Masculinity, body image, and sexual behavior in HIV-seropositive gay men: a two-phase formative behavioral investigation using the internet.The purpose of this study was to understand the synergistic synergistic /syn·er·gis·tic/ (sin?er-jis´tik)
1. acting together.
2. enhancing the effect of another force or agent.
1. relationships between conceptions of masculinity masculinity /mas·cu·lin·i·ty/ (mas?ku-lin´i-te) virility; the possession of masculine qualities.
1. The quality or condition of being masculine.
2. , body image, and sexual behavior sexual behavior A person's sexual practices–ie, whether he/she engages in heterosexual or homosexual activity. See Sex life, Sexual life. in HIV-positive gay men. The data were drawn from a two-phase formative behavioral mixed methodologies investigation with the use of the Internet. Findings demonstrated that conceptions of masculinity were intimately linked to body image and sexual adventurism ad·ven·tur·ism
Involvement in risky enterprises without regard to proper procedures and possible consequences, especially the reckless intervention by a nation in the affairs of another nation or region: , such that men defined their masculinity by their physical appearance and sexual behavior. Further, the data support high levels of risk taking, including steroid use and intentional unprotected anal intercourse Noun 1. anal intercourse - intercourse via the anus, committed by a man with a man or woman
anal sex, buggery, sodomy
sexual perversion, perversion - an aberrant sexual practice; (barebacking), which correlated with the participants' conception of physical masculinity. Clinical implications suggest that it is critical to examine the interaction that occurs between the individual's gay, masculine, and HIV-positive identities as these appear to be overlapping realities that have an impact on the decisions and behaviors in which these men engage.
Keywords: masculinity, body image, gay men, sexual behavior, HIV HIV (Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States. , barebacking, steroid use, Internet, sexual adventurism
The developmental trajectory Trajectory
The curve described by a body moving through space, as of a meteor through the atmosphere, a planet around the Sun, a projectile fired from a gun, or a rocket in flight. of gay culture to construct a conception of masculinity distinct from heterosexual males may have been thwarted thwart
tr.v. thwart·ed, thwart·ing, thwarts
1. To prevent the occurrence, realization, or attainment of: They thwarted her plans.
2. in the 1980s with the onset of the HIV epidemic (Halkitis, 1999; 2001). After the emergence of HIV, the emphasis on physicality among some gay men in large urban centers was directed to preserve and increase the health of men infected in·fect
tr.v. in·fect·ed, in·fect·ing, in·fects
1. To contaminate with a pathogenic microorganism or agent.
2. To communicate a pathogen or disease to.
3. To invade and produce infection in. with the virus who were experiencing weight loss, muscular wasting and deterioration de·te·ri·o·ra·tion
The process or condition of becoming worse. , decreases in libido libido (lĭbē`dō, –bī`–) [Lat.,=lust], psychoanalytic term used by Sigmund Freud to identify instinctive energy with the sex instinct. , and eventual death (Shilts, 1987). As many gay men began to physically deteriorate de·te·ri·o·rate
1. To grow worse in function or condition.
2. To weaken or disintegrate. due to the disease, heterosexual perceptions of gay men as non-masculine and fragile were realized.
In order to combat the physical weakness brought on by the virus, many HIV-positive gay men undertook complementary therapy measures such as steroid replacement as well as weight training and nutritional supplements Nutritional Supplements Definition
Nutritional supplements include vitamins, minerals, herbs, meal supplements, sports nutrition products, natural food supplements, and other related products used to boost the nutritional content of the diet. to increase strength and maintain health. Today, while these therapies are still important elements in the lives of HIV-positive gay men, they have moved beyond the goals of health and survival and have become associated with a physically based conception of masculinity espoused by many gay men, regardless of HIV serostatus (Signorile, 1997).
Central to this conception of physical masculinity is body image and muscularity (Halkitis, 1999; 2001). To this end, some HIV-positive gay men describe lives driven by a desire to achieve an ideal physical appearance of muscularity, characterized by what has been labeled as the "buff agenda" (Halkitis, 1999). While therapeutic approaches to body enhancement serve to decrease HIV-related morbidity and mortality Morbidity and Mortality can refer to:
A second tenet TENET. Which he holds. There are two ways of stating the tenure in an action of waste. The averment is either in the tenet and the tenuit; it has a reference to the time of the waste done, and not to the time of bringing the action.
2. of this conception of physical masculinity among HIV-positive gay men is that of sexual prowess. Sexual behaviors and associated risk-taking have been linked to masculine identity (Chapple, Kippax, & Smith, 1998; Halkitis, 1999; 2001 Kippax & Smith, 2001). HIV-positive men describe sexual partnering as a means of enhancing conceptions of attractiveness; thus some seek out sex as an affirmation of self and as a means of eradicating feelings of undesirability (Halkitis & Wilton, in press). Recent increases in sexually transmitted infections (Centers for Disease Control & Prevention, CDC See Control Data, century date change and Back Orifice.
