Information, Motivation and Behavioral Skills as Mediators Between Sexual Minority Stigma and Condomless anal Sex Among Black South African Men Who have Sex with Men.

We assessed pathways between sexual minority stigma and condomless anal intercourse (CAI) among two samples of Black South African men who have sex with other men (MSM). Two cross-sectional surveys were conducted in Tshwane, South Africa; one among 199 Black MSM and another among 480 Black MSM. Men reported on external and internalized experiences of sexual minority stigma, mental health, alcohol use, information-motivation-behavioral skills (IMB) model constructs, and CAI. Structural equation modeling was used to test whether external and internalized stigma were directly and indirectly associated with CAI. In both studies, external stigma and internalized stigma were associated with CAI through IMB model constructs. These results suggest a pathway through which stigma contributes to HIV risk. For HIV prevention efforts to be effective, strengthening safer sex motivation and thus decreasing sexual risk behavior likely requires reducing sexual minority stigma that MSM experience and internalize.

The involvement matrix as a framework for involving youth with severe communication disabilities in developing health education materials.

INTRODUCTION: Involving youth with severe communication disabilities in health research is foregrounded in a perspective of rights and participation. Researchers aligned with a participatory and inclusive research agenda recommend that involving youth in health research should be a deliberate and well-planned process. However, limited examples exist of how researchers can facilitate the involvement of youth with severe communication disabilities in research projects. METHOD: The aim of this paper was to describe the application of the Involvement Matrix as a conceptual framework to guide the three phases of a research project with youth with severe communication disabilities. RESULTS: Six youth aged 19-34 years consented to be involved in the project. All youth had a severe communication disability and used augmentative and alternative communication (AAC) to support their involvement in the research project. The Involvement Matrix provided a structure to delineate four involvement roles in three research phases: In Phase 1, youth were listeners to research information and advisors in the needs analysis. In Phase 2, as advisors and decision-makers, youth provided their opinions on selecting picture communication symbols for health materials. In Phase 3, as partners, they were copresenters at an online youth forum. CONCLUSION: The Involvement Matrix was used to plan and implement the involvement of youth with severe communication disabilities in codeveloping health materials for use during the COVID-19 pandemic. The Involvement Matrix can be applied together with AAC to enable meaningful involvement of youth in a health research project as listeners, advisors, decision-makers and partners. PATIENT OR PUBLIC CONTRIBUTION: This study project was codeveloped with youth with severe communication disabilities who use AAC in South Africa. A person with lived experience was involved as an advisor to the health material development process and in the drafting of the manuscript.

The social and sexual lives of Black sexual minority men 30 years of age and older in South Africa.

BACKGROUND: Black sexual minority men (SMM) ages 30 and older are under-represented in HIV studies in sub-Saharan Africa, despite being at increased risk of HIV infection and contributing to potential onward HIV transmission. To better understand the social and sexual lives of older Black South African SMM, we conducted in-depth interviews with SMM who were > 30 years old. METHODS: From March-September 2016, we recruited a convenience sample of 37 SMM ages 30 and older by partnering with an LGBTQ+ organization in Tshwane, Pretoria. Men were interviewed about various aspects of their lives, including their sexual orientation, social connectedness, experiences with stigma and perspectives on participating in research. RESULTS: Participants described their experiences with their sexual identities, cultural and social implications of disclosure, and their perspective on South Africa's political perspectives on the LGBTQ+ community. Men described how these experiences influence their trust in research and comfort participating in studies. CONCLUSIONS: Inferences drawn from these findings provide direction on how to improve middle-aged SMM's representation in research, such as recruiting a higher proportion of older and middle-aged SMM to serve as seed participants and building stronger community partnerships to disseminate study findings to settings where data collection is conducted.

African Same-Sex Sexualities and Gender Diversity: A Framing Note.

This article introduces the concept of African same-sex sexualities and gender diversity which refers to variation pertinent to gender expressions and identities, sexual expression and sexual orientation. The article describes the emerging and evolving African scholarly production evident in the last two decades and describes key underlying themes that bring together this special issue.

Southern African Lesbian and Bisexual Women Responses to Symptoms of Sexually Transmitted Infections.

