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New Article Criticizes Term "on the Down low": Moving beyond "the Down Low": A critical analysis of terminology guiding HIV prevention efforts for African American men who have secretive sex with men
 
 
  Lena Denise Saleha, and Don Operariob,
aSocial Policy and Social Work, University of Oxford, Barnett House, 32
Wellington Square, Oxford OX1 2ER, United Kingdom
bDepartment of Community Health, Brown University School of Medicine, Providence, RI, USA
Corresponding author. Tel.: +44 (0) 7506 381 732.
 
Abstract
 
HIV continues to affect African American populations in the United States at disproportionate levels. Recent reports have described potentially high-risk behaviors of African American men who identify as heterosexual but who engage in secretive sex with other men. These men have been referred to as being "on the Down Low," and this terminology has been used to label subgroups of African American men and explain sexual risks for HIV infection in the African American community. In this paper, we argue that an uncritical use of this terminology for guiding public health and HIV prevention strategies can be problematic and counterproductive because it (a) stigmatizes and exoticizes secretive same-sex sexuality as a unique issue among African American men, and (b) ignores the social conditions under which HIV transmission occurs. We explore some historical roots contributing to current perspectives on African American men's sexuality, describe the use of the term "on the Down Low" and its application to same-sex behavior among African American men, and explain how this term can both clarify and potentially ambiguate efforts to address HIV risk among African American men. Recommendations for research and HIV prevention strategies are also provided.
 
Introduction
HIV/AIDS is among the most urgent health issues for the African American population in the United States. Compared to all other ethnic groups, African Americans are represented at disproportionately higher levels at every stage of HIV-related illness, from infection to death (Centers for Disease Control and Prevention (CDC), 2003). While comprising just 13% of the total national population, African Americans accounted for 51% of all new HIV/AIDS diagnoses from 2001 to 2005 in data collected from 33 states using name-based reporting (CDC, 2007). As of 2005, annual rates of HIV/AIDS diagnoses in African American men and women were, respectively, seven times and twenty times the rate among White men and women. Male-to-male sexual contact serves as the primary mode of HIV transmission among African American men, whereas African American women are primarily infected by their male partners (CDC, 2007). Reducing HIV incidence in the African American community is a national health priority, but prevention efforts have not been adequately supported (Black AIDS Institute, 2008).
 
A notable challenge to HIV prevention efforts for African American men derives from poor understandings of African American cultural norms and attitudes toward sexuality. This challenge is particularly evident with regard to African American men who engage in sex with other men (MSM) ([Ford et al., 2007] and [Mays et al., 2004]). Discrete categories of sexual identity used in targeted public health and HIV prevention campaigns (i.e., gay/homosexual, heterosexual, bisexual) may not adequately capture complexities underlying the sexuality of African American men who have sex with other men (Ford et al., 2007). Oftentimes, these men do not self-identify as gay or homosexual ([Mays et al., 2004], [Operario et al., 2008] and [Woodyard et al., 2000]) and prevention messages directed toward individuals fitting into these sexual-identity categories may not reach them. Recently the term "on the Down Low" ("DL"), which connotes any activity or concept meant to remain secretive and private, has been used by heterosexual-identified African American men to describe their secretive sexual behaviors and sexual attraction to men. The DL classification has been co-opted by some public health and HIV prevention professionals to highlight the subgroup of African American MSM who might be overlooked by health education and outreach strategies targeted toward gay/homosexual communities (Ford et al., 2007). According to existing reports, heterosexual-identified African American men who engage secretively in sex with other men might operate as a bridge population for transmission of HIV in African American communities, and so innovative strategies to reach these men can potentially reduce rates of infection ([Dodge et al., 2008], [Siegel et al., 2008] and [Wheeler et al., 2008]).
 
In this paper we argue that the DL classification may serve as a convenient but simplistic explanatory tool for understanding HIV transmission among African American men. Issues raised by DL terminology speak to larger challenges inherent in a risk group approach to HIV prevention that neglects social, cultural, and historical factors that determine sexual identity and HIV risk behaviors. Specifically, we argue that an uncritical use of the DL concept for guiding public health and HIV prevention can be problematic and counterproductive by (a) stigmatizing and exoticizing secretive same-sex sexuality as a unique issue among African American men, and (b) ignoring the social conditions under which HIV transmission often occurs. We will substantiate this argument by exploring some historical roots contributing to current perspectives on African American men's sexuality, describing the term "on the Down Low" as an endogenous expression emerging from within the African American community, and examining its exogenous application to understanding same-sex behavior among African American men. This paper posits that an ahistorical, asocial use of DL terminology can potentially ambiguate and undermine efforts to address the nature of HIV risk among African American men.
 