CDC - Control Data Corporation , 2003a) and HIV (CDC, 2003b) indicate that certainly some HIV-positive men-who-have-sex-with-men are engaging in unprotected sexual behaviors. These unprotected behaviors, and the recent emergence of the phenomenon of barebacking, or intentional unprotected anal sexual acts (Halkitis & Parsons Parsons, city (1990 pop. 11,924), Labette co., SE Kans.; inc. 1871. It is a shipping point for dairy products, grain, and livestock. Manufactures include ammunition, wire and paper products, plastics, and appliances. , 2003; Halkitis, Parsons, & Wilton, 2003; Mansergh et al. 2002; Suarez & Miller, 2001) are described by some HIV-positive men as "sexy" and "masculine" and provide a direct route to physical and emotional connection with others (Halkitis, 1999). A physically attractive body often provides the route by which many of these men attract partners. Thus, these sexual acts provide further reinforcement to achieve body perfection, perpetuating the "buff agenda."
Body image and sexual prowess are central to the conceptions of masculinity espoused by some HIV-positive gay men. Yet these interconnections between masculinity, body image, and sexual prowess are complex and not always apparent among individuals who are attempting to balance their identities as male, gay, and HIV-positive. Thus, we undertook an investigation using mixed methodologies to further elaborate these constructs as well as to disentangle the relationships that exist between body image, sexual prowess, and conceptions of masculinity as physicality among gay men living with HIV/AIDS HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome .
The ideas presented here are based on two sources of data that represent an integration of an investigation incorporating both qualitative/ethnographic and quantitative methodologies with the use of the Internet as a source of data collection. The qualitative study (Phase I) was undertaken to explore and more fully understand the meanings that HIV-positive gay men assigned to their conceptions of physical masculinity. Based on the data from the qualitative study, measures were developed as part of a quantitative investigation (Phase II) to assess these emerging relationships among a larger sample of participants. It should be noted that the qualitative data presented here expand upon our previously published ethnographic eth·nog·ra·phy
The branch of anthropology that deals with the scientific description of specific human cultures.
eth·nog work (Halkitis, 1999; 2001).
PARTICIPANTS AND PROCEDURE
The sample for Phase I consisted of 15 men ranging in age from 29 to 56 with a mean age of 36 years (SD = 8.16) and eight years (SD = 3.08) since they had been diagnosed with HIV. Approximately 77% of the participants were currently taking medications to treat HIV. Racial and ethnic data were not collected from this sample.
A total of 114 men participated in Phase II. The mean age for the sample was 42 (SD = 6.82) and yielded a similar age range (27 to 57) to Phase I participants. Participants had first been diagnosed with HIV 11 (SD = 5.27) years prior to the study, slightly earlier than those who participated in the qualitative interviews. Comparable to Phase I, 86.0% (n = 98) of the participants in Phase II indicated that they were currently on some form of HIV antiretroviral antiretroviral /an·ti·ret·ro·vi·ral/ (-ret´ro-vi?ral) effective against retroviruses, or an agent with this quality.
adj. therapy. The sample for Phase H was predominantly White, 77.2% (n = 88); 9.6% (n = 11) Black; and 6.1% (n = 7) Latino; 7.0% (n = 8) provided no racial/ethnic identification.
PHASE I: QUALITATIVE/ETHNOGRAPHIC INVESTIGATION
In Phase I, we sought to consider the behaviors and meanings associated with physical notions of masculinity among HIV-positive gay men residing in New York City New York City: see New York, city.
New York City
City (pop., 2000: 8,008,278), southeastern New York, at the mouth of the Hudson River. The largest city in the U.S. . Men were identified through use of the Internet using passive recruitment (postings on listserv accounts) as well as active methodologies (engaging in conversations in Information Relay Chats [IRCs] and chat rooms). Participants were screened on the following criteria: a self-reported HIV-positive serostatus test result, self-identification as a gay man, and a self-report of regular (three or more clays per week) exercise at a physical fitness center. Those exercising regularly were intentionally selected in order to examine the interconnections of masculinity, physical appearance, and sexual behaviors. Men who met the eligibility criteria and were willing to participate were scheduled for an interview.
All communications between the researcher and the participants were conducted through an electronic medium (e-mail). To assure confidentiality, no identifying information was obtained, and all participants were identified through the use of pseudonyms This article gives a list of pseudonyms, in various categories. Pseudonyms are similar to, but distinct from, secret identities. Artists, sculptors, architects
Interviews consisted of 10 questions focused on definitions of masculinity, the impact of HIV on masculinity, and the interplay in·ter·play
Reciprocal action and reaction; interaction.
intr.v. in·ter·played, in·ter·play·ing, in·ter·plays
To act or react on each other; interact. of physicality and masculinity among HIV-positive gay men. Questions, which sought to ascertain how the participants defined masculinity for themselves, focused on personal definitions of masculinity rather than cultural norms and expectations. The 10 questions were as follows: (1) How do you define masculinity? (2) Give an example of an act that you label as masculine or an example of a masculine person. Explain. (3) To what extent is masculinity related to physical appearance? (4) How does masculinity relate to sex or sexual behavior? (5) How much do others' perceptions of your masculinity matter to you? Explain. (6) Have you made changes in your lifestyle since you became HIV-positive to enhance your masculinity? Describe these. (7) How has being HIV-positive affected the way you perceive your masculinity? (8) How do you think that HIV affects or threatens one's masculinity? (9) Do you think HIV-positive men overcompensate o·ver·com·pen·sate
v. o·ver·com·pen·sat·ed, o·ver·com·pen·sat·ing, o·ver·com·pen·sates
To engage in overcompensation.
To pay (someone) too much; compensate excessively. on the physical aspects of their masculinity? Explain. (10) To what extent do matters of masculinity impact on your daily life, and how much time per day would you say you spend on these matters?
