“The Fight is Two Times as Hard”: A Qualitative Examination of a Violence Syndemic Among Young Black Sexual Minority Men

Abstract

Young Black men who have sex with men (YBMSM) are disproportionately impacted by violence, including violence rooted in anti-Black racism, sexual identity bullying, and neighborhood violence rooted in structural racism and inequities. These multiple forms of violence are frequently co-occurring and interactive creating syndemic conditions that can negatively impact HIV care. This qualitative study is based on in-depth interviews with 31 YBMSM, aged 16–30 years, living with HIV in Chicago, IL, to examine how violence has impacted their lives. Using thematic analysis, we identified five themes that reflect how YBMSM experience violence at the intersection of racism, homonegativity, socioeconomic status, and HIV status: (a) the experience of intersectional violence; (b) long histories of violence contributed to hypervigilance, lack of safety, and lack of trust; (c) making meaning of violence and the importance of strength; (d) normalizing violence for survival; and (e) the cyclical nature of violence. Our study highlights how multiple forms of violence can accumulate across an individual’s life and contribute to social and contextual situations that further contribute to violence and negatively impact mental health and HIV care.

Keywords

Black gay and bisexual men HIV neighborhood violence mental health intersectionality

Young, Black, gay, bisexual, queer, and other men who have sex with men (YBMSM) living with HIV are disproportionately exposed to violence and marginalization (Bottiani et al., 2021), including high rates of community violence, bullying, and parental or caretaker violence (Phillips et al., 2014). These experiences of violence can lead to syndemic conditions, the co-occurrence and interaction of multiple social and health conditions and inequities (Singer, 1994), and can negatively impact HIV care. Through in-depth interviews, this study explored how multiple forms of violence have intersected and impacted the lives of YBMSM living with HIV.

Syndemic theory demonstrates how health, social, and psychological conditions can co-occur and be mutually reinforcing (Tsai & Burns, 2015), to collectively increase disease burden for certain populations (Singer, 1994, 1996), including HIV (Tsai & Burns, 2015). Early syndemic models largely focused on individual psychological constructs including mental health, substance use, and victimization (Godley & Adimora, 2020; Halkitis et al., 2013; Stall et al., 2003, 2008). Although violence was included as part of Singer’s original syndemics research (Singer, 1996), the majority of syndemics research examines a single type of violent victimization exposure (e.g., childhood sexual abuse or intimate partner violence) at the individual level (Dyer et al., 2012; Wu, 2018; Wu et al., 2015). More recently, the intersecting and reinforcing nature of multiple forms of violence and their impact on HIV outcomes and other health conditions has been conceptualized as a violence syndemic (Voisin & Takahashi, 2021).

Importantly, syndemics provides an important lens to examine how multiple forms of violence can intersect. Black men and boys are disproportionately affected by violence. For example, in the United States in 2020, the crude rate of premature death due to homicide by firearms for Black men and boys aged 10–24 years far exceeded than that of White men (71.18 vs. 6.3 per 100,000, respectively; Centers for Disease Control and Prevention, 2022). Black men and boys were over 20 times more likely to be killed by firearms than White men (Kegler et al., 2022). Furthermore, Black youth are significantly more likely to witness and be victims of violence than other youth (Crouch et al., 2000). Black MSM report anti-Black racism and hostile atmospheres in LGBTQ (lesbian, gay, bisexual, transgender, and queer) environments such as bars and nightclubs (Parker et al., 2017) and bullying victimization is up to six times higher among YBMSM than their heterosexual counterparts (Mueller et al., 2015).

Research has revealed how these experiences of violence can cluster and operate within a feedback loop (Lemke et al., 2020), shaping exposure and resources related to violence risk and creating syndemic conditions. For example, recent research demonstrated that the intersection of anti-Black and anti-LGBTQ policies is associated with an increase in suicide risk factors among young Black sexual minority men (English et al., 2022). A longitudinal study of Black MSM found that the intersection of race and sexual identity-based discriminatory policing practices was associated with subsequent physical violence, including intimate partner violence (Feelemyer et al., 2021). Research has also demonstrated how co-occurring mental health, substance use, intimate partner violence, and childhood sexual abuse can adversely impact HIV outcomes for Black MSM (Kuhns et al., 2016; Martinez et al., 2016; Stall et al., 2003).