Constructed notions of the Black body and Black masculinity
 
Given the long history of attention focused on the Black body (Jackson, 1997), media and public-health attention to the DL phenomenon is not surprising. Since the days of slavery, Black bodies have been subject to speculation and scrutiny. From their human capture in Africa and arrival to the United States, African American men and women, and their bodies, have been viewed as objects and possessions, and their bodies used as tools for economic advancement. The patterns of historical, social, and economic domination of Black individuals in plantation societies gave rise to modern sociocultural constructs of race, which continue to shape patterns of Black-White interaction and assumptions about gender roles and masculinity among African Americans (Whitehead, 1997).
 
Racialized assumptions of masculinity in the United States emerged from historical, economic, and social dominance dynamics (Bowleg, 2004). Idealized notions of masculinity for White American males were associated with economic power to provide for one's family, a value and cultural norm reinforced by the capacity to exert, maintain, and strengthen economic control (Cazenave, 1984). African American men lacked opportunities to achieve economic and hegemonic forms of power and masculinity generally enjoyed by White men. Consequently, among African American men, idealized notions of masculinity tended to take the form of corporeal and sexual prowess, values that were reinforced by stereotypical views among Whites of Black bodies as instruments for brute labor and sexual reproduction ([Hodes, 1993], [Hunter and Davis, 1992] and [Whitehead, 1997]).
 
Current cultural depictions of African American men tend to perpetuate and reinforce the historical perspective of the Black male body as a hyper-masculine, hyper-sexualized, and de-personalized entity (Ferber, 2007). News media, fictional narratives, and popular music have promoted images of African American men as aggressive and dangerous, and with tendencies to be sexually promiscuous and irresponsible (Yousman, 2003). Behaviors that are seen as sensitive, nurturing, or monogamous might accordingly be considered anathema to generalized cultural images of Black masculinity. Discriminatory law enforcement practices and biased depictions of African American men in the media have also portrayed African American men as irresponsible fathers who are "interested in sex and spreading uncared-for babies all over the place" without providing any financial support (Whitehead, 1997).
 
Cultural stereotypes of the Black body have become apparent in public-health notions of risk. For example, epidemiological studies reporting high HIV prevalence among African Americans, and African American men in particular, suggest that race operates as a risk factor for HIV infection ([CDC, 2003] and [CDC, 2007]). Using race as a variable for predicting the likelihood of HIV infection or other forms of illness - without considering dimensions of race such as socioeconomic status, stigma and discrimination, and structural factors such as access to health and social services - is problematic because it overlooks historical and societal underpinnings that have given way to racial disparities in HIV and other health outcomes (Kaplan & Bennett, 2003). A similar argument can be made about studies that use "culture" to explain health outcomes without examining the historical bases of culture or viewing culture as a mutable, socially produced process (Gjerde, 2004). Although monitoring health disparities among racial groups and other social categories is needed to allocate resources and plan interventions, researchers must acknowledge underlying factors rooted in history and society that define and give meaning to social categories ([Krieger, 2004] and [Schiller, 1992]).
 
Emergence of the Down Low as a cultural notion and public-health category
 
"So I creep yeah,
 
Just keep it on the down low,
 
Said nobody is supposed to know.
 
So I creep yeah,
 
'Cause he doesn't know what I do
 
And no attention goes to showc"
 
Creep - TLC
 
Originating in the African American community in the early 1990s, the term "Down Low" or "the DL" signified the speaker's desire for discretion or secrecy ([Boykin, 2005] and [Ford et al., 2007]). The original understanding of the term made no specific allusions to sexual behaviors being kept secret and, notably, did not suggest any perceived immoral or inappropriate actions, sexual or otherwise. Its first associations with secretive sexual relations occurred primarily within the context of heterosexual relationships, as used in songs lyrics of music artists of the 1990s such as TLC and R. Kelly ([Boykin, 2005] and [Ford et al., 2007]).
 