Sexually transmitted infection (STI) in lesbian and bisexual women is a relatively unexplored topic, particularly for women from low- and middle-income countries. Despite perceptions that women who have sex with women (WSW) are at negligible risk of contracting STI, existing research demonstrates that WSW do become infected with STI. Given the opposition between assumptions of invulnerability and the observed risks, we explored how WSW would respond to symptoms of STI (i.e., wait until symptoms passed, see a medical doctor, and inform sexual partners). We used data collected as part of a collaboration between academic researchers and community-based LGBTQ organizations in Botswana, Namibia, South Africa, and Zimbabwe. Chi-squared tests were used to test whether participants' responses to hypothetical STI symptoms varied in relation to several intrapersonal, interpersonal, and structural factors. Multivariable logistic regression (backward) was used to assess whether these variables were independently associated with women's responses. Most women would be proactive in response to potential STI symptoms and would see a medical doctor. However, most women would not inform their sexual partner of symptoms of STI. Findings demonstrate several intrapersonal, interpersonal, and structural factors that influence WSW's health agency, and show a clustering of high-risk factors among women who would not be proactive about their health. Our findings suggest the need for improved health and health care of WSW in Southern Africa.

HIV and sexually transmitted infection knowledge among women who have sex with women in four Southern African countries.

Women who have sex with women in Southern Africa, where HIV prevalence is high, are often presumed to have minimal risk for sexually transmitted infections (STI) and HIV despite research documenting female-to-female transmission. This study examined the demographic and social factors contributing to female-to-female STI/HIV transmission knowledge among Southern African women who have sex with women using an integrated model of health literacy. In collaboration with community-based organisations in Botswana, Namibia, South Africa and Zimbabwe, data were collected through anonymous surveys (N = 591). Multivariable stepwise forward logistic regression assessed independent associations between participant characteristics and high vs. low knowledge using five items. Overall, 64.4% (n = 362) of women had high knowledge; 35.6% (n = 200) had low knowledge. Higher education (adjusted odds ratio [aOR]: 2.24, 95% confidence interval [CI]: 1.48, 3.40), regular income (aOR: 2.14, 95% CI: 1.43, 3.21), residence in Botswana (aOR: 3.12, 95% CI: 1.15, 8.48) and having ever received tailored STI/HIV information (aOR: 2.17, 95% CI: 1.41, 3.32) predicted significantly higher odds of high knowledge in the final multivariable model. Results suggest opportunities for peer-led sexual health programming and expanded HIV prevention campaigns addressing women who have sex with women.

Sexual violence experiences among black gay, bisexual, and other men who have sex with men and transgender women in South African townships: contributing factors and implications for health.

This study examined experiences with sexual violence among Black African gay, bisexual, and other men who have sex with men (GBMSM) and transgender women (TGW) in townships surrounding Pretoria, South Africa. Of 81 GBMSM and TGWs interviewed, 17 reported to have experienced sexual violence perpetrated by other men. Qualitative analysis of interviews revealed the social and relational context of these experiences as well as their psychological and health consequences. The described context included single- and multiple-perpetrator attacks in private and public spaces, bias-motivated attacks, and violence from known partners. Several participants reported refusing propositions for sex as a reason for being victimized. HIV-positive individuals were overrepresented among survivors compared to the sample as a whole. Following victimization, participants described feelings of pain, fear, anger and self-blame. The results demonstrate the need for interventions designed to (a) prevent sexual violence against GBMSM and TGW in this population, and (b) reduce the negative psychological and health outcomes of sexual victimization. The discussion also highlights the need to examine more closely the link between experiences of sexual violence and risk for HIV infection.

Gender Expression and Mental Health in Black South African Men Who Have Sex with Men: Further Explorations of Unexpected Findings.

Unlike studies conducted in Western countries, two studies among Black South African men who have sex with men (MSM) found no support for the association between gender nonconformity and mental distress, even though gender-nonconforming men experienced more discrimination and discrimination was associated with mental distress (Cook, Sandfort, Nel, & Rich, 2013; Sandfort, Bos, Knox, & Reddy, 2016). In Sandfort et al., gender nonconformity was assessed as a continuous variable, validated by comparing scores between a categorical assessment of gender presentation (masculine, feminine, no preference). Using the same dataset, we further explored this topic by (1) testing differences between gender expression groups in sexual minority stressors, resilience factors, and mental distress; (2) testing whether the impact of elevated discrimination in the feminine group was counterbalanced by lower scores on other stressors or higher scores on resilience factors; and (3) exploring whether relationships of stressors and resilience factors with mental distress varied between gender expression groups. Controlling for demographics, we found several differences between the gender expression groups in the stressors and resilience factors, but not in mental distress. We found no support for the idea that the lack of differences in mental distress between the gender expression groups was a consequence of factors working in opposite directions. However, internalized homophobia had a differential impact on depression in feminine men compared to masculine men. In our discussion of these findings, we explored the meaning of our participants' self-categorization as it might relate to gender instead of sexual identities.

Substance Use and Sexual Risk Behavior Among Black South African Men Who Have Sex With Men: The Moderating Effects of Reasons for Drinking and Safer Sex Intentions.

