White Gay Men Research Articles

Disclosure, discrimination and desire: experiences of Black and South Asian gay men in Britain

Using findings from a qualitative investigation based on in-depth email interviews with 47 Black and South Asian gay men in Britain, this paper explores the cross-cutting identities and discourses in relation to being both gay and from an ethnic minority background. Taking an intersectional approach, detailed accounts of identity negotiation, cultural pressures, experiences of discrimination and exclusion and the relationship between minority ethnic gay men and mainstream White gay culture are presented and explored. The major findings common to both groups were: cultural barriers limiting disclosure of sexuality to family and wider social networks; experiences of discrimination by White gay men that included exclusion as well as objectification; a lack of positive gay role models and imagery relating to men from minority ethnic backgrounds. Among South Asian gay men, a major theme was regret at being unable to fulfil family expectations regarding marriage and children, while among Black gay men, there was a strong belief that same-sex behaviour subverted cultural notions related to how masculinity is configured. The paper concludes by highlighting the importance of social location, particularly education and income, when examining the intersection of ethnicity and sexuality in future research.

Intersectionality, Critical Race Theory, and American Sporting Oppression: Examining Black and Gay Male Athletes

This article examines the influence of the racial categories of White and Black and the sexual categories of gay and straight on sporting American men. The effect of the intersection of these cultural categories is discussed by investigating the exclusion of athletes who are both Black and gay, as well as highlighting the culturally perceived differences of (straight) Black and (White) gay men. However, the analysis accounts for more than just difference, examining the commonalities of oppression between these discrete identity groups. We use the research on Black athletes to call for further empirical study on gay athletes. It is argued that critical race theory and intersectionality offer complex and nuanced understandings of these oppressions, which, when theorizing is left solely to the realm of poststructuralism, can otherwise be missed.

Social Support, Ethnic Identity, and Sexual Identity of Lesbians and Gay Men

Social support, sexual identity development, and ethnic identity development play key roles in individuals’ health and well-being. This study explores social support and identity variables in samples of ethnic minority (N = 297) and White (N = 294) lesbians and gay men. Ethnic minority participants as well as white participants reported generally high levels of satisfaction with social support, strong ethnic and sexual identities, and high levels of outness. Significant differences were found between satisfaction with overall social support and satisfaction with support for same-gender identity for all participants, and significant differences were found between White and ethnic minority participants in levels of outness. Positive relationships were found among coming out, ethnic identity, and satisfaction with support for the ethnic minority participants. Implications for research and practice are discussed.

Boys must be men, and men must have sex with women: a qualitative CBPR study to explore sexual risk among African American, Latino, and White gay men and MSM.

Men who have sex with men (MSM) continue to be disproportionately affected by HIV and sexually transmitted diseases. This study was designed to explore sexual risk among MSM using community-based participatory research (CBPR). An academic-community partnership conducted nine focus groups with 88 MSM. Participants self-identified as African American/Black (n=28), Hispanic/Latino (n=33), White (n=21), and biracial/ethnic (n=6). The mean age was 27 years (range=18-60 years). Grounded theory was used. Twelve themes related to HIV risk emerged, including low knowledge of HIV and sexually transmitted diseases, particularly among Latino MSM and MSM who use the Internet for sexual networking; stereotyping of African American MSM as sexually "dominant" and Latino MSM as less likely to be HIV infected; and the eroticization of "barebacking." Twelve intervention approaches also were identified, including developing culturally congruent programming using community-identified assets, harnessing social media used by informal networks of MSM, and promoting protection within the context of intimate relationships. A community forum was held to develop recommendations and move these themes to action.

Walking the line: Stimulant use during sex and HIV risk behavior among Black urban MSM