There are numerous health and social consequences associated with high levels of violence exposure. For example, trauma due to physical or sexual assault or exposure to extreme violence has been found to be associated with lower antiretroviral therapy (ART) adherence among a sample of men living with HIV, of whom 77% were Black (Brown et al., 2019). Furthermore, even when individuals are not the direct victims of violence, exposure to violence can lead to similar outcomes. Having witnessed violence with a deadly weapon is significantly associated with increased alcohol and drug use (Phillips et al., 2014), and with the development of post-traumatic stress disorder (PTSD; Fowler et al., 2009; McCart et al., 2007). Exposure to community violence among Black MSM is also associated with criminal justice involvement, psychological distress, problematic substance use (Hotton et al., 2019), and depressive symptoms (Phillips et al., 2014). Finally, racial discrimination, a documented form of structural violence (Farmer, 2004), is associated with lower self-esteem, behavioral risk-taking, delinquency, and greater mental health morbidity (Cave et al., 2020; Yang et al., 2019). Race and sexuality-based discrimination experienced by gay and bisexual men is associated with an increase in the odds of experiencing intimate partner violence (Brooks et al., 2021). Importantly, the majority of this research has focused on a single type of violence and does not consider how various forms of interpersonal and structural violence can interact to contribute to poor HIV outcomes among Black MSM.

Understanding syndemic violence experienced by YBMSM is strengthened by incorporating an intersectional perspective (Quinn, 2019). Rooted in Black feminist scholarship and activism (Bowleg, 2008; Collins, 2000; Crenshaw, 1989), intersectionality reveals how multiple social identities intersect and reflect social and structural inequities and oppression (e.g., racism, heterosexism; Collins, 2000; Crenshaw, 1989). Scholars have recently examined how syndemics research may benefit from intersectionality, which highlights how social oppressions along the axes of race, gender, class, or sexual identity influence syndemic health and social conditions (Carnes, 2016; Quinn, 2019; Smith et al., 2022). Applied to this study, an intersectional approach to examining syndemics considers how violence is shaped by power dynamics, structural factors, oppression, and marginalization, and how that can shape health outcomes (Di-Capua, 2015). This conceptualization of violence recognizes the societal and systemic contributions to violence and trauma experienced by YBMSM, including oppression and marginalization (Baird et al., 2021).

This study used in-depth qualitative interviews with YBMSM living with HIV to elicit narratives about how violence has influenced their lives. We highlight the interconnected nature of multiple types of violence described by study participants, applying an intersectional lens to violence syndemics. Qualitative data provide important first-person accounts of lived experiences of violence and can explore the complexity of intersectional violence.

Methods

Between October 2020 and December 2021, we conducted semi-structured, in-depth interviews with 31 young Black, sexual minority men in Chicago to examine how violence has influenced their lives, well-being, and HIV care. Black men living in Chicago face high rates of exposure to violence. Estimates indicate that nearly 60% of Black adults have experienced lifetime exposure to neighborhood violence which is associated with HIV sexual risk behaviors among Black youth (Voisin et al., 2012, 2014, 2016).

Eligibility criteria were (a) self-identification as a Black sexual minority cisgender man; (b) being between 16 and 30 years old; (c) living with HIV for 3 months or longer; and (d) residing in Chicago. Participants were recruited using a variety of purposeful recruitment strategies such as through relationships with HIV clinics and LGBTQ service organizations, distribution of flyers on social media platforms (e.g., Instagram, Facebook), and referrals from other study participants. Interested participants were screened for eligibility by the study team. Eligible individuals were invited to participate in an interview via Zoom with research associates trained in qualitative interviewing. Prior to the interview, participants completed the informed consent process; we received a waiver of parental consent for individuals under the age of 18 years. To minimize participation barriers, we used an altered informed consent process that provided individuals with a detailed yet plainly written letter explaining the study purpose, risks, and benefits and did not require participant signatures. Individuals reviewed the study details with the study team and provided verbal consent to participate. Participants received a $50 gift card for their participation and a $10 bonus for the successful referral of other participants. Recruitment continued until we achieved saturation around general life course experiences of violence and the effects of violence on mental health and HIV care. Specifically, we continued to look at our data on how participants described the direct and indirect effects of violence in their lives. When we noticed repeating patterns and experiences and were able to begin to answer our primary research question, we ceased enrollment.

The interview guide covered several main content areas including lifetime experiences of violence, history of HIV care, and experiences with structural and interpersonal racism. The semi-structured format of the interview allowed for flexibility in the interview and allowed interviewers to follow participants’ lead in the discussion. Study protocols were approved by the Institutional Review Board at the Medical College of Wisconsin.

Interviews were digitally recorded, and transcribed verbatim, checked for accuracy, and coded using MAXQDA software. We used a team-based approach (Corbin & Strauss, 2015) to develop a codebook. Five members of the research team began by independently reading two randomly selected transcripts and developing a list of candidate codes and categories (Saldana, 2016). We met as a team to discuss our draft codebooks and created a single agreed upon codebook that included both inductive codes identified from the interviews and codes identified a priori based on our literature reviews of violence and HIV among Black MSM. Team members then independently applied this updated codebook to two additional interviews, refining code definitions, combining codes, and identifying duplicate or overlapping codes. The team met again to discuss and update the codebook. We continued this process one additional time until all members reached consensus on the finalized codes, its definitions, and code inclusion and exclusion criteria.

