Perceptions of heterosexual African American males' high-risk sex behaviors.

African American heterosexual men's perceptions of HIV/AIDS risks has not been well explored. This study's objectives were to gain insight into how heterosexual African American men's unsafe sexual behavior may place them at higher risk for HIV and sexually transmitted infections. Sexually active, heterosexual African American men (N = 57) participated in semi-structured focus group discussions. Themes were identified to assess the men's responses regarding high-risk sex practices and cultural influences. The results highlight risk behaviors and cultural influences. Understanding these men's risky sex behaviors and their culture can assist researchers to develop more effective HIV and STI interventions.

Keywords: HIV risk, African American males, sexual behavior

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HIV/AIDS cases are occurring in alarming rates among African Americans. For example, between 2001 and 2004, among the 33 states in the U.S. reporting HIV data in addition to AIDS data, 12,426 African American males reported exposure to HIV through heterosexual contact compared to 23,777 African American females. In 2004, African American females accounted for 64% of reported HIV cases. For African American females between the ages of 25 and 34, AIDS has become the leading cause of death in 2002. It is also one of the top three causes of death for African American males 25 to 54 years (U.S. Centers for Disease Control and Prevention, 2006).

As the face of the AIDS epidemic throughout the southeastern United States has become increasingly nonwhite and heterosexual (Southern State AIDS/STD Directors Work Group, 2003), very little is known regarding the high risk of sex behaviors and cultural influences of heterosexual African American males. Researchers have examined the status of African male/female relationships (Brewer, 1995; McAdoo, 1998; Wilson, 1985), but studies of the HIV risk among heterosexual African American males have been limited.

Regarding high-risk sex behaviors, one researcher posited that younger African American males showed more "braggadocio" particularly in regards to sexual conquests and control (Whitehead, 1997). As African American males grow older, they tend to adopt different views of masculinity than do Caucasian males (Harris, Torres, & Allender, 1994). Given the rising rates of HIV among African American women due to heterosexual contact, it is necessary to understand factors that influence the sexual risk behaviors of African American men. This information may help to provide interventions that ultimately reduce HIV among African American men and women.

For the purpose of this research, high-risk sex behaviors are defined as having multiple sex partners, little or no communication about HIV/AIDS with a sex partner, lack of condom usage, and not being tested for HIV. Studies with African American males have pointed to the necessity of sexual communication between partners to curtail high-risk sex behaviors (Billy & Tanfer, 1993; Grady & Tanfer, 1996; Jemmott & Jemmott, 1990; Zimmerman, Salem, & Maton, 1995). These studies advocate that research with heterosexual African American males regarding sexual relationships should integrate cultural influences as it relates to high-risk behaviors. Culture is the beliefs, systems of knowledge, and patterns of behavior shared by a group of people. Furthermore, cultural influences as reported in this research are the societal/environmental factors, which have a beating on the high-risk sex behaviors of African American males.

The present study examined perceptions of heterosexual African American males about high-risk sex behaviors and cultural influences. Specifically, the purpose of this exploratory research with heterosexual African American males was: 1) to gain insight as to why high-risk sexual practices take place and, 2) to determine how culture influences these sexual practices.

Method

Participants

Nine focus groups were conducted in rural and urban locations in South Carolina and Georgia. All of the participants self-identified as heterosexual, sexually active African American men ranging in age from 18 to 70 years old. The participants were recruited from local churches, community centers, and universities. Personnel at each location where a focus group was held assisted with recruitment of participants by providing the names and telephone numbers of African American men who would be willing to participate in a focus group discussion about HIV risk communication. To ensure that the participants were members of the target population, a screening questionnaire was utilized to determine participant eligibility. The screening questionnaire gathered demographic information regarding age, ethnicity, highest level of education completed, sexual orientation, residency, and present and past sexual activity.

Initially, sixty-eight men were scheduled to meet in a focus group. Each participant received a phone call prior to the focus group's meeting as a reminder. For this analysis, nine focus groups met with a total of 57 participants ranging from five to eight participants in each.