Background Although the association of stimulant use to sexual risk taking and HIV transmission has been well documented among white gay men, stimulant use during sex continues to be under-explored among Black men who have sex with men (MSM). Methods Black MSM ( n = 197) recruited via modified respondent-driven sampling between January and July 2008 completed an interviewer-administered quantitative assessment and optional HIV counseling and testing. Bivariate logistic regression procedures were employed to examine the association of demographics, sexual risk, and other psychosocial factors with stimulant use (at least monthly during sex in the past 12 months). Variable elimination using the backward selection process was used to fit two separate final multivariable logistic regression models examining stimulant use as the outcome and HIV sexual risk in the past 12 months by gender as the primary predictor: (1) Model 1: HIV sexual risk behavior with a casual male sex partner as a primary, forced predictor; (2) Model 2: HIV sexual risk behavior with a female sex partner as primary, forced predictor. Results One-third (34%) of Black MSM reported using stimulants monthly or more frequently during sex in the past 12 months. The following factors were independently associated with stimulant use during sex: (1) Model 1: unprotected anal sex with a casual male sex partner in the past 12 months (AOR = 2.61; 95% CI = 1.06–6.42; p = 0.01), older age (AOR = 1.09; 95% CI = 1.05–1.15; p < 0.001), erectile dysfunction (ED) medication use monthly or more during sex in the past 12 months (AOR = 7.81; 95% CI = 1.46–41.68; p = 0.02), problematic alcohol use (AOR = 3.31; 95% CI = 1.312–8.38; p = 0.005), and higher HIV treatment optimism (AOR = 0.86; 95% CI = 0.76–0.97; p = 0.01). (2) Model 2: unprotected vaginal or anal sex with a female partner in the past 12 months (AOR = 3.54; 95% CI = 1.66–7.56; p = 0.001), older age (AOR = 1.10; 95% CI = 1.05–1.14; p < 0.001), ED use monthly or more during sex in the past 12 months (AOR = 3.70; 95% CI = 1.13–12.13; p = 0.03), clinically significant depressive symptoms (CES-D) at the time of study enrollment (AOR = 3.11; 95% CI = 1.45–6.66; p = 0.004), and supportive condom use norms (AOR = 0.69; 95% CI = 0.49–0.97; p = 0.03). Conclusion Frequent stimulant use is an important factor in HIV and STD sexual risk among Black MSM, particularly for older men and those with co-occurring psychosocial morbidities. HIV and STD prevention interventions in this population may benefit from addressing the precipitants of stimulant use and sexual risk taking.

Queering Apartheid: The National Party's 1987 ‘Gay Rights’ Election Campaign in Hillbrow

This article investigates the anomaly in apartheid history of the ruling National Party's (NP) fielding a ‘pro-gay rights’ candidate in the Hillbrow constituency during the 1987 whites-only election in South Africa. The NP was aided in its Hillbrow campaign by the gay magazine Exit, which encouraged its readership to ‘vote gay’ in the election and published a list of candidates who were favourable to gay rights in South Africa. The Hillbrow campaign is intelligible when the intersections between race and sexuality are analysed and the discourses wielded by the NP and Exit are spatially and historically situated. The Hillbrow/Exit gay rights campaign articulated discourses about the reform of apartheid in white self-interest and conflated white minority and gay minority rights, thereby contributing to the NP's justification for apartheid. The NP candidate's defeat of the incumbent Progressive Federal Party (PFP) MP for Hillbrow, Alf Widman, was trumpeted by Exit as a powerful victory and advance for gay rights in South Africa, but the result provoked a sharp backlash among many white gay men and lesbian women who organised to openly identify with the liberation movement. The Exit/Hillbrow campaign problematises the singular assumptions that are often made about race and sexuality in apartheid South Africa, and illustrates how political, social and economic crisis can provoke reconfigurations of identities vis-à-vis the status quo.

Teaching &amp; Learning Guide for: Queer Theory and its Future in Psychology: Exploring Issues of Race Privilege

Teaching &amp; Learning Guide for: Queer Theory and its Future in Psychology: Exploring Issues of Race Privilege

Visual representation, editorial power, and the dual ‘othering’ of black men in the South African gay press: The case of Gay Pages

This article considers some of the ways in which black gay men are marginalised within the queer community and have limited ‘visibility’ in mainstream queer visual culture. The formation of a minority within a minority (or the ‘other’ Other) is ultimately what the article sets out to expose. Thus, we argue that images of black gay men are far less ubiquitous than, for example, those of white, male and middle-class gay men. In order to illustrate this, a purposive sample from the South African gay men's lifestyle magazine Gay Pages is considered and critiqued. We argue that the visual mode of Gay Pages gives the impression of promoting a hegemonic gay male identity. This identity appears to be ‘natural’, but is in fact one-sided and stereotypical, as are most cultural constructions and representations. The narrow and limited representation of gay men endorses an exclusive, homogenous and inaccurate portrait of the queer constituency (in the minds of heterosexual and gay South Africans alike) and suggests the question that leads this investigation: If ‘belonging’ is articulated through the consumption of queer culture, what then of those queers who do not fit the ‘mould’ standardised by mainstream gay print media? This exploration of queer visual media deals not only with that which is frequently represented (white homomasculinity), but also, more significantly, with that which is not (black homomasculinity).