In the first round of coding, transcripts were coded with participant demographic data, including age, length of time living with HIV, and sexual identity. In the second round of coding, we applied the codebook to all interviews. In addition to applying the codebook, we used analytic memos (Saldana, 2016) to capture semantic and latent concepts in the data, preliminary categories and themes, and reflections and questions about the data. All data were coded twice using the developed codebook, by separate team members, to enhance coding reliability.

The coding process was coupled with reflective thematic analysis to examine patterns within the data. Thematic analysis allows for inductively developed analysis that can capture both semantic and latent meaning in the data and offer both descriptive and interpretive accounts of the data. This approach calls for repeated movement between coding and analysis to develop robust interpretation and themes (Braun & Clarke, 2022). Themes were developed through an iterative process of engagement with the full data corpus, identifying candidate themes, refining themes, and focusing on the primary research question: How have YBMSM experienced violence and what are the consequences associated with those experiences?

Results

We interviewed 31 YBMSM living with HIV in Chicago. Sample characteristics are presented in Table 1. Through our analysis process, we identified five primary themes that reflect how YBMSM experience violence at the intersection of racism, homonegativity, socioeconomic status, and HIV status: (a) the experience of intersectional violence; (b) long histories of violence contributed to hypervigilance, lack of safety, and lack of trust; (c) making meaning of violence and the importance of strength; (d) normalizing violence for survival; and (e) the cyclical nature of violence.

Table 1.

Demographic characteristics of study participants (n = 31).

Continuous variables	M	SD
Age	28	3.2
Categorical variables	N	%
Race/ethnicity
Black	29	94
Multiracial (with Black as one of those races)	2	6
Sexual identity
Gay	23	74
Bisexual	4	13
Queer	2	6
Nonconforming	1	3
Pansexual	1	3
Education
Less than a high school degree/GED	1	3
High school graduate/GED	9	29
Some college or technical school	16	52
College graduate	4	13
Missing	1	3
Viral Load (self-report)
Undetectable	14	45
Missed ART doses in the last week
None	16	52
1–2	10	32
3–4	2	6
5+	1	3
Missing	1	3

Note. Percentages represent the number of people who responded to each question. Percentages may not add to 100 due to rounding. ART = antiretroviral therapy.

The experience of intersectional violence

Our interviews revealed complex narratives of violence and trauma experienced by YBMSM living with HIV in Chicago. Individuals described how experiences of structural violence were interconnected in their lives: racialized poverty, reinforced by housing segregation, was embedded within a culture of White heteronormative, anti-Black racism. These structural drivers exposed many study participants to multiple forms of violence.

For most participants, their earliest experiences of violence and trauma were through neighborhood violence, which were frequently attributed to the intersection of structural racism and living in high poverty, highly segregated, and predominantly Black communities. As one participant stated, “Oh the Southside, it’s just always rough. It was just always a survival technique. They [society] don’t really care about us” (Roger, age 28). Similarly, some participants described being born into violent public housing projects in the late 1980s and early 1990s.

There’s been a lot of violence. I’m from Cabrini Green projects. So yeah, I witnessed my first shooting when I was 5 years old. I witnessed somebody get pushed off the 10th floor of the building. I witnessed a rape. I witnessed police being shot. I witnessed police shooting at multiple people. I’ve been shot, I’ve been jumped.—RJ, age 30

As this description highlights, many of the study participants had extensive exposure to violence over their lifetimes, much of which was rooted in or stemmed from structural forces, including the creation of racially and socioeconomically segregated neighborhoods.

Intersectional violence was also evident in the way participants discussed their experiences of violence, frequently centering their identities as Black men and noting heteronormative expectations. Centering their Black identities is an approach that intentionally focuses on anti-Black racism and racist structures that contributed to their experiences of violence and oppression. In the excerpt below, Mateo described the impact of violence and HIV on Black men in Chicago.

Violence and the words, “young Black males,” sometimes seems to go hand and hand. It’s serious because what we have to realize is that the fight is two times as hard because we’re dealing with the violence that’s from guns and gangs, but we’re also dealing with the violence that people are facing at home. We’re dealing with things that are years in the making. There’s no way we’re going to be able to come in and just break 21 years of hustling and gang banging or 21 years of living life thinking about is today going to be our last day? Or 23 years of trying to hide your sexual orientation because you’re worried about what friends and family may think. No way we’re going to be able to break down all those traumatic experiences with one shot. It takes repeated shots. It takes, like we said, those goals, you just have to keep going.—Mateo, age 23

This participant succinctly highlighted the challenges young Black men face in overcoming violence and trauma, including anti-Black racism and homonegativity. As he notes, the challenges they face as young Black men, including in HIV care, are “years in the making” and to overcome those challenges requires repeated opportunities, supports, and interventions.

