Sexo y la Ciudad : Sexual , Ethnic and Social Identity Intersections of Latino Gay Men in New York City

While Latino gay men have been the focus of HIV prevention efforts for decades, there remains a dearth of Latino gay male-specific HIV interventions. As part of a formative assessment to adapt an HIV prevention intervention, this study explored the process in which urban immigrant Latino gay men negotiate their ethnic, sexual and social identity. The assessment consisted of four focus groups of 28 adult immigrant Latino gay men in New York City. Two major themes emerged: 1) the need for identity formation and integration (including sexuality and ethnic identity); and 2) the need for venues for expression and defining community (including places that accepted the participants as Latino and gay). Based on the emerging themes, we recommend HIV prevention services for Latino gay men be comprehensive and holistic, fostering identity development and integration, as well as skill development. Intervention adaptations need to enhance linguistic translation with deeper knowledge and inclusion of key cultural and community values. In addition, the data indicated few spaces in New York City where Latino gay men felt comfortable articulating a whole self. © 2012 Californian Journal of Health Promotion. All rights reserved.


Introduction
Latino gay men experience a disproportionate amount of HIV/AIDS burden.Latinos constitute approximately 15% of the United States population, but 19% of reported new HIV/AIDS cases (CDC, 2009).Among Latinos, gay men constitute 47% of all reported HIV cases (CDC, 2009).Among gay men in New York City, Latinos comprised 31.6% of those diagnosed with HIV in 2007 (compared to 29.3% of white gay men).Latinos living with HIV also suffer from the second highest rate of AIDS mortality in New York City (NYC DOHMH, 2008).The Centers for Disease Control and Prevention (CDC) reported that immunosuppression at the time of diagnosis was generally least among whites and greatest among Latinos (CDC, 2011) indicating late stage diagnosis, or barriers to care even when diagnosed.
HIV risk for gay men has been linked to the social environment.Gay men active in the bar scene have higher rates of HIV risk behaviors (Flores et al., 2009).Psychological well being of ethnic minority gay men has been correlated with feelings of connectedness to a larger communitywhether that community is considered by race, sexuality, class or age (Kertzner, Meyer, Frost & Stirratt, 2009).Even with this evidence, few studies have looked at Latino gay men's connection to their social environments.For Latino gay men, there is a dearth of evidence-based interventions that focus on cultural, environmental and identity factors that may affect their HIV risk (Ramirez-Valles, 2007).

Impact of Social Forces on Latino Gay Men
Latino gay men are affected by three socially oppressive forces -poverty, racism and homophobiawhich are associated with experiences of alienation and personal shame (Diaz, 1997;Diaz et al., 2001).Latino communities, especially those foreign born, rely on informal and formal social networks to obtain basic services.Homophobia can cause a schism and lack of acceptance of Latino gay men in the larger Latino community (Diaz, 1997).It is also possible that their sexual orientation negatively impacts their healthcare access and support-seeking behavior at the personal, familial and community levels (Diaz, Ayala & Bein, 2004).
Just as Latino gay men are part of a larger Latino community, they are part of a larger gay community.Gay communities have developed their own spacessuch as neighborhoods, businesses and community centers (Dowsett, 1996).When racial/ethnic minorities enter these gay spaces, racism may prevent them from fully accessing services targeting gay populations (Dube & Savin-Williams, 1999).Racial/ethnic minority gay men may feel caught between racial and Lesbian, Gay, Bisexual, and Transgender (LGBT) communities (Crawford, Allison, Zamboni, & Soto, 2002), thereby negatively impacting their HIV risk (Wilton et al., 2009).Furthermore, for Latino men, sexual identity can be considered a construct contingent upon certain behavioral and contextual factors such as whether they adopt an insertive role in sexual practices, have sex with effeminate men or have romantic relations with women (Zellner et al., 2009).The selective circumstances in which some Latino gay men define their own sexual identity can have implications in the design of public health strategies (Finlinson, Colon, Robles & Soto, 2006).