After the data were collected, a thematic codebook codebook - data dictionary was developed based on the structure proposed by Miles and Huberman (1984) such that independent readers noted themes and sub-themes that emerged in the words of the participants. Each set of responses was coded independently by the two researchers and yielded an inter-rater agreement of 89.6%.
PHASE II: QUANTITATIVE INVESTIGATION
The development of the quantitative survey was based on the knowledge generated from Phase I. We sought to quantify definitions and perceptions of masculinity as well as the behaviors that were clearly delineated de·lin·e·ate
tr.v. de·lin·e·at·ed, de·lin·e·at·ing, de·lin·e·ates
1. To draw or trace the outline of; sketch out.
2. To represent pictorially; depict.
3. in the qualitative interviews: body building, physical appearance, and sexual adventurism including sexual risk-taking in the form of intentional unprotected anal intercourse (barebacking). In this phase, 114 participants throughout the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. were administered surveys via the Internet. Electronic postings tailored to HIV-positive gay men seeking sexual partners were placed on listserv accounts describing the study and asking interested participants to contact the researcher via e-mail. Men were also directly recruited through IRCs and chat rooms.
Participants were required to meet the following eligibility criteria: 18 years of age or older, self-reported as HIV-positive, self-identified as a gay man, and ability to read/comprehend English. Participants who completed the survey were encouraged to return their responses via e-mail yet were given the option of sending the responses through traditional mail or fax. All e-mail correspondences were deleted from the investigator's account upon downloading responses. To prevent duplication of participants, the entered data were checked for matches on age, postal code Noun 1. postal code - a code of letters and digits added to a postal address to aid in the sorting of mail
postcode, ZIP code, ZIP
code - a coding system used for transmitting messages requiring brevity or secrecy , and years since testing HIV-positive. This analysis yielded one set of duplicate data, which were eliminated from the final data set.
Participants were assessed on several measures developed for the purposes of this investigation.
Sociodemographics. Participants were asked to self-report their age, race/ethnicity, HIV serostatus, length of time since HIV diagnosis, and whether they were taking HIV meds.
Sexual behavior (barebacking). Participants first were asked to indicate whether or not they had engaged in bareback bare·back also bare·backed
adv. & adj.
On a horse or other animal with no saddle: rode bareback; a bareback rider. sex with HIV-positive, HIV-negative, and status-unknown partners in the three months prior to assessment. In cases when an affirmative answer was given, the participant was then asked to indicate the number of times in which the bareback sex was anal insertive ("How many times did you top") and anal receptive ("How many times did you bottom?") for each type of partner.
Sexual Adventurism Scale. This construct was assessed through an initial set of 12 items and factor analytic Adj. 1. factor analytic - of or relating to or the product of factor analysis
factor analytical methods yielded a final set of 10 items loading on one factor with an explained variance Explained variance is part of the variance of any residual that can be attributed to a specific condition (cause). The other part of variance is unexplained variance. The higher the explained variance relative to the total variance, the stronger the statistical measure used. of 59.91% and loadings ranging from .61 to .88. (alpha = .92). Item responses were based on a five-point, Likert-type scale (1 = not at all like me to 5 = completely like me). Sample items included "'I try to have bareback sex," "I go to bathhouses and sex clubs to look for sex," and "I love taking the cum [semen semen
or seminal fluid
Whitish viscous fluid emitted from the male reproductive tract that contains sperm and liquids (seminal plasma) that help keep them viable. ] of other men."
Conceptions of Masculinity Scale. An original set of 34 items were used to assess the men's conceptions of masculinity based on a five-point, Likert-type Scale (1 = completely disagree to 5 = completely agree), and factor-analytic methods yielded three subscales: conceptions of masculinity as physical appearance (n = 9, alpha = .81, explained variance of 41.05% with factor loadings ranging from .30 to .90); conceptions of masculinity as sexual behavior (n = 4, alpha = .83, explained variance of 66.41% with factor loadings from .72 to .87); conceptions of masculinity as social behavior In biology, psychology and sociology social behavior is behavior directed towards, or taking place between, members of the same species. Behavior such as predation which involves members of different species is not social. (n = 5, alpha = .67, explained variance of 43.58% with factor loadings of .51 to .75). Based on factor analyses Verb 1. factor analyse - to perform a factor analysis of correlational data
analyse, analyze - break down into components or essential features; "analyze today's financial market" , the remaining items were omitted from the scale. Sample items for the three subscales were as follows: (1) Conceptions of Masculinity as Physical Appearance. Items included the following: "Physical appearance is an important dement de·ment
tr.v. de·ment·ed, de·ment·ing, de·ments
1. To make (a person) insane.
2. To cause (a person) to lose intellectual capacity. of masculinity in the gay community," "Masculinity is more about how one looks than how one acts," "Physical appearance does define masculinity," and "Well-built men give the impression of masculinity at first sight"; (2) Conceptions of Masculinity as Sexual Behavior. The four items for this subscale are as follows: "Sexual performance is an important part of masculinity," "Sex is a celebration of masculinity," "A masculine man has lots of sex"; and "Masculinity celebrates male form and virility Virility
See also Beauty, Masculine; Brawniness.
archetypal he-man. [Comics: “Sergeant Fury and His Howling Commandos” in Horn, 607–608]
Henry, John "; (3) Conceptions of Masculinity as Social Behavior. The five items for this subscale are as follows: "I am not comfortable around unmasculine gay men," "I would not have sex with a masculine looking man who acted in any way feminine," "A masculine man is both butch in behavior and appearance," "I watch my behavior to make sure that I act masculine around other gay men," and "Drag queens This is a list of drag queens and female impersonators. Only those subjects who are notable enough for Wikipedia articles should be included here.