In alluding to above, in addition to extensive neighborhood violence, some individuals were also exposed to violence at home or in school, often due to their sexuality. Yet, this violence was closely intertwined with their experiences as Black boys and young men.

It was kinda rough at home too. I’m getting bullied at home and then I’m getting bullied at school. Then, when I come home, it’s my mother, now, my dad, telling me to act a certain way that I couldn’t act. I’ve always been flamboyant. And then she put me in sports and stuff like basketball, football, but I did not wanna play basketball. I did not wanna play football. I felt like she was just doing this because she felt as if I was too feminine.—Michael, age 30

For some participants, violence was all encompassing, and some individuals had difficulty finding spaces where they were both physically safe and safe to be their authentic selves as gay, bisexual, or queer young people. In this sense, violence was often conceptualized beyond physical violence, to include the stigma and homonegativity men experienced and the mental and emotional trauma that created.

And race and ethnicity are important, because that would tell you a lot about some of the social barriers or social challenges that those people are facing, not just in their community, but also at home. I always want to use the example of sexual identity. There’s a lot of people that are not ever going to have that support system. And they may be living a lie because at the end of the day, they’re not going to ever feel comfortable enough to even reach out to a parent [about their HIV status]. You would rather die than disappoint them, let them know some news like that, when they didn’t even have the parents to let them know the news of their sexuality in the first place.—Mateo, age 23

Another individual made a similar reference to the violence of internalized stigma associated with his identity as a Black gay man. Individuals wrestled with their identities, struggled to find acceptance in various facets of their lives, and expressed self-doubt and feelings of inadequacy.

The only violence I have endured or encountered is the violence of myself. Is the violence of me not trying to accept the truth for whatever the truth may be, trying to always see the best in people, but that’s what makes me, me.—Eric, age 24

Finally, intersectional trauma was also evident in the way YBMSM talked about not being afforded space or time to process the multiple experiences of violence in their lives. Several participants highlighted how they lived in survival mode, which often meant they had to bury their experiences of violence and keep moving forward. One participant described the violent, homophobic bullying he experienced in high school, recounting a particularly traumatic experience in the football team’s locker room. He stated he “didn’t speak of it” to anyone, noting:

As Black people, we are taught to, I guess, not heal through our things. We are taught to move forward and just keep going. So, I had that mindset for a while, until recently. I healed through everything that I’ve been going through. I had to just keep going no matter what.—Anthony, age 25

Violence, hypervigilance, and lack of safety and trust as a consequence of violence

As described above, participants in this study had long histories of violence, often beginning in early childhood. As children, many participants were exposed to community violence, family violence, and neighborhood and school bullying. One of the most commonly discussed reactions to this bullying was hypervigilance. Participants described feeling “on edge” and anxious. One participant explained:

It’s made me more of a vigilant person when it comes to people and watching their actions and their body language and what they may want from you. . .violence, in general, has made me feel like I have to kinda protect myself in a way. Probably more so of not just being vigilant, but having some sort of protection around me.—Peter, age 23

Like this individual, several participants described how violence contributed to a general suspicion of others, a lack of trust, and a need to be hyperaware of their surroundings at all times. Individuals described needing to “keep my guard up” and expressed a lack of trust of other people. One participant described feeling as being “paranoid.” When discussing barriers to seeing his doctor he noted:

I have PTSD because I did have an experience recently where I had got robbed. Yeah, I got a gun pulled on me twice. So, that gave me PTSD. So sometimes I don’t even want to go outside.—Jackson, age 29

Importantly, this was part of a conversation around barriers to seeing his HIV provider. He noted the anxiety he experienced when leaving the house due to more recent violence he had experienced. He stated: “I’m definitely real paranoid now. I’m very cautious now. I don’t trust anybody anymore” (Jackson, age 29).

Trauma-related symptoms and reactions to violence were frequently reported, although not always described as PTSD as with this participant. For example, another participant described a shooting that occurred in front of his home when he was 13:

That was the first time I actually seen somebody actually get killed in front of me. It left an impact because that was the first time, but it wasn’t the last time. It just prepared me for the next time. But it wasn’t really traumatic. I wasn’t shot at, at that time. But I’ve been shot at before.—Pete, age 28

He noted that although this experience “left an impact,” he didn’t consider it traumatic since he was not shot at. When asked how the experience impacted him, he stated, “To see the visual, it does something to you. You see it in your nightmares and stuff.”

