The purpose of this study was to understand the synergistic relationships between conceptions of masculinity, body image, and sexual behavior in HIV-positive gay men. The data were drawn from a two-phase formative behavioral mixed methodologies investigation with the use of the Internet. Findings demonstrated that conceptions of masculinity were intimately linked to body image and sexual adventurism, such that men defined their masculinity by their physical appearance and sexual behavior. Further, the data support high levels of risk taking, including steroid use and intentional unprotected anal intercourse (barebacking), which correlated with the participants' conception of physical masculinity. Clinical implications suggest that it is critical to examine the interaction that occurs between the individual's gay, masculine, and HIV-positive identities as these appear to be overlapping realities that have an impact on the decisions and behaviors in which these men engage.
Keywords: masculinity, body image, gay men, sexual behavior, HIV, barebacking, steroid use, Internet, sexual adventurism
The developmental trajectory of gay culture to construct a conception of masculinity distinct from heterosexual males may have been thwarted in the 1980s with the onset of the HIV epidemic (Halkitis, 1999; 2001). After the emergence of HIV, the emphasis on physicality among some gay men in large urban centers was directed to preserve and increase the health of men infected with the virus who were experiencing weight loss, muscular wasting and deterioration, decreases in libido, and eventual death (Shilts, 1987). As many gay men began to physically deteriorate due to the disease, heterosexual perceptions of gay men as non-masculine and fragile were realized.
In order to combat the physical weakness brought on by the virus, many HIV-positive gay men undertook complementary therapy measures such as steroid replacement as well as weight training and nutritional supplements to increase strength and maintain health. Today, while these therapies are still important elements in the lives of HIV-positive gay men, they have moved beyond the goals of health and survival and have become associated with a physically based conception of masculinity espoused by many gay men, regardless of HIV serostatus (Signorile, 1997).
Central to this conception of physical masculinity is body image and muscularity (Halkitis, 1999; 2001). To this end, some HIV-positive gay men describe lives driven by a desire to achieve an ideal physical appearance of muscularity, characterized by what has been labeled as the "buff agenda" (Halkitis, 1999). While therapeutic approaches to body enhancement serve to decrease HIV-related morbidity and mortality (Charlin, Carrasco, Sepulveda, Tortes, & Kehr, 2002)) and the associated body dissatisfaction experienced by many (Tate & George, 2001), some HIV-positive men have taken this to an extreme. Even given the advances in HIV treatment in the last decade, which have drastically reduced AIDS-related deaths (Mocroft et al., 2003), many HIV-positive men still implement exercise, steroid use, and nutritional supplements, perhaps not as a way of avoiding their wasting and mortality, but rather as a way to achieve psychical perfection.
A second tenet of this conception of physical masculinity among HIV-positive gay men is that of sexual prowess. Sexual behaviors and associated risk-taking have been linked to masculine identity (Chapple, Kippax, & Smith, 1998; Halkitis, 1999; 2001 Kippax & Smith, 2001). HIV-positive men describe sexual partnering as a means of enhancing conceptions of attractiveness; thus some seek out sex as an affirmation of self and as a means of eradicating feelings of undesirability (Halkitis & Wilton, in press). Recent increases in sexually transmitted infections (Centers for Disease Control & Prevention, CDC, 2003a) and HIV (CDC, 2003b) indicate that certainly some HIV-positive men-who-have-sex-with-men are engaging in unprotected sexual behaviors. …