Becoming a Member of a Society
Civic participation can both demonstrate that a specific identity is integrated into the community (Sommers, 1993), or can be a means to publicly express the identity of a specific group.In London, for instance, Speakers' Corner of Hyde Park has a longstanding and accepted tradition of public expression.
Opinions find an audience in passer-bys, who often retort if the mood strikes them (Kurlantzick, 2000(Kurlantzick, /2001)).Others join in or publically voice their own testimonials.Even those new to London -immigrants and touristsget drawn into the conversation; willingness to participate illustrates desire for a public voice (McIlvenny, 1996).Speakers' Corner is a visible public sphere, a space where the rules of a society are demarcated, expressed and controlled (Habermas, 1989).
The public sphere is not always visible but has direct bearing on an individualby providing normative rules for inclusion and exclusion.An individual's capacity to confront, shape or conform to these rules can affect a range of behaviors that could lead to poor health outcomes (e.g.self-medicating with alcohol or drugs to cope with low self-esteem, increased risk taking to accommodate feelings of exclusion, and even a lack of knowledge on community norms on health and safety).Immigrants entering a new public have to negotiate identity and practices (Kinefuchi, 2010;Wong-Rieger & Quintana, 1987); combining elements of the country of origin and the new home (Wilson, 2009).Immigrant Latino gay men experience multiple cultural values, gender roles, religious values and homophobia, all of which affect the formation and integration of their sexual identity in the United States (Parks, Hughes, & Matthews, 2004).In one study of young Latino men-whohave-sex-with-men (MSM), a lack of ethnic and gay community attachments were associated with reported unprotected anal intercoursea risk for HIV transmission (O'Donnell et al., 2002).
This study serves as a formative assessment examining Latino gay men's cultural, community and identity HIV-risk factors for the purpose of adapting an HIV prevention intervention originally targeting white gay men (Vega, 2009).
The program is to be implemented at a community-based organization (CBO) in New York City, and address both surface cultural sensitivity issues (e.g.language) and deeper cultural sensitivity issues (e.g., cultural values and needs) in order to effectively recruit, retain and impact intervention participants (Vega & Cherfas, in press).Four focus groups were conducted to adapt the intervention.Focus group data was used to assess two exploratory research questions: 1) what are the needs of NYC Latino immigrant gay and bisexual men, ages 18-35 (and their sexual partners) considering the intersection of ethnic, sexual and social identity; and 2) what are program design needs for HIV prevention programs targeting Latino immigrant gay men.

Study Design
Qualitative methods were used as they have been useful in determining personal and community trajectories in health and risk behaviors (Boeri, Harbry & Gibson, 2009).As a methodology, focus groups utilize a moderated group discussion to get at specific issues (Robinson, 1999).Focus groups provide an interactive dynamic among research participants that can elicit information in a naturalistic way (Kitzinger, 1994), an effective way to gain insight from a small group on specific phenomena, especially among socially marginalized groups (Hudson, Aranda & McMurray, 2002).Focus groups have been successful with Latino populations due, perhaps, to interactive communication appropriate to the community (Saint-Germain, Bassford, & Montano, 1993).

Participants
Participants were recruited for four focus groups.The selection criteria for the focus groups included: a) ages 20 and older; b) selfidentify as Latino/Hispanic; c) male; d) and gay or bisexual.Participants were asked how long they had been in the US.Participants were recruited utilizing convenience sampling, through phone and email contacts of individuals who previously participated in a programs or event at the CBO.Phone and email contacts were also made to local Latino LGBT service providers.Snowball recruitment techniques were also utilized, in that respondents were asked to disseminate study information to others in their social networks.

Instruments
The research team adapted the original intervention formative assessment guide (Kegeles, Hayes & Coates, 1996).The original instrument explored issues for young gay/bisexual men in how they view the LGBT community; their perceptions of the greatest needs of the community; and how to build an effective peer based program to address those needs.The original instruments were scale instruments; in this project, six cognitive interviews were conducted to determine understanding of the questions for the qualitative approach (data not shown).For this study, questions were added to assess the experiences of immigrant Latino gay and bisexual men based on the cognitive interviews.At the end of the focus groups, demographic data were collected with a brief self-report survey.
All instruments utilized during the focus group were translated and back translated from Spanish to English, to ensure reliability of the data collected.After all focus groups were completed, the principal investigator, research team and focus group facilitators discussed overall trends and patterns that emerged.The focus groups were audio taped with the permission of participants and subsequently transcribed by a professional transcription service.IRB approval was granted by the CBO's external IRB.

