics.

The young men who avoided syndemic production had rich, fulfilling, supportive
relational lives that included relationships with empathic others who supported them as young
Black gay and bisexual men, helped them develop a strong sense of personal identity, and
provided them with opportunities to give back to their communities. They also had diverse
relational networks of people –particularly family members, male friends, and men in the gay
community- who promoted pro-social norms about health behaviors. In contrast, the young men
experiencing syndemics described numerous instances of trauma and oppression that infringed
upon their desire or ability to form strong, healthy relational connections. In these men,
pervasive experiences of oppression were associated with shame, identity incongruence, social
isolation, relational disconnect, mistrust in other men, and expectations of further rejection and
marginalization. Participants’ different relational experiences were examined through
community psychology’s conceptualization of sense of community.
As an initial glimpse into relational resilience among young Black gay and bisexual men,
results of this study provide evidence for a number of strength-based intervention strategies that
researchers may utilize not just in HIV prevention programs, but also in addressing antecedent
psychosocial health conditions (i.e., syndemics) that increase vulnerability to HIV. As means of
attenuating men’s socio-structural barriers to health and addressing comorbid psychosocial
health issues, interventions must address young men’s social isolation, identity-related issues,
and sense of community.

ACKNOWLEDGEMENTS

I want to thank the members of my committee- Robin Miller, Rebecca Campbell, Miles
McNall, Jenna Neal, and Tina Timm- for your thoughtful feedback and willingness to meet
during the summer for my defense. Thank you all for being so committed to my progress as a
researcher, writer, and scholar.
I would also like to thank my graduate school friends who have encouraged me and
provided valuable console over the last half a dozen years: Maria Valenti, Jason Forney, Charlie
Collins, Megan Greeson, Jessica Shaw, Jodi Petersen, and Elizabeth Polk. I am incredibly
blessed to have shared my doctoral journey with such amazing, intelligent, inspirational
colleagues.
This dissertation was part of a larger study, and could not have been accomplished
without the participation of all the members of the Young Men’s Health Study project staff.
Thank you to Robin Miller and Miles McNall for allowing me to use your data to complete this
study. Thank you to the members of our youth advisory board –William Bowen, Dwain Bridges,
Courtney Deloney, Charles Trammel, Ryan Webster, and Dorwin Wiggins – for providing sage
insight into Black gay culture. Thank you to all of the project personnel for your work on this
project. Lastly, thank you to the Michigan Department of Community Health for funding the
Young Men’s Health Study and to the Michigan State Graduate School for providing me with a
dissertation completion fellowship so that I could complete this work.
I appreciate the experiences that have led me to feel passionately about LGBT health
research and to cultivate a critical eye toward sexual health research with marginalized
populations. Specifically, my work with the Adolescent Trials Network, NIH Fellowship at the
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LGBT Population Health Institute, and job with the Michigan Department of Civil Rights have
helped me develop a research agenda and perspective that is social justice oriented,
interdisciplinary, and focused on issues of diversity. Through these wonderful opportunities, I
have met and worked with many innovative and influential scholars in the fields of LGBT health
and HIV prevention.
Thank you to all of my teammates and instructors at the Mid-Michigan Academy of
Martial Arts and to Robin for urging me to start training there. I remember my first class: how
intimidated I was and how outrageous I thought it to fork over so much money while living on a
graduate student stipend. Six years later, training in martial arts has been one of the most
cathartic and humbling experiences of my life. The personal growth and wisdom that I have
acquired through martial arts has gotten me through many trying times.
I also need to recognize my beautiful niece and nephew. Mollie and Tanner, your smiles
and cuddles are the best medicine for whatever ails me. It is downright silly how even just a
picture of your precious baby faces can brighten my entire day. A special thank you to my
parents: your unwavering support and confidence means so much to me. Up until recently, I have
taken it for granted how privileged I am to have two loving parents who have always respected
and accepted me.
Thank you to the ‘best partner ever.’ You embody resiliency. That you have chosen to
share your life with me leaves me feeling blessed every day. It is no coincidence that I finally
stopped dragging my feet on completing this project when you came into my life. Seeing myself
through your eyes, I started to think of myself as resilient, to believe in myself a bit more, and to
let my fears of the unknown subside.

v

Lastly, I want to acknowledge Robin. Your mentorship, encouragement, and friendship
have been invaluable to me over the course of my graduate career. I cannot imagine having had
an adviser more fitting to my personality, accepting of my quirks, responsive to my needs, and
supportive of my professional goals. Repeatedly and consistently, you have gone beyond an
advising role. I am grateful for your prompt and cogent feedback, tactful criticisms, and
occasional polite kicks in the rear when I needed it. You believed in me when I did not believe in
myself, trained me to value my own intellect and opinions, and taught me to trust my own
process. I also appreciate your patience, guidance, and emotional support through personal issues
and professional insecurities. I owe all of my professional achievements and successes, at least in
part, to your influence.

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TABLE OF CONTENTS
LIST OF TABLES ...................................................................................................................... x
LIST OF FIGURES ...................................................................................................................xi
INTRODUCTION ...................................................................................................................... 1
CHAPTER 1: LITERATURE REVIEW ..................................................................................... 4
Epidemiology of HIV ..................................................................................................................4
Epidemiology of HIV in Michigan ..............................................................................................7
HIV prevention and young Black MSM ......................................................................................9
Syndemics overview ................................................................................................................. 11
Characteristics of a syndemic framework applied to sexual health ......................................... 13
Implications of using a syndemics framework applied to sexual health .................................. 14
Syndemics as a theoretical framework among MSM .............................................................. 16
The empirical syndemics literature among MSM ................................................................... 17
Syndemics as a theoretical framework befitting community psychology ................................ 20
Empirical and conceptual mismatch ....................................................................................... 21
Resilience ................................................................................................................................. 23
Resilience as a tool for intervention ........................................................................................... 25
Family ................................................................................................................................... 29
Gay community ..................................................................................................................... 31
Alternative families ............................................................................................................... 33
Mentorship ............................................................................................................................ 35
Resilience summary .................................................................................................................. 37
The current study ...................................................................................................................... 37
CHAPTER 2: METHOD........................................................................................................... 39
YMHS participants ................................................................................................................... 39
Procedures (YMHS) .................................................................................................................. 40
Instrument ................................................................................................................................. 43
Demographics ....................................................................................................................... 44
Syndemic variables ................................................................................................................ 45
Relational data ....................................................................................................................... 46
Dissertation case selection ......................................................................................................... 49
Stage 1: experience of syndemics .......................................................................................... 49
Stage 2: geographic considerations ........................................................................................ 50
Stage 3: sexual behavior considerations ................................................................................. 50
Analytic participants ................................................................................................................. 52
Analysis .................................................................................................................................... 53
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Credibility ................................................................................................................................. 61
Prolonged engagement with the data ...................................................................................... 61
Interrater reliability ................................................................................................................ 62
Analytic memoing ................................................................................................................. 64
CHAPTER 3: RESULTS .......................................................................................................... 65
Men who lack evidence of syndemics ....................................................................................... 65
Pride ...................................................................................................................................... 65
Maintaining pride using stigma management techniques ........................................................ 68
Social support from families of origin .................................................................................... 72
Community affiliation and support ........................................................................................ 76
Social action .......................................................................................................................... 82
Summary................................................................................................................................... 87
Men who evince syndemics ....................................................................................................... 88
Shame ................................................................................................................................... 88
Lack of social support ............................................................................................................ 93
Relational disconnect ........................................................................................................... 100
Summary................................................................................................................................. 102
CHAPTER 4: DISCUSSION .................................................................................................. 104
Establishing well-integrated identities influences men’s well-being ......................................... 106
Family sexuality-related support influences young men’s well-being ...................................... 108
Affiliation with gay communities defined by peer norms for health influences well-being ....... 111
Men exhibiting syndemics experience heightened minority stress and social isolation ............. 114
Participants lacking syndemic production lived in Detroit ....................................................... 117
Syndemics and the psychological sense of community ............................................................ 121
Limitations .............................................................................................................................. 125
Implications for research ......................................................................................................... 127
Resilience and syndemics .................................................................................................... 132
Implications for practice .......................................................................................................... 134
Clinical interventions ........................................................................................................... 134
Family interventions ............................................................................................................ 137
Peer interventions ................................................................................................................ 139
Community interventions..................................................................................................... 139
Conclusion .............................................................................................................................. 141
REFERENCES ....................................................................................................................... 143

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LIST OF TABLES
Table 1: Demographics…………………………..……………………………………………….53

Table 2: Structural coding example……………………………………………………………..57
Table 3: Assertions related to men lacking evidence of syndemic production…………………87
Table 4: Assertions related to men experiencing syndemic production………………………..103

x

LIST OF FIGURES
Figure 1: Example of assertion generation and testing…………………..………...…………….60
Figure 2: Representative eco-maps of young men’s relationships………………..……………106

xi

INTRODUCTION
My study describes young Black gay and bisexual males who are thriving and
healthy; it also describes young Black gay and bisexual males who are adapting to adversity.
Much of the HIV prevention literature addressing the HIV burden among Black gay and
bisexual males stems from a deficits-oriented perspective and tends to homogenize and
pathologize Black gay and bisexual males. Much of the extant research focuses on poor
health outcomes and the conditions under which negative health outcomes arise (Harper,
Brodsky, & Bruce, 2012). Research often treats Black gay and bisexual men as if they are a
monolithic group, undifferentiated, and prone to pathology (Beatty, Wheeler, & Gaiter, 2004;
Mays, Chatters, Cochran, & Mackness, 1998). The deficits-oriented approach assumes that
Black gay and bisexual males and their communities are flawed, deficient, and incapable of
thriving without outside intervention.
Many Black gay and bisexual males are healthy and thriving despite social
marginalization, suggesting a need for a concomitant line of research focused on Black gay
and bisexual males who are resilient. From these men, we can learn what skills, resources,
and strengths facilitate health and capitalize on this knowledge to improve health promotion
efforts. Numerous researchers have recommended that HIV interventions could be enhanced
by building on the existing strengths, skills, and resources of gay and bisexual males (Harper
& Schneider, 2003; Harper, et al., 2012; Harper & Riplinger, 2012; Herrick, et al., 2011) and
Black gay and bisexual males in particular (Bing, Bingham, & Millett, 2008; Harper,
Jernawall, & Zea, 2004).
Resiliency-based research corresponds with sexual health promotion approaches to
HIV prevention (Wolitski, 2011). A sexual health promotion approach: a) emphasizes

1

wellness rather than disease prevention, b) acknowledges that single-disease oriented
approaches lack effectiveness because they do not address underlying causes of poor sexual
health outcomes; and c) recognizes men’s strengths, resiliencies, and resources as a basis for
HIV intervention design. Consistent with this approach, in this dissertation I use a framework
suggesting that there are overlapping, synergistic epidemics (e.g., depression, substance
abuse, etc.) that contribute to HIV transmission risk (Mustanski, Garofalo, Herrick, &
Donenberg, 2007; Stall, Friedman, & Catania, 2008; Stall, et al., 2003) to identify factors
associated with resiliency among young Black gay and bisexual males. Known as syndemics
theory, this framework suggests that co-occurring and synergistic psychosocial health
problems heighten HIV risk.
I use the syndemics framework to take a resilience-based approach to examining the
lives of young Black gay and bisexual males in Michigan. A better understanding of the
strengths that exist among young Black gay and bisexual men offers a more comprehensive,
contextualized view of the lives of young Black gay and bisexual males. Using a resiliencybased approach, I identify patterns associated with the psychosocial health of young Black
gay and bisexual males and the mechanisms through which they may contribute to sexual
health. This study was guided by three aims: 1) to describe the protective factors/strengths
within young Black gay and bisexual males who lack evidence of psychosocial syndemic
production; 2) to explore how young men who have avoided syndemic production differ in
their relational experiences from men who evince syndemics; and 3) to explore how
relationships and relational factors may promote the development and health of young Black
gay and bisexual men.

2

I organized the dissertation literature review as follows: First, I discuss the
epidemiological profile of HIV within the young Black gay and bisexual male population. In
this section, I argue that HIV is one of many social issues with a socially unjust impact on
Black Americans and sexual minorities and that traditional prevention paradigms may do a
disservice to Black gay and bisexual males at risk of HIV. In the second section, I describe
syndemics as a conceptual framework through which to view HIV risk among Black gay and
bisexual males. I argue that even though the seminal syndemics literature (Singer, 1994)
suggests identifying socio-cultural antecedents of syndemic production, much of the
syndemics literature has prioritized the identification of syndemics, rather than the causes of
syndemics or the factors that preclude syndemic production. Thereafter, I argue that rather
than study the socio-cultural antecedents of syndemics, researchers may learn from
examining the socio-cultural antecedents (e.g., resiliencies/protective factors) associated with
a lack of syndemic production. In the third section, I discuss resiliency-based research as an
oft-neglected line of inquiry in regards to Black men and sexual minorities.
To identify whether and how key social settings and relationships promote the health
of Michigan’s young Black gay and bisexual males, I used data from a statewide needs
assessment conducted with 180 Black men who have sex with men (MSM). Using subsamples of these men (e.g., those who have avoided syndemic production and those who
evince syndemics), I used analytic induction to identify patterns associated with syndemic
production, and the lack thereof, in these data.

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CHAPTER 1: LITERATURE REVIEW
Epidemiology of HIV
HIV is one of many social issues with a socially unjust impact on Black Americans
and sexual minorities. In the United States, HIV infections and AIDS-related deaths have had
a disproportionate toll on Black Americans. While the percentage of HIV diagnoses among
whites has decreased since the beginning of the HIV epidemic, the percentages among racial
minorities has increased. In 2009, Black Americans represented approximately 14% of the
United States population, but accounted for nearly half of persons living with HIV and all
new HIV diagnoses (CDC, 2012). In 2009, Black Americans had eight times the odds of
receiving an HIV diagnosis as did white Americans (Prejean et al., 2011). Additionally, HIVinfected Black Americans die earlier from disease progression than do HIV-infected white
Americans (Losina et al., 2009; Millett et al., 2012).
Domestically, male-to-male sexual contact is the predominant means of HIV
exposure. According to HIV incidence estimates, men who have sex with men (MSM)
account for more than half of all new HIV infections despite accounting for approximately
2% of the U.S. population (Hall et al., 2008). Recently, Beyrer and colleagues (2012)
conducted a review of HIV surveillance studies published from the beginning of 2007 to the
end of June 2011: regional aggregated surveillance data collected with MSM populations in
North America indicated the prevalence of HIV was approximately 15%. Among MSM, the
HIV epidemic is also heavily concentrated within the Black population and has been since the
early days of the epidemic. In one of the earliest sero-prevalence studies conducted in San
Francisco, 66% of Black MSM (compared to 49% of White and 50% of Hispanic MSM)
tested positive for HIV infection (Samuel & Winklestein, 1987). This racial distribution of

4

HIV cases remains, despite 25 years of researchers and surveillance specialists having
acknowledged its existence.
According to population-based estimates, racial minority MSM have higher HIV
incidence, prevalence, and mortality rates than do white MSM (Hall, Byers, Ling, Espinoza,
2007; Lieb, White, Grigg, Thompson, Liberti, & Fallon, 2010; Millett et al., 2012; Prejean et
al., 2011). In a five-city, venue-based survey in which sero-status data were collected, Black
MSM had an HIV prevalence of 46%, compared with 21% and 17% for White and Latino
MSM, respectively (CDC, 2005). In 2008, a study conducted across 21 cities observed that
28% of Black MSM (compared to 18% among Latino and 16% among White MSM) were
HIV-infected. Further, half of the HIV-infected Black MSM were unaware of their infection
(CDC, 2010). Recently, Millett and colleagues (2012) conducted a meta-analysis of 174
studies conducted between 1981 and the end of 2011: Black MSM had three times the odds
of contracting HIV when compared to other MSM.
Epidemiological data paint an alarming picture of increasing numbers of young Black
MSM diagnosed with and living with HIV. Nationally, racial differences in HIV infection
rates are particularly acute among young MSM (13-29 years). From 2006-2009, there was a
48% increase in HIV diagnoses among young Black MSM (aged 13-29) (Prejean et al.,
2011). Young Black MSM were also the only demographic group to experience a significant
increase in infections during this time (Prejean et al., 2011). A study carried out in seven
urban centers reported an HIV-prevalence of 16% among young Black MSM (ages 15-22),
7% in Latino MSM, and 3% in white MSM (Harawa et al., 2004). Multi-site studies suggest
that young Black MSM have seven to 12 times greater odds of having HIV as compared with
young white MSM (Harawa et al., 2004; MacKellar et al., 2005). In the meta-analysis
performed by Millett and colleagues (2012), the results of 33 studies among young MSM
(aged 13-29) demonstrated young Black MSM had five times the odds of being HIV positive
5

as compared to other young MSM. Among young MSM (18-24), young Black MSM are
particularly unaware of their HIV status (CDC, 2005; Millett et al., 2012).
A recent review of the literature addressed reasons for such a pronounced racial
difference in HIV rates among adult MSM (Millett, Flores, Peterson, & Bakeman, 2007).
Millet et al (2007) analyzed 12 hypotheses thought to influence HIV burden among Black
MSM. Behavioral risk factors did not contribute to elevated HIV prevalence in Black MSM;
rather, unrecognized infection, late diagnoses in the course of the infection, and a higher
prevalence of sexually transmitted infections (STIs; which increase biological susceptibility
to HIV) contributed to the higher rates of HIV among Black MSM (Millett et al., 2007).
High-risk sexual behavior among Black MSM may be more likely to lead to new infections
because of men’s higher probability of exposure to an HIV-infected partner and their
increased biological susceptibility due to higher incidence rates of STIs. Similar evidence
emerged in Millett and colleagues’ (2012) recent meta-analysis. Though Black MSM had
much higher odds of being HIV-infected, they engaged in fewer sexual risk behaviors, less
sex-related drug and alcohol use, and more preventive behavior (e.g., more frequent HIV
testing, fewer sexual partners) than white MSM.
Millett and colleagues’ (2007) study showed that the disproportionate burden of HIV
among Black MSM cannot be explained by their engagement in high rates of sexual risk
behavior. The authors noted that these data are “paradoxical” in that Black MSM’s greater
likelihood of HIV infection is consistently associated with less sexual risk behavior compared
to other MSM. Others have argued that the paradoxical racial dimensions of the HIV
epidemic are best explained by structural inequalities (e.g., isolation, racism, marginalization,
poverty) that make Black communities more likely to come into contact with HIV and less
likely to test for and treat it (Maulsby et al., 2014; Robinson et al., 2012). For example, in a
meta-analysis of racial comparative studies with outcomes associated with HIV risk and
6

infection, Millett and colleagues (2012) found that Black MSM have a two-fold greater odds
of having experienced structural barriers to health such as unemployment, low income,
incarceration, low education, and lack of health insurance. Structural barriers to health such
as these lower the availability and accessibility of health sustaining resources and limit the
availability and choice of sex partners.
Prompted by Millett’s work, Feldman (2010) conducted a review of the literature
focused on young Black MSM because Millett and colleagues’ (2007) earlier study had
overlooked this population. Feldman’s (2010) findings also revealed scant evidence to
suggest that the disproportionately high rates of HIV among young Black MSM were
attributable to higher frequency of engaging in sexual risk behavior. Rather, Feldman’s
(2010) review supported the notion that increased risk for HIV among young Black MSM
may be attributable to their sexual networks and tendency to engage in sex with higher risk
partners (e.g., older partners, within-race partners, known HIV-infected partners). These
findings corroborate analyses conducted with racially diverse heterosexual youth in that they
suggest that reported sexual behaviors do not account for disparate rates of HIV infection
among Black youth (Halfors, Iritani, Miller, & Bauer, 2007). Taken together, these studies
provide strong evidence that sexual risk behavior is an insufficient explanation for the overrepresentation of Black MSM among men infected with HIV.
Epidemiology of HIV in Michigan
As is the case nationally, Michigan’s (where the current research takes place) HIV
epidemic disproportionately affects the Black population. According to the Michigan Census
(2010), approximately 14% of Michigan’s population is Black. Statewide, Black adolescents
accounted for 84% of teenagers diagnosed with HIV in the last 5 years; among people over
age 20 diagnosed with HIV during this period, 60% were Black (Michigan Department of

7

Community Health, 2012a). The impact of the epidemic on this demographic group is evident
among males (Black males: 7,750 HIV cases; white males: 5,850 HIV cases) and females
(Black females: 3,070 HIV cases; white females: 860 HIV cases) (Michigan Department of
Community Health, 2010).
MSM constitute the most affected behavioral risk group, accounting for 53% of
reported HIV cases statewide (Michigan Department of Community Health, 2010). Whereas
new HIV diagnoses remained stable from 2004 to 2008 across all MSM, the percent of cases
among Black MSM has increased by an average of 4% per year during this same time
(Michigan Department of Community Health, 2010). From 2006-2010, young Black MSM
accounted for 58% of new HIV diagnoses in persons aged 13 to 19 (Michigan Department of
Community Health, 2012a). In this same period, Black MSM accounted for approximately
one-quarter of new diagnoses in persons over age 20. These data stress the importance of
HIV prevention tailored to young Black MSM in Michigan.
HIV cases in Michigan are geographically dispersed; however, the epidemic
concentrates in Southeast Michigan. Nearly two-thirds of Michigan’s HIV-infected MSM
reside in Detroit, though less than 10% of the state’s residents live in the Detroit Metropolitan
area (Michigan Department of Community Health, 2010). Further, new cases of HIV among
adolescents and young adults (ages 13 to 24) occur primarily in Southeast Michigan (almost
three-quarters of the state’s cases in this age group); of the new HIV-infected young adults in
Southeast Michigan, nearly two-thirds (62%) were residents of the city of Detroit at the time
of diagnosis (Michigan Department of Community Health, 2010). As is the case statewide,
the majority of persons living with HIV in Detroit are Black males who have contracted the
virus through sex with another male (Michigan Department of Community Health, 2012b).
Further, nearly half of these men in Metro Detroit are co-infected with other sexually
transmitted infections such as syphilis (Michigan Department of Community Health, 2013).
8

HIV prevention and young Black MSM
Cohen (1999), in an exploration of the history and politics of the HIV epidemic within
Black communities, describes how Black gay men were relatively invisible during the early
years of the epidemic. She chastises the political and epidemiological response as being slow
to recognize that the epidemic was wreaking disproportionate havoc and death in the Black
community. She details ways in which political and systemic biases resulted in a failure to
respond adequately to the HIV epidemic in this population. Historically, the HIV prevention
response among Black MSM is rife with social injustices (Cohen, 1999; Hill Collins, 2004).
Currently, Black MSM occupy a marginal position in the HIV prevention literature and are
infrequently the targets of intervention.
In 2010, the White House released the National HIV Strategy (NHAS), the United
States’ first coordinated HIV implementation plan. Its goals include: reducing the number of
new HIV infections, improving access to and outcomes of HIV-related care, and reducing
HIV-related health disparities by 2015. In an effort to focus on the populations most affected
by HIV, the NHAS suggests prioritizing young Black MSM in prevention, testing, treatment,
and linkage-to-care efforts. This clarion call is necessary, as few interventions specifically
target racial minority MSM. Despite the disproportionate impact of the domestic HIV
epidemic on Black MSM, prevention efforts have had limited focus on this population.
Prevention experts and practitioners argue that there is an urgent need for interventions
tailored to young Black MSM (Bing et al., 2008; Harper & Riplinger, 2012; Peterson &
Jones, 2009; Mays, Cochran, & Zamudio, 2004; Purcell & Hubbard McCree, 2009: Wilson &
Moore, 2009).
Harper & Riplinger (2012) reviewed 92 research studies describing primary HIV
prevention interventions for adolescents and young adults over a 20-year span. Of these

9

studies, only five detailed interventions focused on gay and bisexual adolescents, two of
which described the same intervention. Notably, these interventions for gay and bisexual
males included fewer Black participants when compared to interventions focused on
heterosexual adolescents. The authors argue that the lack of concentrated focus on young gay
and bisexual male populations, and the disparate rates of HIV infection within this
population, signifies an urgent need for the development, implementation, and evaluation of
primary HIV prevention interventions for young gay and bisexual males.
There are few evidence-based interventions for Black MSM. Collins (2011) described
how most evidence-based HIV interventions targeting Black communities do not target to
MSM. Further, evidence-based HIV interventions targeting MSM rarely specifically target
Black MSM. Among other demographic groups, interventions frequently target racial groups
with the highest HIV prevalence rates (Collins, 2011). Currently, only two evidence-based
interventions (Many men, Many Voices and D-UP!) currently available in the Centers of
Disease Control and Prevention’s (CDC) Compendium of Effective Behavioral Interventions
are specifically tailored to the cultural values and needs of Black MSM (Jones et al., 2009;
Wilton et al., 2009).
The lack of accessible HIV prevention interventions to a disproportionately high-risk
population indicates a socially unjust prevention approach. According to Prilleltensky (2001),
social justice requires the fair and equitable distribution of power, resources, and obligations
to groups of people in consideration of their needs, societal position, and abilities. Socially
just HIV prevention approaches would therefore start by targeting groups disproportionately
affected by the epidemic and for whom the prevention response has not been commensurate.
The lack of interventions tailored to Black MSM is one structural barrier to health and
evidence of inequality. Prevention approaches prefaced on social justice would also recognize

10

that while behavioral/individual level interventions have been effective, they will not mitigate
the harsh racial inequalities that precipitate HIV transmission within marginalized
communities. Prevention approaches myopically attuned to sexual behavior and norms fail to
recognize the crosscutting issues that plague these communities or acknowledge the role that
structural, relational, and systemic factors play in perpetuating the alarming rates of HIV
among young Black MSM (see “Syndemics overview” section).
Syndemics overview
Syndemics theory (Singer, 1994; Stall et al., 2008) frames this dissertation.
Syndemics theory has flourished in the study of HIV prevention and received attention from
public health professionals and the Centers for Disease Control as a way of conceptualizing
and identifying the antecedents of HIV among culturally and socioeconomically marginalized
populations. Conceptually, syndemics has broadened the scope of sexual health research
beyond the myopic attention to HIV.
According to the Centers for Disease Control and Prevention (2009), a syndemic is
“two or more afflictions, interacting synergistically, contributing to excess burden of disease
in a population.” Syndemics operate synergistically and additively such that one epidemic
amplifies or magnifies the likelihood or the effects of another (Singer, 1994; Singer et al.,
2006). Merrill Singer (1994), a critical medical anthropologist, introduced syndemics into the
epidemiological and public health lexicon. Singer coined the term to explain the poor health
profiles of substance-abusing ethnic minority women in the North-eastern U.S. who were
concomitantly experiencing high rates of STIs and HIV. According to Singer, syndemics are
culturally produced within a context of poverty and cultural marginalization.
Singer (1996) introduced the concept of syndemic to define what he saw as the
intertwined and mutually reinforcing links between substance abuse, violence, and AIDS

