Barriers and Facilitators to Pre-exposure Prophylaxis Uptake Among Black Women: A Qualitative Analysis Guided by a Socioecological Model.

ABSTRACT: Black women experience disparities in HIV incidence. Pre-exposure prophylaxis (PrEP) is a once-daily pill that can prevent HIV transmission. To enhance PrEP uptake among Black women, it is essential to examine their perceptions of PrEP. In 2018, 33 Black women in New York City completed interviews about their attitudes, knowledge, and perceived barriers and facilitators to PrEP use. Emergent themes were organized using a socioecological model. Participants identified barriers at the sociocultural level, including stigma, medical mistrust, and health care avoidance. At the community level, health care access issues and limited community knowledge were reported. Partner-level barriers included trust in partners and meaning attributed to PrEP use within the context of monogamy. Individual-level barriers included low perceived risk and concerns about PrEP's safety and efficacy. Our findings can inform future PrEP research with Black women, as well as PrEP implementation efforts aimed at increasing uptake among this population.

The Role of Structural Barriers in Risky Sexual Behavior, Victimization and Readiness to Change HIV/STI-Related Risk Behavior Among Transgender Women.

This study examines the role of structural barriers experienced by a community-based sample of 63 HIV-positive and negative transgender women that may elevate HIV infection and transmission risks. Separate hierarchical linear multiple regression analyses tested the association between structural barriers (e.g., unemployment, lack of food, shelter) and condomless anal sex acts, abuse, and readiness to change risk behavior, while controlling for other related factors. Among this primarily Hispanic and African-American sample, HIV-positive and negative transgender women experienced a similar number of structural barriers and experiencing structural barriers was significantly associated with an increased number of condomless anal sex acts (p = .002), victimization (p = .000) and a decreased readiness to change HIV-related risk behavior (p = .014). Structural-level interventions are needed to address this elevated risk among this underserved and hard-to-reach population.

Butch bottom-femme top? An exploration of lesbian stereotypes.

Lesbian gender labels (i.e., butch, soft butch, butch/femme, femme, and high femme) have set the stage for assumptions about lesbian attractions to sexual behaviors. This study explored the intersection of lesbian gender labels and attraction to sexual behaviors in 214 lesbian-identified women. Participants ranged in age from 18 to 69 with 48% being women of color. Contrary to stereotypes about sexual behavior in the lesbian community, very few differences emerged in regard to lesbian gender label. Overall, results do not support stereotypes about lesbian gender labels and suggest that behaviors in the lesbian community are fluid across labels.

Girlfriends: evaluation of an HIV-risk reduction intervention for adult transgender women.

This study evaluated Girlfriends, a behavioral HIV intervention, developed for male-to-female transgender persons, for whom there are few scientifically evaluated prevention programs. The Girlfriends intervention included four group-level sessions. We used a single group, pre-post test design to assess changes in sexual risk behaviors at 3-month follow-up. We enrolled 63 transgender women into the study. Forty-six percent were Hispanic and 35% were African American. Three months after the intervention, participants had fewer sexual partners (p = .043) and were less likely to have any unprotected anal intercourse (UAI) with male exchange partners (p = .013) and unprotected sex at last vaginal or anal sex episode with female and male partners (p = .039). The findings of this study are promising. We observed behavioral effects among a largely ethnic minority sample of transgender women. Replication with a larger sample and a control group is needed.

Sexual victimization and health-related indicators among sexual minority men.

This study reports rates of childhood and adult sexual victimization among a community sample of 634 gay and bisexual-identified men, and examines how men with differing sexual victimization histories compare on a number of health-related outcomes. Results indicate that men with histories of childhood and adult sexual victimization are more likely to report substance use, more lifetime STIs, higher sexual compulsivity scores, and greater gay-related stigma scores than men with no histories of sexual victimization. Few differences are found in comparisons of health outcomes based on age at first sexual victimization (childhood vs. adulthood). Furthermore, men with histories of sexual victimization report healthier coping skills than men with no histories of sexual victimization, but no significant group differences are found in social support or stress-related growth. Findings underscore the importance of assessing lifetime sexual victimization among sexual minority men during counseling, with special attention given to the enhancement of protective factors among those at risk for harmful behaviors and subsequent poor health outcomes.

Consistency and change in club drug use by sexual minority men in New York City, 2002 to 2007.