Measures and Procedures

A semi-structured focus group discussion guide was developed utilizing constructs from the Ecological Model (Glanz, Rimer, & Lewis, 2002; National Cancer Institute, 2005). The following are those questions from the discussion guide, which are pertinent to this study.

1. Even if he knows the risks, describe the reasons why you think an African American male might continue to have unprotected sex with a female who is at high risk for HIV.

2. Even if she knows the risks, describe the reasons why you think an African American female might continue to have unprotected sex with a man who is at high risk for HIV.

3. How do you think culture influences African American males' decision about sexuality and sexual practices?

4. How do you think culture influences African American females' decision about sexuality and sexual practices?

The focus groups had no more than eight participants and were further divided by age to facilitate open discussion (Morgan, 1997). All of the men volunteered to participate and completed an informed consent that was approved by the University of South Carolina Institutional Review Board (IRB). The participants that completed the group discussion were paid $25. The focus groups were audio-recorded and lasted between 45 to 90 minutes. Subsequently, each group's discussion was transcribed verbatim for further analysis.

Data Analysis

The verbatim transcripts were analyzed utilizing NVivo 2.0. The initial codebook developed for analysis was based on the Ecological Model constructs. Once the code book was developed, two researchers independently coded a portion of the data to ensure that the coding schema accurately represented the data to address the reliability of the coding model (Denzin & Lincoln, 2003; MacQueen & McLellan, 1998; Sliverman, 2000). Table 1 shows the content areas with corresponding themes and definitions. The codebook was then modified accordingly and the remainder of the data was analyzed. Fine fingered, secondary data analysis was conducted after consensus to further identify emerging and recurring themes utilizing data searches available through NVivo. Themes were identified as ideas, sentiments, or concepts that were expressed in at least once in three of the focus groups.

Results

The study population consisted of 57 African American males (mean age = 32.8, age range = 18 and 70 years). Just over 26% of the participants were college graduates, while 52.6% were either currently enrolled or had some college experience. Lastly, all of the participants self-identified as being heterosexual and had had a sexual relationship with an African American woman within the last 12 months.

Factors Influencing African American Men's Risk Behaviors with African American Women at High Risk for HIV

Focus group participants were asked: "Even if he knows the risks, describe the reasons why you think an African American male would continue to have unprotected sex with a female who is at high risk for HIV?" The men in the focus groups generally agreed that there were really no good reasons to continue to have unprotected sex with a woman at high risk for contracting HIV. The men's responses were categorized into the following themes: attractiveness of partner, being in love, sex without a condom, substance abuse, perception of risk from other men's prior experience, and male libido.

Theme: Attractiveness of partner. The participants indicated that if a woman is perceived to be attractive and in good health they were more likely to engage in unprotected sex with her.

   ... if a pretty woman is right here and an ugly woman is right
   here. Which one would you use a condom with? Most men be like the
   ugly woman. They won't even use a condom with the pretty woman.

Theme: Being in love. Some of the men thought being in love was a good reason for an African American male to have unprotected sex with a woman at high risk for HIV.

   Sometimes it could be straight from the heart. Love. Time and
   emotions. You have seen her with every Tom, Dick and Harry, but
   your mind tells you. "Damn, I still wanna get with this woman."

   But the thing is, when you in a relationship like that, you gotta
   ask, "Do I wanna die with this girl?" I don't think if my girl had
   [AIDS], I would still be with her. There are people who would stay,
   "That's unconditional love. Crazy love."

Theme: Sex without a condom. Several of the participants discussed the sensation of having sex without a condom as rationale for having unprotected sex.

   Some prefer raw (without a condom) and some prefer condoms. I like
   to go up in 'em raw to be honest with you.

Respondents explained that many men do not think about using a condom during sex. The men focus on personal satisfaction and concern for "getting theirs."

   Guys will have unprotected sex. You don't think about that she's at
   high risk to get AIDS and become pregnant. Guys think like, "I'm
   about to get mine."

Theme: Substance abuse. Throughout the discussion, the participants revealed that sometimes their judgment maybe impaired by mood altering substances, like alcohol and drugs.

   A lot of dudes have sex with a girl because they were drunk. When
   you're drunk or on ecstasy and your condoms are not within reaching
   distance ... then you just jump right into it.