Racial Minorities Then and Now: The Continuing Significance of Race

It has been 27 years since the last special issue on racial minorities appeared in Social Work. When the issue appeared in 1982, Jerome Schiele was pursuing an undergraduate degree in sociology at Hampton University. June Gary Hopps was editor of the 1982 special issue and had by then distinguished herself as a social work educator, scholar, and administrator. This generational difference provides an opportunity to reflect on the evolution and status of the social problems that racial minorities disproportionately experience and the response from the social work profession. Whether in the past or present, these minorities experienced and continue to experience social problems that in large part emanate from racial oppression. The social work profession's response to this form of injustice has varied over time and speaks to the specific social circumstances and challenges of a particular historical epoch. EARLIER ISSUES AND PROBLEMS The 1982 special issue emerged primarily from the need to examine the profession's contributions to the debate regarding and resolution of the issue of oppression and the success or lack of success relative to its leadership. When it was published, the editor of that issue viewed the term with skepticism because of its juxtaposition with and pejorative assumption of lesser value. Problems associated with the definition of minority were addressed by several contributors outlining concerns relative to African Americans, Hispanics, and Asian Pacific Americans. Co-relatively, concerns of women were raised, recognizing the disadvantaged of women of color in comparison with their European American counterparts who held and continue to hold deferred meaning more white women are in a socially advantageous position (Hopps, 1982, p. 4). Why? of their individual and collective relationships to the power structure (Hopps, 1982, p. 4), they can use leverage that the vast majority of women and men of color can only imagine. Although their power base and potential for greater influence was obvious, no one should interpret this observation as implying that white privilege would diminish. It did not and is not only alive, but also thriving. The 1982 special issue also emerged from questions regarding whether the social work profession benefited from the 1960s freedom struggles launched primarily by people of color. African Americans and other people of color were present, persistent, and persuasive in pressing their case for constitutionally granted political rights that were denied to them. No doubt, there were those who experienced and remembered the Holocaust and also shared the vision for major structural change. Because of the protests and political activities by the poor and the socially conscious, the cause for civil, human, and political rights was a priority. People of color received attention, and some rightful gains were realized. People of color were joined by other oppressed groups, such as white women, gay men and lesbians, physically and mentally challenged citizens, and new immigrants. Although the 1960s paradigm that originally advanced major structural change and enhanced corrective social justice was successful, people of color remained vulnerable relative to non-Hispanic white Americans through the 1970s and into the early 1980s. Twenty years prior to the 1982 publication, the profession demonstrated some concern about issues relevant to people of color, then largely regarded as the Negro problem better known as the black phenomenon during the 1969 to 1975 period. In a 2007 literature review analysis of articles published from 1960 to 1975, the second editor found that at least 89 articles in Social Work addressed race-relevant questions, policies, and program practices. The points of discussion and presentation were derived mainly from theoretical, descriptive, and qualitative analyses. Writers were also not as representative of the populations reviewed or served. …

Asian Girls are Prettier: Gendered Presentations as Stigma Management among Gay Asian Men

Despite the well‐documented cases of racism toward gay Asian men in the gay community, there is currently little research on how gay Asian men manage racial stigma. In this article, I examine the racial stigma management strategies of gay Asian men. I examine the nature of gay racial stigma toward gay Asian men and find that they use gendered presentations to counter the stereotype that they are more feminine than gay white men. While some gay Asian men engender a hypermasculine presentation, others use a hyperfeminine presentation to trade a more‐stigmatized status for one that is less stigmatizing. More important, these men actively embrace stereotypes to successfully make these transitions. This article demonstrates that stigmatized groups can manage stigma by highlighting their spoiled identities rather than attempting to minimize them.