We used repeated cross-sectional data from intercept surveys conducted annually at lesbian, gay, and bisexual community events to investigate trends in club drug use in sexual minority men (N = 6489) in New York City from 2002 to 2007. Recent use of ecstasy, ketamine, and γ-hydroxybutyrate decreased significantly. Crystal methamphetamine use initially increased but then decreased. Use of cocaine and amyl nitrates remained consistent. A greater number of HIV-positive (vs HIV-negative) men reported recent drug use across years. Downward trends in drug use in this population mirror trends in other groups.

The role of religiosity, social support, and stress-related growth in protecting against HIV risk among transgender women.

Transgender women completed questionnaires of religiosity, social support, stigma, stress-related growth, and sexual risk behavior. In a multivariate model, both social support and religious stress-related growth were significant negative predictors of unprotected anal sex, but religious behaviors and beliefs emerged as a significant positive predictor. The interaction between religious behaviors and beliefs and social support was also significant, and post-hoc analyses indicated that high-risk sex was least likely among individuals with high-levels of social support but low levels of religious behaviors and beliefs. These data have important implications for understanding factors that might protect against HIV risk for transgender women.

Sexual compulsivity and sexual risk in gay and bisexual men.

Much of our understanding of the association between the Sexual Compulsivity Scale (SCS) and sexual risk behavior among men who have sex with men (MSM) has been limited to samples of HIV positive MSM only. Using data from a community-based survey of gay and bisexual men (n = 1214), this analysis sought to further evaluate the association between the SCS and sexual risk behavior. The SCS was significantly associated with a variety of sexual risk behaviors, including having sex under the influence of club drugs, engaging in unprotected anal sex (receptive or insertive) with partners of the same and/or different HIV serostatus, identity as a barebacker, intentions to have bareback sex, number of recent sex partners, and temptation for unsafe sex. The SCS was also significantly associated with having engaged in a variety of specialized sexual behaviors (i.e., fetishes), many of which can increase HIV transmission risks. Finally, in multivariate analyses, the SCS significantly predicted unprotected sex with a non-main partner even when controlling for race, HIV serostatus, age, identity as a barebacker, and club drug use. These data indicate that the SCS may be able to serve as an indicator to detect HIV-associated sexual risk behavior in community-based samples of gay and bisexual men.

The association between penis size and sexual health among men who have sex with men.

Larger penis size has been equated with a symbol of power, stamina, masculinity, and social status. Yet, there has been little research among men who have sex with men assessing the association between penis size and social-sexual health. Survey data from a diverse sample of 1,065 men who have sex with men were used to explore the association between perceived penis size and a variety of psychosocial outcomes. Seven percent of men felt their penis was "below average," 53.9% "average," and 35.5% "above average." Penis size was positively related to satisfaction with size and inversely related to lying about penis size (all ps < .01). Size was unrelated to condom use, frequency of sex partners, HIV status, or recent diagnoses of HBV, HCV, gonorrhea/Chlamydia/urinary tract infections, and syphilis. Men with above average penises were more likely to report HPV and HSV-2 (Fisher's exact p

Experiences of familial acceptance-rejection among transwomen of color.

Because of the stigma associated with transgenderism, many transwomen (biological males who identify as female or transgender) experience rejection or abuse at the hands of their parents and primary caregivers as children and adolescents. The Parental Acceptance-Rejection (PAR) theory indicates that a child's experience of rejection may have a significant impact on their adult lives. The purpose of this study was to conduct a qualitative analysis of adult transwomen of color's experiences with caregivers, guided by PAR theory. Twenty transwomen of color completed semi-structured interviews exploring the reaction of their parents and primary caregivers to their gender. While many participants reported that at least one parent or close family member responded with warmth and acceptance, the majority confronted hostility and aggression; reports of neglect and undifferentiated rejection were also common. Many transwomen were forced out of their homes as adolescents or chose to leave, increasing their risk of homelessness, poverty, and associated negative sequelae. Future research is needed to explore how families come to terms with having a transgender child and how best to promote acceptance of such children.

Stress and coping among HIV-positive barebackers.

HIV-positive MSM may report high-risk behaviors-including drug use and intentional unprotected anal sex-as a means of coping. We recruited a diverse sample of HIV-positive men (n = 66) at gay community events. One third of these men self-identified as barebackers. Barebackers were more likely to report drug use and sex under the influence of drugs (i.e., PnP). Beyond this, those who identified as barebackers also tended to report greater stigma, gay-related stress, self-blame-related coping, and substance abuse coping. Providers must attend to issues of stress and coping to engage men who may not respond to traditional risk reduction efforts.