Non-gay-identified African American MSM later appropriated the term as an endogenous means of describing secretive same-sex behavior and as a form of self-identification. Referring to themselves and their behavior as "on the DL" allowed men to avoid use of the terms gay, homosexual, or bisexual, which are stigmatized in the African American community and viewed as inconsistent with beliefs about Black masculinity. Racism in the mainstream White gay community has exacerbated feelings of exclusion for African American MSM, contributing to the sense of discordance between these men's racial and sexual identities (Teunis, 2007). Consequently, appropriating the term DL for self-identification has functioned to reinforce men's sense of masculinity and membership in the African American community. This self-categorization may also serve a core psychological function, as stronger racial/ethnic identity development is associated with greater levels of life satisfaction among African American MSM whereas sexual-identity development is not (Crawford, Allison, Zamboni, & Soto, 2002).
 
With the publication of media reports and several influential memoirs, the DL entered North American consciousness ([Denizet-Lewis, 2003], [Harris and Roberts, 2004], [King and Hunter, 2004] and [Wright, 2001]). Early publications discussed structured networks of heterosexually partnered African American men who have secretive sex with other men and implied these men practiced mostly unsafe sexual behaviors. Reports often warned "unsuspecting" African American women of the risks of sexual relations with African American men who might expose them to HIV, and opened an upsurge of dialogue about infidelity, promiscuity, and latent homosexuality in African American men. In light of the HIV epidemic in the African American community, this issue was framed as a public-health concern.
 
The exogenous, clinical use of DL terminology to refer to African American men who secretly engage in sex with men is troublesome for several reasons. First, this expression reveals how the concept of non-gay-identified MSM has become disproportionately associated with African American men despite research evidence about secretive same-sex behavior among White, Hispanic, and Asian men ([Caceres, 2002], [CDC, 2003] and [Ross et al., 2003]). Focus on this particular nexus of race and sexuality suggests that there is something unique and peculiar about African American men's same-sex behaviors that merits specific language and classification schemes.
 
A second problematic issue associated with the DL concept is the assumed inherent linkage between secretive same-sex behavior and HIV risk. Writings about DL men often equate these men's sexuality with unprotected sex with both male and females partners, limited awareness among men of their HIV status, and, if sero-positive, concealment of their status to partners ([Denizet-Lewis, 2003] and [King and Hunter, 2004]). While the disconnection between sexual identity and sexual practices among some African American men may contribute to high rates of HIV among African American women, this is not an exclusive determinant of HIV risk (Malebranche, 2008).
 
A third problematic issue to note is the underlying assumption that these men are inherently gay but have not yet embraced their gay identity and behaviors (Millett, 2004). French philosopher Michel Foucault (1978) argued that sexuality is not opposed to and subversive of power, but instead it is a "dense transfer point" of power. The assumptions regarding African American sexuality and comparisons made with understandings of White American sexuality serve as a form of control over the ways by which African American men engage in and understand their sexual behavior. These exogenous assumptions of African American men's sexuality further distance them from the "general" population, and characterize their subjective experiences and self-identifications as flawed and dishonest.
 
A fourth problematic issue derives from the imposition of an additional category label (i.e., the DL) on African American men without examining the historical and cultural derivation of the terminology. Much as race categories have oversimplified human group differences, the ahistorical, asocial, and de-contextualized use of the DL label places these men as exotic sexual objects, casting them as the sexual "other" with implicit comparisons made to "valid" heterosexual African American men and homosexual or gay-identified men. In overlooking the social dynamics that call for new expressions and self-identifications of sexuality among these men, exogenous use of this label connotes a pathological sense of denial for men who identify themselves or their behavior as DL.
 
Caution in using the Down Low concept for HIV prevention in African American communities
 
Risk groups are a basic component of most HIV prevention efforts, and are necessary for assessing distribution of illness and allocating appropriate resources. The first decade of the HIV epidemic saw prevention efforts in the United States target openly gay men and homosexual communities; sexual identity, sexual orientation and sexual practices were largely considered to be equivalent for the purpose of risk group identification in HIV prevention. The second decade brought a realization that use of sexual identity as a risk group, mainly homosexuality, was problematic and unnecessarily stigmatized gay males. As a result, prevention efforts shifted to target behavior-based groups (such as MSM) rather than identity-based groups. However, as Young and Meyer (2005) noted, whereas referring to MSM allowed epidemiologists and HIV prevention professionals to circumvent value-laden terms such as gay or bisexual, the acronym also erased meanings of identity, community, and society that might contribute to HIV risk and inform intervention strategies.
 