Research studies suggest an association between substance use and sexual risk behavior, but are not completely consistent. The moderating effects of other psychosocial factors might help explain these inconsistencies. The current study therefore assessed whether substance use is associated with sexual risk behavior, and whether this relationship is modified by expectancies about the effects of alcohol, reasons for consuming alcohol, or intentions to engage in safe sex. A cross-sectional survey was conducted among 480 black South African men who have sex with men recruited using respondent-driven sampling. In multivariable analyses, the effect of alcohol use on unprotected receptive anal intercourse (URAI) was modified by drinking to enhance social interaction (R2 change = 0.03, p < 0.01). The effect of drug use on URAI was modified by safe sex intentions (R2 change = 0.03, p < 0.001). Alcohol use was positively associated with URAI only among those who drink to enhance social interaction (ß = 0.08, p < 0.05). Drug use was positively associated with URAI only among those with high safe sex intentions (ß = 0.30, p < 0.001). Our findings suggest that efforts to minimize the impact of substance use on HIV risk behavior should target men who drink to enhance social interaction and men who intend to engage in safer sex. Efforts made to increase safer sex intentions as a way to reduce HIV risk behavior should additionally consider the effects of substance use.

Breakage is the norm: use of condoms and lubrication in anal sex among Black South African men who have sex with men.

This paper explores condom use and lubrication practices among Black men who have sex with men in South African townships. Results are from 81 in-depth individual interviews conducted among a purposive sample from four townships surrounding Pretoria as part of a larger qualitative study. Awareness that condoms should be used to have safer anal sex was ubiquitous. Fewer men reported that lubricants should be used to facilitate anal intercourse. Partner pressure and partner distrust were the most common barriers cited for not using condoms and lubricants. Knowledge about condom-lubricant compatibility was rare. Condom problems were a norm, with widespread expectations of condom failure. Men's subjectivities - their perceptions of and preferences for specific brands, types and flavours of condoms and lubricants - influenced engagement with such safer-sex technologies. However, what was available in these settings was often neither what men needed nor preferred. Findings show the need to enhance access to appropriate and comprehensive: safer-sex supplies, health services and health education, and underline the importance of efforts to develop targeted programmes relevant to experiences of men who have sex with men in the South African context.

Gender Nonconformity, Discrimination, and Mental Health Among Black South African Men Who Have Sex with Men: A Further Exploration of Unexpected Findings.

Using data from a study about HIV risk among Black South African MSM, we aimed to ascertain whether unexpected findings about the relationship between gender nonconformity, discrimination, and mental health in this population, as reported by Cook, Sandfort, Nel, and Rich (2013), could be replicated, and to explore more in-depth how gender nonconformity relates to health. Cook et al. found that feminine men were not more likely to be depressed despite the observation that they were more likely to be discriminated against and that discrimination increased the likelihood of depression. This is in contrast to what studies among gay and bisexual men in Western countries have consistently shown. In the current study, 196 Black South African MSM (ages between 18 and 40; M age, 26.65 years) were surveyed. Assessments included stressors (identity confusion, internalized homophobia, and sexual orientation-based discrimination) and resilience factors (openness about one's sexual orientation, social support, and identification with the gay community). We observed that gender-nonconforming men were not more likely to be depressed despite having experienced more discrimination, which was associated with depression. The same relationships were observed when considering anxiety as the mental health outcome. We found an indirect negative effect of gender nonconformity on depression through internalized homophobia, suggesting that, in this population, internalized homophobia masks the effect of discrimination on mental distress. Implications for the sexual minority stress model, used to guide our analyses, are discussed. Further research is needed to disentangle the complex relationship between gender nonconformity and mental health among MSM populations.

Gender Expression and Risk of HIV Infection Among Black South African Men Who Have Sex with Men.

To explore demographic, behavioral and psychosocial risk factors for HIV infection in South African MSM we recruited 480 MSM (aged 18 and 44 years) using respondent-driven sampling. Data were collected through individual computer-assisted face-to-face interviews. Participants were tested for HIV. RDS-adjusted HIV prevalence is 30.1 % (unadjusted 35.6 %). Few participants had ever engaged in both receptive and insertive anal sex; sex with women was frequently reported. Independent demographic and behavioral correlates of HIV infection include age, education, number of male sexual partners, ever having been forced to have sex, and ever having engaged in transactional sex; engagement in sex with women was a protective factor. Psychosocial risk factors independently associated with HIV infection were feminine identification, internalized homophobia, and hazardous drinking. Our findings confirm what has been found in other studies, but also suggest that the dynamics and context of sexual transmission among MSM in South Africa differ from those among MSM in Western countries.