Data Collection Procedures.
All four focus groups were administered in a combination of Spanish and English (colloquially known as "Spanglish") at the New York City CBO, the Latino Commission on AIDS.Participants could speak English or Spanish.The focus group facilitators were male, bi-lingual (Spanish/English) and self-identifed as gay.They each had four years of experience providing bilingual (Spanish/English) services to Latino gay men in New York.This experience was key in ensuring that facilitators could "code switch" with participants and moderate appropriately, considering the range of idiomatic words common to diverse pan-ethnic Latino/Hispanic groups.

Data Analysis
For each focus group, data was compiled from the transcripts, facilitators' notes, supplemental questionnaires and audiotapes.The audiotranscriptions and notes were read twice by the primary investigator and a senior research associate and discussed with an experienced qualitative researcher.The primary investigator and qualitative researcher were trained in human subject research and have doctorates in their respective fields.Transcripts were uploaded into Atlas.ti,a software application used with qualitative data to uncover and systematically analyze themes.The transcripts were coded to index categories of responses to identify emerging themes in those responses.Categories were reduced to code families of responses, and these were grouped into major themes.Each major theme was comprised of more specific minor themes.The principal investigator conducted the first coding and then the senior qualitative researcher coded the data.The team achieved an acceptable level of reliability (a Kappa statistic of .80).

Participant Demographic Characteristics
Across the four focus groups there were a total of 28 participants.Ages ranged from 17-48 years.In looking at HIV status and sexual orientation, 60% of those who reported being bisexual also reported being HIV positive, and 50% of those participants who reported being gay also reported being HIV-positive.The majority of focus group participants (62%) had attended previous programs at the CBO.All (100%) of the participants indicated they had been in the country for ten years or less, an indicator of recent immigrant status (Finch & Vega, 2003).

Theme Identifications
Categories were grouped into two major topics through ongoing discussion between researchers and the re-reading of transcripts.The researcher then examined each topic area for themes within the code families that would be relevant for this project.The two major themes were: 1) Identity Formation and Integration for Latino gay men; and 2) Venues for Expression and Defining Community.Three minor themes were created in terms of the overall research question of the intersection of ethnic, sexual and social identity.

Major and Minor Themes
The two major themes and their subsequent minor themes are outlined below.A table has been included that shows examples of each minor theme.
Major Theme 1: Identity Formation and Integration for Latino Gay Men One major theme was the process of identity formation with three key identities: 1) holistic identity; 2) sexual identity; and 3) ethnic identity.In this section we describe experiences of Latino gay men in searching for comprehensive, holistic, and fully integrated identities.

Minor Theme 1: Holistic Identity Recognition
The first theme was the desire to be recognized in a holistic fashion.Across all focus groups, participants emphasized wanting to be seen as a "whole person", "human being".Some participants expressed frustration that HIV prevention programs targeting Latino LGBTs often only address topics such as condom use, and fail to engage in discussions about other areas of identity.When asked about topics they would be interested in talking about in peer based programs participants wanted to engage in discussion outside of the conventional HIV prevention model, and see programs that were "no céntrico HIV" [not HIV centered], engaging other facets of their identities as human beings.
Minor Theme 2: Sexual Identity Formation.When asked about sense of community among New York City LGBTs, participant opinions varied about level of inclusion and cohesiveness.Focus group participants varied in their opinions of the local LGBT community.When asked if participants felt part of the community, some reported experiencing difficulty integrating into the LGBT community.Participants lacked consensus that a unified LGBT community existed in New York.The bisexual focus groups commented that they did feel that there was a unified community, while the gay identified focus groups felt there was not a unified LGBT community.Numerous participants in the focus groups expressed a desire for a place to "desahogarse" or in other words, place to vent and communicate to and with others about their life story.