   ... in a party setting, or an atmosphere where there's some
   marijuana and alcohol, I think that plays a factor, "I could
   probably have sex with this girl right. I'm pretty drunk."

Theme: Perception of risk from other men's prior experience. Throughout many of the discussions, it was revealed that man would have sex with a woman if a friend or associate had prior experience with her and did not contact HIV or any other sexually transmitted disease.

   My boy hit it and I don't think he got nothing, so I should be
   straight (safe from HIV and STIs).

Theme: Male libido. A man's libido or desire proved to be another factor that affects decision making related to having unprotected sex.

   Some people are too horny ... some feel like they need it, knowing
   the risk of what's gonna happen. They go for it.

Cultural Influences on African American Men's Perceptions of Sexual Behaviors

An individual's culture influences his perceptions and behaviors. When asked about cultural influences on African American males' decisions about sexuality and sexual practices, participants felt that social networks, media, and religious doctrine had the greatest influence over African American men's thoughts and sexual behaviors.

Theme: Male social networks. Throughout the focus group, the participants indicated that their male social networks and peers greatly impacted both their perceptions and behaviors relative to sex and HIV.

   When you get around the age 16 or 17 and your friends are talking
   about how many girls they done been with and you sitting there
   quiet. You thinking, "I hadn't been with anybody yet." And that
   makes you ... find a girl that's down with [having sex].

   Peer pressure has a lot to do with [having sex].

Theme: Media. A majority of the participants indicated that music and television had a great impact upon African American males, their sexual behaviors and perceptions of HIV risk. For instance, the men shared their thoughts on television and the Hip-Hop culture.

   you do watch BET and MTV, you see all these females in these videos
   shaking their asses and doing whatever. It definitely has an affect
   on your psyche. If you not hitting (having sex) all these females,
   then in a sense you less of a man.

   ... on TV, the women, the houses, the cars, looking at that and you
   don't have it, you want it.... You see these shorties (women) and
   say, "I wanna have that." That's what causes all this random sex.

Theme: Religious doctrine. The majority of participants disclosed that the religious doctrine that they were taught as children did impact both their perceptions about sex and sexuality as well as served to guide their sexual behaviors.

   Like if you have Christian or religious background, that might can
   play into it.

   With religion.... black males, growing up in the south is very
   strong. I don't care what denomination you're in. that's one thing
   most black families taught.

Discussion

The focus group discussions showed that there were many psychosocial factors that influence African American males' decision to engage in sexual behaviors that place them at risk for HIV. The findings of the present study complement the existing body of literature. The men of this study indicated the influence of personal perceptions, peer pressure, alcohol, and illegal substances such as ecstasy impairing judgment whereby risky sexual behavior could occur. Studies showing examples of the correlation between alcohol and substance abuse and increase high-risk sex behaviors of African American men exist (Rich, 2001).

Any sexual relationship that occurs outside of a mutually faithful life-long monogamy has a degree of risk for exposure to disease, including HIV, regardless of the levels of protection (U.S. Centers for Disease Control and Prevention, 2006). According to the men is this research, the "good feeling" of unprotected sex is worth the risk. Some of the men admitted that they preferred having unprotected sex while other men indicated that their behaviors were more strongly driven by concerns about pregnancy more than acquiring HIV or an STI. This finding is consistent with previous findings concerning the risk perceptions of young adults and condom use (Bazargan, Kelly, Stein, Husani & Bazargan, 1997; Carter, McNair, Corbin, & Williams, 1999; Ku, Sonenstein, Lindberg, Bradner, Boggess, & Pleck, 1998), and other studies have looked at older adults (Grady & Tanfer, 1996).

Implications for Further Research

Further implications for those in the helping profession to consider are the impact of culture on African American males. According to Harrison (1997), "cultural value ... leads to economically and politically disempowered men of racialized social locations to seek both sexual and economic power, though these two forms of power are not equally accessible to them." (p. 449) Culture is at the mental foundation of a group of people. This present study has shown the influence that culture has on the participants' sexual behaviors. Therefore, incorporating African American culture into activities is deemed necessary.