HIV testing practices of South African township MSM in the era of expanded access to ART.

While men who have sex with men (MSM) in Africa are at high risk for HIV infection, few of those already infected know their status. Effectively promoting frequent HIV testing-of increasing importance with the expanding accessibility of antiretroviral treatment-requires an understanding of the testing practices in this population. To understand men's HIV testing practices, including their behavior, experiences, and perceptions, we conducted in-depth interviews with 81 black South African MSM (ages 20-39), purposively recruited from four townships. Many men in the sample had tested for HIV. While ever having tested seemed to facilitate repeat testing, men still expressed a high level of discomfort with testing. It was common to test after having engaged in risky behavior, thus increasing anxiety about testing that was already present. Fear that they might test HIV positive caused some men to avoid testing until they were clearly sick, and others to avoid testing completely. HIV testing may increase in this population if it becomes a routine practice, instead of being driven by anxiety-inducing incidents. Mobilization through social support might facilitate frequent testing while education about current treatment options is needed.

"This will not enter me": painful anal intercourse among Black men who have sex with men in South African townships.

Little is known about painful receptive anal intercourse (RAI) and its relationship to HIV risk and protective behaviors among men who have sex with men (MSM). The purpose of this study was to identify attributions for and responses to painful RAI among Black MSM in South African townships. In-depth interviews were conducted with 81 Black MSM (ages 20-39 years) who were purposively recruited from four townships. The semi-structured interviews addressed sexual behavior and identity, alcohol use, and safer sex. Pain during RAI was brought up by many participants without specific prompting from the interviewer. Analysis of the interview transcripts revealed that pain was a common feature of first RAI experiences but was not limited to first-time experiences. The participants attributed pain during RAI to partner characteristics, interpersonal dynamics, lack of lubricant, and alcohol use or non-use. The main strategies participants used to address pain during RAI were setting sexual boundaries and lubricant use; a small number of participants reported purposefully consuming alcohol to prevent the pain associated with RAI. Black South African MSM can be supported to reduce pain during RAI in ways that reduce their HIV/STI risk. Culturally specific sexual health education, supportive sexual health services, and improved access to condom-compatible lubricants are important components of HIV/STI interventions for this population.

Histories of forced sex and health outcomes among Southern African lesbian and bisexual women: a cross-sectional study.

BACKGROUND: Experiences of forced sex have been shown to be prevalent in Southern Africa. Negative outcomes of forced sex have been documented in general populations of women and men and include alcohol abuse, drug use, mental health problems, mental distress, sexual health problems and poor overall health. This study is the first to examine experiences of forced sex and associated health problems among lesbian and bisexual women in Southern Africa. METHODS: This study is based on data collected as part of a collaborative endeavor involving various Southern African community-based organizations. Lesbian and bisexual women in four Southern African countries participated in a cross-sectional survey, for a total study sample of 591. RESULTS: Nearly one-third of participants had been forced to have sex at some time in their lives. Thirty-one percent of all women reported to have experienced forced sex at least once in their life: 14.9% reported forced sex by men only; 6.6% reported forced sex by women only; 9.6% had had forced sexual experiences with both men and women. Participants experienced forced sex by men as more serious than forced sex by women; forced sex by women was more likely to involve intimate partners compared to forced sex by men. Participants who experienced forced sex by men were more likely to report drug problems, mental distress and lower sense of belonging. Forced sex by women was associated with drinking problems and mental distress. Having experienced forced sex by both men and women was associated with lower sense of belonging to the LGBT community, drug use problem and mental distress. CONCLUSIONS: The findings indicate that forced sex among Southern African women is a serious issue that needs further exploration. Clinicians should be made aware of the prevalence and possible consequences of forced sex among lesbian and bisexual women. Policies and community interventions should be designed to address this problem.

'They think that gays have money': gender identity and transactional sex among Black men who have sex with men in four South African townships.

Transactional sex has not been studied much among men who have sex with men in Africa. Consequently, little is understood about attitudes towards the practice, the circumstances that give rise to it or how transactional sex relationships are managed. We conducted in-depth interviews with 81 Black men aged 20-44 from four low-resourced townships in Tshwane, South Africa. We found that transactional sex was a widely used strategy for initiating and sustaining relationships with regular and casual partners, and was motivated by both the need for subsistence and for consumption. Alcohol-based exchanges in particular provided men in the townships with a covert and safe platform to communicate erotic, sexual and romantic attraction to other men, and bars and other drinking places were a popular venue for meeting potential sexual partners. The majority of 'feminine-identifying' men had engaged in transactional sex as the providers of money and material goods compared to men who identified as either 'masculine' or as 'both masculine and feminine'. Surprisingly, however, this did not necessarily give them greater control in these relationships. Our study provides an initial foray into a complex sociosexual phenomenon and suggests that gender identity is an important construct for understanding transactional sex relationships among men in Africa.