Furthermore, three items that were dropped from the original scale were maintained as stand-alone items in our analyses because they provided interesting information about the participants' view of societal norms regarding masculinity. These three stand-alone items are as follows: "Our society reserves the idea of masculinity for straight men," "A man can be gay and be masculine," and "For most people in the U.S., masculinity makes no room for same-sex desires."
Emphasis on Body Scale. A set of five items based on a five-point, Likert-type scale (1 = not at all like me to 5 = completely like me) were used to assess emphasis that the participant placed on his physical appearance, specifically with regard to muscularity and bodybuilding bodybuilding
Developing of the physique through exercise and diet, often for competitive exhibition. Bodybuilding aims at displaying pronounced muscle tone and exaggerated muscle mass and definition for overall aesthetic effect. (alpha = .82). Factor-analytic methods yielded one factor for this scale with an explained variance of 57.90% and loadings ranging from .64 to .83. Items included "I work out regularly each week," "I use testosterone testosterone (tĕstŏs`tərōn), principal androgen, or male sex hormone. One of the group of compounds known as anabolic steroids, testosterone is secreted by the testes (see testis) but is also synthesized in small quantities in the or deca durabolin to help pump up," "I use other steroids steroids, class of lipids having a particular molecular ring structure called the cyclopentanoperhydro-phenanthrene ring system. Steroids differ from one another in the structure of various side chains and additional rings. to help build up my body," "I use creatine creatine /cre·a·tine/ (kre´ah-tin) an amino acid occurring in vertebrate tissues, particularly in muscle; phosphorylated creatine is an important storage form of high-energy phosphate. , vitamins, or other nutritional supplements for bodybuilding," and "I work hard to look muscular."
CONCEPTIONS OF MASCULINITY
Based on the qualitative interviews, many participants believed that heterosexuals oftentimes of·ten·times also oft·times
Adv. 1. oftentimes - many times at short intervals; "we often met over a cup of coffee"
frequently, oft, often, ofttimes did not view them as masculine or "manly." This notion was elaborated in the words of a Phase I qualitative interview participant:
I know that I am masculine, mostly because of the way I look. Women look at me on the street all the time. But when I tell people I'm gay, that seems to erase what they think of me as a man. They just think of me as gay and not a real man.
Similarly, as demonstrated in the Phase II quantitative data, 83.3% (n = 87) of the
participants agreed that society reserved the idea of masculinity for heterosexual men only; 76.3% (n = 73) agreed that most people think of gay men as non-masculine; and 78.4% (n = 78) believed that for most people in the United States, masculinity could not be associated with same-sex desires. Regardless of what the participants believed about society's heterosexist views, the majority of the men in both phases of the study maintained that gay men have both a gay and a masculine self. In fact, 99.1% (n = 113) of the participants in Phase II agreed that an individual could be concurrently gay and masculine.
The majority of the participants in the qualitative interviews clearly indicated their definition of masculinity as physicality, both in appearance and behavior: "Society makes masculinity and physical appearance go hand in hand," according to according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. one of the qualitative interview participants. An association between conceptions of masculinity and physicality emerged when participants described the idealized i·de·al·ize
v. i·de·al·ized, i·de·al·iz·ing, i·de·al·iz·es
1. To regard as ideal.
2. To make or envision as ideal.
1. masculine male, their sexual partners, their exercise routines, and their sexual behaviors. These are reflected in the words of a 40-year-old HIV-positive gay man, who suggested: "I do a significant amount to make myself more masculine looking. My workout Workout
Informal repayment or loan forgiveness arrangement between a borrower and creditors.
1. The process of a debtor's meeting a loan commitment by satisfying altered repayment terms. , diet, and grooming Combining, consolidating and segregating network traffic using devices such as digital cross-connects, add/drop multiplexers and SONET switches. Grooming is a telephone term that typically refers to managing high-capacity lines between central offices, carriers, ISPs and very large are all pointed toward maintaining attractiveness and sexual opportunity."
BODY IMAGE IN RELATION TO MASCULINITY
In the qualitative interviews, almost all of the participants described the emphasis they placed on their physical appearances. The statements reflected the importance the men placed on "looking good" and "feeling strong" and how these elements interacted with their sense of masculinity. As stated by one interview participant, "Physical appearance does define masculinity on the outer shell."
For some of the interview participants, the emphasis on physical appearance was related to the impressions they emitted when they were seen in social situations (e.g., bars, dance clubs, pride events). A few of the participants expressed an ongoing concern that potential sexual partners perceived them as masculine, because such a perception would increase their probabilities of meeting these men. This concern, on the part of the interview participants, was related to what they believed was revered by the gay community and what was sanctioned as appropriate masculine appearance. One of the participants in the qualitative interview, a 46-year-old gay man who has been HIV-positive for 11 years, summarized this reality:
Initial perceptions of masculinity are strongly tied to physical appearance. Well-built men usually give an initial feeling of masculinity at first sight. Since I like this perception, since it matters a lot to me to be masculine, I work out and watch my diet.