Caution is warranted in using the DL as a risk group in HIV prevention. As Schiller (1992) noted, the determination of public-health risk groups is informed by cultural processes and typically reflects hegemonic structures associated with race, class, gender, and sexuality. Deborah Stone's (1990) work written nearly twenty years ago still bears repeating:
 
"risk factors and designations of high-risk groups do not grow immediately and automatically out of epidemiological research. They are created in a social context that involves judgment, persuasion, bargaining and political maneuvering. This larger social context also shapes decisions about what is considered a risk factor, (and) how broadly categories are drawn." (1990, pp. 91-92).
 
Without considering the contextual underpinnings of identity and language, public-health appropriation of DL terminology may be affected by social biases that portray these men negatively.
 
Among the more significant and consistent contextual themes in the lives of many African Americans are poverty and racism, which have been shown to influence rates of HIV infection and hinder effective HIV intervention efforts for African Americans ([Mays et al., 2004] and [Smith et al., 2000]). In 1999, approximately 1 in 4 African Americans were living in poverty (United States Census Bureau, 2003), and studies have demonstrated a relationship between higher AIDS incidence and lower income (Diaz et al., 1994). However, few known HIV prevention interventions address factors that operate at the structural level (Waldo & Coates, 2000). An exclusively behavioral and epidemiological focus on men who fit the DL prototype conforms to a narrow, individual-level approach to HIV prevention. Notably, a meta-analytic study of determinants of HIV risk in African American MSM by Millett, Peterson, Wolitski, and Stall (2006) found no significant differences in unprotected anal intercourse between African American MSM and other racial/ethnic groups, and showed that African American MSM reported fewer lifetime male sexual partners and were less likely to engage in sex for money than other racial or ethnic groups. Findings from this study point to the need to examine HIV risk factors for African American men that extend the traditional individual-behavioral level of epidemiological analysis.
 
Recently, Operario et al. (2008) conducted in-depth individual interviews with non-gay-identified African American MSM to learn about their perceived risks for unsafe sex. Findings highlighted several determinants of HIV risk operating beyond the individual-behavioral level. For example, men described cultural norms and social pressures that reinforce heightened masculinity and male gender dominance, discourage overt emotionality and help-seeking, and punish same-sex attraction. Men who felt sexual attraction to other men often had sex secretively, spontaneously, and in anonymous settings. Some men used alcohol or other substances to divert emotional frustrations, and others engaged impulsively in sex to express repressed sexual desires. As discussed earlier, men's understandings of their personal HIV risks appeared rooted in anti-homosexual stigma in the African American community, historically produced gender-role expectations and norms of masculinity for African American men, and racial barriers for inclusion in the mainstream gay community. This study recommended that HIV prevention education programs for African American men should address matters beyond sexual behavior, such as family and relationship dynamics, gender roles, social and emotional support, and systemic forms of oppression that contribute to health risk behaviors ([Diaz et al., 2004] and [Williams et al., 2003]).
 
Conclusion
 
In this paper we have argued for a more critical use of language when providing public health and HIV prevention services for African American men who have sex with men, secretive or otherwise. We specifically urge for a reconsideration of the DL concept in public-health research and practice, although we acknowledge the importance of African American men's self-references to the DL. It is unlikely that the application of the DL terminology to HIV risk will disappear quickly or completely, and so we offer specific recommendations for future steps.
 
Cautious and critical use of risk group labels
 
There are notable risks in using de-contextualized group labels such as the DL to target HIV prevention services for African American men. As noted by Schiller ([Schiller, 1992] and [Schiller et al., 1994]), categorization of groups such as the DL might conflate specific high-risk behaviors with African American "culture," especially in the absence of reference to historical, economic and societal factors. Uncritical use of risk group labels may also assume that group characteristics are homogenous and static. Subjective meanings and connotations of labels and identities change over time, and understanding these changes will be critical to designing appropriate HIV interventions.
 