Sexual partnership types as determinant of HIV risk in South African MSM: an event-level cluster analysis.

While individual determinants of HIV risk among MSM have been widely studied, there is limited understanding of how relational characteristics determine sexual risk. Based on data collected among 300 South African men who have sex with men (MSM) and using cluster analysis, this study developed a typology of four partnership types: the "Race-Economic Similar," "Age-Race-Economic Discordant," "Non-regular Neighbourhood," and "Familiar" partnership types. Support for the meaningfulness of these types was found through associations of these partnership types with participant characteristics and characteristics of the last anal sex event. Furthermore, in a multivariate analysis, only partnership type independently predicted whether the last anal sex event was unprotected. Findings of the study illustrate the importance of taking into account the relational context in understanding unprotected sexual practices and present ways to target intervention efforts as well as identify relationship specific determinants of unprotected sex.

Communicating HIV status in sexual interactions: assessing social cognitive constructs, situational factors, and individual characteristics among South African MSM.

This study assessed whether social cognitive constructs, situational factors, and individual characteristics were associated with communicating HIV status and whether communication was related to sexual risk behavior. A quota-sampling method stratified by age, race, and township was used to recruit 300 men who have sex with men to participate in a community-based survey in Pretoria in 2008. Participants reported characteristics of their last sexual encounter involving anal sex, including whether they or their partner had communicated their HIV status. Fifty-nine percent of participants reported that they or their partner had communicated their HIV status. HIV communication self-efficacy (aOR = 1.2, 95 % CI: 1.04-1.68), being with a steady partner (aOR = 0.36, 95 % CI: 0.19-0.67), and being Black (versus White; aOR = 0.08, 95 % CI: 0.03-0.27) were independently associated with communicating HIV status. Communicating HIV status was not associated with unprotected anal intercourse. HIV communication self-efficacy increases men's likelihood of communicating HIV status. Being with a steady partner and being Black reduces that likelihood. Communication about HIV status did not lead to safer sex.

"I thought we are safe": Southern African lesbians' experiences of living with HIV.

HIV-prevention and service programmes have long either ignored or overlooked lesbians. The experiences of lesbians with HIV have similarly been unrecognised and unreported. This erasure has contributed to the invisibility of lesbians in relation to HIV and related health risks. This community participatory study, based on in-depth interviews with 24 self-identifying African lesbians living with HIV in South Africa, Zimbabwe and Namibia, focuses on their personal experiences and circumstances. Women's experiences shed light and challenge popular notions around lesbian risk. In particular among this group are lesbians who self-report exclusive sexual relationships with women. For these women, experiences of living with HIV are challenging as they struggle to understand the possibility of female-to-female transmission. While battling with their own perceptions of invulnerability and accepting their HIV-positive status, they have to deal also with wide-ranging misconceptions about risk. The paper argues that within the context of HIV, lesbians cannot be regarded as a 'no-risk' group. Health services and health providers are encouraged to respond to the health needs of lesbians living with HIV.

Maximising Grip on Deception and Disguise: Expert Sports Performance During Competitive Interactions.

Expert performers in fast-ball and combat sports continuously interact with their opponents and, if they are to be successful, adapt behaviour in order to gain an advantage. For example, disguise and deception are recognised as skilful behaviours that are employed to disrupt an opponent's ability to successfully anticipate their actions. We contend that such skilled behaviour unfolds during the interaction between opposing players, yet typical research approaches omit and/or artificially script these interactions. To promote the study of skilled behaviour as it emerges during competitive interactions, we offer an account informed by contemporary ecological perspectives for shaping investigation into how deception and disguise can be used to gain an advantage over an opponent and the challenges it poses to anticipation. We propose that each player attempts to develop maximum grip on the interaction through exploiting information across multiple timescales to position themselves as to facilitate openness to relevant affordances. The act of deception can be understood as offering a misleading affordance that an opponent is invited to act on, imposing a significant challenge to an opponent's ability to attain grip by manipulating the information available. Grounded in our ecological perspective, we emphasise the need for future investigation into: (1) the role of disguise for disrupting anticipation; (2) how deception can be employed to gain an advantage by manipulating information on multiple timescales, before detailing; (3) how opposing performers go beyond merely exploiting information and actively elicit information to deal with deception and disguise during an interaction.