Some of the men articulated the social pressures within the gay community to conform to Verb 1. conform to - satisfy a condition or restriction; "Does this paper meet the requirements for the degree?"
coordinate - be co-ordinated; "These activities coordinate well" this ideal standard of masculinity associated with the leather man, construction worker, and sports jock 1. jock - A programmer who is characterised by large and somewhat brute-force programs.
2. jock - When modified by another noun, describes a specialist in some particular computing area. , which are iconic i·con·ic
1. Of, relating to, or having the character of an icon.
2. Having a conventional formulaic style. Used of certain memorial statues and busts. in this masculine view of the world (Halkitis, 2001; Signorile, 1997). An example of this ideal was provided by a 38-year-old interview participant actively involved in the "leather scene" and a former contestant in the International Male Leather Contest, who unconditionally supported this concept of masculinity suggesting that it is the core of what he is and what he desires: "I am a man and want to be with men. Men are strong, muscular, and tough. They roll around with each other." Similarly, in describing this prescribed concept of masculinity, a 37-year-old man who has been HIV-positive since 1986 suggested the following:
Of course, you are told what to look like. When I first came out, I had long hair and didn't really work out. One trip to the Eagle [a bar in New York City], and I knew that had to change. I cut my hair real short and haven't missed the gym for more than three days in a row in years.
The importance of physical exercise and bodybuilding was revealed by the fact that 59.7% (n = 68) of the HIV-positive gay men assessed in the quantitative survey indicated they had a regular workout plan.
In the qualitative interviews, several participants clearly discussed the steps they take to ensure the manifestation of their physical masculinity, including a regimented exercise schedule, the use of nutritional supplements, and/or the utilization of anabolic anabolic
pertaining to or arising from anabolism.
steroids with a tissue-building effect. Testosterone is an example of a natural anabolic steroid with the, sometimes undesirable, effect of causing masculinization. and androgenic steroids androgenic steroids
the androgens produced in small amounts in the adrenal cortex. , such as testosterone and deca durabolin, to enhance muscularity and growth. In one interview, a participant commented:
I use a collection of weight-training enhancements such as creatine, androstene, and HMB for the personal choice to build muscle, not necessarily for my HIV. As a secondary consideration, by keeping my body as healthy as possible, I can help stave off infections and maintain my t-cells and low viral load naturally.
In the quantitative survey, 33.3% (n = 38) reported the use of testosterone, and 17.5% (n = 20) reported the use of deca durabolin while 15.8 % (n = 18) used both substances in combination. Furthermore, 25.4% (n = 29) revealed they used testosterone or deca durabolin specifically to "pump up," while 36% (n = 41) reported the use of other substances, such as creatine and vitamins for bodybuilding.
The relationship between the use of steroids and the emphasis on muscularity among HIV-positive men is further demonstrated by the data of the quantitative survey as shown in Table 1. Specifically, with regard to the Emphasis on Body Scale, those reporting the use of testosterone and/or deca durabolin indicated that they assigned greater importance to looking muscular and strong (M = 17.73, SD = 5.38) than those who did not report use of either steroid (M = 10.58, SD = 4.42) (t (110) = 7.58, p < .001). Similarly, there was a trend toward significance between the use of steroids and the relative importance placed on the "Conceptions of Masculinity as Physical Appearance" subscale (t (104) = 1.85, p = .07), with those using steroids tending to place greater emphasis on masculinity as defined by physical appearance. This is further confirmed by the relationship between emphasis on body and conceptions of masculinity. As shown in Table 2, those who placed greater emphasis on the appearance of their bodies also scored higher on the "Conceptions of Masculinity as Physical Appearance" subscale (r = .371, p < .001). In addition, this body image construct was related to conceptions of masculinity as a social behavior and masculinity as appearance but was unrelated to age or any HIV-related characteristics (e.g., years living with HIV, AIDS diagnosis, treatment characteristics, or opportunistic infections Opportunistic infections
Infections that cause a disease only when the host's immune system is impaired. The classic opportunistic infection never leads to disease in the normal host. ). These data suggest that the emphasis HIV-positive gay men place on their overall physical appearance and muscularity supersedes developmental and HIV progressive factors.
SEXUAL BEHAVIOR IN RELATION TO MASCULINITY
For many of the interview participants, sexuality was intimately tied to the construct of masculinity as physicality. When describing their sexual behaviors, these men spoke of sex in terms of the frequency of the sexual behaviors as well as the adventurism associated with sexual encounters, including HIV related sexual risk-taking. In the words of one of the interview participants, "I try to have sex as much as possible with as many men as possible and as anonymously as possible."
For a few of the participants, the need for frequent and adventurous sex was heightened by their HIV-positive serostatus. The impact of an HIV-positive status on sexual behavior was clearly discussed by some of the men as an affirmation of their attractiveness and, in effect, their masculinity. In this regard, a 28-year-old interviewee stated:
Sex is so important to me, maybe more important than before, when I was negative. By being with men, I feel desired, I feel wanted. When a man wants me, it means that all my efforts to look hot, to have a great body have paid off. Yeah, that makes me feel surer of my masculinity.