11

among the urban poor (the “SAVA” epidemic). To qualify as a syndemic, multiple
psychosocial and health related issues must be epidemic in a community, they need to cluster
together, and they need to result in additional health consequences. Since Singer coined this
term, numerous syndemics have been identified (Singer & Clair, 2003), not all of which
pertain to HIV. Stall et al. (2003; 2008) extended this work by reporting on a syndemic of
psychosocial health problems (e.g., substance abuse, mental health, and violence) that
increased risk for sexual risk-taking and HIV among MSM. A notable difference between
Singer’s and Stall’s conceptualization of what constitutes a syndemic is in regards to their
treatment of HIV. Singer considered HIV as part of syndemics, whereas Stall considered HIV
as a consequence of syndemics. HIV may be conceptualized as part of a syndemic or as an
outcome of syndemics depending on the population and research purpose. Singer’s emphasis
was on how diseases interact with one another (e.g., synergism and disease interplay) and to
elucidating the social conditions that give rise to, and maintain, the SAVA epidemic. These
two lines of scholarship (e.g., biological disease synergism and examination of social
context) have largely split along disciplinary lines as syndemics theory has evolved.
Biomedical scholars have largely relied on syndemic’s concept of synergism to examine
biological disease interactions (e.g., how one disease may make one more biologically
susceptible to another, such as how STDs make one more biologically susceptible to HIV);
these scholars often conceptualize HIV as part of syndemics (Singer & Clair, 2003). This line
of inquiry and conceptualization of HIV as part of syndemics makes sense given a
disciplinary orientation toward understanding disease states and interactions. Social science
and public health scholars such as Stall have instead appropriated a syndemic framework
focused on identifying syndemics in various communities that are associated with heightened
HIV risk and to identifying the social processes by which these syndemics emerge. This line
of inquiry and conceptualization of HIV as a consequence of syndemics makes sense given a

12

disciplinary orientation toward a) primary prevention of HIV and b) understanding diseases
in social context. Though both lines of inquiry are necessary in order to understand (and
prevent) a disease such as HIV from a biopsychosocial perspective (Singer & Clair, 2003), it
is this latter conceptualization that pertains to the current study.
Characteristics of a syndemic framework applied to sexual health
Numerous characteristics undergird a syndemic framework as applied to sexual
health. The syndemic nomological net begins with the definition of syndemics as described
above; yet syndemics must also be distinguished from similar concepts such as epidemics and
co-morbidity (Singer, 1994: CDC, 2009). A syndemic refers to the concentration (within a
certain population, place, and time) of multiple co-occurring epidemics that interact and
reinforce one another and ultimately giving rise to other health problems. Though each health
problem may independently have a negative impact on overall health and well-being (e.g., an
epidemic), an increasing body of evidence suggests that when these problems co-occur (e.g.,
are co-morbid), they interact in a way that amplifies the effects of each other. Simply,
syndemics a) are epidemics that cluster within marginalized populations, b) interact
synergistically, and c) additively contribute to poor health outcomes.
Importantly, syndemics theory dissociates HIV from the concept of an epidemic, and
instead conceptualizes HIV as one of many social problems that infringes upon the health of
affected populations (Halkitis, 2010). Traditionally, the biomedical approach to public health
has treated diseases such as HIV as distinct social problems, separate from one another, and
separate from the contexts within which they are produced and maintained. In contrast, a
syndemics framework assumes social problems do not develop in isolation from one another.
The public health research perspective has been to research and respond to diseases as
discrete phenomena with discrete solutions. Only within the last decade have theories such as

13

syndemics suggested that this conceptualization is a distortion and that HIV, in reality, is
never separate from other diseases and social problems (Halkitis, 2010).
Implications of using a syndemics framework applied to sexual health
A syndemics orientation has important implications for research agendas and public
health practices because recognition of syndemics calls into question the feasibility of
standard HIV prevention interventions. The recognition that multiple diseases and social
problems concentrate within specific populations and environments necessitates a more
holistic, contextualized approach to the study of sexual health (Halkitis, 2010). A syndemic
framework reminds researchers that despite the devastating toll that HIV has had on
particular communities, it may not be the preeminent concern afflicting marginalized
populations. Accordingly, syndemic theory implies it is necessary to identify and understand
the other epidemics that work in tandem to predispose MSM to HIV. Ideally, a syndemics
research agenda emphasizes the identification of the deleterious social conditions that
perpetuate disease and the conditions facilitative of well-being and sexual health.
Rather than solely focusing on disease clustering and identifying co-terminus
epidemics, the syndemics literature has segued into an emphasis on the social conditions
under which syndemics arise. From its earliest incarnation, syndemics were assumed to be
caused by social marginalization and deleterious social conditions (Singer, 1994). This causal
assumption is consistent with the assumptions similar theories such as problem-behavior
theory have made in regards to the antecedents and determinants of adolescent risk behavior.
Problem-behavior theory, a conceptual framework for understanding the confluence of
problem behaviors, is one of the most renowned frameworks explaining adolescent
developmental difficulties (Jessor, 1991). A key precept of problem-behavior theory is that
problem behaviors (e.g., those which run counter to conventional legal or social norms for

14

adolescents) and their associated health conditions exist in a constellation whereby
involvement in one risk behavior increases the likelihood of engagement in others. The
foremost premise of this theory, as with syndemics theory, is that social problems or
behavioral concerns result from person-environment interactions. In both theories, enmeshed,
mutually enhancing health or behavioral problems develop in a context of social inequalities
and are predisposed by noxious social conditions.
Much progress has been made identifying the social and structural conditions driving
syndemic processes and the HIV epidemic. Identifying these conditions is important to the
development of interventions that address the underlying socio-environmental root causes
that develop, link, and, exacerbate syndemics processes among MSM. Researchers recognize
that mental health and other psychosocial determinants greatly impact sexual behavior and
risk among YMSM (Halikitas, 2010; Rosario, Schrimshaw, & Hunter, 2006). Yet, HIV
prevention has operated with limited regard to concomitant health and social problems, an
oversight which advocates of a syndemic orientation have argued may compromise
intervention effectiveness (Halkitas, 2010; Safren, Reisner, Herrick, Mimiaga, & Stall, 2010;
Safren, Blashill, & O’cleirigh, 2011; Stall et al., 2003; Stall et al., 2008.) Without recognition
of the numerous other concerns woven into the fabric of MSM’s lives and without addressing
antecedent concerns, the outcomes of HIV prevention efforts will not reach full fruition.
Recently, Safren and colleagues argued that syndemic production may be the driving
force behind the HIV epidemic (Safren et al., 2010). These authors argue that psychosocial
factors influence sexual behavior (primary prevention), HIV/STI testing behavior (secondary
prevention), adherence to care (tertiary prevention), and intervention effectiveness. They
claim that interventions focused exclusively on sexual behavior and cognition may have
yielded small effect sizes that last a short period of time because they have not concurrently
addressed these other co-occurring psychosocial health problems. Accordingly, to the extent
15

that sexual risk co-occurs with other psychosocial health problems, interventions must
address these co-occurring health issues.
Despite recognition of concomitant health concerns in MSM communities, current
interventions do not address syndemic concerns. Review of the CDC’s evidence-based
interventions tailored to MSM indicates that only few address the interplay between
substance use and HIV infection (Tilley, 2009). More complex intervention designs attuned
to syndemic production and concerns are warranted.
Syndemics as a theoretical framework among MSM
Consistent with the focus on culture marginalization underlying the syndemic
approach (Singer, 1994, 1996), Stall et al. (2008) laid out a model for syndemic development
in MSM. Stall’s (2008) conceptualization of syndemics among MSM is fundamentally
developmental in nature. Stall notes that these syndemic health issues tend to be present in
adolescence and young adulthood; as a result, Stall et al.’s model (2008) identifies
phenomena that occur during childhood and adolescence that may shape health problems into
adulthood. This model posits that three primary dynamics are the cause of syndemic
production among gay men: a) early adolescent male gender socialization, including gender
policing, violence and victimization for not meeting gender ideals, and abusive sexual
initiation; b) homophobic attacks that occur early and often within men’s lives; and c)
migration to gay communities amidst high background prevalence rates of substance abuse,
mental health problems, violence, STIs, and HIV. Like other prominent health-related
frameworks for sexual minorities such as Ilan Meyer’s social minority stress model (Meyer,
1995: 2003), Stall emphasizes heterosexism and homophobia as primary structural causes of
poor development and ill health among MSM. Stall’s theoretical model suggests that cultural
marginalization and adversity play a key role in syndemic development and that the presence

16

of co-occurring psychosocial health conditions (e.g, substance abuse, depression, violence
exposure) mediates the effect of adversity on HIV risk behavior.
The empirical syndemics literature among MSM
The empirical syndemics literature among MSM is still in its infancy; investigators
have yet to examine whether syndemic production mediates the relationship between
adversity and HIV risk behavior; additionally, potential moderators of the relationship
between adversity and syndemics or syndemics and risk behavior have yet to be empirically
examined. Instead, the syndemics empirical literature among MSM has focused on
identifying syndemics in various communities that are associated with heightened HIV risk
and to identifying the social processes under which syndemics emerge.
Specifically, Stall et al. (2003) adapted syndemic theory to illustrate the co-occurring
epidemics facing MSM that that make them more susceptible to HIV. The researchers
postulated that sexual assault, depression, substance abuse, and intimate partner violence
have an additive effect on the likelihood of engaging in sexual risk behavior and of
contracting HIV. In their probability sample of 2881 MSM from four major US cities, the
odds of a participant having engaged in unprotected anal intercourse increased based on the
number of psychosocial problems he experienced; the odds of a participant being HIV
infected also increased with the addition of each psychosocial problem. Specifically, greater
number of psychosocial health problems was associated with ascending odds ratios for
having high-risk sex and ascending prevalence rates for HIV infection compared with the
group of men with no self-reported psychosocial health problems (Stall et al., 2003).
Stall’s (2003) approach to measuring the impact of syndemics on sexual health risk
has become the most popular way to assess whether multiple psychosocial factors have an
additive influence on sexual risk behavior and HIV status. Simplistic analytically, Stall’s

17

approach involves: a) identifying the psychosocial conditions thought to be prevalent in
particular populations, b) assessing the bivariate relationships among indicators of sexual
behavioral risk or health, c) and computing a count of psychosocial health problems (e.g.,
referred to as the ‘syndemic variable’) that is used to test the additive relationship between
psychosocial problems and sexual risk behaviors or HIV/STI history. Since Stall’s (2003)
original application of syndemic theory to test the additive effect of psychosocial health
problems on the sexual health of MSM, empirical research using a similar methodological
approach has been used to locate syndemics among YMSM (Mustanski et al., 2007) and
Black MSM ( Dyer et al., 2012).
Dyer et al. (2012) used a similar analytic approach in their analysis of 301 Black
MSM. Dyer and colleagues (2012) examined the association between depression, substance
use, intimate partner violence, stress, sexual compulsion, and unprotected anal intercourse.
These researchers analyzed whether there was an additive effect of the number of health
conditions on unprotected anal intercourse. Findings suggested that Black MSM who
reported three or more co-occurring health conditions engaged in more unprotected anal
intercourse with their partners compared to those who reported fewer health conditions .
Though much of the syndemics literature has emphasized adult syndemic production
over the experiences of youth, researchers have validated Stall’s additive syndemic model in
populations of YMSM. Mustanski et al. (2007) found a significant additive relationship
between substance use, psychological distress, partner violence, sexual assault, and risk of
HIV infection in a sample of 310 ethnically diverse YMSM (aged 16 to 24). The additive
effects of these four psychosocial problems increased the odds of having multiple sex
partners, engaging in unprotected intercourse, and of being HIV infected (Mustanski, et al.,
2007). Additionally, participants with four or more psychosocial health problems had three
times the prevalence of HIV relative to those with fewer problems.
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Investigators have used the aforementioned analytic approach to identify proximal
psychosocial antecedents of sexual risk behavior and HIV among MSM. The syndemics
literature has evolved away from a sole focus on the elucidation of overlapping epidemics,
towards one focused on the identification of socio-cultural, economic, and environmental
antecedents of syndemic production. This line of research seeks to examine factors
influencing vulnerability and to identify the conditions under which HIV becomes embroiled
within particular populations. Herrick et al (2012) assessed lifetime predictors of syndemic
production, defined as having experienced two or more of the following psychosocial
problems: drug use, depression, stress, sexual compulsion, and intimate partner violence.
Using a life course perspective consistent with the syndemic framework, Herrick and
colleagues (2012) divided predictors into 4 life stages: early life events (e.g., childhood
satisfaction, parental substance abuse, parental domestic violence, physical abuse, childhood
sexual assault, childhood victimization, gay-related victimization, aggressive environment,
masculinity attainment), coming out events (e.g., internalized homophobia), adulthood events
(sexual assault, event discrimination), and occurrences in the past year (e.g., current
marginalization, internalized homophobia, and life satisfaction). In bivariate modeling, each
of the 16 life course events was significantly associated with the syndemic variable. Using a
subsample of Black MSM from the same larger study, Dyer and colleagues (2012) conducted
a similar analysis, using the same predictors to examine the differences between Black MSM
with and without a syndemic condition (i.e., two or more psychosocial health problems). In
this study, Black MSM exhibiting syndemic production were significantly more likely to
have been the target of gay and non-gay related victimization, lack social connectedness
during childhood, have struggled with masculinity attainment, have experienced more
internalized homophobia when coming out, and report more discrimination and internalized
homophobia in adulthood compared to men who did not exhibit syndemic production. These

19

studies extended syndemic theory among MSM by empirically examining the development of
syndemic production.
Syndemics as a theoretical framework befitting community psychology
As a conceptual framework, Stall’s model resonates with me as a community
psychologist. The framework is consistent with the principles of the field because of its focus
on marginalized groups and attentiveness to structural and macrosystemic etiological causes
of disease and social problems. Singer (1994) originally theorized that cultural
marginalization, inequitable distribution of resources, and other macrosystemic causes were
the etiological roots of syndemics. Subsequent research using a syndemics framework has
shown that divergent marginalized groups evince syndemic production, suggesting that
oppressive social conditions create the conditions under which synergistic epidemics develop
and interact with one another (Dyer et al., 2012; Egan et al., 2011; Herrick et al., 2012). In
the HIV prevention and treatment literature, syndemics theory is one of the only frameworks
to insinuate that adverse social conditions put marginal groups at heightened risk of social
problems and disease (Easton, 2004). Indeed, syndemics is one of the few frameworks to
hypothesize environmental and social causes for the adverse health outcomes experienced by
groups such as MSM. Unlike many other

HIV-related theories, syndemics theory

recognizes that HIV burden falls most heavily on the disenfranchised, oppressed, and socially
marginalized. These key theoretical precepts force researchers to confront the reality that
HIV takes its toll on already vulnerable communities and recognize that HIV is only one of a
diverse array of problems confronted by communities prone to poor sexual health outcomes.
Conceptually, Stall’s model also holds appeal because it implies that a psychological
sense of community may moderate the pathway from adversity to syndemics. Rather, the
model posits that participation in gay communities may moderate the pathway from adversity

20

to syndemics. Stall’s model proposes that as gay men access gay community networks, they
must balance the stressors and resources that come with participation in a new setting. Gay
community involvement can allow men to access strengths. At the same time, men’s
participation in gay community networks and settings may require breaking linkages to other
(e.g., family) forms of support, confer added risk, and create difficulties in creating new
social networks. Stall’s conceptualization of the strengths and stressors that come along with
participation in gay community networks can be interpreted through the lens of community
psychology’s concept of the psychological sense of community. Community involvement
may confer upon men a feeling of belonging, shared emotional connection with other men,
and a fulfillment of their needs – a positive psychological sense of community that we would
expect to be associated with positive outcomes (McMillan & Chavis, 1986). On the other
hand, participation in the gay community can also be seen to have liabilities such that men
may experience a negative psychological sense of community, or a negative relationship with
the gay community to the extent that the perceived risks of participation outweigh the
rewards (Brodsky, 1996). Stall’s conceptualization of the gay community is thus appealing
from a community psychological perspective because he proposes it as a protective factor,
but also because he articulates it in a way that is sensitive to the fact that not all men may
experience it in the same way. Stall’s model thus suggests that in the understanding of
syndemics among MSM, there is a fundamental need to examine not only if men participate
in the gay community, but to explore how they experience their involvement.
Empirical and conceptual mismatch
In proposing that positive community affiliation with the gay community may provide
young gay men with sources of support that are protective against syndemic health threats,
Stall suggests that it is important to examine the relational contexts of young men’s lives.

21

However, the syndemic literature has not yet segued into a focus on young men’s lives in
relational context. Rather, empirical work (as described above), has measured variables at the
individual (e.g., internalized homophobia) or the macrosystemic (e.g., discrimination,
victimization, poverty) level. The syndemics literature has yet to examine more proximally
(e.g., microsystemic) related influences on young men’s health and development. A lack of
empirical consideration of relational or microsystemic constructs in the study of syndemics
among MSM is curious given: a) Stall’s conceptual model specifies their importance; b) the
developmental nature of the model and the fact that developmental theory calls explicit
attention to the influence or microsystems on youth health and development
(Bronfrennbrenner, 1979); c) the fact that a number of correlates of HIV-related risk behavior
related to YMSM’s microsystems have been identified (Mustanski et al., 2011); and d) the
plethora of research on psychosocial syndemic conditions indicating the important protective
effects of microsystemic factors (see section on resiliency factors). This dearth of empirical
focus suggests that in order to further investigate the processes involved in syndemic
production, more data are needed on young men’s relational experiences.
The syndemic framework is also inherently resilience-based (see next section) in that
it outlines potential sources of gay men’s strength and healthy development. However, the
bulk of the syndemics literature has focused on the identification of risk factors that make
young men vulnerable to syndemics. There has not been a concomitant line of inquiry
examining sources of young men’s resilience. Like much formative research with sexual
minority populations (see next section), the syndemics literature has not yet evolved from
focusing on the negative experiences of marginalized youth to examining their strengths and
coping strategies. As such, there is also a need for an analytic focus on conditions associated
with young men’s healthy development and well-being.

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Resilience
Researchers operationalize resiliency in numerous ways. Resilience generally refers to
a state of positive development or health within a context of adversity. Masten (2001)
proposed a popular definition of resiliency (2001): resiliency is about obtaining good
outcomes in spite of serious threats to adaptation or development (p. 221). Resiliency-based
research often focuses on groups who have experienced significant life-course hardships
across various domains of their lives and seeks to identify why and how some people have
the capacity to overcome adversity and achieve good health in marginal circumstances.
Many researchers conceive of resilience as an interpersonal trait or individual-level
phenomenon (e.g, self-esteem) (Kaplan, 1999; Masten, 1994; Stevenson & Zimmerman,
2005). Theoretical models from this individual-level approach conceptualize resilience as
personality traits (e.g., self-esteem) or intrapersonal variables (e.g., intelligence) that protect
individuals from the adverse effects of adversity and/or help them to cope with personal
challenges. At the individual level, resilience research focuses on identifying assets that
distinguish youth who obtain healthy outcomes or development within a context of adversity
from those who do not.
Researchers have criticized this conceptualization of resilience for its over-emphasis
on individual level phenomena; they have argued that resilience research might also look at
socio-ecological factors that contribute to the same outcomes. These conceptualizations of
resilience are more dynamic and attuned to proximal and distal contextual mechanisms that
affect individual expressions of resiliency. For example, the construct of relational resilience
focuses on relationships as the main mechanism for fostering interpersonal resilience. This
conceptualization of resilience posits that relationships enhance (or impede) adaptive growth
and health. From a relational resilience perspective, resilience is not merely an internal trait,

23

but a relational process formed through “growth-fostering relationship” (Connelly, 2005;
Jordan, 2005). This model of resilience assumes that some of the main motives in life are to
“grow through and toward connection” and to “participate in growth-fostering relationships”
(Jordan, 2005, p. 82). Relational resilience thus underscores the centrality of relationships on
youth development and health and embeds our understanding of resilience within
relationships (with the self and others) and relational environments such as community
settings.
I emphasize this conceptualization of resilience in this dissertation research for four
primary reasons. First, on a theoretical basis (as specified above), the syndemics conceptual
model implicates that relational factors that support young men’s developing sexual identities
(e.g., gay community involvement) may be important sources of resilience in young gay
men’s lives. Second, from a disciplinary orientation, this emphasis on factors beyond the
individual-level is in keeping with the principles and values of community psychology. Third,
from a conceptual perspective, a relational model of resilience offers a promising analytic
framework for work with marginalized populations. Placing emphasis on the underlying
processes of relationships that encourage health and development brings to the fore the often
misunderstood and neglected relational aspects of marginalized group’s lives. A relational
focus is imperative when examining health-promoting factors among historically
marginalized groups. Many marginalized groups, Black Americans and sexual minority
groups alike, have strong community ties and often value interdependence; therefore,
research attentive to learning what promotes their health may be best served by considering
how marginalized communities engage in mutually supportive and responsive relationships
(Jordan, 2005). Indeed, much of the extant literature on resilience within gay communities
(see next section) focuses on constructs (e.g., mentoring, social support) underscoring that the
presence of supportive and nurturing relationships is critical to attenuating the negative

24

impact of adversity in the lives of gay and bisexual youth. Fourth, oppression (e.g.,
heterosexism, sexism, racism) often promulgates relational disconnection in the lives of
young gay and bisexual men. As men, they are reared in a socio-cultural framework that
emphasizes independence, autonomy, and self-reliance. As individuals who are sexually,
romantically, and relationally attracted to members of their same-sex, they sometimes must
conceal important aspects of themselves (e.g., passing as heterosexual) or engage in “survival
strategies” that may cause relational disconnect and isolation. Western masculinity norms and
heterosexist oppression thus operate in ways that complicate young gay and bisexual men’s
ability and desire to seek out and form intimate, authentic relationships. Developing and
sustaining growth fostering relationships is therefore indicative of men’s resilience to
overcome oppressive socio-cultural edicts and conditions. Attention to relationships and
relational elements (including the relationship with the self) that are growth fostering among
young Black MSM was the focus of this dissertation.
Resilience as a tool for intervention
Numerous researchers have suggested resiliencies and protective factors can be
harnessed to facilitate sexual health interventions (Bing et al., 2008; Herrick et al., 2011;
Millett & Peterson, 2007; Mustanski, Newcomb, DuBois, Garcia, & Grov, 2011). Few
studies, however, identify resiliency factors that might inhibit or mitigate health problems or
risk behavior (Millett & Peterson, 2007). In general, researchers and practitioners prioritize
the study of people who exhibit risk behavior or developmental problems, rather than people
who are healthy and well adjusted. Put another way, people who exhibit psychosocial
problems are generally the foci of research. However, men who do not exhibit such problems
may also be valuable as sources of intervention insights. This former perspective often

25

undergirds a deficit orientation toward the study of social problems and has permeated the
literature on sexual minorities and Black populations alike.
Black families and communities have historically been studied from a deficits
perspective that paints a pathological portrait of racial minorities (Briscoe, 2000). Other
scholars have noted that studies related to Black sexuality and sexual behaviors have
particularly been framed in a social problems framework (Cohen, 1999; Hill Collins, 2000).
Such is also the case with sexual minorities, whereby pathology and problem behavior have
taken center stage, often with an assumption that sexual minorities are in some way deficient
or deviant (Harper et al., 2012; Harper & Schneider, 2003; Savin-Williams, 2001: 2008).
Speaking to this issue with research on same-sex attracted youth, Savin-Williams (2008)
describes the current conundrum of this deficits paradigm as “… the irresistible and
overpowering attention to the problematic nature of same-sex oriented populations rather
than a focus on their capacities to adjust, thrive, and lead exceptionally ordinary lives. It is as
if same-sex oriented populations are only interesting to the extent that they differ in the
negative (p. 137).” Research by Stevenson & Zimmerman (2005) makes a particularly
poignant statement in this regard; their review of the public health literature among
adolescents showed that there is a paucity of research with sexual minority youth stemming
from a strengths-based perspective.
Black gay and bisexual men have been particularly absent from the research and
scholarly literature (Harper et al., 2004). As Harper and colleagues (2004) argue, the voices
of healthy and thriving Black sexual minorities are almost entirely absent in academic
literature. Such researchers have argued for a concomitant focus on the positive attributes of
sexual minority populations that is attentive to protective factors, resiliencies, and strengths
(Harper et al., 2012; Harper & Schneider, 2003; Russell, 2005; Saewyc, 2011; SavinWilliams, 2008). As voiced by Harper et al. (2012):
26

While continuing research is needed on the developmental challenges faced by LGB
adolescents, especially those who are also members of other oppressed groups such
as youth of color, a parallel line of scientific inquiry is also needed to explore the
strengths and resiliencies demonstrated by LGB youth….a strengths-based focus on
sexual orientation identity acceptance for LGB youth is warranted (Harper et al.,
2012, p. 26).
Resiliency based research is desperately needed to provide a more comprehensive portrayal
of Black sexual minority youth and to dispel myths and misconceptions about these
communities (Anderson, 1998).
Herrick and colleagues (2011) issued the clarion call for a resilience-based approach
to HIV prevention among MSM. These authors argued that harnessing the strengths of MSM
may increase the effectiveness and acceptability of interventions to treat, manage, and
prevent HIV. They further urged scholars to acknowledge that the majority of MSM do not,
in fact, become HIV positive or even participate in high risk sexual behavior. The largely
unwritten story is that even though MSM contend with a multitude of social stressors, a
sizable number of MSM must have noteworthy reservoirs of resilience to mitigate and
withstand negative sexual and psychosocial health outcomes (Herrick et al., 2011; Herrick et
al., 2012; Moeller et al., 2011; Parsons et al., 2011). Resiliencies that they proposed studying
further included shamelessness (e.g., regarding their identities), sexual creativity (e.g., risk
reduction strategies), social creativity, social activism, self-monitoring, and social support.
Notably, a number of these constructs are explicitly (e.g., social support and social activism)
or implicitly (e.g, social creativity) relational in nature.
Why focus on resiliency as a basis for informing HIV prevention or sexual health
interventions? The alternative model fosters interventions that seek to address risk factors for
poor health outcomes; understandably, it makes intuitive sense that understanding what is
27

going wrong may lead to the identification of solutions. According to Herrick et al., (2011)
potential fallacies exist with this perspective. In general, deficits-based approaches identify
that which produces risk, rather than that which is associated with safety or well-being; based
on analysis with the highest risk people, these interventions are reactive rather than proactive.
Deficits-based approaches also identify what not to do (e.g., do not have unsafe sex with
sero-discordant partners), rather than identify what to do (e.g., be sexually creative by using
these risk reduction strategies). Such messages, particularly those that decry particular
behavior, may often sound uninviting and therefore preclude intervention uptake. Being
person-focused, they also leave people in environments that may well not be conducive to
sustained behavior change or health. Given these limitations, the authors concluded that
focusing on the naturally occurring strengths, resources, and skills that already exist within
MSM and their communities may increase intervention effectiveness.
Building upon that which is already occurring and helping MSM access their existing
strengths and resources has explicit benefits. Strengths-based intervention strategies are
culturally and contextually relevant (Wyatt, 2009); for example, the elucidation of naturally
occurring strengths and resources implies a valuation of the protective strategies already
utilized in these communities. At the individual or community level, this value consonance
may decrease resistance to participation (Miller & Shinn, 2005). Strength-based interventions
that build pre-existing resources or organic community strengths are akin to indigenous
prevention approaches as described by Barrera and colleagues (2011). Indigenous prevention
approaches are “prevention interventions that have been developed in the community, have
demonstrated feasibility of implementation and acceptability in that community, but lack
experimental evidence of effectiveness (O’Connell, Boat, & Warner, 2009, p. 7). These
interventions develop organically in the community, making them intrinsically high in
external validity, and thus highly consonant with the values of community psychology

28

(Miller & Shinn, 2005). Resiliency-based approaches to sexual health promotion may
similarly aim to bolster existing resources, individual strengths, and community assets.
However, implementing these intervention strategies is contingent upon garnering sufficient,
contextually relevant information about the strengths and resources that exist among young
Black MSM and how these strengths and resources contribute to healthy development. The
following sections describe key socializing settings and relational factors that may promote
healthy development of young Black MSM in spite of risk exposure.
Family
Family is one of the most the most fundamental social systems influencing human
development and families play critical roles in healthy development. Particularly, family is a
key socializing influence on youths’ gender roles, sexual values, sexual attitudes, and sexual
behaviors (Perrino et al. 2000). Family influence is particularly important for Black youth
who come from a cultural background that emphasize the primacy of the family (Murry &
Brody, 2004).
Parental relationships influence the health and well-being of sexual minority youth. In
general, research with sexual minority youth has focused on the poor relationships youth have
with their families. In one study, sexual minority youth who reported higher levels of family
rejection were 8.4 times more likely to report suicide attempts, 5.9 times more likely to report
high levels of depression, 3.4 times more likely to use illegal drugs, and 3.4 times more likely
to report having engaged in unprotected sexual intercourse compared with peers who
reported no or low levels of family rejection (Ryan, Huebner, Diaz, & Sanchez, 2009). While
many sexual minority youth experience strained relationships, parental rejection, and
disenfranchisement, not all sexual minority people share these experiences (Garofalo et al.
2008). Bouris et al (2010) conducted a systematic literature review to assess whether parents