The study warrants further research to expand our understanding of factors impacting the sexual communication between heterosexual African American males and their female partners. It is recommended that the study be repeated with more focus groups with African American males outside Georgia and South Carolina.

Limitations

The study's findings are based on qualitative methodology using a non-random, convenience sample of African American males residing in two southeastern states. The size of the sample population (N = 57) is relatively small. The results, therefore, may not be generalizable to all African American males living throughout the United States.

The qualitative design of the study enabled researchers to capture the essence of the participants' responses. Despite the best efforts of a highly trained moderator, some participants in focus group research tend to speak more than others, and their views may influence other participants.

Although efforts were made to ensure that there was reliability to the coding model, the reality is that the coding was still based on the subjective interpretation of the coders. This subjectivity is a potential limitation of this study. In addition to adhering to a coding model, data was coded independently to reduce the potential impact of subjectivity on the results presented here.

The men selected for this research disclosed that they were heterosexual. The men could have, in fact, had sex with a man at some point in time. The screening questionnaire did not fully address this issue.

Conclusion

This present study has shown that according to the risk perceptions of heterosexual African American men, culture does indeed influence their sexual behaviors. In essence, sexually active African American men must understand that they are at risk for contracting HIV whenever they are involved in high-risk sex behaviors. Secondly, the men need to understand that their culture has, in some way, influenced their thinking toward sexuality and sexual practices.

In order to combat the proliferation of sexually transmitted infections and unwanted pregnancies in the African American community, African American males must 1) be imbued with the skills to communicate about high-risk sex behaviors and 2) understand how culture has shaped their patterns of thinking. Findings from this research propose the need for messages from health professionals to encourage safer sex dialogue between sexually active African American men and their partners, regardless of age and marital status. Health professionals should also implore that sexually active men practice the primary modes of protection: 1) condom usage with every sexual encounter; 2) alternative sexual acts which do not involve exchange of body fluids; and 3) abstinence (Quina, Harlow, Morokoff, Burkholder, & Deiter, 2000). As heterosexual African American males heed the advice of those in the helping profession and the implications suggested by the present research, many lives in the African American community can be saved and the spread of HIV via heterosexual contact could be reduced.

References

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Melva Thompson-Robinson, Department of Health Promotion, University of Nevada, Las Vegas; Mike Weaver, Atlanta, GA; Marya Shegog and Donna Richter, Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia; Stuart Usdan, Department of Health Sciences, University of Alabama, Tuscaloosa; and Ruth Sannders, Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia.

Correspondence concerning this article should be sent to Melva Thompson-Robinson, DrPH, Department of Health Promotion, School of Public Health, University of Nevada Las Vegas, 4505 Maryland Parkway, Box 453050, Las Vegas, NV 89154-3050. Electronic mail: [e-mail]

Table 1
Content Areas with Corresponding Themes and Definitions

Content area          Theme              Definition

Reasons jus-
tifying or not
justifying African
American males
to engage in
unprotected

sex                   Attractiveness     A female sex partner's physi-
                      of partner         cal appearance can dictate
                                         whether a man engages in
                                         unprotected sex with her

                      Being in love      Any emotional attachment a
                                         man may have with his
                                         female sexual partner

                      Sex without        "Doing it raw" or the
                      a condom           sensation of having sex
                                         without a condom as rationale
                                         for unprotected sex

                      Substance abuse    The use of licit and illicit
                                         substances as a precursor to
                                         sexual activity

                      Perceptions        Knowing that another man
                      of risk from       has had sexual contact with
                      other men's        a woman and did not contract
                      prior experience   any disease may result
                                         in another man having
                                         unprotected sex with a high
                                         risk female

                      Male libido        A man's physical state, which
                                         can overpower the ra-
                                         tional thought process

Cultural influences
on African
American males'
sexual behaviors
and practices

                      Social networks    Friends and acquaintances

                      Media              Any form of print or audio/
                                         visual communication out-
                                         lets, which incorporates
                                         music, clothing, cars,
                                         jewelry, dance, and
                                         hairstyles

                      Religious          The outward expression
                      doctrine           of one's spirituality