Gay Artists in Modern American Culture: An Imagined Conspiracy (review)

Reviewed by: Gay Artists in Modern American Culture: An Imagined Conspiracy Scott Herring Gay Artists in Modern American Culture: An Imagined Conspiracy. By Michael S. Sherry. Chapel Hill: University of North Carolina Press. 2007. Through exhaustive research, historian Michael S. Sherry's Gay Artists in Modern American Culture argues that predominantly white gay men found themselves at the epicenter of national and international public debates over the United State's cultural preeminence during the Cold War era. These men—composers such as Aaron Copland and Samuel Barber as well as dramatists such as Tennessee Williams and Edward Albee—were considered members in an imaginary homintern (a pun on Comintern, the Communist International) that was held to both exemplify and undermine the nation's attempts at cultural imperialism. Think of it as an arms race with treble clefs directed by Maggie the Cat. For Sherry, these artists exemplified the United States high cultural achievement through the circulation of their major productions in opera, drama, literature, and film. Yet they nevertheless undermined these achievements because of their stigmatized gay-identifications, thereby effeminizing the self-image of a masculinist Cold War nation-state. Sherry convincingly supports this paradoxical thesis through close readings of Richard Nixon's transcripts, plays such as Suddenly, Last Summer, Cat on a Hot Tin Roof, and Who's Afraid of Virginia Woolf?, homophobic critiques by Stanley Kauffman, and, brilliantly, the spectacular failure of Samuel Barber's opera 1966 Antony and Cleopatra (directed by Franco Zeffirelli) at New York City's Metropolitan Opera. As this detailed list suggests, the accomplishments of Gay Artists are many. First, Sherry enables scholars to review queer American modernist works in both a national and an international frame and provides a strong overarching thesis for braiding these disparate artists into a thick cultural weave. Second, his book overflows with anecdotal evidence that not only makes good use of its case studies but also incorporates an astonishing range of references to support its layered arguments. An incomplete list would include not only the white gay males already listed, but also Audre Lorde, James Baldwin, Susan Sontag, Stephen Sondheim, Leslie Fiedler, Erving Goffman, Andy Warhol, Jasper Johns, Joseph McCarthy, Roy Cohn, Lyndon Johnson, Montgomery Clift, Rock Hudson, and John Cage. Third, Sherry tracks the afterlife of talk surrounding the national value of queer creativity as it continues well into the present. And fourth, the historian is admirably self-reflexive about his own positioning in relation to his research, oftentimes linking his archival analyses to personal biography and thereby avoiding the trap of an impossible objectivity. Gay Artists in Modern Culture is highly recommended for scholars—and also for non-academics—who have interests in twentieth-century American culture, in queer studies, and in studies of modern U.S. empire. It should become a vital reference for those studying how these three interconnected subjects collided in sound, in print, on celluloid, and on the stage during the pivotal decades of the Cold War era. Gay Artists recently won the 2008 LGBT Award for Nonfiction from the Lambda Literary Foundation. It deserves to pick up several more. Scott Herring Indiana University Bloomington Copyright © 2010 Mid-America American Studies Association

(E)Racing Edmund White: Queer Reading, Race, and Sexuality in A Boy’s Own Story

A history of racialized sexuality in the US suggests that sexuality is saturated by race even in American literature written by white gay men. Reading Edmund White’s coming out novel, A Boy’s Own Story , in relation to a little-known work of gay pulp fiction, André Tellier’s Twilight Men , the essay provides a fictional example of the ways white gay identities might be seen simultaneously to collude with and undermine the history of whiteness. The essay also elaborates a strategy for queer reading of the incoherencies of sexual identities within multiple historical discourses.

Exploratory Notes on the Geography of Black Gay Leisure Spaces in Bloemfontein, South Africa

Gay leisure space development has of late been an important area of investigation in geography. Generally, these investigations have primarily concerned white gay men in Western countries. Most of these debates have not been considered in the developing world context, particularly in Africa. This investigation explores the leisure geography of black gay men in the city of Bloemfontein. It is shown that differences in race and class positions explain a gay leisure geography which stands totally separate from that of white gay men. The investigation argues that differences in class position, linked to race, explain these separate geographies. However, it is also revealed that the black gay men of this investigation do not see exclusively gay leisure spaces as desirable and would rather seek leisure spaces that are inclusive of different sexual orientations.