29

of sexual minority youth (aged 10-24) can promote health and well-being. Their review
suggested that supportive and caring parent-child relationships provide protection from
sexual risk behavior, substance use, violence and victimization, mental health disorders, and
suicide.
Family support protects against HIV infection among young MSM and Black youth.
In a study of 302 ethnically diverse YMSM (aged 16-24), Garofalo et al (2008) found that
family connectedness significantly lowered the odds a youth was HIV positive by 30%.
LaSala (2007) conducted a study on parental influences on the safer sex practices of gay male
youth (ages 16-25). In his sample of 35 parents and 30 youth, 83% of parents regularly
discussed safer sex practices with their sons and 57% of the youth reported that their
relationship with their parents influenced their safer sex practices. Among Black heterosexual
youth, supportive, communicative family environments reduce the risk of engaging in sexual
risk behavior (Murry & Brody 2002). Indeed, in one longitudinal study, Black youth who
regularly discussed sex and sexuality with their parents were less influenced by their peers
and less likely to engage in sexual risk behavior (Brody, Ge, Katz, & Arias, 2000).
Mothers, in particular, may be resources for Black MSM. Data consistently show that
mothers are most frequently the family member who knows of their son’s sexual orientation
identity (Dube, & Savin-Williams, 1999; D’Augelli, Hershberger, & Pilkington, 1998;
Garofalo et al., 2008; Mays, Chatters, Cochran, & Mackness, 1998). For example, Garofalo
et al’s (2008) data suggested that over 80% of youth (ages 16-24) had disclosed their sexual
orientation identity to their mothers. Mothers are the family member most likely to be
supportive and accepting of their son’s sexual identity (D’Augelli et al., 1998; Garofalo et al.,
2008) and are frequently cited as sources of sexuality specific social support by sexual
minority youth (Doty, Willoughby, Lindhl, & Malik, 2010). To examine youths’ perceptions
of support for coping with sexuality stress, Doty et al. (2010) examined the sources of
30

sexuality-specific forms of social support among lesbian, gay, and bisexual individuals (ages
14-21). Mothers were cited as a source of sexuality-specific social support by 85% of
participants. In regards to sexual health, mothers may try to influence the sexual behavior of
their gay son’s through sex education, provision of condoms, and discussions of sexuality
(Kubicek, Beyer, Weiss, Iverson, & Kipke, 2010).
Other female relatives such as sisters may also offer positive sources of support for
young Black MSM. In addition to mothers, Black sexual minority youth (Mays et al., 1998)
and gay youth (D’Augelli et al., 1998; Mustanski et al., 2011) frequently cite sisters as being
accepting of their sexual orientation identity. In research with sexual minority youth, sisters
were the family member participants cited as the most likely to be accepting of their sexual
orientation identity (Mustanski et al., 2011). For gay male youth, sisters are also the family
members least likely to verbally abuse and physically threaten their siblings upon disclosure
of their sexual orientation (D’Augelli et al., 1998).
These data suggest that family acceptance or rejection shapes youths’ views of their
selves and supportive family members can play a role in the healthy development of Black
YMSM. It is unclear how family members, particularly mothers, shape resiliency among
Black YMSM. They may influence sexual health directly through the propagation of sexual
values and provision of sexual health resources or provide a buffer against various forms of
distress through the provision of social support and sexuality-specific social support in
particular.
Gay community
As indicated earlier, Stall’s conceptual model suggests it is likely that felling
connected to the gay community is an important relational factor to consider in the study of
syndemics among MSM. Though the term gay community is operationalized in a variety of

31

ways, it generally refers to the collective identity constructed around relational ties between
people who are sexual and/or gender minorities (Ferris, 2006). From a developmental
perspective, connecting with the gay community tends to coincide with and be invaluable to
young gay men’s coming out processes and the abatement of internalized homophobia (e.g.,
Corrigan & Matthews, 2003; Galatzer-Levy & Cohler, 2002; Rosario, Hunter, Maguen, &
Gwarz, 2001).
Numerous studies across a variety of different health-related issues suggest that gay
community connections may serve health protective functions. Protective effects of gay
community connectedness have been demonstrated in studies regarding mental health and
psychological well-being (Kertzner et al., 2009; Ramirez-Valles, Fegus, Reisen, Poppen, &
Zea, 2005), sexual risk (Flowers, Duncan, & Frankis; 2000; Ramirez-Valles, 2002), and safer
sex practices (Herek & Glunt, 1995; Ramirez-Valles & Brown, 2003).
Theoretical literature suggests that connectedness to the gay community may play an
ameliorative role in the relationship between structural adversity and health because
involvement with other sexual minorities helps young MSM build buffers against sexual
minority stress, establish comfort or pride in one’s sexual identity, and develop connections
with individuals facing similar developmental and socio-structural struggles (Meyer, 2003;
Ramirez-Valles, 2002). For example, Meyer’s social minority stress model indicates that
connectedness to the gay community is important in that it allows sexual minority youth to
make positive social comparisons to people like them, instead of internalizing negative
beliefs based on heterosexist beliefs and sexual prejudice (Meyer, 2003).
Community connectedness has also been associated with protection against sexual
risk and protection against HIV infection. For young MSM who often lack culturally
appropriate sexual health education, being connected to the gay community may be the only

32

avenue through which to be exposed to relevant HIV prevention, education, and testing
(Grov, Parsons, & Bimbi, 2007; Mullens, Staunton, Debattista, Hamernik, & Gill, 2009).
Young MSM who are connected to the gay community may also take advantage of other
services and resources specifically designed for gay and bisexual youth such as medical care
and testing services, support and empowerment groups, and gay-straight alliances. RamirezValles (2002) articulated a conceptual framework for considering the protective effects of
community involvement for gay and bisexual men’s sexual health. Ramirez-Valles’ (2002)
model suggests that involvement in the gay community and HIV-related groups and
organizations promotes men’s health by providing social support, enhancing feelings of selfefficacy and positive sexual-identity, and reinforcing norms supportive of safer sex practices
(Ramirez-Valles, 2002). Stall postulates and these studies suggest that connectedness to a
community of similar others is important for young men’s identity development and health.
Alternative families
Historically, Black communities often form extended families, fictive kin, and
alternative families due to a history of economic and social exclusions (Brisco, 2000; Hill
Collins, 2000). Alternative families are a normative cultural phenomenon in Black
communities. As such, they lay the foundation for the formation of alternative families for
racial minority gay and bisexual men. When biological families are unwilling to nurture
sexual minority youth, gay and lesbian youth may create families of choice (Dahlheimer &
Feigal, 1994). In the gay community, the House/Ball scene is an exemplar of this Black
cultural tradition to respond to marginalization through communal modes of social support
(Rivera Colon, 2009).
Existing prior to the Harlem Renaissance, house/ball culture is a clandestine
community consisting of mostly Black and Latino/a sexual minorities (Arnold & Bailey,

33

2009). Houses provide a familial structure for YMSM of color and transgender people; often
structured like fraternities, houses often consist of people who are a part of “house families”
comprised of a “house mother and father” and their “house children” (Arnold & Bailey,
2009); Murrill, et al., 2009). House members engage in balls (i.e., fashion and dance
competitions) at which young MSM congregate for social support and entertainment. Houses
thus often function as alternative families whose purpose is to organize balls and provide
support (e.g., a network of friends, settings allowing sexual and gender expression) for
socially marginalized youth of color (Arnold & Bailey, 2009).
Evidence suggests that house-ball communities have embraced the need for HIV
prevention and may promote health and positive development. Wilson & Moore (2009)
interviewed 71 HIV service staff personnel across nine states and asked about their
perceptions of barriers and facilitators of the HIV epidemic among Black MSM. Participants
thought that the house and ball community was an important, though undervalued, context for
HIV prevention activities. Further, these experts suggested that promoting communitybuilding efforts that connect Black MSM to one another, such as the house-ball community
provides, is an important part of promoting health in this community (Wilson & Moore,
2009). House communities also have a history of assuming salient leadership roles in HIV
prevention within MSM communities (Wilton, 2009). Wilton (2009) further describes houseball communities that sponsor balls with prevention themes and details how HIV prevention
services are commonly provided at ball competitions. These examples show that participation
in houses/balls may directly affect sexual health by increasing access to and the acceptability
of using prevention services. Membership in these communities may also affect sexual or
psychosocial health less directly.
For socially disenfranchised youth, house/ball communities are often critical to the
provision of familial, cultural, and kinship networks (Phillips, Peterson, Binson, Hidalgo, &
34

Magnus, 2011; Wilton, 2009). Core values associated with the house/ball scene often include
stressing the importance of sexual and gender expression (Arnold & Bailey, 2009; Wilton,
2009). Balls provide a celebratory context for identity expression, validation, and expansion
and houses provide a means through which to construct these identities in relation to others
(Arnold & Bailey, 2009). For groups that have experienced multiple forms of marginalization
based on the intersections of their racial, sexual, and gender identities, these types of organic
support networks may provide a buffer against life stressors (Sanchez, Finlayson, Murrill,
Guilin, & Dean, 2010). Arnold & Bailey (2009) also imply that participation in houses may
facilitate health because of the emphasis placed on personal development by house parents. In
their ethnographic study, “house mothers” often provided their “house children” with advice
(including about sexual health) and emotional support, whereas “house fathers” helped
members overcome structural barriers to health (e.g., obtaining employment, returning to
school, staying out of prison). As these examples show, houses/balls may promote resiliency
due to the emphasis placed on positive youth development, the provision of various forms of
sexuality-specific social support, advocacy of self-protecting behaviors, and creation of
avenues for identity expression.
Mentorship
Natural mentors, role models, or non-parental adults are people such as extended
family members, teachers, counselors, or neighbors sought out informally by youth for
support and guidance who often play an integral role in youths’ healthy development.
Mentors may provide advice, serve as models of adult behavior, teach youth to regulate their
emotions and behaviors, provide opportunities or social support, and help shape youth’
conceptions of their emerging identities (Rhodes, 2005). This type of mentoring relationship
is common among both sexual minority youth and Black youth.

35

Sexual minority youth may find formal mentoring programs and opportunities hostile
to who they are (Gastric & Johnson, 2009; Harper et al., 2012). As such, sexual minority
youth often lack social support from adults who do not require that they compartmentalize
their identities. Lacking access to supportive adults, sexual minority youth may find
mentoring relationships appealing. Research suggests that sexual minority youth are more
likely than heterosexual youth to seek informal, non-parental adult mentors (Gastric &
Johnson, 2009).
Natural mentors and non-parental adults often play a primary role in the development
of Black youth. In Harper and colleagues’ (2012) study of 63 multi-ethnic gay youth, Black
participants most commonly reported seeking out non-parental adults as mentors and role
models. Given the importance placed upon alternative family structures and mentors in the
Black community, incorporating natural mentors into HIV prevention efforts may be one
means of enhancing the cultural relevance of interventions for this population (Wyatt, 2009).
Research suggests there are numerous benefits to having natural mentors in the lives
of Black youth. For example, natural mentors have a longitudinal positive impact on mental
health and sexual risk behaviors on Black youth (Hurd & Zimmerman, 2010). More
specifically, female mentors are associated with positive mental health outcomes among
Black youth (Bryant & Zimmerman, 2003). Among Black MSM, mentors are an important
means of social support (Harper et al., 2012). Further, in qualitative research on the strategies
racial minority MSM (aged 18-49) use to manage racism and homophobia, Black MSM
described learning identity-management strategies, including how to cope with racism, from
their role models (Choi, Han, Paul, & Ayyala, 2011). These results suggest that natural
mentors may promote resiliency in the lives of young Black MSM.

36

Resilience summary
In the previous sections, I detailed ways in which various types of relationships may
be fundamental to the health and well-being of young Black gay and bisexual males. I
described the literature on how family, the gay community, mentoring relationships, and
constructed families promote the health and well-being of young Black gay and bisexual
males; there are undoubtedly other relationships (e.g., romantic, online friendships) that
promote healthy growth and development in the lives of young Black gay and bisexual males.
Additionally, there are numerous other potential protective factors and mechanisms at the
individual and systemic (e.g., policy) level that have health and development implications for
young Black gay and bisexual males. I bounded the review of the literature based on my
study’s analytic emphasis on relational resilience (see section on “resilience”).
The current study
My study offers an initial glimpse into relational resilience in the lives of young Black
MSM. Its focus on young men’s relational experiences and emphasis on resilience in the face
of adversity is consistent with Stall’s conceptual model. Specifically, in this study, I
examined the relational lives of young Black MSM who have avoided syndemic production
(i.e., the expression of psychosocial health issues associated with heightened risk for HIV) to
understand how they differ in their socio-cultural relational characteristics from men who
manifest syndemic production. The first aim of this study was to describe the protective
factors/strengths that exist within young Black gay and bisexual males who lack evidence of
psychosocial syndemic production. This approach to examining these young men recognizes
and celebrates young Black MSM’s resiliencies and resources Given the lack of empirical
data upon which to base this analysis, I undertook an emergent and largely descriptive

37

approach to examining the data associated with the participants who have avoided syndemic
production.
The second aim of this study was to explore how young men who have avoided
syndemics differ in their relational experiences from men who evince syndemics. Though
young men who have avoided syndemic production were the analytic foci, I also examined
those participants who evince syndemic production. I conducted two separate qualitative
analyses, one with a sample of young men who have avoided syndemics and one with a
sample of young men who evince syndemics. This approach allowed me to identify necessary
conditions that distinguish these two samples of men. Comparing the relational themes
generated from analysis of these two samples allowed me to identity relational patterns
uniquely associated with young men’s well-being.
The third aim of this study was to explore how relationships and relational factors
may promote the healthy development and the health of young Black MSM. I answered this
research question with a more fine-grained qualitative analysis of the data from the men who
have avoided syndemic production. For example, the comparative analysis suggested that
men who have remained healthy have supportive relationships with females in their
immediate family. A more in-depth analysis of these men’s data described how these females
provide growth-fostering relationships for these young men and what these young men are
taking away from these relationships.

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CHAPTER 2: METHOD

I present cross-sectional data from a study of young Black MSM between the ages of
14 and 24. Analyses compare a sample of young men who show no evidence of syndemic
production to a sample of young men who show extensive syndemic production. The data I
used were derived from a larger study conducted on behalf of the Michigan Department of
Community Health. The Young Men’s Health Study (YMHS), which took place from winterfall 2009, was designed to document the HIV prevention needs of adolescent and young adult
Black MSM for the purpose of informing the statewide community planning process for HIV
prevention (PI: Robin Miller; Co-PI: Miles McNall).
YMHS participants
My dissertation was focused on examination of young Black gay and bisexual men
who have avoided syndemic production and young men who have experienced syndemics.
As such, using the sampling strategies described below (see case selection section), young
men who met these criteria were considered in this effort. In all, the YMHS study recruited
180 participants across the state. Eligibility criteria included the following: 13 to 24 years of
age, identified as Black or African American, born a biological male, had sex with a male in
the prior 2 years, resided in Michigan, and had not been interviewed before.
For the purposes of this analysis, I theoretically sampled a group of 46 participants
from among the YMHS sample: 23 Detroit participants who engaged in safer sex practices
and exhibited a lack of syndemic production and 23 participants who exhibited a history of
sexual abuse, depression, and substance abuse (i.e., syndemic production). These samples
form the basis for two separate analyses (described in the analysis section).

39

Throughout this dissertation, I refer to this first sample of participants as men who
lack syndemic production or men who do not evince syndemics. I refer to the second sample
of participants as men who evince syndemic production or young men who are experiencing
syndemics. I recognize that these terms are linguistically cumbersome. However, I want to be
conscientious of the language used to describe these young men’s health profiles. I do not
wish to imply that men who do not personally express syndemics are not affected by
syndemics; they are part of a small, insular group about which stereotypes and
misconceptions abound regarding the health of their community. Further, as a part of that
community, they are affected by others who do experience syndemics. Though different
terms (e.g., healthy, resilient, or non-syndemic) may be more linguistically pragmatic, I
disagree with the semantic meanings that these terms imply.
Procedures (YMHS)
We used three recruitment strategies to identify eligible participants. First, we used
elements of respondent driven sampling (RDS), a sampling method developed to recruit
samples of hard -to-reach and hidden populations in a way that ideally possess the
characteristics of a probability sample (Heckathorn, 1997). When effective as a recruitment
strategy, RDS provides social network data and provides a way to evaluate sexual and drugusing networks in high-risk populations.
In RDS, seeds participate in a study; after study participation, these seeds recruit
people in their social networks who meet study criteria. We gave each participant three
coupons, each marked with a unique serial identification number and date of expiration.
Participants who gave coupons to people in their networks who met study criteria received
additional $5.00 remuneration if we heard from their network members. Through our
advisory panel (see section on instrument), we recruited six young men who met study

40

eligibility criteria as our initial seeds. We identified two seeds in Wayne County, and one
seed in each of Washtenaw, Kent, Berrien, and Ingham counties; these counties have the
highest HIV prevalence rates in the state. We recruited two seeds in Wayne County given its
population size relative to other counties.
We intended to use RDS as the sole recruitment strategy until we obtained a sample
size of 180; however, after a few weeks of data collection, it became apparent that the rate of
return was too slow to meet the reporting deadline set by the funder. Due to difficulties with
RDS, we supplemented our data collection using alternate recruitment procedures. Alternate
recruitment procedures entailed venue-based methods. We posted fliers and announcements
about the study in bars, community-based organizations, and other venues where members of
the target population were likely to spend time (again, within the aforementioned high
prevalence counties, as well as in Genesee and Saginaw counties). These fliers provided
prospective participants with a phone number and an email address they could use to contact
study personnel to assess eligibility. Additionally, we sent interviewers to locations and
events where members of our target population congregated (e.g., bars, community-based
organizations, balls). Recruitment locations were identified by our advisory council, internet
searches, local newspapers, and through the information we obtained during key informant
interviews. Participants recruited via these convenience sampling procedures were also
offered the opportunity to recruit three network members and receive up to $15.00 additional
remuneration. Roughly 20% of the participants were referred by other participants.
Recruiters and project staff assessed eligibility and scheduled interview times for
those persons who were eligible and interested in participating. We assessed study eligibility
for the YMHS using a brief screening interview. Participants also provided us with their
name and contact information so that at the end of the study period, they could be reimbursed
for any coupons that they distributed to their network members. In all, we screened 352
41

people, of whom 280 were eligible. The primary reasons for ineligibility included: failure to
meet the age requirement (53%), no sex within the required time frame (14%), no sex with
males (13%), or having already been interviewed (8%). During spring and fall of 2009, we
interviewed 197 young Black MSM from throughout the state of Michigan. Of these, 180
men completed the interview and provided usable data. Geographically, 59% resided in the
Detroit Metropolitan area and 41% lived elsewhere, approximately reflecting the distribution
of the HIV epidemic in the state.
We scheduled eligible participants for interviews at times and locations they found
convenient; due to having a large cadre of interviewers diverse in gender, race, and sexual
orientation, we asked participants if they had any demographic preferences regarding their
interviewer. When possible (e.g., due to interviewer availability), participant preferences
were taken into account when scheduling interviewers. If participants did not have a
preference, we scheduled interviewers according to their availability and geographic
proximity to the desired location. Interview locations included public and university libraries,
community-based organizations, public parks, interviewees’ homes, and interviewers’ cars.
Prior to interviews, participants signed informed consent (age >18 years) or assent
forms (age <17 years), depending on age. The Michigan State University institutional review
board granted a waiver of parental consent. The consent process informed participants about
the nature of the study, the risks associated with participation, their right to decline
participation or withdraw from the study, and the procedures in place meant to ensure their
confidentiality. Interviews were recorded with the permission of participants; one participant
declined to have his interview recorded. Interviews lasted an average of 70 minutes (range =
36 to 138 minutes). At the end of the interview, participants were compensated $25.00 for
their time and provided with a list of local referrals for HIV services and LGBT resources.

42

We trained and monitored 13 interviewers who performed data collection. Most
interviewers were doctoral and Master’s level graduate students from diverse disciplinary
backgrounds (e.g., clinical and community psychology, public health, and human
development). Due to the geographic distribution of potential interviewees, we recruited
interviewers who studied at universities in close proximity to the aforementioned geographic
target areas. Additionally, a few community members with experience in social work, HIV
prevention, and/or working with the target population also performed interviews. All
interviewers were trained on the project background and purpose, HIV and HIV prevention,
cultural competency with Black MSM, and the use of the protocol. Training entailed
conducting mock interviews performed with the project investigators or research assistants.
Throughout data collection, a project staff member checked interviews to ascertain their
quality and provide feedback to interviewers.
To ensure confidentiality, all data were securely kept in the principal investigator’s
project space. The study also obtained a special designation from the Michigan Department
of Community Health that provided special confidentiality protection for these data. Research
assistants transcribed, de-identified, and cleaned (i.e., checked for accuracy) the interviews.
Following transcription, we destroyed audio recordings to protect participants’
confidentiality. The YMHS was approved by Michigan State University’s Social Science,
Behavioral, Education Institutional Review Board (ID#i031939).
Instrument
HIV prevention and care leaders around the state were involved in project design. We
interviewed 21 key informants from local community-based organizations, health
departments, and representatives of the Michigan HIV Council (the CDC-mandated
prevention planning body for Michigan) to ascertain their informational needs. We developed

43

the interview protocol around these information needs in collaboration with six young men
from the target population who served as an advisory panel on the project. The advisory
council also helped process the key informant data, established interview topic priorities,
determined what questions should be asked qualitatively instead of through quantitative
measures, and reviewed drafts of the interview protocol. The final protocol contained a
combination of standardized survey measures, open-ended questions, and demographic
information. The protocol inquired about participants’ sexual and ethnic identity, peers,
family, Black communities, involvement in the gay community, experiences with religion,
role models, sources of social support, health care use, knowledge of HIV and sexually
transmitted infections, HIV and sexually transmitted infection testing experiences, sexual and
substance use behavior, mental health, and exposure to various forms of violence and abuse.
Only the items used in the current study are described.
Demographics
Age: To measure age, participants were asked to report their current age in years.
Sexual Identity: We asked participants to describe their sexual identity. Response
options included gay, bisexual, heterosexual/straight, and other. We included a
heterosexual/other response option because youth may engage in same-sex behavior yet
identify as heterosexual.
Gender Identity: We asked participants to describe their gender identity. Response
options included male, female, transgender, and other. We included a response option of
female because some gender non-conforming youth may identify as female rather than
transgender.

44

Educational Attainment: Participants were asked three questions about their
educational experiences. Given the age range of participants, we asked them a closedresponse question about whether they were currently in school. Additionally, we asked them
the highest grade they had completed in school (e.g., 8th grade or less, some high school,
high school graduate, some college, college graduate, more than 4 year degree) and, among
those currently in school, their current grade level.
Employment: Participants were asked about their employment. In a closed response
question they were asked if they were currently employed either full or part time.
Income: Among those who were employed, we asked for their monthly salary.
Syndemic variables
I used the following measures to theoretically sample (see section on case selection)
young men based on their degree of syndemic production. Notably, these measures are akin
to those that researchers have consistently applied across studies of syndemic development in
MSM populations (Dyer et al., 2012; Herrick et al., 2012; Mustanski et al., 2007; Stall et al.,
2003).
Sexual abuse: We assessed various forms of traumatic experiences (e.g., physical,
sexual, emotional, and financial abuse) using a modified version of a lifetime traumatic
experiences index (Widom, Dutton, Czaja, and Dumont (2005).A single item (yes/no), having
experienced coerced sex, was used to measure sexual trauma. In the full sample, 32% of
participants reported a history of sexual abuse. For these analyses, data were coded so that 0
= no history of sexual abuse and 1 = history of sexual abuse.
Depression: We assessed depression with the Center for Epidemiological Studies
Depression (CES-D) scale (Radloff, 1977). This 20-item scale is summed and scores may

45

range from 0 to 60; a score of 16 or higher indicates a clinically significant level of
depression. In the full sample, 33% scored in the clinically significant range (M = 14.7; SD =
10.7). Internal consistency (Cronbach’s Alpha) for this sample was .89. For these analyses,
data were recoded as 0 = mentally healthy; 1 = clinically significant level of depression.
Substance abuse: To measure substance use, we used a brief screening instrument for
detecting substance abuse in adolescents (Knight et al., 1999). Scores may range from 0 to 9;
scores of 2 or higher indicate problem substance use. In the full sample, 54% scored in the
problem substance abuse range (M = 3.1; SD = 2.3). Cronbach’s alpha for this sample was
75. For these analyses, data were recoded so that 0 = non-substance abusing and 1 =
substance abusing.
Sexual behavior: We asked participants detailed information about their sexual
histories and recent sexual relationships (Fishbein & Coutinho, 1997). For participants who
reported having had sex in the last 90 days, they were asked to provide detailed demographic
(e.g., age, race, type of partnership) and behavioral (e.g., type of sex act, frequency of sex
acts, frequency of condom use) information on up to three sexual partnerships over the
previous 90 days. In addition, many participants elaborated on aspects of current sexual
relationships in the open-ended sections on HIV and STI testing, knowledge of HIV and
STIs, and safer sex influences.
Relational data
I conducted the primary analyses (see analysis section) using the qualitative portions
of the interview protocol that assessed young men’s relationships and interactions with other
people and organizations. Participants discussed facets of various relationships throughout
the protocol; men described their relationships with family, peers, mentors/role models, the
gay community, the black community, and in religious settings. Young men also commonly

46

discussed their relationships with family, peers, sexual partners, or others when discussing
who influenced their safer sex practices and/or describing previous HIV and STI testing
experiences. As a needs assessment, the interview protocol covered a breadth of topics, many
of which pertained to the relational nature of these men’s lives.
Feelings about racial and sexual identity: We asked young men five identity related
questions that pertained to their race and five similar questions that pertained to their
sexuality. We asked them how their race and sexuality affected how people treat them in
general; we also asked participants how their race and sexuality affected how sex partners
threated them. Four open-ended questions ascertained their feelings about their race and
sexuality (e.g., “How does being Black/gay affect how you feel about yourself?” And “how
does being Black/gay affect how you feel having sex with men?”). We also asked participants
how their race and their sexuality affected their exposure to HIV.
Family: Five questions assessed the composition and quality of young men’s family
relationships. To assess the make-up of participants’ families, we asked them to describe their
families (“Who do you think of when you things about your family?”) and to specify whether
they were referencing biological families or families of choice. To assess the quality of
family relationships, we asked participants about their relationship with their families (e.g.
“describe your relationship with your family”) and whether they felt supported by their
families. We also asked participants what they had learned from their families about
homosexuality to gauge familial response to and support for participants’ sexuality.
Gay Community: Young men were asked five open-ended questions and one closedresponse question about their involvement in the gay community. The closed-response
question inquired as to whether participants considered themselves a part of the LGBTQ
community. Participants who did considered themselves a part of this community were then

47

asked whether they felt supported by this community. Young men were also asked to
describe their involvement in groups for young Black gay and bisexual men and how they
became involved in these groups. Due to the nature of the needs assessment, we also asked
men health-related questions about these groups (e.g., “What health issues are members of
these groups talking about?” And “How do members of these groups learn to care for their
health?”).
Mentors and role models: We asked about the presence, function, and quality of
mentoring relationships through four open-ended questions: “Who are the role models or
mentors in your life?”; “What makes them your role models or mentors?”; “How do your role
models or mentors influence the choices you make or the things you do?”; and “How do the
role models or mentors in your life affect your decisions about practicing safer sex?”
Religion: To assess involvement in religious settings, we asked participants two
closed-response questions: whether they were formally a member or a church and whether
they were a current member. We also asked participants one open-ended question about
church teachings regarding HIV and one open-ended question about church teachings about
homosexuality. To gauge perceptions of religious support, participants were asked whether
they felt supported at church.
Safety: We asked participants to compare how they felt across various social settings
and to explain and elaborate on where (e.g., at church, among peers, in the Black community,
among family, or in the gay community) they felt the most and least safe, protected and
respected (“where do you feel the most/least safe, protected, and respected” and “Why”).