Sexual adventurism as an affirmation of masculinity was a central theme in many of the interviews we conducted. One of the participants described the role of the masculine man as the "hunter-gatherer who seeks his conquest in other men; the more he succeeds, the more he is able to prove his manhood MANHOOD. The ceremony of doing homage by the vassal to his lord was denominated homagium or manhood, by the feudists. The formula used was devenio vester homo, I become you Com. 54. See Homage. , his desirability, his masculinity." Similarly, reflecting upon the importance and meaning of sex as an affirmation of his masculinity in tight of his HIV-positive status, a 36-year-old interview participant who had been HIV-positive for five years commented as follows:
HIV-positive men take advantage of sexual opportunities more that HIV-negative men, perhaps because they feel, due to their status, they may get less opportunities in total. For example, in a bar you might strike up a conversation, which seems to be headed to the bedroom. But it quickly dissipates when your positive status is revealed. When your partner is willing, you move fast.
The importance of sexual adventurism as a part of the masculine self was supported by the quantitative data. Men who were more sexually adventurous, as measured by the Sexual Adventurism Scale, also scored higher in terms of the importance that they placed on sex as a means of defining their own masculinity ("Conceptions of Masculinity as Sexual Behavior" subscale of the Conceptions of Masculinity Scale) (r = .359, p < .001). As shown in Table 2, this construct was also related to masculinity as social behavior as well as masculinity as appearance.
A few of the interview participants suggested that the HIV epidemic has forced gay men, collectively, to re-examine re·ex·am·ine also re-ex·am·ine
tr.v. re·ex·am·ined, re·ex·am·in·ing, re·ex·am·ines
1. To examine again or anew; review.
2. Law To question (a witness) again after cross-examination. their sexuality. One of the participants suggested, "Sex affirms strong physical needs as well as social needs." With regard to safer sexual practices, about half the men in the qualitative study revealed their dislike of condoms and spoke of intentional anal sexual intercourse sexual intercourse
or coitus or copulation
Act in which the male reproductive organ enters the female reproductive tract (see reproductive system). without condoms (i.e., barebacking) with other HIV-positive men (and in some cases HIV-negative or status-unknown men) as a means of overcoming this emotional barrier associated with protected sexual behaviors. Several men suggested that sex was an affirmation of life, and by barebacking they could "share their manhood with others." To this point, one of the participants noted: "An HIV-positive man is able to perform in the way a man is prescribed to perform, to overcome the impact of the virus and prove to oneself that one is still strong, sexual, virile virile /vir·ile/ (vir´il)
2. specifically, having male copulative power.
1. , and masculine." And one other stated:
I was dating this other really hot poz guy for about two months, and I thought for sure when we had sex we would bareback. But he kept insisting that when I fuck him I use a condom, and so I did. But I didn't really like it. I did it but never got really hard. And then one day we agreed to do it raw, and I came inside him, and we ended up in bed for like three days. Now, even when I think about doing it raw, it excites me. It's the most amazing feeling. It's what two men are supposed to do. It's what real men do. It feels right.
This link between masculinity and sex was corroborated cor·rob·o·rate
tr.v. cor·rob·o·rat·ed, cor·rob·o·rat·ing, cor·rob·o·rates
To strengthen or support with other evidence; make more certain. See Synonyms at confirm. by the survey data that indicated those who scored higher on the "Conceptions of Masculinity as Sexual Behavior" subscale of the Conceptions of Masculinity Scale also reported more frequent bareback anal insertive intercourse with HIV-positive partners (r = .246, p = .01), bareback anal receptive sex with HIV-positive partners (r = .257, p < .01), and bareback anal receptive sex with HIV-negative/status-unknown partners (r = .273, p < .01).
Furthermore, this link between sex and masculinity corresponds with the use of steroids and Viagra, suggesting the synergistic relationship between physical appearances/functioning, sexual performance, and conceptions of masculinity. Specifically, those who reported the use of Viagra in the three months prior to assessment reported more frequent bareback anal insertive sex (t (103) = 1.99, p = .05) and bareback anal receptive sex with other HIV-positive partners (t (42) = 3.70, p = .001) as well as more frequent bareback anal receptive sex with HIV-negative/status-unknown partners (t (42) = 3.92, p < .001) than those who did not report Viagra use. Similar patterns emerged when we compared bareback sexual behaviors to steroid use. These data are fully shown in Table 3.
The data collected from HIV-positive gay men in this two-phase investigation certainly suggest a conception of masculinity based on physical and sexual ideals that is embraced by certain segments of the gay community. Levine (1998) described men who adhere to adhere to
verb 1. follow, keep, maintain, respect, observe, be true, fulfil, obey, heed, keep to, abide by, be loyal, mind, be constant, be faithful
2. this ideal as the "manliest of men," embracing a type of "hyper-masculinity." And while certainly it may be argued that masculinity is not a monolithic Single object. Self contained. One unit. concept and that multiple types of masculinities may function within gay culture (Nardi, 2000; Plummer, 1999), the masculinity described by the participants in this study represents a type of masculinity that is revered and respected by many gay men. In a pluralistic plu·ral·is·tic
1. Of or relating to social or philosophical pluralism.
2. Having multiple aspects or parts: "the idea that intelligence is a pluralistic quality that ... society, where diversity is seemingly celebrated and individual expression is encouraged, the idea that multiple types of masculinities exist certainly is politically correct politically correct Politically sensitive adjective Referring to language reflecting awareness and sensitivity to another person's physical, mental, cultural, or other disadvantages or deviations from a norm; a person is not mentally retarded, but . Unfortunately, the workings of our society seem to transgress these types of notions. In the day-to-day workings of gay life, it is the buff men--the muscular, masculine men--who are the objects of much attention and desire.