Social and economic hardship among people living with HIV in London

To examine the social and economic circumstances of people living with HIV in London. Between June 2004 and June 2005, 1687 people living with HIV (73% response) receiving treatment and care in north-east London National Health Service out-patient clinics completed a confidential, self-administered questionnaire. The questionnaire sought information on employment, income, education, residency status in the UK and housing. In total, 1604 respondents were included in the analysis: Black African heterosexual women (n=480) and men (224); White (646) and ethnic minority (i.e. non-White) homosexual men (112); White heterosexual men (64) and women (39); and Black Caribbean heterosexual women (26) and men (13). Black African heterosexual men and women consistently reported more difficulties than any other group in relation to employment, income, housing and residency status. Half the Black African heterosexual men (46.8%) and women (51.2%) reported insecure residency status in the UK, significantly more than any other group (P<0.001). Just under half the respondents (46.6%) were employed at the time of the survey; Black African heterosexual women (35.3%) and men (45.4%) were less likely to be employed than White (57.6%) or ethnic minority (53.7%) homosexual men (P<0.001). Forty per cent of Black African heterosexual men and women, 22.9% of ethnic minority homosexual men and 9.6% of White homosexual men did not have enough money to cover their basic needs (P<0.001). In this study of people living with HIV in London, a substantial number faced social and economic hardship, particularly Black African and other ethnic minority respondents. Our findings provide further evidence that in London HIV is associated with poverty, particularly among migrant and ethnic minority populations.

Averting White Male (Ab)normality: Psychiatric Representations and Treatment of ‘Homosexuality’ in 1960s South Africa

South Africa arguably has the most progressive constitution in the world, one that includes the recognition of gay rights. However, just over four decades ago, when gay rights movements were gaining momentum worldwide, the South African government, in its homophobia, became increasingly vigilant at cracking down on any ‘homosexual’ activities within its borders. Heteropatriarchal views of sexuality in South Africa supported white male power structures, promoted binary ideas of masculinity and femininity, normalised heterosexuality, and determined social roles by biological sex. The state's control over the sexual activities of its population was more than just about controlling sexuality: it sought to prohibit interracial sex and to ensure that whites continued to propagate and retain political dominance. Ideas about homosexuality, in particular, threatened the Christian-nationalist procreative ideals of the apartheid government and increased fears about the perceived moral degeneration of society. Scholarship about homosexuality in South Africa, has shown how, in the 1970s and 1980s, psychiatrists in the South African Defence Force Military Hospital partook in human rights abuses by utilising aversion therapy, hormone therapy, sex change operations and barbiturates on young white homosexual men as a means to ‘cure’ them from their homosexual ‘disease’. Implicit in these studies of abuse is the notion that psychiatric practitioners were simply corrective agents of the apartheid state. However, most ignore the complex views of all those involved in debates about homosexuality that took place before the 1970s and outside the military. This article argues that psychiatric practitioners' attempts to quell the state's intensification of legislation on ‘homosexuality’ should be recognised. While many practitioners did support heteropatriarchal ideals of sexuality and normality, practitioners held disparate ideas about the aetiology and treatment of homosexuality that sometimes, but not always, supported the Nationalist government's objectives.

Disclosure of HIV Status

To examine HIV disclosure among people living with HIV in London. Between June 2004 and June 2005, 1687 people living with HIV (73% response) receiving medical care in National Health Service (NHS) clinics in northeast London completed a confidential, self-administered questionnaire. Respondents were asked whether they had told anyone else that they had HIV, and if so, whom. The analysis included 1407 people: 667 black African heterosexual respondents (453 women, 214 men) and 740 gay men (633 white, 107 ethnic minority). The majority of respondents (88.0%) had told at least 1 other person about their HIV infection, but this varied between groups: white gay men, 95.0%; ethnic minority gay men, 93.5%; black African heterosexual women, 84.8%; black African heterosexual men, 76.6% (P < 0.001). Black African heterosexual men (65.3%) and women (60.4%) were less likely to have told their current partner about their HIV infection than white (86.2%) or ethnic minority gay men (85.2%): black African men, adjusted odds ratio (AOR) 0.25, 95% confidence interval (CI) 0.14, 0.44, P < 0.001; black African women, AOR 0.24, 95% CI 0.15, 0.39, P < 0.001 (reference group, white gay men). Only 1 in 5 respondents (21.6%) had disclosed their HIV status to their employer (white gay men, 30.5%; ethnic minority gay men, 15.8%; black African heterosexual women, 10.5%; black African heterosexual men, 8.8%; P < 0.001). In this London study there were striking differences, by ethnicity, in the extent to which people with HIV disclosed their infection. This has important implications in light of the 2005 Disability Discrimination Act and recent prosecutions in the UK for the reckless transmission of HIV.