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Dissertation case selection
This dissertation examines young Black gay and bisexual men who have avoided
syndemic production and young men who have experienced syndemics. I derived analytic
samples from the larger YMHS dataset. For the purposes of this study, I theoretically
sampled a group of 46 participants from among the YMHS sample: 23 Detroit participants
who engaged in safer sex practices and exhibited a lack of syndemic production and 23
participants who exhibited a history of each sexual abuse, depression, and substance abuse
(i.e., syndemic production).
To identify the men in each sample, I used theoretically informed cluster analysis. As
a data reduction strategy, researchers often intentionally select cases based on theory
(Marshall, 1996; Namey, Guest, Thairu, & Johnson, 2008). I used theory-driven clustersampling to select groups of young Black MSM based on the degree to which they express
syndemic production associated with HIV risk within this population.
Stage 1: experience of syndemics
I used three psychosocial variables (e.g., depression, substance abuse, and sexual
abuse) to identify cases of theoretical relevance for this study (Dyer et al., 2012; Mustanski et
al., 2007; Stall et al., 2003; Stall et al., 2008). To identify typologies of men, I used the list
cases function in SPSS version 20 (IBM, 2011) to identify men who did not exhibit syndemic
production (i.e., no history of sexual abuse, substance abuse, or depression) and men who
exhibited syndemic production (i.e., history of sexual abuse, substance abuse, and
depression). This initial sampling strategy identified 23 men who evinced syndemics and 29
participants who have avoided psychosocial health issues associated with heightened odds for
HIV.
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Stage 2: geographic considerations
Based on previous analyses (Miller et al., 2013), I anticipated that participants from
the Detroit area would exhibit different health profiles than participants from elsewhere. I
anticipated that a primary demographic difference between the two groups would concern
their county of residence. In the interest of creating a homogenous analytic sample, I analysed
the county of residence of the 23 men who evinced syndemics and the 29 participants who
have avoided syndemic production. Men experiencing syndemic production represented a
geographic cross section of participants in the YMHS data set. In contrast, 28 of the 29 (97%)
young men who did not exhibit syndemic production were Detroit residents (the remaining
man who lacked evidence of syndemic production was from Flint).
As there was only one case from out-State in the analytic sample of men who lacked
syndemic production, I excluded this case from analysis. Excluding this case was justified
because it is likely that Detroit participants possess a different set of resources available to
them that serve as protection from syndemic production. Additionally, as there was only one
participant from Out-State Detroit, I lacked sufficient data with which to conduct case
analysis. This case exclusion left me with an analytic sample of 28 men from Detroit who
exhibited a lack of syndemic production.
Stage 3: sexual behavior considerations
As a second strategy to create a homogenous sample, I delimited the cases of young
men who avoided syndemic production to those who also engaged in safer sex practices.
Syndemic theory would predict that the men in this sub-sample engage in little sexual risk
behavior associated with HIV risk. They are likely to have few sexual partners and engage in
sexual risk reduction practices such as condom use or HIV testing prior to discontinuing
condom use in relationships. As expected, the majority of participants (23/28; 82%) engaged
50

in low risk or safer sex practices. The majority (14) of participants had sex with 1 or 2
partners in the last 90 days while using condoms 100% of the time. Four men had not had sex
in the last year, 2 men had not had sex in the last 90 days, and 1 man only participated in oral
sex within the last 90 days. Two men did not use condoms with their long-term sexual
partners, but in their qualitative data they described being tested for HIV with their
boyfriends prior to sex. The remaining 5 participants were not included in analysis, leaving
an analytic sample of 23 young men who have avoided syndemic production and who engage
in safer sex practices. There are a few reasons why sexual behavior was used to delimit the
cases only from the sample of young men who did not experience syndemics. Because these
young men do not exhibit psychosocial conditions associated with heightened HIV risk or
behavioral risk associated with HIV, it is from these men that I could best hope to identify
protective factors that may assist young Black MSM in avoiding syndemic production as well
as sexual behavioral risk. I refrained from delimiting the cases of men experiencing
syndemics by their sexual risk behavior due to this study’s focus on protective resilience
(Stevensen & Zimmerman, 2005) rather than compensatory resilience (i.e., protective factors
that may counteract syndemic exposure and provide protection against behavioral risk). An
implication of this decision is that the comparative component of this study compares the
relational experiences of young men who differentially expressed syndemic production
(regardless of sexual risk behavior). This decision was also informed by Safren and
colleagues’ (2010) work suggesting that it is not only sexual behavioral risk that makes MSM
experiencing syndemics more vulnerable to HIV; they may be more susceptible to negative
outcomes along the continuum of care. Therefore, delimiting these men by their behavioral
risk would neglect the fact that they may face added health burden in multiple ways.

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Analytic participants
Table 1 displays demographic information for the two analytic samples. As can be
seen, the vast majority of men in each group had a male gender identity. Men experiencing
syndemics were more likely to identify as bisexual when compared to men who avoided
syndemics; however, this difference was not statistically significant. Similar proportions of
each group were in school (57% vs 55%) and employed (65% each). The two analytic
samples also did not significantly differ in their level of education (most having at least
graduated high school), monthly income (predominantly low income), or housing status
(most having stable living situations on their own or with family). I conducted difference
tests (e.g., chi-square test for categorical variables and independent sample t-tests for
continuous variables) to assess whether there were significant demographic differences
between the two analytic samples. The two analytic samples did not significantly differ on
any characteristic but age. An independent samples t-test indicated that men experiencing
syndemics were significantly older (M=20.91, SD = 1.91) than men who were not
experiencing syndemics (M = 19.35, SD = 1.95), t (44) = 2.76, p, .01.). The men experiencing
syndemics reflected a geographic cross section of the YMHS sample. Among these
participants, 9 lived in Detroit, 4 in Lansing, 4 in Flint, 3 in Benton Harbor, 2 in Ann Arbor,
and 1 in Saginaw.
As sexual assault history distinguishes these two samples, I also examined the limited
data that men experiencing syndemics supplied about their sexual assaults. Men reported
experiencing sexual assault between the ages of 5 and 19 (M= 9.96; SD = 4.51). A few
reported multiple sexual assault experiences. Among these participants, their relationships
with their assailants were most frequently family members (n=12), strangers (n=9) and peers
(n=4).

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Table 1: Demographics

Mean Age (SD)
Sexual orientation
Gay
Bisexual
Gender Identity
Male
Transgender

Men
Men who
experiencing
do not
syndemics (23) evince syndemics
(23)
20.91(1.91)
19.35(1.95)**
59%
41%

83%
17%

91%
9%

96%
4%

Currently in School
57%
55%
Level of education
Less than high school 22%
17%
High school/GED
44%
63%
Some college
35%
21%
College graduate
Employed (part or full
65%
65%
time)
Mean Monthly Income
1249 (1179)
1633(1118)
(SD)
Housing
Lives with family
52%
61%
Lives on own
35%
30%
Unstable
13%
9%
Note. Mean differences between samples were assessed using independent sample t-tests.
Differences in proportions between samples were assessed using chi-square tests of
independence. **Statistically significant at P < .01

Analysis
The analysis approach I employed primarily followed the principles of analytic
induction (Robinson, 1951; Erickson, 1986). Researchers use analytic induction to develop,
modify, and test assertions- comparable to quantitative hypotheses- inductively derived from
empirical data. In this case, I performed two separate analyses, one using the subsample of 23
men who evinced syndemics and one using the subsample of 23 men from Detroit who did

53

not evince syndemics and who engaged in safer sex practices. I analyzed each subsample
separately to identify assertions that distinguish conditions between cases.
Classical analytic induction (Znaniecki, 1934; Robinson, 1951) was conceived of as a
qualitative method through which to identity universal, causal processes. More modern and
modified forms of analytic induction (Turner, 1953; Robinson, 1951) now de-emphasize the
search for causal explanations and mechanistic processes. In addition, modern forms of
analytic induction may instead identify, as is the case in this study, more descriptive
assertions that delineate participant behaviors, perceptions, and relationships (Baillien,
Neyens, DeWitte, & DeCuyper, 2009; Bhattacharyya, Volk, & Lumpe, 2009; Gilgun, 1995;
Graham, Walsh, & Shier, 2009; Swan, 2009). Modified analytic induction thus has the goal
of constructing descriptive propositional statements of relationships among concepts.
Descriptive analytic induction was deemed an appropriate analytic method for a
couple of reasons. First, as a qualitative method, analytic induction is especially ideal for
identifying and examining contradicting outcomes in data (Katz, 2001). Analytic induction
entails the identification of a set of assertions that pertain to groups of people reporting
particular experiences. In the instance where reference groups can be identified that do not
report those experiences, analytic induction may be used as a way to distinguish categories of
cases. Though not typically conceived of as a qualitative comparison technique, analytic
induction’s emphasis on identifying necessary conditions (Robinson, 1951) that define
categories of cases implies that it can be used to examine contrasting outcomes in data, or in
this case, to contrasting the histories of men experiencing syndemics from men who have
avoided syndemic production.
Second, analytic induction is an appropriate form of analysis due to the topical
emphasis on resilience in the lives of a marginalized group. Many of the formative studies in

54

which analytic induction was employed involved analysis of groups that were socially
marginalized and often considered deviant such as opiate addicts (Lindesmith 1968), abortion
seekers (Manning, 1971), marijuana users (Becker, 1953), and youth thieves (West, 1978).
As a method, analytic induction helps shed light on the surrounding circumstances and
antecedent conditions associated with a group of people. In this way, the method helps
reconceptualize marginalized groups, such as Black MSM, which was an important epistemic
goal of this study.
Last, even in its descriptive application, analytic induction supports retrodiction: the
development of assertions that if a given condition (e.g., syndemics) is evident, it will be
associated with one or more things (Katz, 2001). Retrodiction is distinct from mechanistic
prediction in which emphasis is placed on the identification of antecedent conditions that
result in particular behaviors or circumstances. Instead, the use of analytic induction results in
the identification of one or more necessary conditions under which a phenomena, such as
syndemics or the lack thereof, is liable to occur. This analytic process, therefore, can help
identify relational conditions associated with the presence or absence of syndemics among
young Black MSM. Because analytic induction supports retrodiction, it is a qualitative
method well suited for studies, such as this one, where a primary intent is the identification of
interventions.
Figure 1 depicts the analytic induction process as used in these analyses. Notably, this
process was akin to the steps in analytic induction as specified by Robinson (1951):
1. Develop an initial definition of the phenomenon of interest.
2. Develop assertions that explain the phenomenon.

55

3. Examine one participant’s interview data (i.e., case) to determine if the assertion
describes their experience.
4. Reframe or re-define the assertion if the data provide disconfirming evidence.
5. Examine the second case with the new assertion.
6. Continue the process of assertion modification and case examination until all cases
are explained by the final assertion.
Figure 1 depicts how this process was conducted in practice. The first step entailed
developing a rough definition of the phenomena to be explained. This process involved
garnering a thorough understanding of syndemics, relevant constructs associated with health
among young Black MSM, and the interview data. I familiarized myself with key relational
constructs associated with young Black MSM’s health by conducting a literature review.
Additionally, this process involved acclimating myself to the data by engaging in initial reads
of the interview transcripts.
I then initially structurally coded the interviews. Prior to assertion development, I
structurally coded each interview as a way to familiarize myself with the data and prepare the
data for more fine-grained analysis (MacQueen, McLellan-Lemal, Bartholow, & Milstein,
2008). Structural coding is a form of high level coding whereby researchers divide the text
into large chunks of data that pertain to key topics of interest (e.g., gay identity, Black
identity, family support, etc.). This coding procedure allows for the quick identification of
key excerpts in the interviews to focus on during later analytic stages. This initial structural
coding helps researchers begin to immerse themselves in the data; as a precursor to a study
using analytic induction, structural coding also necessitates a broad inspection of all the
cases, a process that facilitates the development of initial analytic assertions. The following

56

table demonstrates how I structurally coded a segment of interview text. Non-italicized codes
were initial topical codes that emerged during a first reading of the interviews. Italicized
codes are more descriptive, fine-grained thematic codes that I applied at later stages of
analysis (see below).
Table 2: Structural coding example
Interview text

Structural code

I: And how else does being gay affect how you,
feel about yourself?

Identity

R: I guess I have a high sense of , pride, I guess,
in myself and I guess whatever I do, it’s not
always you know, gay related but gay is a big
part of who I am and I’m happy with, myself
today.

Pride in sexual identity

I: What is it that gives you, uh, high sense of
pride?
R: The work that I do. Would be the main thing
as far as helping the community, and, helping
out being a part in, serving the community that
I’m a part of….I’m a part of the miracle
program which is a, national program, and I
just relate it to HIV, AIDS work and prevention
so we um pretty much work around the state
just doin’ , um, you know, teachin’ people about
HIV and prevention and STD’s and things where
people get tested, and for everything, has to do
with the healthcare field and HIV related. So we
test people, counsel people, you know.

Sexual identity salience

Community involvement
Relationship between identity and community
involvement
HIV prevention involvement

After engaging in this high level structural coding, I then drafted initial assertions.
Analytic induction allows researchers to develop assertions based on extant theory and
literature, our assumptions, or initial reads of the data; assertion generation may therefore be
a priori or emergent. For the current study, I developed assertions based on the interview
data. I also identified which structural codes I could query to test these assertions (e.g., text
coded as ‘identity’ could be queried for assertions related to identity). I then tested each of

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these initial assertions, case by case. As I re-read each participant’s interview transcripts, I
determined whether the information confirmed, disconfirmed, or was not applicable for each
assertion. When originally testing assertions, I also engaged in more fine-grained structural
coding as described above. This coding delineated various themes in the data that provided
evidence for the assertions. For example, one of my assertions was that ‘young men not
experiencing syndemics exhibit pride in their sexual identities and recognize that there are
benefits associated with being gay and bisexual.’ Various structural codes (e.g., sexual
identity pride, sexual identity salience, positive conceptualizations of being gay) within and
across cases identify text which provides support for that assertion. Within individual cases,
there may thus be numerous instances of validation for key assertions.
Data analyses then proceeded across cases, meaning that I examined each case for
confirming and disconfirming evidence for each assertion. One of the strengths of analytic
induction is that final assertions should pertain to all cases under investigation. In analytic
induction, assertions are developed and refined in an iterative process until they are
maximally generalizable to all cases under investigation Put another way, analytic induction
entails the progressive redefinition of assertions; as analysis proceeds across cases, those
cases that do not conform to the initial assertions result in a modification of the assertions.
For example, one of my initial assertions was that young men experiencing syndemics exhibit
characteristic attitudes and behaviors associated with internalized homophobia; for a majority
of cases, this assertion fit the data quite well. However, further case examination suggested
this initial assertion was too simplistic. Whereas many participants exhibited internal
homophobia, others struggled with other facets of their identities such as their race, class,
religious identity, or gender. I changed this assertion (e.g., “these young men believe two or
more of their identities to be mutually incompatible”) to accommodate these cases and to
create an assertion that was maximally generalizable across all cases.

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Cases may also provide disconfirming evidence for assertions. In these instances,
there are three options that may be appropriate: noting contingencies in the case that may
allow you to explain and keep the assertion, removing assertions if they are not adequately
explained in the data, and creating new assertions. Not all of these options may be relevant
for each analysis. Analytic decisions as to how to handle disconfirming evidence within and
across cases largely depends on whether analysts can identify key contingencies in the
disconfirming cases and whether an evidentiary warrant can be established for newly
generated assertions (see below on explanation of evidentiary warrant). In my analytic
process, I used two of these analytic techniques (as depicted in figure 2) to address cases that
exhibited disconfirming evidence.
In one instance, I was able to identify key contingencies in disconfirming cases that
allowed me to maintain my initial assertion. Contingencies define the conditions under which
assertions do not pertain to particular cases. One of my assertions for the group of young men
experiencing syndemics contains such a contingency: “Young men experiencing syndemics
experienced extreme family conflict and alienation; however, having another ‘out’ gay
relative was an important contingency, as these young men did receive sexuality-related
social support from their families of origin.” This assertion therefore did not pertain to the
cases of the two participants who grew up with other sexual minority persons in their families
of origin. Assertions then apply to those cases that remain.
I also excluded assertions for which I could not establish an adequate evidentiary
warrant. One of the assertions that I discarded was not explained sufficiently across cases, by
which I mean that this assertion was not supported by the data after I engaged in a more
thorough analysis of the interview transcripts. After my first read of the interview transcripts,
I proposed that ‘young men not experiencing syndemics participate in alternate family
networks.’ Subsequent reads of the data suggested that the majority of participants did not
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participate in alternate or gay family networks; discrepant cases outnumbered those cases that
fit this assertion. I therefore determined that this proposition did not adequately fit the data
and eliminated it. Upon looking more closely at the young men’s experiences in gay or
alternate families, I noted (via structural codes) that many of these participants develop gay
families; as such, this finding provided evidence that young men engage in forms of social
action (i.e., the creation of alternate family structures for gay youth being one example) that
support the gay community. Thus, though I discarded the proposition related to involvement
in alternative families, looking at these data through an alternate lens provided evidence that
validated an alternate proposition that I had generated.

Figure 1: Example of assertion generation and testing

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Throughout this analytic process, researchers aim to establish the evidentiary warrant
for each assertion. That is, they seek conforming and disconfirming evidence by repeatedly
reviewing the data to test the validity of and examine the strength of the support for each
assertion. Assertions with a strong evidentiary warrant have been tested and re-tested, exhibit
confirming evidence frequently within individual cases, are validated by all cases under
examination, and contain what Erickson ( 1986) refers to as key linkages. Key linkages
indicate that there are relationships or patterns between or among assertions; key linkages
indicate that there are cross-cutting themes within the data. Throughout the results I briefly
indicate key linkages between assertions and then describe these linkages more fully in the
discussion.
Credibility
There are manifold ways to increase the data’s credibility, or the believability of the
results (Miles & Huberman, 1994). In this proposed research, I used the following strategies
to increase the credibility and confirmability of this analysis: 1) prolonged engagement with
the data, 2) interrater reliability, and 3) analytic and reflexive memoing.
Prolonged engagement with the data
A technique for increasing analytic credibility is for the analyst to experience
prolonged engagement with the data. Some of this engagement came prior to analysis, as I
was involved in the development of the research protocol, data collection process, and data
management. I listened to many of the interviews to evaluate the quality of the interviewers
and for the purpose of transcription. I developed a familiarity with the transcripts due to my
involvement with other analyses using these data. For this analysis, prolonged engagement
with the data entailed multiple reads of the transcripts and iterative code development and
application over a period of nine months.
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Interrater reliability
According to Miles and Huberman (1994), code stability is achieved once the
definitions of each code are cogent and clear enough that another person can reliably fit the
codes to the text; coding checks are therefore a way to assess the quality of the process by
which qualitative data yield conclusions. To this end, I employed a research assistant with
previous training in qualitative coding and the use of qualitative software to assess inter-rater
reliability. Though this secondary coder was not involved in data collection or the YMHS,
she had previous experience working on projects related to HIV among young MSM.
The secondary coder helped assess reliability at the level of the codes. This check
entailed assessing the degree to which she could reliably apply the more fine-grained codes to
the text (i.e., child nodes). To facilitate this process, I utilized a number of guidelines for
facilitating the efficiency of coding as specified by Hruschka and colleagues (2004). They
recommend that coders utilize data and codes that are clearly organized. The use of software
aided in the organization of texts and codes. They also recommend that when employing
multiple coders, analysts place limits on the number of codes that are assessed during each
coding round. Analysts may limit code comparison to only a few interview questions or limit
the number of codes used overall. In this case, I placed restrictions around topic themes
coded during each coding round. For example, during a given coding round, we placed
emphasis on key content areas as delineated by high-level structural codes. As an example,
querying ‘family’ allowed for the identification of key text to which family-related sub-codes
(e.g., family sexuality-related support, family sex-related support) applied. Third, we engaged
in an iterative code development and analysis process whereby we engaged in intermittent
assessment of the coding schema and instructions (Hruschka et al., 2004). This process
entailed first piloting all the sub-codes on a small sample of the interviews. We each coded
the same sample of interviews from each group of cases (e.g., men experiencing syndemics

62

and men who lack syndemic production). Thereafter, we used NVIVO’s code comparison
function to compute reliability statistics (e.g., kappa) to assess to the degree to which codes
could reliably be applied. We then met to discuss the use of our codes and the corresponding
reliability statistics. Notably, it is common that there will initially be low agreement on
coding (Hruska et al., 2004). Discussion about the instances in which there was a low degree
of reliability resulted in the refinement to particular codes or alterations to coding
instructions. For instance, on this first pass we noted that much of the disagreement was not
due to the conceptual application of the codes or definitional ambiguity, but rather due to the
lack of rules regarding coding boundaries (e.g., inclusion/exclusion of interview questions,
inclusion/exclusion of blank space). As a result, we made rules concerning how much text
around each node to code so that a coding comparison query would more accurately assess
the conceptual application of the codes (kappa is computed by character, not by word).
Additionally, we discussed instances where there was a conceptual difference in the way that
we were applying particular codes. For instance, at an early stage of this process, my
definition for ‘internalized homophobia’ did not accurately convey the way in which I had
coded textual instances indicative of internalized homophobia. As a result, these
conversations resulted in refinement and additions to code definitions. After these initial pilot
tests and subsequent alterations, we coded a randomly selected subsample of each group of
cases (e.g, men experiencing syndemics and men who lack syndemic production) using these
new procedural rules and code definitions. At this stage, I purposefully chose cases that were
different from those in the pilot test, as including those cases that we had already discussed
would have artificially deflated our reliability statistics (due to having coded them prior to
procedural changes and addressing definitional ambiguity). Thereafter, again using NVIVO’s
code comparison function, I computed reliability statistics (e.g., kappa) to assess inter-coderagreement. Inter-rater agreement for all codes was above .82, indicating that the codes, which

63

provided evidence for the assertions, could reliably be applied. Despite attempts to limit the
coding of extraneous characters, much of the disagreement between coders was not due to
conceptual use of the codes, but to the coding of irrelevant space surrounding the text.
Analytic memoing
I used memoing to refine and keep track of ideas and evolutions to assertions.
Memoing is a way to develop ideas, organize concepts and relationships between codes, and
investigate the merits of particular analytic categories (Charmaz, 2006). Throughout analysis,
I wrote two different types of memos. Analytic memos focused on code development,
application, assertion refinement, and relationships among assertions. These memos also
constitute an audit trail as they describe the development and modification of assertions,
detail why assertions were altered, and contain key verbatim text and codes that provide
evidence for assertions. In qualitative research, these memos often form the backbone of
analysis because, when integrated together, form the basis of a results section that is
intimately grounded in the data.
I also kept reflexive memos to gauge how my beliefs and preconceptions were
directing my examination and interpretation of the data. Consistent with feminist,
constructivist epistemological beliefs, I believe that my interpretation of participants’
experiences is reliant on my own standpoint (Charmaz, 2006). My knowledge of HIV risk
among Black MSM, educational rearing in psychology and public health, or personal beliefs
and influence my attunement to and interpretation of the data (Charmaz, 2006). Reflexive
memoing was a way to examine the view I brought to the data. These personal memos helped
me examine hidden assumptions in my own, as well as in the participants’ inferences.

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CHAPTER 3: RESULTS
In this study, I examined the relational lives of young Black MSM who have avoided

syndemic production to understand how they differ in their socio-cultural relational
characteristics from men who manifest syndemic production. In the sections that follow, I
describe the assertions that emerged within the sample of young men who did not evince
syndemics. Then, I describe assertions that emerged when analyzing the interviews of young
men experiencing syndemics associated with heightened HIV risk. Though I primarily report
the findings related to these samples separately, I do occasionally reference key differences
that emerged between the samples. The next five assertions pertain to participants from
Detroit who did not show evidence of syndemics.
Men who lack evidence of syndemics
Pride
Assertion 1: Black gay and bisexual males who do not evince syndemics, exhibit
pride in their sexual identities and recognize that there are benefits associated with being gay
and bisexual. Additionally, these men experience identity integration such that being Black or
being a man is not mutually incompatible with being gay or bisexual. They are proud Black
gay and bisexual men. Herrick et al. (2011) suggest that a sense of shamelessness or pride
“may be one of the greatest strengths that sexual minority communities have developed and it
may be very important in disrupting syndemic progression and its impact on HIV risk and
infections” (p. S28). Pride is antithetical to prototypical internalized heterosexism (e.g., a
sense if being different, less than, defective, or alone).
Participants staved off prototypical forms of internalized oppression. Young men
were asked how being gay or bisexual affects how they feel about themselves. They all
conveyed self-acceptance and described positive facets of being Black gay and bisexual men.
65

For example, responses to this question included: “it’s cool, all I can say is, mmmm great,”
“it makes me feel good about myself,” “I feel positive about myself,” “I really love myself,”
and “I love bein’ a boy that likes boys.”
Participants live within a heterocentric culture, meaning that they are surrounded by
negative attitudes, biases, and discrimination in favor of opposite-sex sexuality and
relationships (Herek, 1990). Though there was considerable variability, participants’ lives
were filled with negative messages (e.g., from school peers, churches, family and strangers)
which largely denied or denigrated same-sex relationships and behavior. These young men
exhibited self-acceptance despite acknowledging pervasive negative societal views of gay
and bisexual men. They developed a healthy sense of being gay or bisexual even with
histories of homophobic attacks, structural heterosexism, and masculine socialization stress
(i.e., the shaming or punishment of boys and men for failing to achieve masculine ideals).
Despite experiences of oppression and marginalization, these young men constructed positive
sexual identities.
Several young men also had a strong sense of a personal sexual identity. They were
critical of and rejected stereotypes associated with gay and bisexual men and stressed the
importance of developing a personal identity that was not restricted by societal messages
regarding what gay and bisexual men “should” do, think, and feel. Several participants
articulated a belief that the majority of societal messages connected with the gay community
or with Black gay men are negative and harmful (e.g., promiscuity, addicts, HIV). These men
described the rejection of these harmful stereotypes.
Participants also indicated self-acceptance by indicating that there were benefits
associated with their sexual orientation identities; they articulated numerous positive

66

conceptualizations regarding their sexual orientation identities. Chief among these positive
personal conceptualizations of being gay or bisexual was a strong sense of pride:
I guess I have a high sense of pride, I guess, in myself… whatever I do, it’s not
always, you know, gay related, but gay is a big part of who I am. And I’m happy with
myself, today.
These young men communicated that pride was related to a sense of authenticity (“I can do
whatever I want to do… that’s why I feel good about myself- I can do it on my own and not do
something that I don’t want to do). Pride also arose from a feeling of being unique, or special,
as was the case with a young man who believed being gay “makes me better than everybody
else. It gives me an advantage in life, ‘cause I’m not like everybody else.” As the quotes by
these participants suggest, exploring and accepting their sexuality allowed for the opportunity
to be who they are and to feel special, resulting in an enhanced sense of self-worth.
Participants also elaborated on aspects of their sexuality that they particularly
enjoyed. They emphasized that their sexuality gave them new means of self-expression,
suggesting that social creativity is valued: “I love myself, it gives me a chance to express
myself through other things.” Others found a sense of life purpose by participating in social
causes through their involvement in AIDS service organizations and LGBT centers,
indicating a proclivity for engagement in social action and community involvement.
Specifically, participants described a desire to be knowledgeable on, and inform others about,
issues that affect the gay community. These young men also described how being gay or
bisexual afforded them new means of friendships and relationships through initiation into gay
culture, highlighting the importance of sexuality-related social support:

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I just feel like a whole ‘nother new person…The reason why it make me feel like a
whole ‘nother person is because…. now it seem like when I’m gay, that’s when I have
more friends than I had before when I was straight.
Black gay and bisexual males who avoided syndemic production acknowledged numerous
benefits of being gay, including increased and valued avenues of self-expression, social
action, and social support.
Noticeably absent from these participants’ interviews are statements indicating
experiences of identity incongruence. None described feeling doubly oppressed as members
of two marginalized groups. None described a sense that their race was incompatible with
their sexual orientation identity, nor that their sense of masculinity was compromised by
virtue of their sexual orientation identity. As a sense of identity incongruence was a core
theme among the participants who are experiencing syndemics, it is noteworthy that these
young men did not describe a similar struggle.
Maintaining pride using stigma management techniques
Assertion 2: Black gay and bisexual males who do not evince syndemics used three
primary stigma management strategies to counter others’ attempts to shame them: cognitive
reframing, being dismissive of stigma, and the strategic avoidance of people and places that
perpetuate heterosexism/homophobia. Young men used the aforementioned stigma
management strategies to help them integrate facets of their sexual and religious identities.
Many young Black gay and bisexual men value attending church; yet, religious
institutions are often among the most oppressive, non-gay friendly contexts (Ward, 2005).
Religious teachings and activities that perpetuate various forms of institutional heterosexism,
sexual prejudice, and masculinity stress may promote shame in young gay and bisexual men.