Community reactions to a syphilis prevention campaign for gay and bisexual men in Los Angeles County.

"Stop the Sores" (STS), a humor-based syphilis prevention campaign, was implemented in response to increasing syphilis prevalence among gay and bisexual men in Los Angeles County. In 2004, 564 men completed surveys measuring exposure and reactions to the campaign and syphilis testing. Mean age was 39, and men of color comprised a significant proportion of the sample (46.8%). Most men reported being HIV-negative (79.3%). Overall, 7.8% of the sample reported ever having syphilis; HIV-positive men were six times more likely to report this. Over one half of the sample (58.5%) reported exposure to the campaign. Men reporting any recent unprotected anal sex were twice more likely (than those who did not) to see the campaign. Men of color were twice more likely than White men to report wanting to speak to their friends about it. Finally, 39.1% of men exposed to the campaign reported being tested for syphilis as a result. Factors related to higher likelihood to test for syphilis included HIV seropositive status, any recent unprotected anal insertive sex, recent use of methamphetamine, recent use of "poppers," and recent use of erectile dysfunction drugs. Although STS was somewhat effective, outreach efforts to particular subgroups may need to increase.

Behind closed doors: an exploration of kinky sexual behaviors in urban lesbian and bisexual women.

This study of 347 urban, self-identified lesbian (n = 289) and bisexual (n = 58) women examined women's engaging in 4 kinky sexual behaviors: bondage/domination, sadomasochism, photo/video exhibitionism, and asphyxiation/breath play. A cross-sectional, brief-intercept survey was administered at 2 New York City gay, lesbian, and bisexual community events. Over 40% reported engaging in at least 1 of these behaviors, and 25% reported engaging in multiple behaviors. Bisexual women were more likely to have engaged in any kinky sexual behavior and photo/video exhibitionism. White women were more likely than women of color to have engaged in bondage/domination. Compared to older women, younger women were more likely to have engaged in photo/video exhibitionism and asphyxiation/breath play. Participants who were younger when they came out to others, and younger at their same-sex sexual debut, were more likely to have engaged in any and each of the behaviors compared to women who were older at those developmental events.

Sexual compulsivity and sexual behaviors among gay and bisexual men and lesbian and bisexual women.

Within the existing body of research, the information pertaining to sexual compulsivity (SC) among women, both homo- and heterosexual, remains rather limited in comparison to men. The aim of this study was to assess the prevalence of SC in a community sample of gay and bisexual men and lesbian and bisexual women and to identify differences in sexual practices based on classification as sexually compulsive within gender. Supporting previous research, the findings indicated that gay and bisexual men were significantly higher in SC when compared to lesbian and bisexual women. Similarly, sexually compulsive gay and bisexual men were more likely to report drug use with sex than their non-sexually compulsive peers, suggesting that "party n' play" may play a larger role for men with SC. In addition, the findings demonstrated empirical support for the proposition that lesbian and bisexual women with symptoms of SC were more likely to engage in specialized sexual behaviors in comparison to their non-sexually compulsive peers. These data suggest that SC manifests differently in gay, lesbian, and bisexual men and women.

In the shadows of a prevention campaign: sexual risk behavior in the absence of crystal methamphetamine.

Because of its ability to reduce inhibitions and increase sexual drive, an emerging body of research has repeatedly identified crystal methamphetamine as a key variable in explaining new HIV transmissions among men who have sex with men (MSM). The implications of which have included the development of HIV prevention policies and public health campaigns centered on curbing methamphetamine use in urban gay centers throughout the United States. Data collected from a diverse sample of gay and bisexual men attending large-scale gay, lesbian, and bisexual community events in New York City (n=738) indicated that 10.2% of men used methamphetamine recently (i.e., <90 days) and that 29.9% of the sample had experienced a recent episode of unprotected anal intercourse. The majority, 81.1%, of those men reporting unsafe sex had not used methamphetamine recently. This analysis identified a bivariate relationship between methamphetamine use and sexual risk, but also highlights other variables that were significantly related to risky sexual behavior. Logistic regression analyses indicated that recent GHB use, temptation for unsafe sex, being younger in age, and identification as a barebacker were better indicators of risky sexual behavior than methamphetamine use. Policies focused on methamphetamine prevention may help to curb risky sexual behavior among select groups of individuals; however, these will not adequately address the sexual health of the many gay and bisexual men who, in the shadows of anti-methamphetamine policies and prevention programs, continue to engage in unsafe sex but are nonusers of methamphetamine.