Having experienced violence in several areas of their lives, many participants described how they frequently lacked a sense of safety, particularly as young children. When asked how childhood violence affected him, one participant stated:

I can answer that this way; I was more scared of my mother than anybody else, so my safety was always more compromised at home than at school, so I wasn’t really afraid of what anybody else could do to me. My safety was always in question for me. . . It’s definitely helped me be stronger than I think I would have been if I did not. I definitely have a strength about me that is not wavering, won’t waver, and so I take pride in that from things I went through. . . Violence in general helped me be a man in this society, in this demographic.—Johnny, age 30

The connection between violence and conceptualizations of masculinity was evident in several men’s narratives. As detailed in the following section, several participants noted that, despite the negative consequences of violence, these experiences helped them to “be a man,” which was particularly important given their identities as sexual minority men. Additionally, some individuals, like the young man quoted above, found pride in their survival and thriving following difficult childhoods plagued by violence, often making reference to their strength.

Making meaning of violence and the importance of strength

Within the context of residing in communities with significant economic disinvestment, racialized poverty, high levels of policing and neighborhood violence, many participants struggled to find ways to make meaning of and cope with the violence they confronted on a regular basis. Knowing that life was going to be difficult by virtue of being Black sexual minority men was a reality. Some individuals framed these experiences of violent trauma as making them stronger. The need to “be strong” was commonly discussed among participants in conversations about the impact of violence in their lives. Several individuals described the need for self-defense and to be “strong” to survive violent episodes in their life. Others described how they stood up for themselves or overcame the trauma of childhood violence and bullying and how those experiences made them “stronger.” Conversely, not standing up to violence or not fighting back when attacked made participants targets of continued violence. The following participant described his experiences of homophobic bullying and harassment in school and how he responded:

I don’t wanna hear all that psychological blah, blah, blah. If you don’t stand up for yourself, they gonna keep on messing with you. That’s just what it is. . . I was probably effeminate, a little bit. But every year, what I’m telling you, every year I got harder and harder and harder. And what I mean by that is, “Okay, I’m gonna be tougher. I’m gonna be tougher.” And I’m happy that it did happen to me, in hindsight because, nothing against effeminate guys, but I don’t want that. I don’t even hang with people like that.—DeJuan, age 29

As evident in this excerpt, childhood bullying was often attributed to not conforming to gender and heterosexuality norms. One common response was a desire to be “tougher” and, in doing so, conform to more traditional conceptualizations of masculinity. This was often evident when men talked about their experiences with sexuality-related violence at home.

I would say that it’s like boot camp. They [My parents] wanted you to be strong because they knew I was going to be gay. And just them trying to make me stronger. That’s what they say these days.—Ricky, age 29

These discussions around strength were tied to their identities as sexual minority men. This was especially true when talking about family violence, as men described how the violence, they experienced at home was often an attempt to make them “strong” or less feminine. This reaction may stem, in part, from internalized homonegativity and the anti-LGBTQ messages participants had been exposed to. Most commonly, this was evident in homonegativity in families of origin, where many participants were teased, ridiculed, or physically or emotionally abused due to their sexuality or “feminine” characteristics.

Strength was also important to defend oneself in physical altercations. While this was occasionally in response to lack of safety within their communities, it was often described within the context of school bullying. Individuals described learning the importance of fighting early in childhood, noting that it was often seen as essential for survival, both literally and mentally. One participant described the constant homophobic bullying he faced in school, including online harassment and physical attacks.

I grew up fighting. I grew up in these poverty-stricken neighborhoods, so you have to fight. You have to know how to stand on your own and stand your ground. But they don’t teach you how to do that with multiple people. When there’s multiple people attacking you, when there’s multiple people putting you down, at some point you’d be like, dang. You start to believe it [the homophobic messages] a little bit. I hate that. . . there wasn’t nobody defending me. It was like me constantly defending myself against all these people. I was just singled out, and I really hated that.—Mateo, age 23

Later, Mateo went on to describe his childhood community as a “warzone” and described how these experiences “made me the person I am today.” He stated:

I learned a lot just living in the warzone and going through that and what it’s like to survive in those type of environments. It really taught me a lot about how to persevere and how to really take advantage of the opportunities given today. You never know when your last moment with a friend and when it’s going to be your last time hanging out with your family and stuff like that.—Mateo, age 23

As evident in many of these young men’s narratives, Mateo was not outwardly resentful, revengeful, or angry about these experiences. Many participants spoke very matter-of-factly about their experiences with violence. While such experiences were certainly traumatic and brought a lot of loss and tragedy into their lives, participants cited these experiences as transformative or important in shaping their identities.

Finally, for some participants, prior experiences of violence had highlighted their need to be “prepared” for violence or mistreatment. One participant described extensive bullying in school related to his sexuality and a learning disability. He recounted numerous instances of being physically and verbally attacked and in response, he started carrying a gun and practicing at a shooting range in preparation for future assaults.