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Young men who did not evince syndemics developed strategies deigned to ameliorate distress
caused by religious and other forms of oppression. These participants reported three primary
stigma management strategies: cognitive reframing, being dismissive of stigma, and the
strategic avoidance of people and places that perpetuate heterosexism/homophobia. Used in
religious settings, these strategies allowed young men to avoid or dismiss sexual shaming and
to integrate facets of their sexual orientation and religious identities. In religious settings,
they made use of the aforementioned cognitive change strategies: in particular, they attended
gay affirming churches or did not attend church and may be atheistic (e.g., strategic
avoidance) or reinterpreted or dismissed heterosexist or sexist church teachings as a reflection
of structural oppression (e.g., cognitive reframing).
Young men used cognitive framing strategies that helped them resist heterosexist and
homophobic messages. Cognitive reframing involves the identification and dispute of
harmful, maladaptive, or irrational thoughts (Goffman, 1974); in this case, young men
exhibited cognitive reframing strategies that provide a form of resistance to other’s attempts
to shame them. In particular, they were adept at restructuring heterosexist messages. These
young men valued their own opinions (“It’s their opinion, I have mine. So, it’s all good with
me”) regarding their sexual orientation over those of others, a strategy used to assuage the
internalization of heterosexism.
Cognitive reframing strategies were used to counter stereotypes of gay and bisexual
men (e.g., all have HIV, are promiscuous, can’t hold down or are not desiring of
relationships), the causes of homosexuality, and heterosexist beliefs, particularly those based
on Biblical interpretation or religious grounds. For example, this young man described his
reinterpretation of church teachings about homosexuality:

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[I’ve been taught] It’s a sin, it’s against the God, that you will go to hell if you do
that. But in the end I think that’s wrong because it says also that if you get tattoos or
piercings, if you have sex before you get married, you still not be able to go [to
Heaven]. But that’s just being a hypocrite I think. ‘Cuz everybody gets their ears
pierced, everybody has sex before they get married. It’s just a select few that don’t,
that abide by those rules.
Young men reassessed religious teachings to be more consistent with their identities as gay
men. In the quote above, the young man conceptualized people whose heterosexist beliefs
were based on religious understandings as “hypocrites” who likely did not abide by other
Biblical “rules.” From this perspective, heterosexist beliefs and comments become a criticism
on others and on the structural factors that perpetuate and maintain heterosexism and
homophobia. These young men recognize heterosexism as oppression, and acknowledge that
some people are “homophobes,” “ignorant,” have “a fear of what they don’t understand,” or
are just trying to protect their own images.
Another strategy that helped these young men preserve a positive self-image was that
of being dismissive of stigma. The most direct form of being dismissive consisted of
participants overlooking or ignoring attempts to ridicule, shame, or threaten them. Young
men said that they “don’t pay no attention” to people who tease them or stare at them, “keep
on with my day” when they perceive others as judgmental, and don’t let others’ ignorance
affect them (“I don’t let it affect me though”).They cultivated a thick skin of indifference. A
second dismissive strategy involved the belief that they were fortunate relative to other gay
and bisexual men. These young men recognized the unfortunate reality that as young gay
men, they could be victims of violent crime, disowned by their families, or institutionally
discriminated against due to their sexuality. By contrast, they considered their experiences as
gay and bisexual men as “nothin’ too bad.”
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Young men were selective in where they went and with whom they interacted,
choosing to go places where they felt safe and respected. Young men’s strategy to avoid
places where they felt unsafe or disrespected was principally evident in their descriptions of
their involvement in church settings. They sought out supportive, gay affirming churches or
ceased attending churches where they did not feel safe, supported, and accepted.
Participants attended gay affirming or gay friendly churches where they learned that
being gay is compatible with religious teachings and doctrines. Their pastors preached,
“everyone’s equal, no matter what they do,” “it doesn’t matter if you’re gay or not…every
person has their own relationship with God,” “it doesn’t matter what their sexual orientation
is, everyone is a child of God.” These young men heard that everyone was equal in God’s
eyes. Churches services and teachings contained affirming messages. Further, congregants
treated gay people tolerantly and “the same as they treat everybody else.”
At these churches, young men also received safer sex advice (“whatever you are is
whatever you is, just be safe.”) and HIV testing advice:
…he’s [the pastor] always saying if you are having sex to always be safe with it.
Don’t have sex without a condom. Always get tested. He even came up with a point
that I always stuck with: when, before you even have sex with a partner for both of
you to get tested to know your HIV status.
One young man even described his church as “a big ol’ happy family” where he and his
boyfriend are very “happy” and participate in a “couple’s ministry” with heterosexual and
same-sex couples. Young men attending gay-affirming churches could align their religious
beliefs and identities with their sexual orientation and were able not only to avoid shame, but
also to find supportive, affirming environments and relationships. For these young men, their
churches and fellow congregants provided sources of sexuality-related social support. At

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these churches, there were avenues to engage in social action on topics (e.g., gay rights or
HIV prevention) of interest and relevance to these young men’s’ lives.
Others ceased attending churches where they did not feel safe, supported, and
accepted. These participants chose not to attend places that taught them being gay was “evil,”
“a sin,” “bad,” “the way of the Devil,” or “against God.” Church, to these young men, was a
place they did not feel “one hundred percent comfortable” or felt liable to be “shunned.”
Non-attendance was described as due to the unwillingness of the church to be accepting of
their sexual orientation: “No ‘cuz I’ve always been gay and I always felt like the church was
against it and they are against it and I don’t care what people say. …so I don’t go to
church.” These young men identified as agnostic/atheist (“I don’t believe in church or the
Bible”) or were actively seeking out gay-affirming churches where they would be supported.
In general, these stigma management strategies indicate that young men have
developed a cadre of approaches that allow them to cope with experiences of heterosexism
and homophobia; additionally, these strategies are particularly useful in helping young men
respond to religious teachings and practices in a way that allows them to develop and
maintain positive sexual orientation identities, and for some, to maintain valued religious
identities.
Social support from families of origin
Assertion 3: Black gay and bisexual men who do not evince syndemics received
sexuality-related social support from their families or origin. Biological family members
provided sexuality-related support in numerous forms, not the least of which was family
members’ acceptance of participants’ sexual orientation. Family conveyed to young men: “no
matter who you are, we acceptin’ of you. Whoever you is, it doesn’t matter.” Some young
men were fortunate to have their entire biological family supportive of their sexual

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orientation. The following excerpt comes from a participant whose family surprised him with
how supportive they have been of his sexual orientation:
Nothin’ negative… they don’t have like a negative vibe against gay people. Period.
They don’t have like a negative vibe about it. Because I thought that they were going
to have a negative vibe when I told ‘em, but it was like, no. My family they’re like
open hearted. So it’s like they don’t really get into the negativity part… they’re very
open with gays…
As this young man indicated, though he originally feared his family’s response to his sexual
identity, he has since learned that they are accepting and “open-hearted.” Indeed, many
participants acknowledged how frequently young gay men do not receive support from their
families and thus recognized that they were fortunate to have understanding and supportive
family members.
Often, when specific people were described as being supportive, they were female
family members such as sisters, mothers, grandmothers, and female cousins. A handful of
participants had other family members who were also sexual minorities: “well my mother is a
lesbian. Her sister is a lesbian, which is my aunt. Their brother is gay, which is my
uncle….I’m a say about 95% of my entire family is gay… So you don’t hear anything too
bad… Just hear be safe.” Gay family members provided emotional support, advice on
coming out to friends and family, and helped young men accept their sexual orientation: “my
sister…she’s bisexual, so she really helped me along. To being, you know, comfortable with
myself.”
Participants described members of their families who were not supportive of their
identities as respectfully tolerant and largely silent on the matter. Young men described how
people in their families “don’t like it, but they accept it because that’s what I am.” Other

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young men said that their sexual orientation is “not really talked about,” family members do
not “speak too much on it,” or that disapproving family members just “ignore it.” This
finding resonates with research showing that while there is often condemnation and ostracism
of same-sex relationships in Black families, there is paradoxically an unspoken acceptance of
sexual minorities who remain silent (Collins, 2004; Gomez et al., 1999). Rust (1996) also
maintained that in Black culture, parents are accepting of same-sex behavior if it is not
explicitly mentioned. As such, young Black men may equate acceptance of their sexual
identities, in some instances, with reticence on the part of family members.
For these young men, family members who spoke with them openly about sexual
orientation related issues were chiefly concerned that young men “be safe” and “be careful.”
Family conveyed concern about participants’ physical and sexual safety: “My mom though
she didn’t really mind it. You know, just long as you was okay and you was happy, my mom
was happy.” A number of participants had family members who gave them safer sex advice
(“they told me to be careful, sex wise. Period. Guys and girls”), which young men took to
heart:
I mean I wasn’t using condoms at first…I mean I just started using condoms because
my mom was telling me that if you are out here having sex with other men and stuff,
you should be out here using condoms because you don’t want to catch the HIV from
one of these people…So, I mean, I listen to my mom.
As the previous excerpt suggests, this young man only incorporated condoms consistently
into his sexual life after his mother expressed a desire for him to protect himself. Family
members (particularly mothers and sisters) also provided young men with condoms. Their
mothers “introduced [them] to a condom,” gave HIV and STD prevention workshops at
churches, and were aware of and supportive of the work they did for the gay community or in
the HIV prevention field:
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Like, when I started doing Mpowerment …when I started doing this and I was telling
them [his family] about ‘oh yeah we do this and we go out to clubs and give out safer
kits and condoms and lube’ and tell ‘em what all we do. And they’re very very
supportive about that.
These young men had parents and family members in the role of HIV educators. Again,
specific family members who promoted sexual health tended to be females such as sisters and
mothers and grandmothers.
Family members also advised participants about the dangers of heterosexism and
homophobia and suggested that they be vigilant of potential attacks. Family members
communicated their concerns to participants, as was the case with this young man’s
grandmother:
When I go to clubs and stuff it be like, she always tell me be careful. But, like being
gay, she just says be careful because there’s a lot of people in the world who doesn’t
like it. So she just says be careful and stuff like that. Said look out for it.”
Family also gave young men advice on how to stave off discrimination. For example, one
young man’s mother suggested he compartmentalize his work and personal life:
I learned things from my momma. And she tells me things and I listen to her. …Like
how you present yourself in life. Like whatever you do sexually it should be between
you and your partner at home. Like you go to work, you can understand you being
gay at work, but you just keep that between you and your partner. Don’t bring it to
work, you know. That’s your personal life.
Supportive family members also defended participants against less accepting family
members, as was the case when this young man’s mother defended him against his
religiously intolerant aunt:

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…when I’m over my auntie’s house or my auntie’s or my uncle’s and then they say
something about me, then my mom always…says stuff like to protect me and stuff like
that. Gives her opinion…Most of time I tell her, I tell her ‘it’s okay.’ I say ‘you don’t
have to do that.’ I say, ‘Mom, I’m old enough to protect myself and stuff.’
These young men had family members who made it apparent to others that they best be
tolerant. Other young men received practical forms of assistance, such as transportation to
gay-identified social events: “They’re supportive. 100%. Uh, they take me to like gay events.
Supporting me. Out of town, and things.” This type of support made it possible for
participants to connect with other gay and bisexual men in social venues they may not have
otherwise been able to access. As these examples show, young men received a variety of
different forms of sexuality-related social support from their families of origin. They had
family members who were affirmative of their identities as young gay and bisexual men.
Community affiliation and support
Assertion 4: Black gay and bisexual males who did not experience syndemics were
initiated into gay culture through friendship networks and involvement in gay-community
settings such as LGBT service centers and AIDS service organizations; through these social
service organizations, they further developed friendship networks, become a part of a gay
culture that promotes health, and developed a healthy sense of group solidarity and
connection.
There is often a natural proclivity among marginalized people to seek out or create
settings that are affirming. Yet amidst a pervasively negative sociocultural context of
heterosexism and homophobia, it is often difficult for young gay and bisexual men to form
strong ties with other gay and bisexual men in healthy ways. Thus, many gay and bisexual
young adults lack social connections with other gay people. This social disconnect from gay

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culture may be especially true among young Black gay and bisexual men who describe the
“gay community” often as one that is racist, unwelcoming, or not meeting of their needs
(Battle, Cohen, Warren, Ferguson, & Audum, 2000).
All participants frequented Detroit’s LGBT and AIDS service organizations and
reported friendship networks of other gay and bisexual men who accepting of their sexual
orientation. Unlike participants experiencing syndemics, none of these young men avoided
LGBT spaces or events, nor did they report dissatisfaction with or experiences of
marginalization within the gay community. Rather, they reported intimate gay friendship
networks and community affiliations.
There are different avenues through which men achieve contact with gay culture (e.g,
at gay bars, sex venues, social organizations, friendship networks), and the means of
initiation may yield different social networks, understandings of gay social norms, and
different experiences of forming bonds with other men. Men who lack evidence of syndemic
health problems initiated contact with gay culture via social organizations or through their
peers. Young men reported that their friendship networks revolved around social service
organizations. Their friends introduced them to social service organizations such as the Ruth
Ellis Center or Affirmations or AIDS service organizations such as Mpowerment Detroit or
Rec Boyz (see social action section). Or, they became aware of these organizations while at
various venues (e.g., bars) where they encountered outreach activities and subsequently
became interested in attending the centers or the events supported by the centers. Participants
who created gay families often discovered their “kids of choice” through these organizations
(see social action section). These organizations thus serve as hubs for the creation of
relationships that are not predicated on substance abuse (e.g, gay bars) or sex (e.g., sex
venues and online communities).

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Participants detailed numerous benefits of their participation within gay male
community settings and connections to the gay community. They described a variety of ways
in which involvement in gay communities or gay friendly spaces was identity affirming.
These young men’s identities are often debased or devalued within larger society. An
important function of gay-friendly settings and communities is therefore to help marginalized
persons create, bolster, maintain, and celebrate facets of their identities. These young men
identified and cultivated relationships with people who affirmed their identities as young
Black gay and bisexual men. Participants alluded to a number of ways in which these
relationships and spaces were identity affirming. The following excerpts describe how young
men experienced participation in local service organizations as affirming of their identities:
Sometimes people have their way of life and a lot of them may closet themselves in
their own home or confine themselves to just their area they’re familiar with
because they don’t believe that the world is accepting of them. So it gives you an
opportunity to branch out into the community….this Ruth Ellis Center is a place for
you

to hang out with people like you, of the same or similar preference for

lifestyle…You may feel alone or you may feel different, but coming to these centers
you feel more subjective to accepting who you are and appreciating it. Because it’s
really a gift because it’s hard to be this way.
To these young men, places where they could openly connect with others like them were “a
gift.” Participants described how this type of environment was especially important for them
when they were younger and just coming to terms with their sexual orientation identities:
So it was actually a place where I could go to be gay. Because at the time I was like
kind of closeted and I wasn’t really, you know, as out as I am today. And I think

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maybe the center helps you find out, find who you are as a person also. Because you
see that it’s not so bad to be that way. So it helps people, especially young people.
As these excerpts indicate, these settings afforded young men opportunities to act in ways
that were consonant with their identities as young Black gay and bisexual men. They helped
young men feel less alienated and alone. Further, they promoted the idea of authenticity and
helped young men find aspects of their identities that they might value and appreciate.
Gay communities and gay-friendly spaces were also described as spaces where young
men felt safe and respected; they were an oasis in an otherwise difficult social environment,
or places they might “feel, I guess, free for just that short period of time.” In these locations,
they felt safe and welcome to “just be myself” without fear of ostracism. Young men also
described how gay friendly spaces provided opportunities for them to enact cultural practices
that are a part of who they are, but that are devalued within the larger society. Dancing or
vogueing, singing, and artistic practices were promoted and celebrated. Young men could be
admired or respected for their skills and interests.
In these settings, men often engaged in conversations about community violence,
poverty, men’s health, and the HIV/ epidemic within their community. These were venues
where men could talk about: “issues in relation to your lifestyle and problems you may be
having at home” or “stress, ‘cause everybody goes through stress” or “just livin’ as a Black,
young, gay man, as a whole.” Some of these discussions gave rise to social criticism and
therefore afforded participants opportunities to critique, as well as obtain advice on how to
cope with, the oppressive conditions under which they lived. These discussions entailed
deconstructing pejorative cultural stereotypes and representations relative to Black gay and
bisexual men. Other discussions revolved around various forms of oppression and ways in
which young men might mitigate or circumvent their experiences with racism, heterosexism,

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and/or homophobia. These venues promoted frank dialogues that may help young men lessen
experiences of, or ameliorate the psychological distress associated with, oppression.
Indirectly, these types of discussions may also articulate to young men that they are capable
of overcoming oppression.
Young men felt connected to other individuals who had gone through similar
experiences. They believed that only other Black gay and bisexual males could understand
the realities that they faced. As one young man described, “they can understand more where I
am coming from.” They valued having a community of others who could empathize with
their experiences and being around people who are “just like you.” Young men also indicated
a penchant for being more accepting of advice from people they felt were similar to them.
They detailed how important it was that they had people in their lives who shared with them
their experiences and knowledge to model or otherwise instruct them in how to be young gay
and bisexual Black men. They also connected with others who served as healthy guides into
gay culture. These young men cited older or well-respected Black gay and bisexual members
of the community who took them “under their wings.” Participants discussed how these
formative relationships with other gay and bisexual men contributed to less of a sense of
alienation and exclusion.
Young men looked up to older Black gay and bisexual whom they met through
community organizations as role models and mentors. They respected these older Black gay
and bisexual men for their work in the community and ability to give sage advice and
guidance of relevance to young gay men:
…the role models I do have, I really look up to them as far as education wise. They

doin’ things, you know, doin’ a lot of things for the community…not only that they

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talk to me about prevention. They also, also help me out when it comes to , you know,
like risky behavior.
As the quote indicates, this participant valued a relationship in which he felt his health was
being encouraged. Role models were people from whom participants felt comfortable seeking
advice; moreover, they were “leadin’ by example.” Role models were also individuals whom
participants felt provided a mechanism for them to become involved in their community; as
leaders in the HIV prevention field, Detroit’s house community, or LGBT service centers,
they were people who paved a way for and urged participants to become more socially
involved (see social action section).
These settings and the relationships developed within them also fostered pro-social
norms about safer sex, HIV and STI counseling, and relationships among men. The settings
promoted sexual health through their interventions, provision of safer sex kits, and delivery
of accessible testing opportunities. They provided resources for young men. Gay affirmative
settings were also ones where young men learned a lot about HIV in their communities and
became knowledgeable about safer sex practices. Participants spoke of their attendance at
local HIV prevention and safer sex programs, saying that they valued the gay community
because “that’s how I learned a lot about HIV or STDs” and that it was often their
participation in non-incentivized groups - “Rec Boyz, YBU, basically HIV prevention
groups”- that taught them how to care for their health, influenced their safer sex practices,
and taught them “how to not get sick.” For example, one young man explained that he and his
friends learn to take care of their health in the following way: “We go to a lot of seminars. To
learn things we’ll go to health meetings whenever we can and get a lot of information. You
know we try to be as healthy as possible.”

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All of these young men indicated a commitment to pursuing HIV education. In
addition to attending prevention groups and safer sex seminars at local HIV service
organizations or LGBT community based organizations, young men showed that they valued
HIV education by reaching out to local HIV experts when they needed advice or wanted to
stay up-to-date on new developments in HIV research. Others relied on their friends who
worked as HIV testers and counselors to provide them with updates, as did this young man
who explained how his friend influences his sexual health practices:
…in our circle we got a friend that works for like this health clinic, and like, when he
get information on different stuff, he’ll talk to us about it. Or if we need some
information, we can call him… me personally, I call him because he works in the
health field I asked him personally, like, ‘as you hear different information, hear
different things, would you call me and let me know and talk to me about it so I could
keep updates with different things.’
Men described the relationships within these settings as facilitative of supportive peer norms
for condom use, HIV testing, and healthy relationships. All participants described ways in
which their friends (and sex partners) positively influenced their sexual health.
Social action
Assertion 5: Black gay and bisexual males who do not evince syndemics supported
their community through advocating for LGBT rights, working with HIV prevention and care
efforts, or constructing supportive communities where gay and bisexual youth can find
support and acceptance. They are actively working to affect change in their communities. In
particular, they engaged in various forms of social action and volunteerism that were
intimately connected to their identities as gay and bisexual men. Through work in formal
organizations, serving as mentors and role models in their friend groups, and developing

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alternate family structures for gay and bisexual youth, these young men display a desire to
provide alternate support mechanisms for, promote the health of, and alleviate socio-cultural
myths and misconceptions about their community. The following section describes activities
and practices that these young men engaged in that support and foster positive connections
among young Black MSM.
Many of the participants were formally involved in some capacity with work in the
HIV service field (e.g., outreach workers, testers, and counselors). A handful of participants
were members of Young Brothers United, a group funded to conduct outreach to the 16-24
year old LGBT community. YBU members attend a 6-month intern process where they gain
leadership skills, essential life skills, learn about HIV, and learn to conduct outreach. In
addition to their HIV/STI outreach activities, YBU members design, plan, and conduct HIV
prevention curricula as a part of Mpowerment Detroit (Miller et al., 2012). Still other
participants were members of Rec Boyz, another group that, at the time of data collection,
was an HIV prevention project in Detroit for young men of color who have sex with men.
The young men who were involved in the HIV prevention and treatment field
experienced a sense of pride associated with their work. They felt a calling to help their
community. They derived meaning from “trying to do as much as I can” for their community.
Their work precipitated a sense of pride in their sexual orientation identities (see pride
section). For example, a young man who was involved in HIV outreach activities explained
why he felt proud to be a gay man; he attributed his positive sense of self to “The work that I
do. Would be the main thing as far as helping the community, and, helping out being a part of
serving the community that I’m a part of.”
Participants who were not involved in local HIV service organizations engaged in
less formal means of community health promotion. These young men encouraged others’

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safer sex practices through the provision of condoms, promotion of risk reduction strategies,
or role modeling behavior. They worked to establish peer norms of condom use or safer sex,
monogamy in relationships, and testing. For example, they encouraged testing in their
community by holding group testing events with their friends. Friend groups would “get
tested together” or participate in “testing parties.” Participants described how they
coordinated, hosted, or advertised the events in an effort to increase others’ comfort with
testing or encourage people to test more often. These efforts were independent of testing
events at HIV service organizations, and related to a desire to “give back to” “provide for,” or
“help people like me.”
Young men also described efforts to increase their own knowledge on HIV and safer
sex practices so that they would be equipped to answer others’ questions. These young men
reached out to local HIV experts when they needed advice or wanted to stay up-to-date on
new developments in HIV/S research. Participants also brought their friends with them to
prevention activities and events in the community. For example, one young man helped his
friends learn to take care of their health by insisting that they attend local seminars, meetings,
and safer sex programs with him. He and others who act as guides to prevention programs
and activities help their friends be “as healthy as possible.” As these examples show, young
men are attempting to influence their friends in a variety of ways in an effort to promote their
health.
Young men also challenged negative stereotypes of their communities. They live in a
social milieu in which people commonly endorse incorrect assumptions about them and about
HIV. Yet, they spoke openly and unapologetically about issues that they face as young gay
and bisexual men. Young men gave examples of how they spoke to women and community
members to debunk “myths and misconceptions” about HIV. They spoke up when others
falsely assumed HIV was a “gay disease” or that HIV infection was equivalent to HIV
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disease. They corrected others’ false beliefs about HIV testing procedures and AIDS
diagnoses.
Participants also expressed how being “out” as a gay man meant that they were
constantly being thrust into the position to explain and teach others about sexual orientation
related issues. As one young man described, when people find out he is gay, it is often the
case that “they actually wanna learn more about it. Once I’m open and out about it, they
usually treat me the same, they just wanna learn more about it.” Participants did not describe
these interactions disdainfully, but rather as opportunities to teach others about the realities of
being a gay or bisexual man. They saw these interactions as opportunities to correct
misconceptions, alleviate others’ fears, and share their experiences as a Black gay or bisexual
man.
Participants also created alternative families, thus helping provide for and protect
other members of the gay and lesbian community. They were gay mothers and fathers who
started alternative family groups that served as safe and welcoming kinship networks for gay
youth. These gay families were described as being developed to assuage the difficulties of
living as a young Black gay man (e.g., see section on social support). The following quotes
describe the ways that these constructed families serve to help and protect gay and bisexual
youth:
Like my kids of choice, I actually consider them as my own kids. Like they come, they
come to me whenever they have a problem and when they need anything and you
know they call me, we talk and I make sure they go to school, make sure they have
clothes, make sure they’re eating and all of that in the end. Because they’re young,
like 15/16. … So it’s very, it’s like a real actual family.