Exploring the internet's role in sexual compulsivity and out of control sexual thoughts/behaviour: a qualitative study of gay and bisexual men in New York City.

Sexual compulsivity and the internet have been investigated separately among gay and bisexual men for their connection to sexual risk behaviour, yet little research has addressed the intersection. This analysis explored qualitative interview data from 111 gay and bisexual men experiencing out of control sexual thoughts and/or behaviours, about the role of the internet in their lives. For some it facilitated their problematic sexual thoughts and behaviours and, to some extent, was a distraction from important facets of their lives. Equally, men identified strategies to limit their internet use and reduce these negative consequences. For some, the internet was attributed to being less discriminating about partners. In contrast, other men compared the internet to other venues for meeting sex partners (e.g. bars) and described the internet as a medium for reducing physical (cruising online versus cruising a dark alley) and sexual (multiple partners at bathhouses versus cyber-sex only) risk. Clinically, service providers should conduct more thorough assessments regarding the role of the internet in the lives of patients who experience sexual compulsivity, as many individual differences exist, and there may be positive benefits that stem from internet use.

Explanations for the origins of sexual compulsivity among gay and bisexual men.

Sexual compulsivity (SC) is a condition characterized by sexual fantasies and behaviors that interfere with personal, interpersonal, or vocational pursuits. This article describes the ways in which gay and bisexual men with symptoms of SC understand and explain the origins of their condition. The data for this article were drawn from Project SPIN, a mixed-methods study of SC among 183 gay and bisexual men in New York City. The article provides an evaluation of how urban gay and bisexual men experience SC and describes how they think about it in their own words. These men articulated both intrinsic and extrinsic sources for the development of SC. Some participants endorsed a belief in a predisposition toward sexually compulsive behavior, whereas others identified factors such as emotional neglect, sexual abuse, or the availability and accessibility of sexual partners. These understandings may influence the ways in which SC can be treated, while also highlighting issues that may be critical in the identification and/or measurement of SC. Insights into the origins of SC may yield new therapeutic models that reduce not only the distress of contending with this condition but its negative health effects and impact on quality of life.

Accounting for the social triggers of sexual compulsivity.

AIMS: To examine the social triggers of sexual compulsivity amongst a diverse sample of gay and bisexual men. DESIGN AND PARTICIPANTS: Qualitative interviews were conducted with 180 gay and bisexual men in the United States who self-identified that their sex lives were spinning out of control. The data were analyzed using a grounded theory approach to explore the range of social triggers that were driving sexual compulsions. MEASUREMENT: An open-ended interview and a structured clinical interview were conducted with each participant. The interviews examined their experiences with sexual compulsivity over time and the impact of their problematic sexual behaviors on their lives. FINDINGS: Two types of social triggers emerged from the data: event-centered triggers and contextual triggers. Event-centered triggers arise from sudden, unforeseen events. Two major event-centered triggers were identified: relationship turmoil and catastrophes. Contextual triggers, on the other hand, have a certain element of predictability, and included such things as location, people, the use of drugs, and pornography. CONCLUSIONS: This framework of triggers has clinical implications for the prevention and treatment of sexual compulsivity. Clinicians can utilize the framework of social triggers in the therapeutic process to provide insight into ways to effectively work through symptoms of sexual compulsivity. Awareness of the contextual aspects of sexual compulsivity may be critical to understanding the behaviors of sexually compulsive clients. Thus, therapeutic assessments should focus upon the social context in addition to the psychological components of the disorder.

Male prostitution: pathology, paradigms and progress in research.

The body of research on male sex workers (MSWs) in the social science literature has evolved concurrently with the research that de-pathologized homosexuality. Unfortunately, the majority of studies focusing on MSWs have been dominated by paradigms that dehumanize the researched. Psychopathology, social deviance and, with the advent of HIV, MSWs as "vectors of disease," framed research questions. Further, many researchers have focused on typologies of MSWs, reporting respective associated characteristics. However, the knowledge gained by past research was often a product of the places MSWs were sampled; social scientists relied heavily on street MSWs. although other places and venues for sex work existed. What has been learned through this narrow focus has often been generalized to all men engaged in sex work resulting in stigmatization, stereotyping, and demonization. In the past decade, two important developments related to the field of sex work have been introduced. First, researchers have embraced a new paradigm that respects MSWs' personal motivations for sex work. Dominant among these motivations is the view of sex work as a job and, hence, a valid source of income. Second, the Internet has emerged as a new venue for sex work; a venue to which researchers are just beginning to turn their gaze.