I don’t start fights, but I will finish them. That’s always been my motto. . . I’m tired of fighting. At this point I mean, I’m just gonna shoot. . . I’m not gonna swing, I’m gonna shoot. And yes, my gun is registered. . . I got tired of fighting people. I don’t want to fight anyone anymore. If you’re gonna insult me, I’m just gonna shoot you, period.—Marcus, age 30

Although firearms were a leading cause of injury and death within participants’ lives, they also contributed to a perceived sense of safety and power. Part of his motivation for carrying a gun stemmed from the murder of his best friend while the two were walking home from school. He stated that he was “not a very violent person” but was prepared to use violence in self-defense.

Normalizing violence to survive

Within the context of multiple forms of violence, many participants assumed a normalization of violence. As noted in prior sections, this was partly attributed to survival norms around strength and masculinity, within the context of trauma.

I’ve seen a lot of fights in my entire lifetime. I seen somebody get shot at. I’ve seen how it looks when somebody does shoot them. It’s pretty terrifying. But around my neighborhood, that’s just something that I was always used to. Something I was accustomed to.—Kayden, age 24

Another participant had similar thoughts:

I’ve been witness to a lot of partner-on-partner violence. I’ve been a witness to child molestation. Not me, but I’ve seen it firsthand on a relative and an older person. I’ve seen drug deals gone bad. I’ve seen a group of people jumping one person and fighting. I’ve seen all of it, but it never affected me. Well, maybe in the beginning, but then after so long it just becomes, okay, this is normal, as long as I’m going to school and able to come home.—Oliver, age 30

Consistent with normalization, participants often dismissed the idea that such violence had affected them in any way. They referred to it as normal and something they were accustomed to. Yet, as one participant insightfully stated, “They may not even realize what they have experienced or gone through because they just deal with it and move on”—Montrell, age 27.

Part of normalizing violence was finding an explanation for the violence they experienced as children, particularly within their homes. Participants gave detailed accounts of physical and sexual abuse and neglect, and yet often normalized the behaviors of their parents or family members in terms of what was typical within their communities.

My mama had to stop my father from whooping us. Like I said, he was an alcoholic and he used to whoop us. And one time, he whooped us so bad, and even today I wouldn’t whoop my kids like that. That would be considered abuse. It wasn’t abuse. That’s what parents did back then. That’s just what it is in the Black community, the Hispanic community. That’s just a cultural thing.—DeJuan, age 29

As this participant explained, this type of child-rearing was “what parents did” in the Black community. Many of these child-rearing practices were rooted in the notion that Black youth had to be strong to survive living in a society that would be especially difficult because of entrenched anti-Black racism rooted within the American experience, especially for youth growing up in Chicago. Such practices were seen as preparations to defend themselves against future violence. DeJuan went on to describe how these experiences impacted him:

How has it impacted me? It’s part of being in the ‘hood. I’m still alive. It’s impacted me where I’m not afraid. How it impacted me? I’m always carrying something. I will stab you right here and pull it out and call the police. And I will do it again. But it’s self-defense. It’s nothing different than them white people or some Black people saying they got their guns and they ready to shoot to protect their selves. That’s what the world has come to, especially America, with all this violence. You’re on alert. How it made me more defensive. I’m not gonna bother you, but when you bother me, I’m gonna make sure I destroy you.—DeJuan, age 29

As this participant explained, although he was “not afraid,” he carried weapons with him for self-defense after having experienced several instances of violent victimization in his life. He also noted that such experiences were “part of being in the ‘hood,” referring to the normalization of violence within some predominantly Black inner-city neighborhoods.

The cyclical nature of violence

For some participants, the normalization of violence fueled the use of violence as a tool for managing conflict and self-defense, which perpetuated a narrative that violence was cyclical. As participants explained, however, such cycles were often complex. They described self-defense, reactions to persistent bullying, and efforts to demonstrate their masculinity (often in response to homophobic violence and bullying) as fueling violence. For some, violence was also how they had been taught to solve problems or cope with anger.

I had noticed that during my college days a couple years ago, I would get drunk, and the guy that I was talking to and stuff like that, I would be real aggressive with him, and be choking him up, hitting, stuff like that. That stuff was not cool, but it was the way that I felt love. It was the way that I was showed love, when somebody messes up, I was taught—when I messed up, I got a whooping, so if somebody doing me wrong, they got to pay for that, or they’ve got to hurt how I hurt, or make them feel how I feel. . . I was just basically a product of what I had seen growing up. I was basically doing the same thing my dad was doing, but instead of doing it to a female, I was doing it to a male.—Mateo, age 23

This reflection provides insight into how participants attempted to make sense of the violence they had experienced as children. For some individuals, their perpetuation of violence was in response to stress, anxiety, and anger resulting from their own traumas.