TILT: a randomized controlled trial of interruption of antiretroviral therapy with or without interleukin-2 in HIV-1 infected individuals

We aimed to see if structured treatment interruption (STI) could be supported safely with the use of two cycles of IL-2 (4.5 MIU q12h subcutaneously 5 days) before STI to prolong the time before therapy restarted. Subjects were randomly allocated to either A - continuous ART; B - continue for 9 weeks, then STI; restart with the same ART when the CD4 count falls below 200 cells; or C - two cycles of IL-2, 8 weeks apart, while still on ART; at week 9 stop ART and use a new cycle of IL-2 alone whenever the CD4 count falls < 300 cells. Patients were followed until week 105. 86 mostly white middle aged homosexual men with a baseline median CD4 count of 754 cells/ml (range 240-1400) and a nadir CD4 count of 268 cells/ml (range 62-822) enrolled. By 96 weeks there was a 66% probability of having restarted ART in arm B compared with 34% in arm C (p = 0.002; log rank test). New drugs were used in 60% in arm A, 57% in arm B and 45% in arm C. 4 subjects had a dose modification in the first cycle due to toxicity with 2 interrupting. There were 39 SAEs with 21 in arm C. There were no deaths. The primary aim of the trial was to gain experience in using IL-2. IL-2 delayed restarting drugs and fewer new drugs were used.

No fats, femmes, or Asians: the utility of critical race theory in examining the role of gay stock stories in the marginalization of gay Asian men

In the last few decades, proponents of critical race theory have uncovered everyday forms of injustice that continue to affect the lives of men and women of color by exposing the subtle forms of racism that exist in the stock stories told by the dominant group as well as the counterstories told by subaltern groups. However, rarely have we examined the stock stories articulated by subaltern groups to marginalize other subaltern groups. In this paper, I consider the stock stories told by gay White men and the counterstories expressed by gay Asian men to examine subtle forms of racism within the gay community. I argue that we need not only to reveal how the stories narrated by the dominant group continue to maintain social inequality, but that we also need to consider how subaltern groups help to maintain social inequality by adapting the language of the dominant group to use against other subaltern groups.

Stress and coping among gay men: Age and ethnic differences.

Previous studies suggest that perceived stigmatization of sexual minority status, ethnicity, and age are associated with negative mental health outcomes, and other studies suggest that coping styles may influence these outcomes. However, no studies have examined these relationships among gay men of varying ethnicities and age groups. Three hundred eighty-three Black and White, younger, middle-aged, and older adult gay men completed measures of perceived stigmatization, coping style, and mental health outcomes. Black older adult gay men reported significantly higher levels of perceived ageism than the older White group, significantly higher levels of perceived racism than the younger Black group, significantly higher levels of homonegativity than the younger Black and the White groups, and were more likely to use disengaged coping styles than White gay men. However, Black older adult gay men did not experience significantly higher levels of negative mental health outcomes. Results suggest that further research should examine how older Black gay men, who perceive higher levels of stigma while reporting greater use of less effective coping styles, do not appear to be experiencing more negative mental health outcomes as a result.

Beliefs About Treatments for HIV/AIDS and Sexual Risk Behaviors Among Men Who have Sex with Men, 1997–2006

Beliefs that HIV treatments reduce HIV transmission risks are related to increases in sexual risk behaviors, particularly unprotected anal intercourse among men who have sex with men (MSM). Changes in unprotected anal intercourse and prevention-related treatment beliefs were recently reported for surveys of mostly white gay men collected in 1997 and 2005. The current study extends this previous research by replicating the observed changes in behaviors and beliefs in anonymous community surveys collected in 2006. Results indicated clear and consistent increases in beliefs that HIV treatments reduce HIV transmission risks and increases in unprotected anal intercourse. These changes were observed for both HIV positive and non-HIV positive men. African American men endorsed the belief that HIV treatments protect against HIV transmission to a greater degree than White men. Results show that HIV prevention messages need to be updated to educate MSM about the realities of HIV viral concentrations and HIV transmission risks.