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This quote and others suggest that gay parents specifically help gay youth come to terms with
their sexuality and to find pride in their identities as gay and bisexual men:
I: What have you heard, umm, you know among your kids of choice about
homosexuality.
R: Well, I actually tell them….they ask questions and I have this book, it’s called, I
think It’s called ‘young, gay and proud’ and I have all of them read the same book
and it really, really helps them understand okay well you’re not alone…It really helps
them understand okay you’re not alone, how to tell your parents, how to accept
yourself and everything. And I always tell each one of them, you have to accept
yourself first before you can have others do it.
These participants are thus influential in helping gay youth craft affirming sexual orientation
identities and to learn skills that help them survive and thrive as young gay and bisexual
Black men. Participants who started these gay families or who have “kids of choice” also
detailed how they specifically aim to promote the health of the people who are a part of their
constructed families. They purposefully picked people to be a part of their families who they
thought both needed help and who were in a position to receive it. Here, one house father
described how he decides who can be a member of this gay family: “I take the ones who
actually want and need help. Not the ones who don’t wanna help themselves or do anything
with their self.” There is a selective process of gaining acceptance into his family. Gay
parents also described supporting their “kids of choice’s” health by providing them with safer
sex advice, holding testing parties as a family network, and being an example of an older
Black gay man who is comfortable talking about relationships, sex, and sexuality among
men. These young men are themselves serving as role models and community builders; they
engage in activities and practices that serve to provide support for other LGBT persons,
facilitate the health of their family members, and address oppressive beliefs about their

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community. Through the construction of alternate families, they provide mechanisms of
support for people who may otherwise lack it, or for youth who require a stronger support
network to thrive amidst an oppressive social milieu.
Summary
Table 3 provides a convenient overview of the assertions related to this sample of
young men. The young men who do not evince syndemic production exhibited a number of
similarities suggesting that they have nurturing and supportive relational lives.
Table 3: Assertions related to men lacking evidence of syndemic production

Pride

Social Support

Social Action

Men Lacking Experience with Syndemics
Black gay and bisexual males who do not evince syndemics, exhibit
pride in their sexual identities and recognize that there are benefits
associated with being gay and bisexual. Additionally, these men
experience identity integration such that being Black or being a man
is not mutually incompatible with being gay or bisexual. They are
proud Black gay and bisexual men.
Black gay and bisexual males who do not evince syndemics used
three primary stigma management strategies to counter others’
attempts to shame them: cognitive reframing, being dismissive of
stigma, and the strategic avoidance of people and places that
perpetuate heterosexism/homophobia. Young men used the
aforementioned stigma management strategies to help them integrate
facets of their sexual and religious identities.
Black gay and bisexual men who do not evince syndemics received
sexuality-related social support from their families or origin.
Black gay and bisexual males who do not evince syndemics were
initiated into gay culture through friendship networks and
involvement in gay-community settings such as LGBT service
centers, and AIDS service organizations; through these social service
organizations, they further developed friendship networks, become a
part of a gay culture that promotes health, and developed a healthy
sense of group solidarity and connection.
Black gay and bisexual males who do not evince syndemics
supported their community through advocating for LGBT rights,
working with HIV prevention and care efforts, or constructing
supportive communities where gay and bisexual youth can find
support and acceptance. They are actively working to affect change
in their communities.

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Men who evince syndemics
These young men were relationally distinct from the young men who did not
experience syndemics in a number of key ways. They were also more likely to describe
socio-structural inequities such as growing up in single parent homes, economic hardships,
imprisonment, homelessness, and institutional discrimination. Socio-structural issues in the
lives of these young men are not surprising given the relationship between socio-structural
disadvantage and poor health outcomes. Additionally, these young men’s interviews were
permeated with descriptions of how their lives were challenging as a consequence of
interlocking oppressions such as heterosexism, rigid gender roles, racism within their sexual
partnerships, and biphobia in the gay community. Additional ways in which these young men
differ from the first subsample may be seen in table 4 (see summary section), where it is
evident that they have drastically different identity-related experiences and attitudes, ways of
thinking about and relating to other gay and bisexual men, and levels of family and
community support.
Shame
Assertion 1: Young men experiencing syndemics believe two or more of their
identities (e.g., sexuality, gender, race, class) to be mutually incompatible. Some young men
have constructed identity narratives intricately tied to their sexual assault histories and
believe that their childhood sexual abuse caused them to be gay. In contrast to men who did
not evince syndemics, this sample exhibited and expressed identity-related confusion and
discomfort. Most exhibited characteristic attitudes and behaviors associated with internalized
homophobia (e.g., aggressive denial of sexuality, sexuality shame, being closeted, and dislike
of other obviously gay persons). These young men “don’t really like being gay” “don’t want
to be gay” and “can’t get away from it.” They view coming to terms with their sexuality as

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“a learning process.” Their discussions of their sexual orientation and desires give the
impression that they wish that they could have more control over their sexuality. Young men
who did not evince syndemics believed that they were born that way, made the way God
intended, or that their sexuality was “natural.” In contrast, these young men described feeling
“consumed by gayness” in a way that they could not control. They desired to “figure out how
to control my feelings,” wished that they could “change [their] mind…not be that way,” or
lamented that they could not just wake up one morning and be “like everybody else.” A
handful even intuitively connected their identity uncertainty to unhealthy, “self-destructive”
behaviors:
like you always know when something’s up with yourself and, you know being bullied
a lot when I was younger and then, trying to conform into something that I wasn’t,
led me on a self-destructive way which led to drugs, alcohol, and then to sex and,
other crazy stuff that you shouldn’t do.
For some young men, their beliefs about their sexuality were intricately connected to
their childhood sexual abuse experiences. These young men came to believe that their current
sexual identity or same-sex behavior was attributable to their sexual assaults. For example,
one young man described how he wavers back and forth on whether he is “supposed to be
gay,” and describes how his confusion largely emanates from his family, especially his
mother, who insinuates that his early childhood sexual abuse explains why he is gay. In and
out of his life while he was a child, his mother frequently conveys to him that she feels
“guilty” or at “fault” for both his abuse and his sexual orientation:
My momma, like right now, she feel guilty like or uncertain. She be thinking like it’s
her fault. And the older I get, I be like ‘you know, mom. It’s not your fault.’ …. I could
see her like this one year and I would say like I was dating. I was in a relationship

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and like a whole year me and her didn’t talk ‘cuz she’s so like.. she’s still like really
guilty. Like this the part of me why I’m gay.
She believes her son’s sexual orientation is a consequence of the abuse for which she feels
guilty. He goes on to describe how she cannot handle seeing any evidence that he is gay
because she is so wracked with guilt. As a consequence, this participant continues to
associate his sexual desires with a traumatic experience. Additionally, he has been thrust into
the position of trying to comfort and reassure his absentee mother, a situation that has left
him wondering “what’s really going on with me?”
Another young man, “tortured” by his male cousins for not acting appropriately
masculine, also described how his early emotional and sexual abuse experiences created a
current identity conflict. Repeatedly sexually abused by his older cousin who “knew better,”
this young man described being confused by how his cousin could “touch on me at night” and
“fool around with me at night” but then “beat me up and call me all kinds of a sissy and
cupcake” when around his brothers. His early childhood abuse experiences made him
question the origins of his sexual orientation:
I think about it like I used to be like really into females like way more than I was into
guys….I wonder am I gay because they told me I was? Like, I coulda just been you
know one of them kinda guys that liked to dress well and get his hair cut and stay
clean and sharp, but because that wasn’t an image of, that’s not what a man is
supposed to be, that’s weak , that’s gay,…then that’s who I became, you know
These young men constructed identity narratives that were tied to their experiences of sexual
assault.

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Other young men felt that their future possible selves were limited by virtue of being
gay. They felt that to be a gay man meant that they would always be “vulnerable” or “a
target for someone.” Some felt that they could only be safe and happy if they were able to
move elsewhere to a place where it was more acceptable to be a gay or bisexual Black man.
They also thought that it was impossible to be a gay man and to have the kind of future that
they desired:
I wouldn’t have to worry about how I’m gonna have a child or, you know, if my gay
relationship is going to last past 6 months. ‘Cause it’s just, you know, heterosexual
people, I mean, you get married, you start a family, it’s like normal. It’s not really
normal for gay people to have a family….I think the only thing that bothers me about
being gay is the, I guess, the possibility of actually having a family. ‘Cause I don’t
really know too many gay Black couples that are together and you know, are happy.
Evident in this young man’s excerpt is a fear about future relationship prospects that he
describes as existing because he lacks happy, healthy relationship role models.
Some participants described their dual identities as Black men and gay men as at
odds. These young men felt doubly affected by the amalgamated effects of racism and
heterosexism. They also described how in the Black community “it’s really looked down
upon if I’m African American and also gay” because of preconceived notions of Black male
masculinity that are at odds with stereotypes and misconceptions of being gay. Not all of
these men wished that they could change their sexual orientations as a consequence; rather,
some wished that they were white: “Sometimes I wish I was white…I’m like oh my God I wish
I was white because it was like white people just get their life as treated like gold.” They
thought that they would be safer and more respected if they were white. Alternatively, they
thought that being white would afford them more freedom to express themselves in ways that

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they desired (“it’s easier for a white person to be gay and happy”). For example, this young
man wished that he could safely dress more like white gay men: “What is the difference
between me and him [a white man] wearing skinny jeans?” He felt limited in his gender
expression because he did not want to be treated like “a fag.” To these young men, being
Black was at odds with their sexuality and they felt that being both Black and gay limited
their freedom of expression. Infused within this dialogue about Blackness being at odds with
young men’s sexuality was also evidence of class. It was the young men who described
growing up “in the hood” or the “ghetto” who were particularly cognizant of how their
gender expression may be perceived or were concerned about how they would be treated for
violations of masculinity expression.
Finally, some of these men felt that their religious and sexual identities were at odds
with one another. They internalized many of the negative messages about sexuality and HIV
that they heard in conservative churches; did not attend accepting and affirming churches.
Rather, they continued going to churches where they felt a need to hide their sexual
orientation, or stopped attending church because they felt hypocritical attending. The other
sample of young men stopped attending churches because they became atheistic, grew
disenchanted with religious institutions, or were seeking out affirming churches. In contrast,
these young men who stopped attending church did so because they felt they did not belong
and that their gay identities were at odds with religious teachings (i.e., internalized
homophobia). The following excerpt from a young man in Benton Harbor depicts this
dilemma between his desire to be gay and his desire to attend church:
once I start going to church, I wanna really be 110% serious about giving my all to
God and leaving behind my sexuality and everything else. …You know how we deal
with things where we be like ‘man, I don’t want to be a hypocrite’. You know what
I’m sayin’? I don’t want to be going to church and still doing the same thing right
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after I get out of church. I don’t wanna be like that…. Where I can just go in and say
I’m done God, I give myself to you. I just hope it don’t be too late before I get a
chance to do that.
Here, it is evident that this young man feels a need to give up religion if he is gay, or give up
being gay if he wants to attend church. He has internalized a belief that these facets of his
identity are mutually exclusive. Young men who felt alienated and ceased attending religious
institutions lamented that they did not feel safe and welcomed in their previous churches (“I
just threw it [my church] away”).
Lack of social support
Assertion 2: Unless they had older family members who were known to be gay,
young men experiencing syndemics experienced extreme family conflict and alienation.
“Fucked up,” that is how one participant concisely described his relationship with his family
of origin. Others were equally as unforgiving in the language that they used to describe their
relationships with their families. “War.” “Horrible.” “Neglect.” “Miserable.” “Rocky.”
“Nasty.” These were the terms that participants used to describe their family relationships.
Many participants described their entire family as having “disowned” or “turned against”
them. Others distanced themselves from large portions of their family (e.g., all the men, their
father’s side) rather than be faced with a barrage of “intolerance,” “ignorance,” and
“discrimination,” and “hate.”
Young men described their issues with their family as intricately connected to their
sexuality. Growing up in families who spoke openly about their dislike for gay men made
them fearful of coming out to family members; they described extreme apprehension about
the decision to come out to their families. After coming out, they faced negative
consequences: people in denial, verbal abuse, ongoing arguments, loss of support, and being

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forced to leave home. Many also reported feeling like family members derided their
masculinity by calling them names insinuating that they were effeminate, poking fun at their
gender expression, blatantly telling them that they were “less than a man,” or trying to get
them to act in more traditionally masculine (i.e., tough and dominant) ways:
I said before earlier in the interview, as a Black man I’m considered to be this strong
leading dominant character and me sleepin’ with other men is seen as, you know, kind
of less than a man or kind of as a weakness… some people in my family they don’t
necessarily think that makes me a strong character…[my male cousins] used to like
literally torture me… I had to walk a certain way I had to eat a certain way I had to
talk a certain way
This young man went on to detail how his male family members would bully, physically
abuse, and chastise him when they thought he was not adhering to traditionally masculine
forms of gender expression; experiencing masculinity stress, he tried to avoid these relatives,
attempted to follow their rules, and experienced extreme anxiety in their presence. Other
participants reported similar expectations about their gender expression and comparable
feelings and reactions. These young men grew to expect that they would be treated
antagonistically and described chronic stress associated when interacting with particular –
usually male- relatives.
Intolerant family members were not content to be silent on the matter of gender and
sexuality, instead, young men were treated “like I’m a joke,” were constantly “criticized,” and
in families where their sexual orientation could “activate an argument out of just nowhere.”
Participants described their family lives as chaotic and people in their families as
disrespectful toward them. A lack of family -and especially parental- acceptance was a key
theme across the interviews; in reference to their sexuality, young men decried how people

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“didn’t accept it at first,” “accept me but [don’t] really like it,” “will never accept me,” and
“didn’t accept me for who I was.”
Participants detailed a number of ways that their interactions with their families
affected them. They described feeling guarded, unsafe, and disrespected when at home, some
even to the point that they preferred to leave home as teenagers. They would lie about where
they were going to avoid an onslaught of questions and ridicule; they would lie or suggest
that their sexual orientation had changed and that they were again dating women. Others
heart wrenchingly described the emotional toll that their family’s intolerance or abandonment
has taken on them:
So sometimes I feel like I wanna die… But it’s like, not in a negative way, it’s like, if I
was to die or something like that then maybe they would realize, like, you know, that
was my son, or that was my brother, and like I really shouldn’t have treated him like
that….and maybe it would make them be better to other people. Or, like better to
themselves, like learn how to respect other people because they don’t respect me….
it’s like, I feel like I can help them by actually dying. Like they will start respecting
people and respecting themselves.
In the case above, the participant grew up in a family where he experienced sexuality-related
problems with every member of his family and now does not communicate with anyone in
his immediate family. This young man has given up on the idea that members of his family
will ever respect and accept him. Rather, he views his premature death as the only way to get
his family to change their beliefs and behavior.
He and other participants insinuated that they would be very different people were it
not for the way that their families have treated them. As described in the following quote,

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participants believe that they would be “totally different” if they had love, respect, and
acceptance from their families.
I feel like if they would’ve accepted me for who I am instead of tellin’ me how who I
was wasn’t right, then I could be a totally different person…. there was a point of time
in my life where I didn’t think about HIV at all. I just did whatever I wanted to do. So
a lot of times, um, because I felt bad, or, like how the way my family’s treating me, I
just felt like the only thing I could turn to was sex. So I didn’t care.
In this example, the participant voices his belief that the negative treatment from his family is
directly related to his sexual decision-making. Other participants described tuning out family
members who would discuss sexual health matters because young men had lost respect for
their opinions.
Two men described accepting family members. Both of these young men had older
relatives (a biological father in one case; a grandmother in another) who provided them with
sexuality-specific social support. Fears about coming out to their families were alleviated
because they witnessed how their families interacted with other gay members. These young
men reported family relationships similar to the sample of men who did not evince
syndemics.
Assertion 3: Young men experiencing syndemics are socially and relationally
disconnected from other Black gay and bisexual males. In contrast to the young men who
were not experiencing syndemics, these young men were disconnected from or disenchanted
with the gay community and struggled to develop, or avoided, platonic relationships with
other Black gay and bisexual men. Whereas the men who did not evince syndemics
developed friendship networks, these participants described themselves as “kind of a loner,”
“not really a people person,” “usually by myself,” and as a “007, basically a free

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agent…available to no one.” They are young men who prefer to “ride solo” and thus chose to
avoid the gay community and others who are gay, or who “feel like I’m in my own little
world” and are not accepted as a part of the local gay community. Social disconnect took an
emotional toll on young men who wished either that there was more of a community to
connect with (Outstate participants) or that the local gay community (Detroit) was more
welcoming, safe, and diverse. As this young man described, being unable to connect with
other gay men made him feel profoundly alone:
…it can mess with somebody’s self-esteem. You know? It can make you feel by
yourself. I have had those things happen to me before. You know you feel alone, feel
like there’s no one there just because of you being gay…it has forced me to go be, I
mean go and become a loner.
Participants who limited their interactions with other gay males or the gay community did so
to protect themselves or because they did not feel safe and respected when around other gay
people. Some of these young men, repeatedly physically and verbally abused due to their
sexuality, chose not to associate with the gay community as a means of self-protection, as
they worried that it would make them a target of anti-gay violence. The following young man
explains why the only place he ever feels truly safe is at home by himself:
when it come to the end of the day, I’m by myself and don’t gotta worry about hearin’
nothin’ from nobody. I can’t handle the straight people, or gay people, I just hope my
Black ass in my car, and I get the hell out, and I don’t gotta worry about nobody
saying shit to me or whatever…
Whereas some participants feared anti-gay violence, others indicated a preference for being a
loner because they had a difficult time trusting anyone:

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…after my trust has been battered a lot…it makes me more guarded and so I don’t let
anyone in. And, you know, and it’s hard because you can’t trust people that you think
you could trust …Just ‘cause the way you look, the way you act. And if you’re a
vulnerable person like I was -I mean I still am- People are gonna take advantage of
the situation.
This young man, sexually, verbally and physically abused throughout his life, feels a need to
be alone to protect himself from further abuse.
Still other men did not trust how they would handle situations that they might
encounter. The following excerpts describe cases in which participants were concerned about
their potential to become angered:
I like being by myself. It’s less bullshit. Less chance of me having to fuck somebody
up.
I don’t feel safe [in the gay community] because I have a lot of triggers. And if the
trigger goes off, I’m gonna spiral out of control. I have done it before.
These young men -one with a history of imprisonment and the other with a history of
institutionalization- rather than fear what others may do to them, feared what they might do to
others in retaliation.
Other men, particularly those from Detroit and Benton Harbor, did not like what the
gay community had to offer and did not feel accepted as a part of it. They described the local
gay scene as one filled with “drama” and “chaos” and “fighting,” where someone was
“always trying to stab you in the back.” Others felt like it was “too gay, gay as fuck” and
indicated that they did not like associating with stereotypical and effeminate gay men. On the
opposite end of the spectrum, young men grew disenchanted with the gay community when

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they felt like they were being stereotyped by other gay men. They felt as if they did not fit
into the gay community:
I’m not like them. The gay community tries to make me feel guilty ‘cause I don’t know
a damn thing about fashion, can’t give relationship advice to females, and cause I’m
not like in the gay scene
This young man felt that to be accepted by the gay community, he had to be a stereotypical
gay male. As a light-skinned, highly educated young man, he felt unaccepted in the gay and
Black community because people think he is “not Black enough and not gay enough.”
A sense of being betwixt and between was especially evident in the narratives of
bisexual participants. They described how they and other bisexuals “get it from both sides” or
“get flak from the heterosexual community….[and] get flak from the homosexual
community.” They described envying gay people who could more easily find an accepting
community to join. Bisexual people often feel they are “doubly closeted” due to their cultural
invisibility (Zinick, 2000); these young men, however, felt misunderstood, “persecuted” and
as if others were “jealous” of their ability to pass as heterosexual. Additionally, they felt that
there was a lot of misunderstanding about bisexuality and that they were falsely aligned with
men who were “discreet” or “on the down low.” Common cultural misconceptions about
down low men at the time tended to paint them as sexually indiscriminate, promiscuous men
who were likely to be HIV-infected. In contrast with the bisexual men in the other sample,
these young men were ostracized as if they were on the down low and wished that “people
had like a better understanding of bisexuality in relationship to the down low.”
Though men did not feel safe with or accepted by other Black gay and bisexual males,
some forged strong friendships with lesbians. A handful of participants, most of whom were
from Outstate, described close personal friendships with gay women. They described feeling

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safer around “butch women” than “effeminate men” and felt that they had more in common
with lesbians. Those from Outstate also felt like there were more openly gay women because
it was more culturally acceptable for them to be gay than it was for men.
Since many of these participants were not actively a part of a gay community, they
could not explain how they became initiated into gay culture. When young men did describe
how they became aware of or were initiated into the gay community, it was through a variety
of high-risk venues: bars, parks, strip clubs, and websites such as Manhunt (i.e., a gay hookup site). In the few instances in which participants described the friends that they had made
through these venues, they described how their friends were bad influences:
Um, very bad ones I think. People who are very sexual. People who are alcoholics,
drug-oriented, kleptomaniacs, users. The list goes on-and-on. Just very very bad
people.
Relational disconnect
Assertion 4: Young men experiencing syndemics are highly critical, disparaging, and
mistrustful of other Black gay and bisexual males. These participants had a difficult time
trusting people, particularly other Black gay and bisexual males. They described heightened
states of anxiety in social situations with other gay and bisexual men where their “guard is
always up” and they “can’t trust people” or “don’t know who to trust.” They attributed this
lack of trust to their histories of abuse: “you don’t know who to trust ‘cuz there’s people out
there that personally try to stomp on your heart, play games with you, personally try to hurt
you, and abuse you.”
These young men also held extremely negative stereotypes of other gay and bisexual
males. They described Black gay and bisexual men as “sluts,” “hounds” and people who are
“promiscuous.” Some of these stereotypes they explained had been substantiated by their

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peers and previous sexual partners who they described as having multiple concurrent sex
partners, lying to their partners about their status and their other relationships, and being
sexually indiscriminant. A few gave examples of friends who had purposefully refrained
from informing their sexual partners about being HIV positive:
Well this one friend I had, he said that the reason why he doesn’t tell people is
because …he don’t wanna have to build a relationship with them and then end up
having to tell them and then reject him or turn away from him and then his business
be on the streets.
Some young men also held stereotypical and critical beliefs about Black men who were
“thugs” or who appeared to be on the down low. According to these participants, the fact that
there were so many down low, or DLs, in the Black community meant that it was difficult to
trust that any Black man could be trusted to be faithful and not “be double dipping.”
Participants felt like in their previous sexual experiences that they had been
objectified; they described being hurt by former sexual partners who had just “used [them]
for [their] body.” They had encountered people who had “played on stereotypes” and had
only wanted to “have sex because you’re Black.” These young men described how
stereotypes about Black men being well endowed, being sexually adventurous, or having
great sexual stamina made them feel fetishized and degraded. As one young man described,
sex partners had treated him like “an aphrodisiac, and not someone that [they] could possibly
date.” Another participant described how he had been with “people who have this….fetish,
for, you know, dating people who are Black and is calling us slaves and all that crazy shit.”
He and other men described how these encounters had left them feeling sexually objectified
and treated like “I was nothing to them.” They lamented that sex partners did not genuinely
“try to get to know me for who I really am” and admitted that these experiences had “hurt my

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feelings a lot.” They also described how these experiences left them mistrustful of the
intentions of new partners or people who appeared interested in them.
Lastly, these youth intimated a connection between their experiences of sexual abuse
and their avoidance of gay male social venues and distrust of gay males. They described how
previous experiences now made them feel unsafe around “older” Black men, men who tried
to act like “thugs,” or men who tried to act “harder than other people.” The excerpt below
aptly describes one man’s avoidance of gay social venues as connected to his fear of further
sexually violation:
some of them guys can get outa control. They wanna do certain shit whatever they get
horny and shit. Especially like the older ones. They see a young looking boy or
whatever walking past or whatever and they think it’s ok to say whatever they can or
they feel like they can touch whatever they can touch and they don’t know it’s not
right. So that can be dangerous as well.
This young man depicts the gay social scene as “dangerous,” a place where older predatory
males act sexually entitled and harassingly.
Summary
Table 4 provides a convenient overview of the assertions related to this sample of
young men. The young men who evince syndemics exhibited a number of similarities
suggesting that they are profoundly relationally disconnected.

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Table 4: Assertions related to men experiencing syndemic production
Men Experiencing Syndemics
Young men experiencing syndemics believe two or more of their identities (e.g,.
sexuality, gender, race, class, religious identity) to be mutually incompatible.
They also construct identity narratives that are intricately tied to their sexual
assault experiences.
Lack of Unless they had older family members who were known to be gay, young men
Social
experiencing syndemics experienced extreme family conflict and alienation.
Support Having another ‘out’ gay relative was an important contingency, as these young
men did receive sexuality-related social support from their families of origin.
Young men experiencing syndemics are socially and relationally disconnected
from other Black gay and bisexual males. When initiated into gay culture, it was
through high risk venues such as hook-up websites, bars, parks, and strip clubs.
Young men experiencing syndemics are highly critical, disparaging, and
mistrustful of other Black gay and bisexual males.
Shame

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CHAPTER 4: DISCUSSION
In this study, I examined the relational lives of young Black MSM who have avoided

syndemic production to understand how they differ in their socio-cultural relational
characteristics from men who manifest syndemic production. To my knowledge, this is the
first study to look at the relationship between protective resilience and syndemic production
among young Black gay and bisexual men. To do so, I focused on the relational elements of
these men’s lives to elucidate community and interpersonal protective factors that may
function beyond the individual-level to help these young men develop resilience.
The young men who avoided syndemic production all had rich, fulfilling, supportive
relational lives (see figure 2). They described numerous providers of sexuality-specific social
support. Across a variety of social contexts (e.g., family of origin, community based
organizations, churches, and gay community), they reported relationships with empathic
others who supported them as young Black gay and bisexual men, helped them develop a
strong sense of personal identity, and provided them with opportunities to give back to their
communities. These men sought out affirming environments, suggesting that they yearn for
growth-promoting relationships. Living in Detroit, they were fortunate that community
organizations, HIV service providers, and racially homogenous gay communities were
available and accessible to them. They also reported a variety of affirming others who
specifically supported their health behaviors. They had diverse relational networks of people
–particularly family members, male friends, and men in the gay community- promoting prosocial norms about health behaviors. Armed with a strong cadre of empathic others, they
were able to further define and appreciate their sexual orientation and develop strategies to
mitigate the socio-environmental stressors they face as young Black gay and bisexual men.

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In contrast, the young men who experienced syndemics described problematic
relational lives (see figure 2). They described numerous forms of trauma and oppression
across a variety of social contexts. Unlike the men who did not experience syndemics, these
young men lacked relationships with others who might encourage and empathize with their
identities as young Black gay and bisexual men. They lacked access to affirming social
environments or did not experience gay-related venues as welcoming and nurturing. Rather,
when these young men sought out what they hoped to be accepting environments, they
experienced further marginalization. Their lives were defined by various forms of oppression
that created and sustained shame, identity incongruence, isolation, relational disconnect,
mistrust in other men, and an expectation of rejection and discrimination. For these young
men, their previous experiences, coupled with systemic oppression, created a chronic
apprehension about further marginalization. Lacking a cadre of empathic others, they were
not able to define and appreciate their sexual orientation, develop strategies that may mitigate
the socio-environmental stressors they face as young Black gay and bisexual men, or connect
with diverse people who might promote pro-social norms about health behaviors.
The figure below displays two eco-maps. Eco Maps are visual representations
highlighting the strength and quality of relationships between people and their microsystems.
The figure depicts the high quality, supportive, diverse relationships that young men not
experiencing syndemics described. These relationships were also defined by reciprocity, as
indicated by the arrows in the figure. These young men engaged in various forms of social
action that provided others with sexuality-related social support and promoted the health of
their community. These young men’s relational lives, as depicted, were in stark contrast to
the tenuous, vulnerable, and abusive relational lives of the young men who exhibited
syndemics.