I was real angry in school. I was angry as a kid. I got into a whole bunch of fights. I got suspended a lot. I broke my teacher’s leg. It’s like, I was just doing a lot of stupid stuff trying to express myself. When I look back, I say, maybe it was me trying to express myself, trying to deal with what was happening to me.—Ray, age 23

Others described how violence at home contributed to their own violent behaviors. One individual described regular “ass whoopings” from his mom:

I would get my ass whooped by my mom, and then the next day I would go to school and start a fight for no reason whatsoever. It didn’t do anything, it just made me want to act up even more because I didn’t get the attention that I wanted when I was doing good. I figured if I did something bad, I would get attention. That’s pretty fucked up, but that’s how it was for me during that time.—Mateo, age 23

Finally, another participant explained how the trauma, mental health challenges, and pain of being rejected by family members because of their sexuality led him to lash out with the use of anger.

[Violence is] coming from because they’re angry. They’re angry because they did catch HIV. They’re angry because their momma did kick them out and things of that nature. They’re angry because they feel marginalized. They’re angry because they feel unloved. . . And it’s a misplaced anger when they around each other and they put the anger on themselves. And so, on a psychological level, they’re bringing their anger out on the wrong people, themselves. . . I don’t even hang with young black gays; They already got a chip on their shoulder, they’re angry. Part of that anger is because they saw the world just don’t care about them. You hear me?—DeJuan, age 29

This participant described the internalization of anger and the emotional and mental health consequences of trauma. He suspects that this anger is due to their marginalization associated with their HIV status, sexual identity, and feelings of neglect.

Discussion

Results from this study demonstrate how violence experienced by YBMSM living with HIV is rooted at the intersection of anti-Black racism, homonegativity, poverty, gender norms, and other social and structural-level factors. A key contribution of this study is its focus on the intersectional nature of violence and trauma, that is, violence shaped by the interlocking nature of structural racism, homonegativity, poverty, and HIV status. This approach recognizes the multiple and interacting forms of violence, abuse, and trauma in men’s lives including, but not limited to, experiences of childhood abuse, racism, sexuality-based discrimination, criminalization, bullying, community violence, and intimate partner violence.

Participants described myriad consequences associated with the violence they experienced as children. Perceptions of extreme danger or having one’s personal well-being severely threatened, can contribute to psychological consequences including hypervigilance and habituation (Monteith et al., 2013). Habituation often results from repeated exposure to violent incidents (Monteith et al., 2013). For many participants, the pervasive combination of family violence, school bullying, and neighborhood violence led to a normalization of violence and for some, perpetuation of violence themselves. In an effort to defend themselves and cope with trauma, many turned to violence as both an act of self-defense and an expression of anger. They reported a need to stand up for themselves; many participants clarified that they were “not violent,” but participated in violence to defend themselves. As one individual stated, “there wasn’t nobody defending me.”

Our study highlights how multiple forms of violence can accumulate across an individual’s life, which lead many participants to conceptualize violence as cyclical. There has been a long debate about the extent to which violence is cyclical and under what circumstances, yet there is evidence that for some people, various forms of exposure to childhood violence can contribute to violence perpetration as adults and increase vulnerability to further violence (Wright et al., 2019). One theory of the cycle of violence characterizes violence as a consequence of community strain (Burrell et al., 2021). Cumulative experiences of violence within a community are posited to create a reinforcing condition of accelerated violence. The “community memory” of violence over time creates rising tension that increases the risk of subsequent violence (Burrell et al., 2021). Importantly, structural racism can increase community strain. One of the major contributing factors to community tension is racist policies and practices (e.g., economic deprivation, spatial isolation, police violence), which can decrease one’s sense of self-worth and limit access to important community resources (Burrell et al., 2021). Future research should examine how such forms of violence influence mental health and HIV treatment among YBMSM.

Given the prevalence of violence experienced by YBMSM, we need to interrogate the relatively little research that has been done to understand various types of violence among YBMSM living with or vulnerable to HIV. Future syndemics research must move beyond a focus on interpersonal violence to examine social and structural violence rooted in racism and homonegativity, and how these systems contribute to disparities in HIV outcomes. Interventions are needed that focus on structural factors including exposure to violence, poverty, discriminatory policing and criminalization, and housing instability. Researchers have called for socio-contextual interventions to deter community violence, move beyond an individual-level approach, and understand violence and emphasize anti-racism community action led by community members (Monteith et al., 2013). However, longitudinal quantitative studies are needed that examine violence syndemics and the intersectional nature of violence experienced by YBMSM to adequately inform the development of such interventions.

Finally, it should be noted that despite the violence syndemics that many of these men were exposed to related to racism, racialized poverty, homophobia, HIV stigma, partner violence, childhood sexual abuse, and family rejection, many participants displayed resilience in many forms. Over 60% had attended or completed college. Nearly 50% had undetectable viral loads and reported high levels of ART adherence. They also described overcoming incredible odds, creating healthy support systems for themselves and their families of choice, and doing important jobs and volunteer work to improve the lives of other Black sexual minority men. Although these results are outside the scope of the current article, we want to acknowledge that despite the trauma and violence described herein, the ways in which these men have thrived are to be commended.