Minor Theme 2 Defining Community Representative Example
"Qué podría ser un grupo de homosexuales para latinos?Bueno, por la razón de ser latinos y la cultura latina, como estamos culturalmente representados, los grupos bisexuales o gays u homosexuales latinos, es un gran avance para mi, un gran avance para que las comunidades donde la cultura latina está bien arraigada y estamos como excluidos en cierta manera" [What could be a group for gay Latinos?Well, the reason for Latinos and Latino culture, as we are culturally represented groups gay or homosexual or bisexual Latino, is a breakthrough for me, a great step forward for communities where Latino culture is well established and excluded in some way ] When asked about sense of community for Latino LGBTs, participants responded they experienced challenges navigating the home and family contexts.Participants reported experiencing cultural stigma, lack of LGBT resources and restrictions to express one's sexual identity.Participants across all focus groups agreed the Latino community is still "conservative with subjects like sexual identity."One participant remarked that the expectation is to "not talk or tell anyone."For many Latinos, family is a central component of identity.Many immigrant Latino gay men fear discussing sexual identity with their families as they fear losing social and emotional support (Parks, Hughes & Matthews, 2004).
A major concern for many participants was lack of ability to express sexual identity in their neighborhoods.Several participants expressed concern that because of culture "we cannot put the [LGBT] flag outside or walk hand in hand [with your partner]."Some focus group participants discussed a preference for patronizing establishments known as "gay establishments" locally.This demonstrates another instance in which Latino gay men are forced to choose between their identities in order to maintain safety or harmony in their home environment.
When asked if there was a Latino LGBT community there was a lack of consensus among all four groups.Regarding Latino LGBT clubs, participants commented there were few establishments, categorized them as hidden and "not overtly gay."One participant in group 2 (primarily HIV negative) commented that based on observation there was no Latino gay community.Several gay HIV-negative focus group participants expressed a lack of desire to patronize establishments located in well-known gay communities and establishments they considered "overtly" gay.
When asked what their experiences were like as immigrant Latino gay men, participants expressed interest in learning and exploring American "gay culture."In terms of having sex with men several of the participants noted they would like to focus on what it means to be gay.
Many felt that in terms of actual sexuality, they were no opportunities to learn how or how to be "socialized" into their sexual identity.Several participants (in particular, younger Latinos) expressed "being in the dark".One participant noted trying to get a book on being gay (and what it entails sexually) for a younger friend, but not finding any in Spanish.He mentioned there is a real need to help Latino gay men learn "how to be gay" or help them socialize into the LGBT community.A gay HIV-negative participant commented, "personas no saben cómo actuar sexualmente y todo eso.Cómo tener relaciones íntimas sería" [People do not know how to act sexually and all that.How to be in intimate relationships].
Minor Theme 3: Ethnic Identity Formation.The third minor theme was the impact of ethnic identity formation.Participants reported that several aspects of ethnic identity, such as family, religion, nationality, cultural stigma and discrimination were major factors in participants' ability to integrate their identities.Several participants reported they felt they had to choose between identities as a way to cope in new community environments.Several participants felt there was a need to address Latino community discrimination towards gays.There was a sense that the Latino community does not embrace them because they are gay and this may impact Latino gay men's feelings of inclusion.

Major Theme 2: Venues for Expression and Defining Community
The second major theme that emerged from the focus groups was two-pronged.First, participants expressed a need for venues to examine issues they face in their daily lives including family, fear and disclosure.The second was the desire to define and integrate a sense of community for the Latino LGBT community in New York.

Minor Theme 1: Venues for Expression.
There was an overwhelming desire to have a venue for testimonials or life experiences.Numerous participants expressed a desire for a place to "desahogarse" or in other words, place to vent and communicate to and with others about their life story.During the focus group, participants expressed desire to engage in dialogue about experiences with stigma, discrimination, isolation, loneliness, relationships and disclosure.
Minor Theme 2: Defining Community.The last minor theme was how to design and create a peer based Latino LGBT community in New York City.Across all focus groups, when asked what types of prevention programs would interest Latino LGBT, the majority of participants responded that they wanted programs that were not just "gay focused," "HIV centered," "only about condom use", but also addressed the social realities experienced by Latino LGBT.Program participants expressed interest in developing a program inclusive of all sexual minorities (bisexuals, transgendered), families and Latino nationalities.
The first key component noted by participants in developing responsive community programs was creating a safe space to develop social identity and skills.Focus group participants mentioned an interest in a wide range of topics including: family communication, relationships, sexual identity, cultural identity and mental health topics.Most importantly participants discussed their desire for opportunities to develop and practice personal, social and even vocational skills in a "safe space." The second key component to defining this peer based community was the idea of including both aspects of sexual identities and nationality.The value of culture was inextricably linked to community, and these had public dimensions of inclusion.Of note, the participants suggested that current public spaces (whether Latino or gay) did not feel inclusive.