The development of masculine identities separate from heterosexual ideals has been an ongoing struggle for gay men. Homophobic ho·mo·pho·bi·a
1. Fear of or contempt for lesbians and gay men.
2. Behavior based on such a feeling.
[homo(sexual) + -phobia. attitudes as well as stereotyping of gay men have served as obstacles to such efforts. The HIV epidemic may have added to this struggle by perpetuating homophobic attitudes of gay men as physically weak and thus thwarted efforts to clearly define a separate gay masculinity (Halkitis, 1999). Gay men themselves who, according to our data, have embraced the idea that the ideal masculine identity is based on physical appearance and sexual performance may perpetuate per·pet·u·ate
tr.v. per·pet·u·at·ed, per·pet·u·at·ing, per·pet·u·ates
1. To cause to continue indefinitely; make perpetual.
2. this reality. Perhaps in part because these efforts at developing a gay masculinity have been so difficult, many gay men have adopted the heterosexual standard of the tough, physically strong male (Kleinberg, 1992).
For HIV-positive gay men who attempt to maintain their own health while at the same time remain desirable, the emphasis on the physical definitions of masculinity seems perfectly justifiable jus·ti·fi·a·ble
Having sufficient grounds for justification; possible to justify: justifiable resentment.
jus (Halkitis, 1999). For these men, physical appearance and sexual expression are the cornerstones of their masculinity. Having a strong muscular body is essential to HIV-positive gay men embracing this ideal and has become increasingly associated with other physical attributes that enhance a masculine appearance. Therefore, these men often associate with others who celebrate this definition of masculinity in a variety of environments where sexual adventurism and multiple sexual partners are encouraged (Halkitis, 1999; Halkitis, Parsons, & Wilton, 2003; Halkitis & Wilton, in press).
In order to be attractive and to be attracted to others, this ideal conception of masculinity described in the words and behaviors of our study participants requires conformation con·for·ma·tion
One of the spatial arrangements of atoms in a molecule that can come about through free rotation of the atoms about a single chemical bond. to an abstract model (Gough, 1989). Clark (1997) contends that some gay men emphasize the values associated with "hypermasculinity," perhaps at the expense of learning the "important lessons of life," such as how to form a loving and caring same-gender relationship. It is unlikely, however, that HIV-positive gay men who hold this ideological stance have forgotten these important lessons, and in fact recent data indicate that many of these men seek intimate connections with others (Halkitis & Wilton, in press). More likely, in their struggle to remain alive and their desire to be loved and accepted given their HIV-positive status, they have learned that their "hypermasculinity" provides a mechanism to meet a partner and share love.
Two methodological limitations of this study are the small sample sizes, especially in Phase I, and the use of convenience sampling in participant recruitment. With regard to our small ethnographic sample, it should be noted that while the sample of 15 men was sufficient to obtain an initial understanding of the constructs, the sample is limited in terms of making greater generalizations to the population of HIV-positive gay men. However, these data are supplemented and supported by the quantitative findings in this study.
Further, the use of the Internet in both phases of this investigation is noted as another potential limitation in terms of the generalizability of the study findings. Recent research has suggested that men who frequent the Internet may demonstrate greater levels of sexual compulsivity com·pul·sive
1. Having the capacity to compel: a frightening, compulsive novel.
2. Psychology Caused or conditioned by compulsion or obsession.
n. (Cooper, Delmonico, & Burg, 2000; Cooper, Putnam, Planchon, & Boise, 1999; Halkitis & Parsons, 2003). Therefore, these findings should be viewed with caution in that hypersexual hy·per·sex·u·al
Excessively interested or involved in sexual activity.
hyper·sex men may be more likely to be represented in our study, and thus their conceptions of masculinity may be appropriate for the specific segment of the gay community in which they socialize so·cial·ize
v. so·cial·ized, so·cial·iz·ing, so·cial·iz·es
1. To place under government or group ownership or control.
2. To make fit for companionship with others; make sociable. and meet sexual partners.
These methodological limitations may have yielded a group of White men from higher socioeconomic and educational backgrounds. Further, men of color not of the white race; - commonly meaning, esp. in the United States, of negro blood, pure or mixed.
See also: Color , who were underrepresented un·der·rep·re·sent·ed
Insufficiently or inadequately represented: the underrepresented minority groups, ignored by the government. in the study, may have culturally specific conceptions of masculinity based on their racial identities and cultural worldviews that differ from the conception of masculinity set forth here. Given the fact that current trends demonstrate that Black and Latino MSM MSM - Micronetics Standard MUMPS have increasing disproportionate rates of HIV (Koblin et al., 2000), the behaviors of these men need to be examined separately and in relation to what may be a culturally specific conception of masculinity. Similar analogies can be drawn along the lines of age. While the men in our studies were primarily in their 30s and 40s, new seroconversions have been most evident among younger MSM (CDC 2003b). Furthermore, generational gaps as well as sociological and cultural shifts toward homosexuality may confound con·found
tr.v. con·found·ed, con·found·ing, con·founds
1. To cause to become confused or perplexed. See Synonyms at puzzle.
2. conceptions of masculinity among younger MSM, and future studies need to consider these phenomena.
Although the participants in both phases of the investigation were assured confidentiality, the issue of socially desirable responses could confound the results. Participants were asked to provide information about potentially sensitive areas of their life, and as a result may have experienced discomfort in responding to some of the questions on the survey or qualitative interview that may have resulted in participants providing false responses.