Despite the significant contributions of this study, there are limitations to note. First, our qualitative data can shed light on the various forms of violence experienced by YBMSM and some of the consequences of those experiences. Quantitative studies are needed to test syndemic theory and determine whether these experiences of violence operate synergistically. Second, although we used a variety of recruitment strategies, most participants were recruited via case managers or HIV service providers. As a result, participants in this study may not have experiences that reflect those of YBMSM who are not engaged in HIV care or social services or are not able to safely discuss their HIV status or experiences with violence. We also did not capture the experiences of YBMSM who were incarcerated or recently released from jail or prison who may not be engaged in HIV care. Third, like most research conducted in 2020 and 2021, our protocol was influenced by limitations due to COVID-19. For example, we were unable to do in-person recruitment and interviews were conducted via Zoom, both of which may have influenced who was able to participate in this study. Finally, in these analyses we did not examine police violence. Participants did discuss police harassment, bullying, and violence and we are working on a separate analysis that allows for an in-depth exploration of those experiences and provides sufficient space for that sensitive conversation.

This study is among the few that examines a violence syndemic experienced by YBMSM. Narratives reveal how participants have navigated myriad experiences of violence in their lives, which was often shaped by structural factors including poverty, racism, and homonegativity. As detailed in this study, violence was normalized for many young men and was often a coping mechanism or means of survival. Such experiences can influence HIV prevention and care and trauma-informed services must be prioritized as part of the effort to reduce the disproportionate effect of HIV on YBMSM.

Citation Diversity Statement

Recently, researchers have shed light on the racial, ethnic, and gender inequities in citation practices in numerous academic fields (Bertolero et al., 2020; Chatterjee & Werner, 2021; Dworkin et al., 2020), such that articles authored by women and racial and ethnic minorities are under-cited relative to the number of those articles in the field. Accordingly, during our writing process, we interrogated the literature we read and cited, and aimed to cite research that reflects the diversity of the field in thought, method, gender, race, and ethnicity of authors. Although this approach is insufficient for addressing these biases, we aim to raise awareness and encourage other scholars to examine their decisions in citation.

Footnotes

Acknowledgements

This work would not be possible without the individuals who agreed to participate in this study. We thank them for their willingness to share their stories with us and their trust in us to use these data to improve HIV care. We are grateful for the contributions of the study team members at the AIDS Foundation of Chicago and our supporting community members and organizations.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the National Institute of Mental Health (R21 MH122010; MPI Quinn and Voisin).

ORCID iDs

Katherine G. Quinn

Lois Takahashi

Author Biographies

Katherine G. Quinn, PhD, is an associate professor at the Center for AIDS Intervention Research at the Medical College of Wisconsin. Her research examines social and structural barriers to HIV prevention and care for young Black sexual and gender minority individuals. She has expertise in qualitative methods, intersectional stigma, and the influence of racism and homonegativity on HIV care and prevention.

Travonne Edwards, PhD, is a candidate in social work at the University of Toronto. His research aims to improve support for Black families involved in the child welfare system.

Anthony Johnson, PhD, is a recent graduate of Loyola University of Chicago School of Social Work. His research focuses on HIV prevention, health disparities, resilience, and intersectionality.

Antoinette Spector, PT, DPT, PhD, is an assistant professor at the University of Wisconsin–Milwaukee. Her research focuses on health disparities affecting women, racial and ethnic minorities, and older adults.

Lois Takahashi, PhD, is the Houston I. Flournoy Professor of State Government and director of the USC Price School of Public Policy in Sacramento. Her research focuses on public and social service delivery to vulnerable populations, including people living with HIV/AIDS.

Andrea Dakin, PhD, is the senior director of Shared Program Services at the AIDS Foundation of Chicago. She has extensive experience in nonprofit management, research on public health and social issues, and evaluation of public health programs.

Nora Bouacha, MPP, is the senior manager of Research and Evaluation at the AIDS Foundation of Chicago. She has expertise in public health research and evaluation and working with communities to address health disparities.

Silvia Valadez, MA, is a research assistant at the AIDS Foundation of Chicago. She is experienced in working with racial and sexual minority communities to address HIV prevention and building partnerships with communities to facilitate research.

Dexter R. Voisin, PhD, LCSW, is the dean in Jack, Joseph, and Morton Mandel School of Applied Social Sciences at Case Western Reserve University. His research examines how structural and interpersonal forms of violence impact health behaviors and outcomes among minority populations. He is a leading expert on the impacts of violence in Black neighborhoods and the ways youth, families, and communities cope with violent trauma.

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