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Figure 2: Representative eco-maps of young men’s relationships
In the following discussion, I review key findings from this study relative to prior
research on gay and bisexual men. Then, I will present a summary of the main limitations of
this study, followed by implications for future research and practice.
Establishing well-integrated identities influences men’s well-being
A key feature distinguishing men experiencing syndemics from men who did not
experience syndemics concerned their achievement of an integrated identity. Given the
challenge of integrating multiple socially devalued social identities, the ability of young
Black gay and bisexual men to develop well-integrated identities is indicative of resilience
(Harper et al., 2007). Though the men lacking syndemic production were significantly
younger than the men experiencing syndemics (and sexual identity formation is a
developmental process), they not only viewed their identities positively, but were able to cite
numerous benefits of being young Black gay and bisexual men. Reasons why young Black
gay and bisexual men viewed their identities positively correspond with constructs Herrick et
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al. (2012) suggested may be indicative of resilience among MSM. Young men appreciated
that their sexual orientation identities afforded them enhanced social connectedness, outlets
for social creativity, and avenues of social activism. This finding suggests that social support,
social creativity, and social activism contribute to a positive sense of self among these
participants (see next sections). Additionally, it suggests that for young Black gay and
bisexual men, there is a relationship between Herrick and colleagues’ (2012) resilience
constructs.
In contrast, the young men experiencing syndemics described various challenges
integrating facets of their identities. Due, in large part, to racism, sexism, and heterosexism,
young Black gay and bisexual males often have difficulty integrating various facets of their
social identities related to sexuality, race/ethnicity and gender (Bowleg, 2012; Battle et al.,
2002; Harper et al., 2004; Malebranche, 2003; Wilson & Miller, 2002). Identity development
and integration is difficult due to pervasive societal messages denigrating their identities and
cultural ideologies that suggest aspects of their identities are mutually exclusive (e.g,.
conflating Black masculinity with heterosexuality; see Bowleg et al., 2011; Wilson et al.,
2010).
Complicating the identity development process is the fact that young Black gay and
bisexual males often face multiple types of oppression not only related to their sexuality and
gender, but also to their race and economic situation (Harper et al., 2004). The young men
experiencing syndemics reported experiences of heterosexism within Black communities and
families, institutionalized heterosexism in churches, racism including from sexual partners,
biphobia in the gay community, rigid gender role norms in their families, negative
stereotypes of Black gay and bisexual men, early abuse experiences tied to their gender
expression, and trauma-related identity conflict. These findings largely mirror those from
other research with Black gay and bisexual males finding that their lives are challenging as a

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consequence of interlocking forms of oppression and marginalization (Bowleg, 2012; Wilson
et al, 2010). Because men experienced forms of social marginalization across numerous
social contexts, these findings also suggest that Black MSM experiencing syndemics may
have nonexistent or tenuous sources of support during a critical stage of their identity
development.
Family sexuality-related support influences young men’s well-being
These data provide examples of affirmative, sexuality-related support that is present
within some Black families. Importantly, young men who avoided syndemic production had
family environments in which they felt safe, accepted, and supported. They described how
families provided sources of social and emotional support. Family members, implicitly and
explicitly, taught them about gender roles, relationships, and sexuality. Family members
actively conversed about participants’ sexuality, advised them on how to remain safe, and
spoke up against heterosexist and homophobic comments. Female relatives and gay relatives
helped participants come to terms with and define their own sexual identities. Participants
also described ways in which their families influenced their decisions to practice safer sex.
Family members, particularly females, provided these participants with a great deal of sexual
education information and made it clear to the young men that they were available for
questions and advice. Young men often cited family these members as influential in their
sexual decision-making; as such family was an important influence on their health and wellbeing.
For all young people regardless of their sexual orientation or identity, positive family
relationships are associated with several healthy developmental outcomes through promoting
psychological and emotional health and serving as a protective factor against drug use and
high-risk sexual behaviors (Garofalo et al., 2008; Mustanski et al., 2012; Ryan et al., 2009).

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Indeed, a systematic review of the literature on parental influences on the health and wellbeing of sexual minority youth showed that family relationships defined by support,
acceptance, and connectedness are generally associated with improved mental health
outcomes, lower risk of substance abuse, and protection from violence and victimization
(Bouris et al., 2010). However, unlike their heterosexual peers, YMSM often cannot turn to
their families for support, or fear turning to their families, because they espouse heterosexist
beliefs and convey sexual prejudice. Fearing sequelae such as invalidation, discrimination, or
rejection to disclosures of sexual identity, youth may choose to conceal their sexuality from
family. As the analysis of the young men experiencing syndemics indicates, in these
situations, youth often find themselves feeling relationally disconnected or isolated from their
families, and mistrustful of any advice they may have to offer.
Young men infrequently mentioned male family members as sources of sexualityrelated social support. Indeed, many of the most hostile and tenuous relationships that young
men described were with the males in their immediate and extended families. Young men
often described male family members as perpetuating theologically driven homophobia,
maintaining rigid gender ideologies, and verbally and physically abusing them for reasons
related to their sexuality and gender expression. Male family members’ intolerance and abuse
toward their non-heterosexual relatives was unfortunately unsurprising. Research literature
shows that Black males have more negative attitudes towards gay males than do Black
women (Herek & Capitano, 1995) and that male family members are less tolerant and
accepting of male relatives who are gay than are females (D’Augelli, et al., 1998).
Additionally, there is a rich literature on the social shaming, gender policing, and violence
that men perpetuate against other males who are gender non-conforming and/or nonheterosexual (Connell, 1987:1995; Diaz, 1998).

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It was often women in the lives of young men not experiencing syndemics that played
identity-affirming and health promoting roles. Historically, women have played key roles in
drawing attention to the HIV crisis in Black communities and have played keys roles in the
prevention of HIV among gay and bisexual men (Cohen, 1999; Hill Collins, 2004). Females
are also typically more accepting of gay and bisexual men than are males (Dube, & SavinWilliams, 1999; D’Augelli, et al.,1998; Garofalo et al., 2008; Mays, et al., 1998); some gay
and bisexual men even cite close knit friendships and bonds with woman as among the key
advantages of being gay (Harper et al., 2012). Furthermore, other than their peers, mothers
are frequently cited as a primary means of social support, including sex-specific social
support, for young gay and bisexual men (Doty et al., 2012). Recent research also suggests
that Black mothers are as likely as Caucasian mothers to be accepting or tolerant of their
child’s sexual orientation (Garofalo et al., 2008).
That young men described families as influencing their identity development and
sexual decision-making suggests that family support and acceptance may be an important
influence over young Black gay and bisexual men’s psychological well-being and sexual
behavior. The research literature offers a few explanations as to why family support may be
particularly protective for young Black MSM. First, studies consistently show that factors
protecting Black youth from sexual risk behavior originate in the family (Brody et al. 2001,
2002; Murry and Brody, 1999). Researchers who study the effect that parents and family
members have on Black youth’s sexual behavior argue that African American’s familycentered orientation and the cultural primacy emphasizing the family is what makes the
family environment serve such a powerful protective role in buffering Black youth from
engaging in sexual risk behavior. Second, from a developmental perspective, young Black
gay and bisexual men may have fewer other venues and communities through which to
validate and develop healthy, integrated identities as young gay and bisexual Black men.

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Third, Black YMSM face challenges integrating their sexual, racial, and cultural identities
(Tremble, Schneider, & Appathurai, 1989). As these data indicate, and research substantiates,
the need to manage more than one stigmatized identity can increase youths’ vulnerability and
stress (Harper, 20007), particularly when identifying as or expressing one facet of identity
(e.g., sexuality) may jeopardize their acceptance by their family or in other communities. As
such, identity-related support and affirmation from one’s family may help facilitate identity
integration and alleviate or buffer identity-related dissonance that young men may
experience. From a developmental perspective, this type of family sexuality support may be
particularly important for adolescents still reliant upon their families for alternate forms of
support and who may have limited access to gay community networks.
Affiliation with gay communities defined by peer norms for health influences well-being
The young men who did not evince syndemics desired participation in the gay
community and had access to gay-specific community organizations that they experienced as
accommodating of their needs. For these young men, groups and organizations that enhanced
interconnectedness and friendships functioned as important social supports. Involvement in
gay community meetings, social events, and community-building opportunities were a way
for these young men to build positive connections with other youth and adults who helped
them cope with health-related stressors, taught them that their sexual identities were natural,
and showed that life as a Black gay man can be fulfilling and fun.
The young men who lacked syndemic production also discussed how formal LGBT
and HIV service organizations functioned to provide them with pro-social avenues of
community involvement. Young Black gay and bisexual men have a desire to facilitate the
health and well-being of their community and to engage in community building activities.
Ramirez-Valles & Diaz (2005) demonstrated an empirical link between community

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involvement and self-esteem and social support among adult gay Latino men. Likewise, these
data suggest that the venues that these young men frequented afforded them community
involvement opportunities and sexuality-related social support. Young men appreciated that
their sexual orientation identities afforded them enhanced social connectedness and avenues
of social activism, further suggesting that communal social support and social activism
contributed to a positive sense of self among these participants.
For the men who did not experience syndemics, HIV service organizations, gay
families, LGBT centers, and gay friendship networks function as “counterspaces,” or settings
that enable adaptive responding in marginalized individuals (Case & Hunter,
2012).Counterspace settings have a long history in both Black and gay culture, serving as
non-oppressive spaces where marginalized individuals can connect with a community of
others who share similar experiences and who engage in mutual support. In these
counterspaces, young men can amass resources to help them deal with or buffer oppressive
experiences and develop a group affiliation that can help them develop and situate their
identities that are largely socially devalued. These data suggest that these settings served as
alternative spaces in a number of key ways that might facilitate men’s identity development
and health behavior. In these settings, they developed kinship networks that helped reduce
feelings of isolation and exclusion. They engaged in identity-affirming activities and events
that celebrated aspects of their identities. They learned to be critical of hegemonic
constructions of sexuality and masculinity, which may have helped them make sense of
negative experiences (Wexler, DiFluvio, & Burke, 2009). Developing group affiliations also
may have helped them develop a sense of purpose that contributed to their communitybuilding and social action desires and activities. As others have noted, establishing and
building community affiliations with supportive groups may help young men identify larger
purposes and goals, which is important for supporting resilience (Wexler et al., 2009). In

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short, these relational connections helped young men reconceptualize their experiences of
oppression, provided them with a group-based identity, and instilled in them a broader sense
of purpose.
Young men also described these settings and the relationships forged with peers and
mentors within them as facilitative of positive sexual health norms such as condom use, HIV
testing, and monogamy. A recent literature review on HIV among Black MSM showed that
studies consistently show that strong peer norms for condom use and other safer sex behavior
among black MSM strongly predict less frequent sexual risk behavior (Maulsby, et al., 2014).
In these groups, young men developed perceptions of normative health behavior among other
men; perceptions of other men’s health behavior –particularly men who are perceived to be
like them- provide information about health behaviors to adopt or not adopt. Belief that gay
men’s perceptions of other men’s normative health behavior influences HIV risk behaviors
was the impetus behind Kelly and colleagues’ (1991) popular opinion leader intervention, as
well as other HIV interventions, such as MPowerment, that utilize community-mobilization
and peer-based strategies (Kegeles, Hayes, & Coates, 1996; Kegeles, Hayes, Pollack, &
Coates, 1999). For these young men, supportive mentoring and peer support for condom use
and safer sex practices were key relationships facilitative of their sexual health.
These findings align with and extend Ramirez-Valles’ (2002) conceptual framework
delineating the protective effects of community involvement for gay and bisexual men.
Ramirez-Valles’ (2002) model suggests that involvement in the gay community and HIVrelated groups and organizations promotes men’s health by reducing alienation, promoting
positive peer norms, developing self-efficacy, and enhancing positive sexual identity. These
data suggest that involvement in the gay community and HIV-related groups and
organizations also serves to ignite young Black men’s drive to engage in social action, thus
providing them with new pro-social opportunities for community engagement. While
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Ramirez-Valles’ model is based on literature with adult (largely white) MSM, its alignment
with these data implies that it may be useful to consider its adaptation as a framework for
conceptualizing the broad protective effects of community involvement and social
engagement for young Black gay and bisexual men. However, such an adaptation may need
to conceptualize social action broadly to account for differential participation that may be a
function of development; in this study, older men participated in more formal capacities
within LGBT and HIV service organizations and were often in roles akin to those of role
models and mentors; in contrast, younger men participated in forms of community
engagement in less formal capacities. This finding may reflect developmental differences in
availability or accessibility to (or the desirability of participating in) gay community
networks.
Men exhibiting syndemics experience heightened minority stress and social isolation
The young men experiencing syndemics recounted numerous instances of trauma and
marginalization, experienced identity-related conflict, were rejected by their families of
origin, lacked social connectedness, and were avoidant of opportunities to establish relational
connections with other Black gay and bisexual men. They experienced social marginalization
across numerous social systems that was perpetrated by multiple people (e.g., family
members), communities (e.g., gay community), and institutions (e.g., churches). These
findings largely align with and extend Dyer and colleagues’ (2012) study of syndemic
antecedents among Black MSM. Dyer et al. (2012) found that factors associated with
syndemics among Black MSM included: victimization, a lack of social connectedness in
childhood, masculinity struggles, and internalized homophobia. In my study, findings also
suggest that social disconnection follows men into adolescence and young adulthood,
identity-related struggles are not confined to issues related solely to young men’s gender and

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sexuality, identity-related issues may be strongly tied to men’s early victimization
experiences, and familial discord and isolation may be additional precursors to syndemic
production.
Young men experiencing syndemics had early socialization experiences and
psychosocial issues that may attenuate their desire or ability to form strong or healthy
relational connections. Is it any wonder that young men experiencing syndemics are
relationally disconnected and socially isolated? In the literature on relational resilience,
syndemic participants might be said to be living in a state of condemned isolation, an
experience of aloneness that occurs when repeated shame, humiliation, and marginalization
occur (Hartling, Rosen, Walker, & Jordan, 2000). The participants experiencing syndemics
faced numerous barriers to relational connection. First, the psychosocial issues that they
experience – depression, substance abuse- tend to be associated with social isolation. Second,
sexual abuse, trauma, and marginalization have taught them that it is difficult to trust other
people, especially men. Repeated shaming, rejection, and abuse due to their sexuality has led
them to believe that being gay or associating with other sexual minorities is dangerous and
unsafe. Amidst this backdrop, further alienation, marginalization, and abuse within gay
spaces thought to be safe havens may be particularly detrimental to young men’s desire or
willingness to connect with others. Third, young men still struggling with their sexuality – as
these young men were- do not want to be gay and have developed internalized homophobia
and problems integrating various facets of their identities. This internalized homophobia is
not only associated with a sense of being different and alone, but also a devaluation and
criticism of other gay and bisexual males. As such, sexuality-related support systems, even if
available and deemed safe, likely do not hold much appeal for these young men.
These findings suggest that stigma, marginalization and trauma are primary causes of
the low sense of self-worth that young Black MSM experience. Theoretical frameworks such
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as the minority stress model provide hypotheses as to why increased exposure to abuse and
marginalization may be associated with syndemics. Meyer’s (1995; 2003) minority stress
model examines social minorities within a social and community context and emphasizes the
impact of stigma and marginalization on gay men’s development and health. The minority
stress model attributes the higher prevalence of psychosocial health issues found in sexual
minority youth as compared with heterosexual youth to the additive stress resulting from
nonconformity with prevailing sexual and gender norms. This model posits that internalized
homophobia (i.e., self-appraisal that adopts society’s negative attitudes about sexuality),
expectations of stigma (i.e., anticipation of rejection and discrimination), and experiences of
marginalization and trauma (i.e., physical, verbal and sexual abuse due to a person’s identity)
have detrimental impacts on sexual minorities. In these data, young men experiencing
syndemics exhibited not only internalized homophobia, but other identity related stressors.
They all had histories of trauma, with many having experienced numerous forms of trauma
within a variety of social environments (e.g., family church, Black community, gay
community). Their continuous vigilance, avoidance strategies, and stated fears of future
violence suggest that they live a guarded existence whereby they have grown to anticipate
rejection and abuse.
These data, considered in light of the social minority stress model, suggest a variety
of different pathways through which marginalization and trauma may have negative
consequences on the health of Black MSM. For men who so closely relate their sexuality
(and perhaps others’ sexuality) to their childhood sexual assault experiences, the coming out
process may be even more complicated. If in men’s minds their sexuality is a consequence of
sexual abuse, then the thought of coming out may be coupled with the fear of admitting to
being a victim of sexual abuse. Minority stress may keep men from desiring or establishing
alternative sources of support, particularly support that may be affirmative of their identities

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as gay and bisexual men; in these data, men were largely avoidant of other MSM, critical of
large portions of the gay community, apprehensive about ‘stigma by association,’ and
disinterested in being a part of the gay community. Additionally, minority stress may
precipitate distrust not only of other men, but of families, peers, and health care professionals.
Indeed, the possible connection between marginalization and the reduced likelihood of young
Black MSM engaging in health-seeking behaviors or being receptive to health-related advice
is cause for alarm. Minority stress may make it difficult for men to form healthy relationships
–platonic, sexual, or otherwise, - with other men. These men exhibited a propensity to prefer
and feel safer in the company of lesbians and other women, a finding that makes intuitive
sense given that it is often men who are the perpetrators of violence (and women who are
more accepting of sexual minorities). It may be particularly difficult for them to form
relationships with men who promote healthy norms due to their propensity to avoid places
that attract men whose relationships are defined by positive sexual health norms.
Additionally, men who experience childhood abuse or abuse perpetrated by much older men
may be avoidant of older MSM who might otherwise serve as role models or mentors.
Finally, minority stress may lead men who do desire to have relationships with other men to
seek them out in discrete, high-risk social environments where they might be afforded some
degree of anonymity. Findings indicating that young Black MSM frequent diverse locations,
have diverse friendship and peer networks, and become initiated in the gay community via
very different venues implies a need for studies that examine young Black men’s sexual
network characteristics (Millett et al., 2007).
Participants lacking syndemic production lived in Detroit
It is notable that Detroit participants accounted for 97% of the participants in the
YMHS who exhibited a lack of syndemic production. Considering the analytic findings in

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tandem with Detroit’s geography provides a few plausible reasons why living in Detroit may
limit syndemic production among young Black gay and bisexual men. The following are a
few explanations as to why young men in Detroit represented the majority of participants
who avoided syndemic production.
None of the participants from Detroit described racism or racial micro aggressions
within gay community settings. Lack of racism in gay community settings likely makes social
services and friendship networks more welcoming and affirming to young Black gay and
bisexual men. Unlike most of the rest of the state, Detroit’s population is relatively racially
homogenous. Most of Detroit’s residents are Black (82.7%) and this demographic make-up
has a few possible implications for young Black MSM (U.S. Census Bureau, 2010). First, as
a function of these demographics and the devastating toll that the HIV epidemic had on Black
MSM in the city, Detroit is among the few places in the state that has evidence-based
interventions specifically tailored to the cultural needs of young Black MSM (see below).
Detroit’s racial make-up may also mean that racism and heterosexism/homophobia (structural
barriers to health) manifest differently in Detroit. Racism, in particular, may be less
widespread in a city that is predominantly Black, as the gay community would be likely to
reflect city demographics. Racism within gay communities and in gay settings is frequently
experienced by Black gay and bisexual men (Bowleg, 2012; Malenbranche, Peterson,
Fullilove, & Stackhouse, 2004) and is one reason why Black MSM find the gay community
exclusionary (Bowleg, 2012; Kraft, Beeker, Stokes, & Peterson, 2000).
Young men in Detroit exhibited a heightened sense of awareness about HIV within
their community and had availability to prevention programming (see below) specifically
tailored to Black MSM. Indeed, many of the young men who lacked syndemic production
were involved in HIV prevention and testing activities, suggesting that they took advantage
of these community resources. Ggeographically, Detroit is the place where the HIV epidemic
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is concentrated in the state. Nearly two-thirds of HIV-infected MSM reside in the Detroit
Metropolitan area (Michigan Department of Community Health, 2010). High HIV prevalence
concentrated in the Detroit area has resulted in increased HIV prevention programming and
funding directed to the Detroit Metropolitan area; the Michigan Department of Community
Health allocates nearly three-quarters of the their prevention funds to the Detroit
Metropolitan area (Michigan Department of Community Health, 2012c). Areas outside of the
Detroit Metropolitan Area lack HIV prevention programming, which was identified as a
significant service gap in the most recent Michigan HIV Prevention Comprehensive Plan
(Michigan Department of Community Health, 2012c).
Young men who did not exhibit syndemics attended many of Detroit’s LGBT and
MSM-specific advocacy and community-based organizations, including organizations and
programs culturally tailored to the needs of Black MSM. At the time of this data collection,
Mpowerment Detroit had operated in Detroit’s Greek Town for 5 years. Mpowerment Detroit
was an HIV intervention adapted for Black MSM based on the CDC’s evidence-based
intervention, The Mpowerment Project; Mpowerment Detroit also helped create the HIV
prevention infrastructure for Detroit’s Black MSM population (Miller, et al., 2012). We
interviewed many of the Detroit participants at Mpowerment Detroit (and similar service
centers). A number of participants attended Mpowerment events or were active members of
the Mpowerment Project, meaning that they had access to an intervention culturally tailored
to their needs. Additionally, attending Mpowerment related events put them into contact with
other young Black MSM who may be likely to support positive health-related norms and
provide sexuality-related social support; program participation also provided them with social
action opportunities. Indeed, Mpowerment’s community-mobilization emphasis, peer-based
prevention strategies, and attentiveness to sexual orientation identity issues means that it is a

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probable conduit for promoting multiple forms of resilience (e.g.,. pride, sexuality-related
social support, social action) in its members and program participants.
Young men who avoided syndemic production described not only participating in
alternative families, but creating gay families for other Black sexual minority youth. These
alternative family structures may be more likely to develop in locations such as Detroit where
there is historical model for them embedded in both gay and Black culture. As described
above, Detroit is a predominantly Black city and Black persons have a collective social
orientation whereby individuals often rely on extended and constructed family networks for
managing risk and adversity (Utsey, Bolden, Lanier, & Williams, 2007). Detroit also has a
thriving house/ball community (Miller, et al., 2012) which provides a family-like structure
for racial minority MSM (Arnold & Bailey, 2009). Gay or alternative families often develop
within the house/ball scene. Young men in such an environment may well have models upon
which to base the development of alternative families.
Detroit is a location seeping with socio-structural barriers to health such as violence,
poverty, broken families, political turmoil, and poor educational opportunities. Yet amidst
these structural barriers to health, a number of young Black gay and bisexual men have
managed to remain healthy, thriving young men set on community building. The picture that
these analyses paint of Detroit is one of an environment that offers peer and communitybased support, supplies community-based resources that serve as ‘counterspaces’, and
provides incentive and opportunities for social action. Indeed, the racially homogenous
construction of Detroit, coupled with the devastating toll that HIV and other social issues has
had on Detroit residents, makes the city a prime location for the development of indigenous
prevention approaches (Arnold & Bailey, 2009). As a result of historical injustices and
research-based mistreatment, one of the main strengths of the Black community is the
tendency to develop their own culturally-specific protective and preventive strategies to
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address health and social injustices (Wyatt, 2009). It may well be in places such as Detroit
where socio-structural challenges are rampant and achieving health seems bleak, that
innovative and resourceful health-promoting strategies among marginalized groups are the
most apparent. In these locations, researchers and evaluators might evaluate homegrown
interventions targeting young Black gay and bisexual men.
Syndemics and the psychological sense of community
Stall originally hypothesized that as gay men access gay community networks, they
must balance the stressors and resources that come with participation in a new setting. These
data show that not all MSM experience the gay community in the same way. Some may
experience it positively and derive numerous benefits from involvement; others experience
the gay community negatively and seek to avoid it or limit their contact with people who are
involved with it. These men’s divergent experiences with the gay community may be viewed
in terms of community psychology’s concept of the psychological sense of community.
For men who have avoided syndemics, involvement with the gay community appears
to have afforded them all of the benefits associated with a positive psychological sense of
community: a feeling of belonging and membership in a group; mutual influence or the
ability to impact the community and visa versa (e.g., social action); fulfillment of their needs;
and a sense of shared emotional connection with other men (McMillan & Chavis, 1986). This
possibility suggests that in the study of syndemics, there is a need to explore men’s positive
psychological sense of community as a moderator of adversity. Typical measures in healthbased research regarding participation in the gay community often include measures of
involvement in events, or even single-item measures asking whether people consider
themselves as part of the gay community (Frost & Meyer, 2012). These measures do not
account for the cognitive/affective components of how men experience their community

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involvement. The fact that men who avoided syndemics described their gay community
experiences in a way that approximates a positive psychological sense of community suggests
that in the empirical study of syndemics, it may be more appropriate to use measures of
community connectedness such as the psychological sense of community among gay men
scale (Proescholdbell, Roosa, & Nemeroff, 2006).
Second, research on the psychological sense of community may also shed light on the
apparent relationship in these data of the coexistence of sexual identity pride, gay community
connectedness, and social action. Developmentally, many gay men initiate contact with the
gay community after self-identifying as sexual minorities; open participation in the gay
community is therefore often precipitated by passing through some gay identity
developmental milestones (Stall et al., 2003). Regarding a positive psychological sense of
community, research suggests that there is a bidirectional relationship between a stronger
sense of community and proactive involvement in that community (Florin & Wandersman,
1984; McMillan & Chavis, 1986). In other words, as men are afforded opportunities for
social action consistent with their emerging identities as gay and bisexual men, it may
promote a higher sense of community; relatedly, a higher sense of community (which may be
related to one’s sexual identity development at the individual-level) may promote social
action. Identity-related theories would suggest that more investment in and commitment to a
group would, in turn, translate into enhanced salience of one’s personal identity (Stryker,
1980; Tajfel & Turner, 1986).
Research by Brodsky and colleagues (1999) also shows that people’s sense of
community is associated not only with individual-level characteristics (e.g., identity
development, abuse history), but also with characteristics of the community itself (Brodsky,
O’Campo, & Aronson, 1999). Put another way, there are individual level correlates, as well
as community level correlates, of a positive psychological sense of community. Because all
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the men who avoided syndemics and reported positive community involvement were from
Detroit, it suggests that there are indeed community-level factors associated with men’s sense
of community. These data only allow for conjecture to be made as to what community-level
factors may promote a positive sense of community among young Black MSM (e.g., racial
homogeneity, norms of sexual identity and gender identity inclusivity, youth-specific
resources, heightened awareness of a social problem- such as HIV- around which to rally).
Importantly, the fact that there are ostensibly community level correlates of a sense of
community among young Black MSM suggests that it is not merely men’s early experiences
that affect community involvement. As such, future research should identify community-level
factors associated with a sense of community among young Black MSM so that community
interventions can be designed in ways that promote a positive sense of community.
Research on the psychological sense of community may also provide an explanation
as to why family sexuality-related support and a positive sense of community occurred
concurrently. Brodsky (2009) implies that the understanding of an individual’s sense of
community must take into account one’s relationship to other communities (notably, Brodsky
also conceptualizes families as a community). Brodsky’s research implies that familial
disapproval of one’s involvement in another community often requires that a choice be made
between one’s family and one’s alternative community. For young men who did not
experience syndemics, such a choice may be unnecessary given that they received family
acceptance of their sexual identities. For these young men, gay community involvement may
not require breaking with family or result in a loss of family support. For young men who
evinced syndemics, such a choice may be necessary given that they received little or no
familial support for their sexual orientation identities. If expression of their sexual orientation
identities is met with discord, dissatisfaction, and hostility within their families (often their
primary support systems when young), then men at a developmentally tenuous time in their

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lives may feel a need to choose between family support and expression of their identities. As
there may be an association between men’s relationships with their families and their
relationships with the gay community, it is even more imperative to assess men’s relational
experiences, support, and resources across contexts.
As the narratives of the young men experiencing syndemics imply, men’s interactions
with the gay community are not always positively reinforcing experiences. Brodsky
conceptualized the psychological sense of community as being either positive or negative
(Brodsky, 1996:2009). It can be argued that men evincing syndemics experience a negative
psychological sense of community. Brodsky’s (1996) analysis of low-income single mothers
in physically dangerous neighborhoods suggested that for many women, identifying with and
depending upon communities was perceived to be threatening; in response, they isolated
themselves and their children as a protective strategy. These women saw withdrawal from
community life as having benefits that outweighed the awards of membership (i.e., a negative
psychological sense of community). Likewise, the young men in this study who avoided or
kept a wary distance from the gay community largely avoided it for self-protective reasons.
Like the young women in Brodsky’s (1996) study, these men may not receive the benefits of
community support and resources. If these young men’s goal is to protect their safety and
avoid further marginalization, then their decisions are adaptive responses given that they have
experienced oppression, marginalization, and violence across numerous settings. Examined
from this perspective, these men are also resilient. Brodsky describes people who are
developmentally thriving and people who adapt to negative circumstances as both being
resilient. The men who chose to become social isolates or avoided gay community life may
thus be conceived of as resilient in that they are attempting to protect themselves from further
marginalization.