Exogenous labeling of African American male subgroups as DL is also problematic because this term might not be endorsed uniformly by men themselves ([Goldbaum et al., 1998], [Wohl et al., 2002] and [Wolitski et al., 2006]). Endogenous meanings associated with the DL may have changed over time, and use of the term by public-health professionals might not be acceptable to some men. Researchers must continually reassess their language and concepts around African American men's sexuality to prevent incorrect assumptions or outdated meanings. In fact, since African American men tend to prioritize their race above their sexual practices (Crawford et al., 2002), future prevention strategies that target African American men in general, regardless of their sexual practices, may be more likely to reach this population. Within male-focused programs for African American men, a diverse range of sexual behaviors must be acknowledged. Assessment of risk behaviors should not be limited by gender of partner, but should include any insertive or receptive sexual behavior (with females, males, transgenders).
 
Reducing stigma associated with same-sex behavior among African Americans
 
Stigma has played an important role in the history of HIV/AIDS in the African American community ([Cohen, 1997] and [Valdiserri, 2002]). Research and interventions which reduce stigma of same-sex behavior and gay or homosexual identity will be necessary for implementing HIV programs and reducing incidence rates throughout the African American community ([Fullilove and Fullilove, 1999] and [Valdiserri, 2002]). Efforts to reduce homophobia in the African American community must be supported by collaborating with community and church leaders to promote understanding and inclusion of gay men and lesbians. Particular attention should be paid to reducing homophobia among service providers working with African American men, including social, health, and HIV prevention services - who themselves might express homophobia and anti-gay bias. In addition to increasing the presence of African Americans administering prevention programs, partnerships with civic groups and lay African American men and women can also increase acceptability, participation, and retention of marginalized African American subgroups into HIV/AIDS prevention and intervention studies.
 
Attention to structural determinants of HIV and other health inequalities
 
As broadly defined by Galtung, 1969 J. Galtung, Violence, peace, and peace research, Journal of Peace Research 6 (1969), pp. 167-191.Galtung (1969), structural violence refers to "sinful" social structures characterized by poverty and deep social inequality. These social structures interfere with the ability of individuals to care for their health or participate in behaviors conducive to their well-being (Farmer, 1999). Racism and discrimination, poverty, unemployment, access to health care, and social immobility are factors that contribute to structural violence against African Americans (Williams, 1999). These factors also contribute to high HIV incidence among African Americans (Mays et al., 2004). HIV prevention and sexual health education strategies for African Americans can more explicitly recognize structural determinants of health, and socially transformative interventions might be essential to achieve sustained reductions in HIV incidence. Structural interventions can include increasing availability of affordable housing, improving rates of school retention and education completion, targeting discriminatory employment policies, and addressing the biases in the judicial system.
 
Increased studies of sexuality in African American communities
 
To better address the contextual nature of HIV risk for African American men who have sex with men and their partners, public-health researchers must forgo the traditional separation imposed between science and society. Qualitative methodologies are useful for studying intersections between structural factors, cultural meanings, individual lives, and health outcomes, and can yield contextualized understandings of African American men's sexual behaviors and decision making. Qualitative studies with African American men can also produce better insight into why prevention interventions do not seem to reach this community and how better to address their needs.
 
Rigorous quantitative research is necessary to measure prevalence and social determinants of risk behaviors for African American men who have secretive sex with men. Due to the hard-to-reach nature of this group, researchers must use innovative recruitment strategies to maximize representativeness of findings such as respondent-driven sampling (Heckathorn, 1997). High-quality evaluations of HIV prevention interventions are crucial for establishing an evidence-base of effective programs for reducing HIV in this group. Community-level or structural interventions might be warranted to address broad determinants of HIV risk for African American men, and potentially can reinforce the effects of traditional individual-level intervention approaches.
 
Closing remarks
 
In light of the apparent troubles with terms such as the DL, is its continued use justified? We have argued that this term has endogenous meaning within the community, and has been a source of self-understanding and identification for non-gay-identified African American men who have secretive sex with men. However, an ahistorical, de-contextualized behavioral risk group approach for targeting public-health services to African American men may be problematic. Substituting category labels in place of contextualized understandings detracts from acknowledgment of the structural violence and environmental factors which drive high-risk behaviors. An increased use of qualitative research will provide more nuanced understandings of African American sexuality and identity negotiation, which are critical to addressing the prevention needs of this population. Development of feasible, effective, and sustainable interventions to reduce HIV among African Americans demands closer attention to the realities of members of the community, and in particular the lived experiences of African American men who have secretive sex with men.
 
Acknowledgements
 
This research was supported by a research grant from California AIDS Research Program to Don Operario (Grant CHRP-AL04-SF-818).
 
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