Discussion
Latino gay men are disproportionately impacted by HIV but there is a dearth of information on prevention interventions and ways to adapt in culturally sensitive ways the currently funded prevention interventions.We found that our sample of urban immigrant Latino gay men are yearning for venues to process topics related to their sexual, social and ethnic identity (Flores et al., 2009).The research team observed several themes centering on mental health issues such as loneliness, depression, family, discrimination and stigma.These are pertinent issues that can significantly impact healthy functioning, wellbeing and ability to utilize strategies to reduce risk of HIV.
Based on this exploratory study, identity would seem to be an integrative practiceone framed by cultural values, personal experience and social norms.The desire to be seen as a whole person could be interpreted as a method in which the community has processed the "disempowerment and marginalization" associated with being labeled as HIV high risk.The Latino gay men in this study articulated deep-rooted needs for holistic approaches to HIV risk, personal identity, and community support.These factors are synergistic in producing isolation and encouraging HIV risks; focusing on a single aspect diminishes opportunities for successfully incorporating health messaging and skills (Diaz & Ayala, 1999).Interventions should consider the impact of identity integration for Latino gay men, as well as participants' skill and capacity in affecting public discourse (Vega et al, 2010).
The public sphere, in this study, proved a place where Latino gay men either saw themselves or notand the absence was deafening.The individual's ability to engage the public has been shown to create higher connectivity and capacity to change social norms (Guidry, 2003).The capacity to engage in a public and social discourse connotes community membership.The struggle to voice one's subject position -"I am" -becomes, in part, a response to the public spaces that frame identity practices.
This study had several limitations.Although our study participants comprised a relatively small convenience sample, the research team will assess the adaptation of the program over the implementation period.Second, we utilized a convenience sample, who had prior contact with the organization.The findings and discussions from this project remain an important part of exploring identity issues related to ethnicity, sexuality and HIV.Third, the participants selfreported several components of their identity (e.g.HIV status, ethnicity, age, sexuality), but in this exploratory project, it was not feasible to externally verify self-reported identity.
This study highlights the need for programs to be culturally specific and sensitive to be effective, salient and inviting to Latino/Hispanic gay men.The recent National AIDS Strategy specifically identifies the need for community and culture-based interventions that situate individual risk within a structural environmental modelincluding considering space and holistic approaches (White House Office of National AIDS Policy, 2010).With shifts in health policy and public health practice, service providers and policy makers must accommodate new strategies in order to meet the goals in the plan.
There is a need for more comprehensive and holistic models of care in order to address systemic issues contributing to HIV related health disparities in Latino gay men.Higher prevalence of HIV infection among Latinos reflect multiple barriers to quality screening and prevention services, including lack of insurance, lack of transportation, concerns about stigma and confidentiality, and socio-cultural and normative beliefs (Zambrana, Cornelius, Boykin & Lopez, 2004).Considering the poor HIV health outcomesincluding immunosuppression of Latinos, there must be ongoing and specific focus on Latinos/Hispanics in HIV/AIDSnot just as part of a larger picture of "minority," but as groups in their own right.Given the ongoing influx of Latinos into the US, dissemination of innovative and grass roots interventions to this vulnerable population is critical and time sensitive.

Table 1
Participant Demographics

Table 2
"En lo particular, en lo que yo he alcanzado a ver en la comunidad latina gay aquí, es que no hay esas cosas.Sí hay quizás clubes, pero son dos o tres" [In particular, in what I have managed to see the gay Latino community here is that there are no such things.Perhaps there are clubs, but they are two or three.][inaudible] y todavía vive en el siglo Diez.yo pienso que las personas, tienen que ser... cualquier secreto que usted tenga en su vida... Yo pienso que las personas tienen que vivir su propia verdad, independientemente de lo que otra persona piense."[Important because, unfortunately, our community has many myths and [inaudible] and still live in century Ten.I think people have to be ... any secret that you have on your life ... I think people have to live their own truth, regardless of what other people think.]