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Limitations
I conducted this analysis retrospectively using a secondary data source. As a needs
assessment, the YMHS was designed to give a broad perspective on the HIV prevention
needs among Michigan’s young Black gay and bisexual men and to identify factors
associated with the health and well-being of this community. Ideally in a qualitative study,
data collection and analysis occur iteratively so that researchers can examine emergent
themes more thoroughly in subsequent cases; that is to say, data collection and analysis are
inextricable. This process allows researchers to strengthen the evidentiary warrant for, and
identify further key linkages between, their assertions. Using an iterative approach, I could
have examined a key topics in a more nuanced manner.
For the purposes of these analyses, the data also did not examine, in a nuanced way,
participants’ sexual assault experiences. Indeed, many participants did not allude to their
history of sexual assault until the end of the interview when asked quantitative questions
(e.g., age, perpetrator) regarding their experience. Where qualitative data describe
participants’ experiences with sexual assault, this information was not elicited by the
interview protocol. I based assertions related to sexual assault a small subsample of
participants who chose to disclose this information. It was evident among a handful of
participants that they had a strong desire to discuss their sexual abuse experiences. Some
participants’ current difficulties accepting their sexual orientation identities and relating to
other gay and bisexual men were tied to their early abuse experiences. Because we did not
ask open-ended questions about assault experiences, it is unknown whether participants aside
from those who organically spoke on the topic experienced similar difficulties as a function
of early abuse. This limitation, coupled with the paucity of research on the sexual abuse

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histories of young Black gay and bisexual men, indicates a critical need for future research to
replicate and extend these findings.
There are a few limitations due to the YMHS sampling approach that are relevant to
the current analysis. In the larger YMHS study, we attempted to use respondent driven
sampling as our primary sampling technique. As data collection progressed, we shifted to a
convenience sampling approach (a typical methodological limitation in samples of sexual
minority youth). In Detroit, many of the venues where we recruited young men were social
service agencies. In contrast, many of the venues where we recruited young men in other
locations were from higher-risk venues such as gay bars. This approach may have interjected
sampling bias into our sampling pool in a couple of ways. Our ability to recruit from social
service agencies in Detroit may have led us to a characteristically distinct subset of young
Black MSM youth who: 1) are more formally engaged with the gay community via
established social service and community based organizations, 2) are more informed on and
committed to working on issues related to and affecting young Black MSM, and 3) are more
comfortable with and accepting of their sexual orientation identities Recruiting from higherrisk venues in other locations may have led us to more high-risk participants. However, it was
not uniformly true that we solely recruited from high risk venues outside of Detroit. We did
recruit in HIV service and LGBT-serving agencies outside of Detroit; however, outside of
Detroit, these agencies were not exclusively youth serving. That the agencies in Detroit were
youth-centered in orientation and focus may thus represent another key distinction that sets
them apart when it comes to working with and serving the needs of young Black MSM.
In addition, the YMHS recruitment approach and eligibility criteria limit the extent to
which findings can be generalized to the larger population of young Black MSM. Our sample
favors young men who would respond to an invitation to be in a study about young Black
MSM. Respondent driven sampling was conceived of a way to locate and interview harder to
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reach subsamples of MSM such as those who were on the down-low, engaged in sex work, or
transgender. We had limited success in tapping into these subcultures. Additionally, all of the
participants who avoided syndemic production were from Detroit, a large urban city that is
mostly Black and contains a large gay and bisexual male community. Demographically, and
in terms of resources, Detroit thus represents a unique urban center for young Black gay and
bisexual men. Whereas this finding is a limitation in terms of generalizability, it also points to
the necessity of appreciating contextual differences when studying protective factors and
syndemic processes in the lives of young Black MSM.
Finally, the present effort was cross-sectional in design, so caution in interpreting
causal relationships among identified assertions and the production or avoidance of
syndemics is warranted. This analysis represents a thin slice in the relational lives of these
young men. My study and methodological approach represents an appropriate starting point
given the absence of an empirical basis for the study of resilience among young Black MSM.
However, this design does not allow us to form confident conclusions about the causes of
syndemics of the avoidance of syndemics among young Black gay and bisexual men.
Implications for research
This study holds a number of implications for the study of syndemic mechanisms
among YMSM. One of the stories worth celebrating in these data is that marginalized men
from a place such as Detroit are developmentally thriving. Though only conjecture can be
made as to why Detroit may serve as protection from syndemics among Black MSM (e.g.,
racial demographics, availability of resources), this finding shows the importance of
considering geography in studies of syndemics. The syndemics conceptual literature (e.g.
Singer et al., 1996; Singer & Clair, 2003) articulates syndemics as the temporal and
locational co-occurrence of epidemics; these authors argue that because syndemics are

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largely socially produced phenomena, they must be considered in context. Stall and
colleagues’ (2008) original conceptualization of syndemics, likewise, suggests that location
matters because it influences the availability and accessibility of resources. Yet much of the
empirical literature has avoided assessing how location may affect syndemic production,
syndemic maintenance, or the experience of syndemics. In empirical population-based
studies, it has often been the case that samples are compiled across varied geographical
locations (Dyer at al., 2012; Herrick et al., 2012; Stall et al., 2003). For example, Stall and
colleagues’ (2003) original empirical paper outlining their syndemic framework among MSM
utilized a sample from Chicago, Los Angeles, New York, and San Francisco. Yet it is likely
that these locations may differentially influence susceptibility to syndemic conditions.
Researchers studying syndemics empirically might begin to account for the influence of place
by studying syndemics in isolated communities and locations, assessing geographic
differences in syndemic production within similar communities, or looking at how factors
such as migration affect syndemic susceptibility.
Findings from this study regarding young men’s identities have implications for the
study of syndemic mechanisms. In the syndemic literature, researchers have found that
identity-related constructs (e.g., internalized homophobia, masculinity attainment) are
significant independent variables associated with syndemic production (e.g., Dyer et al.,
2012; Herrick et al., 2012). However, these data suggest that using identity related variables
in isolation as predictors of syndemic production may paint too simplistic a picture of the
struggles that these young men experience. For example, a novel finding of this study is the
suggestion that young men’s early experiences of abuse influenced their current identityconflicts. The finding that young men’s abuse and trauma experiences are influencing
identity-development and integration suggests a need for more complex causal modeling in
quantitative studies of syndemic antecedents.

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An important limitation of Stall et al.’s (2008) model is that it was developed based
on research with middle-class, American, gay-identified men. This limitation, coupled with
findings from this study, suggest, there are a few additional ways in which the syndemic
literature may more aptly account for the complexity of identity-related issues that racial
minority MSM may experience. As this study showed, these men’s lives are rooted in
structural inequalities such as racism, classism, sexism, and heterosexism. Their identityrelated conflicts are not solely related to their sexual identities, but rather to the intersection
of their race, gender, class, and sexual identity. As these studies tenuously suggest, race,
class, ender presentation and/or sexual orientation may intersect among Black MSM in ways
that influence vulnerability to syndemics. Empirical studies of syndemics among Black MSM
have not yet accounted for other identity salient factors such as race (Dyer et al, 2012). At the
least, studies inclusive of racial minority men should consider racism and racial identity
formation as precursors of syndemic production. Second, it may be useful to further examine
how young Black gay and bisexual men experiencing syndemics describe and experience the
multiple intersections of their race, gender, and sexuality. Third, as these data suggest, these
young men have differential experiences, opportunities, and access to resources based on
their sexual orientation, class, gender expression, geographic location and/or appearance. For
example, in these analyses, young bisexual men may experience the gay community
differently than young gay men; or, there may be class-based differences in regards to
masculinity norms and experiences of masculinity stress. These findings suggest that in
studies of syndemics, it may be important to consider within-group differences, or to examine
syndemic production or resilience among particular subsamples of young Black MSM such
as those who are bisexual, on the down-low, or who are gender nonconforming. Additionally,
given that there are elevated HIV prevalence rates among gay men of color, an expansion of

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the syndemic model to include effects of and responses to alternate types of stigma (e.g.,
racism) is warranted.
This has been the first study using a syndemics framework to consider family as a
source of resilience among young Black MSM. In fact, only one other study to my
knowledge has examined family-related variables in relation to syndemic production (Herrick
et al., 2012). Herrick and colleagues found that parental substance abuse and parental
domestic violence were each independently associated with syndemic production among
adult MSM. This empirical oversight is a glaring omission from the syndemics literature
given that syndemic production is conceptualized as a developmental theory and family is a
primary socializing setting for youth. Additionally, this omission is glaring given the
preponderance of family related factors that have been associated with outcomes related to
sexual health and HIV transmission among YMSM ( Mustanski et al., 2011; Mustanski &
Hunter, 2012) and other syndemic issues among LGBT youth (Bouris et al., 2011). This
omission may be due to the predominant macrosystemic orientation of syndemic frameworks
and a concomitant empirical literature that has emphasized identifying individual-level (e.g.,
internalized homophobia) and macrosystemic (e.g., discrimination) predictors of syndemic
production. The empirical syndemic literature has not yet evolved to examination of
relational or microsystemic variables that may influence syndemics among MSM. However,
this oversight is problematic given that many of these structural issues (e.g, racism,
homophobia, discrimination, structural violence) MSM face are experienced within relational
environments (e.g., family, peers, sex partners, romantic dyads). Without studying the
experience of macrosystemic issues within relational context, it remains unclear a) the extent
to which MSM experience similar issues across multiple ecological systems; b) how
experiences with one system (e.g., family) may influence experiences in another (e.g, gay
community); and c) in what varied ways MSM are affected by these experiences. Empirical

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examinations of syndemics should therefore begin accounting for how various microsystems
(e.g, family, peers, dyads, community) or relational processes may moderate the relationship
between structural adversity and syndemic production. As the case of the young men
experiencing syndemics suggests, such an analytic emphasis is especially called for given
that MSM are liable to experience structural adversity across numerous ecological systems.
Additionally, as a developmental framework, a relational resilience emphasis on MSM’s
microsystems is necessary to ascertain whether certain microsystems matter more at one
developmental stage than another, or in light of certain contexts and events.
Consistent with Stall’s original conceptual formulation of syndemic production
among MSM, this analysis suggests that participation in the gay community may be an
important moderator between adversity and syndemic production. This study showed that
young men have very different experiences within gay community networks. Men who did
not experience syndemics described a positive psychological sense of that may be protective
against syndemic production. In contrast, the men experiencing syndemics described a
neutral relationship with the gay community or a negative psychological sense of community.
Future research into syndemics among YMSM should expand upon this exploratory study,
and go back to the conceptual roots of the syndemic model, by empirically testing the
association between adversity, a multi-faceted conceptualization of sense of community, and
syndemic production. Additionally, this study suggests that young men experiencing a
positive sense of community also experience sexuality related social support within their
families whereas those young men reporting a negative psychological sense of community
lacked similar family support. As such, family sexuality-related support, in addition to
psychological sense of community, may moderate the pathway from adversity to syndemics.
Future research should also examine in more depth, the relationship between family support
and gay community involvement.

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Resilience and syndemics
This study offers an initial glimpse into resilience among young Black gay and
bisexual men and to the growth-promoting relational experiences of young men who have
avoided syndemics. Greater emphasis needs to be placed on developing a more nuanced
understanding of growth-promoting connections, relational processes, and resilience in their
lives. Study of the considerable strengths, assets, and resources that Black gay and bisexual
men manifest is important to the study of their health. A continued focus on resilience and
strength by Black gay and bisexual men in the face of adversity will yield important insights
into how to maintain their health. In this section, I identify a few key ways that research on
syndemics might be attentive to resilience.
The syndemic literature suggests that syndemics influence people along the HIV care
continuum (Safren et al., 2010), meaning that similar psychosocial factors influence sexual
behavior, HIV/STI testing behavior, linkage and adherence to care, and intervention
effectiveness. As both the syndemic and continuum of care literature are flourishing, it is
likely that researchers will begin to look more closely at how syndemic exposure affects
people along the HIV care continuum. I examined sexual risk behavior as an outcome in this
study. Might similar factors (e.g., pride, family social support, social action) protect people
along the care continuum? These data suggest a number of ways in which the identified
assertions may influence participants’ testing behavior. As the syndemic literature
proliferates, researchers should consider protective factors, and whether those that are
protective against HIV exposure are similar to or distinct from those that are protective along
the HIV care continuum.
Resilience is typically conceived of as the process by which marginalized
individuals maintain psychological well-being despite oppressive conditions. The use of this

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definition, in this current analysis, considers resilience to be indicated by a lack of
psychosocial health outcomes typically associated with heightened HIV risk. Other
definitions provide alternate lenses by which to view these data. My focus, on protective
relational resilience, limited analysis to those young men who did not experience, at the time
of data collection, psychosocial health outcomes associated with heightened HIV risk. This
analysis sheds light on factors associated with participants’ well-being. Future research might
consider looking at compensatory resilience (Stevenson and Zimmerman, 2005), or those
resources and assets that may counteract syndemic exposure. Research along these lines
would examine how men with multiple syndemic conditions remain sexually safe and HIV
negative.
A constructivist definition of resilience provides another way to conceptualize and
examine resilience among young Black gay and bisexual men. According to Unger, resilience
is the outcome from negotiations between individuals and their environments for the
resources to define themselves as healthy amidst adverse conditions (Unger, 2004).
Resilience from this perspective is the negotiation by individuals for the resources to develop
and sustain health, as understood as their preferred constructions. This definition assumes that
people place particular values upon their health and that health is context specific. I and
others may assume, even if only implicitly, that health and well-being are indicated by the
presence or absence of a particular ailment. According to Unger, this is a cultural bias, one
that is not attentive to alternate discourses on health and well-being that may stem from
marginal voices. Unger’s definition of resilience affords that there are situations and
circumstances which may appear to indicate vulnerability (e.g., social isolation), but that may
be preferred to the alternative (e.g., further marginalization). As such, future research that
assesses resilience from a constructivist standpoint among young Black gay and bisexual men
may examine what young men themselves discern as healthy functioning or how resilience

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can be achieved through alternate pathways thought by the dominant discourse to indicate
vulnerability.
Implications for practice
Resilience focused researchers argue that interventions that focus on enhancing
strengths and resources may be more effective in promoting health than interventions that
focus specifically on negative health outcomes (e.g., HIV transmission, substance use)
(Herrick et al., 2012). These analyses provide justification for a number of strength-based
intervention strategies that researchers may utilize not just in HIV prevention programs, but
also in addressing antecedent psychosocial health conditions (i.e., syndemics) that increase
vulnerability to HIV.
Clinical interventions
A syndemics orientation to the prevention of HIV and other sexual health issues
necessitates an intervention emphasis on the psychosocial issues associated with heightened
HIV risk. As such, results of these studies have several implications for mental health
providers working with young Black gay and bisexual men with mental health concerns,
substance abuse issues, or histories of trauma. First, mental health professionals must be
sensitive to the unique confluence of issues facing young Black MSM. These studies in
tandem provide insight into how societal messages, relational experiences, and trauma play a
role in young Black gay and bisexual men’s self-perceptions. Stigma and trauma represent
primary causes of the low sense of self-worth and isolation that many Black MSM
experience, thus complicating the identity integration process and preventing Black MSM
from connecting with supportive and accepting others. To facilitate treatment planning,
clinicians and therapists would be wise to consider how men’s presenting psychosocial health
issues (e.g., mental health and substance abuse) may be precipitated and maintained by socio134

cultural factors such as discrimination, marginalization, and oppression. In particular, mental
health providers must understand how young men’s self-perceptions are influenced by
messages they receive about their sexuality, race, masculinity, and history of trauma. This
cultural awareness and sensitivity is necessary in order for mental health professionals to help
young Black gay and bisexual men develop a healthy, integrated sense of self (Harper et al.,
2007; Harper et al., 2012).
These data suggest that two gay-affirmative counseling approaches with young Black
MSM may include the promotion of cognitive reframing strategies and an emphasis on the
positive conceptualizations of being gay or bisexual Black men. Cognitive reframing can be
taught by offering education about heterosexism and teaching young men to deconstruct
heterosexist assumptions (Chernon & Johnson, 2002; Lebolt, 1999); this gay-affirmative
counseling strategy is an important tool for aiding the emotional well-being of sexual
minority youth (Johnson & Chernon, 2002). As multiply marginalized persons, learning
cognitive reframing strategies may help young men develop a critical eye toward understand
the manifold affects that racism, sexism, and heterosexism have on their daily lives. Previous
research has suggested that cognitive reframing strategies are often used among sexual
minority youth of color (McDavitt, Iverson, Kubicek, Weiss, Wong, & Kipke, 2008; Reed &
Valenti, 2012; Wilson & Miller, 2002). Wilson & Miller (2002) interviewed 37 Black gay
and bisexual men about the strategies that they use to deal with heterosexism. The authors
contend that cognitive reframing strategies may be common among Black gay and bisexual
men due to their ability to generalize strategies for coping with racism to coping with
heterosexism. As a therapeutic strategy with young Black gay and bisexual men, cognitive
reframing may be a particularly effective tool given its cultural salience. The young men in
this study who did not experience syndemics oft cited cognitive reframing strategies, which
again suggests that it is a useful and culturally congruent stigma management strategy.

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Based on these analyses, a second gay-affirmative therapeutic recommendation for
work with young Black gay and bisexual men may be to help them identify and focus on the
positive aspects of their sexual orientations. Harper and colleagues (2012) contend that
teaching sexual minority youth to focus on positive conceptualizations of their sexual
identities is a key way in which they develop well-developed, integrated identities. Indeed,
HIV prevention interventions for young gay and bisexual men often highlight participant’s
positive identity conceptualizations to enhance young gay and bisexual men’s acceptance of
their sexual orientation. These data suggest that young Black gay and bisexual men who
avoid syndemics have identified and found ways to celebrate positive facets of their
identities; further, much of what they tend to value –increased social support, opportunities
for social engagement- tends to be related to other forms of resilience associated with wellbeing. As there appears to be a cyclical relationship between identity acceptance, sexualityrelated social support, and opportunities for social action, mental health and health care
providers should also be aware of local community connections and opportunities that may
support young Black gay and bisexual men’s healthy identity development.
A final recommendation for mental health professionals concerns the case of young
men with histories of sexual abuse. The data were sparse concerning how young men’s
sexual abuse experiences influenced their current sexual orientation identities; however, the
available data suggest that sexual abuse problematized participants’ sexual identity
development and decreased their desire or willingness to connect with other young Black gay
and bisexual men. Previous research suggests that childhood sexual assault is associated with
sexual identity confusion among gay and bisexual men (King, Coxell, & Mezey, 2002).
Further, the only qualitative study on Black gay and bisexual men’s experiences of sexual
abuse substantiates that men may blame their same-sex desire on their childhood sexual
abuse experiences (Fields, Malenbranche, & Feist-Prince, 2008). As such, mental health

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professionals may consider examining young men’s associations between sexual abuse and
their current constructions of sexual (and gender) identity.
Family interventions
For heterosexual youth, families are frequently enlisted in family-based interventions
designed to prevent and treat HIV (McBride, Berkel, Pantin, & Prado, 2000). Even though
family factors are among the correlates of sexual risk among YMSM, the same cannot be said
for gay and bisexual youth (Mustanski & Hunter, 2012). In a review of the literature to assess
parental influences on sexual minority youth’s health, Bouris et al (2011) also note that
despite the positive influence of supportive parents and family sexual minority youth’s health
and well-being, that there is a dearth of family-based interventions that address mental health
issues, substance use, and sexual behavior. For YMSM, family-based approaches to
preventing HIV and substance abuse and promoting mental health have not yet been
developed and tested (Bouris et al., 2011; Mustanski & Hunter, 2012). However, researchers
are beginning to suggest that efforts to develop such programs should be prioritized given
their potential to increase sources of resilience and address multiple syndemic issues
experienced by young gay and bisexual males (Bouris et al., 2011; Harper & Riplinger, 2012;
Garofalo et al., 2008; Mustanski et al., 2012; Mustanski & Hunter, 2012; Ryan et al., 2009).
Family members can play important roles in comprehensive HIV prevention for gay
and bisexual men (Garofalo, et al., 2008; Mustanski et al., 2011; Mustanski & Hunter, 2012).
The lack of family-based interventions for young gay and bisexual males to date may reflect
the misconception that families are unavailable for interventions because they are not
involved in the lives of sexual minority youth or they are unaware of their child’s sexual
identity (Garofalo et al., 2008). Emerging research indicates that many parents are aware of
their child’s sexual orientation (Garofalo et al, 2008), aware of the unique needs of gay youth,

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(Kubicek, et al., 2010; LaSala 2007), open to understanding how their responses influence
their child’s well-being (Ryan et al. 2009), and want assistance in supporting their child’s
health (LaSala, 2007). These findings suggest that family interventions may be a relevant
modality for health promotion among young gay and bisexual males.
From a resilience perspective, researchers should develop interventions to draw on the
existing resources and strengths that exist in Black families and communities. These data
indicate that some young Black gay and bisexual men have supportive family relationships,
particularly with female members of their families. As such, these supportive family
members may be feasible routes through which to deliver family-based prevention efforts or
programs for young Black gay and bisexual men. This alternative intervention approach
would draw on the strong kinship networks in Black families and deeply engrained
community ethos of protecting the health and well-being of Black boys and men. Given the
protective role that mothers and other women play in young Black men’s lives and their
esteemed role in Black families and communities, women should be considered as potential
targets of family-based interventions. Women are not typically thought of as targets of
intervention when it comes to promoting the health of gay and bisexual men. These data
suggest that women’s inclusion in health promotion efforts for young Black gay and bisexual
men may be warranted, a finding that represents a significant conceptual shift in the current
prevention literature among young Black gay and bisexual men. In addition, further research
should address how supportive family members can most effectively be leveraged in
delivering family-based prevention programs (for HIV and issues related to HIV) for young
Black gay and bisexual men.

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Peer interventions
These data suggest that peer-led and social network-based prevention approaches may
be an effective way to engage young Black MSM. Many of the young men who did not
exhibit syndemics actively recruited their friends and peers to attend HIV-related events and
programming, receive HIV counselling and testing services, and join LGBT-supportive
groups and organizations. These young men exhibited a drive to engage in social action that
might facilitate the health and well-being of their community. Recent research evidence
substantiates that peer-based HIV prevention and outreach strategies may be an effective
approach to engaging young Black MSM in prevention services. For example, Outlaw and
colleagues (2010) conducted a randomized control study to assess whether motivational
interviewing conducted by Black YMSM peer educators led to increases in HIV counseling
and testing in 188 Black YMSM, compared to traditional field outreach methods. They found
that intervention group participants were significantly more likely than control group
participants to receive HIV counseling and testing services and to return for the test results.
Additionally, d-up!, one of the few evidence-based HIV interventions specifically designed
for young Black MSM, uses a peer-based approach to promote positive norms that encourage
safer sex (Jones et al., 2008). Given the strong communal ethos among the Black community
and within some sexual minority-communities, researchers might consider developing peerbased interventions along the continuum of care.
Community interventions
Interventions that strengthen young Black MSM’s communal support systems may be
useful for disrupting syndemics, particularly if they focus on developing or strengthen a
positive psychological sense of community among young men. Wyatt (2009) discusses
aspects of culturally congruent intervention strategies for preventing HIV among African

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Americans and recommends that a key intervention strategy should be the enhancement of
interconnectedness. Further, Wilson and Moore (2009) interviewed 71 leaders who worked in
community-based organizations and AIDS programs that serviced Black MSM about their
perceptions of barriers to and facilitators of prevention within this community. Participants
identified community-building efforts that connect Black MSM to each other as an important
way to reduce social isolation and facilitate prevention responses. In interviews with 76
African American MSM about the perceptions of community, men also noted that a way to
strengthen their community is through the creation of nonsexualized meeting spaces (Kraft,
Beeker, Stokes, & Peterson, 2000). Building sexuality-specific communal support systems
may be a particularly relevant intervention strategy for young Black MSM.
Though these participants largely described community involvement in formal LGBT
and HIV service organizations, there are other innovative ways that communal support
systems may be developed that provide important sources of support for young Black gay and
bisexual men struggling with social isolation. Black gay social groups, sports teams, or faithbased groups may all provide ways for young Black gay and bisexual men to build positive
connections with others. Given the importance placed upon religious life in the Black
community, strengthening the viability of faith-based groups where men can grow spiritually
and personally may be a particularly relevant modality for creating and enhancing
interactions among Black MSM (Kraft et al., 2000). LGBT service centers, community based
organizations, gay social groups, and HIV service centers may consider providing young men
with opportunities to engage in meaningful, identity-congruent social action. Additionally,
older Black MSM can be encouraged to serve as role models and mentors. However, the
developmental needs and struggles of youth and the hesitance some youth exhibit when
interacting with older MSM suggest that the creation of youth-specific social events and
opportunities may be especially necessary.

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There should be efforts to ensure that existing sexuality-related groups and
organizations are welcoming to Black sexual minorities, people of various gender
expressions, and people of diverse sexual orientations. Young Black gay and bisexual men
experience interpersonal rejection across a variety of social systems. Access to the gay
community can provide opportunities, as the young men who lacked syndemic production
experienced, for obtaining social support, developing a sense of community, and developing
a healthy sense of being gay. However, when gay community groups or organizations are
exclusionary, then access to the gay community leads to interpersonal rejection, further
marginalization, continued identity related shaming, and a heightened sense of social
disconnection. Men who experience interpersonal rejection or identity-related oppression
within gay community settings are not afforded the opportunity to develop important
relational connections or gain freedom from oppressive social environments. It is important,
therefore, to make gay spaces and communities welcoming, to reduce factions among young
Black MSM, and to develop ways of enhancing a sense of community. In Black MSM
communities, it may be particularly important to address myths and misconceptions about
bisexuality, examine and deconstruct stereotypes of men on the “down low,” and critique
norms and expectations regarding masculinity and gender expression. Such efforts may
enhance the sense of “macrobelonging” or the sense of community that incorporates all
members of the larger community (Weisenfeld, 1996).
Conclusion
This research represents a significant departure from the literature on young Black
gay and bisexual men due to its focus on resilience. Many scholars purport that interventions
are most likely to succeed when they are culturally congruent and designed to support and
enhance organically occurring sources of resiliency and strength in communities. The lack of

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information about resilience among young Black gay and bisexual men is thus a serious gap
that hinders intervention efforts. Interventions should build on resiliency factors, from family
acceptance to community involvement to social activism, which may alleviate the negative
consequences of socio-structural barriers to health.
A relational resilience emphasis on syndemic processes is one way of taking an
ecosystemic approach to the study of contextual influences that shape the development and
well-being of young Black gay and bisexual men. Syndemic frameworks fundamentally call
attention to the important fact that macrosystemic structural adversity and violence
precipitates poor development and negative health outcomes among MSM. Yet the fact that
men experience these structural stressors across multiple relational and socializing
environments suggests a need for a more contextualized and ecosystemic empirical focus in
the study of syndemics among MSM. While structural interventions that address the
marginalization, trauma, and oppression that young men of color face are needed for quelling
syndemic processes, this study also suggests that such approaches must be complemented by
peer-based, family-based, community-based, and clinical interventions. As means of
attenuating men’s socio-structural barriers to health and addressing comorbid psychosocial
health issues, interventions must address young men’s social isolation, identity-related issues,
and sense of community.

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