Both phases of the study are limited by the fact that alternative definitions of masculinity were not fully examined. Rather, our work focused on understanding the specific masculine-physical ideal. Furthermore, our data do not truly capture the attitudes of heterosexuals regarding masculinity among HIV-positive men specifically and gay men in general. While our participants described their views of heterosexual attitudes toward gay men and masculinity, it should be noted that these are simply perceptions. Future work should seek to gather data from non-gay men regarding homosexuality and masculinity.
CLINICAL AND RESEARCH IMPLICATIONS
The data presented in this study suggest a conception of masculinity that is evident among some HIV-positive gay men. This physical construction of masculinity appears to be intimately linked to the social and sexual behaviors in which HIV-positive gay men engage. Further, these behaviors appear to be viewed as desirable by certain segments of the HIV-positive gay male community. Because such behaviors, which seem to have permeated the gay community at large, often involve sexual adventurism, sexual risk-taking, and an overemphasis o·ver·em·pha·size
tr. & intr.v. o·ver·em·pha·sized, o·ver·em·pha·siz·ing, o·ver·em·pha·siz·es
To place too much emphasis on or employ too much emphasis. on the body, they may create a social, emotional, and physical burden on HIV-positive gay men. For clinicians working with HIV-positive gay men, it is crucial to examine the synergistic interaction that occurs between the individual's gay, masculine, and HIV-positive identities since these appear to be overlapping realities that have an impact on the decisions these men make and the behaviors in which these men engage. Further, it is imperative to understand that, for some of these men, the decisions to engage in risk behaviors associated with their conception of masculinity may not be a matter of choice but rather driven by the perceived community norms. For marginalized HIV-positive gay men, inclusion and acceptance by the gay community may be essential.
In terms of HIV prevention research, there is a scarcity Scarcity
The basic economic problem which arises from people having unlimited wants while there are and always will be limited resources. Because of scarcity, various economic decisions must be made to allocate resources efficiently. of literature that has focused on the role of masculinity and body image for HIV-positive gay men as well as a lack of understanding of HIV-positive gay men as sexual beings. We believe that both these elements are central to understanding HIV-positive gay men and how they define their masculine self in relation to their gay self and their "HIV-positive self." Much more elaborate studies are needed in this area, particularly as these constructs may serve as salient contextual factors for HIV prevention. In particular, empirical and qualitative investigations should be undertaken to examine how masculinity for HIV-positive gay men may interface with race/ethnicity, geographical location, and other demographic factors as well as how alternative definitions of masculinity may impact sexual and social behaviors. Masculinity may certainly take many forms among HIV-positive gay men, and future investigations should explore these alternate constructions in relation to the "buff agenda" put forth here.
Table 1 Use of Steroids in Relation to Scores on Conceptions of Masculinity, Emphasis on Body, and Sexual Adventurism Steroids (1) Yes No Scale Mean (SD) Mean (SD) Masculinity as Sexual Behavior 9.55 (3.14) 8.75 (2.77) Masculinity as Appearance * 21.79 (4.05) 20.25 (4.18) Masculinity as Social Behavior 14.26 (3.61) 13.62 (3.89) Emphasis on Body *** 17.73 (5.38) 10.58 (4.42) Sexual Adventurism ** 35.08 (11.17) 29.71 (11.15) (1) Testosterone and/or Deca durabolin * p = .07 ** p = .02 *** p < = .001 Table 2 Interrelationships Between Emphasis on Body, Conceptions of Masculinity, and Sexual Adventurism A B C D E Masculinity as Sexual -- .562 ** .436 ** .372 ** .359 ** Behavior (A) Masculinity as -- -- .381 ** .371 ** .386 ** Appearance (B) Masculinity as Social -- -- -- .334 ** .224 * Behavior (C) Emphasis on Body (D) -- -- -- -- .444 ** Sexual Adventurism (E) -- -- -- -- -- * p = .02 ** p <.001 Table 3 Mean Frequencies (Standard Deviation) of Barebacking Acts in Relation to Use of Viagra and Steroids Viagra Barebacking Behavior Yes No AI HIV+Partners 9.18 (12.46) * 5.19 (8.49) AR HIV+ Partners 13.05 (17.00) *** 2.74 (4.77) AI HIV-/UK Partners 1.95 (4.44) 0.90 (2.81) AR HIV-/UK Partners 3.75 (5.21) *** 0.47 (l.15) Steroids (1) Barebacking Behavior Yes No AI HIV+Partners 9.30 (12.61) * 5.29 (8.26) AR HIV+ Partners 11.94 (17.07) *** 3.77 (6.96) AI HIV-/UK Partners 1.24 (2.97) 1.31 (3.81) AR HIV-/UK Partners 3.29 (4.96) ** 0.81 (2.26) (1) Testosterone and/or Deca durabolin * p<=.05 ** p < = .01 *** p < =. .001
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Correspondence concerning this article should be address to Perry N. Halkitis, New York University New York University, mainly in New York City; coeducational; chartered 1831, opened 1832 as the Univ. of the City of New York, renamed 1896. It comprises 13 schools and colleges, maintaining 4 main centers (including the Medical Center) in the city, as well as the , Department of Applied Psychology, 239 Greene Street, Room 537J, New York, NY 10003. Electronic mail: firstname.lastname@example.org.
PERRY N. HALKITIS, KELLY A. GREEN New York University
LEO WILTON Binghamton University